Chi Dola

Pregnancy outcomes following placement of elective, urgent and emergent cerclage

Objective. To describe pregnancy outcomes following elective (history-indicated), urgent (ultrasound-indicated) or emergent (physical-exam indicated) cerclage placement. Materials and Methods. Study design was retrospective chart review. Women with singleton gestation and cervical cerclage were categorised into: elective, urgent and emergent group. Results. One hundred and thirty-three women were included; 89 in elective, 26 in urgent and 18 in emergent group. Difference was detected when elective and urgent groups were compared with emergent group for: gestation at delivery (35.9 ± 5.1 vs. 34.2 ± 5.9 vs. 29.3 ± 7.2 weeks, respectively, P < 0.05), delivery beyond 36 weeks, (73.9%, 57.7%vs. 23.5%, respectively, P < 0.05), neonatal death (6.8%, 9.5%vs. 43.8%, respectively, P < 0.05) and Apgar score <7 at 5 min (9.1%, 11.5%vs. 47.1%, respectively, P < 0.05). Difference was also detected between elective vs. urgent and emergent groups for: preterm premature rupture of membranes (PPROM) (19.3%vs. 38.5%vs. 64.7%, respectively, P < 0.05) and chorioamnionitis (1.4%vs. 18.2%vs. 42.9%, respectively, P < 0.05). Conclusions. Emergent cerclage group had the poorest obstetric outcomes. The urgent cerclage group reached similar gestational age at delivery as the elective group but is more likely to have PPROM and chorioamnionitis.

Preeclampsia and eclampsia revisited

Hypertensive disorders during pregnancy, which account for approximately 15% of pregnancy-related deaths, represent the second-leading cause of morbidity and mortality in the United States. New classifications recommended by the National Institutes of Healths Working Group on High Blood Pressure in Pregnancy have decreased the confusion often associated with these disorders. The cause of preeclampsia-eclampsia still remains elusive, but continued research has provided hope with regard to screening, improved diagnosis, and management. Risk factors that have recently gained attention include inherited thrombophilias, inherited metabolic disorders, and lipid disorders. Treatment and management of the hypertensive disorders of pregnancy have not changed substantially in the past 50 years. Prevention of preeclampsia-eclampsia has been unsuccessful, and recurrence risks remain high. Careful diagnosis, classification, and further investigation of the causes of hypertensive disorders in pregnancy are needed to achieve optimal management of affected women and their fetuses.

Postoperative Infectious Morbidities of Cesarean Delivery in Human Immunodeficiency Virus-Infected Women

Objective. To compare the infectious complication rates from cesarean delivery of human immunodeficiency virus (HIV)-infected women and HIV-negative women. Materials and Methods. A retrospective analysis was performed on data derived from HIV-infected women and HIV-negative women, who underwent cesarean delivery at two teaching hospitals. Main outcome measures were infectious postoperative morbidity. Descriptive, comparison analysis, and multiple logistic regression analysis were performed. Results. One hundred and nineteen HIV-infected women and 264 HIV-negative women delivered by cesarean section and were compared. The HIV-negative women were more likely than the HIV-infected women to deliver by emergent cesarean section (78.0% versus 51.3%, resp., P < .05), to labor prior to delivery (69.4% versus 48.3%, resp., P < .01), and to have ruptured membranes prior to delivery (63.5% versus 34.8%, resp., P < .05). In bivariate analysis, HIV-infected and HIV-negative women had similar rates of post-operative infectious complications (16.8% versus 19.7%, resp., P > .05). In a multivariate stepwise logistic analysis, emergent cesarean delivery and chorioamnionitis but not HIV infection were associated with increased rate of post-operative endometritis (odds ratio (OR) 4.10, 95% confidence interval (95% CI) 1.41–11.91, P < .01, and OR 3.02, 95% CI 1.13–8.03, P < .05, resp.). Conclusion. In our facilities, emergent cesarean delivery and chorioamnionitis but not HIV infection were identified as risk factors for post-operative endometritis.

Combination antiretroviral therapy with protease inhibitors in HIV-infected pregnancy.

