Arrhythmias in Pregnancy.

The prevalence of arrhythmias in pregnant women are rising, particularly among women with a history of structural heart disease or prior arrhythmia. The physiological changes of pregnancy increase the risk of both benign and pathologic arrhythmias, with atrial fibrillation representing the most common pathologic arrhythmia. While bradyarrhythmias rarely require treatment during pregnancy, pharmacotherapy is frequently required for tachyarrhythmias. Electrophysiological procedures including cardioversions, ablations, and device placement are occasionally required during pregnancy and can be performed safely with proper precautions. This chapter will discuss the diagnosis and management of a broad array of cardiac arrhythmias that may be encountered in pregnant women.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Skin Preparation for Prevention of Surgical Site Infection After Cesarean Delivery: A Randomized Controlled Trial.

OBJECTIVE: To compare chlorhexidine with alcohol, povidone-iodine with alcohol, and both applied sequentially to estimate their relative effectiveness in prevention of surgical site infections after cesarean delivery. METHODS: Women undergoing nonemergent cesarean birth at greater than 37 0/7 weeks of gestation were randomly allocated to one of three antiseptic skin preparations: povidone-iodine with alcohol, chlorhexidine with alcohol, or the sequential combination of both solutions. The primary outcome was surgical site infection reported within the first 30 days postpartum. Based on a surgical site infection rate of 12%, an anticipated 50% reduction for the combination group relative to either single skin preparation group, with a power of 0.90 and an α of 0.05, 430 women per group were needed to detect a difference. RESULTS: From January 2013 to July 2014, 1,404 women were randomly assigned to one of three groups: povidone-iodine with alcohol (n=463), chlorhexidine with alcohol (n=474), or both (n=467). The groups were similar with respect to demographics, medical disorders, indication for cesarean delivery, operative time, and blood loss. The overall rate of surgical site infection-4.3%-was lower than anticipated. The skin preparation groups had similar surgical site infection rates: povidone-iodine 4.6%, chlorhexidine with alcohol 4.5%, and sequential 3.9% (P=.85). CONCLUSION: The skin preparation techniques resulted in similar rates of surgical site infections. Our study provides no support for any particular method of skin preparation before cesarean delivery. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT01870583. LEVEL OF EVIDENCE: I.

A Fatal Case of Strongyloidiasis in Pregnancy.

BACKGROUND: Strongyloides stercoralis is a common human parasite worldwide and has been associated with severe infection in immunosuppressed patients. High mortality rates have accompanied this severe disseminated infection. There is a scarcity of literature surrounding severe Strongyloides infection in pregnancy. CASE: A 30-year-old primigravid Haitian woman at 25 weeks of gestation presented with acute abdominal pain and an abnormal fetal heart tracing. Mild anemia and eosinophilia were laboratory abnormalities on admission. She received corticosteroids for the fetus and subsequently developed septic shock. Sputum and stool were positive for S stercoralis larvae. Hyperinfection was diagnosed, stillbirth occurred, and the patient died. CONCLUSION: A more global awareness and education surrounding helminth infection during pregnancy may improve response, reduce delay in diagnosis, and potentially improve outcome.

Neuromyelitis optica in pregnancy complicated by posterior reversible encephalopathy syndrome, eclampsia and fetal death.

Neuromyelitis optica (NMO) is a demyelinating syndrome characterized by optic neuritis and acute myelitis with poor recovery and a progressive course. We report a poor outcome complicated by posterior reversible encephalopathy syndrome (PRES) and eclampsia and review available literature and current evidence for anticipation of adverse fetal and maternal effects. After a pregnancy complicated by multiple admissions for painful NMO exacerbations, a primiparous patient with seropositive NMO presented at 31 + 3/7 weeks with eclampsia, HELLP and subsequent fetal death. MRI confirmed PRES. NMO may be associated with eclampsia and leads to adverse maternal and fetal outcomes. Posited mechanisms include antibody-mediated placental damage and a heightened risk of eclampsia-associated PRES. Further characterization of the course of NMO and its relationship with pregnancy outcomes in larger series would be invaluable.

Pediatric neurology participation in a fetal diagnostic service.

Fetal neurologic consultations were provided to 166 maternal-fetal pairs over a 5-year period. Consultations were initiated during the second trimester in 46% (74/166) of pairs. Fifty-percent (83/166) of these consultations involved brain malformations, of which 55% (46/83) were also associated with other organ abnormalities. Brain malformations principally consisted of encephalocele, dorsal neural tube defects, holoprosencephaly, schizencephaly, cerebellar dysgenesis, and ventriculomegaly. Non-central nervous system organ system anomalies were observed in another 50% (83/166), in decreasing order of occurrence-cardiac, renal, gastrointestinal, pulmonary, in utero growth restriction, and hydrops fetalis. Outcome data on 128 children included survival at delivery for 86/128 or 67.2%, termination in 16/128 (12.5%), stillborn 6/128 (4.7%), and postnatal deaths in 20/128 (15.6%). Maternal medical histories were abnormal for 65% of women. Placental pathology was abnormal in 80% (72/102) of available specimens, consisting of both chronic and acute lesions. Postnatal diagnoses were obtained in 128 neonates; 64% (82/128) remained the same diagnosis, 28.1% (36/128) had a worse or improved diagnosis, and 10/128 (7.8%) were normal. Pediatric neurologists can provide useful fetal consultations early during gestation, and must consider multiple organ diagnoses and maternal-placental diseases. Postnatal diagnoses may be different from the fetal diagnoses which will influence continuity of care for the child at older ages.