Simultaneous decompressive craniectomy and caesarean section.

A 24-year-old primigravid woman at 29-weeks gestation presented with headache, hypertension and proteinuria. A diagnosis of pre-eclampsia was made. Later that day she developed a left hemiparesis and neuroimaging demonstrated an intracerebral haemorrhage in the right frontal lobe as well as thrombosis of the superior sagittal sinus. She was commenced on an IV heparin infusion to manage the sinus thrombosis, and nifedipine and labetalol to treat the hypertension. GCS remained 15/15. However, 12 hours later, she became progressively agitated. Her GCS decreased to 10/15 (E3V2M5). Repeat imaging demonstrated enlargement of the haematoma, causing significant mass effect and midline shift. A decision was made to perform decompressive hemicraniectomy to save the life of the mother, and caesarean section to protect the foetus as well as providing definitive treatment of pre-eclampsia. Due to further neurological deterioration of the mother it became necessary to perform the two procedures simultaneously. We present the first reported case of decompressive craniectomy and caesarean section performed simultaneously. After discussing the case, we consider why this clinical scenario is rare and why it became necessary in this patient to perform the two procedures simultaneously.

[Pregnancy after simultaneouspancreasandkidney transplantation].

In this case report, a 41-year-old nullipara obtained pregnancy one and a half year after a simultaneous pancreas and kidney transplantation (SKP). After SKP, the woman had no need for insulin and no hypertension. Her kidney function was stable during pregnancy and no insulin was needed. During the last weeks of pregnancy, increased blood pressure was seen. Biochemically, there were no signs of preeclampsia and no proteinuria. An elective cesarean section was performed in gestational week 37+5 and a healthy boy, 2,710 g. (-1.2 standarddeviation) was born. Pregnancy after SKP is possible and can have a good prognosis.

Management of a multiple endocrine neoplasia type 1 during pregnancy: a case with primary hypertension.

Multiple endocrine neoplasia type 1 (MEN 1) is a rare hereditary disease which transmitted as autosomal dominant disorder with high penetrance. MEN1 includes vary combinations of more than 20 endocrine and non-endocrine tumors. Clinically, MEN1 is characterized by tumor or hyperplasia in two or more endocrine tissues (parathyroid, pituitary, pancreas, adrenal glands). Since it is a rare condition, there are no guidelines with respect to the follow-up of pregnant women with MEN 1, here we the first Asian case of a 32-year-old primigravida with a confirmed diagnosis of MEN1 and primary hypertension prior to conception, cesarean section was performed at 34+2 weeks for severe preeclampsia and potential risks, both the patient and fetus recovered well.

Neurological manifestation in severe hypothyroidism in pregnancy.

Neurological manifestations of hypothyroidism include peripheral neuropathy and pituitary hyperplasia. However, these associations are rarely encountered during pregnancy. We report a case of a known hypothyroid with very high thyroid stimulating hormone (TSH) values (512 µIU/mL) in the second trimester. At 24 weeks she developed facial palsy and pituitary hyperplasia which responded to a combination of steroids and thyroxine. She had caesarean delivery at 35 weeks and 3 days gestation in view of pre-eclampsia with severe features and was discharged on oral antihypertensives and thyroxine. On follow-up at 5 months, TSH normalised and pituitary hyperplasia showed a greater than 50% reduction in size. To our knowledge, this is the first reported case of facial palsy and pituitary hyperplasia associated with hypothyroidism during pregnancy.

Crashing eclamptic patient and a resulting peri-mortem C-section.

BACKGROUND: Cardiac arrest in pregnancy is high acuity, low occurrence event. It involves the coordination of multiple teams to take care of ultimately two patients. This is further compounded by physiology that is frequently unfamiliar to the providers taking care of the patient. CASE REPORT: This case report will detail sudden onset eclampsia in a patient whose condition deteriorated rapidly into cardiac arrest. It will delve into the complexities of managing this complex disease process and how the multi-disciplinary team quickly integrated to manage both the mother and the baby. Why should the emergency physician be aware of this?: Cardiac arrest in pregnancy is an incredibly difficult situation due to both the physiological differences in the pregnant woman and the emotional factors on the treating providers (1). Due to its rarity, the pregnant cardiac arrest situation should be frequently reviewed to ensure appropriate care when the time arrives. The per-mortem c-section for a woman in cardiac arrest is a critical resuscitation technique that must be understood by providers who take care of critically ill patients ranging from emergency medicine to obstetrics and gynecology (Ob/Gyn) clinicians.

