Sandra McCalla

The biologic and social consequences of perinatal cocaine use in an inner-city population: Results of an anonymous cross-sectional study

Cocaine use among pregnant women and reports of its adverse perinatal consequences have increased substantially over the past 10 years. However, most researchers have studied patients registered at drug treatment centers or have relied on voluntary participation by patients, either of which introduces the possibility of selection bias. To determine the frequency and consequences of prenatal cocaine use among an unselected inner-city obstetric population, we collected urine samples from parturient women at a municipal hospital and anonymously tested these specimens for metabolites of cocaine, marijuana, opiates, and methadone. Urine specimens, with linked obstetric data sheets, were available from a study population of 1111 patients, and pediatric data sheets were available for 846 mother-infant pairs. Cocaine metabolites were found in 11.5% of the urine samples collected, whereas metabolites of marijuana, opiates, and methadone, respectively, were present in 1.1%, 1.2%, and 0.3% of the specimens. Cocaine users were more likely than nonusers to have had no prenatal care (51% vs 8.8%; p less than 0.0001), to be American-born rather than Caribbean-born (71% vs 33%; p less than 0.001), and to have a higher parity (1.83 vs 1.14; p less than 0.0001). Infants of cocaine users had a lower mean gestational age (-0.93 weeks; p less than 0.01), a lower mean birth weight (2560 +/- 788 vs 3151 +/- 699 gm; p less than 0.001), and an increased probability of having an Apgar score of less than 7 at 5 minutes (12.5% vs 3.2%; p less than 0.0001). Multiple linear regression analysis that isolated confounding variables such as the presence or absence of prenatal care, maternal age and parity, and the use of cigarettes and alcohol did not substantially affect the differences described above. The effect of cigarette smoking on reducing fetal size was cumulative. In conclusion, cocaine is the most commonly used illicit drug among parturients in this community and is strongly associated with underutilization of prenatal care services. Infants of cocaine users are more likely to be preterm and depressed at birth and to have a low birth weight. Cocaine use, through the above-noted effects, increases the need for prenatal care while simultaneously decreasing the likelihood that it will be obtained.

Methicillin-resistant Staphylococcus aureus necrotizing pneumonia arising from an infected episiotomy site.

BACKGROUND: We report a case of methicillin-resistant Staphylococcus aureus (MRSA) sepsis and pneumonia in a postpartum patient. CASE: A 21-year-old gravida 1 para 1 presented on postpartum day 9 with persistent elevated fever, dyspnea, cellulitis of the upper extremities, and an infected episiotomy site. Computed tomography of the chest revealed multiple widely distributed nodules and bilateral infiltrates with central cavitations. Sputum, blood, urine, and episiotomy site cultures grew MRSA, subsequently demonstrated by molecular fingerprinting and antibiotic susceptibility to be community acquired. A magnetic resonance imaging of the pelvis demonstrated pelvic thrombophlebitis. CONCLUSION: Community-acquired MRSA is an emerging problem, which may present as skin and soft tissue infections or sepsis. Seeding from an infected episiotomy site seems to be a potential route of systemic infection. The use of empirical treatment with &bgr;-lactam agents may fail. Appropriate cultures should be obtained and if MRSA is diagnosed, vancomycin should be employed.

Alpha-fetoprotein as a tool to distinguish amniotic fluid from urine, vaginal discharge, and semen.

