Tamera Hatfield

Magnetic resonance imaging demonstrates long-term changes in brain structure in children born preterm and exposed to chorioamnionitis

OBJECTIVE We sought to determine if children born preterm and exposed to chorioamnionitis have differences in brain structure measured at 6-10 years of age using magnetic resonance imaging (MRI). STUDY DESIGN Structural MRI was performed with 11 preterm children (8.5 ± 1.7 years) with chorioamnionitis and 16 preterm children (8.7 ± 1.4 years) without chorioamnionitis. Cortical surface reconstruction and volumetric segmentation were performed with FreeSurfer image analysis software. Subcortical structures were analyzed using multivariate analysis. RESULTS Widespread regional differences in cortical thickness were observed. With chorioamnionitis, the frontal and temporal lobes were primarily affected by decreased cortical thickness, and the limbic, parietal, and occipital lobes were primarily affected by increased cortical thickness when compared to the comparison group. Subcortical differences were observed in the hippocampus and lateral ventricle. CONCLUSION Using MRI, chorioamnionitis is associated with longterm widespread regional effects on brain development in children born prematurely. Our study is limited by its small sample size.

Limitations of the fetal anatomic survey via ultrasound in the obese obstetrical population

Objective: To evaluate limitations of the fetal anatomic survey in obese women. Methods: Retrospective cohort study of obese gravidas with singleton gestations who had at least one, sonographic fetal evaluation at ≥14 weeks between January 2009 and March 2011. The impact of pre-pregnancy body mass index (BMI), placental location, prior cesarean scar and sonographer experience on ability to achieve an adequate ultrasound was evaluated using multilevel modeling. Ability to visualize specific fetal parts by BMI class and gestational age was also evaluated. Results: There were 245 obese women (42% with class III obesity). Senior faculty (>20 years experience) were more likely to achieve adequate visualization (adjusted odds ratio [aOR] 3.27; 95% confidence interval [CI] 1.15–9.25) compared with junior faculty. Among women with BMI > 40.0, odds of inadequate views of the face and spine were 10.0 (95% CI 1.31–76.0) and 5.17 (95% CI 0.65–40.8), when compared with women with a BMI = 30–34.9. Odds for inadequate views of sex (OR 3.83; 95% CI 0.86–17.1) and extremities (OR 4.37; 95% CI 0.99–19.4) were similarly increased with a BMI ≥ 40. The optimal gestational age for a complete anatomic survey was 22–24 weeks (93% completion rate), with an OR of 41.3 (95% CI 7.89–215.8), compared with a survey at 14–16 weeks. Conclusions: Attending sonographer experience is associated with improved visualization of fetal anatomy among obese gravidas. Face, spine, sex and extremity views are particularly difficult in the highest BMI category.

Necrotizing pancreatitis associated with severe preeclampsia.

BACKGROUND: Necrotizing pancreatitis is rare in pregnancy and usually is associated with symptomatic cholelithiasis. We present a case of fatal necrotizing pancreatitis in a patient with severe preeclampsia. CASE: A 25-year old primigravid woman at 35 weeks of gestation presented with decreased fetal movement, pruritus, and malaise. Intrauterine fetal demise was diagnosed in the context of severe thrombocytopenia, hypertension, proteinuria, hemolysis, elevated transaminases, and renal failure. Postpartum, the patient developed metabolic acidosis, hyperglycemia, and hypoxemia followed by cardiopulmonary arrest and death. Autopsy revealed extensive acute pancreatic necrosis, pleural effusions, ascites, and fatty liver without evidence of microthrombi. The cause of death was acute necrotizing pancreatitis resulting from severe preeclampsia. CONCLUSION: Severe preeclampsia may cause widespread end-organ damage and may affect the gastrointestinal system, resulting in fatal necrotizing pancreatitis.

Murine typhus in a pregnant woman.

BACKGROUND: Murine typhus is a flea-borne disease caused by Rickettsia typhi. Although uncommon in most of the United States, it is endemic in Southern California. Most cases are unrecognized given its nonspecific viral symptoms and rare complications. CASE: A pregnant patient presented with complaints of fever and chills. Physical examination was benign. Laboratory abnormalities included elevated transaminases, proteinuria, and thrombocytopenia. The patient gave a history of exposure to cats and opossums in an area endemic for murine typhus. After empiric treatment with azithromycin, her clinical symptoms and laboratory abnormalities promptly improved. Serologies confirmed acute infection with R. typhi. CONCLUSION: Although the signs and symptoms of murine typhus can mimic other pregnancy-related complications, a high index of suspicion in endemic areas can lead to the correct diagnosis and prompt treatment.

Synchronous autotransfusion during cesarean hysterectomy.

Placenta accreta is associated with major morbidities including massive hemorrhage. We report a cesarean hysterectomy for placenta accreta with synchronous autotransfusion using a standard cardiopulmonary bypass machine. This technique requires complete intraoperative heparinization yet has the advantage of autotransfusion of autologous clotting factors and platelets in addition to red blood cells.

The use of ultrasound to detect small-for-gestational-age infants in patients with elevated human chorionic gonadotropin on maternal serum screening.

We evaluated serial sonography for the antenatal detection of small-for-gestational-age (SGA) infants in pregnancies with elevated human chorionic gonadotropin (hCG) levels on midtrimester triple-marker screen. A retrospective cohort study was performed at Saddleback Memorial Medical Center where serial ultrasounds from 26 weeks to delivery are generally recommended for patients with hCG levels >2.0 Multiple of the Median (MoM). From 1999 to 2007, 659 subjects were identified for analysis. The incidence of intrauterine growth restriction (IUGR) and SGA were 5.2% and 7.3%, respectively. Antenatal ultrasound identified 31.3% of SGA infants. Compared with estimated fetal weight (EFW) <10th percentile alone, abdominal circumference (AC) <10th percentile improved the detection of SGA from 31.3% (95% confidence interval [CI], 18.7 to 46.3) to 35.4% (95% CI, 22.2 to 50.5). Using either EFW or AC further increased the sensitivity to 45.8% (95% CI, 31.4 to 60.8). The sensitivity for the detection of SGA was 100% when an EFW cutoff of 75% was used. Ultrasound can be used to detect SGA infants in patients with elevated hCG levels on midtrimester serum screening. A sonographic estimated fetal weight > or = 75th percentile appears to be a safe cutoff to rule out all fetuses at risk for SGA.

Successful pregnancy after aortic stent-graft in a patient with middle aortic syndrome

A 32-year-old multigravida woman had 3 pregnancies complicated by hypertensive disease, requiring iatrogenic preterm delivery. Middle aortic syndrome was diagnosed when uncontrolled hypertension persisted postpartum, and was treated with aortic stent-graft placement. A pregnancy subsequent to the endovascular repair was uneventful, culminating in repeated cesarean section at term.