Natalie Meirowitz

Diagnosis of placental abscess in association with recurrent maternal bacteremia in a twin pregnancy

BACKGROUND: Placental abscess formation is rarely recognized prenatally. We present a case detected ultrasonographically that developed from a central line infection and caused recurrent maternal bacteremia. CASE: A young woman with a 21-week twin gestation presented with recurrent fevers. She had received treatment for bacteremia due to Serratia marcescens. The initial source of the infection was a peripherally inserted central catheter line placed in the first trimester for hyperemesis gravidarum. Fevers continued throughout the second course of antibiotics. An abscess seen sonographically in twin A’s placenta was aspirated using a spinal needle, revealing Serratia bacteria. Aspiration was performed at 22 weeks of gestation. Amniotic fluid samples obtained from both sacs were negative for infection. Over 4 weeks, the abscess enlarged and she was delivered. Twin A died of sepsis and twin B had a relatively favorable neonatal course. CONCLUSION: Prenatal diagnosis of placental abscess presents a difficult management dilemma. Traditional amniotic fluid studies did not predict the poor outcome of the affected fetus.

Flushing and papules in a middle-aged woman.

To the Editor: I was happy to see that the new series “In the Trenches” presented a review of the diagnosis and management of rosacea. However, I was disappointed that it failed to mention an important aspect of the condition that is often overlooked by dermatologists. Clinical symptoms of rosacea can be triggered or worsened by vasomotor flushing from declining ovarian function that characterizes the perimenopausal period. The transition from subclinical disease (prerosacea) to overt disease may be triggered in some women by falling estrogen levels. Although rosacea has been classified into subtypes based on the predominating feature, flushing is believed to be the underlying cause for all subtypes. Rosacea is most often diagnosed in women in their 40s, which coincides with a time of waning ovarian function. In fact, menstruating women with rosacea will often experience premenstrual worsening of rosacea symptoms when hormone levels are declining. This has important implications for therapy, particularly in difficult, treatment-resistant cases. Hormonal therapy (ie, oral contraceptives) is likely to decrease flushing and have an overall suppressive effect on other features of rosacea. Another option would be treatment with a selective serotonin reuptake inhibitor, which has been shown to decrease vasomotor flushing in perimenopausal women. I believe there is better data to support the effectiveness of these drugs for flushing than there is to support the use of clonidine or nadolol.

Detecting Pulmonary Edema in Obstetric Patients Through Point-of-Care Lung Ultrasonography

BACKGROUND Point-of-care lung ultrasonography is used in critical care settings for evaluating respiratory symptoms. Lung ultrasonography is sensitive and specific for the diagnosis of pulmonary edema in nonpregnant patients but is not well-studied in pregnancy. TECHNIQUE Lung ultrasonography was performed using a portable ultrasound machine with a 2- to 5-MHz curvilinear probe that is available on many labor and delivery units. EXPERIENCE Lung ultrasonography guided management decisions in a case of shortness of breath after induction of labor for preeclampsia and a case of hemolysis, elevated liver enzymes, and low platelet count syndrome complicated by pulmonary edema. Findings expedited diagnosis and treatment in both cases. CONCLUSION Lung ultrasonography has potential to be used in obstetrics for detecting pulmonary edema in preeclampsia. It is a well-established tool in critical care settings and use in obstetric patients should be studied given the availability of ultrasonography on labor and delivery and the importance of timely care for critically ill pregnant patients. It is a safe modality to evaluate pregnant women with respiratory symptoms and the necessary skills can be easily acquired by obstetric practitioners familiar with obstetric ultrasonography. Training of obstetric practitioners in this application of ultrasonography is needed.

Is There an Association Between Placenta Previa and Serum Analytes

INTRODUCTION: The objective of this study was to evaluate the association between maternal serum analytes and placenta previa. METHODS: Chart review of deliveries from 2004 to 2012 with two comparison groups: placenta previa without accreta and a control group. Patients in the control group were randomly selected from deliveries without placenta previa. Patients with previa were confirmed by third-trimester ultrasonography. Exclusion criteria were placenta previa with pathology-confirmed accreta, multiple gestations, fetal anomalies, or growth restriction. Primary outcomes were maternal serum analytes in the first trimester: pregnancy-associated plasma protein A and free &bgr;-human chorionic gonadotropin (&bgr;-hCG), and second trimester: &agr;-fetoprotein), free &bgr;-hCG, unconjugated estriol, and inhibin. RESULTS: Twenty-six women with previa met inclusion criteria and 43 women in the control group. The groups did not differ with respect to maternal age, gravidity, or parity. Alpha-fetoprotein multiples of the median was significantly higher in women with previa cases than women in the control group (P<.005). Pregnancy-associated plasma protein A multiples of the median was higher (but was not statistically significant) in women with previa than in the women in the control group (P<.064). There were no differences between groups with respect to first-trimester free &bgr;-hCG, second-trimester free &bgr;-hCG, unconjugated estriol, or inhibin (Table 1). The following analytes were not available on all specimens: second-trimester free &bgr;-hCG, unconjugated estriol, and inhibin. Table 1 Comparison of Serum Analytes Between Placenta Previa Without Accreta Cases and Control Cases. CONCLUSIONS: In our women with placenta previa, maternal serum &agr;-fetoprotein was significantly higher than in women in the control group. We also observed higher levels of pregnancy-associated plasma protein A in women with previa but this did not reach statistical significance. Prospective studies are needed to confirm these findings and determine the relationship with pregnancy outcome.

Maternal Assessment With Sonography for Hemorrhage (MASH): A Prospective Cohort Study [33P]

INTRODUCTION:Intra-abdominal hemorrhage must be diagnosed and managed expeditiously in women with hemodynamic instability after Cesarean delivery. Our objective was to determine the amount of free intra-abdominal fluid normally present on ultrasound after Cesarean delivery, and whether intra-operati

Implementing an Obstetric Triage Acuity Tool in a High-Volume Obstetric Unit

INTRODUCTION: Our objective was to evaluate an obstetric triage acuity tool that we developed and implemented in January 2013. METHODS: A four-level triage acuity tool, Level 1 (most acute) to Level 4 (least acute), was developed to prioritize patients presenting for urgent care to the obstetric triage unit. Acuity scores, assigned by a triage nurse, dictated acceptable wait times for a medical screening examination (Level 1, 5 minutes; Level 2, 15 minutes; Level 3, 30 minutes; Level 4, 60 minutes). This was a prospective cohort study of all 2,228 urgent triage visits from March 1 to May 31, 2013. The validity of obstetric triage acuity tool was evaluated by comparing hospital admission rates across acuity levels to determine whether admission rates increased with increasing acuity level. Wait times from acuity score to medical screening examination and to final disposition were calculated and assessed by acuity level. RESULTS: Admission rates increased significantly across acuity levels from least acute to most acute; admission rates at Level 4, 3, 2, and 1 were respectively, 16%, 40%, 54%, and 84%, respectively (Table 1; P<.001). Goals for acceptable wait time for a medical screening examination were met for 89% of Level 1, 84% of Level 2, 91% of Level 3, and 94% of Level 4 visits. Table 1 Hospital Admission and Triage Evaluation Times Stratified by Acuity Level CONCLUSIONS: Increasing hospital admission rates across acuity levels supports the validity of obstetric triage acuity tool. Since implementing the obstetric triage acuity tool, most patients presenting for urgent care were seen for a medical screening examination within clinically acceptable wait times.