Jeffrey A. Kuller

Use of magnetic resonance imaging and ultrasound in the antenatal diagnosis of placenta accreta

Objective: To determine whether magnetic resonance imaging (MRI) and ultrasound (US) are effective methods for diagnosing placenta accreta, increta, or percreta antenatally. Methods: We retrospectively reviewed radiologic reports of patients who had the diagnosis of placenta accreta, percreta, or increta by pathologic analysis. The gestational age at first ultrasound diagnosis of accreta and first MRI diagnosis of accreta was recorded. Ultrasound and MRI reports were examined for findings of a distorted retroplacental myometrial zone, disrupted uterine-bladder interface, focal exophytic masses, and presence of vascular placental lacunae. Surgical history, cesarean hysterectomy, and blood loss were also recorded. Results: Thirteen patients were identified, and 14 had true pathologic confirmation of accreta, increta, or percreta. Nine of thirteen had MRI, and of those, seven received gadolinium. Placenta accreta was diagnosed by MRI in five of nine patients, but only four were confirmed pathologically to have accreta. Four women who had a normal MRI had accreta confirmed by pathology (sensitivity 38%). Of the 13 patients who had US, four were considered to have an accreta, and these four had pathologic confirmation. Nine were negative for accreta by US; however, eight of those women had pathologic confirmation of accreta, and one was normal (sensitivity 33%). Conclusion: Both MRI and US had poor predictive value in the diagnosis of placenta accreta, and further refinement in the techniques of both MRI and US is needed for these tests to be used to reliably diagnose these pathologic conditions.

Urinary incontinence in pregnancy and the puerperium: A prospective study

OBJECTIVE Pregnancy and childbirth are commonly thought to be associated with the development of urinary incontinence and lower urinary tract symptoms. The purpose of this study was to assess the relationship, if any, between pregnancy and the development of lower urinary tract symptoms. STUDY DESIGN A prospective study of lower urinary tract symptoms was carried out in a cohort of pregnant women who answered a series of symptom questionnaires and kept a 24-hour bladder chart on which frequency of urination and volumes voided were recorded throughout pregnancy and for 8 weeks after birth. RESULTS A total of 123 women participated in the study. Mean daily urine output (P =.01) and the mean number of voids per day (P =.01) increased with gestational age and declined after delivery. Episodes of urinary incontinence peaked in the third trimester and improved after birth (P =.001). White women had higher mean voided volumes and fewer voiding episodes than did black women. Ingestion of caffeine was associated with smaller voided volumes and greater frequency of urination. CONCLUSION Pregnancy is associated with an increase in urinary incontinence. This phenomenon decreases in the puerperium. Pregnancy and childbirth trauma are important factors in the development of urinary incontinence among women. These findings warrant further investigation.

PERIPARTUM CARDIOMYOPATHY : A REVIEW OF THE LITERATURE

UNLABELLED Peripartum cardiomyopathy (PPCM) is a poorly characterized, rare form of cardiomyopathy. The etiology of PPCM is unknown, but viral, autoimmune, and idiopathic causes may contribute. The presentation is similar to other forms of congestive heart failure; the diagnosis of PPCM should not be considered until other causes of cardiac dysfunction are ruled out. Echocardiography is central to diagnosis. Early diagnosis and initiation of treatment are essential to optimize pregnancy outcome. Intensivists and anesthesiologists should be consulted to assist with management in complicated cases. Management of PPCM is essentially supportive. Prognosis is poor, although cardiac transplant is improving prognosis and should be considered when conventional therapy fails. TARGET AUDIENCE Obstetricians & Gynecologists, Family Physicians LEARNING OBJECTIVES After completion of this article, the reader will be able to understand the typical presentation of peripartum cardiomyopathy including adverse outcome predictors, to understand how to make the diagnosis of PPCM and how to manage it, and to understand the natural history of the disease.

Hyperemesis gravidarum complicated by Wernicke’s encephalopathy

BACKGROUND Wernickes encephalopathy is usually associated with alcohol abuse, but can also occur with hyperemesis gravidarum. The effect of delay in thiamine replacement on fetal outcomes is unknown. We present a case of this complication. CASE A primipara with hyperemesis was admitted for mental status changes in her 14th week of pregnancy. Physical examination revealed a lethargic patient with ophthalmoplegia, ataxia, and hyporeflexia. Parenteral thiamine therapy was started. The patient improved rapidly although the ataxia persisted. A spontaneous abortion occurred 2 weeks later. CONCLUSION Wernickes encephalopathy can complicate hyperemesis gravidarum. Early thiamine replacement may decrease the chances of spontaneous abortion.

Analysis of the risks associated with calcium channel blockade: Implications for the obstetrician-gynecologist

Calcium channel antagonists are widely prescribed in obstetrics and gynecology for blood pressure control and tocolysis. Concerns have recently arisen regarding the safety of these agents. Several studies found that short-acting forms of calcium channel blockers were associated with increased cardiovascular mortality, malignancy, and gastrointestinal bleeding. A recent meta-analysis found a significant increase in the risk of mortality in patients treated with a short-acting form of nifedipine. Another subgroup analysis of an observational study of older hypertensive patients found a significantly increased risk of cancer and gastrointestinal hemorrhage in patients prescribed calcium channel blockers. Both in vitro and small human in vitro series have reported a potential for cardiac toxicity in pregnant women treated concomitantly with calcium channel blockers and magnesium sulfate. Until additional data are available, we suggest that when calcium channel blockers are used in obstetrics and gynecology, the long-acting variety be prescribed. Concurrent use of calcium channel blockers and magnesium sulfate should be undertaken cautiously because of the potential for synergistic depression of cardiac function.

