Emergency C-section Research Articles

Variation in Breastfeeding Initiation and Duration by Mode of Childbirth: A Prospective, Population-Based Study.

Introduction: Despite known benefits of breastfeeding, including prevention against infections for infants, in the presence of numerous barriers, less than half of infants in high-income countries breastfeed for 6 months. One potential barrier to breastfeeding is birth by cesarean section (C-Section), which can invoke long-term difficulties. However, our structured literature review found that existing empirical research does not fully elucidate this relationship due to differences in operationalization of C-section and breastfeeding, omission of important confounders, and failure to exclude those who did not initiate breastfeeding (or use time-to-event analyses). In this article, we attempt to overcome these limitations. Methods: We analyzed data from 14,414 mother-infant dyads enrolled in the United Kingdom-based prospective Millennium Cohort Study, beginning in 2001. Using multivariable logistic regression, we examined the association between mode of birth (vaginal, emergency C-section, and elective C-section) and likelihood of breastfeeding initiation. We then applied adjusted Accelerated Failure Time survival models to examine the associations between mode of birth and duration of any and exclusive breastfeeding. Results: Those with planned (but not emergency) C-section were less likely to initiate breastfeeding (odds ratio: 0.84, 95% confidence interval [CI]: 0.71-0.99) relative to vaginal births. However, those with either planned or unplanned C-section discontinued both any and exclusive breastfeeding sooner than vaginal births. This effect was more pronounced for those with planned C-section (time ratio [TR]: 0.75, 95% CI: 0.64-0.89) than unplanned C-section (TR: 0.85, 95% CI: 0.74, 0.97) compared with vaginal births. Conclusions: Through application of rigorous methods, this study provides compelling evidence that breastfeeding duration may be impeded by C-section birth. The findings suggest that additional support for mothers who intend to breastfeed and have a C-section birth may be warranted.

Harlequin Ichthyosis – Genetic and Dermatological Challenges: A Case Report and Literature Review

Harlequin ichthyosis (HI) is an extremely rare and severe genetic skin disorder characterized by thick, diamond-shaped scales covering the body, often giving the appearance of a harlequin costume. This paper provides an overview of the genetic and dermatological aspects of HI, delving into its etiology, clinical manifestations, and management. The genetic underpinnings of HI involve mutations in the ABCA12 gene, leading to impaired skin barrier function and abnormal keratinization. Understanding the molecular basis of the disorder is crucial for accurate diagnosis and potential therapeutic interventions. Clinically, HI presents challenges related to skin integrity, thermoregulation, and potential complications, such as infections. The management of HI requires a multidisciplinary approach involving dermatologists, geneticists, and other healthcare professionals. Supportive care, including emollients, careful bathing, and prevention of infections, is essential to improve the quality of life for individuals affected by this condition. Despite its rarity and severity, advancements in medical research and genetic therapies offer hope for improved treatments and interventions. This paper aims to contribute to the collective understanding of HI, fostering ongoing research and compassionate care for those living with this unique and challenging dermatological condition. We presented a premature eutrophic harlequin baby, born at 32+ weeks of gestation via emergency C-section. A clinical diagnosis was established minutes after birth, based on the typical features of HI, from scaly skin, marked fissures, and limbs in flexion contractures to prominent eclabium and bilateral ectropion.

Mode of Delivery by Maternal Characteristics: The Case of C-sections in Slovakia

This study focuses on mode of delivery by maternal characteristics such as age, education, marital status, region, and mode of previous delivery. We use microdata provided by the Ministry of Health and find that the likelihood of a C-section increases with the age of the mother, but a previous natural delivery weakens this association. Women who are married more often give birth by planned C-section. Emergency C-sections occur more often among unmarried women. Women in the Trenčín region more often deliver spontaneously, and women in the Bratislava and Nitra regions more often deliver by C-section. Due to the early onset of fertility, women with primary education more often deliver spontaneously. Women with secondary education under the age of 35 more often deliver by planned C-section than university-educated women. Our results are policy-relevant for further decision-making and planning in obstetrics and gynaecology in Slovakia, especially by pinpointing the different risk categories in terms of maternal education or marital status by mother’s age.

