Implementation of a multidisciplinary perinatal emergency response team improves time to definitive obstetrical evaluation and fetal assessment.

BACKGROUND: Trauma is the leading cause of nonobstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of nontrauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a perinatal emergency response team (PERT) would improve time to patient and fetal evaluation and monitoring by the obstetrics (OB) team and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our university-affiliated, level I trauma center. Patients in the pre-PERT cohort (before April 2015) were compared with a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, Injury Severity Score, and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%) and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared with 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in level I (highest acuity) trauma activations pre-PERT and post-PERT (46% vs. 21%, p = 0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. .37 min, p = 0.01) CONCLUSION: Implementation of a multidisciplinary PERT improves time to evaluation by the OB team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: Retrospective review, level IV.

Myelomeningocele sac associated with worse lower-extremity neurological sequelae: evidence for prenatal neural stretch injury?

OBJECTIVE: To determine whether the presence of a myelomeningocele (MMC) sac and sac size correlate with compromised lower-extremity function in fetuses with open spinal dysraphism. METHODS: A radiology database search was performed to identify cases of MMC and myeloschisis (MS) diagnosed prenatally in a single center from 2013 to 2017. All cases were evaluated between 18 and 25 weeks. Ultrasound reports were reviewed for talipes and impaired lower-extremity motion. In MMC cases, sac volume was calculated from ultrasound measurements. Magnetic resonance imaging reports were reviewed for hindbrain herniation. The association of presence of a MMC sac and sac size with talipes and impaired lower-extremity motion was assessed. Post-hoc analysis of data from the multicenter Management of Myelomeningocele Study (MOMS) randomized controlled trial was performed to confirm the study findings. RESULTS: In total, 283 MMC and 121 MS cases were identified. MMC was associated with a lower incidence of hindbrain herniation than was MS (80.9% vs 100%; P < 0.001). Compared with MS cases, MMC cases with hindbrain herniation had a higher rate of talipes (28.4% vs 16.5%, P = 0.02) and of talipes or lower-extremity impairment (34.9% vs 19.0%, P = 0.002). Although there was a higher rate of impaired lower-extremity motion alone in MMC cases with hindbrain herniation than in MS cases, the difference was not statistically significant (6.6% vs 2.5%; P = 0.13). Among MMC cases with hindbrain herniation, mean sac volume was higher in those associated with talipes compared with those without talipes (4.7 ± 4.2 vs 3.0 ± 2.6 mL; P = 0.002). Review of the MOMS data demonstrated similar findings; cases with a sac on baseline imaging had a higher incidence of talipes than did those without a sac (28.2% vs 7.5%; P = 0.007). CONCLUSIONS: In fetuses with open spinal dysraphism, the presence of a MMC sac was associated with fetal talipes, and this effect was correlated with sac size. The presence of a larger sac in fetuses with open spinal dysraphism may result in additional injury through mechanical stretching of the nerves, suggesting another acquired mechanism of injury to the exposed spinal tissue. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Role for Cystathionine γ Lyase (CSE) in an Ethanol (E)-Induced Lesion in Fetal Brain GSH Homeostasis.