Abstract Objective: To evaluate the possible association between protease inhibitor (PI) and premature birth and low birth-weight in HIV-infected pregnancies. Materials and methods: Data were collected retrospectively for maternal and pregnancy characteristics, antiretroviral medication, lowest CD4 count and highest viral load during pregnancy, and pregnancy outcomes. χ2 Analysis, Student’s t-test, and multiple logistic regression analysis were performed. Results: Data from 161 HIV-infected women who delivered singleton gestation were analyzed. Fifty-three received an antepartum regimen with PI, 84 received a regimen without PI, and six did not receive antepartum treatment. The mean estimated gestational age (EGA)±SD at delivery was 37.7±3.2 weeks. The premature birth rate was 18.4%. No difference was detected between women receiving the antiretroviral regimen including PI and those on the regimen without PI or on no antepartum medication with regard to: EGA±SD at delivery (37.7±3.2 vs. 37.6±3.1 weeks, respectively, P=0.87), rate of premature birth (14% vs. 20.6%, respectively, P=0.32) and low birth-weight (12.5% vs. 20.2%, respectively, P=0.25). In multiple logistic regression analysis, PI was not associated with premature birth or low birth-weight. Conclusion: Women receiving antiretroviral therapy with PI have a similar rate of premature birth and low birth-weight as women receiving antiretroviral therapy without PI or on no medication.

Preterm birth after mature fetal lung indices: is there any neonatal morbidity?

Objective. To determine the frequency of immediate morbidities in neonates with evidence of mature fetal lung indices who delivered before 37 weeks gestation. Methods. A retrospective analysis was performed on pregnancies resulting in birth at < 37 weeks after mature fetal lung was documented by phosphatidylglycerol, lecithin/sphingomyelin ratio, or TDx-FLM studies. Pregnancies with multifetal gestations, maternal diabetes, or fetal anomalies were excluded. Results. 179 patients were included. Eighty-one (45.3%) neonates did not sustain any morbidity, and 98 (54.7%) neonates sustained one or more morbidities. Compared to neonate without any morbidity, neonates experiencing morbidities were delivered at significantly younger gestation (35.7 ± 1.1 vs. 34.9 ± 1.5 weeks, respectively, p < 0.001) had lower birth- weight (2632.2 ± 475.5 vs. 2395.3 ± 496 g, respectively, p < 0.001), and required longer hospital stay (3.7 ± 2.8 vs. 6.9 ± 7.5 days, p < 0.001). A multivariate regression model was performed to control for the effect of birth-weight, steroid administration, and preterm premature rupture of membrane. An earlier gestational age at delivery was associated with a higher risk of neonatal morbidity. The risk of neonatal morbidity decreased by 40% (OR = 0.60, 95% CI = 0.41–0.88; p = 0.009) for each 1 week increase in gestational age. Conclusion. Even in the presence of documented fetal lung maturity, major morbidities – including respiratory distress – may still occur.

Relationship Among Age, Race, Medical Funding, and Cervical Cancer Survival

OBJECTIVE To examine the impact of age, race, and medical funding on cervical cancer survival. MATERIALS AND METHODS Study design was a retrospective chart review of cervical cancer patients. Charts were abstracted for demographic characteristics, Pap smear history, clinical presentation, treatment, and survival. Descriptive studies, Spearman correlation, and Coxs proportional hazards regression model were performed. RESULTS One hundred-twenty-five cervical cancer patients were included. Mean age at diagnosis was 46.1 +/- 13.2 years, and median survival time from cervical cancer was 31 months; 11.2% of the study population was aged greater than 65 years; 63.4% were African American; and 44.6% had no medical funding. Diagnosis at age of at least 65 years was significantly correlated with suboptimal cervical cancer screening pattern (r = 0.36, p = .0003). Women aged at least 65 years old had a 3.39 time increased hazard of death compared to younger patients (p = .02; OR, 3.39; 95% CI, 1.20-9.56) after adjusting for advanced stage of disease and treatment modality. There was no significant association between medical funding or race on cervical cancer screening pattern, stage at diagnosis, or survival. CONCLUSION Age at diagnosis (> or = 65 years), but not medical funding or race, was correlated with suboptimal cervical cancer screening pattern and poor survival.

