Implementation of a multidisciplinary perinatal emergency response team improves time to definitive obstetrical evaluation and fetal assessment.

BACKGROUND: Trauma is the leading cause of nonobstetric death during pregnancy and is associated with an increased risk of maternal and fetal mortality. In an effort to improve the delivery of care to pregnant trauma patients, we developed an institutional multidisciplinary quality initiative designed to improve response times of nontrauma specialists and ensure immediate availability of resources. We hypothesized that implementation of a perinatal emergency response team (PERT) would improve time to patient and fetal evaluation and monitoring by the obstetrics (OB) team and improve both maternal and fetal outcomes. METHODS: We performed a 6-year (2012-2018) retrospective cohort analysis of consecutive pregnant trauma patients presenting to our university-affiliated, level I trauma center. Patients in the pre-PERT cohort (before April 2015) were compared with a post-PERT cohort. Variables analyzed included patient demographics, mechanism of injury, Injury Severity Score, and level of trauma activation. The main outcome measure was time to OB evaluation. Secondary outcomes included time to cardiotocometry, and mortality. RESULTS: Of 92 pregnant trauma patients, there were 50 patients (54.3%) in the pre-PERT cohort and 42 (45.7%) in the post-PERT group. Blunt injuries predominated (98.9%), with the most common mechanism being motor vehicle collisions (76.1%), followed by assaults (13%) and falls (6.5%). The mean time to obstetrical evaluation was 44 minutes in the pre-PERT cohort compared with 14 minutes in the post-PERT cohort (p = 0.001). There was a significant decrease in level I (highest acuity) trauma activations pre-PERT and post-PERT (46% vs. 21%, p = 0.01), and the time to cardiotocography was significantly decreased post-PERT implementation (72 vs. .37 min, p = 0.01) CONCLUSION: Implementation of a multidisciplinary PERT improves time to evaluation by the OB team and time to cardiotocometry in the pregnant trauma patient. LEVEL OF EVIDENCE: Retrospective review, level IV.

Hoyuelos cutáneos tras amniocentesis traumática / Skin dimpling due to traumatic amniocentesis

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[Trauma and pregnancy: Is the Kleihauer-Betke test really useful?] / Traumatisme et grossesse : le test de Kleihauer est-il vraiment utile ?

OBJECTIVE: To evaluate the pertinence of Kleihauer-Betke (KB) test, in case of abdominal trauma during pregnancy in forecast of fetal outcomes, according to trauma severity. METHODS: A single-center retrospective study conducted between January 2014 and April 2016 in a maternity type III and a trauma center, which included the pregnant women admitted for abdominal trauma. The trauma's severity was assessed using the guidelines of the Society of Obstetricians and Gynaecologists of Canada. The impact of a positive KB test, defined as>0.1%, was analyzed. Adverse outcome was defined as one or more of the following complications: intrauterine fetal death, placental abruption, pre-term birth<37 weeks of gestation, and fetal or neonatal anemia. RESULTS: During the study period, 265 pregnancies involved into an abdominal trauma were included: 69% with a minor trauma and 31% with a severe trauma. Of all patients, 5.6% presented a positive KB test, among then 15.4% had an adverse outcome. There was no significant difference in the rate of adverse outcomes in the positive KB group and the KB negative group either in the overall population (P=0.16), in the minor trauma population (P=1) or in the major trauma population (P=0.14). The predictive positive values were respectively in the global population, in the minor trauma group and in the severe trauma group 15.4%, 0% and 25%. CONCLUSIONS: The KB test does not seem to be useful in case of trauma during pregnancy to define adverse outcome.

A Rare Fetal Firearm Injury.

Firearm injury (FAI) in pregnant women is reported in the literature; however, no reference to date was found to address the neonatal abdominal surgery performed after maternal FAI. FAI during fetal life is extremely rare and very few cases have been reported. We present a report of a 37-week gestation newborn whose mother had an accidental FAI. The neonate was delivered by emergency caesarian section along with emergency laparotomy of the newborn. The baby presented at eight hours of life, who was managed surgically in emergency for multiple small and large bowel perforations and a piece of bullet was recovered from anterior part of thigh.

[HEAD INJURY DURING PREGNANCY].

No matter how severe is head injury during pregnancy, it can threaten both- the maternal and (or) the fetal life. The risk derives from systemic and cerebral consequences of high intracranial pressure, hypotension, anemia or expanding mass lessions in the cranial cavity. The specific hormonal background of the mother may contribute the better outcome after traumatic brain injury (TBI). Pregnancy and trauma push the doctors to create different and specific management than the usual case. Investigating literature data we figure out the initial assessment, management priorities for resuscitation of the head injured pregnant patient, concidering the specific anatomic and physiologic changes during pregnancy. We accept the principal: first save the mother, then the child, if possible, proposing algorithm for severe head injured pregnant patient management.