Earlier, we reported that gestational ethanol (E) can dysregulate neuron glutathione (GSH) homeostasis partially via impairing the EAAC1-mediated inward transport of Cysteine (Cys) and this can affect fetal brain development. In this study, we investigated if there is a role for the transulfuration pathway (TSP), a critical bio-synthetic point to supply Cys in E-induced dysregulation of GSH homeostasis. These studies utilized an in utero E binge model where the pregnant Sprague⁻Dawley (SD) rat dams received five doses of E at 3.5 g/kg by gastric intubation beginning embryonic day (ED) 17 until ED19 separated by 12 h. The postnatal day 7 (PN7) alcohol model employed an oral dosing of 4 g/kg body weight split into 2 feedings at 2 h interval and an iso-caloric and iso-volumic equivalent maltose-dextrin milk solution served as controls. The in vitro model consisted of cerebral cortical neuron cultures from embryonic day (ED) 16⁻17 fetus from SD rats and differentiated neurons from ED18 rat cerebral cortical neuroblasts. E concentrations were 4 mg/mL. E induced an accumulation of cystathionine in primary cortical neurons (PCNs), 2nd trimester equivalent in utero binge, and 3rd trimester equivalent PN7 model suggesting that breakdown of cystathionine, a required process for Cys supply is impaired. This was associated with a significant reduction in cystathionine γ-lyase (CSE) protein expression in PCN (p < 0.05) and in fetal cerebral cortex in utero (53%, p < 0.05) without a change in the expression of cystathionine ß-synthase (CBS). Concomitantly, E decreased Cse mRNA expression in PCNs (by 32% within 6 h of exposure, p < 0.05) and in fetal brain (33%, p < 0.05). In parallel, knock down of CSE in differentiated rat cortical neuroblasts exaggerated the E-induced ROS, GSH loss with a pronounced caspase-3 activation and cell death. These studies illustrate the importance of TSP in CSE-related maintenance of GSH and the downstream events via Cys synthesis in neurons and fetal brain.

Fetal brain imaging following laser surgery in twin-to-twin surgery.

OBJECTIVE: To describe the incidence and nature of prenatal brain damage following fetoscopic laser selective coagulation (FLSC) of placental vessels for twin-to-twin transfusion syndrome (TTTS). DESIGN: Retrospective observational study. SETTING: Single center cohort. POPULATION: All consecutive cases referred for TTTS treated by FLSC between 2003 and 2015. METHODS: After the FLSC, patients were followed weekly by ultrasound. Fetal magnetic resonance imaging (MRI) scans were systematically planned at 30-32 weeks of gestation. MAIN OUTCOME MEASURES: Brain damage diagnosed prenatally by ultrasound or MRI. RESULTS: In total, 1023 cases were reviewed. Brain damage was diagnosed prenatally in 22/1023 (2.1%) cases. Diagnosis was performed by ultrasound prior to MRI in 18 (82%) cases. All lesions were within the spectrum of ischaemic haemorrhagic lesions. Postoperative twin anaemia polycythaemia sequence and recurrence of TTTS were significantly associated with brain damage. CONCLUSION: The incidence of prenatal brain damage is low following FSLC, and is strongly associated with incomplete surgery. TWEETABLE ABSTRACT: Following FSLC for TTTS, prenatal brain damage occurs in 2% of cases and is associated with incomplete surgery.

A Rare Fetal Firearm Injury.

Firearm injury (FAI) in pregnant women is reported in the literature; however, no reference to date was found to address the neonatal abdominal surgery performed after maternal FAI. FAI during fetal life is extremely rare and very few cases have been reported. We present a report of a 37-week gestation newborn whose mother had an accidental FAI. The neonate was delivered by emergency caesarian section along with emergency laparotomy of the newborn. The baby presented at eight hours of life, who was managed surgically in emergency for multiple small and large bowel perforations and a piece of bullet was recovered from anterior part of thigh.

Hipoacusia neurosensorial secundaria a infecciones perinatales / Sensorioneural hearing loss secondary to perinatal infections / A perda auditiva neurossensoral secundária a infecções perinatais

Introducción: 1 a 2 de cada 1.000 recién nacidos tienen una pérdida auditiva neurosensorial significativa. De las deficiencias auditivas congénitas, el 50% resultan de infecciones en el embarazo y/o parto; como las provocadas por: Toxoplasmosis, rubéola, citomegalovirus, herpes y sífilis. Métodos: Se realizó una búsqueda bibliográfica sistemática de artículos utilizando bibliotecas virtuales y libros de texto de relevancia dentro de la especialidad. Resultados: La rubéola en mujeres susceptibles puede producir el síndrome de rubéola congénita. La sordera es la manifestación más frecuente de la enfermedad y es la secuela más importante. El 15% de los niños infectados por Citomegalovirus padecen una pérdida auditiva por daño coclear y alteraciones en el sistema nervioso central al nacer. Otro 15% pueden desarrollar luego del nacimiento hipoacusia, retardo mental o dificultades en el desarrollo del lenguaje y del aprendizaje. Aproximadamente el 80% de los recién nacidos infectados por toxoplasmosis son asintomáticos; el resto presentará manifestaciones clínicas de afectación sistémica incluyendo compromiso auditivo como parte del cuadro. La infección por Herpes simple suele ser devastadora en el recién nacido. Se ha descrito hipoacusia en más del 50% de los casos. La sordera se asocia frecuentemente con la sífilis congénita. Junto con la queratitis intersticial y las malformaciones dentarias, forma parte de la tríada de Hutchinson. Conclusiones: La hipoacusia es un problema de gran importancia en la infancia. Las infecciones agrupadas en el término TORCHS causan hipoacusia neurosensorial adquirida en forma prenatal, dando lugar a sorderas presentes al nacer o de desarrollo diferido o progresivo.

