The Rising Triad of Cesarean Scar Pregnancy, Placenta Percreta, and Uterine Rupture: A Case Report and Comprehensive Review of the Literature.

As the rate of cesarean sections continues to rapidly rise, knowledge of diagnosis and management of cesarean scar pregnancies (CSPs) is becoming increasingly more relevant. CSPs rest on the continuum of placental abnormalities which include morbidly adherent placenta (accreta, increta, and percreta). A CSP poses a clinical challenge which may have significant fetal and maternal morbidity. At this point, no clear management guidelines and recommendations exist. Herein we describe the case of a second trimester CSP with rapid diagnosis and management in a tertiary care center. The case underscores the need for well-coordinated mobilization of resources and a multidisciplinary approach. A review of the literature is performed and deficits in universal management principles are underscored.

Maternal Obesity Is an Independent Risk Factor for Intensive Care Unit Admission during Delivery Hospitalization.

OBJECTIVE: We aim to quantify the impact of obesity on maternal intensive care unit (ICU) admission. MATERIALS AND METHODS: This is a population-based, retrospective cohort study of Ohio live births from 2006 to 2012. The primary outcome was maternal ICU admission. The primary exposure was maternal body mass index (BMI). Relative risk (RR) of ICU admission was calculated by BMI category. Multivariate logistic regression quantified the risk of obesity on ICU admission after adjustment for coexisting factors. RESULTS: This study includes 999,437 births, with peripartum maternal ICU admission rate of 1.10 per 1,000. ICU admission rate for BMI 30 to 39.9 kg/m2 was 1.24 per 1,000, RR: 1.20 (95% confidence interval [CI]: 1.07, 1.35); BMI 40 to 49.9 kg/m2 had ICU admission rate of 1.80 per 1,000, RR: 1.73 (95% CI: 1.38, 2.17); and BMI ≥ 50 kg/m2 had ICU admission rate of 2.98 per 1,000, RR: 1.73 (95% CI: 1.77, 4.68). After adjustment, these increases persisted in women with BMI 40 to 49.9 kg/m2 with adjusted relative risk (adjRR) of 1.37 (95% CI: 1.05, 1.78) and in women with BMI ≥ 50 kg/m2, adjRR: 1.69 (95% CI: 1.01, 2.83). CONCLUSION: Obesity is a risk factor for maternal ICU admission. Risk increases with BMI. After adjustment, BMI ≥ 40 kg/m2 is an independent risk factor for ICU admission.

Atrial Fibrillation as a Rare Complication of the Use of Nifedipine as a Tocolytic Agent: A Case Report and Review of the Literature.

Calcium channel blockers are commonly used tocolytic agents on Labor and Delivery units worldwide as part of the management of preterm labor. Despite their overall reassuring safety profile, rare cardiovascular complications have been reported. In this report, we describe the case of threatened preterm labor managed with nifedipine with subsequent development of atrial fibrillation. This type of cardiac arrhythmia may have considerable consequences for both the mother and the fetus. The aim of this case report and comprehensive review of the literature is to raise awareness.

Acute kidney injury during pregnancy.

Acute kidney injury complicates the care of a relatively small number of pregnant and postpartum women. Several pregnancy-related disorders such as preeclampsia and thrombotic microangiopathies may produce acute kidney injury. Prerenal azotemia is another common cause of acute kidney injury in pregnancy. This manuscript will review pregnancy-associated acute kidney injury from a renal functional perspective. Pathophysiology of acute kidney injury will be reviewed. Specific conditions causing acute kidney injury and treatments will be compared.

Initial experience with a dual-balloon catheter for the management of postpartum hemorrhage.

OBJECTIVE: When uterotonics fail to cause sustained uterine contractions and satisfactory control of hemorrhage after delivery, tamponade of the uterus can be effective in decreasing hemorrhage secondary to uterine atony. STUDY DESIGN: These data are from a postmarketing surveillance study of a novel dual-balloon catheter tamponade device, the Belfort-Dildy Obstetrical Tamponade System (ebb). RESULTS: A total of 57 women were enrolled: 55 women had the diagnosis of postpartum hemorrhage, and 51 women had uterine balloon placement within the uterine cavity. This study reports the outcomes in the 51 women who had uterine balloon placement within the uterine cavity for treatment of postpartum hemorrhage, as defined by the "Instructions for Use." We further assessed 4 subgroups: uterine atony only (n = 28 women), placentation abnormalities (n = 8 women), both uterine atony and placentation abnormalities (n = 9 women), and neither uterine atony nor placentation abnormalities (n = 6 women). The median (range) time interval between delivery and balloon placement was 2.2 hours (0.3-210 hours) for the entire cohort (n = 51 women) and 1.3 hours (0.5-7.0 hours) for the uterine atony only group (n = 28 women). Bleeding decreased in 22/51 of cases (43%), stopped in 28/51 of cases (55%), thus decreased or stopped in 50/51 of the cases (98%) after balloon placement. Nearly one-half (23/51) of all women required uterine balloon volumes of >500 mL to control bleeding. CONCLUSION: We conclude that uterine/vaginal balloon tamponade is very useful in the management of postpartum hemorrhage because of uterine atony and abnormal placentation.

Risk factors for a prolonged length of stay in women hospitalized for preeclampsia in Texas.