Penetrating chest wound of the foetus.

Traumas of the foetus caused by stabbings are rare but actually life-threatening for both the foetus and the mother. We report a case of penetrating chest wound on a baby taken from the obstetrics unit to the paediatric surgical department. His mother was assaulted by his father, a mentally sick person with no appropriate follow-up. The foetus did not show any sign of vital distress. Surgical exploration of the wound has revealed a section of the 10 th rib, a laceration of the pleura and a tearing of the diaphragm. A phrenorraphy and a pleural drainage were performed. The new-born and its mother were released from hospital after 5 days and the clinical control and X-ray checks 6 months later showed nothing abnormal. We insisted a medical, psychiatric follow-up be initiated for the father. As regards pregnant women with penetrating wounds, the mortality rate of the foetus is 80%. The odds are good for our newborn due to the mild injuries and good professional collaboration of the medical staff. Penetrating transuterine wounds of the foetus can be very serious. The health care needed should include many fields due to the mother and the foetus' lesions extreme polymorphism. In our case, it could have prevented by a good psychiatric followed up of the offender.

Infecção transplacentária e intrauterina por Brucella abortus em búfalos (Bubalus bubalis) / Placenta and intrauterine infection by Brucella abortus in buffaloes (Bubalus bubalis)

O objetivo deste trabalho foi verificar a presença de Brucella abortus e as lesões causadas por esse agente nos anexos fetais e nos fetos de búfalas. Para isso, 20 búfalas em diversos meses de gestação, sorologicamente positivas para brucelose, foram submetidas ao abate sanitário. A idade fetal foi determinada através de exames ultrassonográficos associados à mensuração dos fetos durante a necropsia. Do útero fechado desses animais foram coletadas amostras para histopatologia e qPCR. A partir do segundo mês de gestação foi possível detectar a presença de DNA de B. abortus em líquido amniótico, líquido alantoide e em útero e, a partir do quinto mês, na placenta, coração, baço, rim, pulmão, intestino, fígado e linfonodos dos fetos. Os principais achados anatomopatológicos foram placentite fibrinopurulenta necrótica e endometrite supurativa crônica...

The objective of this study was to detect Brucella abortus and injuries caused by the bacteria in fetal membranes and fetuses. Twenty buffaloes serologically positive for brucellosis were used and subjected to stamping for collection of material from the closed uterus of several months gestation. Fetal age was determined by ultrasound examination and the size of fetuses was measured at necropsy. The samples were subjected to histopathology and qPCR. From the second month of pregnancy on it was possible to detect the presence of B. abortus DNA in amniotic fluid, allantoic liquid and uterus, and from the fifth month on in placenta, heart, spleen, kidney, lung, intestine, liver and lymph nodes of the fetuses. The main pathological findings were fibrinous suppurative necrotic placentitis, and chronic endometritis...

[NEURODEVELOPMENT DISORDERS AND POSSIBILITY OF THEIR PRENATAL DETECTION].

Neurodevelopment disorders including cerebral palsy are a group of non-progressive and noninfectious diseases characterized by different levels of abnormal neurodevelopment. Most often, diagnosis is made at the age of 5 years or later. It has been recognized that most of the cerebral damages appear prenatally. This fact stimulated researchers all over the world to detect the possible causes in utero. These studies have been possible due to the development of ultrasound technology in real time and display of fetal mobility. Thanks to the development of four-dimensional (4D) ultrasound, prenatal screening neurological test was developed. The test is based on assessment of the number and quality of spontaneous movements of the fetus. The question arises whether fetal behavior, observed on 4D ultrasound, reflects neurological development of the fetus in a manner that will allow detection of brain damage in utero.

Fetal intracranial injuries following motor vehicle accidents with airbag deployment.

The effects of airbag deployment in motor vehicle accidents (MVA) on the fetus are poorly understood. A 22-year-old woman at 24 weeks of gestation collided with a telephone pole while driving. She was restrained and an airbag deployed. Although she had no major injuries, she experienced decreased fetal movements. Fetal heart rate (FHR) monitoring revealed loss of variability without any evidence of abruptio placentae, and 4 days later, the variability spontaneously recovered. Two weeks after the MVA, ultrasonography showed unilateral ventricular dilatation suggestive of fetal brain injury. Magnetic resonance imaging revealed subdural hematoma, intraventricular hemorrhage and cystic lesions, interpreted as indirect (hypoxic-ischemic) and direct (hemorrhagic) intracranial injuries. After MVA with airbag deployment, FHR monitoring can show a transient loss of variability, which may precede the appearance of fetal brain injury.

