Reinaldo Figueroa

Emergency peripartum hysterectomy: Experience at a community teaching hospital

OBJECTIVES To estimate the incidence, indications, risk factors, and complications associated with emergency peripartum hysterectomy at a community‐based academic medical center. METHODS We analyzed retrospectively 47 of 48 cases of emergency peripartum hysterectomy performed at Winthrop‐University Hospital from 1991 to 1997. Emergency peripartum hysterectomy was defined as one performed for hemorrhage unresponsive to other treatment less than 24 hours after delivery. Fisher exact test, Wilcoxon rank sum test, and Cochran‐Armitage exact trend test were used for analysis. RESULTS There were 48 emergency peripartum hysterectomies among 34,241 deliveries for a rate of 1.4 per 1000. Most frequent indications were placenta accreta (48.9%, 12 with previa, 11 without previa), uterine atony (29.8%), previa without accreta (8.5%), and uterine laceration (4.3%). Placenta accreta was the most common indication in multiparous women (58.8%, 20 of 34), uterine atony the most common in primiparas (69.2%, nine of 13). Twenty‐two of 23 (95.6%) women with placenta accreta had a previous cesarean delivery or curettage. The number of cesarean deliveries or curettages increased the risk of placenta accreta proportionally. Thirty‐eight (80.9%) of the hysterectomies were subtotal. Postoperative febrile morbidity was 34%; other morbidity was 26.3%. CONCLUSION Placenta accreta has become the most common indication for emergency peripartum hysterectomy.

Randomized controlled trial of vaginal misoprostol versus dinoprostone vaginal insert for labor induction.

Objective: To compare the safety and efficacy of vaginal misoprostol versus dinoprostone vaginal inserts for cervical ripening and labor induction. Methods: Two hundred singleton gestations with an indication for cervical ripening and induction of labor were randomized to receive either 50 μg of misoprostol intravaginally every 3 h or a 10-mg dinoprostone vaginal insert every 12 h for a maximum of 24 h. Statistical analysis included Students t test, the Mann-Whitney U test, χ2 analysis and Fishers exact test. Results: Ninety-seven women received vaginal misoprostol while 89 women received the dinoprostone vaginal insert. Fourteen women were removed from the study after randomization. The interval from start of induction to vaginal delivery (794.5 ± 408 min vs. 1005.3 ± 523 min; p < 0.02) was significantly shorter in the misoprostol group. Women receiving misoprostol were more likely to deliver vaginally both in < 12 h (44% vs. 12%; p < 0.0001) and < 24 h (68% vs. 38%; p < 0.001). A non-reassuring fetal heart rate tracing was the indication for 71.4% (20/28) of Cesarean deliveries in the misoprostol group compared to 40% (14/35) in the dinoprostone group (p = 0.03). There were no significant differences in neonatal outcomes. Conclusion: Intravaginal misoprostol and dinoprostone are safe and effective medications for use in cervical ripening before labor induction. Misoprostol results in a shorter interval from induction to delivery. However, Cesarean delivery for a non-reassuring fetal heart rate tracing was more common with misoprostol.

Glioblastoma multiforme in pregnancy

Brain tumors in pregnancy are uncommon occurrences. A 48-year-old female at 36 2/7 weeks of gestation presented with right-sided weakness and parasthesias, a facial droop, and an unsteady gait. Brain imaging studies revealed a left-sided parietal lesion impinging upon the lateral ventricle. She underwent a cesarean delivery and then a craniotomy with resection of a glioblastoma multiforme two days later. Despite treatment with radiation and chemotherapy, she died nine months later. Glioblastoma multiforme is a rare diagnosis during pregnancy which may present as a neurologic emergency.

Comparison of obstetric outcomes in twin pregnancies after in vitro fertilization, ovarian stimulation and spontaneous conception.

