Jennifer S. Hernandez

Community-acquired methicillin-resistant staphylococcus aureus among patients with puerperal mastitis requiring hospitalization

OBJECTIVE: To estimate the incidence of puerperal mastitis requiring hospital admission and to describe demographic and obstetric risk factors for this condition. We also sought to identify trends in bacteriology among isolates obtained from breast abscesses and breast-milk aspirates, with a focus on treatment strategies used for community-acquired methicillin-resistant Staphylococcus aureus (MRSA). METHODS: Patients with puerperal mastitis who were admitted to a county-based teaching hospital between January 1997 and December 2005 were identified by International Classification of Diseases, 9th Revision, codes (675.1, 675.2). Data collected included demographic characteristics, clinical presentation, treatment, duration of admission, premorbid antibiotic exposure, and bacteriology. Demographic variables and obstetric outcomes were compared with all other pregnant women delivered at our hospital. RESULTS: One hundred twenty-seven of 136,459 women delivered at our teaching hospital were admitted for puerperal mastitis (9.3 [95% confidence interval (CI) 7.8–11.1] per 10,000 deliveries). The incidence of mastitis only during the study period was 6.7 (95% CI 5.4–8.3) per 10,000 deliveries, and the incidence of mastitis with breast abscess was 2.6 (95% CI 1.8–3.6) per 10,000 deliveries. Puerperal mastitis was significantly associated with younger women (23.4 years compared with 25.1 years, P<.001) and decreased parity (P=.02). Clinically significant breast abscess (n=35, 28%) was seen most commonly with community-acquired MRSA (n=18, 67%) during the data-collection period. The majority (15 [56%]) of women with culture-proven MRSA did not receive antibiotic therapy to which this organism was sensitive. They were discharged without complication, and there were no treatment failures. CONCLUSION: Community-acquired MRSA was most commonly associated with breast abscess. The empiric use of antibiotics ineffective against community-acquired MRSA did not adversely affect the outcomes in this study. LEVEL OF EVIDENCE: III

Calculated Blood Loss in Severe Obstetric Hemorrhage and Its Relation to Body Mass Index

OBJECTIVE To evaluate total calculated blood loss at the time of severe obstetric hemorrhage. STUDY DESIGN This is a prospective observational study of women with obstetric hemorrhage. Women who received a blood transfusion for hypovolemia and those in which a body mass index (BMI) could be calculated were included. Total blood volume lost was calculated. Blood loss was analyzed in relation to maternal size as reflected in the BMI. RESULTS Fourteen hundred forty-three women meeting inclusion criteria delivered at our hospital between March 2002 and June 2006. The median calculated volume of blood lost was 3529 mL, and 93% of women sustained losses ≥3000 mL. The blood loss sufficient to provoke signs and symptoms of hypovolemia was proportional to the womans BMI. CONCLUSION Women who develop hypovolemia during childbirth have suffered very large losses of blood, and infusion of blood products is required to restore circulation and prevent further morbidity.

Hydramnios in twin gestations.

OBJECTIVE: To estimate the effect of hydramnios on pregnancy outcomes in dichorionic and monochorionic twins. METHODS: This is a retrospective cohort study of women with twin pregnancies who underwent ultrasound evaluation between 1997 and 2010 and delivered liveborn neonates or stillborn fetuses at 24 weeks of gestation or more at a single institution. Hydramnios was defined as a single deepest pocket of amniotic fluid of at least 8 cm, and it was further categorized as mild (8–9.9 cm), moderate (10–11.9 cm), or severe (12 cm or more). The greatest degree of hydramnios identified during pregnancy was used for analysis. Monoamniotic pregnancies and pregnancies complicated by twin–twin transfusion syndrome were excluded. Anomalous neonates and stillborn fetuses were analyzed separately. RESULTS: Of 1,951 twin pregnancies, 1,311 were dichorionic (67%) and 640 were monochorionic (33%). Hydramnios was identified in 348 pregnancies (18%). Major anomalies were more common with increasing hydramnios in both dichorionic and monochorionic twins (P<.001), with anomaly prevalence nearly 20% in cases of severe hydramnios. Severe hydramnios was significantly associated with stillbirth in monochorionic gestations (3 of 11, 27%, P<.001). Hydramnios was not associated with preterm delivery, fetal growth restriction, neonatal intensive care unit admission, or neonatal death in either dichorionic or monochrorionic pregnancies. CONCLUSION: Hydramnios is common in twins, occurring in one of six dichorionic and monochorionic pregnancies. Anomaly prevalence increased with degree of hydramnios; in monochorionic gestations, severe hydramnios was associated with risk of stillbirth. Despite this, adverse outcomes do not appear to be more frequent in the setting of hydramnios in twin getstaions. LEVEL OF EVIDENCE: II