Esophageal atresia, small omphalocele and ileal prolapse through a patent omphalomesenteric duct: a methimazole embryopathy? [Corrected].

Newborns prenatally exposed to methimazole (active metabolite of carbamizole) for maternal hyperthyroidism may present some disorders in common, but the phenotype is not well defined. Choanal atresia is the most frequent, and other anomalies such as esophageal atresia and aplasia cutis were described with this embryopathy. Additionally, patent omphalomesenteric duct or Meckel's diverticulum in similar association was reported in some patients. The predisposed genetic background has to be considered. We report the case of a newborn exposed to carbamizole during the first 4 weeks of pregnancy and define an association related to prenatal methamizole exposure consisting of esophageal atresia, small omphalocele, and ileal prolapse through a patent omphalomesenteric duct.

Imaging of trauma: Part 2, Abdominal trauma and pregnancy--a radiologist's guide to doing what is best for the mother and baby.

OBJECTIVE: The pregnant trauma patient requires imaging tests to diagnose maternal injuries and diagnostic tests to evaluate the viability of her pregnancy. This article will discuss abdominal trauma in pregnancy and the specific role of diagnostic imaging. Radiation concerns in pregnancy will be addressed. CONCLUSION: Trauma is the leading cause of nonobstetric maternal mortality and a significant cause of fetal loss. Both major and minor trauma result in an increased risk of fetal loss. In major trauma, when there is concern for maternal injury, CT is the mainstay of imaging. The risks of radiation to the pregnancy are small compared with the risk of missed or delayed diagnosis of trauma. In minor trauma, when there is no concern for maternal injury but there is concern about the pregnancy, ultrasound is performed but is insensitive in diagnosing placental abruption. External fetal monitoring is used to dictate patient care.

Penetrating fetal trauma with late complications: a case report.

Survival after direct penetrating trauma to a fetus is very unusual. Our case below illustrates nonoperative management of a penetrating thoracoabdominal gunshot injury to the retroperitoneum with a late complication arising 15 years after the initial incident.

Fear of the unknown: ionizing radiation exposure during pregnancy.

Ionizing radiation during pregnancy can negatively impact a fetus. In light of the Fukushima nuclear plant disaster in Japan, we discuss existing knowledge on the health effects of radiation and preventive measures for pregnant women. Overall, the risk of exposure to radiation is limited but severe defects can result from fetal radiation exposure >100 mGy equivalent to 10 rad (>1000 chest x-rays). While such high-level exposure rarely occurs during single medical diagnostic procedures, caution should be exercised for pregnant women. As a protective public health measure in light of a disaster, evacuation, shielding, and elimination of ingested radioactive isotopes should all be considered. Detailed radiation reports with health effects and precautionary measures should be available for a population exposed to more than background radiation.

[Pregnancy and trauma].

Anatomic and physiologic changes in pregnancy can mask or mimic injury, making diagnosis of trauma-related problems difficult. Care of pregnant trauma patients with severe injuries often requires a multidisciplinary approach involving an emergency clinician, trauma surgeon, obstetrician, anesthesiologist and neonatologist. The pregnant trauma patient presents a unique challenge because care must be provided for two patients--the mother and the fetus.

Anomalías físicas menores y esquizofrenia: revisión de la literatura / Minor physical anomalies and schizophrenia: literature review

La esquizofrenia es considerada una enfermedad del neurodesarrollo por muchos autores. Saber si en los pacientes hay variantes morfológicas producidas durante el desarrollo de áreas anatómicas diferentes al cerebro y entenderla relación de esas variantes con el desarrollo cerebral o con la exposición prenatal a posibles noxas, podría dar pistas sobre los eventos que llevan al trastorno. Variantes morfológicas inespecíficas producidas durante el primer y segundo trimestre de gestación denominadas anomalías físicas menores (AFM) que pueden ser usadas como marcadores de riesgo de una enfermedad en personas susceptibles se vienen relacionando con la esquizofrenia, independientemente de la región anatómica en la que se presenten. La importancia de estas anomalías en relación con la esquizofrenia estaría dada porque podrían ser el reflejo de un sustrato (esquizotaxia) heredado o adquirido como consecuencia de alguna injuria(s) que resultaría en la enfermedad en personas susceptibles. Esta idea se apoya además en evidencia indirecta proporcionada por estudios con familias, entre otros. Por otro lado, el rol de las AFM en otros trastornos del neurodesarrollo es similar al propuesto en la esquizofrenia (AU)