Outcome of antenatally diagnosed cystic adenomatoid malformations

OBJECTIVE Twenty-two cases of antenatally diagnosed congenital cystic adenomatoid malformations are reported. STUDY DESIGN Case management is reviewed. RESULTS Eighteen women continued pregnancy after diagnosis. In nine cases nonimmune hydrops fetalis did not develop and all infants survived. Nonimmune hydrops fetalis developed in the other nine; fetal intervention was performed in eight cases. In the single case of nonimmune hydrops fetalis without intervention, the neonate died. In four cases aspiration of macrocystic lesions was performed. In two cases cystoamniotic shunts were placed. Neither aspiration or shunting provided long-term benefit. In six cases fetal lobectomy was ultimately performed and four survived. Two fetuses did not undergo in utero surgery; one was delivered prematurely after cyst aspiration and lived, and the other previable fetus was delivered soon after shunting. CONCLUSIONS Fetal survival is best related to development of nonimmune hydrops fetalis. Aspiration of cystic lesions and cystoamniotic shunts generally provide short-term benefit. Early experience with fetal surgery for congenital cystic adenomatoid malformations has been encouraging.

Pregnancy in transplant recipients.

A growing number of transplant recipients are women of reproductive age or children who will reach reproductive age. Thus, menstrual function and pregnancy increasingly are important issues because fertility is restored to women who were previously unable to conceive. To date, successful pregnancies have been reported in female recipients of kidney, liver, heart, pancreas-liver, bone marrow, and lung transplants. Women often become pregnant while being maintained on numerous medications, including immunosuppressive agents, and their care providers must be able to counsel and care for them. Information to date suggests that immunosuppressive medications are safe for use during pregnancy and are important in preventing maternal and fetal complications secondary to graft rejection. Although no formal guidelines have been established due to limited clinical experience, there are a few criteria that are commonly agreed on to improve the probability of a successful pregnancy outcome and the maintenance of graft function in transplant patients. Successful management of the pregnant transplant patient requires a cooperative effort between the obstetrician and transplant team. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader will be able to identify the complications associated with transplant recipients during pregnancy, to outline the potential immunosuppressive drug therapies and how they relate to pregnancy, and to list some of the effects of pregnancy on transplant function.

Gastroschisis: The effect of labor and ruptured membranes on neonatal outcome

OBJECTIVES The purpose of this study was to examine the relationship between labor and ruptured membranes on the neonatal outcome of infants with gastroschisis. STUDY DESIGN We reviewed the outcomes of 60 neonates who were prenatally diagnosed with gastroschisis and who were delivered at the University of North Carolina Hospitals between June 1989 and April 1999. RESULTS The mean gestational age at delivery was 36 weeks. Four infants (7%) died in the neonatal period, and 19 infants (32%) had a major morbidity. No significant differences appeared in any of the neonatal outcomes when they were stratified by the presence or absence of labor and presence or absence of ruptured membranes. After being controlled for confounding variables, the risk of neonatal death or major neonatal morbidity because of exposure to either labor or ruptured membranes was no different than the risks caused by no labor or intact membranes, respectively. CONCLUSION Labor and ruptured membranes do not appear to be associated with increased neonatal morbidity or mortality rates in neonates with gastroschisis.

Pharmacologic treatment of psychiatric disease in pregnancy and lactation : Fetal and neonatal effects

Objective To review published data pertaining to safety of psychoactive drugs used to treat psychiatric disorders during pregnancy and lactation. Data Sources A computerized search of articles published through July 1995 was performed on the MEDLINE data base. Additional sources were identified through cross-referencing. Methods of Study Selection All identified references were reviewed with particular attention given to study design. Data Extraction and Synthesis Each reference was reviewed to determine the safety of psychoactive agents to treat depression, bipolar disease, schizophrenia, and anxiety during pregnancy and lactation. Prospective or large retrospective studies were given more importance than case reports. Conclusion Psychoactive medications may be used during pregnancy. Because data on safety are largely retrospective, treatment decisions must be weighed carefully.

Prenatal diagnosis using fetal cells from the maternal circulation.

Current prenatal diagnosis relies on invasive methods such as amniocentesis and chorionic villus sampling. Because these methods carry a low, but finite risk of pregnancy loss, noninvasive genetic screening techniques are the focus of intense research. Isolating fetal cells from maternal blood for genetic analysis is the least invasive method currently being investigated. We discuss the various methods that have been used to isolate these cells. Nucleated red blood cells have emerged as the ideal fetal cell type. This is because they have the DNA material necessary for genetic analysis, they are consistently present in maternal blood, they can be easily identified based on their morphology, and they have a definite gestational life span.