Sreedhar Gaddipati

Morbidity and mortality of peripartum hysterectomy.

OBJECTIVE: To perform a population-based analysis to examine the morbidity and mortality of peripartum hysterectomy in comparison with nonobstetric hysterectomy. METHODS: Data from the Nationwide Inpatient Sample were used to compare peripartum and nonobstetric hysterectomy in women younger than 50 years of age. Intraoperative, perioperative, and postoperative medical complications were examined. The outcomes of peripartum and nonobstetric hysterectomy were compared using chi square. Odds ratios were calculated using multivariable logistic regression models for each individual complication. RESULTS: A total of 4,967 women who underwent peripartum hysterectomy and 578,179 patients who had a nonobstetric hysterectomy were identified. Bladder (9% compared with 1%) and ureteral (0.7% compared with 0.1%) injuries were more common for peripartum hysterectomy (P<.001). There were no differences in the rates of intestinal or vascular injuries between peripartum and nonobstetric hysterectomy. Rates of reoperation (4% compared with 0.5%), postoperative hemorrhage (5% compared with 2%), wound complications (10% compared with 3%), and venous thromboembolism (1% compared with 0.7%) were all higher in women who underwent peripartum hysterectomy. In multivariable analysis, the odds ratio for death for peripartum compared to nonobstetric hysterectomy was 14.4 (95% confidence interval 9.84–20.98). CONCLUSION: Peripartum hysterectomy is accompanied by substantial morbidity and mortality. Compared with nonobstetric hysterectomy, the procedure is associated with increased rates of both intraoperative and postoperative complications. The mortality of peripartum hysterectomy is more than 25 times that of hysterectomy performed outside of pregnancy. LEVEL OF EVIDENCE: II

Lopinavir exposure with an increased dose during pregnancy.

Background:Use of standard adult lopinavir/ritonavir (LPV/RTV) dosing (400/100 mg) during the third trimester of pregnancy results in reduced LPV exposure. The goal of this study was to determine LPV exposure during the third trimester of pregnancy and 2 weeks postpartum with a higher LPV/RTV dose. Methods:The Pediatric AIDS Clinical Trials Group Protocol 1026s is an ongoing, prospective, nonblinded study of antiretroviral pharmacokinetics in HIV-infected pregnant women that included a cohort receiving LPV/RTV 400/100 mg twice daily during the second trimester and 533/133 mg twice daily during the third trimester through 2 weeks postpartum. Intensive steady state 12-hour pharmacokinetic profiles were performed during the third trimester and at 2 weeks postpartum and were optional during the second trimester. LPV and RTV were measured by reverse-phase high-performance liquid chromatography with a detection limit of 0.09 μg/mL. Results:Twenty-six HIV-infected pregnant women were studied. Median LPV area under the plasma concentration-time curve (AUCs) for the second trimester, third trimester, and postpartum were 57, 88, and 152 μg·h−1·mL−1, respectively. Median minimum LPV concentrations were 1.9, 4.1, and 8.3 μg/mL. Conclusions:The higher LPV/RTV dose (533/133 mg) provided LPV exposure during the third trimester similar to the median AUC (80 μg·h−1·mL−1) in nonpregnant adults taking standard doses. However, the AUC on this increased dose at 2 weeks postpartum was considerably higher. These data suggest that the higher LPV/RTV dose should be used in third trimester pregnant women; that it should be considered in second trimester pregnant women, especially those who are protease inhibitor experienced; and that postpartum LPV/RTV dosing can be reduced to standard dosing by 2 weeks after delivery.

