Federico G. Mariona

Anesthesia-related maternal mortality in Michigan, 1972 to 1984

Abstract We reviewed maternal deaths in the state of Michigan occurring from 1972 through 1984. There were 15 maternal deaths in which anesthesia was considered the primary cause and 4 deaths in which anesthesia was a contributory factor. Complications of regional anesthesia were the main cause of death during the early part of the period, whereas the inability to accomplish endotracheal intubation emerged as the principal cause of death in recent years. Eleven of the 15 patients had undergone cesarean section. Obesity was a risk factor in 12 patients, in an equal number of patients the risk factor was the emergent nature of the operation, and hypertensive disease was a risk factor in eight. Thirteen of the 15 deaths occurred in black patients.

Preeclampsia, delivery, and the hemostatic system

To determine the effects of preeclampsia and delivery, the hemostatic system was evaluated before and 24 to 48 hours after delivery in 59 nulliparous patients without clinical signs of disseminated intravascular coagulation. Fifteen patients with mild preeclampsia and 18 with severe preeclampsia were compared with 26 pregnant control patients. Preeclampsia was associated with high fibronectin (p less than 0.001), low antithrombin III (p less than 0.001), and low alpha 2-antiplasmin (p less than 0.005), suggesting endothelial injury, clotting, and fibrinolysis, respectively. After delivery, fibronectin decreased only in preeclamptic patients (p less than 0.005); alpha 2-antiplasmin increased in all groups (p less than 0.001). Endothelial injury in preeclampsia appeared to resolve soon after delivery, which could contribute to the rapid clinical improvement noted in the early puerperium.

Antenatal phenobarbital for the prevention of neonatal intracerebral hemorrhage

Forty-six pregnant women less than 35 weeks of gestation were enrolled in a prospective randomized controlled study evaluating the effects of antenatal phenobarbital on neonatal intracerebral hemorrhage. The women were randomly assigned to control (n = 22) or treatment (n = 24) groups; the treatment group received 500 mg of phenobarbital intravenously. The time interval between the dose of phenobarbital and delivery was 5.5 +/- 4.8 hours (mean +/- SD). The infants in the control group (n = 23) and those in the phenobarbital-treated group (n = 25) were comparable regarding birth weight, gestational age, and other obstetric and neonatal risk factors associated with intracerebral hemorrhage. The incidence of intracerebral hemorrhage was 56.5% (13 of 23 infants) in the control group and 32% (eight of 25 infants) in the phenobarbital-treated group (p = 0.08). Moderate or severe hemorrhage was diagnosed in six of 13 control infants and in none of the phenobarbital-treated infants (p less than 0.01). The mortality rate was significantly lower in the phenobarbital-treated group (two of 25 infants) than in the control group (eight of 23 infants; p less than 0.05). Our study suggests that antenatal phenobarbital administration results in a decrease in mortality and in the severity of intracerebral hemorrhage in the preterm neonate.

Are we ready for a new look at the diagnosis of premature rupture of membranes

Abstract Premature rupture of membranes is a significant contributor to preterm birth with its associated short- and long-term complications. The absence of a standard approach to its management places a burden on the clinicians’ ability to promptly and accurately diagnose premature rupture of membranes. For the last half century, there have been no significant changes in the way premature ruptured membranes is diagnosed. With the advent of newer, amniotic fluid-specific, noninvasive, and accurate markers, there is an opportunity to update the diagnosis of premature rupture of membranes.

The role of placental alpha microglobulin-1 amnisure in determining the status of the fetal membranes; its association with preterm birth. Traditions … traditions …

Abstract The integrity of the fetal amnion-chorion is an imperative for the preservation of a normal pregnancy in the human. The diagnosis of the status of the fetal membranes has traditionally been reduced to either intact or ruptured. In the last decades, evidence has accumulated demonstrating that this clinical approach may well be an over simplification. Practically, all maternal organs experienced physiologic or eventually pathologic changes during the length of the gestational period. We propose that the fetal membranes are also significantly impacted by those changes. The accurate, specific, simplified and low-cost diagnosis of the status of the fetal membranes is of critical importance for the assessment of risk to the pregnancy followed by efficient and prompt treatment. The presence of placental alpha macroglobulin-1 in the vagina specifically indicates a disruption in the integrity of the fetal membranes and may indirectly mean increased risk for preterm birth. Further research to properly characterize this marker and its importance in the care of pregnant woman at risk for preterm birth is strongly recommended.

Comment and reply on: The clinical significance of a positive Amnisure test in women with term labor with intact membranes

Lee et al. reported that among term women in labor without clinically apparent rupture of membranes, those patients with a positive Amnisure have a shorter admission-to-delivery interval than those patients with a negative result [1]. The median interval in the positive group was 6.88 h versus 9.79 h in the negative group (range 1.18–15.98 h and 2.32–33.07 h, respectively; p5 0.05). Although this was found to be a statistically significant result, we suggest that it is not clinically significant given the stated gestational age.