Obstetric and Neonatal Outcomes Following Hospital Transfers of Home Births and Births in Midwife-led Units in Austria.

Home births and births in midwife-led units and the associated potential risks are still being debated. An analysis of the quality of results of planned home births and births in midwife-led units which require intrapartum transfer of the mother to hospital provides important information on the quality of processes during births which occur outside hospital settings. The aim of this study was to analyze neonatal and maternal outcomes after the initial plan to deliver at home or in a midwife-led unit had to be abandoned and the mother transferred to hospital. The method used was an analysis of data obtained from the Austrian Birth Registry. The dataset consisted of singleton term pregnancies delivered in the period from 1 January 2017 to 31 December 2021 (n=286056). For the analysis, two groups were created for comparison (planned hospital births and hospital births recorded in the Registry as births originally planned as home births or births in midwife-led units but which required a transfer to hospital) and assessed with regard to previously defined variables. Data were analyzed using frequency description, bivariate analysis and regression models. In Austria, an average of 19% of planned home births have to be discontinued and the mother transferred to hospital. Home births and births in midwife-led units which require transfer of the mother to hospital are associated with higher intervention rates intrapartum, high rates of vacuum delivery, and higher emergency c-section rates compared to planned hospital births. Multifactorial regression analysis showed significantly higher risks of poorer scores for all neonatal outcome parameters (Apgar score, pH value, transfer rate). If a birth which was planned as a home delivery or as a delivery in a midwife-led unit fails to progress because of (possible) anomalies, the midwife must respond and transfer the mother to hospital. This leads to a higher percentage of clinical interventions occurring in hospital. From the perspective of clinical obstetrics, it is understandable, based on the existing data, that giving birth outside a clinical setting cannot be recommended.

Cesarean sections and sociodemographic disparities in Ecuador: A nationwide study from hospital registries between 2015 and 2022.

This study aimed to analyze sociodemographic factors associated with cesarean sections (c-sections) in Ecuador. Data were extracted from the Ecuadorian National Institute of Statistics and Censuses (INEC). Multivariate binary and multinomial logistic regression analyses were performed to assess sociodemographic factors associated with c-sections overall and with each type of c-section (elective or emergency c-section). This study included 1 118 842 in-hospital deliveries during 2015-2022 in Ecuador, of which 41.3% were c-sections. This exceeds the recommended levels of medical justified c-sections. Those who were older than 20-29 years showed a higher probability for c-sections overall. Regarding ethnicity, Montubios had 57% higher probability for c-sectioned with an adjusted odds ratio (aOR) of 1.57 and a 95% confidence interval (CI) of 1.45-1.71; while indigenous, black, and white individuals exhibited 73%, 29%, and 21% lower probabilities, respectively. However, this varied according to specific type of c-sections: black individuals had 11% higher probability of elective c-section but 44% lower probability of emergency c-section. Deliveries in private healthcare facilities exhibited significantly higher probabilities of c-sections overall (aOR 15.38, 95% CI 15.20-15.56). Higher probability of emergency c-section was also observed during 2020-2022. Cesarean sections in Ecuador still exceed the recommended levels of medically justified c-sections, highlighting the importance of adopting an approach to childbirth that reduces unnecessary interventions. These results suggest an important role of sociodemographic factors, which aligns with the reported need for multicomponent and locally tailored strategies for addressing c-section overuse. The increase in c-sections during the COVID-19 pandemic (2020-2022) might suggest the influence of external health crises on maternal healthcare.

Observational Analysis: A Prospective Study of the Correlation Between the State of the Maternal Spine and the Progress of Labor Under Epidural Analgesia

