Interrater reliability of qualitative ultrasound assessment of gastric content in the third trimester of pregnancy.

BACKGROUND: Pulmonary aspiration of gastric contents in pregnant women undergoing general anaesthesia is one of the most feared complications in obstetric anaesthesia. Bedside gastric ultrasonography is a feasible imaging tool to assess the gastric content. The purpose of this study was to investigate the reliability of qualitative bedside assessment of the gastric content performed by anaesthesiologists on third trimester pregnant women. METHODS: Pregnant women (≥32 weeks gestational age) were randomized to undergo ultrasound (US) assessments of their stomach in a fasting state (>8 h), or after ingestion of clear fluids only, or solid food. Three anaesthesiologists trained in gastric ultrasonography performed the assessments using a low-frequency curved-array US transducer (5-2 MHz). Primary outcome of the study was the consistency of raters in diagnosing the correct status of the gastric content, which was used to determine the interrater reliability among the three anaesthesiologists. Secondary outcomes were overall proportion of correct and incorrect diagnoses and the specific proportions of correct diagnosis across the three gastric content groups. RESULTS: We analysed 32 pregnant women. The interrater reliability displayed a kappa statistic of 0.74 (bias corrected 95% CI: 0.68-0.84). The overall proportion of correct diagnosis was 87.5% (84 of 96). The odds of correct diagnosis for 'solid contents' were 16.7 times the odds for 'empty', and 14.3 times for 'clear fluid'. CONCLUSIONS: Our results show the consistency of the qualitative US assessment of gastric contents of pregnant women in the third trimester by anaesthesiologists. A kappa of 0.74 suggests substantial agreement in terms of interrater reliability for this diagnostic measurement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01564030.

Autoantibodies to phospholipids and nuclear antigens in non-pregnant and pregnant Colombian women with recurrent spontaneous abortions.

Autoantibodies to negatively charged phospholipids have been reported to be associated with thrombotic events, thrombocytopenia and adverse pregnancy outcome, such as intrauterine growth retardation and recurrent spontaneous abortions (RSAs). In this study, autoantibodies to 6 phospholipid antigens and antinuclear antibody (ANA) were tested in Colombian women with a history of RSAs. Sixty-eight non-pregnant and 25 pregnant women with a history of RSAs comprised the study group. Twenty-five non-pregnant normal healthy women and thirty-one normal pregnant women served as controls. The non-pregnant women with RSAs showed a higher incidence of autoantibodies to cardiolipin (23% positive) as compared with non-pregnant normal controls (0% positive; P < 0.005). The incidence of autoantibodies to cardiolipin (28%; P < 0.005), phosphatidylethanolamine (16%; P < 0.005), phosphatidylserine (16%; P < 0.05), phosphatidylglycerol (16%; P < 0.05), phosphatidic acid (16%; P < 0.01) and phosphatidylinositol (20%; P < 0.01), in the pregnant women with RSAs was significantly higher than that of normal pregnant controls. There was no difference in the incidence of ANA in either group. In conclusion, women with a history of RSAs have a higher incidence of autoantibodies to phospholipids when compared to pregnant and non-pregnant normal controls. Autoimmune serological work-up is indicated during pregnancy in women with a history of RSAs.

An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient.

BACKGROUND: The Focused Assessment for the Sonographic Examination of the Trauma patient (FAST) sequentially surveys for the presence or absence of blood in dependent abdominal regions including the right upper quadrant, left upper quadrant, and the pelvis. But it does not readily identify intraparenchymal or retroperitoneal injuries, and a CT scan of the abdomen may be needed to reduce the incidence of missed injuries. We hypothesized that select patients who are considered high risk for occult injuries should undergo a CT scan of the abdomen when the FAST is negative so that occult injuries can be detected. STUDY DESIGN: An algorithm was prospectively tested for the evaluation of select injured patients over a 3 1/2-year period. Entrance criteria included adult patients with a blunt mechanism of trauma, a negative FAST examination, and a spine fracture (with or without cord injury), or a pelvic fracture. Trauma team members performed the FAST on patients during the Advanced Trauma Life Support secondary survey. Data recorded included the patient's mechanism and type of injury, the results of the FAST and CT scan examinations, operative or postmortem findings or both, and patient outcomes. Patients with spine injuries were grouped according to spine level and the presence or absence of neurologic deficit. The patients with pelvic fractures were grouped according to the Young and Resnick classification. RESULTS: One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. CONCLUSIONS: Based on these preliminary data, we conclude that patients with pelvic ring-type fractures should have CT scans of the abdomen because of the higher yield for occult injuries.

Immune abnormalities in endometriosis compromising fertility in IVF-ET patients.

