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3.
Am J Obstet Gynecol ; 222(1): 48-52, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31376394

RESUMO

Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. Where available, we recommend performing transthoracic or transesophageal echocardiography as soon as possible because this is an easy and reliable method of identifying a failing right ventricle. If such failure is identified, treatment that is tailored at improving right ventricular performance should be initiated with the use of inotropic agents and pulmonary vasodilators. Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.

5.
Acta Obstet Gynecol Scand ; 98(11): 1386-1397, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31070780

RESUMO

Normal pregnancy leads to a state of chronically increased intra-abdominal pressure. Obstetric and non-obstetric conditions may increase intra-abdominal pressure further, causing intra-abdominal hypertension and abdominal compartment syndrome, which leads to maternal organ dysfunction and a compromised fetal state. Limited medical literature exists to guide treatment of pregnant women with these conditions. In this state-of-the-art review, we propose a diagnostic and treatment algorithm for the management of peripartum intra-abdominal hypertension and abdominal compartment syndrome, informed by newly available studies.

6.
AJP Rep ; 9(1): e88-e91, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31041117

RESUMO

Objectives This study was aimed to familiarize obstetricians with the legal environment surrounding Effexor lawsuits and emphasize the importance of documenting informed consent in the medical records when prescribing a medication that is being targeted for litigation. Study Design We used the LexisNexis legal search engine to review legal documents from Effexor-related cases and also used Google to search for Effexor-related lawsuits online, further researching these cases via publically available court records from district clerk offices. Finally, we conducted a year-by-year literature review from 1993 to 2017 to establish the history and evolution of scientific studies surrounding Effexor use during pregnancy. Results Litigation involving Effexor typically arises due to congenital cardiac birth defects in the neonate allegedly associated with maternal Effexor use in pregnancy. Medication manufacturers have employed a legal strategy termed the learned intermediary doctrine in an attempt to shift liability away from themselves and on to prescribing obstetricians. Manufacturers claim they adequately inform obstetricians of the risks and benefits of prescribing their product and it is the duty of the obstetrician to relay those risks and benefits to their patients. Conclusion To reduce the risk of liability exposure, obstetricians must adequately document informed consent in the medical records when prescribing medications to their pregnant patients.

7.
Obstet Gynecol ; 133(5): 933-939, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-30969218

RESUMO

Acute stroke in pregnancy can be devastating. Although neurologists will at some point be involved in the management, most of these patients are likely to first be evaluated by an obstetric care provider. It is, therefore, important for obstetric care providers to have an understanding of the presentation and management of stroke, particularly in the initial period when the window of opportunity for therapy is critical. Once suspected, a head computed tomography (CT) without contrast media should be performed without delay to rule out a hemorrhagic component. Patients presenting within 4.5 hours of symptom onset and with an initial normal head CT scan are candidates for alteplase (tissue plasminogen activator [tPA]). Blood pressure (BP) control is paramount when administering tPA. During pregnancy, we recommend maintaining a BP between 140-160/90-110 mm Hg during tPA treatment. Pregnancy should not be a contraindication for mechanical thrombectomy in carefully selected patients. The use of therapeutic anticoagulation during the acute management of ischemic stroke is not indicated owing to an increased risk of hemorrhagic transformation. Supportive therapy should include aggressive treatment of fever, avoidance of hypotonic maintenance fluids, and maintenance of normal serum sodium levels. Serum glucose levels should be kept between 140 and 180 mg/dL. Antiplatelet agents are indicated for secondary prevention. The management of cerebral venous sinus thrombosis, carotid and vertebral dissections, and reversible cerebral vasoconstrictive disease should overall follow same guidelines as for nonpregnant individuals.

8.
Am J Perinatol ; 2019 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-30780183

RESUMO

BACKGROUND: Obesity and pregnancy are risk factors for venous thromboembolism (VTE). In nonpregnant individuals, abdominal obesity is associated with venous insufficiency. OBJECTIVE: To compare venous Doppler volume flow and velocity in the lower extremities of obese versus nonobese women. STUDY DESIGN: A prospective cohort study was performed. Duplex ultrasound examined bilateral lower extremity venous flow and velocity (time-averaged mean velocity, TAMV). Flow was analyzed at the superficial femoral (SFV), distal external iliac (DEI), common femoral, profunda femoris, and popliteal veins. Mann-Whitney U-test, Spearman's correlation, and chi-square tests were used, with a significance of p < 0.05. RESULTS: Left SFV TAMV and volume flow were higher in the obese group (5.1 [4.1-5.7] vs. 2.8 [1.7-3.4] cm/second; p < 0.001) and (89 [73-119] vs. 48 [26-62] cm/minute; p = 0.005). Significant differences were noted for right DEI flow (obese 326 [221-833] vs. nonobese 182 [104-355] cm/minute; p = 0.049). The right femoral profunda flow was also higher in obese (49 [40-93] cm/minute) compared with nonobese (31 [22-52] cm/minute; p = 0.041). CONCLUSION: Volume flow and TAMV in the lower extremities of obese gravidas are higher compared with nonobese ones. Thus, the increased risk of VTE among obese pregnant women may not be caused by venous stasis.

