Fadi Mirza

Trauma in Pregnancy: A Systematic Approach

Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. Many of the assessment and management aspects of obstetric trauma are unique to pregnancy, although initial evaluation and resuscitation should always be maternally directed. Once maternal stability is established, vigilant evaluation of fetal well-being becomes warranted. Continuous fetal heart monitoring, ultrasonography, computed tomography, open peritoneal lavage, and/or exploratory laparotomy may be indicated in a case of obstetric trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount.

Cesarean Delivery in the Developing World

Two trends are apparent regarding cesarean delivery in the developing world. In the least developed countries, access to the procedure remains limited at levels much less than 5% of all births. This limited access is linked with increases in maternal and neonatal mortality. Safety concerns are equally valid when more than half of women in certain socioeconomic strata are having surgical delivery, as is evident in the more advanced developing economies of Latin America and China. The optimal minimum and maximum cesarean delivery rates continue to be a matter of debate and may never be resolved; however, these two extremes of cesarean delivery use evident in the developing world deserve critical examination.

Accuracy and reliability of fetal heart rate monitoring using maternal abdominal surface electrodes.

Objective. Compare the accuracy and reliability of fetal heart rate identification from maternal abdominal fetal electrocardiogram signals (ECG) and Doppler ultrasound with a fetal scalp electrode. Design. Prospective open method equivalence study. Setting. Three urban teaching hospitals in the Northeast United States. Sample. 75 women with normal pregnancies in labor at >37 weeks of gestation. Methods. Three fetal heart rate detection methods were used simultaneously in 75 parturients. The fetal scalp electrode was the standard against which abdominal fetal ECG and ultrasound were judged. Main outcome measures. The positive percent agreement with the fetal scalp electrode indicated reliability. Bland–Altman analysis determined accuracy. The confusion rate indicated how frequently the devices tracked the maternal heart rate. Results. Positive percent agreement was 81.7 and 73% for the abdominal fetal ECG and ultrasound, respectively (p = 0.002). The abdominal fetal ECG had a lower root mean square error than ultrasound (5.2 vs. 10.6 bpm, p < 0.001). The confusion rate for ultrasound was 20‐fold higher than for abdominal ECG (8.9 vs. 0.4%, respectively, p < 0.001). Conclusion. Compared with the fetal scalp electrode, fetal heart rate detection using abdominal fetal ECG was more reliable and accurate than ultrasound, and abdominal fetal ECG was less likely than ultrasound to display the maternal heart rate in place of the fetal heart rate.

Poly Cystic Ovarian Syndrome: An Updated Overview.

Poly Cystic Ovarian Syndrome (PCOS) is one of the most common metabolic and reproductive disorders among women of reproductive age. Women suffering from PCOS present with a constellation of symptoms associated with menstrual dysfunction and androgen excess, which significantly impacts their quality of life. They may be at increased risk of multiple morbidities, including obesity, insulin resistance, type II diabetes mellitus, cardiovascular disease (CVD), infertility, cancer, and psychological disorders. This review summarizes what the literature has so far provided from guidelines to diagnosis of PCOS. It will also present a general overview about the morbidities associated with this disease, specifically with its more severe classic form. Finally, the review will stress on the various aspects of treatment and screening recommendations currently used in the management of this condition.

Pre-eclampsia and the Kidney

Pre-eclampsia is a multisystem disorder that is unique to pregnancy, affecting at least 5% of all gravidas. The mainstay of this diagnosis is a combination of new-onset hypertension and proteinuria. The kidney deserves particular attention because of the physiologic as well as pathologic changes that can affect this vital organ in pregnancy. In fact, there is a major interplay between renal disease and pre-eclampsia. Proteinuria is universal to all cases of pre-eclampsia, yet some cases can progress to acute renal failure. Furthermore, it is well-established that the latter is more frequent in women with underlying renal disease. This chapter reviews the physiologic changes that the human kidney adapts during pregnancy, the impact of pre-eclampsia on the kidney and its function, and the risk of pre-eclampsia in women with chronic renal disease. Two groups that warrant special consideration are pregnant women with systemic lupus erythematosus and those with history of renal transplantation.

