Predictors of massive blood loss in women with placenta accreta.

OBJECTIVE: We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy. STUDY DESIGN: A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥ 5000 mL) and large-volume transfusion (≥ 10 units packed red cells) were examined. RESULTS: A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion (P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥ 5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning (P = .01). CONCLUSION: There are few reliable predictors of massive blood loss in women with placenta accreta.

Trauma in pregnancy: a systematic approach.

Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. Many of the assessment and management aspects of obstetric trauma are unique to pregnancy, although initial evaluation and resuscitation should always be maternally directed. Once maternal stability is established, vigilant evaluation of fetal well-being becomes warranted. Continuous fetal heart monitoring, ultrasonography, computed tomography, open peritoneal lavage, and/or exploratory laparotomy may be indicated in a case of obstetric trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount.

A systematic, multidisciplinary approach to address the reproductive needs of HIV-seropositive women.

Nearly 130,000 American women are human immunodeficiency virus (HIV) seropositive. The present study sought to establish a comprehensive programme to address their fertility needs in order to minimize infectious, medical and reproductive risks to prospective patients. Forty women, aged 27-42 years, were evaluated. HIV was diagnosed 7.2 +/- 0.7 years prior to their seeking care, and most women (n = 38) were on highly active antiretroviral therapy. Their prenatal CD4 counts were 712.2 +/- 56 cells/mm(3) (range 327-1881) and HIV-1 concentrations were undetectable in all cases prior to initiating treatment. HIV-seropositive women were statistically identical to their age-matched HIV-seronegative counterparts with respect to the IVF clinical outcome parameters measured. Throughout the pregnancies, maternal HIV-1 RNA concentrations remained undetectable and CD4 counts were stable. All infants, tested at birth and at 3 and 6 months of age, remained HIV negative. This is the first report of an institutional paradigm in the USA dedicated to evaluate and treat HIV-seropositive women. Using a multidisciplinary approach to care, HIV-seropositive women may be successfully managed in a programme of assisted reproduction.

Mechanisms of hemostasis at cesarean delivery.

Postpartum hemorrhage is an obstetric emergency that represents a major cause of maternal morbidity and mortality. With the recent rise in the cesarean delivery rate, prompt recognition and proper management at the time of cesarean delivery are becoming increasingly important for providers of obstetrics. Preparedness for hemorrhage can be achieved by recognition of prior risk factors and implementation of specific hemorrhage protocols. Medical and surgical therapies are available to treat obstetric hemorrhage after cesarean delivery.

Glyburide for the management of gestational diabetes: risk factors predictive of failure and associated pregnancy outcomes.

OBJECTIVE: The purpose of this study was to identify characteristics that may predict failure of glyburide therapy for the management of A2 gestational diabetes, and to evaluate whether those that fail are at increased risk for adverse pregnancy outcomes. STUDY DESIGN: This was a retrospective cohort of gestational diabetics requiring medical therapy (A2DM) treated between January 2002 and July 2005. RESULTS: Of the 235 gestational diabetics identified, 79% of the 101 A2DMs were successfully treated with glyburide as first-line therapy. Those that failed had a higher mean glucose value on glucose challenge test (GCT) (200.5 +/- 57.3 vs 176.6 +/- 33.8 mg/dL, P = .019) and were more likely to have a GCT > or = 200 mg/dL (45 vs 22%, P = .043). Only GCT and GCT > or = 200 mg/dL were predictive of failure. Those successfully managed with glyburide had increased NICU admissions, primarily for hypoglycemia and respiratory distress, which resolved prior to discharge. There was no difference in birth weight, cesarean delivery, macrosomia, or shoulder dystocia. CONCLUSION: Predicting glyburide failure is difficult, but failure does not appear to be associated with increased adverse pregnancy outcomes.

Diagnosis and management of obstetrical complications unique to multiple gestations.

Obstetrical complications unique to multiple gestations pose a number of unique challenges. The presence of more than one fetus complicates the diagnosis and management of a pregnancy when one fetus has a structural or chromosomal abnormality, intrauterine demise, preterm premature rupture of the membranes, or delivers prematurely. Similarly, the diagnosis and management of monoamniotic twins and conjoined twins is challenging. These obstetrical complications that are unique to multiple gestations require thorough counseling of the expectant parents, as well as care by physicians with expertise in the management of multiple gestations.

Intrapartum management of twins: truths and controversies.