Trauma in Pregnancy: A Systematic Approach

Trauma in pregnancy remains one of the major contributors to maternal and fetal morbidity and mortality. Potential complications include maternal injury or death, shock, internal hemorrhage, intrauterine fetal demise, direct fetal injury, abruptio placentae, and uterine rupture. The leading causes of obstetric trauma are motor vehicle accidents, falls, assaults, and gunshots, and ensuing injuries are classified as blunt abdominal trauma, pelvic fractures, or penetrating trauma. Many of the assessment and management aspects of obstetric trauma are unique to pregnancy, although initial evaluation and resuscitation should always be maternally directed. Once maternal stability is established, vigilant evaluation of fetal well-being becomes warranted. Continuous fetal heart monitoring, ultrasonography, computed tomography, open peritoneal lavage, and/or exploratory laparotomy may be indicated in a case of obstetric trauma. In view of the significant impact of trauma on the pregnant woman and her fetus, preventive strategies are paramount.

Regionalization of care for obstetric hemorrhage and its effect on maternal mortality.

OBJECTIVE: To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality. METHODS: We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios. RESULTS: Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10–0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47–0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34–0.83). CONCLUSION: Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings. LEVEL OF EVIDENCE: II

Predictors of massive blood loss in women with placenta accreta

OBJECTIVE We examined predictors of massive blood loss for women with placenta accreta who had undergone hysterectomy. STUDY DESIGN A retrospective review of women who underwent peripartum hysterectomy for pathologically confirmed placenta accreta was performed. Characteristics that are associated with massive blood loss (≥ 5000 mL) and large-volume transfusion (≥ 10 units packed red cells) were examined. RESULTS A total of 77 patients were identified. The median blood loss was 3000 mL, with a median of 5 units of red cells transfused. There was no association among maternal age, gravidity, number of previous deliveries, number of previous cesarean deliveries, degree of placental invasion, or antenatal bleeding and massive blood loss or large-volume transfusion (P > .05). Among women with a known diagnosis of placenta accreta, 41.7% had an estimated blood loss of ≥ 5000 mL, compared with 12.0% of those who did not receive the diagnosis antenatally with ultrasound scanning (P = .01). CONCLUSION There are few reliable predictors of massive blood loss in women with placenta accreta.

Minimally invasive management of an advanced abdominal pregnancy.

BACKGROUND: Advanced abdominal pregnancy is a rare, life-threatening condition that presents a number of challenges. CASE: A 29-year-old primigravida with 10 years of secondary infertility and a previous tuboplasty had a 21-week abdominal pregnancy treated with preoperative arterial embolization before laparoscopically assisted fetal delivery. Postoperatively, 4 cycles of methotrexate were administered at 50 mg/m2 intramuscularly every 3 weeks for the retained abdominal placenta. Subsequent spontaneous conception occurred, and a live, full-term infant was delivered by cesarean delivery 17 months later. No adverse sequelae were found during long-term follow-up. CONCLUSION: This report demonstrates successful minimally invasive management of an advanced abdominal pregnancy with a multimodal approach that included preoperative arterial embolization, laparoscopically assisted delivery, and judicious use of postoperative methotrexate.

Pregnancy in a persistent vegetative state: case report, comparison to brain death, and review of the literature.

Severe maternal neurologic injury during pregnancy has the potential for fetal demise without advanced critical care support to the mother. Brain death is the unequivocal and irreversible loss of total brain function, whereas patients in a vegetative state, by contrast, have preserved brain stem function but lack cerebral function. They can appear to be awake, have sleep–wake cycles, be capable of swallowing, and have normal respiratory control, but there are no purposeful interactions. These conditions have different maternal prognoses, but both have resulted in near-normal neonatal outcomes with long latencies from maternal injury to delivery in previously published cases. This article compares and contrasts the 11 cases of brain death with 15 cases of persistent vegetative state in pregnancy. We found that the mean latency between maternal brain injury and delivery was significantly shorter in the brain-dead patients as compared with those in a vegetative state (46 days vs. 124 days, P ≤.001). Correspondingly, the gestational ages at delivery (29.7 weeks vs. 33.2 weeks, P ≤.01) and the birth weights (1380 g vs. 2145 g, P ≤.01) were shorter in duration and smaller in size in the brain-dead group. We also present a case of persistent vegetative state in pregnancy at our institution with both maternal and neonatal death in the context of previously published literature with a focus on obstetric and ethical management. We hope this information will help elucidate the issues for providers confronted with these unique and challenging cases. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to state the difference between coma, persistent vegetative state and brain death, to describe the neurologic aspects of a patient in a persistent vegetative state, and to list the fetal effects of maternal brain injury.

