Thromboelastometry Predicts Thromboembolic Events, Hospital Length of Stay, and Mortality in Patients with COVID-19 Infection and Mild Hypoxemia: A Prospective Observational Study.

Background: The aim of this study was to assess changes in hemostasis and associated outcome of hospitalized patients with COVID-19 infection and mild hypoxemia. Methods: Adult patients with COVID-19 infection and hypoxemia admitted to ICU were included in this prospective observational study. The primary outcome was defined as an unfavorable course of the disease if a patient: (1) developed a thromboembolic event while receiving anticoagulation prophylaxis, (2) had prolonged ICU stay, or (3) died. Demographic data, laboratory parameters and thromboelastometry (ROTEM) test results were collected. Results: Twenty-five patients were recruited into the study. There were 16 patients with an unfavorable course of the disease. Compared to the 9 patients in the favorable course group, patients with an unfavorable course had a lower platelet count, median difference of 154 (95% CI, 26 to 223 x109/L), P = 0.012, and lower clot firmness parameters in EXTEM assay: amplitude at 20 minutes (A20), median difference of 7 (95% CI, 2 to 11) P = 0.006, maximum clot firmness (MCF), median difference of 6 (95% CI, 3 to 10) P = 0.006 and area under the curve (AUC) with a median difference of 671 (95% CI, 244 to 1029) P = 0.005. They also demonstrated suppression of fibrinolysis: higher lysis index 60, median difference of -3 (95% CI, -6 to 0), P = 0.023. Results of functional fibrinogen (FIBTEM) assay were similar between the groups. Conclusion: The platelet count and the results of EXTEM assay, but not FIBTEM assay, were associated with the difference in clinical outcome among patients with COVID-19 infection and hypoxemia. The role of platelets in the outcome of COVID-19 infection calls for further investigation. Future studies on adjusting anticoagulant therapy based on the results of viscoelastic testing may be beneficial.

Successful Anesthesia Management of Postoperative Maternal Pulmonary Edema and Uterine Hyperactivity following Open Fetal Myelomeningocele Repair.

Effective tocolysis is essential after fetal myelomeningocele repair and is associated with the development of pulmonary edema. The increased uterine activity in the immediate postoperative period is commonly treated with magnesium sulfate. However, other tocolytic agents such as nitroglycerine, nifedipine, indomethacin, terbutaline, and atosiban (outside the US) have also been used to combat uterine contractility. The ideal tocolytic regimen which balances the risks and benefits of in-utero surgery has yet to be determined. In this case report, we describe a unique case of fetal myelomeningocele repair complicated by maternal pulmonary edema and increased uterine activity resistant to magnesium sulfate therapy.

Characterizing the Effects of Diabetes and Obesity on Insulin and Leptin Levels amongst Pregnant Women.

OBJECTIVE: In this study, we assess the impact of obesity and diabetes on maternal brain and periphery, as well as fetal exposure to insulin and leptin, and two hormones that play an important role in regulating energy homeostasis. STUDY DESIGN: Fasting maternal plasma, fetal cord vein and artery plasma, and maternal cerebrospinal fluid (CSF) were collected in 37 women (12 lean, nondiabetic [prepregnancy body mass index (BMI): 22.9 ± 1.7 kg/m2]; 12 overweight/obese nondiabetic [BMI: 37.8 ± 7.3 kg/m2]; 13 gestational/type 2 diabetes mellitus [BMI: 29.8 ± 7.3 kg/m2]) with uncomplicated singleton pregnancies undergoing elective Cesarean delivery. HbA1C, insulin, glucose, and leptin levels were measured. RESULTS: Compared with lean mothers, mothers with obesity and diabetes mellitus (DM) had significantly lower CSF-to-plasma ratios of insulin. Moreover, mothers with obesity and DM had significantly lower cord arterial and cord venous to maternal plasma ratios of insulin, but not leptin, compared with lean mothers. There were no differences in CSF and cord blood insulin and leptin levels between obese and DM mothers. CONCLUSION: Compared with lean individuals, mothers with obesity and DM have relative deficiencies in insulin exposure. The patterns observed in mothers with obesity and diabetes were similar highlighting the importance of the maternal metabolic environment in obesity and suggesting obese patients warrant further clinical focus.

An Open Fetal Myelomeningocele Repair With Incorporation of a Skin Allograft.

BACKGROUND: Myelomeningocele (MMC) is the most frequent congenital abnormality of the central nervous system that leads to significant physical disabilities. Historically, treatment involved postnatal repair with management of the hydrocephalus with ventricular shunting. Animal and early human studies demonstrated the feasibility of fetal closure. The benefit of in-utero closure was debated until the results of the prospective randomized multicenter Management of Myelomeningocele Study (MOMS trial) were published, demonstrating a decreased need for shunting, reversal of hindbrain herniation, and better neurologic function in the prenatal repair group compared to postnatal repair. Fetal MMC closure has become a standard of care option for prenatally diagnosed spina bifida. The size of the spinal defect may require modification of the classic surgical technique requiring patching. CASE: This report describes a case of open fetal myelomeningocele repair, which required incorporation of a skin allograft. CONCLUSION: Large myelomeningocele defects may be successfully repaired with utilization of a skin allograft.