Background: People have always believed that going through the process of childbirth is a gift, although pain experienced during labor by a woman occupies the second level in the pain score table. But that belief that one has to undergo pain during labor is slowly fading away, as we are entering an era where women are seeking options for painless labor, and delivery. Objective: To evaluate the spine of women in labor opting for epidural analgesia. To correlate the abnormal position of the maternal spine to the progress of labor and outcomes. Methods: The current prospective observational study performed between 2021-2023 had enrolled 200 women who were given epidural analgesia irrespective of stage of labor. Women who had a history of spine surgeries or congenital spinal deformities were excluded. Results: Of the 200 women included in the study, 80 women showed a deviation of spine mostly to the right from the midline or significant lordosis, irrespective of babies’ weight and maternal height. Out of the 80 women, 70 women ended up in an emergency cesarean section. Of the 70 women who were taken up for emergency c-sections, the major indication was nonprogress of the second stage of labor. Ten patients had a vaginal delivery, of which 3 had assisted instrumental delivery due to a prolonged second stage and poor maternal efforts. Conclusion: Irrespective of maternal height, weight of the baby, and stages of labor, if the spine shows lordosis with significant deviation from the midline most commonly towards the right it can have a significant impact on the progress of labor and outcomes.

Disparities in Elective and Emergency Caesarean Section Rates Among Public and Private Hospitals in the Districts of Andhra Pradesh, India.

Background In India, there has been a steady increase in the rate of caesarean section (C-section) deliveries over the past decade, rising from 17% during National Family Health Survey-4 (NFHS-4 (2015-16)) to as high as 21.5% during NFHS-5 (2019-21). Andhra Pradesh,India, is experiencing a particularly high rate of 42.4% as per NFHS-5, which is the highest among the states in the country. This study aims to investigate the prevalence of C-section deliveries across the districts of Andhra Pradesh and to identify the disparities in elective and emergency C-section rates among public and private hospitals in districts of Andhra Pradesh, India. Methods The study utilized secondary data from theNFHS-5conducted by the International Institute for Population Sciences, Mumbai. A statistical software package was used to perform the analysis, while a quantum geographic information system​​​​​​​ (QGIS) was used to prepare a map. Descriptive statistics, bivariate analysis, and multivariate binary regression were used for statistical analysis. Results Significant variations in the prevalence of C-section deliveries were found across the districts in Andhra Pradesh. The prevalence ranged from 22.2% in Anantapur to 66% in Krishna. It was also found that private hospitals were the primary drivers of the high prevalence of C-section deliveries. Approximately 31.51% of women underwent C-sections in public institutions, whereas it was 68.49% in private institutions. The overall occurrence of C-section deliveries in Andhra Pradesh was 65% for elective cases and 35% for emergency cases, indicating a relatively higher prevalence for elective procedures. Conclusion The choice of the medical institution, whether private or public, is the most significant factor influencing the high prevalence of C-section deliveries. Additionally, C-section deliveries were found with higher complication rates than normal deliveries. Elective C-sections are more prevalent in the state, and factors such as wealth quintile and birth order are impacting the likelihood of elective versus emergency C-section deliveries. The study suggests that the government should provide awareness and regulations to promote vaginal deliveries and prevent unnecessary C-sections in hospitals.

The Association between Cesarean Section Delivery and Child Behavior: Is It Mediated by Maternal Post-Traumatic Stress Disorder and Maternal Postpartum Depression?

Cesarean sections (C-sections) account for up to 21% of births worldwide. Studies have linked delivery via C-section with an increased risk of child behavior problems, such as internalizing and externalizing behaviors. Maternal postpartum depression (PPD) is also linked to child behavioral problems and may play a mediating role in the association between the mode of delivery and child behavior. Mixed findings between mode of delivery and PPD may be due to a failure to distinguish between C-section types, as unplanned/emergency C-sections are linked to post-traumatic stress disorder (PTSD), which has been linked to PPD. The objectives of this study were to determine whether, (1) compared with spontaneous vaginal delivery (SVD) and planned C-section, unplanned/emergency C-sections are associated with increased child behavior problems at two to three years of age and (2) maternal PTSD and PPD mediate the association between delivery type and child behavior problems. A secondary data analysis was conducted on 938 mother-child dyads enrolled in the Alberta Pregnancy Outcomes and Nutrition (APrON) study. Conditional process modeling was employed. Child behavior was assessed using the Child Behavior Checklist (CBCL) 1.5-5 years, and maternal PPD and PTSD were assessed using the Edinburgh Postnatal Depression Scale (EPDS) and the Psychiatric Diagnostic Screening Questionnaire (PDSQ), respectively. No associations were found between delivery type and child behaviors; however, the indirect effect of emergency C-section on child behaviors was significant via the mediating pathway of maternal PTSD on PPD symptoms.