9.
Am J Obstet Gynecol ; 220(4): B2-B10, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30684460

RESUMO

Maternal sepsis is a significant cause of maternal morbidity and mortality and is a preventable cause of maternal death. The purpose of this guideline is to summarize what is known about sepsis and to provide guidance for the management of sepsis in pregnancy and the postpartum period. The following are SMFM recommendations: (1) we recommend that sepsis and septic shock be considered medical emergencies and that treatment and resuscitation begin immediately (GRADE 1B); (2) we recommend that providers consider the diagnosis of sepsis in pregnant patients with otherwise unexplained end-organ damage in the presence of an infectious process, regardless of the presence of fever (GRADE 1B); (3) we recommend that empiric broad-spectrum antibiotics be administered as soon as possible, ideally within 1 hour, in any pregnant woman in whom sepsis is suspected (GRADE 1B); (4) we recommend obtaining cultures (blood, urine, respiratory, and others as indicated) and serum lactate levels in pregnant or postpartum women in whom sepsis is suspected or identified, and early source control should be completed as soon as possible (GRADE 1C); (5) we recommend early administration of 1-2 L of crystalloid solutions in sepsis complicated by hypotension or suspected organ hypoperfusion (GRADE 1C); (6) we recommend the use of norepinephrine as the first-line vasopressor during pregnancy and the postpartum period in sepsis with persistent hypotension and/or hypoperfusion despite fluid resuscitation (GRADE 1C); (7) we recommend against immediate delivery for the sole indication of sepsis and that delivery should be dictated by obstetric indications (GRADE 1B).


Assuntos
Antibacterianos/uso terapêutico , Hidratação/métodos , Hipotensão/terapia , Complicações Infecciosas na Gravidez/terapia , Transtornos Puerperais/terapia , Sepse/terapia , Vasoconstritores/uso terapêutico , Soluções Cristaloides , Técnicas de Cultura , Parto Obstétrico , Feminino , Humanos , Hipotensão/etiologia , Ácido Láctico/sangue , Norepinefrina/uso terapêutico , Guias de Prática Clínica como Assunto , Gravidez , Complicações Infecciosas na Gravidez/diagnóstico , Transtornos Puerperais/diagnóstico , Ressuscitação , Sepse/diagnóstico , Choque Séptico/diagnóstico , Choque Séptico/terapia
10.
Am J Perinatol ; 36(13): 1351-1356, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30609428

RESUMO

OBJECTIVE: To assess whether distraction using music and/or video games influences timing of analgesia request and improves pain outcomes in women undergoing labor induction. STUDY DESIGN: A total of 219 pregnant women with singleton gestation undergoing labor induction with a Foley bulb (FB) at term were randomized to distraction with music and video games via iPod (n = 109) or no iPod (n = 110). The primary outcome was the time from FB placement to request for pain medication. Secondary outcomes included number of patients requesting pain medication within 6 and 12 hours, type of pain medication received, pain visual analog scale scores, and patient satisfaction. Mann-Whitney's, chi-square, Kaplan-Meier's curves, and Pearson's product moment correlation were used for statistical analysis (significance: p < 0.05). RESULTS: Baseline characteristics were similar between the two groups. There was no difference in the time from FB placement until pain medication request between the groups. There were no significant differences in secondary outcomes. Increased per cent time of iPod use correlated with a longer time until pain medication request (R 2 = 0.22, p = 0.03). CONCLUSION: We were not able to show that distraction using music and video games delays timing of analgesia request or improve pain outcomes in pregnant women undergoing mechanical labor induction at term.

11.
Semin Perinatol ; 43(1): 22-26, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30503399

RESUMO

Obstetrical hemorrhage is the most common cause of maternal mortality worldwide. Together with adequate surgical control and judicious transfusion of blood products, the use of pharmacological agents (e.g., tranexamic acid) and clotting factor concentrates (e.g., fibrinogen concentrates and prothrombin complex concentrates) results in improved hemostasis and decreased bleeding-associated mortality. Guidance in the administration of these agents with the use of viscoelastic testing will likely become standard of care in the near future.


