Meike Schuster

Foley catheter vs prostaglandin as ripening agent in pregnant women with premature rupture of membranes.

CONTEXTnAlthough studies support the efficacy of the Foley catheter (FC) as a cervical ripening agent in pregnant women at term with intact membranes, its efficacy has not been well studied in women with premature rupture of membranes (PROM).nnnOBJECTIVEnTo compare the interval to delivery in women with PROM who underwent induction of labor and cervical ripening with mechanical (FC) vs nonmechanical (prostaglandin [PG]) cervical ripening agents.nnnDESIGNnRetrospective medical record review at 2 hospitals of pregnant women who delivered between January 2009 and April 2011.nnnSETTINGnThomas Jefferson University Hospital in Philadelphia, Pennsylvania, and Christiana Care Health System in Newark, Delaware.nnnPATIENTSnPregnant women with singleton gestations 36 weeks or greater who presented with PROM.nnnINTERVENTIONSnCervical ripening with FC or PG.nnnMAIN OUTCOME MEASURESnThe primary outcome was time from induction until delivery. Secondary outcomes included epidural use, maximum temperature during labor, number of vaginal examinations, occurrence of tachysystole, oxytocin dose, delivery mode, chorioamnionitis, and neonatal Apgar score.nnnRESULTSnOf 155 medical records of patients who met the inclusion criteria, 33 women underwent cervical ripening with PG (ie, misoprostol) and 122 with FC. The interval to delivery was almost halved in women who underwent cervical ripening with FC compared with misoprostol (736 vs 1354 minutes; P<.01). Compared with the women in the misoprostol group, those in the FC group received a statistically significant higher dose of oxytocin (P<.01). There were no statistically significant differences between the groups with respect to the remaining secondary outcomes. Of note, all of the women who received FC were from Christiana Care Health System, and all women who received misoprostol were from Thomas Jefferson University Hospital.nnnCONCLUSIONnFoley catheters may help shorten the interval to delivery in women who are candidates for cervical ripening after PROM at or near term. There does not appear to be an increased risk for cesarean delivery or chorioamnionitis in those treated with FC.

Fetal endometriosis: a case report

OBJECTIVEnTo report a case of a large fetal pelvic mass diagnosed at 35 weeks gestation.nnnDESIGNnReport of a unique case of a fetal abdominal mass, emphasizing the wide range of differential diagnoses. Although rare reports of fetal ovarian cysts exist, even fewer describe endometriosis or endometriomas in infants. As of 2014 there have not been any published reports of fetal endometriosis from the United States.nnnSETTINGnLarge tertiary community hospital.nnnPATIENT(S)nAn 18-year-old pregnant woman diagnosed with a large fetal pelvic mass at 35 weeks gestation.nnnINTERVENTION(S)nDiagnosis of a fetal abdominal mass at 35 weeks with documented enlargement at 37 weeks leading to delivery, with subsequent removal of the mass on day of life 2.nnnMAIN OUTCOME MEASURE(S)nOn day of life 2, a pediatric surgeon performed an exploratory laparotomy and left salpingo-oophorectomy.nnnRESULT(S)nFinal pathology showed a 7.0 × 4.5 cm cyst-like structure consistent with hemorrhagic ovarian cyst wall and focal endometriosis.nnnCONCLUSION(S)nIt can be very difficult to counsel patients regarding an abdominal mass in their unborn child. These difficulties stem from the large list of differential diagnoses and the range of prognoses they portend. As more and more of these cases appear in the literature, we are able to gain a better understanding of how each of these diagnoses present and appear on imaging, allowing us to provide a more accurate diagnosis and counseling antenatally.

The Impact of Pre-Pregnancy Body Mass Index and Pregnancy Weight Gain on Maternal and Neonatal Outcomes [24A]

INTRODUCTION: This study investigates the relative risk of obstetric complications stratified by pre-pregnancy body mass index (BMI) and pregnancy weight gain. METHODS: This was a retrospective cohort study of 17,393 pregnant women with singleton births between January 2004 and May 2015. We stratified patients based on pre-pregnancy BMI category (as per the Institute of Medicine, IOM) and amount of weight gain (appropriate, less than or greater than recommended). Primary maternal outcomes included: gestational diabetes (GDM), preeclampsia, macrosomia, fetal growth restriction (FGR), and rates of cesarean delivery, shoulder dystocia, preterm delivery (PTD), blood loss and operative delivery. Primary neonatal outcomes included hypoglycemia, length of NICU stay, APGAR score at 5 minutes, and rate of respiratory distress syndrome (RDS). RESULTS: The relative risk of GDM, preeclampsia, fetal macrosomia, cesarean delivery, blood loss, neonatal hypoglycemia and RDS increased with each successive BMI category. The risk for FGR mostly decreased with increasing BMI. Risks of other obstetric and neonatal complications did not appear to be correlated with increasing BMI category. FGR risk decreased with increasing weight gain for non-obese patients. For all classes of obesity, patients weight gain was positively correlated with a higher risk of cesarean delivery and inversely proportional to the risk of PTD. CONCLUSION: This large retrospective cohort study showed that as BMI category changed from I to II to III, there were significant increases in the rates of maternal and neonatal complications. In addition pregnancy complications are increased when weight gain does not conform to IOM recommendations.

Trauma in pregnancy: A review of the Pennsylvania Trauma Systems Foundation database:

Objective The goal of this study is to determine if injury severity score (ISS) of ≥9 and systolic blood pressure (SBP) predict poor maternal/pregnancy outcomes in blunt and penetrating trauma, respectively. Methods The Pennsylvania Trauma Systems Foundation database was used to identify pregnant trauma patients. Blunt trauma patients were analyzed with regard to ISS, while penetrating trauma patients were analyzed to determine whether SBPu2009<u200990u2009mmHg was predictive of poor maternal outcome. Results Patients with severe blunt injury (ISSu2009≥u20099) due to motor vehicle accident were less likely to wear seatbelts (51% vs. 63%, pu2009=u20090.005), and delivery was required in 17% of these patients as compared to 6% of the less severely injured, and only 6% of those were vaginal deliveries. Severely injured patients were discharged home 68% of the time and 6% died compared to less severely injured patients of which 83% were discharged home and <1% died; all other patients required discharge to a rehabilitation facility. Patients with penetrating trauma and SBPu2009<u200990u2009mmHg on arrival were more likely to require delivery (35% vs. 5%, pu2009<u20090.001) and were 14 times more likely to die (58% vs. 4%, pu2009<u20090.001) when compared to the normotensive group. Conclusion ISSu2009≥u20099 and SBPu2009<u200990u2009mmHg are predictors for poor outcomes after trauma during pregnancy. Severely injured blunt trauma patients often require surgery and delivery. Patients who present with SBPu2009<u200990 after penetrating trauma are more likely to deliver and are 14 times more likely to die.

Preeclampsia, Eclampsia and HELLP Syndrome

The patient with severe preeclampsia and its associated conditions of eclampsia and HELLP (Hemolysis, Elevated Liver enzymes and Low Platelets) syndrome usually present to Labor and Delivery and are often cared for completely by the obstetrical team, however in more complicated cases these patients should be treated with a multidisciplinary approach including critical care and other subspecialties as needed. Preeclampsia is a systemic disease characterized by hypertension and proteinuria that occurs in pregnancy and the puerperium. Severe complications include seizure (eclampsia), cerebral hemorrhage, liver capsule hematoma and rupture, renal failure and oliguria as well as pulmonary edema, heart failure and cardiomyopathy. This chapter reviews a typical presentation of severe preeclampsia, eclampsia and HELLP syndrome and management of this condition.