Prenatal Diagnosis and Outcome of Congenital Complete Heart Block: The Role of Fetal Echocardiography

Between January 1, 1980, and March 1, 1986, congenital complete heart block (CCHB) was diagnosed in 11 fetuses utilizing 2-dimensional and M-mode fetal echocardiography. Four of the eleven cases (36.4%) had otherwise structurally normal hearts; 3 survived the perinatal and neonatal period and 1 patient died at 22 days of age. All mothers in this group had systemic lupus erythematosus. Seven of the eleven fetuses (63.6%) presented with CCHB and associated cardiac malformations. All patients in this group died either in utero or shortly after birth. The discovery of CCHB with associated structural malformations of the heart carries an ominous prognosis for fetal and neonatal survival. The diagnosis of CCHB without associated cardiac malformations carries a more favorable outlook. Accurate prenatal diagnosis of CCHB and underlying cardiac status facilitates parental counseling and patient management planning.

Does maternal obesity impact pregnancy-related deaths? Michigan experience

Abstract Obesity is a multifactorial non-communicable condition that has become a public health epidemic worldwide. The Fifth Millennium Development Goal established the goal of a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. Maternal mortality has been difficult to track over time. Obesity affects pregnancy in more than 50% of women of reproductive age in the state of Michigan; the potential impact of maternal obesity and pregnancy-related deaths (PRDs) has not been studied in Michigan. We conducted a secondary analysis of maternal death cases originally reviewed by the Michigan Maternal Mortality Review Committee from 2004 to 2006 seeking to evaluate the impact of maternal obesity on PRD. Two hundred and five maternal deaths occurred during the period of the study, 61 were classified as PRD. The observed occurrence of PRDs in the obese population was 36 cases while in the non-obese was 25 cases. The study showed a 3.7× risk of PRD in the obese parturient.

1519 ANTENATAL PHENOBARBITAL FOR PREVENTION OF NEONATAL IANTRAVENTRICULAR HEMORRHAGE

A prospective randomized controlled study was performed evaluating the effects of antenatal phenobarbital (PB) on neonatal intraventricular hemorrhage (IVH). Forty-six pregnant women in labor <35 wks gestation were assigned to control (n=22) or treatment groups (n=24); the treatment group received 500 mg PB by slow intravenous infusion prior to delivery. Echoencephalograms were performed on all infants. The time between dose of PB and delivery was 5.6 ± 4.6 hrs (all values mean ± SD). Maternal PB levels at delivery were 8.72 ± 2.01 μg/mL and cord serum PB levels were 8.85 ± 1.57 μg/mL. The infants in the control group and those in the PB treated group did not differ regarding delivery route, presentation, Apgar scores, ventilatory support, episodes of acidosis, hypoxemia, hypercarbia, hypotension and fluid therapy in the first 3 days. The results indicate a significant decrease in mortality and occurrence of moderate and severe IVH in the PB treated group as compared to the control group.

ANTENATAL PHENOBARBITAL FOR PREVENTION OF NEONATAL INTRAVENTRICULAR HEMORRHAGE: PRELIMINARY OBSERVATIONS

Eighteen mothers in premature labor <35 week gestation were enrolled in a study to evaluate the effect of antenatal phenobarbital(PB) in preventing neonatal intraventricular hemorrhage.Mothers were randomly assigned to treatment or control groups; the treatment group received 500 mg PB administered intravenously.Maternal and cord blood PB levels were measured at delivery. Echoencephalograms were performed on days 3 and 14 and hemorrhage graded as mild, moderate and severe.Nine mothers(including one multiple pregnancy) received antenatal PB. Mean time between administration of PB and delivery was 2.9±2.7 hours. Maternal PB levels at delivery were 9.2±2.3 μg/ml. Cord blood PB levels were 9.8±2.1 μg/ml. The PB and control groups were comparable regarding maternal age,duration of rupture of membranes, route of delivery, presentation, birth weight,gestational age,Apgar scores and incidence of pneumothoraces, hypotension,acidosis, hypoxemia,hypercarbia or amount of fluid intake or bicarbonate therapy during the first 3 days. Seven of 10 infants in the PB group had no hemorrhage while 1 had a mild and 2 had severe hemorrhages. Five of 9 infants in the control group had no hemorrhage while 2 had moderate and 2 had severe hemorrhages. When comparing mild or no hemorrhage vs moderate and severe hemorrhage in the 2 groups no significant difference has been found thus far (p = .21).