Introduction: 1 to 2 of every 1,000 newborns have significant sensorineural hearing loss. From all the congenital hearing empairments, 50% take place during pregnancy and/or childbirth; such as those caused by: toxoplasmosis, rubella, cytomegalovirus, herpes and syphilis. Methods: A systematic literature research was performed using virtual libraries and relevant specialty textbooks. Results: Rubella in susceptible women may cause congenital rubella syndrome. Deafness is the most common manifestation of the disease and is the most important sequel. 15% of those children infected with Cytomegalovirus children suffer hearing loss from cochlear damage and alterations in the central nervous system at birth. Another 15% can then develop birth hearing loss, mental retardation or difficulties in language development and learning. Approximately 80% of newborns infected with toxoplasmosis are asymptomatic; the rest will present clinical manifestations of systemic disease including hearing impairment as part of the picture. Herpes simplex infection is devastating in the new born. Hearing loss has been described in over 50% of cases. Deafness is often associated with congenital syphilis. Along with interstitial keratitis and dental malformations, it is part of the Hutchinson triad. Conclusions: Hearing loss is a major problem in childhood. Gathered as TORCHS acquired infections cause sensorineural hearing loss prenatally, resulting in hearing loss present at birth or deferred or progressive development.

Introdução: 1 a 2 em cada 1.000 recém-nascidos têm perda auditiva neurossensorial significativo. Das deficiências auditivas congênitas, 50% das infecções resultar em gravidez e / ou parto; tais como aquelas causadas por: toxoplasmose, rubéola, citomegalovírus, herpes e sífilis. Métodos: Uma busca sistemática da literatura foi realizada utilizando bibliotecas virtuais e livros relevantes no art. Resultados: A rubéola em mulheres suscetíveis pode causar a síndrome da rubéola congênita. A surdez é a manifestação mais comum da doença e é a sequela mais importante. 15% das crianças infectadas com Citomegalovírus sofrer perda de audição de danos e alterações coclear no sistema nervoso central no nascimento. Outros 15% podem desenvolver perda auditiva nascimento, retardo mental ou dificuldades no desenvolvimento da linguagem e aprendizagem. Cerca de 80% dos recém-nascidos infectados com toxoplasmose é assintomática; o resto vai apresentar manifestações clínicas da doença sistêmica, incluindo a deficiência auditiva como parte da imagem. Infecção Herpes simplex geralmente devastadores no recém-nascido. A perda de audição tem sido descrita em mais de 50% dos casos. A surdez é frequentemente associada a sífilis congênita. Junto com ceratite intersticial e malformações dentárias, faz parte da tríade Hutchinson. Conclusões: A perda auditiva é um problema grave na infância. Agrupados nas infecções TORCHS causam perda auditiva neurossensorial pré-natal, resultando em perda auditiva presente no nascimento ou em diferido ou desenvolvimento progressivo.

Penetrating chest wound of the foetus.

