Bicoastal Spontaneous Coronary Artery Dissection: A Therapeutic Dilemma.

Due to the potential for severe maternal morbidity and even mortality, pregnancy-associated spontaneous coronary artery dissection (P-SCAD) often presents as a clinical conundrum. While current recommendations encourage coronary interventions when medically indicated even during pregnancy, the hesitation still understandably exists. Meanwhile, given the rarity of the condition, the guidelines for management are still based on expert consensus. We present a case of P-SCAD in a 38-year-old woman with initial presentation at 28 weeks' gestation and recurrence at 9 days postpartum. A unique complication of this case is its transcontinental nature: the initial event occurred while the patient was on vacation across the country from her home. Questions arose not only with regard to her immediate management and care but also when she would be able to travel and how her complex care would be continued cross-country. This case raised important questions regarding the antepartum management of acute coronary syndrome (ACS). It also highlights the importance of multidisciplinary care, especially with a cardio-obstetrics team, in the management of P-SCAD and emphasizes the role for universal screening for cardiac diseases in pregnancy.

The Effect of Body Mass Index on Post-Bolus Magnesium Levels in the Obstetric Patient.

OBJECTIVE: In the setting of a growing obese obstetric population, we sought to determine whether differences in body mass index (BMI) and obesity class influenced both serum magnesium levels and the likelihood of achieving therapeutic levels for eclampsia prophylaxis after standard boluses of magnesium sulfate. STUDY DESIGN: This is a retrospective cohort study of patients treated with magnesium sulfate in the setting of either preeclampsia with severe features or preterm labor between 2010 and 2016. Subjects were categorized by BMI: Normal (BMI < 30 kg/m2), Class 1 (BMI 30-34.9 kg/m2), Class 2 (BMI 35-39.9 kg/m2), and Class 3 (BMI ≥ 40 kg/m2). Study participants' demographics, intrapartum characteristics, and adverse reactions were compared among the groups. Logistic regression models were used to calculate unadjusted and adjusted odds ratios comparing the likelihood of each BMI class reaching therapeutic eclamptic prophylactic levels. Linear regression models were also evaluated to determine the relationship between BMI and post-bolus serum magnesium levels. RESULTS: Of the 760 people who met the inclusion criteria, 313 (41.1%) had normal BMI, 190 (25.0%) had Class 1 obesity, 135 (17.8%) had Class 2 obesity, and 122 (16.1%) had Class 3 obesity. When adjusted for confounders, those with Class 1 obesity were 54% less likely to achieve serum levels deemed therapeutic for seizure prophylaxis compared with normal BMI counterparts. Meanwhile, those with Class 2 or 3 obesity were 90% less likely. Linear regression models also demonstrated an inverse association between BMI and post-bolus serum magnesium levels. CONCLUSION: Increasing BMI has a significant effect on post-bolus serum magnesium levels regardless of standard loading dose used. Immediately after bolus administration, obese gravidas are significantly less likely to reach levels effective for eclamptic seizure prophylaxis. When considering which bolus to administer in an obese gravida, it may be more beneficial to choose a 6 g load. KEY POINTS: · BMI has an inverse relationship with post-bolus serum magnesium levels.. · Obese gravidas were less likely to reach eclampsia prophylaxis levels regardless of bolus type.. · Obesity class, not just the presence or absence of obesity, plays a role in serum magnesium levels..

Quincke versus Diamond-Tip Needles for Entry in Placental Laser Surgery for Twin-to-Twin Transfusion Syndrome.

INTRODUCTION: Chorioamniotic membrane separation (CAS), preterm prelabor rupture of membranes (PPROM), and preterm delivery (PTD) remain as major complications of fetoscopic laser photocoagulation (FLP) for twin-to-twin transfusion syndrome (TTTS). We sought to examine whether use of Quincke-tip needles for initial entry during FLP reduces the risk of these complications. METHODS: This is a secondary analysis of prospectively collected data from patients that had FLP for TTTS at a single tertiary care center (2011-2021). We excluded patients for whom direct trocar entry was used. Patients for whom a Quincke-tip needle was used were compared to those for whom a diamond-tip needle was used during Seldinger entry. Demographics, ultrasound findings and operative characteristics were compared between groups. Postoperative outcomes and complications (including CAS, PPROM, and PTD) were also compared. Multivariate logistic regression models were fit to assess independent risk factors for complications. RESULTS: 386 patients met inclusion criteria; Quincke-tip needles were used in 81 (21.0%) cases, while diamond-tip needles were used in 305 (79.0%). Rates of CAS (11.1 vs. 9.5%, p = 0.67) and PPROM (44.4 vs. 41.0%, p = 0.57) were similar between groups. Patients in the Quincke-tip group delivered 1.5 weeks earlier than those in the diamond-tip group (30.5 vs. 32.0 weeks, p = 0.01). However, these patients were more likely to be delivered for maternal (35.9 vs. 19.0%) and fetal (23.1 vs. 15.3%) indications (p < 0.01). In multivariate analysis, needle type was not identified as an independent risk factor for PPROM. However, Quincke-tip needle use was associated with PTD less than 32 weeks (aOR 1.74, 95% CI: 1.02-2.97, p = 0.043). CONCLUSION: Membrane complications following FLP were not associated with the needle type used for entry. Earlier delivery in the Quincke-tip group was likely attributable to higher rates of delivery for maternal and fetal indications, and not membrane complications. The needle chosen for entry is likely best determined by operator preference.