Emergent Bedside Cesarean Section for COVID-19 Patient on Veno-venous Extracorporeal Membrane Oxygenation: A Case Report

Background & Case: A 38-year-old Spanish-speaking, pregnant woman at 26.1 weeks’ gestation with two previous Cesarean sections (C-section) presented with acute respiratory distress syndrome secondary to COVID-19 pneumonia. She was intubated and ventilated, complicated by bilateral pneumothoraces and emphysema requiring bilateral chest tubes and blow holes. She had worsening hypoxic respiratory failure ultimately requiring cannulation for venovenous extracorporeal membrane oxygenation (VV-ECMO). She was started on cefazolin for Methicillin-susceptible Staphylococcus aureus bacteremia. On day three of VV-ECMO, there was non-reassuring fetal heart tone necessitating emergent bedside non-sterile Cesarean section at 27.2 weeks’ gestational age in the surgical intensive care unit. Post-Cesarean section, her respiratory failure improved, and she was decannulated from VV-ECMO 13 days later. This case report highlights that VV-ECMO can be a life-saving treatment option for pregnant women with cardiopulmonary failure who are unresponsive to conventional therapy. Literature describing Caesarean section on VV-ECMO is limited. Specifically, there have been only a handful of case reports of C-sections on patients put on VV-ECMO due to respiratory failure. Results: The obvious benefit of proceeding with this emergent bedside C-section was to save the fetus. However, this had to be weighed against the risks of hemorrhage in this high-risk patient since she had two previous C-sections and was on a therapeutic heparin drip while on VV-ECMO. Additionally, there is the risk of infection due to having the C-section done in a non-sterile manner, especially in a patient who is bacteremic. This was mitigated by using additional prophylactic antibiotics post-operatively. The patient’s respiratory status improved significantly after the fetus was delivered, likely due to improvements in respiratory mechanics post-partum. The successful outcome of this patient and her baby required the timely coordination of a multidisciplinary team. Conclusions: Emergent C-section on a pregnant woman with respiratory failure on VV-ECMO can be life-saving for the fetus and the mother. However, the inherent risks associated with it requires close monitoring of the patient and the fetus in order to determine when this is truly necessary. Keywords: Acute respiratory distress syndrome, Cesarean-section, COVID-19, Pregnancy, Veno-venous extracorporeal membrane oxygenation

Breech presentation - maternal and neonatal outcomes and obstetric challenges

Introduction/Objective. Breech presentation occurs in 3-4% singleton pregnancies at term and its management is still a controversial in obstetric practice. The aim of this study was to determine the factors that indicate breech delivery management and to compare maternal and neonatal outcomes in vaginal breech delivery, planned Cesarean section and emergency C-section at the Hospital for Gynecology and Obstetrics of the Zemun Clinical Hospital Centre. Methods. This was a retrospective study conducted from 2015 to 2019. Depending on the mode of delivery patients were divided in three group. In the study we have analyzed maternal risk factors and postpartum complications, delivery details and neonatal characteristics and outcomes. Results. Study included 176 women with singleton fetus in breech presentation. The incidence of breech deliveries was 2.12%. Most common way of delivery was vaginal with 47.72%. In all three groups the majority of women were primiparous, at term, mostly without chronical and gestational diseases. Vaginal delivery was stimulated with oxytocin in 91.67% and as a help for delivery various maneuvers were used. Maternal mortality and short-term complications during hospitalization period were not reported in none of the groups. No significant difference in newborns birth weight between the groups was observed. The highest rate of birth injuries was in newborns from emergency C-section - 10%. Conclusion. The results of our study have shown that vaginal delivery could be a very safe option for both mother and newborn.

