Disseminated primary herpes simplex infection imitating preterm prelabor rupture of membranes - a case report.

Background: We describe a case of primary herpes simplex virus (HSV) infection imitating preterm prelabor rupture of membranes (PPROM) and review the intricacies of establishing the diagnosis. Case presentation: At 18 weeks of gestation, a patient was referred for suspected PPROM following leakage of fluid and a positive nitrazine test. The patient had a swollen inguinal lymph node, intermittent fevers, transaminitis, labial lesions, and cervical ulceration with vaginal discharge. Amniotic fluid volume was normal. An HSV PCR test was positive. Intravenous acyclovir followed by oral valacyclovir resulted in resolution of symptoms. Conclusion: Discharge from HSV cervicitis can present as nitrazine-positive pooling, imitating PPROM. A high index of suspicion is warranted, especially when the amniotic fluid volume is normal and arborization is not seen on microscopic exam.

Rh Immune Globulin After the Transfusion of RhD-Positive Blood in a Patient with a Partial D Antigen.

BACKGROUND: Patients with a serologic weak D phenotype may demonstrate variable RhD expression. We present a case in which clinical management would have been simplified if RHD genotyping had been performed previously. CASE: A 33-year-old patient, G11P4155, presented with an incomplete miscarriage and was transfused RhD-positive packed red blood cells after typing RhD-positive. The patient had been historically typed RhD-negative by a different testing methodology. Indirect antiglobulin testing was performed, which revealed a serologic weak D phenotype. The patient was given 9,600 micrograms of Rh immune globulin. Molecular testing revealed a partial D antigen, which was originally thought to be at risk for alloimmunization; however, this has since been disproven. CONCLUSION: Although not yet universal practice, prenatal RHD genotyping for partial D antigen could have prevented the characterization of this patient as RhD-positive at the time of transfusion.

Diagnosis of mid-second trimester fetal growth restriction and associated outcomes.

OBJECTIVE: To evaluate maternal and neonatal outcomes of low-risk singleton pregnancies, without underlying maternal medical conditions or genetic and fetal anomalies associated with fetal growth restriction, that were diagnosed with fetal growth restriction (FGR) (EFW < 10th %) in the mid-second trimester (between 17 and 22 weeks and 6 days' gestation). METHODS: A retrospective cohort study of all women who underwent a routine fetal anatomy ultrasound between 17 and 22 weeks and 6 days' gestation at a community-based academic hospital was performed to identify subjects with an EFW <10th%. Pregnancies with inadequate dating, multiple gestations, preexisting maternal vascular disease (chronic hypertension and pregestational diabetes), lethal fetal anomalies, and abnormal prenatal genetic screening were excluded. Descriptive statistics were computed to describe the study population. Subjects were stratified into two groups, estimated fetal weight (EFW) <5th% and EFW 5th-9th%. The primary outcome was a small for gestational age neonate (SGA) at delivery. Secondary outcomes included a composite adverse neonatal outcome, perinatal death, hypertensive disorders of pregnancy, medically indicated delivery, and mode of delivery. A comparison of the two groups, EFW <5th% and EFW 5th-9th %, was performed. Continuous variables were compared utilizing Wilcoxon Rank Sum tests and categorical variables were compared using Fisher's exact test or Chi-squared tests, and a dichotomous composite variable for adverse neonatal outcomes was also calculated. RESULTS: In total, 3,868 unique patient records were screened. Thirty-two patient records (0.8% of the total screened records) were eligible for inclusion. The primary outcome, SGA at delivery, occurred in 13/32 (41%) of the subjects. The secondary outcomes of the composite neonatal morbidity occurred in 9/32 (28%), hypertensive disorders of pregnancy in 10/32 (31%), and medically indicated delivery at <28 weeks gestation in 7/32 (22%) of the subjects. When comparing EFW <5th% and EFW 5th-9th%, EFW <5th% had a larger percentage of SGA newborns (66% vs. 25%, p = .02, OR = 8.0 95% CI 1.5-42.5). EFW <5th% was also significantly associated with a greater composite adverse neonatal outcome when compared to EFW 5th-9th% (54% vs. 10%, p = .015). The subgroup with an EFW <5th% also had higher rates of adverse outcomes including preeclampsia (42% vs. 10%, p = .073), abnormal umbilical artery Doppler studies (50% vs. 15%, p = .049), and medically indicated delivery <28 weeks (42% vs. 10%, p = .07). CONCLUSIONS: Early onset FGR is a associated with high rates of SGA at delivery, as well as several adverse maternal and neonatal outcomes which include hypertensive disorders of pregnancy, a greater composite neonatal morbidity, perinatal death, and medically indicated preterm delivery. EFW <5th% was associated with worse outcomes when compared to those with an EFW 5th%-9th%.