Rapid HIV Testing and Obstetrical Characteristics of Women With Unknown HIV Serostatus at Time of Labor and Delivery

OBJECTIVE To describe the obstetrical characteristics of women without prenatal care and/or undocumented human immunodeficiency virus (HIV) serostatus who presented for delivery and to assess the usefulness of rapid HIV screening in these women. MATERIALS AND METHODS The study design was a retrospective analysis. Demographics, labor, delivery characteristics, and pregnancy outcomes of women without prenatal care and/or unknown HIV serostatus were reviewed. RESULTS Three hundred fifty parturients met the inclusion criteria: 15.2% presented at complete cervical dilation, 48.6% with cervical dilation of at least 5 cm, and 43.1% with ruptured membranes. Twenty-two percent of parturients delivered within 1 hour of admission, 47.6% delivered within 4 hours of admission, and 5.5% delivered prior to arrival to the hospital. With the lengthy admission process and procurement of zidovudine from the pharmacy requiring at least 1 hour at best, 27.5% would not have the benefit of intrapartum zidovudine treatment. Single Use Diagnostic System HIV-1 rapid test was reactive and confirmed in 7 women (2.5%). CONCLUSION Rapid HIV screening is a useful tool for guiding immediate obstetrical management and coordinated care for the neonate. In some circumstances, the full benefit of rapid HIV detection will not be realized due to advanced labor, ruptured members, or delivery prior to arrival.

Resolution of Internal Carotid Dissection with Middle Cerebral Artery Occlusion in Pregnancy

Introduction. Cervical artery dissection (CAD) is a common cause of stroke in younger patients. While the incidence of stroke in pregnancy is increasing, CAD remains a rare cause of ischemic stroke in the pregnant population, with only 30 cases described in the literature, most in the postpartum period. Methods. The case of a pregnant patient at 18 weeks of gestation presenting with CAD and ischemic stroke following intercourse is discussed. Discussion. CAD results from an intimal tear in the carotid artery, allowing accumulation of blood in the vessel wall. Stroke results from embolization of thrombogenic material in the wall. Etiology includes minor trauma, connective tissue disorders, or anatomic variations of the carotid artery. Most patients present with headache and/or neck pain, while ischemic symptoms are seen in at least 50% of patients. In the pregnant population, imaging with MRI or MRA of the head and neck aids in diagnosis. Once the diagnosis is made, patients are treated with either anticoagulation or antiplatelet medications. The optimal treatment in both pregnant and nonpregnant patients has not been well-studied. Conclusion. CAD is an important diagnosis to consider in a pregnant patient with persistent headache, especially if neurological symptoms are present. Imaging should be quickly obtained so treatment can be initiated.

Significantly Elevated Serum Lipase in Pregnancy with Nausea and Vomiting: Acute Pancreatitis or Hyperemesis Gravidarum?

Hyperemesis gravidarum is a severe manifestation of nausea and vomiting of pregnancy and it is associated with weight loss and metabolic abnormalities. It is known that abnormal laboratory values, including mildly elevated serum lipase level, could be associated with hyperemesis gravidarum. However, in this case report details of two women with hyperemesis gravidarum but with significantly elevated serum lipase levels were discussed. These patients presented with severe nausea and vomiting but without abdominal pain. They were found to have severely elevated lipase levels over 1,000 units/liter. In the absence of other findings of pancreatitis, they were treated with conservative measures for hyperemesis gravidarum, with eventual resolution to normal lipase levels. Although significantly elevated lipase level in pregnant patients with nausea and vomiting is a concern for acute pancreatitis, these two cases of significantly elevated serum lipase without other clinical findings of pancreatitis led to this report that serum lipase could be quite elevated in hyperemesis gravidarum and that it might not be an accurate biochemical marker for acute pancreatitis. Imaging studies are thus necessary to establish the diagnosis of acute pancreatitis.

Screening for HIV Infection in Pregnancy

Approximately 100 to 200 infants annually in the United States are infected with HIV (CDC, 2007). Most were born to mothers who were unaware of their infected HIV status or who did not receive preventative services during their pregnancy to reduce transmission rates. Therefore, in 2006, the CDC updated its guidelines for screening of various populations for HIV, including pregnant women. Obstetricians and gynecologists are ideally suited to such screening of their patients during annual exams and prenatal visits.