Traumas of the foetus caused by stabbings are rare but actually life-threatening for both the foetus and the mother. We report a case of penetrating chest wound on a baby taken from the obstetrics unit to the paediatric surgical department. His mother was assaulted by his father, a mentally sick person with no appropriate follow-up. The foetus did not show any sign of vital distress. Surgical exploration of the wound has revealed a section of the 10 th rib, a laceration of the pleura and a tearing of the diaphragm. A phrenorraphy and a pleural drainage were performed. The new-born and its mother were released from hospital after 5 days and the clinical control and X-ray checks 6 months later showed nothing abnormal. We insisted a medical, psychiatric follow-up be initiated for the father. As regards pregnant women with penetrating wounds, the mortality rate of the foetus is 80%. The odds are good for our newborn due to the mild injuries and good professional collaboration of the medical staff. Penetrating transuterine wounds of the foetus can be very serious. The health care needed should include many fields due to the mother and the foetus' lesions extreme polymorphism. In our case, it could have prevented by a good psychiatric followed up of the offender.

Role of oxidative injury in affecting the foetal & placental weights on exposure to tobacco smoke.

OBJECTIVE: To investigate the role of oxidative injury in affecting foetal and placental weights in mice by exposing them to tobacco smoke with or without supplementation with antioxidants. METHODS: The randomized control trial of pregnant mice at day one of gestation was conducted at Anatomy Department CPSP Regional Center Islamabad, from March 2005 to October 2005. The mice were divided into three groups: Group C had controls, while the two other groups, groups S and SV were exposed to secondary tobacco smoke in a whole body exposure chamber with and without supplementation with vitamins respectively. At term, the animals were sacrificed and the placentae and foetuses were weighed. The average values were calculated. The means for each group were analysed and the foetal placental ratio was calculated. SPSS 17 was used for statistical analysis. RESULTS: There were 44 mice; 15(34%) each in S and SV groups, while Group C had 14(32%) mice who acted as the controls. The mean foetal weight in Group S was 0.65±0.52g which was significantly less (p<0.0001) than1.48±0.19g in Group C. The mean foetal weight in Group SV was 0.97±0.65g which was not significantly different from S (p=0.124). The mean placental weight in Group S was 0.16±0.02g which was significantly less than 0.21±0.05gin Group C (p=0.014). In Group SV it was significantly more than Group S (p<0.0001). The ratio of mean foetal and mean placental weights in the groups C, S and SV were 7.05, 3.92 and4.41 respectively. CONCLUSIONS: Prenatal exposure to tobacco smoke decreased the mean foetal and placental weights and the foetal-placental ratio. This may partly be attributed to oxidative injury induced by free radicals in the tobacco smoke as it is prevented to some extent by simultaneous administration of antioxidants.

Fetal laceration during caesarean section and its medico-legal sequelae.

Fetal laceration is a recognized complication of caesarean delivery. The aim of this study was to investigate the incidence, type, location, risk factors and long-term consequences of accidental fetal incised wounds during caesarean delivery. During a five-year period, we observed 25 cases of fetal lacerations caused by the scalpel during hysterotomy. In 20 of these cases, we observed these lesions as consultants for the Neonatologic Care Unit; the other five cases came under our care after an insurance claim for damages against the gynaecologist. All the infants had a lesion located to the head. In only 5 of the 25 cases the lesion was reported in the operative summary, and only 16 of the 25 mothers had signed an informed consent before surgery. With regard to the 20 cases diagnosed at the Neonatologic Care Unit, the lesion was closed using single stitches in nine cases, and with biological glue in 11 cases. Concerning the five cases that underwent legal proceedings against the gynaecologist, a clinical examination was performed by an expert in Public Health and Social Security in collaboration with a paediatric surgeon to evaluate the degree of biological damage. In all five cases, the result of the legal challenge was monetary compensation for the physical and moral damage caused by the gynaecologists to the patients and their parents. Accidental fetal lesions may occur during caesarean delivery; the incidence is significantly higher during emergency caesarean delivery compared to elective procedures. Patients should sign an informed consent in which they should be informed about the risk of the occurrence of fetal lacerations during caesarean delivery in order to avoid legal complications.

Gastrointestinal endoscopy in pregnancy.

