Wendy F. Hansen

Detection of cesarean scars by transvaginal ultrasound

OBJECTIVE: To assess the ability of transvaginal ultrasound to detect cesarean scars and their defects in the nonpregnant state. METHODS: Asymptomatic, parous volunteers underwent transvaginal ultrasound of the cervix, uterus, and adnexa. Uterine measurements, the presence or absence of a cesarean scar, and the presence of a scar defect, defined as fluid within the scar, were recorded. All subjects completed a self‐report questionnaire regarding obstetric history. Sonographers and investigators were blinded to subject history. RESULTS: A total of 70 subjects were enrolled. Of these, 38 women had a prior vaginal delivery and 32 women a prior cesarean delivery. One woman with a bicornuate uterus and three cesarean deliveries was excluded from data analysis. Real‐time transvaginal ultrasound proved 100% sensitive (exact 95% confidence interval [CI] 88.8, 100) and 100% specific (exact 95% CI 90.7, 100). Stored image review had a sensitivity of 87% (exact 95% CI 70.2, 96.4) and a specificity of 100% (exact 95% CI 90.7, 100). Fluid was visualized within the scars of 13 of 31 subjects (42%) with a prior cesarean delivery. All 13 were found among the 23 subjects (56%) who had labored prior to cesarean delivery. Moreover, women with cesarean scar defects had a greater number of cesarean deliveries (P < .04) than women without scar defects. CONCLUSION: Transvaginal ultrasound is highly accurate in detecting cesarean hysterotomy scars. Cesarean scar defect, defined by the presence of fluid within the incision site, was more common when labor preceded cesarean delivery and with multiple cesarean deliveries. (Obstet Gynecol 2003; 101:61‐5.

MATERNAL UNIPARENTAL DISOMY OF CHROMOSOME 2 AND CONFINED PLACENTAL MOSAICISM FOR TRISOMY 2 IN A FETUS WITH INTRAUTERINE GROWTH RESTRICTION, HYPOSPADIAS, AND OLIGOHYDRAMNIOS

We present a case of maternal uniparental heterodisomy for chromosome 2 (UPD 2) detected after trisomy 2 mosaicism was found on placental biopsy. This case presented prenatally with severe intrauterine growth restriction (IUGR) and oligohydramnios. The diploid newborn had hypospadias and features consistent with oligohydramnios sequence. He died shortly after birth of severe pulmonary hypoplasia. The term placenta had high levels of trisomy 2 in both the trophoblast and the stroma. A comparison of this case with others reported in the literature suggests that the IUGR and oligohydramnios are likely related to placental insufficiency due to the high levels of trisomy 2 present in the trophoblast of the term placenta and the presence of UPD 2 in the diploid placental line.

Metoclopramide effect on breastfeeding the preterm infant: a randomized trial.

OBJECTIVE: To investigate the effect of metoclopramide on breast milk volume and duration of breastfeeding in women delivering preterm. METHODS: Women who planned to breastfeed and delivered between 23 and 34 weeks of gestation were eligible to participate in this randomized, double-blind, placebo-controlled study. Women were randomized to receive 10 mg of metoclopramide or placebo 3 times a day for 10 days, starting within 96 hours of birth. Breastfeeding education was standardized for all women. Mothers recorded the volume of breast milk expressed at each pumping for 17 days. Duration of breastfeeding was measured by monthly follow-up phone calls to each subject. RESULTS: Sixty-nine women were enrolled and 57 (82%) women completed the study: 28 in the metoclopramide group and 29 in the placebo group. The 2 groups were similar in age, education, ethnicity, gestational age, and marital status. There was no significant difference between breast milk volumes in the metoclopramide and placebo groups at each of the 17 days of the study (P = .26 to .98; test for mean metoclopramide effect P = .80). There was no significant difference between groups in duration of breastfeeding, with a median of 8.8 weeks, an interquartile range of 3.4 to 12.0 weeks for the metoclopramide group and a median of 8.6 weeks, and an interquartile range of 5.6 to 16.9 weeks for the placebo group (P = .09). CONCLUSION: Metoclopramide did not improve breast milk volume or duration of breastfeeding in this population of women. Regardless of therapy received, breastfeeding duration in this study of preterm mothers was poor. LEVEL OF EVIDENCE: I

Transcranial Doppler findings of cerebral vasospasm in preeclampsia.

The objective of this study was to evaluate the effect of preeclampsia and its severity on maternal mean middle cerebral artery blood flow velocity (mean MCA-CBFV) using transcranial doppler sonography (TCD), as well as the effect of magnesium on mean MCA-CBFV in preeclampsia. This study used a prospective, comparative design. TCD was used to examine maternal mean MCA-CBFV in both healthy subjects (controls) and preeclamptic subjects (cases). The two groups were similar in age, gestational age, and parity. Healthy subjects were categorized into three groups: Group I, 6-14 weeks, n = 10; Group II, 24-40 weeks, n = 27; Group III, postpartum n = 15, 12-36 h. Serial TCD examinations of the middle cerebral artery were completed in 21 preeclamptic subjects at four different points in time: Time I is an initial measurement before delivery; Time 2 is also before delivery but after magnesium had been administered. Time 3 is postpartum while on magnesium (12-24 h), Time 4 is postpartum off magnesium, (24-48 h). Preeclamptic subjects had significantly increased mean MCA-CBFV when compared to healthy subjects: antepartum (mean 78.2 vs. 55.1 cm/sec, P < 0.0005); postpartum (mean 101.3 vs. 69.8 cm/sec, P < 0.0001). Severe preeclamptics had significantly higher mean MCA-CBFV than mild preeclamptics at each point in time: Time 1: P < 0.016; Time 2: P < 0.040; Time 3: P < 0.002; and Time 4: P < 0.028. These data support the theory that cerebral vasospasm of the smaller diameter vessels is a major component of preeclampsia.

