Prospective study of infantile haemangiomas: incidence, clinical characteristics and association with placental anomalies.

BACKGROUND: The aetiology and exact incidence of infantile haemangiomas (IHs) are unknown. Prior studies have noted immunohistochemical and biological characteristics shared by IHs and placental tissue. OBJECTIVES: We investigated the possible association between placental anomalies and the development of IHs, as well as the demographic characteristics and other risk factors for IHs. PATIENTS AND METHODS: Pregnant women (n = 578) were prospectively enrolled and their offspring followed for 9 months. Placental evaluations were performed and demographic data collected on all mother-infant pairs. RESULTS: We evaluated 594 infants: 34 haemangiomas [either IH or congenital (CH)] were identified in 29 infants, yielding an incidence of 4·5% for IH (27 infants) and 0·3% for CH (two infants). Placental anomalies were noted in almost 35% of haemangioma-related pregnancies, approximately twice the incidence noted in pregnancies with unaffected infants (P = 0·025). Other risk factors for IH included prematurity (P = 0·016) and low birth weight (P = 0·028). All IHs were present by 3 months of age, and cessation of growth had occurred in all by 9 months of age. Most occurred on the trunk. Of note, 20% of identified IHs were abortive or telangiectatic in nature, small focal lesions that did not proliferate beyond 3 months of age. Only one IH required intervention. CONCLUSIONS: This is the first prospective American study to document the incidence of IHs in infants followed from birth to early infancy. The association with placental anomalies was statistically significant. The overall incidence mirrors prior estimates, but the need for treatment was lower than previously reported.

External cephalic version: predictors of success.

OBJECTIVE: To evaluate predictive variables for successful external cephalic version. METHODS: During 1987-1996, 128 women had external cephalic version attempts. Uterine tone, fetal spine position, breech location, breech type, gestational age, placental location, parity, maternal weight, amniotic fluid index, and estimated fetal weight were evaluated as predictors of success. RESULTS: Seventy-eight (64%) women were successfully converted from breech to vertex presentation. All subjects with low uterine tone had successful version. In women with high uterine tone, the combination of anterior or lateral fetal spine, noncornual placental location, and breech location out of the pelvis predicted success. Other independent variables associated with successful version included non-frank breech presentation, gestational age under 38 weeks, and parity of at least 1. CONCLUSION: Uterine tone may be the most important predictor of success when selecting candidates for external cephalic version.

Respiratory arrest during therapy for premature labor in a patient with myasthenia gravis.

A case of premature labor in a woman whose pregnancy was complicated by myasthenia gravis is presented. Ritodrine was given for tocolysis, and betamethasone was administered to accelerate fetal lung maturation. An acute, life-threatening exacerbation of muscular weakness requiring intubation and mechanical ventilation occurred. It appears that betamethasone initiated the respiratory crisis. It is apparent, however, that tocolytic agents currently being used in patients with premature labor (namely, beta-2-sympathomimetics and magnesium sulfate) also have the potential to produce severe exacerbations of weakness, and even respiratory arrest in patients with myasthenia gravis. Each must be used with extreme caution if prescribed for women with this disorder.

Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes.

OBJECTIVE: To describe causes, courses, complications, and outcomes of patients with pregnancy-associated acute respiratory distress syndrome (RDS). METHODS: Twenty-eight women with ARDS during pregnancy or within a week postpartum formed the study population. Eight cases had been reported previously. Charts were abstracted for maternal demographics, etiology, and treatment of acute RDS, and maternal outcomes. For antepartum acute RDS, newborn charts were also reviewed. RESULTS: The incidence of acute RDS, excluding maternal transports, was one per 6277 deliveries or 0.016% (95% confidence interval [CI] 0, 0.027%). Leading causes were infection (12 cases), preeclampsia or eclampsia (seven cases), and aspiration (three cases). Eleven mothers died, a maternal mortality rate of 39.3% (CI 21.5%, 59.4%). Six of eight women who were ventilated for over 14 days survived. Nine of the acute RDS cases might have been preventable. Ten mothers with living fetuses were ventilated during the third trimester; nine delivered within 4 days. Among six infants delivered because of fetal heart rate abnormalities, one died and at least three had evidence of asphyxia. CONCLUSIONS: Acute RDS occurs more frequently in pregnancy than the 1.5 cases per 100,000 per year reported for the general population. Prolonged ventilator support is warranted. The high rate of perinatal asphyxia in infants who have fetal heart rate abnormalities supports a strategy of expeditious delivery during the third trimester.

