Hepatitis B virus serology in pregnant women: transmittal of results from obstetricians to pediatricians in California.

From late 1992 to early 1993, in order to assess the knowledge, attitudes and practice patterns of California obstetricians regarding hepatitis B virus screening of pregnant women and how maternal hepatitis B virus serologies are communicated by obstetricians to pediatricians, we mailed questionnaires to a random sample of 801 California obstetricians and 1030 California pediatricians. Response rates were 65.7% (526) for obstetricians and 71% (732) for pediatricians. Although 99.8% of the surveyed obstetricians indicated that they routinely screened all pregnant women for hepatitis B virus, their knowledge of the correct screening tests to order and their interpretation was mixed. Only 56.3% (95% confidence interval, 51.2 to 61.2) were aware of the California law and approximately 12% did not understand that it mandated universal screening of pregnant women. There was a great difference of opinion between obstetricians and pediatricians regarding how to communicate hepatitis B virus serology results on the mother. Forty-nine percent of obstetricians report that they always request the nurse to inform the pediatrician (48.6%), 51.2% always verbally inform the pediatrician, 39.1% always place an order in the mother's chart and 5.7% always send a letter to the pediatrician. In contrast only 12.9% of pediatricians responded that they always received maternal hepatitis B virus serology results from the obstetrical or nursery nurse, only 2.6% always received a verbal communication from the obstetrician, 14.1% always retrieved it from a written report in the mother's chart and 4.2% reported that they always received a letter from the obstetrician. A uniform system should be adopted to ensure efficient transmission of maternal hepatitis B serology results from obstetricians to pediatricians to ensure prompt treatment to prevent vertical transmission of hepatitis B.

Aloe vera dermal wound gel is associated with a delay in wound healing.

We evaluated the time interval required for wound healing using a standard wound management protocol with and without aloe vera gel. Twenty-one women were studied who had wound complications requiring healing by second intention after cesarean delivery or laparotomy for gynecologic surgery. Wounds treated with standard management healed in a mean (+/- SD) time interval of 53 +/- 24 days, whereas those treated with aloe vera gel required 83 +/- 28 days (P = .003). The use of aloe vera dermal wound gel was associated with a significant delay in wound healing compared with treatment with an otherwise identical regimen that did not include aloe vera.

Rubeola during pregnancy.

We report three cases of rubeola during pregnancy complicated by pneumonia. All had bacterial superinfection of the lungs and a clinically mild hepatitis. One woman delivered at term and two underwent successful tocolysis, one of whom had an unexplained stillbirth 7 weeks later. Rubeola virus is not a teratogen, although it has been associated with increased spontaneous abortion and perinatal mortality.

Transient ischemic attack: a complication of mitral valve prolapse in pregnancy.

A case of transient ischemic attack presumably due to cardiogenic thromboembolism during pregnancy is described in a 32-year-old woman. The patient had documented mitral valve prolapse which was uncomplicated until this episode. This is the first report in the literature of such a complication during pregnancy. The clinical management is described.

Use of the peripherally inserted central catheter for parenteral nutrition during pregnancy.

BACKGROUND: Parenteral nutrition is required during pregnancy to treat hyperemesis gravidarum and other conditions in which enteral intake is inadequate. We describe the peripherally inserted central catheter. The catheter is inserted into the antecubital vein using local analgesia, thus eliminating some of the risks associated with obtaining central venous access. CASE: Three pregnant patients required parenteral nutrition for refractory hyperemesis gravidarum. The peripherally inserted central catheter was successfully placed, and central venous administration of hyperosmolar solutions was accomplished without complication for periods of 28-137 days. Maternal weight gain and fetal growth were adequate. CONCLUSIONS: The peripherally inserted central catheter avoids some of the risks related to obtaining central venous access and permits long-term administration of parenteral nutrition into the central venous circulation.

Cardiac tamponade in pregnancy during central hyperalimentation.

