Cardiac Arrest in Pregnancy: A Scientific Statement From the American Heart Association.

This is the first scientific statement from the American Heart Association on maternal resuscitation. This document will provide readers with up-to-date and comprehensive information, guidelines, and recommendations for all aspects of maternal resuscitation. Maternal resuscitation is an acute event that involves many subspecialties and allied health providers; this document will be relevant to all healthcare providers who are involved in resuscitation and specifically maternal resuscitation.

Work and work-related stress in pregnancy.

Work, in general, does not increase the risks of pregnancy complications. Work that is stressful, physically, psychologically, or both, has deleterious effects on pregnancy. Stressful work increases the risks of miscarriage, preterm labor, preterm birth, low birth weight, and preeclampsia. The greater the stress, the greater the risks of pregnancy complications. Women with a history of pregnancy complications should be counseled about reducing stressful work before pregnancy. Women with stressful jobs should be followed closely during pregnancy, and if signs of preterm labor or delayed fetal growth develop, then occupational stress should be decreased or eliminated. Some occupations expose pregnant women to teratogens such as organic solvents, heavy metals, or pesticides. A careful work history should be part of every preconception and early pregnancy visit.

Magnetic resonance-based serial pelvimetry: do maternal pelvic dimensions change during pregnancy?

OBJECTIVE: The purpose of the study was to evaluate the stability of the maternal pelvis over the course of the third trimester and the puerperium. STUDY DESIGN: Pregnant patients were recruited to undergo comparative magnetic resonance-based pelvimetry and fetal ultrasonography at 37 to 38 weeks of gestation. Most of the patients were recruited from a study of women who planned a trial of labor after a previous cesarean delivery for cephalopelvic disproportion. These results have been reported previously. Patients then underwent magnetic resonance-based pelvimetry within 3 days and at 3 months after delivery. Postdelivery analysis was used to answer the question: Do pelvic dimensions change after delivery? RESULTS: Eighteen patients completed the study. Eleven of the patients underwent cesarean deliveries, of which 4 deliveries were before labor. Seven patients had successful vaginal births after their previous cesarean delivery. Statistical analysis of the 18 patients determined that pelvic measurements did not demonstrate change over the course the study. CONCLUSION: Serial magnetic resonance-based pelvimetry showed relative stability of pelvic measurements through the course of pregnancy and delivery. If comparative pelvimetry is to be useful as an antepartum predictor of labor success, then it may be possible to obtain reliable pelvimetry in those patients anytime after delivery.

Cardiac Arrest and Resuscitation Unique to Pregnancy.

Maternal cardiopulmonary arrest (MCPA) is a catastrophic event that can cause significant morbidity and mortality. A prepared, multidisciplinary team is necessary to perform basic and advanced cardiac life support specific to the anatomic and physiologic changes of pregnancy. MCPA is a challenging clinical scenario for any provider. Overall, it is an infrequent occurrence that involves 2 patients. However, key clinical intervention performed concurrently can save the life of both mother and baby.

Umbilical cord prolapse in current obstetric practice.

OBJECTIVE: To assess the incidence, risk factors and outcomes of umbilical cord prolapse in current obstetric practice. STUDY DESIGN: This study was a retrospective chart review at both a community hospital and a tertiary referral center. RESULTS: There were 52 cases of cord prolapse in our patient population, for an incidence of 3.0/1,000, similar to that in the literature. Of viable singleton pregnancies with frank prolapse, the rate was 1.6/1,000. In this series we found an approximately 40% higher rate of frank cord prolapse in induced patients at the community hospital than in the general population. Other than 2 fetal deaths related to extreme prematurity, all mothers and infants did well. CONCLUSION: The higher incidence of cord prolapse among women with induction of labor in this population merits further study. The lack of significant morbidity and mortality in the study suggests that modern obstetric practices may influenced the natural history of umbilical cord prolapse.

Focus on primary care: from nevus to neoplasm: myths of melanoma in pregnancy.

Malignant melanoma is one of the few malignancies that regularly affect women during their childbearing years. Additionally, the incidence of melanoma has been increasing over the last several decades. Early diagnosis of stage I disease may lead to curative therapy; thus it is important for physicians and midwives to do a full examination of the skin. However, the myth that nevi may naturally grow or change during pregnancy has been shown not to be true and should not delay a diagnostic evaluation of a suspicious nevus. Older studies had theorized a worse outcome for pregnant women with melanoma. However, multiple controlled series and investigations have found that stage for stage this cancer is not affected adversely by pregnancy. Prognosis, recurrence, and incidence of melanoma seemed to be unaffected. Estrogen-containing oral contraceptives, as well as hormone replacement therapy, have no adverse affect on the disease.

Perimortem cesarean delivery: its role in maternal mortality.