Screening for Cardiovascular Disease in Pregnancy: Is There a Need?

Maternal mortality in the United States has been on the rise. Every year, about 700 women die from pregnancy-related complications. Cardiovascular disease (CVD) accounts for a large majority of pregnancy-related deaths driven by the lack of recognition and delays in diagnosis due to the overlap of normal pregnancy symptoms with those of CVD. Risk factors for CVD including race, advanced maternal age, hypertension, diabetes, obesity, socioeconomic status, and geographic region play an important role in CVD-related deaths. Several risk assessment models are available to stratify women with a known diagnosis of CVD. However, most women who die from CVD during pregnancy or the postpartum period do not have a prior diagnosis of CVD, and cardiomyopathy is an important contributor. The California Maternal Quality Care Collaborative (CMQCC) developed an algorithm to screen all pregnant and postpartum women to allow stratification into low or high risk for CVD. The algorithm has been validated in diverse patient populations. We propose universal CVD screening for all women in the antepartum and postpartum period to identify women at risk and to provide education and awareness for both patients and healthcare providers. This screening tool would work to reduce the increasing rates of severe maternal mortality and morbidity while having a significant impact on healthcare costs in the United States.

Membrane Separation and Perinatal Outcomes after Laser Treatment for Twin-Twin Transfusion Syndrome.

INTRODUCTION: Postoperative membrane separation is a complication of selective laser photocoagulation of communicating vessels (SLPCV) for the treatment of twin-twin transfusion syndrome (TTTS). OBJECTIVE: The aim of this work was to determine whether a quantitative grading system of membrane separation following SLPCV was associated with preterm premature rupture of membranes (PPROM) and preterm delivery (PTD). METHODS: Patients with membrane separation after SLPCV on postoperative day 1 were stratified into greatest width of separation <1 cm (Group A) or ≥1 cm (Group B) and compared to patients without separation by the following outcomes: PPROM ≤21 postoperative days, PTD <28 gestational weeks, and PTD <32 gestational weeks. RESULTS: Of 654 patients, 123 (18.8%) had membrane separation. Of these, 120 patients were eligible for study and divided into Groups A (n = 91) and B (n = 29). Multiple logistic regression analysis yielded associations with PPROM ≤21 days for Groups B (OR 8.60, 95% CI 3.38-21.90, p < 0.0001) and A (OR 2.39, 95% CI 1.05-5.40, p = 0.0369) compared to those without membrane separation. In similar models, Group B was associated with PTD <32 weeks (OR 2.41, 95% CI 1.10-5.28, p = 0.0274). CONCLUSION: Postoperative membrane separation was associated with an increased risk of PPROM ≤21 days. Membrane separation ≥1 cm had a higher risk of PTD <32 weeks.

Teenage pregnancy complicated by primary invasive ovarian cancer: association for oncologic outcome.

OBJECTIVE: To examine survival of teenage women with pregnancies complicated by primary ovarian cancer. METHODS: This is a secondary analysis of a previously organized systematic literature review of primary ovarian cancer diagnosed during pregnancy. Cases eligible for analysis were patients whose age at cancer diagnosis and survival outcome were known (n=201). Pregnancy and oncologic outcome were then examined based on patient age. RESULTS: These were comprised of 95 (47.3%) epithelial ovarian cancers (EOCs), 82 (40.8%) malignant germ cell tumors (MGCTs), and 24 (11.9%) sex-cord stromal tumors (SCSTs). Teenage pregnancy was seen in 21 (10%) cases, and was highest among the SCST group compared to the other cancer types (EOC, 1.1%; MGCT, 14.6%; and SCST, 29.2%, p<0.001). Live birth rates, neonatal weight, full term delivery rates, and Cesarean section rates were similar between the teenage group and the non-teenage group (all, p>0.05); however, teenage pregnancy was significantly associated with an increased risk of serious maternal/neonatal adverse events (50% vs. 22.7%, p=0.013). On univariable analysis, teenage pregnancy was significantly associated with decreased ovarian cancer-specific survival (5-year rate: age ≥30, 79.6%; age 20-29, 87.2%; and age <20, 41.6%; p<0.001). On multivariable analysis controlling for calendar year, cancer type, cancer stage, and gestational age at ovarian cancer diagnosis, teenage pregnancy remained an independent prognostic factor for decreased ovarian cancer-specific survival compared to women aged ≥30 (adjusted-hazard ratio=4.71; 95% confidence interval=1.17-18.9; p=0.029). CONCLUSION: Teenage women with pregnancies complicated by primary ovarian cancer may be at increased risk of poor survival from ovarian cancer.

Successful resuscitation after cardiac arrest secondary to carboplatin infusion: A case report.

•Sudden cardiac arrest can be a form of carboplatin hypersensitivity reaction.•Platinum retreatment and cumulative cycles of ≥ 8 are risk factors.•Awareness of the reaction related to carboplatin infusion is necessary.•Successful resuscitation with high quality CPR is achievable with trained staffs.