Point-of-care viscoelastic testing improves the outcome of pregnancies complicated by severe postpartum hemorrhage.

Study Objective. To compare the clinical outcomes of patients with severe postpartum hemorrhage (PPH) managed with and without the use of Point-of-Care Viscoelastic Testing (PCVT) to direct blood product replacement. Design. A retrospective cohort study of consecutive cases of severe PPH managed at a single tertiary care center between January 1, 2011 and July 31, 2015. Cases included patients managed using PCVT. Controls were patients managed using a standardized massive hemorrhage transfusion protocol, either because PCVT was not yet available or because no PCVT credentialed providers were on site. Setting. Delivery room, postoperative recovery area, intensive care unit. Patients. There were 6,708 cesarean deliveries and 13,641 vaginal births during the study period. Eighty six patients (0.4% of all deliveries) developed severe PPH. Severe PPH occurred in 1% (68/6,708) of cesarean and 0.1% (18/13,641) of vaginal deliveries. Twenty-eight of these 86 patients (32.6%) were managed with PCVT and 58 (67.4%) without PCVT. Interventions. Patients with severe PPH were managed according to a standardized massive transfusion protocol or a PCVT-based protocol to direct blood product replacement. Measurements. PCVT testing was performed using a ROTEM delta device. Results. Patients in the PCVT cohort received significantly fewer transfusions of packed red blood cells, fresh frozen plasma, and platelet concentrates. They also had a significantly lower estimated blood loss, and a significantly lower incidence of cesarean hysterectomy and postoperative ICU admission as compared with patients not managed using PCVT. The length of postpartum hospitalization was also significantly shorter in the PCVT cohort. Among patients who gave birth within 24 hours of admission, the direct cost of hospitalization was 40% lower for patients in the PCVT cohort. Conclusions. PCVT-based goal-directed blood product replacement management was associated with substantial benefits over a standardized massive transfusion protocol both in terms of patient outcomes and cost of care.

Fructose levels are markedly elevated in cerebrospinal fluid compared to plasma in pregnant women.

BACKGROUND: Fructose, unlike glucose, promotes feeding behavior in rodents and its ingestion exerts differential effects in the human brain. However, plasma fructose is typically 1/1000 th of glucose levels and it is unclear to what extent fructose crosses the blood-brain barrier. We investigated whether local endogenous central nervous system (CNS) fructose production from glucose via the polyol pathway (glucose → sorbitol → fructose) contributes to brain exposure to fructose. METHODS: In this observational study, fasting glucose, sorbitol and fructose concentrations were measured using gas-chromatography-liquid mass spectroscopy in cerebrospinal fluid (CSF), maternal plasma, and venous cord blood collected from 25 pregnant women (6 lean, 10 overweight/obese, and 9 T2DM/gestational DM) undergoing spinal anesthesia and elective cesarean section. RESULTS: As expected, CSF glucose was ~ 60% of plasma glucose levels. In contrast, fructose was nearly 20-fold higher in CSF than in plasma (p < 0.001), and CSF sorbitol was ~ 9-times higher than plasma levels (p < 0.001). Moreover, CSF fructose correlated positively with CSF glucose (ρ 0.45, p = 0.02) and sorbitol levels (ρ 0.75, p < 0.001). Cord blood sorbitol was also ~ 7-fold higher than maternal plasma sorbitol levels (p = 0.001). There were no differences in plasma, CSF, and cord blood glucose, fructose, or sorbitol levels between groups. CONCLUSIONS: These data raise the possibility that fructose may be produced endogenously in the human brain and that the effects of fructose in the human brain and placenta may extend beyond its dietary consumption.

Anesthetic management of patients with placenta accreta and resuscitation strategies for associated massive hemorrhage.

PURPOSE OF REVIEW: Placenta accreta is one of the leading causes of peripartum hemorrhage. The goal of this article is to review anesthetic management of parturients with placenta accreta and to examine a modern approach to massive peripartum hemorrhage. RECENT FINDINGS: The incidence of placenta accreta is rising in parallel with the increased rate of cesarean delivery. If accreta is diagnosed or suspected preoperatively, anesthetic management can be optimized. Even with the best possible management, the blood loss associated with placenta accreta can resemble that of a major trauma. The use of Damage Control Resuscitation strategies to guide transfusion may improve morbidity and mortality. SUMMARY: Careful planning and close communication are essential between anesthesiology, obstetric, interventional radiology, gynecologic oncology, blood bank, and specialized surgical teams when taking care of a patient with placenta accreta.