OBJECTIVE: To estimate whether alpha-fetoprotein (AFP) can be used to distinguish amniotic fluid absorbed in sanitary pads from other similarly absorbed substances (semen, urine, and normal vaginal discharge). METHODS: A prospective cohort study. Urine and amniotic fluid specimens were collected from 52 pregnant women admitted for labor. Semen specimens were collected from 17 men undergoing infertility evaluation. Alpha-fetoprotein concentrations were measured directly from urine, amniotic fluid, and semen and from pads instilled with samples from these specimens. Alpha-fetoprotein concentrations were also measured from pads absorbed with normal vaginal discharge collected from 27 pregnant women. RESULTS: Alpha-fetoprotein levels in amniotic fluid (245.38±21.03 ng/mL, n=52) were significantly higher than those measured in maternal urine (0.84±0.17 ng/mL, n=52, P<.001), or semen (1.52±0.35 ng/mL, n=17, P<.001). The same trend was seen when AFP was extracted from pads: amniotic fluid levels (19.44±1.98 ng/mL, n=52) were significantly higher than those of urine (undetectable, n=52), semen (undetectable, n=17), or normal vaginal discharge (0.53±0.16 ng/mL, n=27, P<.001). Receiver operator characteristic curve analysis demonstrated 96.2% sensitivity and 100% specificity for distinguishing the presence of amniotic fluid from normal vaginal discharge on sanitary pads (cutoff 3.88 ng/mL, area under the curve 0.99). CONCLUSION: When the diagnosis of rupture of membranes is in doubt, AFP levels can assist in differentiating amniotic fluid from other bodily fluids. A method that utilizes sanitary pads and an assay for AFP quantification may be an accurate and convenient way to confirm the diagnosis of rupture of membranes. LEVEL OF EVIDENCE: II

Conservative Management of Cesarean Scar Ectopic Pregnancy with Fetal Heart Activity and a Very High β-hCG

Cesarean scar ectopic pregnancy (CSP) is a rare type of ectopic pregnancy that is growing in incidence. The diagnosis of most CSP occurs when patients present in unstable conditions requiring surgical management and leading sometimes to hysterectomy. It has been shown that medical management is a safe option for early diagnosed hemodynamically stable CSP. However, no cases of CSP with β-hCG higher than 62,000 IU/L, conservatively treated, have been reported. We report the case of a 29-year-old patient who presented for her first prenatal visit at 13-week gestation and was diagnosed with CSP with present fetal heart tones and a quantitative β-hCG of 144,337 IU/L. She was treated with bilateral uterine artery embolization and systemic methotrexate. Her β-hCG significantly decreased and became undetectable within 10 weeks. We propose that patients with CSP with very high β-hCG and fetal heart activity can be offered conservative or fertility preserving management.

Determinants of women's choice of obstetrician/gynecologist

Reportedly more and more women wish to have female medical providers, but whether this extends to their obstetrician/gynecologist remains uncertain. The investigators administered a questionnaire concerning this matter and several demographic characteristics to 537 women from Brooklyn, New York. Both male and female interviewers were used. The women were asked to rate satisfaction with their current gynecological experience using a 10-point Likert scale. The participants had a median age of 38 years and represented a mix of religious affiliations. About two thirds reported using an obstetrician/gynecologist for their care, 15% used another type of physician, and 20% used a midwife. A preference for a woman to provide health care was expressed by 61% of the women, and this did not vary significantly with the interviewers gender or the participants age. More women who currently had a female provider said that they preferred a female. The proportion of women with a female provider who preferred a male was comparable to that of women with male providers who indicated a preference for a female. The gender of the current provider, as related to the stated gender preference, did not influence expressed satisfaction with the current provider. There was no difference in satisfaction with the current provider between women preferring a male provider and those preferring a female. The importance of the providers gender did not relate to age, religious affiliation, or the actual/preferred provider gender mix. Approximately 40% of respondents felt strongly that gender is important. Apart from the providers gender, age, experience, cost, and office location were claimed to be important factors. On multivariate analysis, the only significant and independent predictors of gender preference were having a current female provider and being a Muslim. It seems that for women seeking an obstetrician/gynecologist, gender now is as important a consideration as experience, age, and office location. A slight majority of the women questioned expressed a preference for a female provider, but only a minority feel strongly about this. Women with current male providers are generally as satisfied as those with female providers.

