Morrison Jc

ANGIOGRAPHIC ARTERIAL EMBOLIZATION AND COMPUTED TOMOGRAPHY-DIRECTED DRAINAGE FOR THE MANAGEMENT OF HEMORRHAGE AND INFECTION WITH ABDOMINAL PREGNANCY

Hemorrhage during or after surgery, pelvic abscess, bowel obstruction, and prolonged febrile morbidity can complicate the puerperal course of the gravida after removal of an extrauterine fetus with nondisturbance of the extrauterine placenta. In this report we describe the successful angiographic arterial gelfoam embolization of the placental vascular bed to control heavy postoperative hemorrhage in a mother suffering adult respiratory distress syndrome after removal of the fetal portion of her abdominal pregnancy. Six weeks later, computed tomography (CT)-directed drainage by catheter of a placental abscess was performed. Selective angiographic transcatheter embolization with gelfoam is a useful tool for the control of hemorrhage in the gravida who is an unfavorable operative candidate or who may present technical hemostasis problems peculiar to the placenta with abdominal pregnancy. Later use of CT-directed catheter drainage of the infected residual placental mass provided a nonoperative means of treatment.

Cost/health effectiveness of home uterine activity monitoring in a medicaid population

It has been shown that an intensive system of preterm birth prevention using home uterine activity monitoring can decrease the number of early births. Such a system was employed in 130 public assistance (Medicaid) patients who were at high risk for preterm birth. A retrospective review of the pregnancy outcome in these subjects was conducted and their data exposed to a model for projected patient care cost. The incidence of preterm labor in the at-risk group was 46%, with an average prolongation of pregnancy of 4.9 weeks. The occurrence of preterm delivery for failed tocolysis or advanced cervical dilatation was less than 10%. Based on a cost-analysis model that considered newborn charges and monitoring expenses, over

Risks and Benefits of Magnesium Sulfate Tocolysis in Preterm Labor (PTL)

3 million (an average of

The diagnosis and management of dystocia of the shoulder

23,573 per patient) was saved using this system

Pregnancy complicated by preeclampsia-eclampsia with the syndrome of hemolysis, elevated liver enzymes, and low platelet count: How rapid is postpartum recovery?

The U.S. Food and Drug Administration issued a drug safety communication on 05/30/2013 recommending “against prolonged use of magnesium sulfate to stop preterm labor (PTL) due to bone changes in exposed babies.” In September of 2013, The American Congress of Obstetrics and Gynecologists issued Committee Opinion No. 573 “ Magnesium Sulfate Use in Obstetrics” , which supports the short term use of MgSO4 to prolong pregnancy (up to 48 hrs.) to allow for the administration of antenatal corticosteroids.” Are these pronouncements by respected organizations short sighted and will potentially result in more harm than good? The FDA safety communication focuses on bone demineralization (a few cases with fractures) with prolonged administration of MgSO4 (beyond 5–7 days). It cites 18 case reports in the Adverse Event Reporting System with an average duration of magnesium exposure of 9.6 weeks (range 8–12 wks). Other epidemiologic studies showed transient changes in bone density which resolved in the short duration of follow up. Interestingly, the report fails to acknowledge the fact that these 18 fetuses were in danger of PTD and the pregnancy was prolonged by 9.6 weeks (e.g. extending 25 weeks to 34.6 wks), thus significantly reducing mortality and morbidity. Evidence does support the efficacy of MgSO4 as a tocolytic medication. The decision to use magnesium, the dosage to administer, the duration of use, and alternative therapies are physician judgments. These decisions should be made based on a reasonable assessment of the risks of the clinical situation (PTL) and the treatments available versus the benefits of significantly prolonging pregnancy.

Plasma exchange for preeclampsia. I. Postpartum use for persistently severe preeclampsia-eclampsia with HELLP syndrome

Dystocia of the shoulder is an unpredictable obstetric emergency that may result in injury to the mother or fetus. In an effort to reduce such risks, attempts have been made to identify patients having a fetus who may subsequently develop shoulder dystocia. The literature, however, clearly reflects that even the combination of prenatal historic facts, estimated fetal weight and sequence of intrapartum events is ineffective in prospectively identifying infants whose births are complicated by shoulder dystocia. During a ten year period at the University of Mississippi Medical Center, the incidence of macrosomia, shoulder dystocia and subsequent brachial plexus injury was reviewed. The majority of instances (89 percent) of shoulder dystocia occurred in patients weighing less than 8 pounds 13 ounces at birth. In the current retrospective review, only 11 percent of the women had risk factors for macrosomia or shoulder dystocia and among these, none were identified prospectively. Additionally, 91 percent of patients with brachial plexus injury recovered with no sequelae. One instance of brachial plexus injury occurred at the time of cesarean section. These data reveal that macrosomia and subsequent shoulder dystocia cannot be predicted. Therefore, it is not feasible to prevent brachial plexus injury prospectively by prophylactic cesarean section. Great clinical acumen and technical expertise by the obstetrician using a variety of methods may be useful in avoiding, as much as possible, injury to the mother and fetus when shoulder dystocia does occur.

Abdominal pregnancy: current concepts of management.

fibroids. In the first series, 75 patients presenting with menometrorrhagia were considered for endometrial ablation using Nd:YAG laser, and 23 met conservative requirements. In the second series, 12 of the 25 patients considered met the conservative requirements. The patients in series I received danazol for 30 days before and 30 days after the procedure; patients in series II received leuprolide acetate. All patients were followed for at least I year after treatment was discontinued. Of the 35 patient in both series, 21 (60%) were found to have complete cessation of menstruation. Eleven (3 1.43%) resumed menstruating but at acceptable levels. Three patients (8.57%) had unsatisfactory results, one who later had a repeat ablation and two who had hysterectomies. Thus. 32 of 35 patients were successfully treated without further intervention after laser ablation. Nd:YAG endometrial ablation is efficacious and cost-effective for recurrent menometrorrhagia in selected patients The additional benefit of this procedure is the avoidance of hysterectomies and postsurgical complications as well as the psychological consequences of a hysterectomy.

Prediction of spontaneous preterm birth by fetal fibronectin and uterine activity

The postpartum use of plasma exchange with fresh-frozen plasma was assessed in a group of seven women with severe preeclampsia-eclampsia and HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) that persisted greater than 72 hours after delivery. During the study interval in which a total of 107 gravid women with HELLP syndrome were seen in our referral center, these seven patients (6.5%) demonstrated persistent thrombocytopenia (platelet count usually less than 30,000/mm3), rising lactic dehydrogenase (greater than 1000 IU/L) and evidence of multiorgan dysfunction. The seven case histories emphasize the variety of clinical and laboratory profiles that can be encountered in this small group of gravid women at risk for severe morbidity or mortality. Up to three 3 L plasma exchanges were required to effect permanent disease arrest and reversal. Utilization of the IBM 2997 Cell Separator system permitted bedside performance of procedures with enhanced convenience and optimal medical management. Successful plasma exchange was associated with (1) sustained increases in the mean platelet count at 24, 48, and 72 hours that were 2.2, 3.6, and 4.5 times the preexchange platelet counts and (2) a decreasing trend in lactic dehydrogenase concentrations below 1000 IU/L within 48 hours of exchange plasmapheresis. The current series of patients supports our recommendation that a trial of plasma exchange(s) with fresh-frozen plasma be considered for treatment of the infrequent postpartum case of HELLP syndrome that fails to abate within 72 hours of delivery and in which other evidence develops of an ongoing, widespread, and life-threatening thrombotic microangiopathy.