Leukemia in pregnancy and fetal response to multiagent chemotherapy

Background Leukemia is rare in pregnancy and treatment with intensive, multiagent chemotherapy produces complete remission in most adults, but might have deleterious effects on fetuses. Case A 24-year-old gravida 3 para 2 presented at 24 weeks with pruritus, rash, pancytopenia, and hepatitis. A bone marrow biopsy found acute lymphocytic leukemia. She completed three cycles of intensive multiagent chemotherapy with transient oligohydramnios in each cycle. Although there was decreased fetal growth rate, umbilical artery Doppler scans were normal. She delivered a normal 2150-g male infant at 36 weeks. Conclusion Pregnant women with newly diagnosed leukemia should not delay treatment, but multiagent chemotherapy might have transient effects on fetuses, most notably oligohydramnios. However, if fetal testing is normal, delivery might not be indicated.

SAFE PRESCRIBING PRACTICES IN PREGNANCY AND LACTATION

Abstract Midwives and other health care providers face a dilemma when a pregnant woman develops a condition that usually is treated with a pharmacologic agent. Understanding of basic teratology associated with drugs as well as the FDA categorization of agents can assist professionals in recognizing which pharmaceuticals should be used or avoided. In addition to reviewing teratology, this article addresses the use of common drugs for the treatment of upper respiratory conditions, minor pain, gastrointestinal problems, psychiatric illnesses, and neurologic disorders. In each category, current evidence is presented pertaining to which agents should be recommended for pregnant women.

Pharmacologic therapy for medical disorders during pregnancy.

Introduction Pregnant women present with the same disorders and diseases as other patients. Consequently, the physician often has to prescribe drugs for medical conditions or is faced with a woman already on a medication who coincidentally learns she is pregnant. A few key principles should be kept in mind. First the clinician should ask, “What would I do if she weren’t pregnant?” The answer to this question is most often the correct choice for the pregnant woman as well. If several choices are available, then the relative safety of each drug for the mother and fetus should be compared. This article will focus on several of the common medical problems encountered during pregnancy including asthma, gastrointestinal disorders, psychiatric problems, common viral infections, seizures, and need for anticoagulation. In approaching the pregnant patient with a medical disorder, two concepts must be dealt with: the potential teratogenic effect and the pharmacokinetic alterations associated with pregnancy.

Extreme morbid obesity and labor outcome in nulliparous women at term.

We examined the prevalence of cesarean delivery (CD) among women with morbid obesity and extreme morbid obesity. Using Kentucky birth certificate data, a cross-sectional analysis of nulliparous singleton gestations at term was performed. We examined the prevalence of CD by body mass index (BMI; in kg/m2) using the National Institutes of Health/World Health Organization schema and a modified schema that separates extreme morbid obesity (BMI ≥ 50) from morbid obesity (BMI ≥ 40 to < 50). Bivariate and multivariate analyses were performed. Multivariate modeling controlled for maternal age, estimated gestational age, birth weight, diabetes, and hypertensive disorders. Overall, 83,278 deliveries were analyzed. CD was most common among women with a prepregnancy BMI ≥ 50 (56.1%, 95% confidence interval 50.9 to 61.4%). Extreme morbid obesity was most strongly associated with CD (adjusted odds ratio 4.99, 95% confidence interval 4.00 to 6.22). Labor augmentation decreased the likelihood of CD among women with extreme morbid obesity, but this failed to reach statistical significance. We speculate a qualitative or quantitative deficiency in the hormonal regulation of labor exists in the morbidly obese parturient. More research is needed to better understand the influence of morbid obesity on labor.

Prenatal diagnosis of Apert syndrome

Objective: The role of the human fibroblast growth factor receptor (FGFR) gene family in current prenatal diagnosis and management of craniosynostosis syndromes and skeletal dysplasias is discussed. Method: We present the antenatal ultrasound findings, diagnosis, and management of 2 cases of Apert syndrome before and after molecular prenatal diagnosis was available. Results and Conclusion: Discovery of mutations in FGFR genes now allows the definitive antenatal diagnosis of Apert syndrome, other craniosynostosis syndromes, and skeletal dysplasias.

Headache and neurological disease in pregnancy.

A review of the approach in pregnancy to a very commonly encountered neurological disorder (headache), along with less commonly encountered neurological entities that none the less deserve the obstetricians attention. Definitions of specific disorders and differential diagnoses are reviewed, along with treatment options and pregnancy-associated morbidities. Headache is reviewed first including the common primary headaches migraine and tension-type headache. The disabling neurological disorders-multiple sclerosis, cerebral palsy, and spinal cord injury are grouped due to common morbidities affecting pregnancy. Finally, Bell palsy is also reviewed.