Gastrointestinal endoscopy has a major diagnostic and therapeutic role in most gastrointestinal disorders; however, limited information is available about clinical efficacy and safety in pregnant patients. The major risks of endoscopy during pregnancy include potential harm to the fetus because of hypoxia, premature labor, trauma and teratogenesis. In some cases, endoscopic procedures may be postponed until after delivery. When emergency or urgent indications are present, endoscopic procedures may be considered with some precautions. United States Food and Drug Administration category B drugs may be used in low doses. Endoscopic procedures during pregnancy may include upper gastrointestinal endoscopy, percutaneous endoscopic gastrostomy, sigmoidoscopy, colonoscopy, enteroscopy of the small bowel or video capsule endoscopy, endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. All gastrointestinal endoscopic procedures in pregnant patients should be performed in hospitals by expert endoscopists and an obstetrician should be informed about all endoscopic procedures. The endoscopy and flexible sigmoidoscopy may be safe for the fetus and pregnant patient, and may be performed during pregnancy when strong indications are present. Colonoscopy for pregnant patients may be considered for strong indications during the second trimester. Although therapeutic endoscopic retrograde cholangiopancreatography may be considered during pregnancy, this procedure should be performed only for strong indications and attempts should be made to minimize radiation exposure.

Fetal intracranial injuries following motor vehicle accidents with airbag deployment.

The effects of airbag deployment in motor vehicle accidents (MVA) on the fetus are poorly understood. A 22-year-old woman at 24 weeks of gestation collided with a telephone pole while driving. She was restrained and an airbag deployed. Although she had no major injuries, she experienced decreased fetal movements. Fetal heart rate (FHR) monitoring revealed loss of variability without any evidence of abruptio placentae, and 4 days later, the variability spontaneously recovered. Two weeks after the MVA, ultrasonography showed unilateral ventricular dilatation suggestive of fetal brain injury. Magnetic resonance imaging revealed subdural hematoma, intraventricular hemorrhage and cystic lesions, interpreted as indirect (hypoxic-ischemic) and direct (hemorrhagic) intracranial injuries. After MVA with airbag deployment, FHR monitoring can show a transient loss of variability, which may precede the appearance of fetal brain injury.

Gunshot wound to the pregnant uterus: case report / Ferimento por tiro em útero gravido: relato de caso

Crime and violence have become a public health problem. Pregnant women have not been the exception and gunshot injuries occupy an important place as a cause of trauma. An important fact is that pregnant women, who suffer trauma, are special patients because pregnancy causes physiological and anatomical changes. Management of these patients should be multidisciplinary, by the general surgeon, the obstetrician and the neonatologist. However, even trauma referral centers could neither have the staff nor the ideal training for these specific cases. In this context we present the following case.

Crime e violência tornaram-se um problema de Saúde Pública. As mulheres grávidas não constituem exceção e ferimentos por arma de fogo ocupam um lugar importante como causa de trauma. Um fato importante é que as mulheres grávidas que sofrem um trauma são pacientes especiais, porque a gravidez provoca modificações fisiológicas e anatômicas importantes. O manejo dessas pacientes deve ser multidisciplinar, realizado pelo cirurgião geral, pelo obstetra e pelo neonatologista. No entanto, até mesmo centros de referência de trauma poderiam nem ter o pessoal nem a formação ideal para esses casos específicos. Neste contexto, apresentamos o seguinte caso.

[Residual pellet in fetal brain tissue following a gunshot injury to a pregnant woman: a case report]. / Gebe bir kadinda av tüfegi yaralanmasi sonucu fetüs beyin dokusunda rezidüel saçma tanesi: Bir olgu sunumu.

Vital functions and the effect of injuries on quality of life are important from a viewpoint of causation in willful injury crimes committed against a pregnant woman. In such conditions, which should be evaluated separately in criminal law and compensation law, permanent losses of organ function that may negatively affect the woman's fertility, the features of permanent functional impairments and premature birth of the fetus can be additive factors for the indemnification amount. In scientific literature, case reports addressing the morphological and physiological changes to the fetus due to firearm injury are rare. In the presented case, we aimed to evaluate the fetus's situation, following firearm injury to a 41-year-old woman at 27 weeks gestation. While the mother was living a healthy life, the significant problem of the child in the first four-year period of his development was hyperactivity. Evaluating the effect of the frontal lobe lesion on the psychiatric findings of the child is important.

