Keisha Reddick

Pregnancy outcomes associated with viral hepatitis

Summary.  The aim of this study was to examine the contribution of hepatitis B virus (HBV) and hepatitis C virus (HCV) to pregnancy‐related complications including gestational diabetes mellitus (GDM), preterm birth (PTB), intrauterine growth restriction (IUGR), pre‐eclampsia, antepartum haemorrhage and cholestasis. The Nationwide Inpatient Sample was queried for all pregnancy‐related discharges, pregnancy complications and viral hepatitis from 1995 to 2005. Logistic regression was used to examine the association between HBV, HCV, HBV + HCV and pregnancy‐related complications including GDM, PTB, IUGR, pre‐eclampsia, antepartum haemorrhage, cholestasis and caesarean delivery. Model covariates included maternal age, race, insurance status, substance use and medical complications including liver complication, hypertension, HIV, anaemia, thrombocytopenia and sexually transmitted infections. Of 297 664 pregnant women data available for analysis, 1446 had a coded diagnosis of HBV, HCV or both. High‐risk behaviours, such as smoking, alcohol and substance use were higher in women with either HBV or HCV. Women with HBV had an increased risk for PTB (aOR 1.65, CI [1.3, 2.0]) but a decreased risk for caesarean delivery (aOR 0.686, CI [0.53, 0.88]). Individuals with HCV had an increased risk for GDM (aOR 1.6, CI [1.0, 2.6]). Individuals with both HBV and HCV co‐infection had an increased risk for antepartum haemorrhage (aOR 2.82, CI [1.1, 7.2]). There was no association of viral hepatitis with IUGR or pre‐eclampsia. Women with hepatitis have an increased risk for complications during pregnancy. Research to determine the efficacy and cost‐effectiveness of counselling patients about potential risks for adverse outcomes is warranted.

Smoking prevalence in early pregnancy: comparison of self-report and anonymous urine cotinine testing.

Objective. Societal pressures against smoking during pregnancy may lead to a reduction in disclosure of smoking status. The objective of this study was to compare prevalence of smoking at prenatal intake by self-report with anonymous biochemical validation. Methods. Women receiving care at the Duke Obstetrics Clinic from February 2005 through January 2006 were eligible for evaluation. Self-reported smoking and urine samples were obtained anonymously at prenatal intake. The NicCheck™ I semi-quantitative dipstick was used to detect urinary nicotine, cotinine, and 3-hydroxycotinine. The difference, with 95% confidence interval, between the proportions of smokers by self-report and urine testing was calculated for (1) high-positive vs. low-positive and negative results combined and (2) any positive vs. negative results. Results. Among 297 subjects, self-reported smoking was 18.2 vs. 14.8% for low-positive and negative results combined with an absolute difference of 3.4%, [−2.9%, 9.6%]. When comparing self-report with any positive result (43.1%), the absolute difference was 24.9%, [17.4%, 32.1%]. Conclusions. Our findings suggest that most pregnant women disclose their smoking and many nonsmokers may have significant second-hand exposure. Universal urinary cotinine screening of pregnant women could aid in appropriately counseling women about second-hand exposure as well as monitoring women at high risk for adverse pregnancy outcomes.

The Effects of Intermittent Pneumatic Compression during Cesarean Delivery on Fibrinolysis

OBJECTIVE Pregnancy is associated with increased risk for thromboembolic events. Intermittent pneumatic compression (IPC) devices are the method of thromboprophylaxis in a nonpregnant population. The aim of this study was to examine the effects of IPC on markers of fibrinolysis during cesarean delivery. STUDY DESIGN We conducted a randomized controlled trial from April 2009 to March 2010 of women undergoing scheduled elective cesarean delivery. Forty-nine women were randomized to IPCs or usual care. All participants had three blood samples obtained: (1) baseline, (2) 1 hour after randomization, and (3) 30 minutes after cesarean delivery. Tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), thrombin-antithrombin complex (TAT), plasminogen activator inhibitor-1 (PAI-1), and plasminogen activator inhibitor-2 (PAI-2) levels were analyzed in each sample using an enzyme-linked immunosorbent assay. Statistical analysis was performed using repeated measures two-way analysis of variance with α = 0.05. RESULTS There was a time-dependent change in tPA, uPA, and PAI-1 levels following delivery but no difference in TAT and PAI-2 levels with time. There were no differences between women randomized to IPCs or usual care. CONCLUSION Markers of fibrinolysis were not significantly altered by IPCs in this study of low-risk pregnant women. Further research regarding the mechanism and efficacy of IPCs in pregnant women is warranted.