Акушерские осложнения в III триместре беременности у пациенток с бронхиальной астмой

Aim: to analyze the rate of asthma-associated obstetric complications in the third trimester of pregnancy, with attention to the severity and level of symptom control Patients and Methods: a retrospective phase involved the analysis of the course of the third trimester of pregnancy in 120 women with asthma. The women were divided into five groups: mild intermittent asthma (n=34), mild persistent controlled asthma (n=40), mild persistent poorly controlled asthma (n=10), moderate to severe persistent controlled asthma (n=26), and moderate to severe persistent poorly controlled asthma (n=10). The prospective phase included examination and treatment of pregnant women in the groups with uncontrolled asthma (n=20). The level of symptom control was assessed using the Asthma Control Test (ACT). Additionally, nitric oxide in exhaled air (NOex) was measured. The control group included 20 women without allergic disorders. Results: the study demonstrated an association between the level of symptom control and the development of associated hypertensive disorders. Severe preeclampsia was reported only in moderate to severe poorly controlled asthma. A significant correlation was revealed between ACT, NOex level, and de novo increase in systolic blood pressure (BP) in the third trimester (Rs=0.581; Rs=0.828). C-section was most often performed for fetal indications (acute hypoxia) in women with moderate to severe persistent poorly controlled asthma. These findings indicate that the choice of delivery method should be based on the level of symptom control at the end of the third trimester, rather than disease severity. Achieving complete control of asthma in pregnant women reduces the risk of acute fetal hypoxia and the rate of emergency C-sections. Conclusions: achieving and maintaining complete asthma control during pregnancy reduces the risk of associated obstetric complications and improves perinatal and maternal outcomes KEYWORDS: asthma, pregnancy, obstetric complications, hypertension, asthma-associated obstetric complications, C-section. FOR CITATION: Pashchenko A.A., Dobrokhotova Yu.E., Fomina D.S. Obstetric complications in the 3rd trimester of pregnancy in women with asthma. Russian Journal of Woman and Child Health. 2024;7(2):98–103 (in Russ.). DOI: 10.32364/2618-8430-2024-7-2-2.

Antenatal Diagnosis of Non-Janiceps Type of Cephalophagus Conjoined Twins: A Case Report

Cephalophagus is the rarest type of conjoined twins. Given the exceedingly dismal prognosis, early prenatal detection is crucial because surgical separation is not an option in many situations. The present case report presents a rare non janiceps cephalophagus conjoined twin pregnancy in a 22-year-old primigravida, identified during the third-trimester antenatal ultrasound. Imaging revealed a single face, a shared thoracic cavity with one heart. There were two lungs, the upper abdomen was fused, and the stomach and liver were shared. Two vertebral columns, separate pelvises, and two pairs of limbs were seen. An omphalocele containing liver tissue was observed. An emergency C-section delivered the cephalophagus foetus, underscoring the vital role of early antenatal ultrasound in managing such cases.

Immigration and C-sections incidence: Maternal care and perinatal outcomes in the context of the pandemic in Chile

IntroductionImmigration has increased significantly in Chile. Despite that all pregnant women, regardless of nationality and immigration status, have the right to access to all healthcare services during pregnancy, childbirth, and postpartum, inequities in health care outcomes and health provision have been reported. During COVID-19 pandemic, these inequities are completely unknown.ObjectiveThe aim of this study was to compare the incidence of c-sections according to mother's migration status, as well as other maternal care and perinatal outcomes in women giving birth at San José Hospital in Santiago, Chile, during the COVID-19 pandemic.MethodsA retrospective cohort study was designed including 10,166 registered single births at the San José Hospital between March 2020 and August 2021. To compare between groups, statistical tests such as Chi-square and Fisher's exact were used. Log Binomial regression models were performed adjusted for potential confounding variables. To estimate the strength of association the relative risk was used.ResultsImmigrant mothers account for 48.1% of the registered births. Compared to non-immigrant women, immigrants exhibit a higher proportion of c-section, specifically, emergency c-section (28.64% vs. 21.10%; p-value < 0.001) but a lower proportion of and having a preterm birth (8.24% vs. 13.45%; p < 0.05), receiving personalized childbirth care (13.02% vs. 14.60%; p-value < 0.05), companion during labor and childbirth (77.1% vs. 86.95%; p-value < 0.001), And postpartum attachment to newborn (73% vs. 79.50%; p-value < 0.001). The proportion of COVID exposure was not significant between groups, not the severity also. Haitians had a highest risk of undergoing emergency c-section (aRR = 1.61) and Venezuelans had a highest risk of elective c-section (aRR = 2.18) compared to non-immigrants.ConclusionThis study reports high rates of c-sections in the entire population, but in immigrant populations it is even higher. Additionally, it found gaps in maternal care and perinatal outcomes between immigrants and non-immigrants. More studies are needed to elucidate the possible causes of these differences and establish new regulations to protect the reproductive rights of the immigrant population.