Change in cost after 5 years of experience with robotic-assisted hysterectomy for the treatment of endometrial cancer.

Health care costs are an important consideration in the decision of hysterectomy routes and robotic surgery is often critiqued for its high cost. We sought to compare the cost of robotic-assisted hysterectomies performed after initial acquisition of the robotic surgical system to cases performed after 5 years of experience. The first 20 patients at a community teaching hospital who underwent robotic-assisted hysterectomy for endometrial cancer by a single gynecologic oncology surgeon were designated Group 1 and 20 patients undergoing robotic hysterectomies 5 years later for the same indication were designated Group 2. Direct hospital costs were divided into operative and non-operative costs. Mean operating room cost and cost of anesthesia per minute for Group 1 were adjusted to Group 2 mean costs. Supply costs were adjusted using the 2015 Consumer Price Index. Baseline characteristics of the groups were comparable. After 5 years of experience, there was a 15.5% [95% CI (-$2865, -$407), p = 0.01] reduction in mean total costs (Group 1 = $10,543, Group 2 = $8907) and a 14.3% [95% CI (-$2378, -$390), p ≤ 0.01] reduction in mean operative costs (Group 1 = $9688, Group 2 = $8304). Significant reductions in procedure time, operating room time, operating room cost, and cost of anesthesia were seen from Group 1 to Group 2. There were no differences in mean non-operative costs, estimated blood loss, cost of supplies or surgeon cost. Experience with robotic-assisted hysterectomies is associated with reduction in costs, which is primarily a result of reduced operative times. This is an important factor when considering costs related to robotic surgery.

Intravenous fluid rate for reduction of cesarean delivery rate in nulliparous women: a systematic review and meta-analysis.

INTRODUCTION: The National Institute of Child Health and Human Development, American College of Obstetricians and Gynecologists, and Society for Maternal-Fetal Medicine have emphasized the need to promote vaginal delivery and have offered recommendations to safely prevent primary cesarean delivery. However, there has been limited discussion regarding management of intravenous fluids and other aspects of labor management that may influence mode of delivery. Therefore the aim of our study was to determine whether an intravenous fluid rate of 250 vs. 125 mL/h is associated with a difference in cesarean delivery rate. MATERIAL AND METHODS: Searches were performed in MEDLINE, OVID, Scopus, ClinicalTrials.gov, the PROSPERO International Prospective Register of Systematic Reviews, Embase, Web of Science, and the Cochrane Library for randomized controlled trials. We included all randomized controlled trials comparing intravenous fluid rates of 250 vs. 125 mL/h in nulliparous women in spontaneous labor at term with singleton pregnancies at ≥36 weeks. Studies were included regardless of the type of intravenous fluids used and regardless of whether oral intake was restricted during labor. Studies including multiparous women or women whose labor was induced were excluded. The primary outcome was the incidence of cesarean delivery. We planned to assess a subgroup analysis according to type of fluids used and according to restriction of oral fluid intake. RESULTS: Seven trials including 1215 nulliparous women in spontaneous labor at term were analyzed; 593 (48.8%) in the 250 mL/h group, and 622 (51.2%) in the 125 mL/h group. Five studies used lactated Ringer's solution, one used normal saline in dextrose water, and in one study it was unclear which intravenous fluid was used. Women who received intravenous fluids at 250 mL/h had a significantly lower incidence of cesarean delivery for any indication (12.5 vs. 18.1%; RR 0.70, 95% CI 0.53-0.92; seven studies, 1215 participants; I2 = 0%) and for dystocia (4.9 vs. 7.7%; RR 0.60, 95% CI 0.38-0.97; five studies, 1093 participants; I2 = 18%), a significantly shorter mean duration of labor of about one hour (mean difference -64.38 min, 95% CI -121.88 to -6.88; six studies, 1155 participants; I2 = 83%) and a significantly shorter mean length of second stage of labor (mean difference -2.80 min, 95% CI -4.49 to -1.10; 899 participants; I2 = 22%) compared with those who received intravenous fluid at 125 mL/h. No differences were found in the other secondary outcomes. There were no maternal or perinatal deaths and only one woman, in the 125 mL/h group, developed pulmonary edema. The findings persisted regardless of the type of intravenous fluid used. No significant reduction in the incidence of cesarean delivery was demonstrated in women with unrestricted oral intake; however, this was limited to only two studies evaluating 254 women. CONCLUSIONS: Our findings provide evidence that the duration of labor in low-risk nulliparous women may be shortened by a policy of intravenous fluids at a rate of 250 mL/h rather than 125 mL/h. A rate of 250 mL/h seems to be associated with a reduction in the incidence of cesarean delivery compared to 125 mL/h. The number needed to treat to prevent one cesarean delivery is 18 women. Our data support increased hydration among nulliparous women in labor when oral intake is restricted. Further study is needed regarding risks and benefits of increased hydration among women with unrestricted oral intake, those undergoing induction of labor, and those with medical comorbidities.