Twin gestations pose a challenge in management, and the intrapartum phase of care is not exempt. Despite increasing numbers of twin gestations, the literature does not adequately answer several basic questions regarding appropriate intrapartum management. This article provides an overview of the available literature supporting appropriate intrapartum actions in twin gestations and highlights areas that are still awaiting further study, with the eventual goal of optimizing intrapartum conditions, leading to an improved neonatal outcome.

Prophylactic dosing adjustment in pregnancy based upon measurements of anti-factor Xa levels.

OBJECTIVE: To determine the necessity for monitoring of anti-factor Xa levels in pregnant women taking low molecular weight heparin (LMWH). STUDY DESIGN: A review of a hematological database with chart review was undertaken to identify patients on LMWH. Levels were drawn monthly. They were considered suboptimal if prophylactic and therapeutic doses of LMWH had an anti-Xa value <0.2 U/mL and 0.6 U/mL, respectively. Variables of interest included age, parity, thrombophilias, and antiphospholipid antibody syndrome. RESULTS: Of 30 patients, three required therapeutic-dose LMWH and 27 were on prophylaxis. Sixty-six percent on a therapeutic dose required a dose change, whereas 11% on a prophylactic dose were changed (p = 0.013). None of the variables were predictive of a need for change. One thromboembolic event was noted while on prophylactic-dose LMWH. CONCLUSIONS: No single variable is predictive of a need for dose change. Patients on a therapeutic dose were more likely to need change.

Noninvasive management of Rh partial null (D--) to supplement traditional management of Rh isoimmunization.

BACKGROUND: Rh partial null (D--) is a rare cause of Rh sensitization in an Rh-positive patient. Noninvasive management for this condition using middle cerebral artery Doppler studies was used to reduce invasive testing. CASE: An Rh D+ woman had an antibody titer of 1:512 to Rh-17, the Rh Cc/Ee protein. Rh typing revealed absence of any antigens at the Cc/Ee locus. Her husband was Rh D--, ccee. Middle cerebral artery Doppler studies and serial amniocenteses for Delta OD(450) were performed. When testing suggested severe fetal anemia, two intrauterine transfusions were performed. CONCLUSION: Middle cerebral artery Doppler studies can be used to predict fetal anemia before the first transfusion. However, the cutoff to predict subsequent anemia in Rh D-- after transfusion remains to be defined.

Is discordant growth in twins an independent risk factor for adverse neonatal outcome?

OBJECTIVE: To estimate whether discordant growth is associated with adverse perinatal outcomes in twins after adjusting for growth restriction. METHODS: This was a retrospective, hospital-based cohort study of twin gestations with 2 live births delivered at 24 weeks or later from 1992 to 2001. Twin gestations were classified as small for gestational age (SGA) if one or both infants was less than the 10th percentile at birth by singleton Brenner norms and discordant if there was a 20% or more weight discordance. RESULTS: Of 1318 twin pairs, 856 were appropriate for gestational age (AGA) and concordant, 70 pairs were AGA and discordant, 254 pairs were SGA and concordant, and 138 pairs were SGA and discordant. The 4 groups had similar maternal demographics and medical comorbidity. When adjusting for chorionicity, antenatal steroid use, oligohydramnios, preeclampsia, and gestational age at delivery, discordant twins were more likely to have a cesarean delivery (odds ratio 1.87; 95% confidence interval 1.22, 2.87) and to be associated with some adverse neonatal outcomes (low and very low birthweight, neonatal intensive care unit admission, neonatal oxygen requirement and hyperbilirubinemia) independent of SGA status. A statistically nonsignificant trend (odds ratio 2.4; 95% confidence interval 0.99, 6.01) toward higher rates of intraventricular hemorrhage was noted in discordant twins, and no difference was seen for ventilator requirement, respiratory distress syndrome, or necrotizing enterocolitis. CONCLUSION: Discordance places twins at increased risk for some adverse perinatal outcomes, whether they are AGA or SGA. Discordance was not an independent risk factor for serious neonatal morbidity or mortality; however, this study was underpowered to detect those differences.

Minimally invasive management of an advanced abdominal pregnancy.

BACKGROUND: Advanced abdominal pregnancy is a rare, life-threatening condition that presents a number of challenges. CASE: A 29-year-old primigravida with 10 years of secondary infertility and a previous tuboplasty had a 21-week abdominal pregnancy treated with preoperative arterial embolization before laparoscopically assisted fetal delivery. Postoperatively, 4 cycles of methotrexate were administered at 50 mg/m2 intramuscularly every 3 weeks for the retained abdominal placenta. Subsequent spontaneous conception occurred, and a live, full-term infant was delivered by cesarean delivery 17 months later. No adverse sequelae were found during long-term follow-up. CONCLUSION: This report demonstrates successful minimally invasive management of an advanced abdominal pregnancy with a multimodal approach that included preoperative arterial embolization, laparoscopically assisted delivery, and judicious use of postoperative methotrexate.