Decision-delivery intervals: Impact of a colour code protocol for emergency caesareans.

OBJECTIVE: Assess the impact of implementation by simple distribution of a "colour code" protocol for emergency caesareans on the course over time of the "decision-delivery interval" (DDI) and neonatal outcome. DESIGN: Observational study in 26 maternity units of the AURORE perinatal network, conducted between October 1, 2017, and April 30, 2018. Each maternity ward́ was supposed to prospectively include 20 consecutive cases of caesareans performed either as an emergency, that is, as a code orange, or an extreme emergency, that is, code red. We compared the DDIs observed in 2017 to those in 2007 according to the degree of emergency, the maternity unit level of care, and their adherence to the protocol. Neonatal outcome in 2007 and 2017, assessed from laboratory and clinical indicators, was also compared, overall and according to the degree of emergency. RESULTS: The DDI was significantly lower in 2017 (n = 478) than in 2007 (n = 447), regardless of the degree of emergency and the level of care (p < 0.0001). In 2017, all code red caesareans were performed in less than 15 min in level 3 maternity units compared with 73 % (p = 0.039) in 2007. Fewer than 20 % of the caesareans in the 2007 study period were performed in less than 15 min in level 1 and 2 maternity units. Today, this is the case for 83 % of these caesareans in level 2 units (p < 0.001) and 36 % in level 1 (p = 0.01). In 2017, code orange caesareans were performed in less than 30 min in 96 % of cases in level 3 units, 67 % in level 2, and 33 % in level 1, compared respectively with 67 % (p = 0.015), 25 % (p < 0.0001) and 16 % (p = 0.0003) in 2007. We did not observe any difference in the neonatal outcome between 2007 and 2017 or as a function of the DDI expected based on the caesarean colour code. CONCLUSION: The implementation of the colour code protocols was associated with an improved DDI and better adherence to the recommendations in all 26 maternity units in this perinatal network.

Pre-eclampsia complicated by severe hyponatraemia.

A 41-year-old woman was diagnosed with pre-eclampsia at 35 weeks gestation. She was treated with antihypertensives but, unfortunately, her condition became complicated by severe hyponatraemia. Her sodium levels rapidly dropped to 125 mmol/L. The cause for the hyponatraemia was the syndrome of inappropriate antidiuretic hormone secretion. She was initially managed with fluid restriction, but an emergency caesarean section was necessary in view of fetal distress. Her sodium levels returned to normal within 48 hours of delivery.Pre-eclampsia is rarely associated with hyponatraemia. A low maternal sodium level further increases the mother's risk for seizures during this state. Additionally, the fetal sodium rapidly equilibrates to the mother's and may result in fetal tachycardia, jaundice and polyhdraminios. All these factors may necessitate an emergency fetal delivery.

Classic metaphyseal lesion of distal tibia following footling breech delivery.

Classic metaphyseal lesions associated with childbirth are rare. We report a distal tibial metaphyseal fracture following a difficult breech delivery. Classic metaphyseal fractures are considered highly specific injuries associated with non-accidental trauma. This case depicts a classic metaphyseal lesion sustained during footling breech extraction in an urgent delivery. The traction and torque placed on the distal extremities during this difficult delivery suggest a potential mechanism for this injury.

Liver Transplantation for Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome: A Propensity-score Matched Long-term Survival of the Scientific Registry of Transplant Recipients Dataset.

BACKGROUND: Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a life-threatening form of pre-eclampsia/eclampsia, with liver transplantation being the life-saving option for treatment for those who develop severe hepatic complications. METHODS: We retrospectively analyzed data from the Scientific Registry of Transplant Recipients (SRTR) through October 1, 1987, to December 31, 2014. Forty patients were listed for liver transplantation, with 18 patients finally receiving their transplant. These 18 patients were matched with 1:10 patients using a propensity-score matched approach. RESULTS: Baseline demographics were comparable between HELLP syndrome patients who received a transplant and those who did not. The 10-year intent-to-treat survival was 63.6% for non-transplanted HELLP patients, 64.2% for transplanted HELLP patients, and 61.8% for matched patients (P = .369). Overall survival was also similar between HELLP patients and matched patients, with 10-year survival at 64.2% and 61.8% respectively (P = .985). However, death-censored graft survival was inferior in HELLP patients, with 10-year survival at 63.4% compared with 75.4% in the matched patients (P = .044). CONCLUSIONS: Patients with HELLP syndrome who did not receive a transplant achieved similar intent-to-treat survival with those transplanted patients, while the death-censored graft survival of transplanted patients was inferior to matched patients. This might guide improved liver donor allocation in clinical practice.