Cardiac tamponade from central venous catheterization occurs in less than 1% of cases. This report describes the first case of cardiac tamponade associated with total parenteral nutrition during pregnancy. Cardiac tamponade with subsequent nutrition during pregnancy. Cardiac tamponade with subsequent cardiac arrest occurred on the seventh day of central hyperalimentation for hyperemesis gravidarum. Maternal cardiopulmonary resuscitation was accomplished after pericardiocentesis, but maternal brain death and fetal death occurred. Diagnostic and therapeutic issues unique to cardiac tamponade during pregnancy are discussed.

Comparison of culture for group B streptococcus versus enzyme immunoassay and latex agglutination rapid tests: results in 250 patients during labor.

Two hundred fifty women in labor were screened for vaginal colonization by group B streptococcus using standard culture and two rapid tests. This primarily Hispanic population had a group B streptococcus vaginal colonization rate of 2.4% (95% confidence interval 0.9-5.2%) for the patients sampled. An enzyme immunoassay and a latex agglutination test for group B streptococcus antigen both had sensitivities of 33% and had specificities of 99 and 95%, respectively, when compared with culture. Neither rapid test appeared to be clinically useful for detecting colonized women in labor, although both can be useful in excluding colonization.

Pyomyoma associated with polymicrobial bacteremia and fatal septic shock: case report and review of the literature.

case of fatal septic shock due to pyomyoma (suppurative leiomyoma of the uterus) is reported. This unusual cause of sepsis and polymicrobial bacteremia should be rapidly identified because surgical therapy is essential for cure. Nine additional cases reported since 1945 are reviewed. Pyomyoma develops in association with either recent pregnancy or in postmenopausal patients who frequently have underlying vascular disease. The triad of: 1) bacteremia or sepsis; 2) leiomyoma uteri; and 3) no other apparent source of infection should suggest the diagnosis of pyomyoma.

Group B streptococcus: the effectiveness of screening and chemoprophylaxis.

Although antepartum screening for Group B Streptococcus is not ideal, it may be the most practical approach until rapid tests are proven to be useful in this clinical setting. The efficacy has been established for intrapartum chemoprophylaxis with a penicillin antibiotic of patients with a positive antepartum culture. There is evidence that supports the concept for selective intrapartum chemoprophylaxis in some populations. Intrapartum chemoprophylaxis prevents maternal morbidity. Rapid tests for intrapartum diagnosis of Group B streptococcus colonization appear promising, providing results are available in time for therapy to be administered before delivery.

Congenital depression of the fetal skull.

One hundred forty-seven cases of congenital skull depression are analyzed, including two presented by the authors, and a review of the literature follows. A management plan emphasizing a conservative approach is outlined.

Massive fetomaternal hemorrhage and fetal death: are they predictable?

OBJECTIVE: To report the incidence of massive fetomaternal hemorrhage (FMH) associated with fetal death and to test the hypothesis that FMH is more likely to occur in those with risk factors for FMH. STUDY DESIGN: All cases of fetal death of infants weighing > 500 gm between January 1, 1990 and December 31, 1994 were reviewed for evidence of massive FMH (> or = 2% fetal cells in the maternal circulation as measured by the Betke-Kleihauer test). Women with risk factors were compared with those without risk factors with respect to the occurrence of massive FMH. RESULTS: The prevalence of massive FMH was 14 of 319 (4.4%) cases, occurring in 4 of 102 (3.9%) of those with risk factors and 10 of 217 (4.6%) of patients without risk factors (p = 0.78). Otherwise unexplained fetal death was associated with massive FMH in 5 of 141 (3.5%). Major fetal anomalies were present in 5 of 14 (35.7%) cases of massive FMH. CONCLUSION: Clinical risk factors do not predict an increased likelihood of massive FMH. Massive FMH is associated with fetal anomalies. Betke-Kleihauer testing should be performed in all cases of fetal death, including those with anomalies regardless of the presence or absence of risk factors for FMH.