Assuntos
Antifibrinolíticos/uso terapêutico , Fatores de Coagulação Sanguínea/uso terapêutico , Hemostáticos/uso terapêutico , Obstetrícia , Hemorragia Pós-Parto/terapia , Ácido Tranexâmico/uso terapêutico , Testes de Coagulação Sanguínea , Transfusão de Sangue/estatística & dados numéricos , Feminino , Humanos , Mortalidade Materna , Hemorragia Pós-Parto/diagnóstico , Hemorragia Pós-Parto/prevenção & controle , Guias de Prática Clínica como Assunto , Gravidez
12.
Reprod Sci ; 26(9): 1243-1248, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-30486735

RESUMO

OBJECTIVE: There is no consensus on which risk stratification approach to use for thromboprophylaxis in pregnancy, and most available risk assessment models (RAMs) for venous thromboembolism (VTE) events have not been validated in pregnancy. Our objective was to compare the performance of some of the most commonly used VTEs RAMs in our patient population in the peripartum period. STUDY DESIGN: This is a retrospective cohort of women who delivered at our institution in 2015 and 2016. We excluded patients with history of prior or current VTEs or those already receiving anticoagulants. Antepartum, intrapartum, and postpartum records were reviewed. Data were collected on known risk factors for VTEs in order to calculate scores for 3 RAMs on admission for delivery: Padua, Caprini, and Royal College of Obstetricians and Gynaecologists (RCOG). The primary objective was to the estimate the performance of the various RAMs in preventing postpartum VTEs. We calculated the proportion of women who would have been high risk, determined the number of VTEs cases within high- and low-risk categories, as well as calculated the number needed to treat (NNT) for each RAM. We performed analyses using different RAM scores cutoffs, VTEs outcome rates, and effectiveness of anticoagulation to prevent VTEs. The P value <.05 was considered statistically significant. RESULTS: A total of 6094 women were included. Three women had VTEs for an overall rate of 0.04% (N = 3; 95% confidence interval [CI]: 0.01-0.15). The proportion of women categorized as high risk for VTEs were 62% (95% CI: 61-64) for RCOG, 0.8% (95% CI: 0.6-1.0) for Padua, and 94% (95% CI: 94-95) for Caprini. Of the 3 VTEs, the RCOG model classified 1 woman as high risk and Padua model classified 3 women as high risk; whereas the Caprini did not identify any women as high risk. Assuming 100% effectiveness of thromboprophylaxis, the observed NNT was 3838 using RCOG, not able to calculate using Padua (no VTEs cases occurred in the high-risk group, thus none were prevented), and 1927 using Caprini. CONCLUSION: The rates of VTEs in pregnancy are very low and the available RAMs do not identify most of them. The RCOG and Caprini RAMs would categorize a large proportion of women as high risk and are associated with high NNTs. The Padua RAM appears to have the lowest NNT but missed all the VTEs in our cohort.

13.
J Matern Fetal Neonatal Med ; 32(2): 271-278, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-28936902

RESUMO

OBJECTIVE: To determine the association between maternal obesity and delivery due to chorioamnionitis prior to labor onset, among expectantly managed women with preterm premature rupture of membranes (pPROM). METHODS: This was a secondary analysis of a multicenter randomized trial of magnesium sulfate versus placebo to prevent cerebral palsy or death among offspring of women with anticipated delivery at 24-31-week gestation. After univariable analysis, Cox proportional hazard evaluated the association between maternal obesity and chorioamnionitis, while Laplace regression investigated how obesity affects the gestational age at delivery of the first 20% of women developing the outcome of interest. RESULTS: A total of 164 of the 1942 women with pPROM developed chorioamnionitis prior to labor onset. Obese women had a 60% increased hazard of developing such complication (adjusted HR 1.6, 95%CI 1.1-2.1, p = .008), prompting delivery 1.5 weeks earlier, as the 20th survival percentile was 27.2-week gestation (95%CI 26-28.6) among obese as opposed to 28.8 weeks (95%CI 27.4-30.1) (p = .002) among nonobese women. CONCLUSIONS: Maternal obesity is a risk factor for chorioamnionitis prior to labor onset. Future studies will determine if obesity is important enough to change the management of latency after pPROM according to maternal BMI.


Assuntos
Corioamnionite/epidemiologia , Ruptura Prematura de Membranas Fetais/epidemiologia , Ruptura Prematura de Membranas Fetais/terapia , Obesidade/epidemiologia , Complicações na Gravidez/epidemiologia , Nascimento Prematuro/epidemiologia , Adulto , Cesárea/estatística & dados numéricos , Corioamnionite/terapia , Feminino , Humanos , Recém-Nascido , Sulfato de Magnésio/uso terapêutico , Obesidade/complicações , Obesidade/terapia , Gravidez , Complicações na Gravidez/terapia , Resultado da Gravidez/epidemiologia , Nascimento Prematuro/terapia , Estudos Retrospectivos , Fatores de Tempo
14.
Obstet Gynecol ; 132(2): 423-427, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29995745

RESUMO

Damage-control surgery (abdominopelvic packing followed by a period of medical stabilization in the intensive care unit) is a life-saving intervention usually reserved for critically injured patients who may not survive an attempt to achieve hemostasis and complete repair of the damage in the operating room. Most obstetricians have little or no experience in this area, although the use of damage-control surgery in selected cases may be life-saving. This approach should be considered when arterial bleeding has been controlled and persistent bleeding is deemed to be secondary to coagulopathy that is refractory to blood product replacement, particularly in the presence of hypothermia, acidosis, and vasopressor requirement. A prototypical (albeit hypothetical) case is described here in which damage-control surgery is indicated.


