The physician's reaction to a malpractice suit.

A malpractice suit can have a devastating impact on a practitioner's professional and personal life. The physician's reaction to this event is profound, affecting his own life-style and that of family, colleagues, and patients. This commentary presents an analogy between the physician's reaction to a malpractice suit and the stages of grief described by Elisabeth Kübler-Ross: the sequence of denial, anger, bargaining, depression, and acceptance. Understanding the psychodynamics of this reaction can help physicians to cope with the problems inherent in a malpractice suit and to maintain a greater stability in their personal lives. Adverse effects on medical practice and private life-style, and on the legal proceedings, can be minimized.

The viscoelastic nature of chorioamniotic membranes.

This study establishes the viscoelastic nature of the human chorioamniotic membrane. Membrane tissue taken from term pregnancies was placed in a state of biaxial stress consistent with the condition in which membranes rupture in normal healthy patients. The phenomena of creep, stress relaxation, elastic recovery, and time-dependent load deformation relations were demonstrated. The experiments needed to produce these phenomena are described. The results are graphically reported. The experiments were performed using samples of fetal membranes and compared to gum rubber which is a known elastic material. From the results, one can conclude that fetal membranes are viscoelastic. The flow freely under applied stress, and they have elastic and viscous properties which are time dependent.

Effect of meconium on the strength of chorioamniotic membranes.

A population of 1320 patients was reviewed to assess the clinical significance of antepartum meconium staining on the occurrence of premature rupture of the membranes. Specimens of amniotic membranes were studied by tensile strength testing from 2 population groups. The results of the retrospective review showed no difference in the incidence of premature rupture of the membranes between the populations with clear amniotic fluid and those with meconium-stained fluid at time of amniorrhexis. The tensile strength testing demonstrated that the study population with antepartum meconium-stained fluid had significantly lower stress tolerance. This investigation demonstrated a significant decrease in stress tolerance of human chorioamniotic membranes associated with a meconium-stained fluid environment, but this loss of stress tolerance is not apparently significant in clinical practice.

Immunologic thrombocytopenia in pregnancy; use of antenatal immunoglobulin therapy: case report and review.

Steroid therapy remains the treatment of choice for immunologic thrombocytopenia in pregnancy. However, for cases refractory to steroid therapy, alternate forms of treatment must be used. This case report and review discusses a successful technique for acute, short-term correction of thrombocytopenia. In limited experience the administration of high-dose immunoglobulin appears to be effective for antepartum use in patients with immunologic thrombocytopenia. The concomitant or subsequent performance of splenectomy appears to be a valuable adjunct in long-term treatment of this condition.

Early placenta previa and delivery outcome.

Ultrasound scan showed some degree of placenta previa in 503 patients. Of this group, 5.6% (28) had clinically significant bleeding or documented placenta previa at delivery. A scoring system based on placental localization was not successful in predicting who was at high risk for bleeding. However, the likelihood of clinically excessive bleeding did significantly increase if the placenta previa was noted after 30 weeks' gestation. The study did not find a greater incidence of small-for-gestational-age babies in women with low-lying placentas.

The effect of labor on the rheologic response of chorioamniotic membranes.

A study of chorioamniotic membranes was undertaken in 2 term populations. One group of women delivered vaginally after normal labor (N = 41), the other by elective cesarean section (N = 41). Rheologic properties were measured in an experimental environment. The membranes in each group responded similarly while intact. Those membranes subject to labor, however, ruptured earlier in cyclic testing. They also required more time to dissipate applied stress. This stress response pattern is similar to that seen with rupture of amorphous materials in which multiple flaws or cracks are aggravated by stress testing. The clinical problem of premature rupture of the membranes may occur by a phenomenon that produces flaws in their structure. The data suggest that these flaws may be aggravated by labor-like uterine activity.

Management of moderate to severe trauma in pregnancy.

Severe trauma to an obstetric patient is truly an injury of double magnitude. While being cognizant of the fetus and its well-being, all expediency must be employed to accomplish a thorough evaluation of the injured patient and allow for the prompt employment of appropriate therapeutic measures. The best key to fetal survival is successful maternal therapy.

Amniography for confirming the diagnosis of monoamniotic twinning. A case report.

In a case of monoamniotic twinning, amniography was used to confirm the diagnosis. This modality, old but now employed infrequently, helps establish the absence of a dividing membrane and complements currently used ultrasound diagnostic methods. A successful outcome resulted. Amniography should be considered a useful diagnostic modality in the management of twin gestations and not be relegated to the past.

