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.

Office hysteroscopy versus transvaginal ultrasonography in the evaluation of patients with excessive uterine bleeding.

OBJECTIVE: Our purpose was to compare office hysteroscopy with transvaginal ultrasonography for diagnosing intrauterine pathologic disorders in patients with excessive uterine bleeding, with specimens obtained from either hysterectomy or operative hysteroscopy used to represent the true diagnosis. STUDY DESIGN: A total of 149 patients underwent office hysteroscopy between July 1993 and December 1994. They were evaluated for complaints of menorrhagia, metrorrhagia, or postmenopausal bleeding. Data encompassing patient age, gravidity, parity, indication, ultrasonographic and hysteroscopic findings, comfort level, time required, and complications were gathered by resident physicians. Most hysteroscopic examinations were preceded by transvaginal ultrasonography. All patients received premedication with 600 mg of ibuprofen and a paracervical block with 1% lidocaine without epinephrine. Sixty-five patients underwent operative hysteroscopy or hysterectomy later. The pathologic diagnoses of these specimens were compared with hysteroscopic and ultrasonographic findings, and the sensitivity and specificity of each test were calculated. RESULTS: Hysteroscopy was 79% sensitive and 93% specific in diagnosing intracavitary pathologic disorders, whereas transvaginal ultrasonography was only 54% sensitive and 90% specific. One hundred forty-one patients were comfortable during the procedure, and inspection of the uterine cavity was considered adequate in 136. The majority of procedures were completed in <10 minutes. Twenty-six patients underwent operative hysteroscopy and another 39 underwent hysterectomy. No patient who underwent operative hysteroscopy has had a recurrence of abnormal bleeding over a 12- to 30-month follow-up. CONCLUSION: Office hysteroscopy is a rapid, safe, well-tolerated, and highly accurate means of diagnosing the cause of excessive uterine bleeding. It permits patient and physician to discuss more treatment options before surgery, including outpatient operative hysteroscopic procedures. This means savings in time and in drug, procedure, professional, and hospital costs.

Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy.

BACKGROUND: Peripartum cardiomyopathy is a rare and sometimes fatal form of heart failure. Little is known about the outcomes of subsequent pregnancies in women who have had the disorder. METHODS: Through a survey of members of the American College of Cardiology, we identified 44 women who had had peripartum cardiomyopathy and had a total of 60 subsequent pregnancies. We then reviewed the medical records of these women and interviewed the women or their physicians. RESULTS: Among the first subsequent pregnancies in the 44 women, 28 occurred in women in whom left ventricular function had returned to normal (group 1) and 16 occurred in women with persistent left ventricular dysfunction (group 2). The pregnancies were associated with a reduction in the mean (+/-SD) left ventricular ejection fraction both in the total cohort (from 49+/-12 percent to 42+/-13 percent, P<0.001) and in each group separately (from 56+/-7 percent to 49+/-10 percent in group 1, P=0.002; and from 36+/-9 percent to 32+/-11 percent in group 2, P=0.08). During these pregnancies, a decrease of more than 20 percent in the left ventricular ejection fraction occurred in 21 percent of the women in group 1 and 25 percent of those in group 2, and symptoms of heart failure occurred in 21 percent of the women in group 1 and 44 percent of those in group 2. The mortality rate was 0 percent in group 1 and 19 percent in group 2 (P=0.06). In addition, the frequency of premature delivery was higher in group 2 (37 percent vs. 11 percent), as was that of therapeutic abortions (25 percent vs. 4 percent). CONCLUSIONS: Subsequent pregnancy in women with a history of peripartum cardiomyopathy is associated with a significant decrease in left ventricular function and can result in clinical deterioration and even death.