Assuntos
Parto Obstétrico/métodos , Hemostasia Cirúrgica/métodos , Hemorragia Pós-Parto/cirurgia , Cuidados Críticos/métodos , Feminino , Humanos , Cuidados Pós-Operatórios/métodos , Gravidez
16.
Semin Perinatol ; 42(1): 21-25, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29179956

RESUMO

Extracorporeal membrane oxygenation (ECMO) can provide respiratory support (VV-ECMO) or both respiratory and circulatory support (VA-ECMO). The use of ECMO has increased dramatically as a result of simpler technology. No level I evidence is yet available reflecting improved outcomes with ECMO. The use of this technology during pregnancy may be indicated in very select cases and should be delivered in centers with dedicated ECMO specialized units.


Assuntos
Circulação Assistida , Oxigenação por Membrana Extracorpórea , Período Pós-Parto/fisiologia , Insuficiência Respiratória/terapia , Circulação Assistida/instrumentação , Feminino , Guias como Assunto , Humanos , Seleção de Pacientes , Gravidez , Insuficiência Respiratória/fisiopatologia
17.
Am J Perinatol ; 35(8): 737-740, 2018 07.
Artigo em Inglês | MEDLINE | ID: mdl-29278864

RESUMO

OBJECTIVE: It is unknown whether the heart operates in the ascending or flat portion of the Starling curve during normal pregnancy. Pregnant women do not respond to the passive leg-raising maneuver secondary to mechanical obstruction of the inferior vena cava by the gravid uterus. Our objective was to evaluate if administration of a fluid bolus increases baseline stroke volume (SV) among healthy pregnant patients during the third trimester. STUDY DESIGN: Healthy pregnant women who underwent elective term cesarean sections were included. A noninvasive cardiac output monitor was used to measure hemodynamic variables at baseline and after administration of a 500-mL crystalloid bolus. RESULTS: Forty-five women were included in the study. Fluid administration was associated with a statistically significant increase in SV from a baseline value of 71 ± 11 to 90 ± 19 mL (95% confidence interval [CI]: 13.67-21.49; p < 0.01) and a significant decrease in maternal heart rate from a baseline of 87 ± 9 beats per minute to 83 ± 8 after the fluid bolus (95% CI: -6.81 to -2.78; p = 0.03). No changes in peripheral vascular resistances or any other measured hemodynamic parameters were noted with volume expansion. CONCLUSION: In healthy term pregnancy, the heart operates in the ascending portion of the Starling's curve, rendering it fluid responsive.


Assuntos
Perna (Membro)/fisiologia , Posicionamento do Paciente , Postura , Terceiro Trimestre da Gravidez/fisiologia , Volume Sistólico , Adulto , Pressão Sanguínea , Feminino , Frequência Cardíaca , Hemodinâmica , Humanos , Monitorização Fisiológica , Gravidez , Estudos Prospectivos , Resistência Vascular , Adulto Jovem
18.
Obstet Gynecol ; 130(6): 1386-1387, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29189684
19.
Obstet Gynecol ; 130(4): 765-769, 2017 10.
Artigo em Inglês | MEDLINE | ID: mdl-28885402

RESUMO

Obstetric hemorrhage remains the most common cause of maternal mortality worldwide. It is believed that increased fibrinolytic activity, secondary to release and activation of endothelial tissue plasminogen activator, is involved in its pathogenesis. Tranexamic acid (TXA), an antifibrinolytic agent, has been shown to be beneficial in trauma patients if used within 3 hours of injury. A recent large randomized controlled trial showed that TXA given to hemorrhaging women within 3 hours after delivery was associated with decreased risk of death resulting from bleeding with no increase in thromboembolic complications. Limited evidence suggests that prophylactic TXA reduces blood loss at the time of delivery and decreases transfusion rates in the obstetric population. Tranexamic acid appears to be a safe and effective option in the treatment of obstetric hemorrhage. In addition, the limited available evidence supports the need for a well-designed adequately powered clinical trial to test its benefit as a prophylactic agent.


Assuntos
Antifibrinolíticos/administração & dosagem , Hemorragia Pós-Parto/tratamento farmacológico , Ácido Tranexâmico/administração & dosagem , Feminino , Humanos , Hemorragia Pós-Parto/prevenção & controle , Gravidez , Resultado do Tratamento
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