Prognostic value of echocardiography in peripartum cardiomyopathy.

OBJECTIVE: To estimate whether echocardiography findings at the time of diagnosis of peripartum cardiomyopathy are predictive of persistent cardiac dysfunction. METHODS: Chart review of patients with peripartum cardiomyopathy between 1988 and 2001 was performed. Data from echocardiography, including fractional shortening and left ventricular end diastolic dimension, were recorded both at the time of diagnosis and at follow-up. Left ventricular dysfunction was defined by echocardiography as fractional shortening less than 30% and left ventricular end diastolic dimension of 4.8 cm or more. RESULTS: Of 32 patients meeting our definition for peripartum cardiomyopathy and for whom follow-up data were available, 13 (41%) had recovery of ventricular function, while 19 (59%) continued to have persistent left ventricular dysfunction. Those who did not recover cardiac function had a higher left ventricular end diastolic dimension and a lower fractional shortening at diagnosis than those who recovered. A fractional shortening value less than 20% and a left ventricular end diastolic dimension 6 cm or greater at the time of diagnosis was associated with a more than 3-fold higher risk for persistent left ventricular dysfunction. CONCLUSION: Along with being an important diagnostic tool in peripartum cardiomyopathy, echocardiography may provide significant prognostic information with regards to recovery of cardiac function.

Obesity as a risk factor for failed trial of labor in patients with previous cesarean delivery.

OBJECTIVE: This study was undertaken to determine whether obesity is a risk factor for failed trial of labor (TOL) in women with previous cesarean delivery (CD). STUDY DESIGN: We performed a review of singleton gestations 36 weeks or greater with previous CD who underwent TOL from January 1998 to June 2002, stratifying by body mass index (BMI, kg/m2): normal (BMI <25), overweight (BMI 25-29.9), obese (BMI 30-39.9), and morbidly obese (BMI >40). Rates for failed TOL were determined, and groups compared. RESULTS: For 725 patients, failed TOL rates were as follows: 14.1%, 20.4%, 27.7%, and 30.3% for normal, overweight, obese, and morbidly obese groups, respectively (P < .0001). Significant risk factors included: no previous vaginal delivery, labor induction, recurrent CD indication, and fetal macrosomia. However, obesity remained an independent risk factor for failed TOL in the obese and morbidly obese groups with odds ratio of 1.99 (95% CI 1.20-3.30) and 2.22 (1.11-4.44) for these groups (P = .03), respectively. CONCLUSION: Obesity is an independent risk factor for failed TOL in patients with previous CD.

Atypical presentation of pheochromocytoma as part of multiple endocrine neoplasia IIa in pregnancy.

BACKGROUND: Pheochromocytoma in pregnancy is extremely dangerous, especially when unrecognized, and can present alone or as part of a multineoplastic syndrome. Hypertension, its hallmark, is not present in all cases, particularly in women with multiple endocrine neoplasia type IIa. CASE: We report a gravida with undiagnosed multiple endocrine neoplasia IIa who presented initially with peripartum cardiomyopathy but was diagnosed with an underlying pheochromocytoma. Once recognized and treated with appropriate alpha-adrenergic blockade, her condition reversed quickly. CONCLUSION: Physicians should be aware that pheochromocytoma can present as cardiovascular collapse rather than just hypertension.

West Nile virus encephalitis during pregnancy.

BACKGROUND: West Nile virus is an emerging pathogen in the United States. Although most cases are subclinical, serious infection can occur in the form of fulminant meningoencephalitis. CASE: We present a case of West Nile virus meningoencephalitis complicating pregnancy. The patient presented in the second trimester with fever, nuchal rigidity, and mental status changes. The diagnosis was made by demonstrating the presence of immunoglobulin M antibody to West Nile virus in the cerebrospinal fluid. Gradual clinical improvement was noted after several days of supportive care. No obvious fetal consequences of infection were noted after birth. CONCLUSION: Obstetricians and health care providers need to be mindful of West Nile virus infection in pregnant women presenting with fever and neurological signs, particularly in endemic areas.

Prenatal diagnosis of methotrexate embryopathy.

BACKGROUND: Methotrexate is an antineoplastic agent used by obstetrician-gynecologists for termination of early pregnancy. The drug is not always successful and is associated with a known array of malformations. CASE: We present a case of a failed pregnancy termination with methotrexate, which resulted in fetal anomalies. Ultrasound revealed absent or markedly shortened long bones, abnormal positioning of the hands, micrognathia, echogenic bowel, and a two-vessel umbilical cord. The patient elected to undergo pregnancy termination, and the ultrasound findings were confirmed at autopsy. CONCLUSION: Because of methotrexate's teratogenic potential, follow-up to confirm successful termination is necessary. Ultrasound evaluation of the fetus is indicated if pregnancy termination is unsuccessful.