Recurrent Cesarean Scar Ectopic Pregnancy Treated with Systemic Methotrexate

Cesarean scar pregnancy (CSP) is a rare event; however its incidence has been rising due to the increasing rates of cesarean deliveries. The majority of cases present with signs or symptoms requiring surgery, which often results in hysterectomy. The recurrence of CSP is even rarer with only few cases which have been reported. This is a report of recurrent cesarean scar ectopic pregnancy (RCSP) that was promptly diagnosed and managed with only systemic methotrexate. This was a 30-year-old woman, with a history of two prior cesarean deliveries followed by a CSP, who presented at 5 weeks and 3 days of gestation for her first prenatal visit. Transvaginal ultrasound revealed a RCSP. Her serum beta-human chorionic gonadotropin (β-hCG) level was 54,295 IU/L. The first CSP, which was diagnosed at a later stage, was treated with uterine artery embolization and systemic methotrexate leading to complete resolution within 10 weeks. The current ectopic was treated with two doses of systemic methotrexate; her serum β-hCG reached undetectable levels within 7 weeks. Thus, patients with a history of prior CSP should be carefully monitored with transvaginal ultrasound during subsequent pregnancies to allow early diagnosis of RCSP, which could then be treated conservatively.

Carcinoembryonic antigen as a biomarker for meconium-stained amniotic fluid

To assess whether elevated carcinoembryonic antigen (CEA) concentration in amniotic fluid can indicate meconium‐stained amniotic fluid (MSAF).

Obstetric Hemorrhage Current Management and Usefulness of Protocols, Checklist, Drills

Obstetrical hemorrhage continues to be an important contributor to maternal morbidity and mortality in the USA. Although preventable, it is still the 5th leading cause of maternal death, often due to factors associated with a delay in recognition by providers and/or delay in treatment. We cannot overlook the fact that for every maternal death due to hemorrhage, there are at least 100 women who suffer severe morbidity. It is known that implementing hemorrhage-specific protocols can improve outcomes related to this condition. This review will update readers in early detection and preparation, diagnosis, and treatment of obstetric hemorrhage while highlighting the different institution-specific protocols, cognitive aids, and drills.

Can Carcinoembryonic Antigen Serve as an Indicator for Meconium-Stained Amniotic Fluid?

INTRODUCTION: Meconium-stained amniotic fluid occurs in approximately 12% of all pregnancies. Although most pregnancies with meconium-stained amniotic fluid end with no fetal or neonatal complications, there is still a significant number that result in immediate life-threatening complications to the neonate such as meconium aspiration syndrome. Meconium aspiration syndrome still poses a challenge to clinicians and leads to serious morbidity in affected newborns. To date, meconium-stained amniotic fluid is simply detected by the naked eye of the examining health care provider. There is no objective laboratory test or imaging study for the detection of meconium-stained amniotic fluid. The goal of our study was to determine whether carcinoembryonic antigen (CEA) levels can serve as a reliable marker for the detection of meconium-stained amniotic fluid. METHODS: Carcinoembryonic antigen levels were measured quantitatively in amniotic fluid, urine, and serum samples of pregnant women at term in labor with ruptured membranes. RESULTS: Eighty-one amniotic fluid samples were obtained, 45 clear, eight indeterminate, and 28 with visible meconium stain. Those managing the course of labor were blinded to the result of the assay. Carcinoembryonic antigen levels were significantly higher in meconium-stained amniotic fluid compared with clear amniotic fluid (mean [micrograms/mL] of 2,658 compared with 238, respectively; P<.001). The critical concentration of CEA in meconium-stained amniotic fluid was assessed and a cutoff level was determined. Carcinoembryonic antigen levels in urine and serum samples of women with meconium-stained amniotic fluid remained low and similar to those with meconium-free amniotic fluid. CONCLUSIONS: Carcinoembryonic antigen level in amniotic fluid offers a diagnostic modality independent of the clinicians visual estimate. This may be useful in cases when the presence of meconium is in question.