Traumatismo encefalocraneano fetal por vía penetrante transvaginal / Transvaginal penetrating fetal head injury

Los traumatismos encefalocraneanos in útero son extremadamente raros y suelen ser consecuencia de lesiones penetrantes a través de la pared torácica o abdominal, que alcanzan la cavidad uterina. Los originados a través de la vagina se han comunicado excepcionalmente. Se presenta el caso de un feto que padeció traumatismo encefalocraneano penetrante, con fractura de la bóveda craneal y hemorragia intraventricular tras la introducción violenta de un objeto contundente a través de la vagina por parte de su madre. La ruptura traumática de las membranas ovulares desencadenó el trabajo de parto pretérmino. Tras el nacimiento, se realizó tratamiento quirúrgico de la fractura deprimida y desbridamiento de la herida; sin embargo, el paciente falleció cuatro semanas más tarde a causa de sepsis neonatal. El tratamiento de estos casos no solo deber ser dirigido a la corrección de las lesiones traumáticas primarias sino también a la prevención de las complicaciones infecciosas.

In utero head traumas are extremely rare and are usually caused by penetrating injuries in the thoracic or abdominal wall that affect the uterine cavity. Transvaginal fetal head injuries have been reported in exceptional cases. This is a case-report of a fetus affected by penetrating head trauma with skull fracture and intra-ventricular hemorrhage after his mother's self-insertion of a blunt object, violently through the vagina. Trauma disrupted the integrity of intrauterine membranes and precipitated preterm labor. After birth, there was a debridement of the scalp and surgical management of the fracture was performed; nevertheless, the patient died four weeks later, due to neonatal sepsis. Management of these wounds must not only be focused on repairing the primary wound, but on preventing the infectious complications.

[Cell phones: health risks and prevention]. / Telefoni cellulari: rischi per la salute e strategie di prevenzione.

The paper describes first of all the electromagnetic radiation of cellular phones and presents the physical parameters used to measure and evaluate the absorption of emissions of radio stations and cellular phones. It then presents selected research results of the experimental studies in vivo and in vitro which examine the biological effects of the emissions of cellular phones. The review of the epidemiologic evidence focuses in particular the epidemiologic studies on the use of cell phones and brain tumours, identifying some of the reasons of the conflicting results obtained. Studies dealing with the health risks involved in the increasing use of cellular phones by adolescents and children, more sensitive to this exposure, are also presented showing the need for special caution. The problem of hypersensitivity observed in some individuals is also briefly discussed. Finally the paper presents a summary of the main prevention measures necessary in order to reduce the risks in the framework of the "precautionary principle" including prevention policies and exposure limits in various countries.

Obstetric and neonatal outcomes of cancer treated during pregnancy.

Cancer diagnosed during pregnancy is a rare occurrence with an incidence of 0.1% of all pregnancies. However, its management can be challenging at times as one balances maternal benefit to fetal risk. Various treatment modalities are used in this context including surgical intervention, chemotherapy, and radiologic therapy. This review seeks to address the impact of pregnancy on disease as well as the effect of malignancy and its treatment on both mother and fetus. Attention is focused on the more common malignancies associated with pregnancy: cervix, breast, melanoma, and hematologic malignancies. In addition, special emphasis is placed on timing of delivery and how that affects neonatal outcomes.

Cancer in pregnancy: fetal and neonatal outcomes.

Cancer during pregnancy represents a potential conflict between optimal maternal treatment and fetal development. Traditionally, clinicians operated under the assumption that cancer treatment during pregnancy is incompatible with normal fetal development. However, recent evidence suggests that many diagnostic and treatment modalities cause little or no harm to the developing fetus. As such, both maternal and neonatal interests should be considered when developing management strategies for pregnant cancer patients. In this review, we will discuss issues related to fetal and neonatal health associated with conventional diagnostic and treatment approaches in the care of pregnant women with cancer. In addition, we offer recommendations on strategies to maximize fetal outcomes in pregnancies complicated by cancer.

