B-Lynch suture for postpartum hemorrhage.

BACKGROUND: Postpartum hemorrhage is a major contributor to maternal morbidity and mortality. Numerous medical and surgical therapies have been used, but none has been uniformly successful. CASE: Two women with postpartum hemorrhage due to uterine atony after cesarean for twins are presented. Neither responded to medical management. In the first subject, O'Leary uterine artery ligation and utero-ovarian branch ligations were done without benefit. The B-Lynch suture immediately sustained correction of hemorrhage in both subjects. Magnetic resonance imaging and hysterosalpingogram after the first case showed no uterine defects. CONCLUSION: The B-Lynch suture might be a valuable addition to the surgical treatment of postpartum hemorrhage due to uterine atony.

Pancreatic adenocarcinoma in the pregnant patient: case report and review of the literature.

BACKGROUND: In this case report, the authors discuss the presentation and treatment of pancreatic adenocarcinoma in a pregnant woman. Pancreatic adenocarcinoma is extremely rare in the pregnant patient. Only three cases of pancreatic adenocarcinoma diagnosed antepartum have been reported. METHODS: A case report and a review of the literature are reported. RESULTS: The authors report a case of pancreatic adenocarcinoma in a pregnant woman at 17 weeks' gestation. Endoscopic retrograde cholangiopancreatography with stent placement and a pancreaticoduodenectomy were performed successfully. CONCLUSIONS: Pancreatic adenocarcinoma is very rare in the pregnant patient. However, pancreaticoduodenectomy can be performed successfully. To the authors' knowledge, this is the first report of a pregnant woman treated with pancreaticoduodenectomy for pancreatic adenocarcinoma.

Outpatient obstetric management of women with type I diabetes.

Conventional obstetric management of diabetic women has frequently incurred extensive hospitalization. Although this approach improved perinatal results for these women and their infants, it is costly and cumbersome. The 3-year experience of an outpatient diabetic obstetric clinic is compared with the results obtained at the same facility during 5 previous years when hospitalization was used more extensively. Perinatal mortality and morbidity were not different in 51 type I diabetic women managed almost entirely as outpatients when compared with 58 similarly complicated diabetic patients receiving more conventional management. Mean prenatal admissions (1 vs 2, p = less than 0.01), mean prenatal hospital days (6 vs 12, p = 0.05), and prolonged delivery admissions of greater than 7 days (31% vs 69%, p = less than 0.01) were significantly less. Outpatient obstetric management of diabetic women efficiently decreases maternal morbidity without increasing infant morbidity and mortality.

Early versus late tocolytic treatment for preterm premature membrane rupture.

The effect of tocolytic therapy before labor was evaluated in 33 pregnant women with preterm premature rupture of the membranes. Either intravenous magnesium sulfate or oral terbutaline was administered at the time of presentation. Intensive surveillance to detect signs of infection was carried out for all patients. In 29 of the patients in this treatment group who were seen at less than 34 weeks, a significantly longer prolongation of pregnancy was achieved when compared with 24 similar women treated after onset of labor in the hospital (169 hours versus 77 hours, p = 0.05). Duration of infant hospitalization was less for those mothers receiving tocolytic agents before labor. Maternal and infant infection were not different in the two groups; nor was the cesarean section rate. When this treatment group was compared with another control group of 96 women already in labor at presentation, the difference in time from admission to delivery was substantial, but it did not achieve statistical significance. In this group the rate of maternal infection was significantly higher, but newborn morbidity was not. Aggressive early treatment with tocolytic agents in pregnant women with preterm premature membrane rupture is more productive but not more dangerous than conservative management.

Glycosylated serum protein level as a screening and diagnostic test for gestational diabetes mellitus.

Glycosylated serum protein assay was examined as an alternative to standard glucose screening and glucose tolerance testing. In a comparison of two groups of gravid women having abnormal 1-hour 50 gm glucose screening tests, there was no difference in glycosylated protein level in the group with abnormal glucose tolerance test results (9.4% +/- 2.0%, mean +/- SD; n = 8) versus normal results (9.2% +/- 1.07%, mean +/- SD; n = 11). Furthermore, correlation of glycosylated serum protein level with glucose screening test results was poor (r = 0.185, p = 0.23, n = 17). Glycosylated serum protein assay is not useful in detecting mild metabolic aberrations associated with gestational diabetes.

