Ido Solt

Methamphetamine use during pregnancy: maternal and neonatal implications.

OBJECTIVE: To report the demographic characteristics and clinical morbidity of methamphetamine-exposed pregnancies compared with control patients in a tertiary care, urban, academic medical center. METHODS: A single-site chart review from 2000 to 2006 was conducted. International Classification of Diseases, 9th Revision code 648.3x was used to identify potential study participants. Specific inclusion criteria required either a positive urine drug screen for methamphetamine use or by patient statement of methamphetamine use during pregnancy. Data from 276 identified patients were then compared with the 34,055 in the general obstetric population during the same period for various demographic factors and perinatal outcomes. RESULTS: Two hundred seventy-six patients responsible for 273 live births were identified between 2000 and 2006. Factors that were significantly associated with methamphetamine use were age younger than 20 years (9% methamphetamine compared with 16% control patients), non-Hispanic white ethnicity (55% compared with 71%), married (12% compared with 46%), preterm delivery (52% compared with 17%), low Apgar scores (6% compared with 1–2%), cesarean delivery (29% compared with 23%), and neonatal mortality (4% compared with 1%). Additionally, the maternal demographic characteristics suggested that these women were more likely to be unemployed, use other abusive substances, and have higher rates of domestic violence and adoption when compared with the control population. CONCLUSION: Methamphetamine use in pregnancy is complicated by more morbid maternal and neonatal outcomes when compared with the general obstetric population. Because the patients in this study were in a variety of ways demographically distinct, attempts to identify these patients early and intervene in an effort to improve pregnancy-related outcomes appears possible and warranted. LEVEL OF EVIDENCE: II

Water intoxication-a dangerous condition in labor and delivery rooms.

Water intoxication, a form of acute hyponatremia, has been described in various clinical situations. Although hyponatremia is a common metabolic disorder in hospitalized patients, it is generally not well known as a hazard in the labor and delivery room. However, several factors predispose laboring women to develop hyponatremia. Moreover, because the fetus acquires water from the maternal circulation via the placenta, and there is a close correlation between maternal and cord blood serum sodium levels, the newborn infant of a hyponatremic mother is also at considerable risk of developing water intoxication. We review the epidemiology, pathophysiology, clinical features, and treatment of this hazardous disorder. We emphasize the need for awareness of this condition, and call attention to the risk of fluid overload during labor. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to recall that clinical hyponatremia can occur during labor, which may be due to the treatments received during labor or to secondary causes, and to state that the fetus may also be adversely affected and the mother must be diagnosed and treated to prevent serious consequences.

Discordance of First-Trimester Crown-Rump Length Is a Predictor of Adverse Outcomes in Structurally Normal Euploid Dichorionic Twins

Objective. The purpose of this study was to determine the association between discordant crown‐rump length (CRL) measurements in structurally normal euploid dichorionic twins and adverse pregnancy outcomes. Methods. This retrospective cohort study included women with dichorionic twins who underwent chorionic villus sampling and delivered in our facility from January 2000 to September 2007. Only pregnancies with viable twin fetuses and normal karyotypes were included. The association between CRL discordance, defined as a CRL discrepancy of 9% or greater, and adverse pregnancy outcomes was evaluated. Results. Seventy‐eight women met inclusion criteria and included 24 discordant twins (group 1) and 54 concordant twins (group 2). Maternal ages were similar: mean ± SD, 38.2 ± 3.1 years in group 1 versus 39.2 ± 3.9 years in group 2 (P = not significant). The median gestational ages at delivery were 35.6 ± 3.1 weeks in group 1 and 37.3 ± 2.0 weeks in group 2 (P < .01). At least 1 major complication occurred in 19 women (79%) in group 1 and 25 (46%) in group 2 (P = .01). Group 1 had significantly more major complications overall (P = .0008). Preterm premature rupture of membranes occurred in 10 women (42%) in group 1 and 6 (11%) in group 2 (P = .005). Delivery before 37 weeks gestation occurred in 19 of 24 women (79%) in group 1 and 24 of 54 (44%) in group 2 (P = .006). There was a significant difference for younger gestational age at delivery in the discordant group (P < .01). Conclusions. Our data suggest that there is an increased risk of adverse pregnancy outcomes in chromosomally normal dichorionic twins with first‐trimester discordant CRL measurements. These results may be clinically useful for counseling, management, and antenatal surveillance.