Asynchronous multiple birth. A report of five cases.

The feasibility of prolonging the delivery interval of the fetus or fetuses in multiple gestations after the preterm delivery of one fetus has been demonstrated. Five clinical reports and a literature review served as the database for this study. Pregnancy was extended in each of five patients with multiple gestations after the extreme preterm delivery of one fetus. Four of the six remaining infants survived. The literature reviewed shows successful survival in 42 of 52 (81%) such asynchronously delivered infants. Use of tocolytic therapy, broad-spectrum antibiotics and cerclage allows pregnancy extension when delivery occurs asynchronously in multiple gestations. The patient's strong desire and full understanding of the potential risks are mandatory before such an endeavor is attempted.

Midwifery co-management of hyperemesis gravidarum.

Hyperemesis gravidarum is an infrequent, yet significant, maternal complication of pregnancy. Beginning with the frequently experienced nausea and vomiting of pregnancy, symptoms can progress to hyperemesis, a debilitating condition affecting maternal and fetal well-being. A basic understanding of the pathophysiology of the disease process and an awareness of the therapeutic interventions that are available will facilitate midwifery planning for either the collaborative care or the potential referral to medical management, both of which may be required with this clinical entity. The diagnosis and initial management of hyperemesis is within the purview of midwifery care. As certain critical features of duration and severity evolve, medical collaboration and ultimate hospitalization may be required. For those few individuals requiring the most intense level of care, the critical support and encouragement afforded by midwifery participation will contribute to timely resolution of this debilitating condition. This article discusses the continuum from differential diagnosis to ultimate care of the woman who has excessive nausea and vomiting of pregnancy. Collaboration among health care providers will allow all to exercise their respective skills in achieving the optimum in safe therapy and support for their patients.

Magnesium deficiency in a pregnancy six years after jejunoileal bypass.

The following case report reviews the obstetrical course of a patient who had undergone a jejunoileal bypass six years prior to her pregnancy. Documentation of hypomagnesemia and parenteral treatment of this condition are reported along with the successful outcome. Bypass procedures may result in biochemical aberrations which affect pregnancy outcome. The implications of such surgery is reviewed as well as its current status.

Placenta previa.

A placenta previa, whether found fortuitously by ultrasound or with the clinical emergency of maternal hemorrhage, carries significant maternal and fetal risk. Accurate diagnosis, judicious expectant management with transfusion as required, and delivery at the time of fetal lung maturation can lead to the most favorable outcome. Anticipation of the clinical complication of placenta accreta may avoid some serious consequences. Clinical judgement and skill in the performance of cesarean sections, dilatation and curettage, and other forms of uterine invasive techniques may help to keep subsequent incidence of placenta previa at a reasonably low rate.

The role of placental examination and its pathology in obstetric risk management.

The placenta is a marker of biologic events that occur during pregnancy. Placental pathologic examination gives insight to pregnancy-related insults, which affect the newborn at and after birth. Clinicians and risk managers can use this information to identify the cause of newborn complications in cases suggested to be birth-related injuries.

The relationship of blood lead levels to obstetric outcome.

Lead represents a significant environmental hazard to pregnant women and their offspring. Exposure to high environmental levels of lead has been associated with spontaneous abortion, premature rupture of fetal membranes (PROM), and preterm delivery. The relationship between lower exposures and obstetric complications is unknown. The concentration of lead in the blood was measured in 635 specimens of umbilical cord blood collected at delivery. No relationship was found between concentrations of lead in cord blood and the incidence of PROM, preterm delivery, preeclampsia, or meconium staining. Maternal and infant capillary blood was collected 24 hours post partum from 154 of these deliveries. The concentrations of lead in the blood did not vary significantly among cord, infant, and maternal samples, and the three measurements were highly correlated. Levels of zinc protoporphyrin (ZnP) were increased in cord blood as compared with mothers' blood, but no concentration-response relationships between the ratio of cord ZnP to maternal ZnP and lead were found.

Subcapsular hematoma of the liver during pregnancy.

We have reported a case of subcapsular hematoma of the liver, diagnosed and observed by ultrasonography, in association with the HELLP syndrome. The patient's condition improved with conservative management, but the hematoma was clearly shown to last for more than 12 weeks, which shows the need for extended postpartum follow-up and appropriate patient consultation.