Melissa H. Fries

Multidisciplinary Management of Pregnancy in Complex Congenital Heart Disease: A Model for Coordination of Care

With advancements in medical care, many women with complex congenital heart disease (CHD) are now living into adulthood and childbearing years. The strains of pregnancy and parturition can be dangerous in such patients, and careful interdisciplinary plans must be made to optimize maternal and fetal health through this process. Several large studies have been published regarding risk prediction and medical management of pregnancy in complex CHD, though few case studies detailing clinical care plans have been published. The objective of this report is to describe the process of developing a detailed pregnancy and delivery care plan for three women with complex CHD, including perspectives from the multidisciplinary specialists involved in the process. This article demonstrates that collaboration between specialists in the fields of cardiology, anesthesiology, high-risk obstetrics, maternal fetal medicine, and neonatology results in clinically successful individualized treatment plans for the management of pregnancy in complex CHD. Multidisciplinary collaboration is a crucial element in the management of pregnancy in complex CHD. We provide a template used in three cases which can serve as a model for the design of future care plans.

Glycemic control, compliance, and satisfaction for diabetic gravidas in centering group care

Abstract Purpose: To determine if diabetic gravidas enrolled in Centering® group care have improved glycemic control compared to those attending standard prenatal care. To compare compliance and patient satisfaction between the groups. Materials and methods: We conducted a prospective cohort study of diabetics enrolled in centering group care from October 2013 to December 2015. Glycemic control, compliance and patient satisfaction (five-point Likert scale) were evaluated. Student’s t-test, Chi-Square and mixed effects model were used to compare outcomes. Results: We compared 20 patients in centering to 28 standard prenatal care controls. Mean fasting blood sugar was lower with centering group care (91.0 versus 105.5 mg/dL, p =0.017). There was no difference in change in fasting blood sugar over time between the two groups (p = 0.458). The percentage of time patients brought their blood glucose logs did not differ between the centering group and standard prenatal care (70.7 versus 73.9%, p = 0.973). Women in centering group care had better patient satisfaction scores for “ability to be seen by a physician” (5 versus 4, p = 0.041) and “time in waiting room” (5 versus 4, p =0.001). Conclusion: Fasting blood sugar was lower for patients in centering group care. Change in blood sugar over time did not differ between groups. Diabetic gravidas enrolled in centering group care report improved patient satisfaction.

Neonatal outcomes in fetuses with cardiac anomalies and the impact of delivery route

BACKGROUND: Congenital fetal cardiac anomalies compromise the most common group of fetal structural anomalies. Several previous reports analyzed all types of fetal cardiac anomalies together without individualized neonatal morbidity outcomes based on cardiac defect. Mode of delivery in cases of fetal cardiac anomalies varies greatly as optimal mode of delivery in these complex cases is unknown. OBJECTIVE: We sought to determine rates of neonatal outcomes for fetal cardiac anomalies and examine the role of attempted route of delivery on neonatal morbidity. STUDY DESIGN: Gravidas with fetal cardiac anomalies and delivery >34 weeks, excluding stillbirths and aneuploidies (n = 2166 neonates, n = 2701 cardiac anomalies), were analyzed from the Consortium on Safe Labor, a retrospective cohort study of electronic medical records. Cardiac anomalies were determined using International Classification of Diseases, Ninth Revision codes and organized based on morphology. Neonates were assigned to each cardiac anomaly classification based on the most severe cardiac defect present. Neonatal outcomes were determined for each fetal cardiac anomaly. Composite neonatal morbidity (serious respiratory morbidity, sepsis, birth trauma, hypoxic ischemic encephalopathy, and neonatal death) was compared between attempted vaginal delivery and planned cesarean delivery for prenatal and postnatal diagnosis. We used multivariate logistic regression to calculate adjusted odds ratio for composite neonatal morbidity controlling for race, parity, body mass index, insurance, gestational age, maternal disease, single or multiple anomalies, and maternal drug use. RESULTS: Most cardiac anomalies were diagnosed postnatally except hypoplastic left heart syndrome, which had a higher prenatal than postnatal detection rate. Neonatal death occurred in 8.4% of 107 neonates with conotruncal defects. Serious respiratory morbidity occurred in 54.2% of 83 neonates with left ventricular outflow tract defects. Overall, 76.3% of pregnancies with fetal cardiac anomalies underwent attempted vaginal delivery. Among patients who underwent attempted vaginal delivery, 66.1% had a successful vaginal delivery. Women with a fetal cardiac anomaly diagnosed prenatally were more likely to have a planned cesarean delivery than women with a postnatal diagnosis (31.7 vs 22.8%; P < .001). Planned cesarean delivery compared to attempted vaginal delivery was not associated with decreased composite neonatal morbidity for all prenatally diagnosed (adjusted odds ratio, 1.67; 95% confidence interval, 0.85–3.30) or postnatally diagnosed (adjusted odds ratio, 0.99; 95% confidence interval, 0.77–1.27) cardiac anomalies. CONCLUSION: Most fetal cardiac anomalies were diagnosed postnatally and associated with increased rates of neonatal morbidity. Planned cesarean delivery for prenatally diagnosed cardiac anomalies was not associated with less neonatal morbidity.

A case of recurrent hyperreactio luteinalis in three spontaneous pregnancies.

