Robert P. Lorenz

Vasa previa: clinical presentations, outcomes, and implications for management.

OBJECTIVE: To review experience with diagnosis, clinical associations, and outcomes of vasa previa in a single institution. METHODS: This was a retrospective review of all identified vasa previa cases from January 1 1990, to June 30, 2010. RESULTS: Sixty cases of vasa previa were identified (53 singletons, seven twins); 56 cases were diagnosed before delivery. An abnormal cord insertion or abnormal placental location was present in 55 cases. Missed diagnoses were attributed to technical and observer factors. Preterm bleeding was encountered in 25 (42%) case group participants. Seven case group participants required an emergent delivery, with significant neonatal morbidity and mortality. Twin pregnancies had a significantly earlier median age at delivery of 32 weeks of gestation compared with 35 weeks of gestations in singletons (P=.01). The seven twin pregnancies had a 28.6% emergent preterm delivery rate, whereas singletons had a 4.1% rate (P=.07). In 14 case group participants, the membranous fetal vessel was located in the lower uterus and not directly over the cervix. The vessel location was not related to the risk of emergent delivery. CONCLUSION: Transvaginal ultrasound scans of at-risk patients can identify most cases of vasa previa. Preterm bleeding does not usually require immediate delivery. The rate of emergent preterm delivery was low in singleton pregnancies. Twins were delivered, on average, 3 weeks earlier than singletons. LEVEL OF EVIDENCE: III

The relationship between reproductive performance and blood pressure in the spontaneously hypertensive rat

Blood pressure was measured serially throughout pregnancy in spontaneously hypertensive rats and in normotensive control rats of the Wistar-Kyoto strain. Changes in blood pressure were also correlated with the outcome of pregnancy. In control rats there was a small but significant decrease in blood pressure between days 20 and 22 of pregnancy (day of birth = day 22.5). In the spontaneously hypertensive rat this decrease occurred earlier, between days 18 and 19 of pregnancy, and was of greater magnitude. There was a positive correlation in the spontaneously hypertensive rat between the number of live-born pups and the magnitude of the decrease in blood pressure. Perinatal mortality, but not litter size, was greater in the spontaneously hypertensive rat than in control rats. Thus the physiologic mechanisms responsible for the decrease in blood pressure in the normal rat are preserved in the spontaneously hypertensive rat, and the successful completion and outcome of pregnancy depend on the capacity of the hypertensive rat to amplify these processes. Consequently, the spontaneously hypertensive rat is not an appropriate experimental model for hypertension of human pregnancy, in particular for preeclampsia, in which the presence of the conceptus characteristically causes blood pressure to rise, especially during the last trimester. However, an investigation of the factors responsible for the profound antihypertensive effect of pregnancy in rats could provide new insights into the mechanisms by which blood pressure is regulated during pregnancy and suggest new therapeutic approaches.

Preparation of prostaglandin E2 vaginal gel for preinduction ripening of the cervix

Low dose prostaglandin E2 (PGE2) vaginal gel has been shown to be an effective method for preinduction ripening of the cervix. A method for preparation of this gel from commercially available reagents is described. A twenty milligram PGE2 vaginal suppository ( Prostin , Upjohn) is added to 100 ccs of hydroxyethyl cellulose gel (K-Y Jelly, Johnson and Johnson), heated to 85 degrees C. Samples of this preparation were stored at a 4 degrees Centigrade (C) or 28 degrees C for one, six, or twenty-four hours. After storage, analysis by radioimmunoassay demonstrated there was no appreciable decrease in concentration of PGE2. A clinical useful prostaglandin E2 vaginal gel may be prepared from commercially available reagents under the conditions described.

Hyperlipidemia-associated pancreatitis in pregnancy managed with fenofibrate.

BACKGROUND: Pancreatitis is a concerning clinical event during pregnancy, with high morbidity and mortality rates for mother and fetus. Hypertriglyceridemia is considered a rare cause of pancreatitis in pregnancy, with the majority of reported cases being associated with the lipid metabolism disorders. CASE: We report on a case of hypertriglyceridemia-induced pancreatitis in a woman presenting at 32 weeks of gestational age. Her dyslipidemia was not controlled with diet alone, necessitating medical intervention. Fenofibrate was used successfully. Recurrence of pancreatitis during the pregnancy was avoided, and a healthy neonate was delivered at 35 weeks of gestation. CONCLUSION: Fenofibrate was used safely and successfully during pregnancy in this case of hypertriglyceridemia-associated pancreatitis refractory to conservative measures.

Insights into angiogenic imbalances during pregnancy.

BACKGROUND: An excess of either angiogenic or antiangiogenic factors may participate in the pathophysiology of life-threatening pregnancy complications. CASES: We describe two patients with severe early onset preeclampsia associated with partial mole or sacrococcygeal teratoma who had an excess of circulating concentrations of the antiangiogenic factors soluble vascular endothelial growth factor receptor-1 and soluble endoglin. In contrast, a patient with severe ovarian hyperstimulation syndrome at 5 weeks of gestation had an excess of circulating free vascular endothelial growth factor, a key angiogenic factor. CONCLUSION: Angiogenic imbalances may participate in the pathophysiology of early onset preeclampsia associated with partial mole or sacrococcygeal teratoma as well as in the pathophysiology of severe ovarian hyperstimulation syndrome during pregnancy.

A case of intrauterine fetal death after a negative oxytocin challenge test.

A recent major review of the complications of heparin therapy by GervinZ points out the increased tendency of elderly women to have hemorrhagic complications secondary to heparin therapy but does not specifically mention the danger of ovarian bleeding in menstruating women. It is a well-recognized fact that hemorrhagic problems arise with significant frequency in patients receiving anticoagulants. Most of these problems are of a minor nature and can be readily managed. It is well documented that the incidence of thromboembolic disorders is higher in women using oral contraceptives. The most widely accepted initial treatment for significant thrombophlebitis and pulmonary embolism is anticoagulation with heparin. The widespread use of oral contraceptives with their thromboembolic side effects and subsequent heparin therapy might well make significant hemorrhage from ovarian cysts a more frequent occurrence. The increased risk of ovarian hemorrhage in patients who will resume ovulating after the discontinuation of the ovarian suppression must be considered in women with abdominal pain who are receiving anticoagulants. The possibility of cystic hemorrhage might make partial interruption of the inferior vena cava a more favorable therapeutic modality in young women with pulmonary emboli.