Practice patterns and knowledge of obstetricians and gynecologists regarding placenta accreta

Abstract Objective: We surveyed obstetricians to determine their knowledge, patterns of care and treatment preferences for women with placenta accreta. Methods: A 27-item survey was mailed to fellows of the American College of Obstetricians and Gynecologists. The survey included demographics, questions regarding knowledge and items to examine practice patterns. Results: Among 994 surveyed practitioners 508 responded including 338 who practiced obstetrics. Among generalists, 23.8% of respondents referred patients with placenta accreta to a sub-specialist. Overall, 20.4% referred women to the nearest tertiary center, and 7.1% referred to a regional center. Delivery was recommended at 34–36 weeks by 41.2%. Adjuvant interventions including ureteral stents (26.3%), iliac artery embolization catheters (28.1%), and balloon occlusion catheters (20.1%) were used infrequently. Six or more units of blood were crossed for delivery by only 29.0% of practitioners. Conclusion: There is widespread variation in the care of women with or at risk for placenta accreta.

Correlation of transthoracic echocardiography and right heart catheterization in pregnancy.

Abstract Objectives: To correlate estimated pulmonary artery pressures (PAP) by echocardiography with right heart catheterization (RHC) measurements and to correlate estimated left ventricular ejection fraction (EF) by echocardiography with cardiac output (CO) measurements by RHC. Study design: All women who had echocardiography at a single institution during a 6-year period and underwent RHC during pregnancy were included. Echocardiography estimates of right ventricular systolic pressure (RVSP) and EF were correlated with measured RHC PAP and CO, respectively. Results: Eighteen patients underwent 21 RHCs, 10 antepartum at the catheterization laboratory and the remaining 11 intrapartum, performed with the use of a pulmonary artery catheter placed prior to the onset or induction of labor. Correlation between RVSP and PAP was good (rho=0.79, P<0.0001); nonetheless, in 30% of cases RHC eliminated the concern for pulmonary hypertension (PHTN). There was minimal correlation between EF and CO. Conclusion: Despite good statistical correlation between echocardiography and RHC for determining pulmonary artery pressure, RHC should be considered for major decisions such as pregnancy interruption or preterm delivery given the proportion of cases where concern for PHTN was excluded by RHC. EF provides a poor proxy for CO.

A systematic, multidisciplinary approach to address the reproductive needs of HIV- seropositive women

Nearly 130,000 American women are human immunodeficiency virus (HIV) seropositive. The present study sought to establish a comprehensive programme to address their fertility needs in order to minimize infectious, medical and reproductive risks to prospective patients. Forty women, aged 27-42 years, were evaluated. HIV was diagnosed 7.2 +/- 0.7 years prior to their seeking care, and most women (n = 38) were on highly active antiretroviral therapy. Their prenatal CD4 counts were 712.2 +/- 56 cells/mm(3) (range 327-1881) and HIV-1 concentrations were undetectable in all cases prior to initiating treatment. HIV-seropositive women were statistically identical to their age-matched HIV-seronegative counterparts with respect to the IVF clinical outcome parameters measured. Throughout the pregnancies, maternal HIV-1 RNA concentrations remained undetectable and CD4 counts were stable. All infants, tested at birth and at 3 and 6 months of age, remained HIV negative. This is the first report of an institutional paradigm in the USA dedicated to evaluate and treat HIV-seropositive women. Using a multidisciplinary approach to care, HIV-seropositive women may be successfully managed in a programme of assisted reproduction.