A Model of Group Prenatal Care for Patients with Prenatally Diagnosed Fetal Anomalies.

The model of group prenatal care was initially developed to include peer support and to improve education and health-promoting behaviors during pregnancy. This model has since been adapted for populations with unique educational needs. Mama Care is an adaptation of the CenteringPregnancy Model of prenatal care. Mama Care is situated within a national and international referral center for families with prenatally diagnosed fetal anomalies. In December 2013, the Center for Fetal Diagnosis and Treatment at Children's Hospital of Philadelphia began offering a model of group prenatal care to women whose pregnancies are affected by a prenatal diagnosis of a fetal anomaly. The model incorporates significant adaptations of CenteringPregnancy in order to accommodate these women, who typically transition their care from community-based settings to the Center for Fetal Diagnosis and Treatment in the late second or early third trimester. Unique challenges associated with caring for families within a referral center include a condensed visit schedule, complex social needs such as housing and psychosocial support, as well as an increased need for antenatal surveillance and frequent preterm birth. Outcomes of the program are favorable and suggest group prenatal care models can be developed to support the needs of patients with prenatally diagnosed fetal anomalies.

Pregnancy outcomes in anti-NMDA receptor encephalitis: Case series.

OBJECTIVE: To report the effects of anti-NMDA receptor (NMDAR) encephalitis in pregnant patients and their babies. METHODS: We studied a retrospective cohort of patients who developed anti-NMDAR encephalitis during pregnancy or became pregnant while recovering from the encephalitis. In addition, we reviewed the English literature between 2010 and 2019 related to this topic. RESULTS: We studied 11 patients; 6 developed anti-NMDAR encephalitis during pregnancy, and 5 became pregnant while recovering. There were no obstetrical complications, but 6 (55%) babies were premature. Ten newborns were healthy, and 1 (9%) developed transient respiratory distress. Nine infants had assessable follow-up (median 18 months; range, 7-96 months), and all showed normal development. We identified 21 cases in the English literature. Obstetrical complications occurred in 7 (33%) pregnancies. Two patients died of septic shock (1 baby successfully delivered), another 2 had miscarriages, and in 2, the pregnancy was terminated. Sixteen babies (76%) were delivered, 9 (56%) premature. At birth, 13/16 (81%) newborns were healthy, 2/16 (13%) had transient neurologic or respiratory symptoms, and 1 (6%) died of brain edema. Follow-up (median 12 months; range, 6-36 months) was reported for 8 children: 7 (88%) showed normal development and behavior, and 1 (13%) cortical dysplasia. Immunotherapy was used during pregnancy in 7 (64%) of our patients and 18 (86%) of the reported cases, including rituximab in 4 cases, without adverse effects. CONCLUSIONS: Patients who develop anti-NMDAR encephalitis during pregnancy or become pregnant during recovery often have obstetrical complications, but most of the newborns are healthy and appear to have normal development.

Plasma and cerebrospinal fluid inflammatory cytokines in perinatal depression.

BACKGROUND: While perinatal depression is one of the most common complications of pregnancy, there is an insufficient understanding of the mechanistic underpinnings of disease. While an association between peripheral inflammatory cytokines and major depressive disorder has been demonstrated, cytokines cannot freely cross the blood-brain barrier, and thus, they give little insight into alternations in brain function. Because the brain is in direct communication with the cerebrospinal fluid, assessment of inflammation in the cerebrospinal fluid may be more directly related to the biologic markers of affective change. OBJECTIVE: Our objectives were to examine the association between perinatal depression and inflammatory cytokines in plasma, the association between perinatal depression and inflammatory cytokines in cerebrospinal fluid, and the correlations between plasma and cerebrospinal fluid inflammatory cytokines. STUDY DESIGN: This was a prospective, observational study of women with a singleton gestation at term undergoing a scheduled cesarean delivery. Women were screened for depression and those with depressive symptomatology preferentially enrolled. The Mini-International Neuropsychiatric Interview was administered to confirm the clinical diagnosis of depression. Maternal plasma and cerebrospinal fluid were collected preoperatively and cytokines measured via flow cytometry. Bivariable and multivariable analyses were used to determine the association between each cytokine and perinatal depression. Correlations were measured between the cytokines in plasma and cerebrospinal fluid. RESULTS: Of the 117 women who met inclusion criteria, 76 (65%) screened positive for depression, 15 (20%) of whom met the clinical diagnostic criteria for depression. There were no significant associations between any of the plasma cytokines and perinatal depression in our sample. Conversely, in multivariable analyses, higher cerebrospinal fluid interleukin-1ß (adjusted odds ratio, 232.7, 95% confidence interval, 5.9-9148.5), interleukin-23 (adjusted odds ratio, 22.1, 95% confidence interval, 1.7-294.5), and interleukin-33 (adjusted odds ratio, 1.7, 95% confidence interval, 1.1-2.6) concentrations were significantly associated with increased odds of perinatal depression. The plasma and cerebrospinal fluid cytokine concentrations were not strongly correlated. CONCLUSION: Higher concentrations of cerebrospinal fluid cytokines were associated with perinatal depression. These cerebrospinal fluid cytokines were not strongly correlated with plasma cytokines, and accordingly, plasma cytokines were not significantly associated with perinatal depression. Central neuroinflammation, as opposed to peripheral inflammation, may represent a mechanistic pathway that contributes to perinatal depression.