Cerebral oxygen saturation monitoring in preeclamptic pregnant women undergoing cesarean section with spinal anesthesia: a prospective, observational study.

It has been suggested that cerebral oximetry can detect acute and chronic changes in cerebral oxygen saturation due to pregnancy related complications. Furthermore, regional cerebral oxygenation saturation (rcSO2) decreases were obtained during spinal anesthesia for cesarean section. The aim of this prospective observational study is to compare the effects of spinal anesthesia on rcSO2 in preeclamptic and normotensive pregnant women. Preeclamptic (Group P, n = 24) and normotensive (Group N, n = 25) women with gestational week 32 and above, and scheduled for cesarean section under spinal anesthesia were included in this study. In addition to routine monitoring, rcSO2 values obtained with right and left frontal cerebral sensors (rcSO2right and rcSO2left) were recorded before (baseline) spinal injection and during the surgery. The baseline rcSO2 values were similar in both groups. In Group P, rcSO2left values were higher than Group N only 3 and 5 min after spinal injection. In Group N, rcSO2 values decreased from baseline 1, 3, 5, and 10 min after spinal injection. In Group P, rcSO2 values decreased from baseline 1, 3, 5, 10, 30 and 35 min after spinal injection and at the end of the operation. There was no difference between the number of declines and the patients with rScO2 below the cerebral hypoxic threshold. There was a positive correlation between rcSO2 and blood pressure only 5 min after spinal injection, but no correlation with peripheral oxygen saturation was detected during the operation. There is decrease in rcSO2 values after spinal anesthesia correlating with hypotension in preeclamptic women. However, the decrease is less than that of normotensive pregnant women, especially the first 5 min after spinal injection when the blood pressure is lowest. The clinical impact of these results and the relationship between cerebral desaturation and neurological complications remain to be determined.

[Cushing's syndrome during pregnancy : diagnostic and therapeutic difficulties]. / Le cas clinique du mois. Syndrome de Cushing au cours d'une grossesse : difficultés diagnostiques et thérapeutiques.

Cushing's syndrome (CS), which is often associated with infertility, exceptionally occurs in pregnancy, and markedly increases maternal and fetal morbidity and mortality. Gestational CS may be challenging. Indeed, symptoms of hypercorticism may overlap with physiological hyperactivity of the hypothalamus-pituitary-adrenal axis in normal pregnancy. This case report describes a pregnant patient that underwent a fertility treatment and developed a gestational CS due to an adrenocortical adenoma. Diagnosis of gestational CS was suspected at 13 weeks by a new onset of hypokalemia and arterial hypertension. A multidisciplinary approach was necessary during follow up. At 24 weeks, laparoscopic surgery retrieved a 4 cm adrenocortical adenoma. Cesarean surgery was successfully practiced at 31 weeks, because of preeclampsia. We discuss the differential diagnosis of hypokalemia and arterial hypertension during pregnancy and the diagnosis and management of gestational CS.

Le syndrome de Cushing (SC), déterminant fréquemment une infertilité, survient exceptionnellement au cours d´une grossesse. La présentation du SC au cours de la grossesse s'accompagne d'une plus grande morbimortalité maternelle et foetale. Son diagnostic représente un véritable défi pour le clinicien, car les symptômes de l'hypercorticisme se superposent aux modifications physiologiques induites par la stimulation de l`axe corticotrope lors de la grossesse. Nous rapportons le cas d'une patiente enceinte après une fécondation in vitro. A 13 semaines de grossesse, un SC gestationnel d'origine surrénalienne est suspecté dans le cadre d'une hypokaliémie et d'une hypertension artérielle inaugurales. Un suivi multidisciplinaire est instauré au cours de la grossesse. Une surrénalectomie gauche par voie laparoscopique est décidée à 24 semaines d'aménorrhée, avec l'exérèse complète d'un adénome cortical, de 4 cm de diamètre. La chirurgie par césarienne est pratiquée avec succès à 31 semaines de grossesse, car la patiente développait une pré-éclampsie. Nous discutons les différents diagnostics différentiels d'une hypokaliémie et d'une hypertension artérielle au cours de la grossesse et les modalités de prise en charge d´un SC gestationnel.

