Gareth Seaward

Pregnancy outcomes in patients after radical trachelectomy.

OBJECTIVES This study was undertaken to review and analyze the fertility and pregnancy outcomes in patients who have undergone radical trachelectomy as the method of management of invasive carcinoma of the cervix. STUDY DESIGN All preoperative, operative, and follow-up data were collected prospectively. Perinatal information was completed by chart reviews and patient questionnaires. RESULTS Of 80 patients having undergone the above procedure, 39 have attempted to conceive for a median of 11 months (range 1-85). There have been a total of 22 pregnancies in 18 patients (4 patients pregnant twice). Of the 22 pregnancies, 18 were viable, with 12 progressing to term and delivering by caesarean section. Preterm premature rupture of membranes was the primary cause of preterm delivery. CONCLUSION This series confirms that pregnancy is a safe and realistic outcome for women undergoing radical trachelectomy for invasive carcinoma of the cervix. Given the apparently high incidence of preterm premature rupture of membranes, these pregnancies should be managed as high risk.

Critical care management of the obstetric patient

PurposeTo review a series of critically ill obstetric patients admitted to a general intensive care unit in a Canadian centre, to assess the spectrum of diseases, interventions required and outcome.MethodsA retrospective chart review was performed of obstetric patients admitted to the intensive care unit of an academic hospital with a high-risk obstetric service, dunng a five-year penod. Data obtained included the admission diagnosis. ICU course and outcome. Daily APACHE II and TISS scores were recorded.ResultsSixty-five obstetric patients, representing 0.26% of deliveries in this hospital, were admitted to the ICU during the study period. All had received prenatal care. Admission diagnoses included obstetric (71%) and nonobstetric (29%) complications. The mean APACHE II score was 6.8 ± 4.2 and mean TISS score was 24 ± 8.1. Twenty-seven patients (42%) required mechanical ventilation. No maternal mortality occurred and the perinatal mortality rate was 11 %.ConclusionsA small proportion of obstetric patients develop complications requiring ICU admission. The out-come in this study was excellent, in contrast to that reported in other published studies with similar ICU admission rates. The universal availability of prenatal care may be an important factor in the outcome of this group of patients. The lack of a specific severity of illness scoring system for the pregnant patient makes comparison of case series difficult.RésuméObjectifsRevoir les dossiers d’une groupe de parturientes sérieusement malades admises à l’unité des soins intensifs (USI) généraux d’un centre hospitalier canadien, évaluer l’éventail des affections, les interventions nécessaires et les résultats obtenus.MéthodesRevue rétrospective de dossiers de parturientes admises à l’USI d’un hôpital universitaire canadien doté d’un service d’obstétrique pour patientes à risques élevés pendant une période de cinq ans. Les données obtenues comprenaient le diagnostic à l’admission, l’évolution à l’USI et les résultats. Les scores APACHE Il et TISS étaient enregistrés quotidiennement.RésultatsSoixante-cinq parturientes représentant 0,26% des accouchements de l’hôpital ont été admises à l’USI pendant la période étudiée. Toutes avaient bénéficié des soins prénataux. Les patientes étaient admises pour des complications obstétncales (71%) ou autres (29%). Les scores APACHE et TilSS moyens étaient respectivement 6.8 ± 4.2 et 24 ± 8.1. Vingt–sept patientes (42%) ont été ventilées mécaniquement. Il n’y a pas eu de mortalité maternelle et le taux de mortalité périnatale était de 11 %.ConclusionsUne faible proportion des partunentes développent des complications nécessitant des soins intensifs. Pour cette étude, les résultats sont excellents, contrairement à d’autres publiés ailleurs comportant des taux d’admission aux soins intensifs identiques. L’universalité de l’accès aux soins prénataux pourrait influencer considérablement les résultats dans ce groupe de patientes. L’absence d’un système de score spécifique à la gravité des affections de la grossesse rend la comparaison entre séries difficile.

An international trial of antioxidants in the prevention of preeclampsia (INTAPP).