Placental and uterine pathology in women undergoing peripartum hysterectomy

OBJECTIVE: To estimate if peripartum hysterectomies performed for intractable uterine atony have pathologic findings consistent with infection more often than those hysterectomies performed for other indications. METHODS: This is a retrospective cohort study of all consecutive peripartum hysterectomies at our institution from 1988 to 2009. Scheduled cesarean hysterectomies were excluded. Maternal, fetal, and pathologic data were obtained by medical record review. Pathologic evaluation was performed for each specimen per a standardized protocol. Patients undergoing hysterectomy for uterine atony were compared with those requiring hysterectomy for another indication. Pearsons &khgr;2 and Students t test were used for analysis. RESULTS: Of 324,654 deliveries during the study period, 558 (1.7%) women underwent emergent peripartum hysterectomies; 190 (34%) were for intractable uterine atony. Those requiring hysterectomy for uterine atony were more likely to be at term (87% compared with 62%), have clinical chorioamnionitis (19% compared with 6%), and have longer labors (8 hours compared with 2.5 hours). Certain placental pathologic findings were significantly more common in the atony group, including chorioamnionitis, umbilical vasculitis, chorionic plate vasculitis, and funisitis. Acute endometritis and cervicitis were also more common in the atony group. Conversely, abnormal placental implantation (37% compared with 8%) and leiomyomas (21% compared with 8%) were significantly more common in the group requiring hysterectomy for other indications. CONCLUSION: Patients requiring emergent peripartum hysterectomies as a result of intractable uterine atony are more likely to have clinical and pathologic findings consistent with acute inflammation and infection. LEVEL OF EVIDENCE: II

Aortoesophageal Fistula in a Child With Undiagnosed Vascular Ring: Life-Threatening or Lethal?

Exsanguinating hematemesis secondary to an aortoesophageal fistula from an impacted foreign body occurred in a patient with a vascular ring. This report describes successful resuscitation and repair in a 6-year-old boy who was transferred from an outside hospital in extremis with an aortoesophageal fistula from a foreign body in the presence of a vascular ring.

12 – Renal Pelvis Dilatation

Abstract Fetal renal pelvis dilatation is identified in 1% to 5% of pregnancies and is often a transient, normal variant. The likelihood of an underlying abnormality increases with the degree of dilatation. The most common underlying abnormalities are ureteropelvic junction obstruction and vesicoureteral reflux. Mild renal pelvis dilation is also a minor marker that confers slightly increased risk for trisomy 21. The pelvis is measured anterior to posterior in the transverse plane, with the calipers placed on the inner border of the fluid collection. Images in other planes (sagittal, coronal) are obtained to exclude evidence of obstruction elsewhere along the urinary tract. If the renal pelvis measurement exceeds a threshold in the second trimester (such as 4 mm before 20 weeks), further evaluation is recommended in the third trimester, at approximately 32 weeks. If there is calyceal dilatation or cortical thinning, more frequent evaluation may be warranted. Neonatal evaluation is typically reserved for those with renal pelvis dilatation of at least 7 mm in the third trimester.

Unilateral Renal Agenesis

Abstract Unilateral renal agenesis has a birth prevalence of approximately 1 : 1000 to 1 : 2000, but it is often undetected prenatally. Sonographically, one kidney cannot be visualized in either the renal fossa or the pelvis, and the adrenal flattens and fills the renal fossa—the “lying-down” adrenal sign. Color Doppler imaging of the descending aorta reveals just one renal artery. The solitary kidney often develops compensatory hypertrophy. Unilateral renal agenesis is associated with other anomalies, particularly genitourinary abnormalities, and it is a component of several genetic syndromes. Therefore, targeted sonography is indicated, and amniocentesis may be offered. Affected individuals are usually asymptomatic; however, they are at increased risk to develop hypertension and renal insufficiency.

Effect of body mass index on maternal morbidity following peripartum hysterectomy

The objective of this study was to estimate the impact of maternal body mass index (BMI) on maternal morbidity following unscheduled peripartum hysterectomy. A retrospective cohort study of consecutive peripartum hysterectomies at our institution from 1988 through 2012; scheduled hysterectomies were excluded. Medical records were reviewed and maternal, foetal and surgical data collected for each subject. Maternal BMI was categorized by the National Institute of Health classifications for overweight and obese. Statistical analyses included evaluation for trend. A total of 360 774 women delivered at Parkland Hospital during the study period with 665 (1.8 per 1000 deliveries) unscheduled peripartum hysterectomies performed. BMI was available for 635 women. Gestational diabetes, chronic hypertension and pregnancy‐related hypertension were significantly higher in all three obesity categories, P = < 0.01. Post‐partum complications, such as venous thrombosis and composite surgical morbidity did not differ among BMI groups. Estimated blood loss and units transfused did not differ across the BMI categories, P = 0.42 and P = 0.38, respectively. Increasing BMI was associated with longer surgical times and more wound infections, P = 0.01. These complications should be considered when approaching a peripartum hysterectomy in patients with obesity.

Pregnant women who smoke: a challenge to the patient-physician relationship.

Approaches physicians can use to encourage pregnant patients to stop smoking while preserving the patient-physician relationship. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.