Accuracy and Reliability of Uterine Contraction Identification Using Abdominal Surface Electrodes

Objective: To compare the accuracy and reliability of uterine contraction identification from maternal abdominal electrohysterogram and tocodynamometer with an intrauterine pressure transducer. Methods: Seventy-four term parturients had uterine contractions monitored simultaneously with electrohysterography, tocodynamometry, and intrauterine pressure measurement. Results: Electrohysterography was more reliable than tocodynamometry when compared to the intrauterine method (97.1 versus 60.9 positive percent agreement; P < 0.001). The root mean square error was lower for electrohysterography than tocodynamometry in the first stage (0.88 versus 1.22 contractions/10 minutes; P < 0.001), and equivalent to tocodynamometry in the second. The positive predictive values for tocodynamometry and electrohysterography (84.1% versus 78.7%) were not significantly different, nor were the false positive rates (21.3% versus 15.9%; P = 0.052). The sensitivity of electrohysterography was superior to that of tocodynamometry (86.0 versus 73.6%; P < 0.001). Conclusion: The electrohysterographic technique was more reliable and similar in accuracy to tocodynamometry in detecting intrapartum uterine contractions.

Gastroschisis: incidence and prediction of growth restriction

Abstract Aims: Fetuses with gastroschisis are at increased risk of intrauterine growth restriction (IUGR). However, there is a tendency for underestimation of fetal abdominal circumference and hence fetal weight, leading to overdiagnosis of IUGR. Our objective was to evaluate the accuracy of ultrasound for the prediction of being small for gestational age (SGA) at birth in these cases. Methods: A retrospective study of prenatally diagnosed cases of gastroschisis was conducted at a tertiary center. Fetal weight was estimated using the formula of Hadlock. IUGR was defined as an estimated fetal weight ≤10th percentile for gestational age. SGA at the time of birth was defined as a birth weight ≤10th percentile for gestational age. The incidence of IUGR on last ultrasound and that of SGA at birth were calculated, and the precision of ultrasound in predicting SGA was determined. Results: IUGR was reported on the last ultrasound prior to delivery in 9/25 cases (36%). Postnatally, 13/25 newborns (52%) were SGA. All sonographically suspected cases of IUGR based on the last ultrasound were SGA at birth. The positive predictive value of the last ultrasound in identifying SGA was 100%. Conclusions: At least half of the infants affected by gastroschisis were SGA at birth. Sonographic estimation of fetal weight within 1 month of birth reliably predicted SGA in infants with gastroschisis.

Intrauterine growth restriction with abnormal umbilical artery Dopplers: a harbinger for preeclampsia?

Objective: To determine whether abnormal umbilical artery Doppler velocimetry in the setting of unexplained intrauterine growth restriction (IUGR) is predictive of preeclampsia. Methods: This was a retrospective cohort study of singleton pregnancies diagnosed with unexplained IUGR between 2005 and 2008. Subjects were classified based on the presence or absence of abnormal Dopplers. The proportions of preeclampsia in the two groups were compared. Results: A total of 268 cases were included in the study. There were 57 cases with abnormal umbilical artery Dopplers. Of those, preeclampsia was diagnosed in 8 (14.0%) cases. In turn, there were 211 cases with normal Dopplers. Of those, preeclampsia was diagnosed in 9 (4.3%) cases. After controlling for age and parity, patients with abnormal Dopplers were 2.9 times more likely to be diagnosed with preeclampsia. Conclusions: Cases of unexplained IUGR with abnormal umbilical artery Dopplers appear to be at increased risk of preeclampsia compared to those with normal Dopplers.