Pregnancy in a persistent vegetative state: case report, comparison to brain death, and review of the literature.

UNLABELLED: Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep-wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P

Meconium enhances the growth of perinatal bacterial pathogens.

OBJECTIVE: To demonstrate the effects of meconium on growth of bacterial pathogens, which are common causes of intra-amniotic infection and neonatal sepsis. METHODS: Meconium collected from 9 healthy neonates was suspended as a 20% solution using sterile saline. In experiment 1, separate test tubes of meconium solution and sterile saline (the control) were individually inoculated with 10(6) colony-forming units of a single species of the following test pathogens: Escherichia coli, Enterococcus faecalis, Group B Streptococcus, Staphylococcus aureus, Pseudomonas aeruginosa, and Listeria monocytogenes. After incubation at 37 degree C for 24 hours, 1 L each of the bacterial-meconium and bacterial-saline solutions was inoculated onto 5% sheep blood agar. After 24 hours of incubation, the number of developing colonies was counted. In experiment 2, equal volumes of meconium and saline solutions were inoculated with 10(5) colony-forming units of either E. coli or Group B Streptococcus. At intervals of 6, 9, and 24 hours post-incubation, 1 L each of the bacterial-meconium and bacterial-saline solutions was inoculated onto 5% sheep blood agar plates, and colonies were counted after overnight incubation. RESULTS: In the first experiment, 24 hours of incubation resulted in bacterial amplification in the meconium solution from an initial inoculum of 10(6) colony-forming units/mL to 10(9) colony-forming units/mL. In contrast, the same inoculation of saline solution (control) showed no increase in colony counts over the same time interval. For E. coli and Group B Streptococcus in experiment 2, growth enhancement in meconium was seen as early as 6 hours, as colony counts of a test species increased from 105 colony-forming units/mL to 10(9)-10(10) colony-forming units/mL. CONCLUSION: Enhanced growth of perinatal pathogens in meconium was constantly observed, and can occur as early as 6 hours after bacterial interaction of meconium.

Comparison between emergent and elective delivery in women with placenta accreta.

OBJECTIVE: To identify possible predictive factors associated with emergent delivery of antenatally diagnosed placenta accreta and to estimate association between emergent delivery and adverse maternal outcomes in comparison to elective delivery. METHODS: A retrospective study of all patients with placenta accreta diagnosed antenatally and confirmed pathologically, who were delivered between 2000 and 2010. Baseline characteristics and outcomes of emergent deliveries were compared with elective deliveries. RESULTS: A total of 48 women met inclusion criteria, of which 24 (50%) were delivered emergently. 79.2% of emergent deliveries were preceded by antenatal bleeding (p = 0.0005), and 62.5% were preceded by recurrent bleeding (p = 0.001). Comparison of elective and emergent deliveries revealed no clinical significant difference in maternal outcome. CONCLUSIONS: Antenatal bleeding is associated with an increased risk of emergent delivery. Emergent delivery in a tertiary care facility with immediate access to blood bank and ICU capabilities does not appear to be associated with an increased risk of adverse maternal outcomes. Consequently, some patients may be candidates for delivery later than 34 weeks of gestation.

Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta.

OBJECTIVE: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta. METHODS: A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns. RESULTS: Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34-36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. CONCLUSION: There is widespread variation in the care of women with or at risk for placenta accreta.

Morbidity and mortality of peripartum hysterectomy.

OBJECTIVE: To perform a population-based analysis to examine the morbidity and mortality of peripartum hysterectomy in comparison with nonobstetric hysterectomy. METHODS: Data from the Nationwide Inpatient Sample were used to compare peripartum and nonobstetric hysterectomy in women younger than 50 years of age. Intraoperative, perioperative, and postoperative medical complications were examined. The outcomes of peripartum and nonobstetric hysterectomy were compared using chi square. Odds ratios were calculated using multivariable logistic regression models for each individual complication. RESULTS: A total of 4,967 women who underwent peripartum hysterectomy and 578,179 patients who had a nonobstetric hysterectomy were identified. Bladder (9% compared with 1%) and ureteral (0.7% compared with 0.1%) injuries were more common for peripartum hysterectomy (P<.001). There were no differences in the rates of intestinal or vascular injuries between peripartum and nonobstetric hysterectomy. Rates of reoperation (4% compared with 0.5%), postoperative hemorrhage (5% compared with 2%), wound complications (10% compared with 3%), and venous thromboembolism (1% compared with 0.7%) were all higher in women who underwent peripartum hysterectomy. In multivariable analysis, the odds ratio for death for peripartum compared to nonobstetric hysterectomy was 14.4 (95% confidence interval 9.84-20.98). CONCLUSION: Peripartum hysterectomy is accompanied by substantial morbidity and mortality. Compared with nonobstetric hysterectomy, the procedure is associated with increased rates of both intraoperative and postoperative complications. The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy. LEVEL OF EVIDENCE: II.

