Daniel H. Saltzman

Emergency peripartum hysterectomy

OBJECTIVES By means of hospital-based data over 9 years we sought to evaluate the clinical indications and incidence of emergency peripartum hysterectomy by demographic characteristics and reproductive history. STUDY DESIGN From the obstetric records of all deliveries at Brigham and Womens Hospital between Oct. 1, 1983, and July 31, 1991, we identified all women undergoing emergency peripartum hysterectomy, calculated crude and adjusted incidence rates, conducted statistical tests of linear trends and heterogeneity, and observed the clinical indications preceding the onset of this procedure. RESULTS There were 117 cases of peripartum gravid hysterectomy identified during this period, for an overall annual incidence of 1.55 per 1000 deliveries. The rate increased with increasing parity and was significantly influenced by placenta previa and a history of cesarean section. The incidence by parity increased from one in 143 deliveries in nulliparous women with placenta previa to one in four deliveries in multiparous women with four or more deliveries with placenta previa. Likewise, the incidence increased from one in 143 deliveries in women with one prior live birth and a prior cesarean section to one in 14 deliveries in multiparous women with four or more deliveries with a history of a prior cesarean section. Both these trends were highly significant (p < 0.001). Abnormal adherent placentation was the most common cause preceding gravid hysterectomy (64%, p < 0.001), with uterine atony accounting for 21%. Although no maternal deaths occurred, maternal morbidity remained high, including postoperative infection in 58 (50%), intraoperative urologic injury in 10 patients (9%), and need for transfusion in 102 patients (87%). CONCLUSIONS The data identify abnormal adherent placentation as the primary cause for gravid hysterectomy. The data also illustrate how the incidence of emergency peripartum hysterectomy increases significantly with increasing parity, especially when influenced by a current placenta previa or a prior cesarean section. Maternal morbidity remained high although no maternal deaths occurred.

Changes in intracardiac blood flow velocities and right and left ventricular stroke volumes with gestational age in the normal human fetus: a prospective Doppler echocardiographic study.

We used Doppler echocardiography to quantitate the changes in intracardiac blood flow velocities and right and left ventricular stroke volumes in 80 normal human fetuses from 19 to 40 weeks gestation. Blood flow velocity spectra across the aortic, pulmonary, tricuspid, and mitral valves were digitized to obtain peak velocities (m/sec) and flow velocity integrals. Aortic and pulmonary diameters were measured at valve level from two-dimensional echocardiographic images and cross-sectional area was calculated assuming a circular orifice. Ventricular stroke volume was calculated as the product of the cross-sectional area of a great vessel and the flow velocity integral through that vessel. The pulmonary arterial and aortic diameters increased linearly with gestational age (r = .82, r = .84), and pulmonary arterial diameter consistently exceeded aortic diameter. There was a positive relationship between stroke volume and gestational age: stroke volume increased exponentially from 0.7 ml at 20 weeks to 7.6 ml at 40 weeks for the right ventricle (r = .87) and from 0.7 ml at 20 weeks to 5.2 ml at 40 weeks for the left ventricle (r = .91). Similar results were obtained for right and left ventricular and combined cardiac outputs. In 44% of the fetuses it was possible to quantitate both right and left ventricular stroke volumes. There was a close correlation between right and left ventricular stroke volumes in these fetuses (r = .96) and right ventricular stroke volume exceeded left ventricular stroke volume by 28%.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of subsequent pregnancy on left ventricular function in peripartum cardiomyopathy

Pregnancy has been discouraged in patients with peripartum cardiomyopathy (PPCM) to avoid the risk of precipitating recurrent or progressive left ventricular dysfunction. We assessed left ventricular size and contractile function using echocardiography in four PPCM patients prior to pregnancy, during the third trimester, and a mean of 6 weeks postpartum. Left ventricular mean diameters at end diastole and at end systole prior to pregnancy (5.2 +/- 0.3 and 3.0 +/- 0.2 cm, respectively) did not change during pregnancy (5.2 +/- 0.3 and 3.1 +/- 0.2 cm). Similarly, left ventricular fractional shortening did not alter significantly during pregnancy or postpartum. Furthermore, no patient developed any symptoms or signs of left ventricular failure. All patients had normal babies, including one who had twins. We conclude that PPCM patients whose left ventricular function returns to normal may undertake further pregnancy with a normal fetal outcome and a low risk of recurrent left ventricular dysfunction.

Changes in Placental Blood Flow in the Normal Human Fetus with Gestational Age

ABSTRACT: We assessed fetoplacental blood volume flow and placental resistance prospectively with Doppler sonog-raphy in 74 normal human fetuses of 19 to 42 wk gestation to determine the changes in placental perfusion with gestational age. Placental blood volume flow was assessed from the umbilical vein as the product of the mean flow velocity integral and the cross-sectional area of the umbil-ical vein. Placental resistance was assessed as the ratio of maximum systolic and minimum diastolic blood flow velocities from an umbilical artery. Umbilical vein blood volume flow increased exponentially (r = 0.86) with gestational age from 19 wk to term, and did not decrease in postdate fetuses. Umbilical vein blood volume flow increased linearly with fetal weight (r = 0.77), although volume flow per unit body weight changed little with gestational age. Umbilical artery velocity ratio decreased progressively, indicating diminishing placental resistance with gestational age, but did not correlate closely with umbilical vein blood volume flow, We submit that fetoplacental blood volume flow can be readily calculated directly from the umbilical vein with Doppler ultrasound and may provide a better index of placental perfusion than the umbilical artery velocity ratio.

Prematurity among insulin-requiring diabetic gravid women.