Objective: To compare the outcomes of liveborn twin gestations conceived after in vitro fertilization (IVF) or ovarian stimulation with spontaneously conceived twin pregnancies. Methods: A review of all twin gestations delivered at Winthrop-University Hospital from 1 January 1999 to 31 December 2000. Women who underwent fetal reduction or had a demise of one twin were excluded. Maternal demographics, antepartum complications, mode of delivery and perinatal outcome were compared. Results: Sixty pregnancies were conceived after IVF, 34 were conceived by ovarian stimulation and 101 were spontaneously conceived. Women in the IVF group were older (p < 0.001), were more often 35 years or older (p < 0.001) and primiparous (p = 0.005). More women in the ovarian stimulation group had a poor obstetric history (p = 0.04). Spontaneous gestations had a higher incidence of monochorionic placentations (p = 0.002). There were no differences in gestational age at delivery, antepartum complications, or mode of delivery. There were fewer low-birth-weight neonates in the IVF group (odds ratio 0.59, 95% confidence interval 0.35-0.98; p = 0.03) than in the spontaneous group, but the difference disappeared when only the dichorionic pregnancies were compared. Other neonatal outcomes studied were the same among groups. Conclusion: Twin gestations conceived following IVF and ovarian stimulation appear to have similar outcomes to spontaneously conceived twin gestations.

Arnold-Chiari malformation in a pregnant woman

BACKGROUND The Arnold-Chiari malformation type I is characterized by the prolapse of the cerebellar tonsils below the foramen magnum. There is a lack of literature on the management of a pregnancy in a woman affected by an Arnold-Chiari malformation. CASE A young primipara with severe headaches underwent an elective primary cesarean delivery under general anesthesia successfully. Five years earlier, she had undergone neurosurgical resection for filum terminale syndrome shortly after her first pregnancy (term vaginal delivery) and decompression of a type I Arnold-Chiari malformation 4 months later. CONCLUSION Careful selection of anesthetic technique for the delivery of a woman with an Arnold-Chiari malformation is of paramount importance.

Uterine rupture associated with castor oil ingestion.

A woman at 39 weeks gestation with a previous Cesarean delivery had severe abdominal pains and rupture of membranes shortly after ingesting 5 ml of castor oil. Forty-five minutes later, repetitive variable decelerations prompted a Cesarean delivery. At surgery, a portion of the umbilical cord was protruding from a 2-cm rupture of the lower transverse scar.

Absent End-Diastolic Velocity in the Umbilical Artery and Its Clinical Significance

It is apparent from cumulative experience that the end-diagnostic component of the umbilical arterial Doppler waveform is of crucial importance for fetal prognostication. AREDV is known to be associated with an unusually adverse perinatal outcome. Most remarkably, these infants suffer from high perinatal mortality and morbidity rates and demonstrate an increased frequency of malformations and chromosomal abnormalities, with a predominance of trisomies 13, 18, and 21. Most infants with AREDV require intensive care. Furthermore, the risk of cerebral hemorrhage, anemia, and hypoglycemia is increased. It has been observed, however, that absent end-diastolic flow may improve, although often only transiently, and that weeks or more may elapse before the fetus shows additional evidence of compromise. Obviously, the presence of absent end-diastolic flow should warn the physician of significantly increased fetal risk. Appropriate surveillance measures should be immediately undertaken. If the pregnancy is significantly preterm, consideration for delivery should include additional signs of fetal compromise. A more aggressive approach should be taken to ensure fetal maturity. If fetal anomalies are present or AEDV cannot be explained by pregnancy complications such as preeclampsia, then fetal karyotype should also be determined to rule out lethal aneuploidies. Although the benefits of emergency delivery for this phenomenon remain controversial, randomized clinical trials have shown improved outcome from intervention in pregnancies with absent end-diastolic velocity. This subject is discussed comprehensively in Chap. 26.

Doppler Velocimetry for Fetal Surveillance: Adverse Perinatal Outcome and Fetal Hypoxia

There is ample evidence that Doppler indices from the fetal circulation can reliably predict adverse perinatal outcome in an obstetric patient population with a high prevalence of complications, such as fetal growth restriction and hypertension. This efficacy is not evident, however, in populations with a low prevalence of pregnancy complications. It is also apparent that fetal Doppler indices are capable of reflecting fetal respiratory deficiency with varying degrees of efficiency. The umbilical arterial Doppler indices are more sensitive to asphyxia than to hypoxia, whereas cerebral Doppler indices demonstrate significant sensitivity to hypoxia. Compared to fetal heart rate monitoring and the biophysical profile, umbilical artery Doppler velocimetry shows mostly similar and often superior efficacy. Furthermore, progressive fetal deterioration manifests in sequential abnormalities of the various fetal assessment parameters, starting with middle cerebral artery vasodilation and eventual progression to disappearance of the fetal heart rate variability, late deceleration, and the absence or reversal of the end-diastolic velocity in the umbilical artery. Evidently, no single testing modality should be regarded as the exclusive choice for fetal surveillance, as these tests reveal different aspects of fetal pathophysiology, often in a complementary manner. Clearly, more work is needed to determine the optimal integration of the various surveillance methods for improving perinatal outcome in a cost-effective manner.