Progressive Functional Underdrainage in Cerebrospinal Fluid Shunt-Dependent Women During Pregnancy: Case Report and Review of the Literature.

BACKGROUND: Since the 1950s cerebrospinal fluid (CSF) shunt dependency has no longer been a contradiction to normal life, including sexuality and pregnancy in women, because of advances in the understanding of hydrocephalus and shunt technology. Although pregnancy in shunt-dependent women is rare, it causes uncertainty among treating physicians. CASE DESCRIPTION: We report the case of a 34-year-old pregnant woman with a ventriculoperitoneal shunt. Throughout her pregnancy she experienced progressive symptoms of CSF underdrainage without any signs of other pregnancy-related complications. After the delivery of a healthy infant, shunt resistance had to be readjusted to prepregnancy levels. A comprehensive review of the literature reports in English, listed in PubMed, is provided. CONCLUSIONS: Conservative treatment of pregnancy-related functional underdrainage by consecutive valve pressure adjustment is possible, easy, and safe.

Cerebrospinal Fluid CRH Levels in Late Pregnancy Are Not Associated With New-Onset Postpartum Depressive Symptoms.

CONTEXT: CRH participates in the hypothalamic-pituitary-adrenal axis and in neural circuits involved in the pathophysiology of depression. During pregnancy, the placenta produces large amounts of CRH, and production ceases abruptly after delivery. The relationship between CRH in the cerebrospinal fluid (CSF) during pregnancy and peripartum mood disorders has not been investigated. OBJECTIVES: The objectives were to determine whether there are differences in CSF CRH concentrations of pregnant and nonpregnant women and whether CSF CRH concentrations in late pregnancy are associated with the presence of depressive symptoms during pregnancy and in the early postpartum period. DESIGN: This was a prospective cohort study conducted from January to April, 2011. SETTING: The study was conducted in one public and two private hospitals in Brasilia, Brazil. PATIENTS: Patients included 107 healthy pregnant women who underwent elective cesarean delivery and 22 nonpregnant healthy women who underwent spinal anesthesia for elective surgical sterilization. INTERVENTION: CRH in CSF was measured in pregnant and nonpregnant women by ELISA. MAIN OUTCOME MEASURE: The association between CSF CRH concentration at delivery and maternal depression assessed before cesarean section and postpartum (4 to 8 wk) with the Edinburgh Postnatal Depression Scale (EPDS), with a cutoff of ≥ 13. RESULTS: CRH concentration in the CSF was significantly higher in pregnant (4.1 ± 0.51 log CRH) than in nonpregnant women (3.6 ± 0.26 log CRH) (P < .001). Depressive symptoms starting after delivery occurred in 5.6% of women. CRH concentration in CSF was not different between women without depressive symptoms and women showing such symptoms during pregnancy or in the postpartum period. CONCLUSION: CRH concentration in the CSF was higher in pregnant women than in nonpregnant women. However, in this sample, CSF CRH in late pregnancy was not associated with new-onset depressive symptoms in the early postpartum period.

The effect of serial in vitro haemodilution with maternal cerebrospinal fluid and crystalloid on thromboelastographic (TEG(®) ) blood coagulation parameters, and the implications for epidural blood patching.

Epidural blood patches may be used to treat post-dural puncture headache following accidental dural puncture in parturients. Their mode of action and the optimum volume of blood for injection remain controversial, with the interaction between injected blood and cerebrospinal fluid unknown. We aimed to establish the effects of serial haemodilution of whole blood with cerebrospinal fluid from 34 pregnant patients compared with serial haemodilution with Hartmann's solution, using the thromboelastogram. Haemodilution with either cerebrospinal fluid or Hartmann's solution had significant procoagulant and clot destabilising effects, enhanced with progressive haemodilution up to 30%. The effect of cerebrospinal fluid was greater compared with Hartmann's solution (p < 0.001). Cerebrospinal fluid led to a mean (95% CI) decrease in r-time by 2.4 (1.6-3.2) min, a decrease in k-time by 0.6 (0.4-0.8) min, an increase in alpha angle by 7.3 (5.5-9.0)°, and a decrease in maximum amplitude by 2.0 (0.6-3.4) mm. This may have implications for epidural blood patch, as success may be reduced near the time of dural puncture when cerebrospinal fluid leak is at its greatest, and large volumes of blood may be required to reduce haemodilution and clot destabilisation by cerebrospinal fluid. In addition, blood patching should be performed at the level of the dural puncture in order to ensure that the maximum volume of blood comes into contact with the cerebrospinal fluid.

A combined spinal-epidural technique for labor analgesia and symptomatic relief in two parturients with idiopathic intracranial hypertension.