Schizophrenia is considered for many authors as a disease of neurodevelopment. Know if there are morphological variants in the patients produced during development of anatomical areas others than the brain and understand the relation of those variants with the brain development or with prenatal exposition to possible noxas could give clues about the events conducting to the disorder. Morphological unspecific variants generated during the first and second gestation trimester denominated minor physical anomalies (MPA) that can be used as risk markers of a disease in susceptible persons have been related with schizophrenia independently of the anatomical region they are. The importance of these anomalies in relation with schizophrenia is that they might be the reflex of a substratum (schizotaxia) inherited or acquired as a consequence of some injuries(s) that become into the disease in susceptible persons. Moreover this idea is supported in indirect evidence provided by studies with families, between others. In the other hand the role of the MPA in other disorders of neurodevelopment is similar to the one proposed in schizophrenia (AU)

Síndrome de perfusión arterial retrógrada en gemelos (trap): feto acardio: reporte de un caso / Reversal arterial perfusion syndrome in twins (trap): acardiac fetus: case report

Se presenta el caso de una paciente de 23 años de edad, procedente del Estado Barinas, II gesta, la cual presenta un embarazo gemelar monocorial, donde el primer feto tuvo desarrollo normal y falleció por dificultad respiratoria en el período neonatal y el segundo, fue un feto acardio anceps. Al examinar el feto se observó ausencia de corazón y pulmones, cerebro rudimentario y anomalías de las extremidades. La disección reveló epidermis con abundantes células vacuolizadas, dermis edematosa y ausencia del epiplón mayor. Los genitales externos femeninos estaban bien desarrollados. El examen radiológico mostró un cráneo pequeño, osificación de columna vertebral y anomalías óseas de manos y pies. Se hizo una revisión de la literatura sobre acardia en los últimos 30 años

We presente the case of a 23 year old patient, from Barinas State, II gravida, with a twin monochorial pregnancy, a normal fetus who died for respiratory distress in neonatal period and the other one, was an acardio anceps. The acardius presented absence of heart and lungs, a rudimentary brain, and anomalies of extremities. The dissection showed epidermis with numerous vacuolized cells, edematous dermis and absence of mayor epiploon. The external female genitals were well developed. Radiological screening showed a rudimentary cranium and anomalies of the hands and feet. We reviewed the last 30 years of acardia literature

Trauma in pregnancy.

In the United States, trauma is the leading nonobstetric cause of maternal death. The principal causes of trauma in pregnancy include motor vehicle accidents, falls, assaults, homicides, domestic violence, and penetrating wounds. The managing team evaluating and coordinating the care of the pregnant trauma patient should be multidisciplinary so that it is able to understand the physiologic changes in pregnancy. Blunt trauma to the abdomen increases the risk of placental abruption. Evaluation of the pregnant trauma patient requires a primary and secondary survey with emphasis on airway, breathing, circulation, and disability. The use of imaging studies, invasive hemodynamics, critical care medications, and surgery, if necessary, should be individualized and guided by a coordinating team effort to improve maternal and fetal conditions. A clear understanding of gestational age and fetal viability should be documented in the record.

Fetal central nervous system malformations on MR images.

Sonography is the method of choice for prenatal malformation screening but it does not always provide sufficient information for correct diagnosis or adequate abnormality evaluation. Fetal magnetic resonance imaging (MRI) is considered as a valuable second line imaging tool for confirmation, completion and correction of sonographic findings. Fetal MRI has proven its value in the evaluation of central nervous system pathologies, especially of midline and posterior fossa malformations. The role of MRI is not only to confirm or exclude possible lesions but also to define their full extent, aiding in their characterization, and to demonstrate associated abnormalities. The authors describe the most common anomalies of CNS revealed by fetal MRI in a chronological way related to the age of pregnancy, with a review of own MR images and with reference to the literature and own experience.

The four most common pediatric immunodeficiencies.

The four most common immunodeficiencies in pediatric patients are transient hypogamma-globulinemia of infancy, IgG subclass deficiency, impaired polysaccharide responsiveness (partial antibody deficiency) and selective IgA deficiency. Most of these patients have normal cellular immune systems, phagocyte function and complement levels. All four illnesses are characterized by recurrent bacterial respiratory infections such as purulent rhinitis, sinusitis, otitis and bronchitis. Except for some IgA-deficient patients, the molecular basis for these illnesses is not known, and indeed each syndrome is heterogeneous, with multiple causes, including genetic factors, drug/environmental toxicant exposure, and/or prenatal physiological events. This paper describes the clinical and laboratory features, postulated causes, current management and prognosis. Only a few of these cases require the use of intravenous IgG (IVIG) and the outlook for long life is excellent.