Trauma and Considerations Unique to Pregnancy.

Trauma complicates 6% to 7% of all pregnancies and requires multidisciplinary education and training for both trauma and obstetric teams to achieve the best outcome. It is important to understand the mechanisms of certain adverse maternal and fetal/neonatal outcomes incurred as a result of trauma, as well as caveats to pregnancy physiology that make some injuries more likely and detection of maternal compromise more difficult. This article focuses on these caveats and how to incorporate these into ongoing trauma protocols and offers suggestions for the formation of obstetric trauma response team.

Principles of the prolactin/vasoinhibin axis.

The hormonal family of vasoinhibins, which derive from the anterior pituitary hormone prolactin, are known for their inhibiting effects on blood vessel growth, vasopermeability, and vasodilation. As pleiotropic hormones, vasoinhibins act in multiple target organs and tissues. The generation, secretion, and regulation of vasoinhibins are embedded into the organizational principle of an axis, which integrates the hypothalamus, the pituitary, and the target tissue microenvironment. This axis is designated as the prolactin/vasoinhibin axis. Disturbances of the prolactin/vasoinhibin axis are associated with the pathogenesis of retinal and cardiac diseases and with diseases occurring during pregnancy. New phylogenetical, physiological, and clinical implications are discussed.

The use of digital peripheral artery tonometry to detect endothelial dysfunction in pregnant women who smoke.

OBJECTIVE: We hypothesized that, as has been shown outside of pregnancy, endothelial dysfunction would be seen in a dose-dependent fashion among women who smoke in the midtrimester of pregnancy. STUDY DESIGN: Endothelial function in women with singleton pregnancies between 16 and 23 weeks was analyzed utilizing the Endo-PAT2000 device (Itamar Medical Ltd., Caesarea, Israel) and expressed as a reactive hyperemia ratio (RHI). Serum was drawn to check cotinine and high-sensitivity C-reactive protein (CRP) levels. SAS 9.2 (SAS Institute, Cary, NC) was used to perform statistical tests including Student t test, analysis of variance, Fisher exact test, and Pearson coefficient. RESULTS: Endothelial function was noninvasively examined in 29 smokers and 31 nonsmokers. Demographics including age, race, and parity were similar between groups. Mean RHI was not significantly different between smokers and nonsmokers (1.43 ± 0.32 versus 1.53 ± 0.39, p = 0.27). No correlation was noted when cotinine values were plotted against RHI or CRP values in smokers (rho = 0.24, p = 0.21 and rho = 0.26, p = 0.18, respectively). RHI did correlate with diastolic blood pressure (rho = -0.40, p = 0.002), systolic blood pressure (rho = -0.35, p = 0.006), and heart rate (rho = -0.37, p = 0.004). CONCLUSION: We did not find an association between smoking status and endothelial dysfunction in the midtrimester utilizing a noninvasive methodology.

Headache and neurological disease in pregnancy.

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetrician's attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.

Extreme morbid obesity and labor outcome in nulliparous women at term.

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m2) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥ 50) from morbid obesity (BMI ≥ 40 to < 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed. CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22). Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

Physician knowledge and opinions about sexually transmitted infections and the human papillomavirus vaccine: a community based survey.

BACKGROUND: The new Human Papillomavirus (HPV) vaccine is targeted to pre-adolescents; therefore pediatric providers will be its most frequent supplier. METHODS: A survey focusing on physician knowledge and opinions about sexually transmitted infections (STIs) and the HPV vaccine was distributed to pediatric providers in Chattanooga, TN. RESULTS: Response rate of 171 distributed surveys was 59 percent. Most doctors rated their STI knowledge base as adequate (93 percent), felt comfortable counseling on STIs (80 percent), and felt comfortable counseling about the vaccine and administering it (78 percent). Most also felt the vaccine should be incorporated into the current pediatric vaccination schedule (63 percent) eventually for males and (females (63 percent), aged 10-14 years (54 percent). While four percent of respondents felt this vaccine might promote a false sense of security against STIs, none felt it would promote promiscuity. CONCLUSION: Most surveyed providers feel comfortable counseling their patients about STIs and support the current recommendations for the HPV vaccine.

Robotic-assisted laparoscopic placement of transabdominal cerclage during pregnancy.

Cervical incompetence treated with transabdominal cerclage can carry significant morbidity with the need for sequential laparotomies and necessitating prolonged postoperative recovery. Laparoscopic transabdominal cerclage placement has been described but has significant limitations with only two-dimensional depth perception and limited dexterity. Robotic-assisted laparoscopic surgery (RALS) is rapidly gaining acceptance in gynecologic surgery. RALS has reportedly been used for placement of an interval transabdominal cerclage. We report the first two cases where the da Vinci robot was used during pregnancy for placement of abdominal cerclage. Two women were successfully treated with robotic-assisted laparoscopic placement of transabdominal cerclage in pregnancy. Robotic-assisted laparoscopic transabdominal cerclage placement is less invasive and is effective not only as an interval procedure but also during pregnancy, offering the patient an alternative to the traditional laparotomy with quicker recovery time.

Elective appendectomy at the time of cesarean delivery: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to compare postoperative morbidity in patients who underwent cesarean delivery with and without elective appendectomy. STUDY DESIGN: Subjects who underwent cesarean delivery were assigned randomly by computer-generated randomization to either standard cesarean delivery or cesarean delivery with appendectomy. Primary variables that were measured were operative times and markers of morbidity. Secondary outcome was appendiceal pathologic condition. RESULTS: Ninety-three subjects whose condition required cesarean delivery from July 2002 to May 2006 were enrolled (control subjects, 48; active subjects, 45). Operative time in the study group was increased by 8.8 minutes (P < or = .028). Postoperative morbidity findings were similar. Pathologic evaluation revealed 9 abnormalities that included acute appendicitis in 2 patients. CONCLUSION: Elective appendectomy at the time of cesarean delivery does not increase inpatient morbidity. Consideration can be given safely to elective appendectomy at the time of cesarean delivery in selected cases, such as women with palpable fecaliths and/or an abnormal appearing appendix, a history of pelvic pain, endometriosis, or anticipated intraabdominal adhesions.