Regionalization of care for obstetric hemorrhage and its effect on maternal mortality.

OBJECTIVE: To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality. METHODS: We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios. RESULTS: Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10-0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47-0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34-0.83). CONCLUSION: Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings. LEVEL OF EVIDENCE: II.

Obstetric emergencies.

Uterine rupture, uterine inversion, and pelvic lacerations/hematomas are all associated with increased risk for hemorrhage at the time of delivery. Certain clinical factors will increase the likelihood that these complications will occur, and clinical management can be adapted to reduce risk. Prior cesarean section is a significant risk factor for uterine rupture, with the degree of risk directly related to the location and quantity of prior uterine incisions. Obstetric trauma is another independent risk factor for uterine rupture. In turn, uterine inversion has traditionally been associated with overly aggressive management of the third stage of labor. The forces of normal labor and delivery will sometimes result in lacerations and hematomas of the lower genital tract. Except for the most superficial tears, these lacerations require surgical repair to restore proper anatomical appearance and support and to limit blood loss. Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality.

Lopinavir exposure with an increased dose during pregnancy.

BACKGROUND: Use of standard adult lopinavir/ritonavir (LPV/RTV) dosing (400/100 mg) during the third trimester of pregnancy results in reduced LPV exposure. The goal of this study was to determine LPV exposure during the third trimester of pregnancy and 2 weeks postpartum with a higher LPV/RTV dose. METHODS: The Pediatric AIDS Clinical Trials Group Protocol 1026s is an ongoing, prospective, nonblinded study of antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving LPV/RTV 400/100 mg twice daily during the second trimester and 533/133 mg twice daily during the third trimester through 2 weeks postpartum. Intensive steady state 12-hour pharmacokinetic profiles were performed during the third trimester and at 2 weeks postpartum and were optional during the second trimester. LPV and RTV were measured by reverse-phase high-performance liquid chromatography with a detection limit of 0.09 microg/mL. RESULTS: Twenty-six HIV-infected pregnant women were studied. Median LPV area under the plasma concentration-time curve (AUCs) for the second trimester, third trimester, and postpartum were 57, 88, and 152 microg.h.mL, respectively. Median minimum LPV concentrations were 1.9, 4.1, and 8.3 microg/mL. CONCLUSIONS: The higher LPV/RTV dose (533/133 mg) provided LPV exposure during the third trimester similar to the median AUC (80 microg.h.mL) in nonpregnant adults taking standard doses. However, the AUC on this increased dose at 2 weeks postpartum was considerably higher. These data suggest that the higher LPV/RTV dose should be used in third trimester pregnant women; that it should be considered in second trimester pregnant women, especially those who are protease inhibitor experienced; and that postpartum LPV/RTV dosing can be reduced to standard dosing by 2 weeks after delivery.

Correlation of transthoracic echocardiography and right heart catheterization in pregnancy.

OBJECTIVES: To correlate estimated pulmonary artery pressures (PAP) by echocardiography with right heart catheterization (RHC) measurements and to correlate estimated left ventricular ejection fraction (EF) by echocardiography with cardiac output (CO) measurements by RHC. STUDY DESIGN: All women who had echocardiography at a single institution during a 6-year period and underwent RHC during pregnancy were included. Echocardiography estimates of right ventricular systolic pressure (RVSP) and EF were correlated with measured RHC PAP and CO, respectively. RESULTS: Eighteen patients underwent 21 RHCs, 10 antepartum at the catheterization laboratory and the remaining 11 intrapartum, performed with the use of a pulmonary artery catheter placed prior to the onset or induction of labor. Correlation between RVSP and PAP was good (rho=0.79, P<0.0001); nonetheless, in 30% of cases RHC eliminated the concern for pulmonary hypertension (PHTN). There was minimal correlation between EF and CO. CONCLUSION: Despite good statistical correlation between echocardiography and RHC for determining pulmonary artery pressure, RHC should be considered for major decisions such as pregnancy interruption or preterm delivery given the proportion of cases where concern for PHTN was excluded by RHC. EF provides a poor proxy for CO.