New approaches to the management of acute puerperal uterine inversion.

Six cases of acute puerperal inversion of the uterus are reported. In four of these, tocolytic agents were used to facilitate replacement of the inverted uterus; and in five, Prostin-15M was given after replacement. The use of tocolytics may obviate the need for general anesthesia for uterine replacement in some patients with uterine inversion. Prostin-15M serves to minimize bleeding and to maintain uterine position after replacement.

Monoamniotic and pseudomonoamniotic twins: sonographic diagnosis, detection of cord entanglement, and obstetric management.

OBJECTIVE: To assess accuracy of detecting cord entanglement in monoamniotic twins, and to describe perinatal outcomes with aggressive obstetric management. METHODS: Seven nonconjoined monoamniotic twin pregnancies and one pseudomonoamniotic twin pregnancy were diagnosed sonographically and evaluated with serial scans and cardiotocography. In the absence of other indications, patients were delivered by elective cesarean on demonstration of lung maturity at or beyond 32 weeks' gestation. RESULTS: Cord entanglement was diagnosed correctly in four pregnancies, missed in one, and excluded correctly in three. Four pregnancies were delivered after demonstration of pulmonary maturity, three because of premature rupture of membranes or uncontrollable preterm labor, and one because of fetal heart rate abnormality during tocolysis for preterm labor. The mean gestational age at delivery was 33.2 +/- 1.6 weeks, with birth weight 2011 +/- 262 g; all neonates were live-born. Newborn stays averaged 12.0 +/- 5.8 days for the eight neonates delivered electively. CONCLUSION: Monoamniotic twin pregnancies and cord entanglement in such twins were diagnosed reliably by ultrasound. Abnormal tracings prompting cesarean delivery occurred in two of the five pregnancies with cord entanglement. Amniocentesis reflected pulmonary maturity of both twins in all pregnancies so assessed, and delivery after 32 weeks' gestation, with lung maturity, resulted in good perinatal outcomes. Statistical validity of these findings is limited by our small sample size.

A comparison of attitudes and practices of episiotomy among obstetrical practitioners in New Mexico.

The routine use of episiotomy is a subject of considerable controversy. To delineate attitudes and practices, we surveyed various groups of obstetrical practitioners in New Mexico. Routine use was favored most by obstetricians, less by family practitioners, less yet by nurse midwives and least by lay midwives. Many of the reasons given both for and against routine use were the same, underscoring the lack of scientific data and prospective studies of episiotomy and its effects.

Adult respiratory distress syndrome in pregnancy: report of three cases and review of the literature.

Adult respiratory distress syndrome (ARDS) is rarely encountered in association with pregnancy, but with the decline in other causes of maternal death, is an increasingly important cause of mortality in obstetric patients. ARDS may result from a variety of different types of pulmonary injury; uniquely obstetric causes include preeclampsia, amnionitis-endometritis, obstetric hemorrhage, and tocolytic therapy. Crucial management issues include support of maternal oxygenation and cardiac output, myriad interactions between the pulmonary process and its treatment, with maternal and fetal physiology, and decision making regarding delivery. Our review of the literature suggests that, for the patient requiring antepartum intubation for ARDS, except at a very early gestational age or when pyelonephritis or varicella pneumonia is a cause of respiratory compromise, delivery will likely be required for maternal and/or fetal indications, and an early decision for delivery may be beneficial. Postpartum management is similar to treatment of the nonpregnant patient with ARDS, with aggressive attention to potential surgically correctable causes for infection. Maternal mortality rates are affected little by duration of intubation, and therefore prolonged mechanical ventilation is justified and appropriate for mothers with ARDS.

