Hen Y. Sela

Maternal cardiac arrest and perimortem caesarean delivery: Evidence or expert-based?

AIM To examine the outcomes of maternal cardiac arrest and the evidence for the 4-min time frame from arrest to perimortem caesarean delivery (PMCD) recommended in current resuscitation and obstetric guidelines. DATA SOURCES AND METHODS Review and data extraction from all reported maternal cardiac arrests occurring prior to delivery (1980-2010). Cases were included if they provided details regarding both the event and outcomes. Outcomes of arrest were assessed using survival, Cerebral Performance Category (CPC) and maternal/neonatal harm/benefit from PMCD. Outcome measures were maternal and neonatal survival. RESULTS Of 1594 manuscripts screened, 156 underwent full review. Data extracted from 80 relevant papers yielded 94 included cases. Maternal outcome: 54.3% (51/94) of mothers survived to hospital discharge, 78.4% (40/51) with a CPC of 1/2. PMCD was determined to have been beneficial to the mother in 31.7% of cases and was not harmful in any case. In-hospital arrest and PMCD within 10 min of arrest were associated with better maternal outcomes (ORs 5.17 and 7.42 respectively, p<0.05 both). Neonatal outcome: mean times from arrest to delivery were 14±11 min and 22±13 min in survivors and non-survivors respectively (receiver operating area under the curve 0.729). Neonatal survival was only associated with in-hospital maternal arrest (OR 13.0, p<0.001). CONCLUSIONS Treatment recommendations should include a low admission threshold to a highly monitored area for pregnant women with cardiorespiratory decompensation, good overall performance of resuscitation and delivery within 10 min of arrest. Cognitive dissonance may delay both situation recognition and the response to maternal collapse.

Preterm premature rupture of membranes complicating twin pregnancy: management considerations.

Preterm premature rupture of membranes (PPROM) is more prevalent in twin gestations and is major contributor to preterm birth. The management of PPROM in twin pregnancies does not differ significantly from that of singletons. In general, antenatal steroids, latency antibiotics, magnesium sulpfate for neuroprotection, and tocolysis are all potential interventions to consider when PPROM complicates a twin gestation. Certain circumstances, such as PPROM following an invasive procedure, at a previable gestational age, or in a monochorionic gestation, warrant special attention as the implications of PPROM and subsequent recommendations for these twin pregnancies may differ. In general, the approach to PPROM in twins should be individualized based on gestational age, and the maternal and neonatal risks of delaying delivery to prolong the pregnancy.

Placental hematoma mimicking twin anemia–polycythemia sequence following selective laser photocoagulation for twin–twin transfusion syndrome

A 31-year-old nullipara was transferred for fetal therapy at19weeks’ gestation following diagnosis of twin–twintransfusion syndrome (TTTS). Intake ultrasound evaluationconfirmed monochorionic, diamniotic twins with a posteriorplacenta and Quintero stage III TTTS. Specific findingsincluded donor twin anhydramnios, recipient twinpolyhydramnios (maximal vertical pocket of fluid 10cm), 22%inter-twin growth discordance, Doppler study absent end-diastolic velocity in the donor twin umbilical artery withnormal peak systolic velocity of the middle cerebral artery(MCA). The patient elected to undergo fetoscopic selectivelaser photocoagulation (SLP) of communicating vessels.Selective laser photocoagulation was performed at 19 1/7weeks gestational age under regional anesthesia. Two large-caliber arterio–venous anastomoses (AVA) were identified andphotocoagulated, as well as seven smaller superficial arterio–arterial and veno–venous anastomoses. Time from the first tolast coagulation was 20min. During photocoagulation of alarge AVA, using diode laser set to 40W and approaching theanastomosis perpendicularly, minor vessel bleeding wasencountered that was controlled with circumferentialphotocoagulation around the area of bleeding. The procedureconcluded with an amnioreduction of 1200cm

OP05.08: Abnormal placental cord insertion in monochorionic-diamniotic twins: an ominous finding

Methods: Between July 2009 and February 2011, 54 pairs of MCDA twins and 2 triplets were delivered in 3 tertiary care centers. All pregnancies were followed with a weekly fetal surveillance for fetal weight discordance and twin-to-twin transfusion syndrome (TTTS). After birth, placentas were observed and stained to search type and number of vascular anastomoses, type and distance between cord insertions and placental distribution. Birth weights as fetal and neonatal mortality and early morbidity were recorded from clinic charts. Placental characteristics were analized in relation to perinatal outcome. Triplets were analized separately. Results: Anastomoses were detected in all placentas with fetal growth alterations in 44% of the studied pregnancies. Between fetuses with growth disturbances 12 pairs were diagnosed as TTTS, 9 pairs as selective intrauterine growth restriction (IUGR) and 3 pairs as growth discordances without IUGR. Eight fetal deaths were recorded, in 2 pregnancies a single fetal death occurred and in other 3 pregnancies both fetuses died in spite of fetal therapy. Relation between abnormal cord insertions and smaller placental territories were seen in all abnormal growth pregnancies and in 50% of pregnancies without growth disturbances. Between discordant growth pregnancies, only all TTTS cases had unequal shared territories and neonatal weight discordance more than 20%. There were 3 cases of severe early morbidity and 6 babies died during the early neonatal period, most in relation to mayor malformations. Conclusions: Placental characteristics are closely related to perinatal outcome, mainly with the presence of TTTS and fetal growth disturbances. Prenatal identification of these characteristics in this group of pregnancies may change parent counselling as surveillance and intrauterine therapy program.