To ignore or not to ignore placental calcifications on prenatal ultrasound: a systematic review and meta-analysis

Abstract Objective: The human placenta is known to calcify with advancing gestational age, and, in fact, the presence of significant calcifications is one of the components of grade III placenta, typical of late gestation. As such, the presence of significant placental calcifications often prompts obstetric providers to expedite delivery. This practice has been attributed, in part, to the presumed association between grade III placenta and adverse pregnancy outcomes. Such approach, however, can be the source of major anxiety and may lead to unnecessary induction of labor, with its associated predisposition to cesarean delivery as well as a myriad of maternal and neonatal morbidities. The objective of this study was to examine the association between grade III placental calcifications and pregnancy outcomes. Materials and methods: A systematic review of the literature was performed for studies evaluating the association between grade III placenta and a number of pregnancy outcomes, including labor induction, fetal distress (abnormal fetal heart tracing), low Apgar score (less than 7 at 5 min), need for neonatal resuscitation, admission to the Neonatal Intensive Care Unit, perinatal death, meconium liquor, and low birth weight. Results: There was a five-fold increase in risk of labor induction with the presence of grade III placenta (OR 5.41; 95% CI 2.98–9.82). There was no association between grade III placenta and the incidence of abnormal fetal heart tracing (OR 1.62; 95% CI 0.94–2.78), low Apgar score of less than 7 at 5 min (OR 1.68; 95% CI 0.84–3.36), need for neonatal resuscitation (OR 1.08; 95% CI 0.67–1.75), and admission to the Neonatal Intensive Care Unit (OR 0.90; 95% CI 0.21–3.74). In turn, the incidence of meconium liquor was higher in the setting of grade III placentae (OR 1.68; 95% CI 1.17–2.39). Similarly, a positive association between grade III placental calcifications and low birth weight (OR 1.63; 95% CI 1.19–2.22) and perinatal death (OR 7.41; 95% CI 4.94–11.09) was identified. Conclusion: The study alerts us to a significant association between grade 3 placental calcifications and labor induction, although it demonstrates that these sonographic findings do not appear to predispose to fetal distress, low Apgar score, need for neonatal resuscitation, or admission to the NICU.

Patient choice compared with no choice of intrathecal morphine dose for caesarean analgesia: a randomized clinical trial

Background: The study aimed to determine whether a patients choice for their intrathecal morphine (ITM) dose reflects their opioid requirements and pain after caesarean delivery and if giving women a choice of ITM dose would reduce opioid use and improve pain scores compared with women who did not have a choice. Methods: A total of 120 women undergoing caesarean delivery with spinal anaesthesia were enrolled in this randomized, double‐blind study. Patients were randomly assigned to a choice of 100 or 200 &mgr;g ITM or no choice. The study involved deception, such that all participants were still randomly assigned 100 or 200 &mgr;g ITM regardless of choice. Rescue opioid use over the 48‐h study period was the primary outcome measure. Pain at rest and movement and side effect (pruritus, nausea, and vomiting) data were collected 3, 6, 12, 24, 36 and 48 h postoperatively. Data are presented as median [95% confidence interval (CI)]. Results: Women who requested the larger ITM dose required more supplemental opioid [median 0.8 (95% CI 0.4‐1.3)] mg morphine equivalents at each assessment interval; P < 0.001] and reported more pain with movement [median 1.2 (95% CI 0.5‐1.9)] verbal numerical rating score of 0‐10 points] than patients who requested the smaller ITM dose (P = 0.0008), regardless of the ITM dose given. There was no difference in opioid use whether the patient was offered a perceived choice or not. Conclusions: Women who were given a choice and chose the larger ITM dose correctly anticipated a greater postoperative opioid requirement and more pain compared with women who chose the smaller dose. Simply being offered a choice did not impact opioid use or pain scores after caesarean delivery. Trial Registration: ClinicalTrials.gov (NCT01425762).