Placental α-Microglobulin-1 in Vaginal Secretions of Women with Evidence of Preterm Labor.

OBJECTIVE: To evaluate the presence of placental α-microglobulin-1 (PAMG-1) in vaginal secretions in women with symptoms of preterm labor and assess its use as a predictor of preterm birth. STUDY DESIGN: A prospective cohort study of women between 16 and 34 weeks of gestation with symptoms of preterm labor and intact membranes was conducted. The presence of PAMG-1 was determined using a commercially available kit (AmniSure, AmniSure International LLC, Boston, MA). RESULTS: A total of 100 women were enrolled, of which 86 had outcome data available. PAMG-1 was detected in 19/86 (22.1%) subjects. These women were more likely to deliver within 7 days than those without PAMG-1 detected (6/19 [31.6%] vs. 5/67 [7.5%]; odds ratio 5.6; 95% confidence interval 1.5-21.6). These findings persisted after adjusting for potential confounders. The sensitivity was 54.6%, specificity was 82.7%, positive predictive value was 31.6%, and the negative predictive was 92.5%. CONCLUSION: The presence of PAMG-1 is associated with an increased likelihood of delivery within 7 days.

Physical Examination-Indicated Cerclage: A Systematic Review and Meta-analysis.

OBJECTIVE: To estimate the effectiveness of physical examination-indicated cerclage in the setting of second-trimester cervical dilatation by systematic review and meta-analysis of published studies. DATA SOURCES: We searched MEDLINE, EMBASE, Scopus, ClinicalTrials.gov, Web of Science, and the Cochrane Library for studies published between 1966 and 2014 that evaluated cervical cerclage for the treatment of cervical insufficiency. METHODS OF STUDY SELECTION: The search yielded 6,314 citations. We included cohort studies and randomized controlled trials comparing cerclage placement with expectant management of women with cervical dilatation between 14 and 27 weeks of gestation. Two investigators independently reviewed each citation for inclusion or exclusion and discordant decisions were arbitrated by a third reviewer. Summary estimates were reported as the mean difference and 95% confidence interval (CI) for continuous variables or relative risk and with 95% CI for dichotomous outcomes. Fixed- and random-effects meta-analysis was used, depending on heterogeneity. TABULATION, INTEGRATION, AND RESULTS: Ten studies met inclusion criteria and were included in the final analysis. One was a randomized controlled trial, two were prospective cohort studies, and the remaining seven were retrospective cohort studies. Of the 757 women, 485 (64%) underwent physical examination-indicated cerclage placement and 272 (36%) were expectantly managed. Cerclage was associated with increased neonatal survival (71% compared with 43%; relative risk 1.65, 95% CI 1.19-2.28) and prolongation of pregnancy (mean difference 33.98 days, 95% CI 17.88-50.08). CONCLUSION: Physical examination-indicated cerclage is associated with a significant increase in neonatal survival and prolongation of pregnancy of approximately 1 month when compared with no such cerclage. The strength of this conclusion is limited by the potential for bias in the included studies.