Hyperreactio luteinalis is a rare condition in pregnancy characterized by enlarged ovaries with multiple theca luteal cysts, and recurrence of disease has seldom been documented in the literature. This is a case report of a woman who developed recurrent hyperreactio luteinalis with three spontaneous pregnancies. Endocrine evaluation was performed and revealed hyperandrogenism. Ultrasonography was used to assess the ovaries throughout each pregnancy. The ovarian cysts required drainage in the first pregnancy due to severe distention and shortness of breath. Cyst resolution occurred in the post‐partum period following each pregnancy.

Catecholaminergic Ventricular Tachycardia, Pregnancy and Teenager: Are They Compatible?

Arrhythmias in pregnancy are becoming more common given more available and effective medical, ablation and device treatment options. Several changes associated with pregnancy, increased blood volume, cardiac output, and heart rate secondary to an increased sympathetic state, facilitate more frequent occurrences of arrhythmias throughout the pregnancy and during labor and delivery. We present a case of successful pregnancy in a teenage female with a previous diagnosis of CPVT, followed by a review of the literature.

Risk factors, clinical findings, and outcomes in pregnancies with coronary artery dissection: A case series

Coronary artery dissection (CAD) occurs due to separation of the vessel layers creating a false lumen and a hematoma within the vessel wall. Occlusion of the coronary artery would then occur leading to an acute coronary syndrome. CAD is usually associated with atherosclerosis and less commonly with connective tissue disorders, systemic inflammatory conditions, pregnancy and the postpartum state. CAD has been detected in up to 1.1% of coronary angiograms. There are limited studies about CAD in pregnancy. The aim of this study is to describe the demographic characteristics, risk factors, management and concurrent and subsequent outcomes of pregnant or postpartum women with CAD.

Third trimester ultrasound for fetal macrosomia: optimal timing and institutional specific accuracy

Abstract Purpose: To determine the performance of third trimester ultrasound in women with suspected fetal macrosomia. Materials and methods: We performed a retrospective cohort study of fetal ultrasounds from January 2004 to December 2014 with estimated fetal weight (EFW) between 4000 and 5000 g. We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, accounting for diabetic status and time between ultrasound and delivery. Results: There were 405 ultrasounds evaluated. One hundred and twelve (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) were performed in diabetics. Sonographic identification of EFW over 4000 g at less than 38 weeks was associated with higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 versus 259.4 g, p < .024). EFW to birth weight correlation was within 1.7% of birth weight for ultrasound performed less than 38 weeks and within 6.5% of birth weight for ultrasound performed at greater than 38 weeks. Conclusions: Identification of EFW with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed later in gestation. EFW to birth weight correlation was more accurate than previous reports.

A Case of Recurrent Hyperreactio Luteinalis in Three Spontaneous Pregnancies [20M]

INTRODUCTION: Hyperreactio luteinalis is a rare condition in pregnancy characterized by enlarged ovaries with multiple theca luteal cysts. This report describes a patient with recurrent hyperreactio luteinalis in three consecutive pregnancies. METHODS: Case report. RESULTS: A 32 year old multigravida woman with hyperreactio luteinalis resulting in bilateral ovarian enlargement during three consecutive pregnancies. Noninvasive imaging was used to assess growth throughout each pregnancy, and drainage was required during the first pregnancy due to severe abdominal distention. Endocrine evaluation revealed elevated testosterone and androstenedione though the patient did not exhibit signs of virilization beyond severe acne. CONCLUSION: Theca lutein cysts resolved in the 3 month postpartum period during all three pregnancies. Many patients who have suffered from hyperreactio luteinalis have undergone cystectomies or oophorectomies even though cyst resolution in this condition has always been documented to occur within a few months postpartum. It is essential to increase awareness of this condition to avoid unnecessary oophorectomies in the future.

Fetal Macrosomia Prediction in Diabetic Gravidas: The Reliability of Third Trimester Ultrasound [27M]

INTRODUCTION: Conflicting evidence exists regarding the reliability of third trimester ultrasound for guiding delivery management for fetal macrosomia. Our objective was to determine the performance of third trimester ultrasound in diabetic and non-diabetic women with fetal macrosomia. METHODS: We performed a retrospective cohort study of fetal ultrasounds from 2004–2014 with estimated fetal weight (EFW) above 4,000 grams (gm). We determined accuracy of birth weight prediction for ultrasound performed at less than and greater than 38 weeks, in non-diabetic and diabetic women. We used student t test, Wilcoxon rank sum test, chi-square, Fisher exact test, and multivariate logistic regression. RESULTS: There were 405 fetal ultrasounds with EFW above 4,000 gm. 112 (27.7%) were performed at less than 38 weeks, 293 (72.3%) at greater than 38 weeks, and 91 (22.5%) in diabetics. Sonographic identification of EFW over 4000 gm at less than 38 weeks was associated with higher birth weight (4183 gm vs 4019 gm, P=.001) and higher correlation between EFW and birth weight than ultrasound performed after 38 weeks (71.5 gm vs 259.4 gm, P<.001). EFW to birthweight correlation was within 1.7% of EFW for ultrasound performed less than 38 weeks. Diabetics had larger birth weight then non-diabetics (4198 gm vs 4022 g, P<.001) but the correlation between EFW and birth weight was the same after adjusting for gestational age at ultrasound (102gm vs 252 gm, P=.103). In all cohorts, average EFW overestimated average birth weight. CONCLUSION: Identification of fetal weight over 4000 gm in patients with ultrasound performed less than 38 weeks has greater reliability of predicting fetal macrosomia at birth than measurements performed greater than 38 weeks.