OBJECTIVE: To evaluate the incidence of immune abnormalities in patients with endometriosis and primary or secondary infertility. STUDY DESIGN: This study analyzed the incidence of alloantibodies and autoantibodies in 100 women with endometriosis and 62 patients with unexplained infertility without endometriosis who enrolled in an assisted reproduction program at the Colombian Fertility and Sterility Center from January 1, 1996, to May 30, 1997. The alloimmune status of the women was determined by testing for the presence or absence of antileukocyte antibodies. The autoimmune studies included antinuclear antibodies, antiphospholipid antibodies and lupus anticoagulant antibody. RESULTS: Negative titers of IgG antipaternal antibodies were identified in 34% of patients with primary infertility and in 34% of women with secondary infertility and a history of pregnancy losses. Positive titers of antinuclear antibodies were found in 27% (27/100) of the group of patients with endometriosis; of them, 30% (15/50) had primary infertility and 24% (12/50), secondary infertility. The average titer was 1/80. Forty-eight percent of the infertile patients (48/100) showed titers of antiphospholipid antibodies for IgG and IgM; 46% of these patients had primary infertility (23/50) and 50% (25/50), secondary infertility. This was significantly higher than in controls (P < .05). Two patients were positive for lupus anticoagulant antibody. In the group of patients with unexplained infertility without endometriosis, the incidence of antinuclear antibodies was 17.7% and of antiphospholipid antibodies, 30.6%. CONCLUSION: For women with endometriosis, alloimmune and autoimmune evaluation is recommended prior to their undergoing assisted reproduction in order to provide appropriate therapy for each case.

Peripartum cardiomyopathy: postpartum decompensation and use of non-invasive cardiac output monitoring.

The utility of a non-invasive cardiac output monitor (NICOM™) in guiding the peripartum management and identification of postpartum complications in a patient with severe peripartum cardiomyopathy is reported. A 31-year-old nulliparous woman at 35 weeks of gestation presented with a three-week history of worsening dyspnea and progressive functional deterioration. A transthoracic echocardiogram showed severe left ventricular systolic dysfunction with an ejection fraction <20%. Cardiac status was monitored using NICOM™ during labor and delivery. The baseline values were: cardiac output 5.3 L/min, total peripheral resistance 1549 dynes.sec/cm(5), stroke volume 42.1 mL and stroke volume variation 18%. She received early epidural analgesia during labor, titrated slowly with a loading dose of 0.0625% bupivacaine 10 mL and fentanyl 25 µg, followed by patient-controlled epidural analgesia (0.0625% bupivacaine with fentanyl 2 µg/mL, infusion at 10 mL/h, bolus dose 5 mL and lockout interval 10 min). After epidural drug administration, total peripheral resistance decreased, cardiac output increased, and satisfactory analgesia was obtained. She had an uneventful vaginal delivery with a forceps-assisted second stage after prophylactic administration of furosemide 20 mg. NICOM™ was discontinued after delivery. Fifteen hours post-delivery, the patient developed cardiogenic shock, which resolved after aggressive therapy with inotropes and furosemide. NICOM™ can be used to guide treatment during labor and delivery in patients with critical peripartum cardiomyopathy. We suggest that use of NICOM™ be extended into the postpartum period to detect signs of cardiac decompensation in such patients.

Incidence of autoantibodies in the infertile population.

The purpose of this study was to determine the incidence of autoantibodies in patients with no term pregnancies. Patients selected included 43 with primary infertility and 110 with a history of pregnancy loss. In the first group the incidence of antinuclear antibodies (ANA) and IgG and IgM antiphospholipid antibodies (APL) was 37.2% (p < 0.05) and 53.5% (p < 0.05), respectively. In the group of patients with a history of miscarriage, 31.8% (p < 0.05) were positive for ANA and 38.2% (p < 0.05) for APL. Controls were 35 healthy patients with proven fertility and no history of pregnancy loss or autoimmune disease. In this group the incidence of ANA was 5.7% and 11.4% for APL. The high incidence of autoantibodies found in patients with primary infertility might suggest a direct involvement of these antibodies in reproductive failure and consequently in IVF and assisted fertility procedures. The prevalence of ANA and APL has been extensively described in patients with a history of recurrent pregnancy losses (RPL). In this study we observed antibodies even after the first miscarriage. We therefore conclude that patients with a history of reproductive failure should be immunologically evaluated and treated before undergoing assisted fertilization techniques or before a new pregnancy in those cases of RPL.

Alelos HLA DQ alfa maternos, pérdida recurrente del embarazo y síndrome de anticuerpos antifosfolípidos

Autoantibodies to phospholopids antigens APL, are associated with a history of RSA in women without autoinmunedisease. APL interfere with the production of prostaciclin allowing the increase of thrombotic events. Phospholipids are compounds of placental mebrane structure and also they have been considered as an adhesion molecules participating in the formation of syncytotrophoblast. Trophoblastic antigens can induce the production of antiphospholipids antibodies. This antiboidies can delay the trophoblast development by the action in the adhesion molecules. We have studied 270 women with RSA and 31 women as a control group which had normal pregnancies. The testing incluided antiphospholopid antibodies and genetic evaluation of class II DQ antigens of the couple. We have showed APL titles no gretaer than 1/25 in normal pregnant women. In RSA the incidence increases in a fifteen percent with each subsequent pregnancy loss. We observed an strong correlation between maternal HLA DQ alfa 4.1 (0501) and increases in APL titles in patients who loss their pregnancy again