Acute leukemia and pregnancy: a review of management and outcome, 1972-1982.

Acute leukemia is a rare complication of pregnancy. Previous reviews that covered cases reported before the introduction of effective combination chemotherapy found fewer than 300 reported pregnancies, with a 36-69 per cent perinatal mortality and median maternal survival, from diagnosis, of less than 6 months. Advances in the fields of hematology-oncology, maternal-fetal medicine, and neonatology have resulted in a marked improvement in both perinatal survival statistics, and median maternal survival. Since 1972, there have been 14 pregnancies reported in patients cured of acute lymphocytic leukemia, with 1 early spontaneous abortion and 13 term infants. All mothers survived. There have been 47 reports of pregnancy in association with acute leukemia. In 40 pregnancies in which acute leukemia was treated, there were 5 abortions, 3 perinatal demises, 1 infant "liveborn in grave condition," and 31 surviving infants. Median maternal survival was at least 6, and possibly more than 12 months from delivery. In seven cases in which leukemia was untreated, there were one abortion, two perinatal demises, and four living infants; only one of six mothers survived beyond 6 months. Here, a case of pregnancy complicated by acute promyelocytic leukemia is presented. The mother was aggressively treated with combination chemotherapy. The fetus was closely monitored and delivered following a course of betamethasone at 34 weeks' gestation, and had no neonatal problems. The mother expired 13 months status-post bone marrow transplantation, 16 months after delivery. Cases of pregnancy complicated by acute leukemia reported in the period 1972-1982 are reviewed, and management is discussed in detail. Aggressive hematologic and obstetric management is advocated, and should result in further improvements in fetal and maternal outcome.

Ovarian vein thrombosis during cesarean section. A report of two cases.

BACKGROUND: Puerperal ovarian vein thrombosis occurs in 0.2-0.5% of deliveries. It is usually thought to result from infection, but it has been hypothesized that thrombosis may occur as a primary event, and radiologic studies raise the possibility that ovarian vein thrombosis may occur quite frequently. CASES: Case 1 had right ovarian vein thrombosis diagnosed at the time of nonemergency cesarean section for placenta previa. This was treated with ligation of the infundibulopelvic ligament above the level of the clot. Subsequent magnetic resonance imaging showed contralateral ovarian vein thrombosis, and therefore anticoagulant therapy was begun. The patient was asymptomatic. Case 2 had right ovarian vein thrombosis extending to the inferior vena cava diagnosed at elective repeat cesarean section. She was heparinized in the recovery room; subsequent ventilation/perfusion scan showed a probable pulmonary embolism. Both patients recovered uneventfully. CONCLUSION: These two cases demonstrate that ovarian vein thrombosis may occur as a primary event, in the absence of infection, and result in pulmonary embolism. Individualized management based on operative findings is recommended.

Computer consultation in neurology: subjective and objective evaluations of the "NEUROLOGIST" system.

NEUROLOGIST is a computer system for clinical consultation in neurology. The system's strategy is patterned after the 'localize first' paradigm of the expert neurologist. The system gives explanations of its conclusions, including drawings of neurologic lesions. It currently covers 130 diagnoses and is readily expandable. In this paper the NEUROLOGIST system is described and results of objective and subjective evaluations are presented and discussed. Directions for improvement and expansion of the present system are outlined.

Anesthetic management of a pregnant woman with Gorham-Stout disease.