Since Roman times, physicians have been instructed to perform postmortem cesarean deliveries to aid in funeral rites, baptism, and in the very slim chance that a live fetus might still be within the deceased mother's womb. This procedure was disliked by physicians being called to a dying mother's bedside. As births moved to hospitals, and modern obstetrics evolved, the causes of maternal death changed from sepsis, hemorrhage, and dehydration to a greater incidence of sudden cardiac arrest from medication errors or embolism. Thus, the likelihood of delivering a viable neonate at the time of a mother's death increased. Additionally, as cardiopulmonary resuscitation (CPR) became widespread, physicians realized that during pregnancy, with the term gravid woman lying on her back, chest compressions cannot deliver sufficient cardiac output to accomplish resuscitation. Paradoxically, after a postmortem cesarean delivery is performed, effective CPR was seen to occur. Mothers were revived. Thus, the procedure was renamed the perimortem cesarean. Because brain damage begins at 5 minutes of anoxia, the procedure should be initiated at 4 minutes (the 4-minute rule) to deliver the healthiest fetus. If a mother has a resuscitatable cause of death, then her life may be saved as well by a prompt and timely cesarean delivery during CPR. Sadly, too often, we are paralyzed by the horror of the maternal cardiac arrest, and instinctively, we try CPR for too long before turning to the perimortem delivery. The quick procedure though may actually improve the situation for the mother, and certainly will save the child.

The morbidity of the 34- to 35-week gestation: should we reexamine the paradigm?

Algorithms for the management of preterm labor avoid the use of tocolysis beyond 34 weeks' gestation, based in large part on low respiratory morbidity found at this gestational age. We sought to delineate the morbidities, not just respiratory, of this age group in a modern neonatal intensive care unit setting. We prospectively looked at hospital resource use and general morbidity in a consecutive 2-year cohort of 34-weekers at our hospital. The concurrent consecutive 35-week cohort was used as a control. Data were prospectively collected from obstetricians and bedside records. Compared with 35-weekers, the 34-week group had similar obstetric characteristics. Significant differences were seen in use of oxygen, nasal continuous positive airway pressure, methylxanthines, home apnea monitoring, antibiotics, and phototherapy. The 34-week group took longer to come off intravenous lines and were discharged later. Overall, they used approximately twice the resources of the 35-week group. To stop or not use tocolysis at 34 weeks' gestation based mainly on low respiratory morbidity ignores the significant other morbidities. These findings suggest a reconsideration of the paradigm regarding 34-week gestation as a cutoff point in decision making.

Activated protein C resistance associated with maternal floor infarction treated with low-molecular-weight heparin.

Factor V Leiden with activated protein C resistance is found in up to 5% of the population. It is associated with current adverse pregnancy outcomes. Maternal floor infarction is a lesion in which fibrin is deposited throughout the placenta, leading to necrosis of villi, and (50% of the time) fetal demise. It is also often recurrent. There is no known etiology of maternal floor infarction, nor is there a known treatment. We report a case of a 34-year-old G5, P2 with multiple pregnancy losses, including two fetal deaths. Placental pathology was obtained from one of the losses and was notable for maternal floor infarction. In the index pregnancy, she was evaluated for thrombophilia and found to have a significant protein C resistance of 1.59, consistent with a factor V Leiden. She was treated with low-molecular-weight heparin, enoxaparin, 40 mg twice a day, titrated to achieve an activated factor Xa activity level of 0.2 prior to her next dose. Her pregnancy was unremarkable until 39 weeks, when she developed a decreased amniotic fluid index. A 2995-kg healthy infant was delivered. The placenta showed no evidence of maternal floor infarction. This case demonstrates an association between maternal floor infarction and activated protein C resistance. It is also notable for a successful treatment of recurrent maternal floor infarction with prophylactic heparin. A single case report can only raise a question regarding associations. As we become more familiar with the thrombophilias, we may better understand the association of thrombophilias and placental disease as well as develop successful treatments.

The magnetic resonance imaging-based fetal-pelvic index: a pilot study in the community hospital.

OBJECTIVE: This study was undertaken to assess feasibility of magnetic resonance imaging (MRI) pelvimetry in conjunction with fetal ultrasonography as a technique in evaluating patients with previous cesarean sections for cephalopelvic disproportion (CPD). STUDY DESIGN: Pregnant patients with one previous cesarean section for CPD who planned a trial of labor after cesarean (TOLAC) were recruited to undergo MRI pelvimetry and fetal ultrasonography at 37 to 38 weeks. Entry criteria included no previous successful vaginal deliveries and no contraindications for vaginal delivery in the ongoing pregnancy. A fetal-pelvic index was calculated for each patient but not disclosed to patients or their physicians. The pregnancies were managed routinely. Analysis after delivery was used to ascertain whether this index would have predicted clinical outcome. RESULTS: There were no difficulties in performing the MRI or ultrasound. Sixteen patients completed their pregnancies. Three patients did not labor. The fetal-pelvic index was plotted on a scattergram and compared with the outcome. Three discriminatory zones were identified. Five of 6 patients in the most favorable zone delivered successfully. Two patients in the most unfavorable zone had failed vaginal birth after cesarean section (VBAC) attempts. In the 5 patients in the middle intermediate zone, TOLAC success appeared to depend on fetal presentation and gestational age. CONCLUSION: The use of comparative MRI pelvimetry and fetal ultrasonography is feasible in a community hospital. In this pilot study, it appeared to have potential in enhancing the management of VBAC candidates. This technique may allow sorting of patients before labor into zones that would favor or preclude VBAC attempts.