Maternal smoking in pregnancy and birth defects: a systematic review based on 173 687 malformed cases and 11.7 million controls.

BACKGROUND ; There is uncertainty over whether maternal smoking is associated with birth defects. We conducted the first ever comprehensive systematic review to establish which specific malformations are associated with smoking. METHODS ; Observational studies published 1959-2010 were identified (Medline), and included if they reported the odds ratio (OR) for having a non-chromosomal birth defect among women who smoked during pregnancy compared with non-smokers. ORs adjusted for potential confounders were extracted (e.g. maternal age and alcohol), otherwise unadjusted estimates were used. One hundred and seventy-two articles were used in the meta-analyses: a total of 173 687 malformed cases and 11 674 332 unaffected controls. RESULTS ; Significant positive associations with maternal smoking were found for: cardiovascular/heart defects [OR 1.09, 95% confidence interval (CI) 1.02-1.17]; musculoskeletal defects (OR 1.16, 95% CI 1.05-1.27); limb reduction defects (OR 1.26, 95% CI 1.15-1.39); missing/extra digits (OR 1.18, 95% CI 0.99-1.41); clubfoot (OR 1.28, 95% CI 1.10-1.47); craniosynostosis (OR 1.33, 95% CI 1.03-1.73); facial defects (OR 1.19, 95% CI 1.06-1.35); eye defects (OR 1.25, 95% CI 1.11-1.40); orofacial clefts (OR 1.28, 95% CI 1.20-1.36); gastrointestinal defects (OR 1.27, 95% CI 1.18-1.36); gastroschisis (OR 1.50, 95% CI 1.28-1.76); anal atresia (OR 1.20, 95% CI 1.06-1.36); hernia (OR 1.40, 95% CI 1.23-1.59); and undescended testes (OR 1.13, 95% CI 1.02-1.25). There was a reduced risk for hypospadias (OR 0.90, 95% CI 0.85-0.95) and skin defects (OR 0.82, 0.75-0.89). For all defects combined the OR was 1.01 (0.96-1.07), due to including defects with a reduced risk and those with no association (including chromosomal defects). CONCLUSIONS ; Birth defects that are positively associated with maternal smoking should now be included in public health educational materials to encourage more women to quit before or during pregnancy.

Pesticides and health risks.

Pesticides are a category of chemicals formulated to kill or repel a pest or halt its reproduction. In this article we review the toxicological and epidemiological literature; describe common potential pesticide exposures; and focus on the associated health risks to fetal development. Clinical implications are reviewed, and recommendations are made regarding the integration of this environmental health concern into nursing education, practice, research, and policy/advocacy work. Recommendations for pesticide elimination and reduction in health care settings are included.

Intrauterine head stab wound injury resulting in a growing skull fracture: a case report and literature review.

INTRODUCTION: Penetrating injuries of the gravid uterus are rare complications of pregnancy with gunshot wounds most common than stab wounds. Fetal head injury is an unusual sequela of these penetrating traumas. MATERIALS AND METHODS: We describe the case of a 20-year-old pregnant woman stabbed at the lower abdomen at 30th weeks of gestation. She was nonsurgically managed by serial examination and continuous fetal monitoring. RESULTS: Spontaneous vaginal delivery occurred at term with good maternal and fetal outcome. The newborn examination revealed a right temporal swelling interpreted as a subcutaneous hemangioma. At 2 years and 6 months of life, the child was led to our attention with a pulsating bulge in the right temporal region. Clinical examination and imaging were indicative of a typical growing skull fracture. The child underwent neurosurgical procedure for repairing of the dural tear and bone defect according to the senior author's personal technique, described in details, with a good neurological and esthetic outcome. CONCLUSION: Thirty-two cases of stab wounds to the pregnant uterus have been reported to date in medical literature with two cases of fetal head injury.Growing skull fractures are rare complications of head injury and only one case has been described in the perinatal period following blunt trauma to the mother's abdomen 2-3 weeks before birth.