Val A. Catanzarite

Vasa previa: the impact of prenatal diagnosis on outcomes.

OBJECTIVE: To evaluate outcomes and predictors of neonatal survival in pregnancies complicated by vasa previa and to compare outcomes in prenatally diagnosed cases of vasa previa with those not diagnosed prenatally. METHODS: We performed a multicenter study of 155 pregnancies complicated by vasa previa. Cases were obtained from the Vasa Previa Foundation and 6 large hospitals. Comparisons were made between groups based on prenatal diagnosis status and neonatal survival. RESULTS: The overall perinatal mortality was 36% (55 of 155). In 61 cases (39%), vasa previa was diagnosed prenatally; 59 of 61 (97%) infants from these pregnancies survived compared with 41 of 94 (44%) in cases not diagnosed prenatally (P < .001). Median 1- and 5-minute Apgar scores in cases diagnosed prenatally were 8 and 9, respectively, compared with 1 and 4 among survivors in cases not diagnosed prenatally (P < .001). More than half (24 of 41) of surviving neonates born to women without prenatal diagnosis required blood transfusions compared with 2 of 59 diagnosed prenatally (P < .001). Multivariable logistic regression analysis showed that the only significant predictors of neonatal survival were prenatal diagnosis (P < .001) and gestational age at delivery (P = .01). CONCLUSIONS: Good outcomes with vasa previa depend primarily on prenatal diagnosis and cesarean delivery at 35 weeks of gestation or earlier should rupture of membranes, labor, or significant bleeding occur. LEVEL OF EVIDENCE: II-3

Acute respiratory distress syndrome in pregnancy and the puerperium: causes, courses, and outcomes.

Objective To describe causes, courses, complications, and outcomes of patients with pregnancy-associated acute respiratory distress syndrome (RDS). Methods Twenty-eight women with ARDS during pregnancy or within a week postpartum formed the study population. Eight cases had been reported previously. Charts were abstracted for maternal demographics, etiology, and treatment of acute RDS, and maternal outcomes. For antepartum acute RDS, newborn charts were also reviewed. Results The incidence of acute RDS, excluding maternal transports, was one per 6277 deliveries or 0.016% (95% confidence interval [CI] 0, 0.027%). Leading causes were infection (12 cases), preeclampsia or eclampsia (seven cases), and aspiration (three cases). Eleven mothers died, a maternal mortality rate of 39.3% (CI 21.5%, 59.4%). Six of eight women who were ventilated for over 14 days survived. Nine of the acute RDS cases might have been preventable. Ten mothers with living fetuses were ventilated during the third trimester; nine delivered within 4 days. Among six infants delivered because of fetal heart rate abnormalities, one died and at least three had evidence of asphyxia. Conclusions Acute RDS occurs more frequently in pregnancy than the 1.5 cases per 100,000 per year reported for the general population. Prolonged ventilator support is warranted. The high rate of perinatal asphyxia in infants who have fetal heart rate abnormalities supports a strategy of expeditious delivery during the third trimester.

External cephalic version: predictors of success.

OBJECTIVEnTo evaluate predictive variables for successful external cephalic version.nnnMETHODSnDuring 1987-1996, 128 women had external cephalic version attempts. Uterine tone, fetal spine position, breech location, breech type, gestational age, placental location, parity, maternal weight, amniotic fluid index, and estimated fetal weight were evaluated as predictors of success.nnnRESULTSnSeventy-eight (64%) women were successfully converted from breech to vertex presentation. All subjects with low uterine tone had successful version. In women with high uterine tone, the combination of anterior or lateral fetal spine, noncornual placental location, and breech location out of the pelvis predicted success. Other independent variables associated with successful version included non-frank breech presentation, gestational age under 38 weeks, and parity of at least 1.nnnCONCLUSIONnUterine tone may be the most important predictor of success when selecting candidates for external cephalic version.

Adult Respiratory Distress Syndrome in Pregnancy: Report of Three Cases and Review of the Literature

Adult respiratory distress syndrome (ARDS) is rarely encountered in association with pregnancy, but with the decline in other causes of maternal death, is an increasingly important cause of mortality in obstetric patients. ARDS may result from a variety of different types of pulmonary injury; uniquely obstetric causes include preeclampsia, amnionitis-endometritis, obstetric hemorrhage, and tocolytic therapy. Crucial management issues include support of maternal oxygenation and cardiac output, myriad interactions between the pulmonary process and its treatment, with maternal and fetal physiology, and decision making regarding delivery. Our review of the literature suggests that, for the patient requiring antepartum intubation for ARDS, except at a very early gestational age or when pyelonephritis or varicella pneumonia is a cause of respiratory compromise, delivery will likely be required for maternal and/or fetal indications, and an early decision for delivery may be beneficial. Postpartum management is similar to treatment of the nonpregnant patient with ARDS, with aggressive attention to potential surgically correctable causes for infection. Maternal mortality rates are affected little by duration of intubation, and therefore prolonged mechanical ventilation is justified and appropriate for mothers with ARDS.

RESPIRATORY FAILURE IN PREGNANCY

Respiratory failure in pregnancy and post partum fortunately is seldom encountered but carries profound implications for survival and health of both mother and fetus/neonate. In the general population, respiratory failure, often initiated by extrapulmonary disease processes, has emerged as a leading cause of death as mortality from many other diseases has been reduced. The same is true for obstetrics. When respiratory failure occurs after delivery, therapeutic considerations are similar to those for the nonpregnant patient, although causes unique to pregnancy may impact treatment. When respiratory failure occurs during pregnancy, there is potential for dual tragedy. Fetal well being depends on maternal oxygenation, cardiac output, and uteroplacental perfusion. When a maternal condition causes critical deterioration in oxygenation, interventions that improve the maternal condition may adversely impact the fetus. Risk/benefit considerations regarding delivery timing arise and the ability to assess fetal health in utero is often hampered by maternal medical therapies. In this article, pregnancy-related changes in respiratory function, the physiology of oxygen delivery to the fetus, and available methods for assessing fetal health are reviewed. Extrapulmonary and pulmonary causes of respiratory failure and their treatments in pregnancy and post partum also are discussed.