OBJECTIVE We sought to investigate whether prenatal vitamin C and E supplementation reduces the incidence of gestational hypertension (GH) and its adverse conditions among high- and low-risk women. STUDY DESIGN In a multicenter randomized controlled trial, women were stratified by the risk status and assigned to daily treatment (1 g vitamin C and 400 IU vitamin E) or placebo. The primary outcome was GH and its adverse conditions. RESULTS Of the 2647 women randomized, 2363 were included in the analysis. There was no difference in the risk of GH and its adverse conditions between groups (relative risk, 0.99; 95% confidence interval, 0.78-1.26). However, vitamins C and E increased the risk of fetal loss or perinatal death (nonprespecified) as well as preterm prelabor rupture of membranes. CONCLUSION Vitamin C and E supplementation did not reduce the rate of preeclampsia or GH, but increased the risk of fetal loss or perinatal death and preterm prelabor rupture of membranes.

Expectant management compared with elective delivery at 37 weeks for gastroschisis.

OBJECTIVE: To estimate obstetric and neonatal outcomes after induction of labor at 37 weeks of gestation compared with expectant management in pregnancies complicated by fetal gastroschisis. METHODS: The management of 296 pregnancies involving fetal gastroschisis (1980–2011) was reviewed from a single perinatal center. Ultrasound surveillance and nonstress testing were performed every 2 weeks from 30 weeks of gestation, weekly from 34 weeks of gestation, and twice weekly after 35 weeks of gestation until delivery. Labor was induced if fetal well-being testing was abnormal and, since 1994, labor was routinely induced at 37 weeks of gestation. RESULTS: Of 153 pregnancies reaching 37 weeks of gestation, labor was induced in 77 (26%) and 76 (25.7%) were allowed to labor spontaneously. There were no significant differences in mean maternal age (22 years in both), parity (56% compared with 66% nulliparous), presence of other fetal anomalies (12% compared with 9%), cesarean delivery rate (20% in both), 5-minute Apgar score less than 7 (10% compared with 12%), meconium at birth (36% compared with 49%), or respiratory distress syndrome (16% compared with 7%) between the induced and expectantly managed groups. However, neonatal sepsis (25% compared with 42%; P=.02) and a composite outcome of neonatal death and bowel damage (necrosis, atresia, perforation, adhesion; 8% compared with 21%; P=.02) were more common in expectantly managed pregnancies. Moreover, time to oral feeds (-3.4 days), time on total parenteral nutrition (-6.2 days), and hospital stay (-6.7 days) were reduced when labor was induced. CONCLUSION: In fetuses with gastroschisis, induction of labor at 37 weeks of gestation was associated with reduced risks of sepsis, bowel damage, and neonatal death compared with pregnancies managed expectantly beyond 37 weeks of gestation. LEVEL OF EVIDENCE: II

Blood Transfusion for Primary Postpartum Hemorrhage: A Tertiary Care Hospital Review

OBJECTIVE To describe the common characteristics, clinical management, and outcome of patients requiring blood transfusion within 24 hours of delivery. METHODS We conducted a retrospective cohort study of patients who received blood transfusion for postpartum hemorrhage (PPH) in the first 24 hours post-delivery, over a five-year period (2000-2005). The medical records of patients were reviewed to obtain information about demographics, pregnancy and delivery characteristics, transfusion data, and complications. RESULTS The overall blood transfusion rate for PPH was 0.31% (104/33,631 deliveries). The rate of blood transfusion in women who had a Caesarean section during labour was 0.49%, whereas in women who had a vaginal delivery or elective Caesarean section it was 0.28% and 0.23%, respectively. Antenatal risk factors for PPH were identified in 61% of patients, and 39% of patients developed intrapartum risk factors. The most important etiological factors were uterine atony (38.5%) and retained products of conception (33.7%). Twenty-one percent of the patients developed coagulopathy, and 24% required admission to the intensive care unit. CONCLUSION Severe primary PPH requiring blood transfusion can be predicted in the majority of patients on the basis of antenatal risk factors, while the remaining patients require vigilant monitoring for risk factors during labour and delivery. In the multidisciplinary effort to prevent and control major PPH, we should re-evaluate the pharmacotherapy for PPH and ensure careful removal of retained placental tissue after delivery.