The relationship between previous treatment for cervical dysplasia and preterm delivery in twin gestations.

OBJECTIVE: To describe the impact of previous cervical surgery on preterm birth prior to 34 weeks in twins. METHODS: A retrospective review of twin pregnancies delivered between January 1998 and December 2005 at two institutions was performed. Women with a prior cold knife cone (CKC), loop electrosurgical excision procedure (LEEP), or ablative procedure were compared to a control group of women who had not undergone a previous treatment for cervical dysplasia. The primary outcome was delivery before 34 weeks of gestation. RESULTS: A total of 876 women met inclusion criteria. Of these, 110 (12.6%) had previous surgical procedures for cervical dysplasia, including CKC (n = 10), LEEP (n = 36), cryotherapy (n = 59) and CO2 laser treatment (n = 5). Delivery prior to 34 weeks was more common in women with a previous CKC compared to women with no prior treatment (40% versus 11.3%; odds ratio [OR], 3.6; 95% confidence interval [CI], 1.7-8.0). Delivery prior to 34 weeks was not more common in women with a previous LEEP (8.3%; OR, 0.8; 95% CI, 0.3-2.3) or ablative procedure (9.4%; OR, 0.9; 95% CI, 0.4-1.9) in comparison to the untreated group. Adjusting for the potential confounders of age, tobacco use, infertility treatments and previous preterm birth did not change the results. CONCLUSIONS: Previous CKC is associated with delivery prior to 34 weeks while LEEP and ablative procedures are not. CKC should be carefully considered and avoided when possible in reproductive age women.

Cabergoline therapy for Cushing disease throughout pregnancy.

BACKGROUND: Cushing disease during pregnancy is rare and is associated with significant maternal and fetal morbidity and mortality. Transsphenoidal pituitary surgery is the first-line therapy; however, in cases of failed surgery or in patients who are not surgical candidates, medical therapy has been used to control symptoms. CASE: A 29-year-old woman with Cushing disease and a noncurative transsphenoidal pituitary surgery was successfully treated with cabergoline, a dopamine agonist. After approximately 1 year of therapy, she became pregnant. She was maintained on high-dose cabergoline throughout her pregnancy and had an uncomplicated antenatal course. She went into spontaneous labor at 38 weeks of gestation and delivered a healthy female neonate. CONCLUSION: Cabergoline can be used to manage Cushing disease successfully during pregnancy with an opportunity for a favorable outcome.

Nitric oxide and carbon monoxide production and metabolism in preeclampsia.

OBJECTIVE: To elucidate the regulation of the nitric oxide (NO) and carbon monoxide (CO) pathways in preeclampsia and to evaluate the ratio of asymmetric dimethylarginine (ADMA) to symmetric dimethylarginine (SDMA) as a marker for preeclampsia. METHODS: Maternal plasma and placental samples were obtained from 20 participants with preeclampsia and 23 controls. Enzyme-linked immunosorbent assay was used to measure plasma NO, ADMA, and SDMA as well as placental NO and hemeoxygnase 1 (HO-1). Western blot was used to measure placental dimethylarginine dimethylaminotransferases (DDAH-I and DDAH-II). RESULTS: Placental DDAH-I, placental DDAH-II, placental NO, and placental HO-1 were significantly decreased in participants with preeclampsia. While ADMA and SDMA levels were decreased in preeclampsia, the ADMA-SDMA ratio was not significantly different. CONCLUSIONS: Decreased DDAH and HO with preeclampsia suggest that they are important points in the regulatory pathways of NO and CO production that are altered in preeclampsia. The ADMA-SDMA ratio is not a useful test for preeclampsia.

Prenatal diagnosis of a paraurethral cyst.

Paraurethral cysts arising from Skene's gland are a rare cause of urogenital masses in the neonate. We report the case of a pelvic mass noted at the vaginal introitus on prenatal ultrasound that following delivery was found to be a paraurethral cyst. On prenatal ultrasound, there was no evidence of involvement of the urinary, gastrointestinal, or upper genital tract. Serial ultrasounds demonstrated slight enlargement of the cyst without other changes. The patient delivered at 33 weeks and postnatal evaluation demonstrated a paraurethral cyst. The cyst was managed expectantly and drained spontaneously on the second day of life with complete resolution.

