Alfredo F. Gei

Neonatal Organ System Injury in Acute Birth Asphyxia Sufficient to Result in Neonatal Encephalopathy

OBJECTIVE To identify the proportion of major organ system injury in cases of acute intrapartum asphyxia that result in neonatal encephalopathy. METHODS A prospectively maintained database was cross‐referenced using medical record coding to identify diagnoses of acute intrapartum asphyxia, acute birth asphyxia, or neonatal encephalopathy over a 6‐year period. An acute intrapartum asphyxial antecedent was validated with emphasis on excluding long‐standing or chronic conditions where injury likely occurred before presentation. Injury pattern was evaluated using routinely available laboratory and imaging tests. RESULTS Forty‐six cases of acute peripartum asphyxia sufficient to result in the diagnosis of neonatal encephalopathy were identified. Clinical central nervous system injury resulting in encephalopathy was present in 100% of cases as it was an entry criteria; of these, 49% had electroencephalogram and 40% had imaging studies diagnostic of acute injury. Liver injury based on elevated aspartate transaminase or alanine transaminase levels occurred in 80%. Heart injury, as defined by pressor or volume support beyond 2 hours of life or elevated cardiac enzymes, occurred in 78%. Renal injury, defined by an elevation of serum creatinine to greater than 1.0 mg/dL, persistent hematuria, persistent proteinuria, or clinical oliguria, occurred in 72%. An elevation in nucleated red blood cell counts exceeding 26 per 100 white blood cells occurred in 41%. CONCLUSION Using common diagnostic tests as markers of acute asphyxial injury, we noted that multiple organs suffer damage during an acute intrapartum asphyxial event sufficient to result in a neonatal encephalopathy.

CARDIAC DISEASE AND PREGNANCY

The pregnant state imposes a supraphysiologic strain on the pregnant womans cardiac performance through complex biochemical, electric, and physiologic changes affecting the blood volume, myocardial contractility, and resistance of the vascular bed. In the presence of underlying heart disease, these changes can compromise the womans hemodynamic balance, her life, and that of her unborn child. Cardiac pathology represents a heterogeneous group of disorders, each with its own hemodynamic, genetic, obstetric, and social implications. Physicians caring for these women should actively address the issue of reproduction. Ideally, pregnancy should be planned to occur after optimization of cardiac performance by medical or surgical means. Once pregnancy is achieved, the concerted effort of a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, nursing, social, and other services provides the best opportunity to carry the pregnancy to a successful outcome.

Cutting-edge advances in the medical management of obstetrical hemorrhage

Hemorrhagic shock is the most common form of shock encountered in obstetric practice. Interventions that may limit transfusion requirements include normovolemic hemodilution, use of recombinant activated factor VII, selective embolization of pelvic vessels by interventional radiology, and the use of the cell saver intraoperatively. Current understanding of the mechanisms of acute coagulopathy calls into question the current transfusion guidelines, leading to a tendency to apply massive transfusion protocols based on hemostatic resuscitation despite lack of prospective data.

The use of a continuous infusion of epinephrine for anaphylactic shock during labor

BACKGROUND Anaphylaxis is a potentially life threatening, acute, and severe systemic reaction that occurs after the reexposure to a specific antigen. This immunoglobulin E-mediated process is the result of the action of basophils and mast cell mediators, causing severe brochospasm, laringospasm, angioedema, urticaria, and cardiovascular collapse. CASE We present a case of anaphylactic shock during labor secondary to administration of ampicillin for group B streptococcus prophylaxis. Generalized itching and hives were soon followed by severe maternal hypotension and tachycardia and prolonged fetal bradycardia. These symptoms responded partially to the administration of fluids and parenteral epinephrine. A continuous infusion of epinephrine was required for persistent maternal symptoms. The infusion did not result in further fetal compromise. The patient delivered a healthy fetus 4 hours after the start of the epinephrine infusion. CONCLUSION This case supports the use of parenteral (intravenous) epinephrine for the treatment of anaphylactic reactions during pregnancy.

Controversies in the Management of Placenta Accreta

Obstetric hemorrhage is one of the most common causes of maternal morbidity and mortality worldwide, and abnormal placentation, including placenta accreta, is currently the most common indication for peripartum hysterectomy. Prenatal identification of these cases and early referral to centers with the capability to manage them will likely result in improved outcomes. Interventions that may limit transfusion requirements include normovolemic hemodilution, selective embolization of pelvic vessels by interventional radiology, conservative management of accretism in a few selected cases, and the use of the cell saver intraoperatively. Current understanding of the mechanisms of acute coagulopathy has questioned the current transfusion guidelines, leading to a tendency to apply massive transfusion protocols based on hemostatic resuscitation. Prospective trials are required to validate the efficacy of this approach. Obstetricians should be familiar with current transfusion protocols, as the incidence of placental accretism is expected to increase in the future.

