Adiel Fleischer

Conservative management of placenta previa percreta in a Jehovah's Witness.

BACKGROUND: Hemorrhage is a serious threat with placenta accreta, often requiring aggressive operative intervention by hysterectomy and resuscitative measures with large-volume blood replacement to ensure survival. Refusal to accept transfusion makes management especially difficult. CASE: We report a Jehovahs Witness patient who had 9 previous cesarean deliveries and presented with anemia and placenta previa percreta invading the bladder wall. Management objectives were to enhance the patients status, using erythropoietin and autologous transfusion, and to minimize the chance of hemorrhage by prophylactic uterine artery embolization. The placenta was left in situ after the delivery with no untoward consequences. Methotrexate was held in readiness, but was not required as adjuvant therapy. CONCLUSION: Effective care of such patients requires close collaborative team effort and advanced planning to ensure a good outcome.

Association between umbilical artery cord pH, five-minute apgar scores and neonatal outcome

A prospective study was conducted of 270 intrapartum patients admitted in labor to investigate the independent and combined relationships between umbilical arterial cord pH and Apgar scores and neonatal outcome. The results revealed that when assessed independently, a low 5-min Apgar score (less than 7) was associated with both NICU admission and neonatal sepsis. When categorized by both cord pH and 5-min Apgar, the majority of patients (75.9%) had both parameters normal, 20.7% had an abnormal pH (less than 7.20) and normal Apgar (greater than or equal to 7) and few patients had either both normal or an abnormal Apgar given a normal pH. Given a normal 5-min Apgar score, additional information about the cord pH did not enhance the predictability for either NICU admission or neonatal sepsis. Neonates with both an abnormal pH and 5-min Apgar had the highest incidence of NICU admission. For all neonates, the presence of meconium greatly increased the likelihood of being admitted to the NICU.

Diagnosis of placental abscess in association with recurrent maternal bacteremia in a twin pregnancy

BACKGROUND: Placental abscess formation is rarely recognized prenatally. We present a case detected ultrasonographically that developed from a central line infection and caused recurrent maternal bacteremia. CASE: A young woman with a 21-week twin gestation presented with recurrent fevers. She had received treatment for bacteremia due to Serratia marcescens. The initial source of the infection was a peripherally inserted central catheter line placed in the first trimester for hyperemesis gravidarum. Fevers continued throughout the second course of antibiotics. An abscess seen sonographically in twin A’s placenta was aspirated using a spinal needle, revealing Serratia bacteria. Aspiration was performed at 22 weeks of gestation. Amniotic fluid samples obtained from both sacs were negative for infection. Over 4 weeks, the abscess enlarged and she was delivered. Twin A died of sepsis and twin B had a relatively favorable neonatal course. CONCLUSION: Prenatal diagnosis of placental abscess presents a difficult management dilemma. Traditional amniotic fluid studies did not predict the poor outcome of the affected fetus.

Determining the Normal Values of Shock Index, Pulse Pressure, and ROPE in the Immediate Postpartum Period [15D]

INTRODUCTION: Shock index (SI), rate over pressure evaluation (ROPE) and the pulse pressure (PP) have been validated as indicators of hypovolemia. The objective of this study is to determine normal ranges for SI, PP and ROPE for postpartum women. METHODS: A chart review was performed from July 2012 to January 2015 at NSLIJ on postpartum women up to 24 hours postpartum who were not given anti-hypertensives, blood products or uterotonics. Logistic regression assessed associations between variables and time after delivery. RESULTS: 8,874 patient charts were analyzed. Patients who had C-sections, have an increase in SI up to 24 hours postpartum with 95% Prediction Interval of up to 1.1, while those who had a vaginal delivery, SI remained stable with 95% Prediction Interval of up to 1.03. For patients who had c sections, a decrease in PP was observed during the first 24 hours post-partum with 95% Prediction Intervals as low as 21.09. For patients who had vaginal deliveries or c sections, there is an increase in ROPE during the first 24 hours post-partum with 95% Prediction Interval (anti-logged) as high as 3.22. There were no clinically significant differences in these outcomes amongst different age groups or BMI categories. CONCLUSION: Shock index greater than 1.1 is abnormal. Normal ranges for pulse pressure and anti log ROPE is 21.09 to 69.32 and 1.01 to 3.22, respectively. These outcomes are not affected by age or BMI. Further studies are needed to assess the utility of these values in improving outcomes during postpartum hemorrhage.