Mode of delivery and neonatal outcomes in preterm, small-for-gestational-age newborns.

OBJECTIVE: To compare neonatal outcomes by method of delivery in preterm (34 weeks of gestation or prior), small-for-gestational-age (SGA) newborns in a large diverse cohort. METHODS: Birth data for 1995-2003 from New York City were linked to hospital discharge data. Data were limited to singleton, liveborn, vertex neonates delivered between 25 and 34 weeks of gestation. Births complicated by known congenital anomalies and birth weight less than 500 g were excluded. Small for gestational age was used as a surrogate for intrauterine growth restriction. Associations between method of delivery and neonatal morbidities were estimated using logistic regression. RESULTS: Two thousand eight hundred eighty-five SGA neonates meeting study criteria were identified; 42.1% were delivered vaginally, and 57.9% were delivered by cesarean. There was no significant difference in intraventricular hemorrhage, subdural hemorrhage, seizure, or sepsis between the cesarean delivery and vaginal delivery groups. Cesarean delivery compared with vaginal delivery was associated with increased odds of respiratory distress syndrome. The increased odds persisted after controlling for maternal age, parity, ethnicity, education, primary payer, prepregnancy weight, gestational age at delivery, diabetes, and hypertension. CONCLUSION: Cesarean delivery was not associated with improved neonatal outcomes in preterm SGA newborns and was associated with an increased risk of respiratory distress syndrome.

Twin versus singleton pregnancies complicated by preterm premature rupture of membranes.

OBJECTIVE: To compare latency period, infectious morbidity, neonatal morbidity and neonatal mortality in twin versus singleton pregnancies complicated by preterm premature rupture of membranes (PPROM) remote from term. METHODS: A retrospective, matched cohort study comparing 41 twin and 82 singleton pregnancies complicated by PPROM between 24-0/7 and 31-6/7 weeks' gestation. The data were obtained by reviewing maternal and neonatal charts. RESULTS: The median latency periods were 3.6 days (interquartile range 1.5-13.9 days) for twins and 6.2 days (interquartile range 2.9-11.8 days) for singletons (p = 0.86). Twins were less likely to be complicated by clinical chorioamnionitis when compared with singletons (4/41 [9.8%] vs. 19/82 [23.2%], relative risk [RR] 0.42, 95% confidence interval [CI] 0.18-0.96). Histological evidence of chorioamnionitis was also lower in twins compared with singletons (14/39 [35.9%] vs. 46/68 [67.7%], RR 0.56, 95% CI, 0.34-0.92). These differences persisted after adjusting for race, insurance status, latency period and route of delivery. Neonatal morbidity and mortality rates were similar between the two groups. CONCLUSIONS: There was not a statistically significant difference in the latency periods for twin and singleton pregnancies complicated by PPROM. Clinical chorioamnionitis and histological evidence of infection were significantly less common in twins compared with singletons.

Epidural analgesia for treatment of a sickle cell crisis during pregnancy.

BACKGROUND: More than 50% of obstetric patients with sickle cell disease will have a pain crisis during pregnancy, and the management of these cases can be challenging. CASE: A 20-year-old African American with sickle cell disease presented at 29 4/7 weeks of gestation with severe, debilitating leg and back pain. Large doses of intravenous narcotics did not result in significant pain relief, so a lumbar epidural was placed. This resulted in complete pain relief within several minutes. The patient's symptoms resolved over several days and after a short course of narcotics she was discharged to home, and the remainder of her pregnancy was uncomplicated. CONCLUSION: Epidural anesthesia should be considered as a potentially effective treatment for a severe sickle cell crisis in obstetric patients.

Herpes simplex and HIV infections and preterm PROM.

Maternal human immunodeficiency virus (HIV) and genital herpes simplex virus (HSV) infection in pregnancy have potential for vertical transmission that may result in death or morbidity. The risk increases with preterm delivery and prolonged ruptured membranes. When managing preterm premature rupture of membranes, the risk of transmission must be weighed against the risk of prematurity. Before 32 to 34 weeks, expectant management is preferred for patients with well controlled HIV or recurrent active genital HSV infection. For patients with advanced HIV disease or primary genital HSV infection, the risk of vertical transmission is higher and many clinical factors need to be considered.