First-trimester visualization of the fourth ventricle in fetuses with and without spina bifida.

The purpose of this study was to examine the efficacy of nonvisualization of the fourth ventricle for first‐trimester detection of spina bifida.

Teaching forceps: the impact of proactive faculty

OBJECTIVEnThe objective of the study was to evaluate the impact on resident forceps experience by a single proactive teacher.nnnSTUDY DESIGNnA study was performed to assess the impact on delivery statistics and outcome following the assignment of a single attending to teach forceps to residents. A 2 year period immediately preceding and 2 years following the study was compared using χ(2) and Student t tests.nnnRESULTSnAfter appointment of the specific teaching attending, forceps deliveries increased by 59% (8% of all births), whereas vacuum procedures decreased to 3% of births (P < .0001) compared with the prior 2 years. The overall percentage of operative vaginal deliveries remained unchanged (11%). Cesarean section rates were unchanged during the study period at 27% of all births. Perineal laceration, 5 minute Apgar less than 7, and birth injuries were also not statistically different. There were fewer fetal pH events less than 7.1 in the teaching period (P = .003).nnnCONCLUSIONnIn the population studied, there was an association between increasing resident forceps use and a positive impact on birth outcomes from the designation of a full-time, experienced, and proactive faculty member to obstetrics teaching duty.

Abnormal placental invasion--a novel approach to treatment case report and review.

The incidence of abnormal placental invasion has increased 10-fold in the past 50 years, reflecting the increased number of cesarean sections performed. Management relies on accurate early diagnosis with appropriate perioperative multidisciplinary planning to anticipate and avoid massive obstetric hemorrhage at delivery. Women at risk should plan to deliver at an institution with appropriate expertise and resources for managing this condition. We report a case of placenta increta management comprising preoperative placement of a pelvic artery balloon catheter, prophylactic balloon occlusion after delivery of the fetus, and embolization-assisted resection of the invaded uterine wall. We review incidence, methods of prenatal diagnosis, risk factors, and management of abnormally invasive placenta. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this educational activity, the participant should be better able to recall risk factors for abnormal placental invasion, explain the diagnostic choices for identifying abnormal placental invasion, and prepare a logical treatment plan for the woman with abnormal placental invasion.

The Great Obstetrical Syndromes and the Human Microbiome—A New Frontier

Over the last two decades, advanced molecular genetics technology has enabled analysis of complex microbial communities and the study of microbial genomics. Interest has grown in characterizing the microbiome, defined as a collective microbial community and its extensive genome, as a clue to disease mechanisms. “The Human Microbiome Project,” sponsored by the NIH Common Fund, was established to characterize the pathology-associated human microbiome in nasal passages, oral cavities, skin, the gastrointestinal tract, and the urogenital compartment. In particular, characterization of urogenital microbiota may elucidate etiologies of complex obstetrical syndromes and factors in fetal development that define risk for pathology in adulthood. This article summarizes recent findings defining the microbiome associated with the female urogenital compartment in child-bearing age women. We also describe our analysis of microbiome samples from the oral, vaginal, and rectal compartments in a cohort of pregnant women. Findings present technical considerations in the characterization of microbial diversity and composition associated with gestational diabetes as a model pregnancy-associated pathology.

OC12.02: Spina bifida detection at 11–14 weeks: systematic analysis of technical factors associated with false‐positive and false‐negative image interpretation

Objectives: Screening at 11–14 weeks is changing from a simple NT measurement to a comprehensive first trimester anomaly scan. However, the detection of open neural tube defect (NTD) before 14 weeks is still a challenge, since lemon and banana signs, used in second trimester ultrasound, are rarely present. Aim of the study is to seek for simple first trimester signs to alert the examiner for the presence of NTD. Methods: The midsagittal view of the face used for NT and nasal bone measurements was analyzed in normal fetuses and fetuses with NTD. The region between the brain stem and occipital bone, includes the 4th ventricle (intracranial translucency = IT), the choroid plexus of the 4th ventricle and the future cisterna magna. Results: In normal fetuses between 11–14 weeks there is an increase in the anterior posterior diameters of posterior fossa structures. Fetuses with NTD detected prospectively and retrospectively showed however abnormal values due to the downward shifting of the brain stem. Conclusions: In the plane used for NT measurement the evaluation of the posterior part of the brain between the brain stem and the occipital bone appears to be the clue in suspecting NTD at the 11–14 weeks scan. Further prospective studies are needed to find the sensitivity of these observations during routine screening.