Hemi-diaphragmatic paralysis

Introduction: Diaphragmatic paralysis (DP) involving the phrenic nerve is related to brachial plexus injury in 80–90% of the cases. Other causes include iatrogenic procedure involving the cardiopulmonary area. It causes respiratory distress which can be severe requiring prolonged need for respiratory support. Recovery can be spontaneous, typically by the first 6–12 months of life though some infants may require surgical intervention if no improvement in DP is noted by 1–2 months of life in the setting of compromised quality of life. Case Report: We present a preterm infant, 31 completed weeks of gestational age, birth weight 1440 g born via emergency C-section due to preterm labor in breech presentation. During delivery, the patient suffered a left brachial plexus injury with phrenic nerve involvement. He developed respiratory distress requiring endotracheal intubation and mechanical ventilation. His clinical course involved multiple failed extubation attempts. Chest X-ray (CXR) and chest fluoroscopy confirmed the diagnosis of left hemi-diaphragmatic paralysis. The patient had a prolonged respiratory support course but was finally weaned to room air by three months of age. Conclusion: Preterm infants can sustain perinatal brachial plexus injury like term or near-term infants in the setting of a traumatic birth irrespective of birth weight. The time and indications for conservative (non-surgical) versus surgical intervention remains debatable. Each case should be tailored to the child’s severity of injury and quality of life and growth. Clinical recovery can occur even with considerable persistence weakness on radiography or chest ultrasound.

Abstract 17605: Multidisciplinary Team Approach in the Management of Pregnant Women With Complex Congenital Heart Disease: A Case Series

Introduction: Women with congenital heart disease (CHD) now live well into adulthood and consider pregnancy. A multidisciplinary team approach is crucial to the management of complex pregnant cardio-obstetrics patients. Here, we present a case series of three patients where careful team-based care resulted in successful delivery and without significant postpartum complications. Case series: Baseline patient characteristics and delivery details are summarized in Table 1. Patient 1, with history of repaired bicuspid aortic valve (AV) and subsequent severe bioprosthetic aortic stenosis, presented with incalcitrant supraventricular tachycardia leading to an urgent c-section. Patient 2, with history of complete Shone complex, underwent emergent c-section in the cardiac OR with extracorporeal membrane oxygenation on standby after developing rapid atrial tachycardia. Patient 3 fortunately did not suffer difficulties during her pre-planned c-section. She had a history of partial AV canal defect and subaortic membrane causing severe left ventricular outflow tract obstruction. Despite the differences between their hospitalizations and pregnancy course, utilizing a multidisciplinary approach led to no long-term postpartum complications and delivery of healthy neonates for all three patients. Discussion: Cardiovascular (CV) disease is the leading cause of maternal mortality accounting for greater than 25% of deaths. CHD is the most common CV condition encountered in pregnant women. Consistent with the Presidential Advisory from the AHA and ACOG, development of a cardio-obstetrics team is vital to managing complex maternal CV disease and minimizing CV morbidity and mortality. Conclusion: Integrating the expertise and collaboration among a multidisciplinary cardio-obstetrics team from preconception through the postpartum period allows for individualized care necessary to optimize maternal and fetal outcomes for women with complex CHD.

