William E. Scorza

Obstetric admissions to the intensive care unit: outcomes and severity of illness.

OBJECTIVE To determine whether mortality prediction based on a current model of outcome prediction is accurate in obstetric patients. METHODS Consecutive obstetric admissions to a medical intensive care unit from 1991 to 1998 were reviewed to determine whether mortality prediction is feasible in obstetric patients based on a widely used model. The Simplified Acute Physiologic Score (SAPS II) was used to predict the probability of hospital mortality. RESULTS The Simplified Acute Physiologic Score overestimated mortality in all patients (19 predicted deaths, eight observed) but accurately predicted mortality in patients admitted to the intensive care unit for medical reasons (seven predicted, five observed). The Simplified Acute Physiologic Score did not predict mortality in patients admitted for obstetric indications or postpartum hemorrhage. Median SAPS II scores were significantly higher in those patients who died, compared with survivors. For all groups, SAPS II scores were correlated with intensive care unit length of stay but not hospital length of stay. CONCLUSION The Simplified Acute Physiologic Score accurately predicts hospital mortality in obstetric patients admitted to the intensive care unit for medical reasons but not for indications related to pregnancy and delivery. An alternate model that predicts outcomes in obstetric patients admitted for obstetric indications should be developed.

The Impact of Prenatal Care on Preterm Births Among Twin Gestations in the United States, 1989-2000

OBJECTIVE The purpose of this study was to determine the association between prenatal care and preterm births among twin gestations in the presence and absence of high-risk pregnancy conditions. STUDY DESIGN Twin birth data in the United States were used to determine the association between preterm birth and prenatal care with the use of logistic regression. RESULTS Of the 779,387 twin births, 54.7% twin births were delivered preterm. The rate was higher among black women than among white women in the presence (57.0% vs 51.2%, respectively) and absence (70.3% vs 61.6%, respectively) of prenatal care. The absence of prenatal care increased the relative risk for preterm birth by 1.24-fold among black women and by 1.22-fold among white women. Lack of prenatal care was associated with increased preterm birth rates in the presence of most high-risk conditions. CONCLUSION Prenatal care is associated with fewer twin preterm births in the presence and absence of high-risk conditions. Increased prenatal care participation may help decrease preterm birth rates and also narrow the black-white twin preterm birth disparity.

A clinicohistopathologic comparison between HELLP syndrome and severe preeclampsia.

OBJECTIVE To determine whether differences in the clinical entities of HELLP syndrome and severe preeclampsia are associated with different placental lesions. STUDY DESIGN This was a case control study of singleton pregnancies with HELLP syndrome or severe preeclampsia. Archived pathology slides were retrieved and reviewed. Clinical and histopathological features were compared between the two groups. RESULTS There were 31 women with HELLP syndrome and 56 with severe preeclampsia. HELLP syndrome was associated with epigastric pain and higher levels of LDH, bilirubin, liver enzymes and fibrin degradation products. Hemoglobin, hematocrit and platelet counts were lower. Abruption lesions of the placenta were less common with HELLP syndrome (Odds Ratio 0.1 95% Confidence Interval 0.01,0.8). None of the other 22 placental features examined were different between the two conditions. CONCLUSION The significant overlap between HELLP syndrome and severe preeclampsia for both clinical and placental features suggests that the two conditions represent a spectrum of essentially the same pathophysiologic process.

Atrial fibrillation in pregnancy associated with oral terbutaline

BACKGROUND Terbutaline has direct effects on the cardiac conduction system, but when used to treat preterm labor it is rarely associated with clinically significant cardiac arrhythmias. Commonly used drug references did not list atrial fibrillation as a complication of terbutaline, and our literature search found only one case of atrial fibrillation that occurred with parenteral administration. CASE A 30-year-old gravida 1 carrying a twin gestation at 35 weeks was taking 2.5 mg oral terbutaline four times daily for premature labor. She developed atrial fibrillation and was ultimately treated by chemical cardioversion with procainamide to restore normal sinus rhythm. CONCLUSION This is the first report of atrial fibrillation during pregnancy associated with oral terbutaline. Atrial fibrillation should be added as a complication of oral terbutaline therapy.

PRENATAL SONOGRAPHIC DIAGNOSIS OF MID SHAFT HYPOSPADIAS

We report the prenatal diagnosis of mid shaft hypospadias and describe the sonographic features of fetal hypospadias including an abnormal urethral canal, ventral curvature of the distal penis, extension of the penile glans beyond the prepuce, and fetal micturation in a plane perpendicular to the penile shaft. An accurate family history is an essential part of the evaluation of the milder degrees of fetal hypospadias.

Recurrent uterine rupture after abdominal pregnancy.

Uterine rupture can occur at any time throughout gestation. We present a woman with a previous Cesarean section followed by an abdominal pregnancy. In her next pregnancy, complete uterine rupture resulted in an emergency laparotomy. This case is unique in that it gives insight into the variable presentations of uterine rupture and the risks associated with prior Cesarean sections.

Second-trimester cervical pregnancy presenting as a failed labor induction

A 44-year-old woman, gravida 4, para 0–0–3–0, presented at 19 weeks’ gestation with cervical dilatation without contractions or vaginal bleeding. The cervix was dilated 4 cm and 100% effaced, with fetal parts palpable at the external os. Abdominal ultrasound confirmed a viable cephalic gestation without fetal anomalies, no evidence of abruption, and a normal volume of amniotic fluid (AF). Amniocentesis findings were consistent with intra-amniotic infection. Labor induction and triple antibiotics were given. Despite 24 hours of oxytocin, followed by prostaglandin E2 vaginal suppositories, 20 mg every 4 hours 3 24 hours, there were no regular uterine contractions. Repeat ultrasound showed markedly decreased AF volume consistent with possible membrane rupture, a fundal placenta, and a fundal “mass” that was interpreted as a uterine contraction after partial placental separation. Prostaglandin E1 vaginal suppositories, 200 mcg every 6 hours 3 24 hours followed. With no labor, on hospital day 4, the previous ultrasounds were reviewed and believed to be compatible with an empty uterine fundus and, on sagittal imaging, anterior bulging of the cervicoisthmic region, consistent with cervical ectopic pregnancy. During laparotomy, the cervix was markedly distended, elongated, and extremely soft and friable. With the use of noncrushing Glassman intestinal clamps to develop pedicles, a hysterectomy was done with a 3000-mL estimated blood loss. On pathologic examination, the placenta was adherent to the upper cervix and lower uterine segment with an extensive accreta and acute chorioamnionitis. After resolution of an ileus, the woman was discharged on postoperative day 7.

The bloodless blood knot.

Just as it is difficult to describe adequately the exhilaration one feels when using a fly rod to land a trout caught from a mountain stream, there is also a tremendous amount of satisfaction in the successful completion of an obstetric operation. Until recently, we were woefully ignorant of how fly fishing expertise could benefit pregnancy. We report with great pride an instance in which fly fishing knot skill was essential to successful placement of a cervical cerclage for a woman with an incompetent cervix.