Embolism during pregnancy: thrombus, air, and amniotic fluid

Pulmonary embolism is the primary cause of acute respiratory decompensation during pregnancy. Regardless of the nature of the embolism, a high index of suspicion, early diagnosis, and aggressive resuscitation need to be instituted to achieve a successful maternal and fetal outcome. Several clinical characteristics will assist practitioners to distinguish among the different forms of embolism and to institute specific measures of treatment.

Forceps-assisted vaginal delivery.

Operative vaginal delivery using forceps has been an important part of obstetric practice for nearly 400 years. Countless women and their children have benefited from timely and expertly performed procedures. Physicians must, therefore, make every effort to retain these skills, to modify and improve them in every possible way, and to pass them on. In this way, women and children of future generations will benefit from the many years of experience that have gone before them.

Burns in pregnancy

BACKGROUND: Treatment of a major burn injury during pregnancy must incorporate modifications in management resulting from gestational physiologic changes. CASE: A 25-year-old woman, at 34 weeks of gestation, sustained a major burn injury at home. She required ventilatory support, invasive hemodynamic monitoring, and massive fluid resuscitation. Labor was augmented and a spontaneous vaginal delivery of a healthy neonate was achieved. Later, wound autografting was performed. CONCLUSION: Pregnancy-induced physiologic changes affect key factors in the management of the burned patient, including airway management and hemodynamic support. Multidisciplinary management is essential to achieve the best possible outcome.

Placenta Percreta: Magnetic Resonance Imaging and Temporary Bilateral Internal Iliac Artery Balloon Occlusion

Placenta percreta is an implantation disorder, which can cause potentially life-threatening hemorrhage especially when diagnosed during delivery. Traditionally, ultrasound has been the first-line diagnostic imaging modality used to diagnose placenta percreta. However, in cases where ultrasound cannot dependably establish a diagnosis or placental invasion involves adjacent structures, such as the bladder, magnetic resonance imaging has been reported as a more precise imaging modality. Magnetic resonance imaging should be considered for early, more accurate diagnosis of placenta percreta to avoid massive hemorrhage during delivery and cesarean hysterectomy. If the diagnosis of placenta percreta is made, temporary balloon occlusion of bilateral internal iliac arteries should be considered to prevent excessive blood loss. This case report should alert radiologists and obstetricians of the precise diagnosis offered by magnetic resonance imaging, the use of temporary balloon occlusion, and the need for further research on magnetic resonance, ultrasound, and Doppler imaging of placenta percreta.

The Evaluation of Prolonged Labor in an Academic Center Using the World Health Organization Partograph: A Retrospective Study of 199 Cesarean Deliveries [270]

OBJECTIVE: The purpose of this study was to evaluate the progress of labor of women who underwent a primary cesarean delivery for labor abnormalities using the World Health Organization (WHO) partograph to determine whether those abnormalities are underdiagnosed or overdiagnosed and evaluate the timeliness of the decision to proceed with a primary cesarean delivery. METHODS: Retrospective cohort study of women carrying singleton pregnancies greater than 34 weeks of gestation who underwent primary cesarean deliveries for “failure to progress,” arrest of dilatation, descent and failure to descend, or all of these. The labor progress was plotted using the WHO partograph and the maternal outcomes evaluated. An adverse maternal outcome was defined in the presence of one or more of the following: intrapartum or postpartum hemorrhage, transfusion, chorioamnionitis, use of intravenous antibiotics, intensive care unit admission, deep vein thrombosis, pulmonary embolism, or death. The groups of women with and without postoperative complications were compared on demographic characteristics, comorbidities, obstetric complications, and partograph characteristics. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for the primary cesarean delivery and time in labor. A P<.05 was considered significant. RESULTS: Data on 199 women (convenience sample) who had primary cesarean deliveries at Memorial Herman Hospital in Houston, Texas, during 13 months (March 1, 2012, to April 25, 2013). Ninety-seven percent of women had their primary cesarean delivery during the first stage and 31.6% of them when the cervix was under 6 cm dilated. Postpartum complications were observed in 30.5% (61/199); the most common were intrapartum or postpartum hemorrhage (20.5%), transfusion (11.5%), and chorioamnionitis (11%). The rate of postpartum complications was higher in patients with previous comorbidities (P=.047). The risk of complications increased significantly when the patient crossed the action line for 6 hours (RR 3.45, 95% CI 2.1–5.6). Thirty-six women (18%) underwent a primary cesarean delivery before or at the action line. CONCLUSION: The implementation of the WHO partograph could be an adequate tool for the evaluation of progress during labor and could reduce at least 18% of cesarean deliveries performed for failure to progress in an academic center in the United States.