A randomized, double-masked trial of prophylactic indomethacin tocolysis versus placebo in women with premature rupture of membranes.

Preterm premature rupture of membranes (PPROM) complicates 3% of pregnancies and frequently results in preterm birth, often within 48 hours of membrane rupture. Our objective was to determine if subjects with PPROM between 24 and 31 (6)/ (7) weeks' gestation benefit from a 48-hour course of prophylactic indomethacin tocolysis. This was a double-masked randomized controlled trial. Subjects with PPROM between 24 and 31 (6)/ (7) weeks' gestation were randomized to receive indomethacin or placebo for 48 hours in addition to corticosteroids and latency antibiotics. The primary outcome of the study was delivery within 48 hours. Maternal and neonatal outcomes were also compared. This study was concluded prematurely due to slow accrual after a total of 50 subjects were enrolled. A total of 23/25 (92%) subjects in the indomethacin group remained pregnant beyond 48 hours compared with 20/22 (90.9%) in the placebo group (relative risk, 1.01; 95% confidence interval, 0.84 to 1.21). The latency period medians and interquartile ranges were similar between the two groups [indomethacin 193 (92 to 376.5) hours versus placebo 199 (77.5 to 459) hours, P = 0.91], and no differences were noted in any maternal or neonatal secondary outcomes. This limited study demonstrates no benefit with the use of prophylactic indomethacin tocolysis for women with PPROM.

Rudimentary horn pregnancy with herniation into the main uterine cavity.

We report a case of a rudimentary horn pregnancy with herniation of a fetal arm and umbilical cord into the main uterine cavity that presented as an incidental finding on a routine second-trimester ultrasound scan. We also review the literature that guides the diagnosis and management of these rare complicated pregnancies.

Limitations of ADAMTS-13 activity level in diagnosing thrombotic thrombocytopenic purpura in pregnancy.

In pregnancy, it may be difficult to differentiate the syndrome of hemolysis, elevated liver enzymes, and low platelets from thrombotic thrombocytopenia purpura. Severely depressed (<5%) or absence of a disintegrin and metalloproteinase with thrombospondin motifs-13 activity levels are associated with thrombotic thrombocytopenia purpura and mildly decreased levels are associated with other disease processes, including pre-eclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. We present a case of a patient that presented at 20 weeks gestation with elevated liver enzymes and thrombocytopenia. The diagnosis was unclear at the time of presentation. She underwent induction of labor, and during the postpartum course, she was eventually diagnosed with thrombotic thrombocytopenia purpura; however, her activity level of a disintegrin and metalloproteinase with thrombospondin motifs-13 was only moderately depressed at 15% (normal pregnancy value 41%-105%).

A retrospective review of ampicillin-sulbactam and amoxicillin + clavulanate vs cefazolin/cephalexin and erythromycin in the setting of preterm premature rupture of membranes: maternal and neonatal outcomes.

OBJECTIVE: The purpose of this study was to compare the efficacy and outcomes of 2 different antibiotic regimens that are used to prolong latency in preterm premature rupture of membranes. The primary objective was to determine whether the use of ampicillin-sulbactam/amoxicillin + clavulanate was associated with an increased risk of necrotizing enterocolitis. STUDY DESIGN: A retrospective review of pregnancies that were complicated by preterm premature rupture of membranes from 1999-2006 at 2 institutions was performed. Outcomes were compared between subjects who received parenteral ampicillin-sulbactam followed by oral amoxicillin + clavulanate (protocol A) and subjects who received parenteral cefazolin and erythromycin followed by oral cephalexin and erythromycin (protocol B). RESULTS: There were 147 women who were evaluated; 88 women received protocol A, and 59 women received protocol B. There were no differences in latency period, gestational age at delivery, or route of delivery. The incidence of necrotizing enterocolitis was 8.0% and 10.2% for protocol A and protocol B, respectively (P = .64). CONCLUSION: Ampicillin-sulbactam/amoxicillin + clavulanate was not associated with an increase in neonatal necrotizing enterocolitis. Erythromycin in combination with cefazolin and cephalexin is an effective latency antibiotic regimen.