Gorham-Stout disease is a rare disorder of bone loss and proliferation of lymphatic and vascular tissue (lymphangiomatosis). A 30-year-old nulliparous woman with Gorham-Stout disease presented at 8weeks of gestation with a fused cervical spine. At 31weeks she developed basilar invagination and neurological symptoms that were managed with a neck brace. Anesthetic considerations were those of airway compromise, development of severe preeclampsia and Kasabach-Merritt coagulopathy. Elective tracheostomy was declined. She presented two days before a planned cesarean delivery at 35weeks in preterm labor. A semi-urgent cesarean delivery under spinal anesthetic proceeded uneventfully, with an otolaryngologist present in case a surgical airway was required. Mother and baby were discharged home after three days. Maternal postpartum recovery was complicated by episodes of respiratory compromise and critical bone loss in the cervical spine, necessitating further surgical reinforcement.

Targeted mid-trimester ultrasound examination: how does fetal anatomic visualization depend upon the duration of the scan?

OBJECTIVE: To determine the relationship between visualization of key fetal anatomic structures during mid-trimester ultrasound examination with gestational age and duration of examination. METHODS: One hundred ultrasound examinations at 16-22 weeks' gestation were reviewed to determine the times at which key fetal anatomic features were seen. Scans were terminated at 30 min or when a comprehensive anatomic survey was complete. Exclusion criteria included multiple gestation, maternal weight>77 kg, abdominal wall scarring, and suspected fetal anomalies. RESULTS: Visualization of cranial anatomy including lips, face, midline, ventricles, choroid plexus, and cerebellum was achieved in 98% of patients within 30 min. The corresponding figures for spine, cardiac screening (four-chamber, aortic, and pulmonary outflow views) and for abdominal anatomy (stomach, kidneys, bladder, ventral wall, and three-vessel cord) were 91%, 91%, and 99%, respectively. A complete anatomic survey including each of the above elements was obtained by 10, 15, 20, 25, and 30 min in 8%, 31%, 53%, 72% and 81% of the subjects. Rates of complete anatomic surveys within 30 min improved by gestational age interval, from 20/30 (67%) at 16-18 weeks, to 36/44 (82%) at 18-20 weeks, and 25/26 (96%) at 20-22 weeks; this rise was primarily due to improvements in visualization of the spine and heart. CONCLUSIONS: A comprehensive anatomical survey can be completed in 10 min or less in a minority of patients. For each 5-min time increment up to 30 min, the rate of complete surveys improves. Rates of completed anatomic surveys rise with gestational age.

FMTUTOR: a computer-aided instructional system for teaching fetal monitor interpretation.

FMTUTOR is a computer program for instruction in the interpretation of fetal monitor recordings. The system runs on IBM-PC-compatible microcomputers and uses text and computer graphics to illustrate and reinforce important concepts. By means of a 2-hour introductory tutorial session and generation and guided interpretation of an unlimited variety of tracings, it simulates one-on-one instructor-student interactions and allows rapid accumulation of a store of information and experience in monitor tracing interpretation. FMTUTOR is currently used to teach third- and fourth-year medical students at the University of New Mexico. Acceptance has been enthusiastic, and development of more advanced instructional systems targeting nurses, residents, and obstetricians is underway.

Prophylactic intramyometrial carboprost tromethamine does not substantially reduce blood loss relative to intramyometrial oxytocin at routine cesarean section.

The influence of intramyometrial injection of 125 micrograms of 15-s-15-methyl prostaglandin F2 alpha (carboprost tromethamine, Prostin/15M) versus 20 U of oxytocin immediately after delivery of placenta on blood loss at cesarean section was investigated by means of a double-blinded, randomized trial. Hematocrit decrease from the day before operation to the third postoperative day was used as an index of blood loss. Decreases in hematocrit were comparable for the oxytocin and carboprost tromethamine groups. Excess blood loss (hematocrit decrease more than 6 vol. %) was significantly associated with the indication for cesarean section (three of four for cephalopelvic disproportion versus 9 of 42 others, p less than 0.01), but not with age, parity, number of prior cesarean sections, or birthweight. Carboprost tromethamine does not appear to be more effective than oxytocin when given by intramyometrial injection at this dose for routine cesarean section; its prophylactic utility in higher doses or in cases at risk for hemorrhage from uterine atony remains to be investigated.