Abducens nerve palsy in pre eclampsia : case report.

Cranial nerves palsy associated with preeclampsia is reported in literature. Facial and abducens palsies were the most nerve disorders described. Only eleven cases have been reported in the literature. We report the case of a 27-years-old patient who presented abducens nerve palsy in immediately after the delivery of severe pre-eclampsia. No specific pathology was found. Symptoms of abducens nerve palsy have resolved spontaneously by controlling blood pressure after delivery.

Potential role for nectin-4 in the pathogenesis of pre-eclampsia: a molecular genetic study.

BACKGROUND: Nectins are cell adhesion molecules that play a pivotal role in adherens junctions and tight junctions. Our previous study using whole-genome oligonucleotide microarrays revealed that nectin-4 was upregulated in pre-eclamptic placentas. We investigated the role of nectin-4 in the etiology of pre-eclampsia. METHODS: We investigated the expression of nectin-4 using real-time RT-PCR, western blot and immunostaining. Additionally, we performed matrigel invasion assay and cytotoxicity assay using cells overexpressing the nectin-4. RESULTS: NECTIN4 transcripts were elevated in pre-eclamptic placentas relative to uncomplicated pregnancies. Nectin-4 protein levels in pre-eclamptic placentas were higher on a semi-quantitative western blot. Nectin-4 was localized at the apical cell membrane in syncytiotrophoblast cells and not at the adherens junctions. Nectin-4 was also detected in cytotrophoblasts and a subset of cells in the decidua. Nectin-4 overexpressing trophoblast cells migrated normally in the matrix. However, Natural killer (NK) cells showed a strong cytotoxic effect against nectin-4 overexpressing trophoblast cells. No causative genetic variation was evident in the NECTIN4 gene from a pre-eclamptic placenta. CONCLUSIONS: There are as yet unknown factors that induce nectin-4 overexpression in trophoblast cells that may contribute to abnormal placentation via an aberrant immune response and the onset of a pre-eclamptic pregnancy.

Maternal cardiovascular hemodynamics in normotensive versus preeclamptic pregnancies: a prospective longitudinal study using a noninvasive cardiac system (NICaS™).

BACKGROUND: Preeclampsia is among the most common medical complications of pregnancy. The clinical utility of invasive hemodynamic monitoring in preeclampsia (e.g., Swan-Ganz catheter) is controversial. Thoracic impedance cardiography (TIC) and Doppler echocardiography are noninvasive techniques but they both have important limitations. NICaS™ (NI Medical, PetachTikva, Israel) is a noninvasive cardiac system for determining cardiac output (CO) that utilizes regional impedance cardiography (RIC) by noninvasively measuring the impedance signal in the periphery. It outperformed any other impedance cardiographic technology and was twice as accurate as TIC. METHODS: We used the NICaS™ system to compare the hemodynamic parameters of women with severe preeclampsia (PET group, n = 17) to a cohort of healthy normotensive pregnant women with a singleton pregnancy at term (control group, n = 62) (1/2015-6/2015). Heart rate (HR), stroke volume (SV), CO, total peripheral resistance (TPR) and mean arterial pressure (MAP) were measured 15-30 min before CS initiation, immediately after administering spinal anesthesia, immediately after delivery of the fetus and placenta, at the abdominal fascia closure and within 24-36 and 48-72 h postpartum. RESULTS: The COs before and during the CS were significantly higher in the control group compared to the PET group (P < .05), but reached equivalent values within 24-36 h postpartum. CO peaked at delivery of the newborn and the placenta and started to decline afterwards in both groups. The MAP and TPR values were significantly higher in the PET group at all points of assessment except at 48-72 h postpartum when it was still significantly higher for MAP while the TPR only exhibited a higher trend but not statistically significant. The NICaS™ device noninvasively demonstrated low CO and high TPR profiles in the PET group compared to controls. CONCLUSIONS: The immediate postpartum period is accompanied by the most dramatic hemodynamic changes and fluid shifts, during which the parturient should be closely monitored. The NICaS™ device may help the clinician to customize the most optimal management for individual parturients. Our findings require validation by further studies on larger samples.