Idiopathic intracranial hypertension is a condition consisting of increased intracranial pressure of unknown etiology, predominantly affecting obese women of childbearing age. Symptomatic relief can be provided by lumbar puncture and withdrawal of cerebrospinal fluid, and the technique has been described in laboring women using an intrathecal catheter. We present two patients who achieved both labor analgesia and symptomatic relief via a combined spinal-epidural technique with small volume cerebrospinal fluid withdrawal. Both women complained of headache of at least a 5 on a 10-point pain scale at the time of labor induction. Between 5 and 6 mL of cerebrospinal fluid were withdrawn at the time of combined spinal-epidural insertion and pain relief was successfully achieved with patient-controlled epidural anesthesia. One patient proceeded to cesarean delivery for fetal indications under epidural anesthesia. Both women described significant improvement in headache symptoms that persisted until discharge from hospital, and neither developed new neurologic symptoms. A combined spinal-epidural technique with a small volume of cerebrospinal fluid withdrawal may provide labor analgesia and symptomatic relief in the parturient with idiopathic intracranial hypertension.

Catecholamine concentrations in venous plasma and cerebrospinal fluid in normal and complicated pregnancy.

The concentrations of adrenaline and noradrenaline were determined in venous plasma and cerebrospinal fluid (CSF) of 41 pregnant women at term scheduled for elective or 'hot' caesarean section and in 7 healthy non-pregnant women scheduled for elective surgery. Group 1: 10 pregnant women at term with a normal history of their pregnancy; group 2: like group 1, but in active labour for more than 4 h; group 3: 10 pregnant women with insulin-dependent diabetes mellitus with or without slightly elevated arterial blood pressure; group 4: 11 women with pre-eclampsia gravis; group 5: 7 healthy non-pregnant women of fertile age. The highest values of mean arterial blood pressure and of venous plasma noradrenaline were found in the pre-eclamptic group 4, mean arterial blood pressure and plasma noradrenaline levels correlated to each other. However, concentrations of noradrenaline in CSF in group 4 did not differ significantly from the other groups. It is speculated that a different origin of hypertension may be the reason for the normal noradrenaline concentrations in CSF. This finding is in contrast to earlier findings in which noradrenaline levels in CSF were elevated in patients with essential hypertension.

[Pregnancy and benign intracranial hypertension]. / Embarazo e hipertensión intracraneal benigna.

Several papers have suggested that pregnancy is one of the etiopathogenic factors of benign intracranial hypertension (BIH). The therapeutic attitude to be taken as regards new pregnancies in women previously afflicted with BIH during pregnancy is still on discussion. This paper is based on a study of 100 BIH cases. The results support the idea that cases, but the obesity involved. The coexistence of BIH and pregnancy does not increase the risk of relapse, does not mean a worse prognosis of BIH nor does it appear to have a negative effect on the child. Any woman who has previously developed BIH during pregnancy should not be advised against future pregnancies. In the case of a new pregnancy, a very close control should be carried out in order to avoid an excessive increase in weight.

[Pregnancy and labor in patients with brain tumor and the pseudotumor cerebri syndrome]. / Beremennost' i rody pri mozgovykh opukholiakh i sindrome tserebral'nogo psevdotumora.

This is a presentation of clinical progress and outcomes of pregnancy in 240 women with cerebral tumors (n-16) and pseudotumors (n-224). Etiologies of cerebral pseudotumors included inflammatory diseases of the nervous system (n-86), cerebrovascular disease (n-81), benign intracranial hypertension (n-20), brain injuries (n-19), late toxemia of pregnancy (n-13) and cranial malformations (n-5). The disease first manifested during the gestation in 103 women. Pregnancy aggravated clinical progress of preexisting disease in 96 (79.3%) of 121 patients with pseudotumors and in 15 (93.7%) of 16 patients with cerebral tumors. Delivery was normal in 124 of 298 pregnancies, premature in 30 pregnancies and operative in 25 pregnancies; 109 pregnancies were terminated by induced or spontaneous abortions. Ten women died before delivery.

Pseudotumor cerebri and pregnancy.

We reviewed 11 pregnancies complicated by pseudotumor cerebri over a 6-year period for an incidence of approximately 1 in 870 births. No pregnancy was adversely affected, but symptoms of pseudotumor increased in 9 of 11 pregnancies. All patients were managed medically, 9 of 11 with analgesics and diuretics. Two cases required steroid therapy.

Effect of chronic maternal hyperkalaemia on plasma, cerebrospinal fluid and brain interstitial fluid potassium in developing rats.

Plasma hyperkalaemia was induced in pregnant and lactating rats using a high potassium diet. Fetuses of high-K-diet mothers showed no increase in the potassium concentration [( K+]) of plasma, cerebrospinal fluid (CSF) and brain interstitial fluid, presumably due to placental control. Neonates from high-K-diet rats did show an increase in plasma [K+] but this increase was very small and there was no increase in CSF or interstitial fluid [K+]. Maternal milk [K+] was not affected by plasma hyperkalaemia. Weanling rats fed the high-K diet directly showed marked plasma hyperkalaemia but no increase in CSF or interstitial fluid [K+]. Thus, prior to weaning, a relatively stable plasma [K+] is maintained by maternal influence reducing the need for direct brain fluid K+ regulation.