Right atrial myxoma mimicking an atrial thrombus in the third trimester of pregnancy

Primary tumors of the heart are rare. Their reported incidence at autopsy is between 0.0017% and 0.19%; 75% of them are benign [1]. Myxomas, the most common primary tumors of the heart, constitute 50% of benign cardiac tumors. Myxomas are found more often in women between the third and sixth decade of life [1]; therefore, they are occasionally encountered during pregnancy [2–7]. More importantly, they may be confused with an atrial thrombus [8]. A 35-year-old multigravida presented at 33 3/7 weeks of gestation with palpitations and increasing exertional dyspnea over the past month. The pregnancy was complicated by severe hyperemesis since gestational week 10 and, since she required home intravenous therapy, a right internal jugular Hickman catheter had been placed for vascular access four months earlier. An echocardiogram performed because of arrhythmia revealed a portion of the Hickman catheter in the right atrium with a thrombus at the tip. She was admitted to the hospital and started on therapeutic doses of intravenous unfractionated heparin. A day later, the catheter was removed and a repeat echocardiogram was done showing a 3.063.0 cm round, mobile echodensity in the right atrium that prolapsed into the right ventricle. The echodensity was believed to be a thrombus because of the foreign body in the right atrium, although the possibility of a tumor, most specifically a myxoma, was considered. A ventilation perfusion lung scan was performed and revealed a low probability of pulmonary embolism. Ultrasonography of the pregnancy revealed a single intrauterine gestation with an estimated fetal weight of 2190 grams placing the fetus in the 50 percentile for gestational age. A maternal echocardiogram was repeated four days later showing that the mass was stable in size and partially prolapsing into the right ventricle. Because the mass was circular and mobile, and attached to the lateral wall of the right atrium, it was now thought to be an atrial myxoma. The heparin was continued at a lower dose in case the myxoma had a thrombus on it. The multiple disciplines involved in the patient’s care met with her to discuss timing of delivery. The decision was made to deliver by cesarean at 34 6/7 weeks despite fetal lung immaturity due to the risk of lethal pulmonary embolization. The woman underwent a primary cesarean delivery, without complications, of a live female neonate weighing 2468 grams with Apgar score of 9 at 1 and 5 minutes. A transesophageal echocardiogram performed on the first postpartum day revealed a 3.163.5 cm mass in the right atrium. The mass was attached to the lateral wall of the right atrium by a stalk, consistent with an atrial myxoma. No thrombus was identified. The woman had an uncomplicated postoperative course and was discharged home four days after her cesarean. Prophylactic doses of unfractionated heparin were given. The myxoma was removed by a cardiothoracic surgeon three weeks after delivery and the patient had an uneventful recovery. She had a normal postpartum examination three weeks after the surgery. Cardiac myxomas are usually sporadic and occasionally recur [1]. Ninety percent occur in the atria with 75–80% occurring in the left side [1]. Myxomas usually originate from the interatrial septum at the border of the fossa ovalis [1]. Myxomas are generally single, polypoid and frequently pedunculated lesions. They are round or oval with a smooth or The Journal of Maternal-Fetal and Neonatal Medicine, January 2007; 20(1): 77–78

Doppler Velocimetry for Fetal Surveillance: Randomized Clinical Trials and Implications for Practice

The development of Doppler sonography has made it feasible to assess the fetal and uteroplacental circulations. Numerous studies have established a significant association between abnormal Doppler indices and the various pregnancy disorders and adverse perinatal outcomes. Most clinical investigations suggest that, in high-risk pregnancies, umbilical arterial Doppler indices may be efficacious for predicting perinatal problems including fetal death. Many randomized trials on Doppler velocimetry have yielded positive results. Furthermore, systematic reviews of the trials by meta-analysis demonstrate a significant reduction in preventable fetal deaths. The current evidence mandates that Doppler velocimetry of the umbilical artery should be an integral component of fetal surveillance in pregnancies complicated with fetal growth restriction or preeclampsia. Obviously, no single testing modality should be regarded as the exclusive choice for fetal surveillance, as these tests reveal different aspects of fetal pathophysiology, often in a complementary manner.