Mary B. Munn

Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial.

OBJECTIVE To determine if high‐dose oxytocin reduces the need for additional uterotonic agents at cesarean. METHODS A randomized, double‐masked trial of two oxytocin regimens was performed to prevent postpartum uterine atony in laboring women. The pharmacy prepared sequentially numbered oxytocin solutions containing either 10 U/500 mL or 80 U/500 mL of lactated Ringers solution infused over 30 minutes after cord clamping. The need for additional uterotonic agents was determined by the surgical team. Hypotension was diagnosed and treated with crystalloid or a pressor agent. To detect a 50% decrease in the need for additional uterotonic agents and considering a βerror of 0.2, 220 patients would be required in each group (α = 0.05, two‐tailed χ2 test). RESULTS The low‐dose group (n = 163) received 333 mU/min, and the high‐dose group (n = 158) received 2667 mU/min of oxytocin. The groups were similar with respect to risk factors for atony. Women in the low‐dose group received additional uterotonic medication significantly more often than those in the high‐dose group (39% compared with 19%, P < .001, relative risk 2.1, 95% confidence interval 1.4, 3.0). Moreover, more women in the low‐dose group received methylergonovine, 15‐methyl prostaglandin F2α or both (9% compared with 2%, relative risk 4.8, 95% confidence interval 1.4, 16) after additional oxytocin (median 20 U) had been added to the study solution. The incidence of hypotension was similar in both groups. CONCLUSION Compared with an infusion rate of 333 mU/min, oxytocin infused at 2667 mU/min for the first 30 minutes postpartum reduces the need for additional uterotonic agents at cesarean delivery.

Pneumonia as a Complication of Pregnancy

Objective: To identify risk factors for the development of antepartum pneumonia and to describe maternal and perinatal outcome in pregnant women with pneumonia.Methods: The study group consisted of 59 women with antepartum pneumonia. Pneumonia was defined by the presence of lower respiratory tract symptoms, radiographic findings, no other source of infection, and at least two of the following: oral temperature ≥38°C, white blood cell count ≥15,000/ml, auscultatory findings, and/or positive sputum cultures. For comparison, a control group (n = 118) of pregnant women was formed by selecting the first mother who delivered immediately before and after an index study subject.Results: Mothers in the study group were significantly more likely than women in the control group to have either a history of asthma (P = 0.022) or an admission hematocrit ≥30% (P < 0.001). Women with pneumonia were also more likely to receive a tocolytic agent (P < 0.001) and/or beta-methasone to enhance fetal lung maturity (P < 0.001). ...

Pregnancy outcome after ultrasound diagnosis of fetal intra-abdominal umbilical vein varix

Fetal intra‐abdominal umbilical vein (FIUV) varix is a focal dilatation of the intra‐abdominal portion of the umbilical vein, which has been reported to be associated with intrauterine death and other anomalies. Our aim was to examine our experience with this diagnosis at a single tertiary‐care center and to correlate it with clinical outcome.

Prenatally diagnosed hypoplastic left heart syndrome—Outcomes after postnatal surgery

OBJECTIVE To identify prenatally diagnosed cases of hypoplastic left heart syndrome (HLHS) and then to determine postnatal outcomes after surgical interventions. METHODS An ultrasound and pediatric cardiology database was used to identify all fetuses diagnosed prenatally from 1991-1996 with HLHS. Fetal karyotypes were performed on cultured amniocytes. After diagnosis, parents were given several management options: pregnancy termination before 22 weeks, postnatal hospice care, or surgery using the Norwood procedure or cardiac transplantation. Ultrasound and echocardiography findings were later compared to karyotype results and postnatal outcome data. RESULTS Fifteen fetuses with HLHS were identified. Two (16%) chromosome abnormalities and three (20%) structural defects were detected. Three mothers (20%) opted for pregnancy termination, two (13%) chose postnatal hospice care, and one aneuploid fetus had an intrauterine death. Nine parents (60%) chose surgery for their infants; however, one infant was not an appropriate surgical candidate due to a coexisting diaphragmatic hernia. Eight infants underwent surgery and two survived (25%). Of the four infants scheduled to undergo the Norwood procedure, one died preoperatively, two died intraoperatively, and one infant survived and is doing well at age 8 months. Of the four infants scheduled for cardiac transplantation, two died awaiting transplant and one died postoperatively. One infant survived cardiac transplantation but has microcephaly and developmental delay at age two. CONCLUSIONS In prenatally diagnosed HLHS at our institution, the survival rate following surgery for infants felt to be the best candidates was only 25%.

Intraoperative Hypothermia and Post-Cesarean Wound Infection

Objective To determine whether intraoperative hypothermia during cesarean delivery is a risk factor for wound infection. Methods Eighteen cases with wound infection and 18 controls matched for age, weight, presence of gestational hypertension, and surgery length were selected from a cohort of 900 women who underwent cesarean delivery and who were assessed for wound infection according to strict criteria. Because immediate postoperative temperatures reflect intraoperative temperature nadir accurately and were available universally, we compared the mean immediate postoperative temperatures between cases and controls. Results In addition to the intentionally matched factors, the groups were well-matched for race, parity, presence of labor, presence of meconium, and duration of membrane rupture. The mean initial postoperative temperatures were similar between the two groups (36.3 ± 0.9C versus 36.6 ± 1.0C, respectively; P = .8). This study had a power of 90% to detect an intergroup difference of 1C. Conclusion In this case-control study of cesarean delivery, intraoperative hypothermia was not a risk factor for wound infection.