From Jan. 1, 1983, through Dec. 31, 1987, 420 gravidas with insulin-requiring diabetes antedating pregnancy delivered on the Joslin Clinic service. Among them, 110 pregnancies (26.2% of the total) delivered before 37 completed weeks of gestation compared with a 9.7% incidence (906/9368) for the general population at the Brigham and Womens Hospital during calendar year 1985. Thirty-three percent of all premature deliveries were the result of the development of preeclampsia. The relative risk of prematurity for diabetic patients with any hypertensive complication was 2.0 (95% confidence interval, 1.40 to 2.87) compared with normotensive diabetic subjects. Compared with the general population, most of the excess risk of prematurity was confined to hypertensive diabetics and normotensive patients of more advanced White class. A history of having had a previous premature delivery, increasing duration of diabetes antedating pregnancy, and carrying a male fetus in the index pregnancy were significantly associated with premature delivery. Future efforts to reduce the incidence of prematurity among diabetic gravidas should be directed toward reducing the incidence of preeclampsia.

Active Second-Stage Management in Twin Pregnancies Undergoing Planned Vaginal Delivery in a U.S. Population

OBJECTIVE: To estimate neonatal morbidity and delivery outcomes according to planned mode of delivery in twin pregnancies with active second-stage management. METHODS: This was an historic cohort of twin pregnancies delivered in one practice between June 2005 and September 2009 using a strict protocol of second-stage management, including breech extraction of a second noncephalic twin and internal version of a nonengaged cephalic second twin followed by breech extraction. Primary outcome was a 5-minute Apgar score less than 7 for twin B. Secondary outcomes were 5-minute Apgar score less than 7 for twin A and 1-minute Apgar score less than 7 and arterial cord pH below 7.20 for each twin. RESULTS: A total of 287 twin pregnancies were included. There were 157 patients (54.7%) in the planned cesarean group and 130 patients (45.3%) in the planned vaginal delivery group. There was no significant difference in the rates of twin B having a 5-minute Apgar score lower than 7 or an arterial cord pH below 7.20. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 15.4%. No patients had a vaginal delivery of twin A followed by cesarean delivery of twin B. Among the patients in the planned vaginal delivery group, patients who had a successful vaginal delivery were more likely to be younger (31.56±6.6 compared with 36.88±6.1 years, P=.001) and were more likely to have a prior vaginal delivery (47.3% compared with 15.0%, P=.007). CONCLUSION: Planned vaginal delivery of twin pregnancies seems to be associated with neonatal outcomes similar to those with planned cesarean delivery. Active second-stage management is associated with good neonatal outcomes and a low risk of combined vaginal-cesarean delivery. LEVEL OF EVIDENCE: II

The effect of maternal obesity on pregnancy outcomes in women with gestational diabetes.

Objective. To examine the impact of maternal obesity on maternal and neonatal outcomes in pregnancies complicated with gestational diabetes mellitus (GDM). Methods. Women with singleton pregnancies and GDM enrolled in an outpatient GDM education, surveillance and management program were identified. Maternal and neonatal pregnancy outcomes were compared for obese (pre-pregnancy BMI ≥ 30 kg/m2) and non-obese (pre-pregnancy BMI < 30 kg/m2) women and for women across five increasing pre-pregnancy BMI categories. Results. A total of 3798 patients were identified. Maternal obesity was significantly associated with the need for oral hypoglycemic agents or insulin, development of pregnancy-related hypertension, interventional delivery, and cesarean delivery. Adverse neonatal outcomes were also significantly increased including stillbirth, macrosomia, shoulder dystocia, need for NICU admission, hypoglycemia, and jaundice. When looking across five increasing BMI categories, increasing BMI was significantly associated with the same adverse maternal and neonatal outcomes. Conclusion. In women with GDM, increasing maternal BMI is significantly associated with worse maternal and neonatal outcomes.

The Cardiac, Obstetric, and Anesthetic Management of Pregnancy Complicated by Acute Myocardial Infarction

Myocardial infarction (MI) occurring during pregnancy is a rare but potentially lethal event for both mother and fetus, particularly when it occurs in the third trimester or peripartum period. The authors report two cases of MI occurring in the third trimester of pregnancy and review the literature. Management of the acute infarct and the medical, obstetric, and anesthetic considerations in such patients during labor and delivery are discussed. Successful use of percutaneous transluminal coronary angioplasty is described in a patient with evolving MI and ongoing pain. The preferred method of delivery in the pregnant MI patient is addressed, with emphasis on the need for individualization of care and coordination between the cardiac, obstetric, and anesthetic teams. Finally, the authors review the risks of subsequent pregnancy in this patient population.

Pneumomediastinum in pregnancy: two case reports and a review of the literature, pathophysiology, and management.

&NA; Pneumomediastinum, free air trapped in the mediastinal connective tissue, is a rare complication of pregnancy, occurring most frequently in the second stage of labor. Symptoms are often not noted until after delivery. Occurrence before and in the first stage of labor, as seen in the two cases reported here, is more uncommon. One case history is the first report of the coexistence of pneumomediastinum and pneumothorax in pregnancy. The prognosis for spontaneous pneumomediastinum in pregnancy is favorable. Pathophysiologic mechanisms, diagnosis, and management are discussed, and a review of the literature is presented. (Obstet Gynecol 64:39S, 1984)

Intravaginal misoprostol versus Foley catheter for labour induction: a meta‐analysis

Please cite this paper as: Fox N, Saltzman D, Roman A, Klauser C, Moshier E, Rebarber A. Intravaginal misoprostol versus Foley catheter for labour induction: a meta‐analysis. BJOG 2011;118:647–654.