Posterior Reversible Encephalopathy Syndrome in a Hospitalized Pregnant Woman with SARS-CoV-2 Infection: A Case Report

: During pregnancy, SARS-CoV-2 infection (COVID-19) can be complicated, and the mother and neonate's prognosis is not fully documented. We are presenting the case of a 33-week pregnant patient with confirmed COVID-19 who developed encephalopathy. During the disease and hospitalization in a critical care setting, an emergency C-section was performed with general anesthesia in the ICU due to acidosis and maternal-fetal instability. The baby boy was delivered with an APGAR score of 8, showing no obvious anomalies, and was subsequently intubated. Eight days later, brain imaging revealed posterior reversible encephalopathy syndrome. The mother received treatment and was discharged without further complications. At the final follow-up six months after discharge, the patient's MRI showed laminar necrosis in the two occipitoparietal cortex areas. However, she remained symptom-free and did not report any complications. We also discussed the possible reasons for these findings and their relationship to the infection.

FRI336 A Case Of Pituitary Apoplexy In Late Pregnancy

Abstract Disclosure: H. Abdelrahman: None. S. Rasiah: None. S. Braunthal: None. L. Mahoney: None. R.M. Carneiro: None. K.K. Chen: None. Case: A 20-year-old primigravida presented at 36 weeks gestation due to persistent left-sided headache of 4 weeks duration. MRI brain demonstrated pituitary enlargement (15x17x14 mm) with hemorrhage as well as suprasellar extension and mass effect upon the optic chiasm, consistent with pituitary apoplexy (PA). She has no known medical history or prior endocrinopathies. Serum prolactin was appropriately elevated for pregnancy (299 ng/mL). She was started on levothyroxine for secondary hypothyroidism (TSH 3.4 mcg/dL, free T4 0.8ng/dL (0.7-1.5 ng/dL)) and hydrocortisone for prevention of adrenal insufficiency. She was admitted for semi-urgent induction of labor following the discovery of visual field defects on formal perimetry testing by ophthalmology. After discussion with neurosurgery and maternal fetal medicine, she was permitted to have a trial of vaginal delivery with a brief period of Valsalva but she ended up requiring an emergency C-section due to failure to progress. Her delivery was complicated by significant blood loss (∼5000ml), resulting in bilateral uterine artery embolization followed by an emergency hysterectomy. Repeat MRI brain with contrast following delivery demonstrated a cystic pituitary lesion, possibly a Rathke’s cleft cyst. She underwent endoscopic transnasal exploration and resection two days following delivery. Discussion: Pituitary apoplexy is a rare cause of acute headache in pregnancy. The majority of PA occurs in the setting of undiagnosed pituitary adenomas. Rapid treatment of possible adrenal insufficiency is imperative. Conservative versus surgical treatment plans are tailored to the patient’s obstetric care and neurological status. The earliest reported PA occurrence is at 7 weeks gestation (associated with subsequent miscarriage). Coordination of care between different specialists is paramount especially in late pregnancy. It is theoretically possible that Valsalva during vaginal delivery may increase intracranial pressure and exacerbate hemorrhage. Women with pituitary adenomas are recommended to undergo standard obstetric care with close surveillance, as C-section deliveries can also be associated with increased blood loss. Timing of surgery in gestational pituitary apoplexy is variable; it may be up to one month after delivery. Dopamine agonist therapy may be started during pregnancy for confirmed prolactinomas. The European Society of Endocrinology recommends transsphenoidal surgery in the second trimester for symptomatic adenomas. In the third trimester, preterm delivery may be considered. Post-operative adverse events are not uncommon due to the high risk nature of these pregnancies. After surgery, most patients should experience some degree of vision improvement but many will continue to need hormone replacement. Presentation: Friday, June 16, 2023