OBJECTIVES: To identify correlates of a prolonged length of stay (PLOS) in women hospitalized for preeclampsia/eclampsia in Texas, USA. METHODS: Statewide hospital data were obtained, and the records of women who were discharged in 2004 and/or 2005 with a principal discharge diagnosis of preeclampsia or eclampsia were extracted using ICD-9-CM codes. PLOS was defined as a stay greater than 5 days. Odds ratios (OR) for PLOS were calculated. Generalized estimating equations were used to account for a small group of women who were hospitalized multiple times during the study period for preeclampsia. A total of 21,203 records were analyzed. RESULTS: The crude incidence of PLOS was 17.5%. Advancing maternal age was positively associated with PLOS: for every 10-year increase, there was a 20% increase in the odds of PLOS (adjusted OR = 1.20,95% confidence interval (CI): 1.13, 1.28). The strongest risk factor for PLOS was the presence of renal disease: adjusted OR 5.81 (95% CI: 3.97, 8.50). Protective factors included Medicaid beneficiary status, and being admitted from the emergency department. CONCLUSIONS: The strongest correlate of PLOS in a large cohort of women hospitalized for preeclampsia was the presence of renal disease.

Bell's palsy and pregnancy.

OBJECTIVE: To describe the epidemiology, pathophysiology, presentation, treatment, and prognosis of Bell's palsy (BP) in pregnancy. RESULTS: The incidence of BP in pregnant women is not significantly greater than expected compared to all women of childbearing age. There is a high incidence of cases in the third trimester and corresponding low incidence during early pregnancy. CONCLUSION: There is no conclusive evidence that the etiology of BP in pregnancy is different than in nonpregnant patients. Altered susceptibility to herpes simplex viral reactivation during pregnancy is the most likely explanation for concentration of cases in the third trimester. Outcome may be poorer in pregnant patients, though historically, treatment is often withheld from these patients. SIGNIFICANCE: Management of BP in pregnancy can mirror that of nonpregnant individuals with the exception of first-trimester cases.

Detection of gestational diabetes mellitus by homeostatic indices of insulin sensitivity: a preliminary study.

OBJECTIVE: We investigated whether homeostatic indices of insulin sensitivity might suitably screen for gestational diabetes mellitus. STUDY DESIGN: One hundred twenty-three pregnant women who were between 24 and 28 weeks of gestation completed a 3-hour 100-g oral glucose challenge test and fasting insulin level in a nested case-control study design. Insulin sensitivity indices were calculated and tested for their ability to detect gestational diabetes mellitus. RESULTS: Fasting glucose demonstrated the best overall accuracy, but the homeostasis model assessment and quick insulin sensitivity check index were also sensitive screening techniques for gestational diabetes mellitus when either the National Diabetes Data Group or Carpenter-Coustan criteria were used. CONCLUSION: Homeostasis model assessment, quick insulin sensitivity check index, and fasting glucose are sensitive screening tests for gestational diabetes mellitus and can avoid oral administration of glucose-containing solutions.

Getting the right cells to the array: Gene expression microarray analysis of cell mixtures and sorted cells.

BACKGROUND: Most biological samples are cell mixtures. Some basic questions are still unanswered about analyzing these heterogeneous samples using gene expression microarray technology (MAT). How meaningful is a cell mixture's overall gene expression profile (GEP)? Is it necessary to purify the cells of interest before microarray analysis, and how much purity is needed? How much does the purification itself distort the GEP, and how well can the GEP of a small cell subset be recovered? METHODS: Model cell mixtures with different cell ratios were analyzed by both spotted and Affymetrix MAT. GEP distortion during cell purification and GEPs of purified cells were studied. CD34+ cord blood cells were purified and analyzed by MAT. RESULTS: GEPs for mixed cell populations were found to mirror the cell ratios in the mixture. Over 75% pure samples were indistinguishable from pure cells by their overall GEP. Cell purification preserved the GEP. The GEPs of small cell subsets could be accurately recovered by cell sorting both from model cell mixtures and from cord blood. CONCLUSIONS: Purification of small cell subsets from a mixture prior to MAT is necessary for meaningful results. Even completely hidden GEPs of small cell subpopulations can be recovered by cell sorting.

Neonatal organ system injury in acute birth asphyxia sufficient to result in neonatal encephalopathy.

OBJECTIVE: To identify the proportion of major organ system injury in cases of acute intrapartum asphyxia that result in neonatal encephalopathy. METHODS: A prospectively maintained database was cross-referenced using medical record coding to identify diagnoses of acute intrapartum asphyxia, acute birth asphyxia, or neonatal encephalopathy over a 6-year period. An acute intrapartum asphyxial antecedent was validated with emphasis on excluding long-standing or chronic conditions where injury likely occurred before presentation. Injury pattern was evaluated using routinely available laboratory and imaging tests. RESULTS: Forty-six cases of acute peripartum asphyxia sufficient to result in the diagnosis of neonatal encephalopathy were identified. Clinical central nervous system injury resulting in encephalopathy was present in 100% of cases as it was an entry criteria; of these, 49% had electroencephalogram and 40% had imaging studies diagnostic of acute injury. Liver injury based on elevated aspartate transaminase or alanine transaminase levels occurred in 80%. Heart injury, as defined by pressor or volume support beyond 2 hours of life or elevated cardiac enzymes, occurred in 78%. Renal injury, defined by an elevation of serum creatinine to greater than 1.0 mg/dL, persistent hematuria, persistent proteinuria, or clinical oliguria, occurred in 72%. An elevation in nucleated red blood cell counts exceeding 26 per 100 white blood cells occurred in 41%. CONCLUSION: Using common diagnostic tests as markers of acute asphyxial injury, we noted that multiple organs suffer damage during an acute intrapartum asphyxial event sufficient to result in a neonatal encephalopathy.