Twin–twin transfusion syndrome: a frequently missed diagnosis with important consequences

To evaluate the incidence and consequences of ‘misdiagnosed’ cases of twin–twin transfusion syndrome (TTTS).

Obstetric Outcome of Extreme Macrosomia

OBJECTIVE To determine the effect of extreme macrosomia on perinatal outcome. METHODS We conducted a retrospective review of all deliveries with birth weight > or = 5000 g in a tertiary centre from 1986 to 2000 and analyzed the method of delivery and perinatal outcome. RESULTS Extreme macrosomia (birth weight > or = 5000 g) was coded in 111 deliveries. There were 62 deliveries by Caesarean section (CS) (25 in labour and 37 elective). The 49 vaginal deliveries were complicated by 10 (20%) cases of shoulder dystocia and 3 (6%) of Erbs palsy. Permanent Erbs palsy was noted in only 1 of these 3 cases. Shoulder dystocia was associated with use of oxytocin and instrumental deliveries. CONCLUSION Implementing the 2002 guidelines from the American College of Obstetricians and Gynecologists (that is, recommending Caesarean delivery of fetuses with an estimated weight of at least 5000 g) would have a negligible effect on the CS rate while eliminating 10 cases of shoulder dystocia in 49 births. A policy eliminating the use of oxytocin and instrumental deliveries would have prevented most birth traumas in this group. Unfortunately, this high-risk group is difficult to identify in the antepartum period, complicating the implementation of these guidelines and probably leading to higher rates of CS. In addition, the effect of endorsing such a policy on overall neonatal and maternal morbidity is minimal, because most morbidity occurs in newborns weighing less than 4000 g.

Treatment options in fetomaternal hemorrhage: four case studies.

BACKGROUND Significant fetomaternal hemorrhage (FMH) is an uncommon event that places the fetus at risk of severe morbidity and mortality. Symptoms and signs at presentation are subtle and, if promptly recognized, appropriate management may permit the fetus to escape serious injury. CASES Four cases of significant FMH were diagnosed in the high-risk obstetrical unit at Mount Sinai Hospital, Toronto, during 2003. Three of the women complained of reduced fetal movements and were investigated initially with a non-stress test, a Kleihauer-Betke test, and ultrasound, including Doppler of the middle cerebral artery. These women all required emergency Caesarean section for non-reassuring fetal status. One fetus was treated by intravascular transfusion. Another identified case was transfused postnatally. One asymptomatic case was identified after spontaneous vaginal birth and also treated by neonatal transfusion. Neurological outcomes were good in all four cases. CONCLUSIONS Reduced fetal movements may be the only complaint of FMH. Increased awareness is required to ensure a diagnosis is made. When a non-stress test for reduced fetal movement is non-reactive, a Kleihauer-Betke test should be ordered, as well as detailed ultrasonography, including fetal Doppler studies. The perinatal prognosis for FMH may improve by facilitating the appropriate use of fetal blood transfusion or delivery by Caesarean section.

Cornelia de Lange syndrome (CdLS): prenatal and autopsy findings.

Cornelia de Lange Syndrome (CdLS) is a multisystem disorder characterized by somatic defects and mental retardation. Prenatal diagnosis of this severe condition is difficult in view of the non‐specific ultrasound abnormalities. We report three cases with prenatally suspected CdLS based on the ultrasound findings as well as low PAPP‐A detected on first trimester screening in one case, and the results of the autopsy and the NIPBL gene mutation analysis. Copyright

Multidisciplinary perinatal management of the compromised airway on placental support: lessons learned

The aims of this study were to review fetal and maternal outcomes after management of the compromised perinatal airway via operation on placental support or ex utero intrapartum treatment and to discuss implications for future management of these complex and rare cases.