P39.08: Cervicovaginal fistula presenting during spontaneous abortion

myxo-fibroblastic proliferation. There was focal chorangiosis with intervening normal placental mesenchyme. The fetal chorionic plate vessels were massively dilated, tortuous and congested. There was a 3-vessel umbilical cord with furcated marginal cord insertion. Immunohistochemical studies of the abnormal myxoid villi showed minimal staining for smooth muscle actin and positive p57KIP2 protein staining. This is only the third case of PMD with normal fetus where the p57KIP2 protein staining was used in the diagnosis. The p57KIP2 gene is paternally imprinted and maternally expressed. The presence of this protein indicates a functional maternal allele. This case supports the utility of p57KIP2 protein staining in distinguishing this disorder from molar pregnancy. In our case elevated free beta-hCG level was detected in the first trimester before placental abnormalities were visualized on ultrasound.

P39.18: Diagnosis and management of uterine cervical varix in pregnancy

Uterine rupture during trial of vaginal birth after caesarean (VBAC) remains a rare but dramatic obstetrical emergency. Although several studies have shown that sonographic evaluation of the lower uterine segment (LUS) near term can predict uterine rupture, the best measuring technique and the cut-off values to be used remain controversial. While a large prospective study demonstrated that an abdominal measurement of the full LUS thickness over 3.5 mm had a strong negative predictive value, other authors suggested to measure the muscular layer only with a cut-off value of 1.5 to 2.0 mm. We report a case of uterine rupture in a healthy 31-year-old patient, which had a prior low transverse caesarean seven years earlier with a single layer closure of hysterotomy. At 36 weeks of gestation, the transvaginal sonographic measurement of the LUS was respectively 3.6 mm for the full thickness and 1.1 mm for the muscular layer only. At 39 weeks’, induction of labor for premature rupture of membranes was initiated with oxytocin. A fetal bradycardia occurred approximately 12 hours after the initiation of induction. The patient underwent an emergency caesarean for clinical evidence of uterine rupture. Operative findings revealed a large uterine lateral tear from the cervix to the uterine cornu with the infant lying in the upper abdomen. In this case, there was a discrepancy between the normal full LUS thickness and the thin muscular layer. As the myometrium measurement could be more representative of the LUS resistance, we should perhaps give more credit to result of the later before proposing a trial of VBAC. Evidently, other risk factors must be taken into account, such as the type of closure of the uterine segment at prior caesarean and the intrapartum assessment. This case emphasizes the need for a consensus on the measuring techniques and cut-off values of the LUS thickness and to investigate its role in estimating the risk of uterine rupture among other predicting factors.

P39.09: Severe adenomyosis requiring cesarean hysterectomy

Case report: A 36 year-old gravida 13, para 0-1-12-0, with a history of cervical incompetence presented at 14 weeks’ gestation for a prophylactic Shirodkar cerclage. The most recent delivery occurred at 22 weeks after a failed prophylactic McDonald cerclage placed at 14 weeks and subsequent rescue McDonald cerclage placed at 20 weeks. At presentation she gave a two-day history of cramping and spotting. Because of the concern for spontaneous abortion, the prophylactic cerclage procedure was postponed and she was referred for ultrasound follow-up three days later. A transvaginal ultrasound revealed the external cervical os as closed and the amniotic sac appeared to be protruding through the posterior wall of the cervix (Figure 1). Bimanual and vaginal speculum exam verified that the amniotic sac was protruding through a defect in the posterior wall of the cervix into the vaginal vault through a defect most likely related to prior laceration. The pregnancy was interrupted by an uncomplicated dilatation and evacuation. Follow-up assessment of her endometrial cavity by saline infusion sonohysterograhy was normal. She later desired to proceed with prophylactic abdominal cerclage placement, which was performed without difficulty. Conclusions: This case demonstrates a cervicovaginal fistula occurring in a woman with cervical incompetence with prior failed cervical cerclage. The ultrasound findings suggest a need for a high index of suspicion for identifying cervicovaginal fistula in a woman with a prior cervical cerclage.

P38.03: Prenatal diagnosis of an obstructing enterogenous cyst

(pyloric atresia), genetic and dermatology services diagnosis was Junctional Epidermolysis Bullosa, skin biopsy was taken, working on identifying the mutation to offer the family PGD. Junctional epidermolysis bullosa: A blistering skin condition inherited in an autosomal recessive manner, due to mutation of a gene that normally promotes the formation of anchoring filaments (thread-like fibers) or hemidesmosomes (complex structures composed of many proteins). Junctional epidermolysis bullosa (JEB) is usually severe. In the most serious forms, large, ulcerated blisters on the face, trunk, and legs can be life-threatening due to complicated infections and loss of body fluid that leads to severe dehydration.