Profound hypotension complicating magnesium therapy.

Two preeclamptic women became profoundly hypotensive while receiving magnesium sulfate. No evidence of toxic levels was present in either. In both, preeclampsia-induced hypovolemia was extreme. That nontoxic magnesium levels can cause severe hypotension is an alarming possibility. Acknowledgment of this complication and expeditious reversal of the problem is essential.

Magnesium sulfate and ritodrine hydrochloride: systemic and uterine hemodynamic effects.

Effects of magnesium sulfate and ritodrine hydrochloride on cardiovascular physiologic characteristics were studied in 70 human subjects treated for preterm labor. Systemic and uterine hemodynamic effects were investigated in five pregnant rhesus monkeys. Systolic blood pressure was minimally affected by either agent. Diastolic pressure, while not affected by magnesium sulfate, decreased 26.3% during ritodrine therapy. Maternal and fetal heart rates were minimally affected by magnesium sulfate. Ritodrine increased maternal and fetal heart rates significantly. In the monkeys, magnesium sulfate increased uterine and placental blood flows (by the microsphere technique) but failed to alter cardiac output. Ritodrine produced an increase in cardiac output but decreased perfusion pressure. Placental blood flow decreased by an average of 27.6%. Ritodrine would therefore seem contraindicated with a compromised fetal environment. Magnesium sulfate, by not altering perfusion pressure, may have a beneficial effect on uterine hemodynamics. These specific and distinct differences in cardiovascular and hemodynamic effects should be considered when either magnesium sulfate or ritodrine is selected as a tocolytic agent.

Antibiotic irrigation prophylaxis in the high-risk cesarean section patient.

Two hundred twenty-three women who underwent cesarean section delivery were studied to assess the effectiveness of operative antibiotic irrigation in preventing postoperative uterine infection. Patients were prospectively randomized into high-risk and low-risk groups according to length of labor, and received irrigation with either a 2 gm solution of cefamandole or normal saline solution, or no irrigation. Infection rates of 48.6% and 54.8% were observed in high-risk patients given either saline solution or no irrigation, respectively. Three of 27 high-risk patients (11.1%) given antibiotic irrigation developed metritis. The authors find this method of preventing infection to be advantageous in terms of both efficacy and minimization of antibiotic exposure.

Thrombocytopenia in preeclampsia: associated abnormalities and management principles.

Severe thrombocytopenia, abnormal liver function, and renal dysfunction may occur as manifestations of preeclampsia. Failure to recognize that this cluster of abnormalities represents a form of preeclampsia may result in erroneous initial diagnoses. Management of 13 such patients has shown a direct correlation between the degree of thrombocytopenia and the measures of liver dysfunction. Platelet counts and liver functions improved prior to delivery in five patients treated with corticosteroids. Management should be directed toward investigation and correction of deranged physiology and appropriate monitoring of maternal-feto-placental status. Early delivery is indicated in patients with progressive thrombocytopenia and in those with evidence of fetal maturity or distress. Provided that the disease process remains stable, consideration should be given in cases of fetal immaturity, to the use of betamethasone therapy. The occurrence of severe thrombocytopenia in 20% of neonates should be a consideration in selecting the mode of delivery.

The significance of fetal heart rate decelerations during nonstress testing.

Over a 9-month time span, eight gravid women at high risk had fetal heart rate decelerations on nonstress tests (NSTs). This form of antepartum evaluation, the standard at our institution, was performed 918 times on 476 women during this period. Decelerations were required to be between 1 and 10 minutes in duration and less than 90 bpm, or greater than 40 bpm below baseline, for inclusion. Of the eight women (1.7% of the total tested), four had reactive and four nonreactive NSTs. All eight had contraction stress tests (CSTs) that were negative by definition. Of four women allowed to labor, two (50%) required cesarean section for fetal distress. Two instances of fetal death (25%) occurred during observation periods of 36 and 48 hours. Two infants were growth retarded, and two had abnormal cord positions. NSTs showing decelerations of this type, regardless of reactivity or of follow-up CST, are abnormal and should be viewed with alarm. In term pregnancy, such fetuses should be delivered. In preterm pregnancy with nonreactive NSTs, decelerations may also be valid grounds for delivery. Some discrimination is possible in preterm pregnancies when the NST is reactive.