Management of burn injuries during pregnancy.

Burns suffered during pregnancy is rare and can be a devastating injury. The presence of a fetus creates many special maternal physiological changes, and the burn wound places additional great stress on systems that are already highly modified. Most of the literature has come from developing countries, and most reports from developed countries have come before 1980 and do not reflect the current standard of care. We have compiled a retrospective review of eight patients burned during pregnancy. The total body surface area (TBSA) burned ranged from 1 to 85% in these patients, and all survived the injury. All patients gave birth to healthy children except the most severely burned patient, whose child suffers from cerebral palsy. Based on our experience as well as a review of the literature, management recommendations are proposed. These include: (1) early pregnancy test for all female patients of childbearing age, (2) prompt and aggressive fluid resuscitation, (3) early supplemental oxygen and low threshold for mechanical ventilatory support, (4) early delivery of the fetus if the pregnancy is in the third trimester, and (5) high suspicion for venous thrombosis and sepsis, with early and aggressive treatment.

Intrauterine manometry: reapplication of an old concept.

Electronic fetal heart rate and uterine activity monitoring during labor requires expensive equipment and a source of electricity. However, it is not available to most of the women in the world. Intrauterine manometry provides a method which can be employed in underdeveloped settings to assess uterine contractions and to time auscultation. The vertical column of fluid in a standard intrauterine pressure catheter (IUPC) correlated well (R = 0.93) with the intrauterine pressure measurements obtained by a standard IUPC/pressure transducer system. Intrauterine manometry provides an alternative measure of uterine tone which may be employed in underdeveloped areas.

Fetal distress associated with the anticardiolipin antibody and a history of intrauterine fetal demise. A case report.

A woman with a history of fetal demise, an elevated anticardiolipin antibody titer, lupus anticoagulant but no evidence of systemic lupus erythematosus received anticoagulation with heparin in adjusted subcutaneous doses. Daily fetal monitoring demonstrated reactive nonstress tests and normal biophysical profiles initially. At 30 weeks' gestation, however, repeated spontaneous decelerations developed, and fetal bradycardia necessitated delivery. The combination of a poor obstetric history and the presence of high cardiolipin antibody titers requires close fetal surveillance. The benefits of anticoagulation in this setting deserve further study.

Could the fasting plasma glucose assay be used to screen for gestational diabetes?

The fasting plasma glucose assay was compared with the one-hour post-glucose test as a screening test for identification of gestational diabetes. Of 4,561 consecutive patients screened with a 50-g glucose test, 968 (21.2%) had results > or = 135 mg/dL; 141 (14.6%, or 3.1% of the total) were found to have diabetes. In the 968 patients, the area under the fasting plasma glucose receiver operating characteristic curve was greater than that under the glucose screening test curve, indicating greater discriminatory value of the former test. Of the 116 patients who had sequential glucose screening tests and fasting plasma glucose assays performed twice during pregnancy, a significant correlation was found for fasting plasma glucose values, but not for glucose screening test values. We conclude that the fasting plasma glucose assay may perform better than the one-hour post-glucose test as a screening test for gestational diabetes. Based on these data, a population-based prospective study seems justified.

Apparent heparin resistance form elevated factor VIII in a patient with postoperative deep venous thrombosis. A case report.

BACKGROUND: During the puerperium, heparin levels, rather than the adjusted partial thromboplastin time test, can be used to identify heparin resistance and guide heparin therapy. CASE: A patient receiving heparin for deep venous thrombosis had artifactual resistance to heparin, with a short adjusted partial thromboplastin time due to elevation of factor VIII. Heparin assay revealed a heparin level above the therapeutic range. CONCLUSION: Direct measurement of heparin concentration and factor VIII activity should be performed when heparin resistance is suspected.

Necessity for routine obstetric screening for hepatitis B surface antigen.