OC12.03: Visualization of the fourth ventricle in first trimester fetuses with a normal spine versus spina bifida

Objectives: Screening at 11–14 weeks is changing from a simple NT measurement to a comprehensive first trimester anomaly scan. However, the detection of open neural tube defect (NTD) before 14 weeks is still a challenge, since lemon and banana signs, used in second trimester ultrasound, are rarely present. Aim of the study is to seek for simple first trimester signs to alert the examiner for the presence of NTD. Methods: The midsagittal view of the face used for NT and nasal bone measurements was analyzed in normal fetuses and fetuses with NTD. The region between the brain stem and occipital bone, includes the 4th ventricle (intracranial translucency = IT), the choroid plexus of the 4th ventricle and the future cisterna magna. Results: In normal fetuses between 11–14 weeks there is an increase in the anterior posterior diameters of posterior fossa structures. Fetuses with NTD detected prospectively and retrospectively showed however abnormal values due to the downward shifting of the brain stem. Conclusions: In the plane used for NT measurement the evaluation of the posterior part of the brain between the brain stem and the occipital bone appears to be the clue in suspecting NTD at the 11–14 weeks scan. Further prospective studies are needed to find the sensitivity of these observations during routine screening.

Chiari malformation eponym– time for historical justice

A 42-year-old sexually inactive woman presented to our emergency department with worsening abdominal pain and high fever of 1 day’s duration. During the previous month, she had had occasional mild lower abdominal pain, but without other symptoms. Her past medical history was unremarkable except for a myomectomy 10 years previously. Physical examination revealed diffuse abdominal tenderness with rebound. Laboratory data were notable for a leukocyte count of 42 880 per mm3 with a left shift. Pelvic sonography showed a large unilocular cystic structure in the upper pelvis measuring 9.0 × 8.0 × 6.5 cm that demonstrated internal debris and a hyperechoic thick wall (Figure 1a). Contrast-enhanced computed tomography revealed a large cystic mass with a thick wall, which was posterior to and superior to the uterus (Figures 2a and c). Bilateral ovarian cysts were also noted (Figure 2b). Even in the absence of risk factors for ascending genital-tract infection, tubo-ovarian abscess was still the primary consideration based on the laboratory results and imaging findings. Antibiotic therapy was started immediately, but the patient’s symptoms persisted. The following day an exploratory laparotomy revealed purulent material in the peritoneal cavity and a thick-walled pelvic mass containing purulent material. The mass was found to originate from the posterior wall of the uterus. Myomectomy could not be performed because the mass had severe adhesions. Instead, a tumor incision, marsupialization and drainage were performed. Microscopically, the mass consisted of fibrous tissue and smooth muscle cells, along with granulation tissue and chronic inflammation. No evidence of malignancy was noted. The patient had an uneventful recovery and was discharged within a week after surgery. Pelvic ultrasound 4 months after surgery showed that the size of the mass had decreased to 3 cm (Figure 1b). She remained well at the 12-month follow-up visit. Pyomyoma, or a suppurative leiomyoma, is a rare and potentially fatal complication of uterine leiomyoma. Only 21 cases have been reported since 19451–10. Most cases occur during pregnancy or after menopause, and are caused by ascending genitaltract infection. To our knowledge, this is the first case of pyomyoma described in a healthy premenopausal female and unrelated to any focus of infection. Figure 1 (a) Preoperative ultrasound image showing a large unilocular cystic structure in the upper pelvis that demonstrated internal debris and a hyperechoic thick wall. (b) Pelvic ultrasound image 4 months after surgery showed that the size of the subserosal fibroid had decreased to 3 cm. M, tumor mass; U, uterus.