Is There an Association Between Placenta Previa and Serum Analytes

INTRODUCTION: The objective of this study was to evaluate the association between maternal serum analytes and placenta previa. METHODS: Chart review of deliveries from 2004 to 2012 with two comparison groups: placenta previa without accreta and a control group. Patients in the control group were randomly selected from deliveries without placenta previa. Patients with previa were confirmed by third-trimester ultrasonography. Exclusion criteria were placenta previa with pathology-confirmed accreta, multiple gestations, fetal anomalies, or growth restriction. Primary outcomes were maternal serum analytes in the first trimester: pregnancy-associated plasma protein A and free &bgr;-human chorionic gonadotropin (&bgr;-hCG), and second trimester: &agr;-fetoprotein), free &bgr;-hCG, unconjugated estriol, and inhibin. RESULTS: Twenty-six women with previa met inclusion criteria and 43 women in the control group. The groups did not differ with respect to maternal age, gravidity, or parity. Alpha-fetoprotein multiples of the median was significantly higher in women with previa cases than women in the control group (P<.005). Pregnancy-associated plasma protein A multiples of the median was higher (but was not statistically significant) in women with previa than in the women in the control group (P<.064). There were no differences between groups with respect to first-trimester free &bgr;-hCG, second-trimester free &bgr;-hCG, unconjugated estriol, or inhibin (Table 1). The following analytes were not available on all specimens: second-trimester free &bgr;-hCG, unconjugated estriol, and inhibin. Table 1 Comparison of Serum Analytes Between Placenta Previa Without Accreta Cases and Control Cases. CONCLUSIONS: In our women with placenta previa, maternal serum &agr;-fetoprotein was significantly higher than in women in the control group. We also observed higher levels of pregnancy-associated plasma protein A in women with previa but this did not reach statistical significance. Prospective studies are needed to confirm these findings and determine the relationship with pregnancy outcome.

Maternal Assessment With Sonography for Hemorrhage (MASH): A Prospective Cohort Study [33P]

INTRODUCTION:Intra-abdominal hemorrhage must be diagnosed and managed expeditiously in women with hemodynamic instability after Cesarean delivery. Our objective was to determine the amount of free intra-abdominal fluid normally present on ultrasound after Cesarean delivery, and whether intra-operati

Evaluating the Normal Urine Output in the Postpartum Period: Have We Been Underestimating What Is Adequate? [24O]

INTRODUCTION: During the postpartum period physiologic changes occur simultaneously with potentially life threatening conditions including postpartum hemorrhage and preeclampsia. We do not have well studied values for normal urine output in this period. The primary goal of this study was to determine the normal urine output in the immediate postpartum period. METHODS: We selected women scheduled for cesarean delivery with singleton, full term gestations and excluded patients with gestational hypertensive disorder, cardiovascular disease, pregestational diabetes, or evidence of postpartum hemorrhage. We recorded demographic data and urinary output for the first 24 hours postpartum. RESULTS: The geometric mean of urine output (UOP) at hour 1 (n=300) 118.7 cc/hr, 2 (n=267) 89.0 cc/hr, 3 (n=176) 85.1 cc/hr, 4 (n=90) 90.1 cc/hr with 95% CIs, (27.9–504.4), (26.8–295.7), (22.8–317.0), (19.9–407.1), respectively. We found that the average weight based at hour 1 (n=288) 1.4 cc/kg/hr, 2 (n=257) 1.06 cc/kg/hr, 3 (n=170) 1.03 cc/kg/hr, 4 (n=86) 1.09 cc/kg/hr with 95% CIs (0.3–6.5), (0.29–3.8), (0.25–4.1), (0.23–4.7), respectively. Averaging urine output over time and adjusted for weight the average at hour 4 (n=105) 1.2 cc/kg/hr, 8 (n=87) 1.07 cc/kg/hr, 12 (n=81) 1.3 cc/kg/hr, 24 (n=64) 2.03 cc/kg/hr with 95% CIs (0.38–3.9), (0.32–3.5), (0.42–4.0), (1.04–3.9). CONCLUSION: The average UOP in the immediate postpartum period ranges 1.03 to 1.40 cc/kg/hr which is higher than the value currently understood as acceptable. With the average urine output higher than the currently used minimum at each time interval, it is possible that a rate below 1.03 cc/kg/hr may be an indication of abnormal clinical status.