Routine serologic testing of pregnant women in a predominantly Hispanic population at the Los Angeles County Medical Center revealed that 8 of 2,000 were positive for hepatitis B surface antigen (HBSAg). Only two of the eight women had a risk factor as currently defined by the Centers for Disease Control. Screening of all pregnant women is necessary to identify those HBSAg-positive women capable of transmitting the hepatitis B virus to their infants. All the other obstetric surveys reviewed support the need to screen obstetric patients and to provide immunoprophylaxis to the infants at risk of perinatal infection. This policy is necessary to prevent perinatal transmission of hepatitis B virus and is cost effective.

Evaluation of lamellar body number density as the initial assessment in a fetal lung maturity test cascade.

The objective of this study was to assess the sensitivity and specificity of lamellar body number density in the prenatal prediction of the respiratory distress syndrome. Seventy consecutive amniotic fluid specimens obtained by amniocentesis within 72 hours of delivery were assessed for lamellar body number density, optical absorbance at 650 nm, lecithin/sphingomyelin ratio and phosphatidylglycerol. A maturity criterion of > or = 46,000/microL for lamellar body number density yielded values for diagnostic sensitivity of 100% (7/7), specificity of 89% (49/55), positive predictive value of 54% (7/13) and negative predictive value of 100% (49/49). These values were also determined for the other analytes, with results similar to those reported elsewhere. Lamellar body number density is an effective and inexpensive first test for the rapid identification of the fetus at high risk for the respiratory distress syndrome. A cascade approach, using lamellar body number density as the first test and optical absorbance at 650 nm as the second test, improves the predictive value as compared to any single test of fetal lung maturity.

Obstetric hemorrhage and blood utilization.

Patients on a busy obstetric service were prospectively evaluated to determine which ones required blood transfusion. During the period January-April 1990, 5,528 deliveries were performed. Fifty-five patients (0.99%) received blood transfusions during their pregnancy and puerperium. The most common conditions associated with transfusion were trauma due to instrumental delivery (16), uterine atony (15), placenta previa (12), retained products of conception (4), abruptio placentae (4) and coagulopathy secondary to the HELLP syndrome (1). Platelets, fresh frozen plasma, whole blood and cryoprecipitate were administered to 7, 6, 1 and 1 patients, respectively. The transfusion rates by procedure were emergency cesarean hysterectomy for bleeding placenta previa or atony, 7/7 (100%); vacuum extraction, 7/114 (6.1%); forceps delivery, 12/285 (4.2%); uncomplicated cesarean delivery, 10/704 (1.4%); and spontaneous vaginal birth, 19/4,425 (0.4%). The hemorrhage and subsequent need for a blood transfusion were not necessarily due to the procedure except in the case of trauma due to instrumental vaginal delivery. The rate of transfusion of red blood cells for patients undergoing vaginal instrumental delivery was significantly higher than the rate for those undergoing cesarean delivery (relative risk, 2.8; 95% confidence interval, 1.5-5.2). The need for transfusion can be anticipated on the basis of antepartum causes in only 23.7% of patients ultimately receiving blood products.

Acyclovir for disseminated herpes simplex virus in pregnancy. A case report.

Seventeen cases of disseminated herpes simplex virus (HSV) infection have occurred during pregnancy. Acyclovir therapy was associated with prolongation of the time from admission until spontaneous rupture of the membranes or delivery and an improved maternal outcome. This life-threatening condition has a typical presentation, which includes a nonspecific viral prodrome. During pregnancy, fever and anicteric hepatitis unresponsive to empiric antibiotics should prompt an evaluation for disseminated herpes simplex. Pharyngitis or skin lesions with a positive herpes simplex culture are common, specific signs associated with dissemination. The fever resolves within 48 hours in response to acyclovir therapy. One case of maternal disseminated HSV occurred at 22 weeks' gestation and resolved with acyclovir therapy; a healthy neonate was delivered vaginally at term.