Pneumonia as a complication of pregnancy

OBJECTIVE To identify risk factors for the development of antepartum pneumonia and to describe maternal and perinatal outcome in pregnant women with pneumonia. METHODS The study group consisted of 59 women with antepartum pneumonia. Pneumonia was defined by the presence of lower respiratory tract symptoms, radiographic findings, no other source of infection, and at least two of the following: oral temperature > or =38 degrees C, white blood cell count > or =15,000/ml, auscultatory findings, and/or positive sputum cultures. For comparison, a control group (n = 118) of pregnant women was formed by selecting the first mother who delivered immediately before and after an index study subject. RESULTS Mothers in the study group were significantly more likely than women in the control group to have either a history of asthma (P = 0.022) or an admission hematocrit < or =30% (P < 0.001). Women with pneumonia were also more likely to receive a tocolytic agent (P < 0.001) and/or beta-methasone to enhance fetal lung maturity (P < 0.001). In addition, study subjects delivered at an earlier mean gestational age (P = 0.002) and had infants who weighed significantly less (P = 0.003) than mothers in the control group. Multivariate analysis indicated that women with asthma or anemia had more than a five-fold increase in the risk of developing pneumonia during pregnancy (P = 0.013), and mothers with pneumonia were significantly more likely to deliver before 34 weeks gestation (P = 0.04). CONCLUSIONS Pneumonia during pregnancy was associated with maternal anemia and asthma. In addition, preterm labor with tocolysis and/or beta-methasone was more common in women with pneumonia, and these women were more likely to deliver preterm and have low birthweight infants compared to women without pneumonia.

Maternal obesity is associated with chorioamnionitis and earlier indicated preterm delivery among expectantly managed women with preterm premature rupture of membranes

Abstract Objective: To determine the association between maternal obesity and delivery due to chorioamnionitis prior to labor onset, among expectantly managed women with preterm premature rupture of membranes (pPROM). Methods: This was a secondary analysis of a multicenter randomized trial of magnesium sulfate versus placebo to prevent cerebral palsy or death among offspring of women with anticipated delivery at 24–31-week gestation. After univariable analysis, Cox proportional hazard evaluated the association between maternal obesity and chorioamnionitis, while Laplace regression investigated how obesity affects the gestational age at delivery of the first 20% of women developing the outcome of interest. Results: A total of 164 of the 1942 women with pPROM developed chorioamnionitis prior to labor onset. Obese women had a 60% increased hazard of developing such complication (adjusted HR 1.6, 95%CI 1.1–2.1, p = .008), prompting delivery 1.5 weeks earlier, as the 20th survival percentile was 27.2-week gestation (95%CI 26–28.6) among obese as opposed to 28.8 weeks (95%CI 27.4–30.1) (p = .002) among nonobese women. Conclusions: Maternal obesity is a risk factor for chorioamnionitis prior to labor onset. Future studies will determine if obesity is important enough to change the management of latency after pPROM according to maternal BMI.

A Novel Mutation in ACTG2 Gene in Mother with Chronic Intestinal Pseudoobstruction and Fetus with Megacystis Microcolon Intestinal Hypoperistalsis Syndrome

Background. A novel mutation in the ACTG2 gene is described in a pregnant patient followed up for chronic intestinal pseudoobstruction (CIPO) during pregnancy and her fetus with megacystis microcolon intestinal hypoperistalsis syndrome (MMIHS). Case. 24-year-old gravida 1 para 1 with CIPO and persistent nausea and vomiting in pregnancy, admitted at 28 weeks of gestation. Ultrasound revealed a fetus measuring greater than the 95th percentile, polyhydramnios, and megacystis. At delivery, the newborn was noted to have an enlarged bladder, microcolon, and intolerance of oral intake. Genetic testing of mother and child revealed a novel mutation in the ACTG2 gene (C632F>A, p.R211Q). Conclusion. This is the first case in the literature describing a novel mutation in ACTG2 associated with visceral myopathy affecting both mother and fetus/neonate. Visceral myopathy should be included in the differential diagnosis of megacystis diagnosed by ultrasound, and suspicion should increase with family history of CIPO or MMIHS.

Prenatal diagnosis and postnatal course of a giant abdominal aortic aneurysm: a case report

Abstract Congenital abdominal aortic aneurysms are rare but have chronic and life-threatening sequelae including hypertension, thromboses, and death. A fetal ultrasound at 27 weeks’ gestation diagnosed a giant abdominal aortic aneurysm. The patient delivered at another tertiary care center where pediatric cardiovascular surgery care was available. Her term 3096-g female infant developed hypertension, biventricular hypertrophy, and right kidney ischemia. She underwent surgical repair at 2 months of life but subsequently lost all residual renal function and was not a candidate for dialysis. Support was withdrawn and she expired. Although isolated fetal AAA is rare, prenatal diagnosis is feasible and facilitates early referral for multi-disciplinary postnatal care. Outcome depends on the size and location of the aneurysm as well as on peri-operative complications.