The Effect of Prophylactic Phenylephrine and Ephedrine Infusions on Umbilical Artery Blood pH in Women With Preeclampsia Undergoing Cesarean Delivery With Spinal Anesthesia: A Randomized, Double-Blind Trial.

BACKGROUND: Spinal anesthesia for cesarean delivery is associated with a high incidence of hypotension. Phenylephrine results in higher umbilical artery pH than ephedrine when used to prevent or treat hypotension in healthy women. We hypothesized that phenylephrine compared to ephedrine would result in higher umbilical artery pH in women with preeclampsia undergoing cesarean delivery with spinal anesthesia. METHODS: This study was a randomized double-blind clinical trial. Nonlaboring women with preeclampsia scheduled for cesarean delivery with spinal anesthesia at Prentice Women's Hospital of Northwestern Medicine were randomized to receive prophylactic infusions of phenylephrine or ephedrine titrated to maintain systolic blood pressure >80% of baseline. Spinal anesthesia consisted of hyperbaric 0.75% bupivacaine 12 mg, fentanyl 15 µg, and morphine 150 µg. The primary outcome was umbilical arterial blood pH and the secondary outcome was umbilical artery base excess. RESULTS: One hundred ten women were enrolled in the study and 54 per group were included in the analysis. There were 74 and 72 infants delivered in the ephedrine and phenylephrine groups, respectively. The phenylephrine:ephedrine ratio for umbilical artery pH was 1.002 (95% confidence interval [CI], 0.997-1.007). Mean [standard deviation] umbilical artery pH was not different between the ephedrine 7.20 [0.10] and phenylephrine 7.22 [0.07] groups (mean difference -0.02, 95% CI of the difference -0.06 to 0.07; P = .38). Median (first, third quartiles) umbilical artery base excess was -3.4 mEq/L (-5.7 to -2.0 mEq/L) in the ephedrine group and -2.8 mEq/L (-4.6 to -2.2mEq/L) in the phenylephrine group (difference -0.6 mEq/L, 95% CI of the difference -1.6 to 0.3 mEq/L; P = .10). When adjusted for gestational age and infant gender, umbilical artery pH did not differ between groups. There were also no differences in the umbilical artery pH stratified by magnesium therapy or by the severity of preeclampsia. CONCLUSIONS: We were unable to demonstrate a beneficial effect of phenylephrine on umbilical artery pH compared with ephedrine. Our findings suggest that phenylephrine may not have a clinically important advantage compared with ephedrine with regard to improved neonatal acid-base status when used to prevent spinal anesthesia-induced hypotension in women with preeclampsia undergoing cesarean delivery.

Advanced abdominal pregnancy, with live fetus and severe preeclampsia, case report.

BACKGROUND: Abdominal pregnancy may account for up to 1.4% of all ectopic pregnancies. The incidence of abdominal pregnancy differs in various literatures and ranges between 1:10,000 pregnancies to 1:30, 000 pregnancies. The clinical symptoms of an uncomplicated abdominal pregnancy are unspecific. There are reports of maternal and fetal survival from advanced abdominal pregnancies. CASE PRESENTATION: Our case was a 26 years old gravida 4, para 3 (2 alive, one early neonatal death) woman. She presented to Felegehiwot Referal Hospital with a principal complaint of vomiting, epigastric pain, headache, and blurring of vision. Emergency cesarean delivery was decided with the impression of bicornuate uterus with intrauterine pregnancy, intrauterine growth restriction and sever preeclampsia.it was found to be advanced abdominal pregnancy. Placenta was removed and pack was used to control bleeding. Both the mother and neonate were discharged in a good condition. CONCLUSION: Abdominal pregnancy with live fetus is an extremely rare condition and requires a high index of suspicion. Endometrial cavity may not be required for development of severe preeclampsia and packing is effective in controlling bleeding in selected cases.