FRI416 Primary Hyperaldosteronism in Pregnancy

Abstract Disclosure: S.M. Seav: None. M. Basina: None. Background: Primary hyperaldosteronism is extremely rare in pregnancy. Since 1962, only approximately 30 cases have been reported in the literature.1 Clinical Case: A 40-year-old female was referred for work-up of primary hyperaldosteronism (PHA). She was first diagnosed with hypertension (HTN) at age 29 during her first pregnancy. Laboratory work-up was consistent with PHA: serum aldosterone 22.6 ng/dL, renin activity 0.1 ng/mL/hr, aldosterone:renin ratio of 226. Post-saline infusion aldosterone level was 10.7 ng/dL. Adrenal CT scan showed a 6mm left-sided adenoma. Surgery was not recommended because adrenal vein sampling did not show lateralization. She was started on Spironolactone 25 mg/day. Despite the significant pregnancy risks, patient continued to desire conception and was switched to Labetolol. She was lost to follow-up and returned to the emergency room for dizziness at 26 weeks pregnant with twins with BP 180/109 mmHg. She had not been taking any anti-hypertensives and there was evidence of severe fetal growth restriction in both babies. After a goals of care discussion, patient deferred emergent C-section and suffered intrauterine fetal demise on hospital day 9. Conclusion: PHA in pregnancy is rare and difficult to diagnose and manage. Newer studies estimate that > 5-10% of patients with HTN have PHA.2 Hence, maintaining high vigilance of this disease in pregnant patients is even more imperative, including screening for PHA during pre-conception period in hypertensive women. A systematic review of 38 cases of PHA in pregnancy showed that 19% of cases were diagnosed with HTN prior to pregnancy without PHA screening.1 The average age of women in this study was 29.8 years. Additionally, there is a correlation in women with younger age at diagnosis and having unilateral PHA, in which case adrenalectomy should be performed prior to conception.3 In pregnancy, first line anti-hypertensive therapies include alpha methyl dopa, labetolol, and nifedipine. In PHA, diuretics such as amiloride and mineralocorticoid receptors should also be considered if BP is not at goal. Spironolactone and eplerenone have been safely used in pregnancy with both male and female fetuses.1,4 If surgery is not an option and medical therapy is ineffective, then physicians should have a low threshold to admit patients for close BP monitoring. 1Landau, et al. Primary Aldosteronism and Pregnancy. Annales d’Endocrinologie. 2016;77:148–160 2Funder, et al. Management of Primary Aldosteronism: Case Detection, Diagnosis, and Treatment: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(5):1889–1916 3Akasaka, et al. Sex Difference in the Association Between Subtype Distribution and Age at Diagnosis in Patients With Primary Aldosteronism. Hypertension. 2019;74(2):368-374 4Cabassi, et al. Eplerenone Use in Primary Aldosteronism in Pregnancy. Hypertension. 2012;59:e18-e19 Presentation: Friday, June 16, 2023

THU316 Relatively Rare And Increasingly Fatal; A Case Of Euglycemic DKA In A Patient With Gestational Diabetes

Abstract Disclosure: C. Dimech: None. E. Rabiei-Flori: None. P.L. Bononi: None. Diabetic ketoacidosis (DKA) is an endocrine emergency and can be a catastrophic event during pregnancy, increasing both maternal and fetal mortality. Euglycemic DKA (EDKA) during pregnancy is a rare, acute, life-threatening emergency characterized by euglycemia, metabolic acidosis and ketosis. EDKA has been reported in pregnancies complicated by Type 1 diabetes, Type 2 diabetes and gestational diabetes. Unlike DKA, the diagnosis of EDKA is often overlooked because of the absence of hyperglycemia. The incidence of DKA and EDKA are higher during pregnancy due to physiologic changes of increasing insulin resistance from human placental lactogen, placental insulinase, and progesterone which result in a relative insulin deficiency as the pregnancy progresses. Additionally, tocolytic therapy to delay preterm labor and antenatal corticosteroids given to promote fetal lung development, pose unique triggering factors in pregnancy which can further precipitate DKA. We report a case of EDKA in a 37-year-old G2P0010 Caucasian female at 29 week 6 day gestation with recently diagnosed gestational diabetes on diet therapy (HbA1c 6.3%), who was admitted for atypical preeclampsia. Initial laboratory studies revealed an anion gap metabolic acidosis (anion gap=24, arterial pH 7.242) with euglycemia (blood glucose 123mg/dL). She underwent emergent C-section 24 hours after admission due to development of pre-eclampsia with severe features. Despite delivery, she had persistent and worsening high anion gap metabolic acidosis (HAGMA). The Endocrinology service was consulted and ordered a beta hydroxybutyrate level which was elevated at 6.18mmol/L (0.02-0.30mmol/L) with 3+ ketonuria. Intravenous insulin and dextrose were instituted with gradual improvement in acidosis. EDKA is an easily missed diagnosis that should always be considered during pregnancy in a patient with high anion gap metabolic acidosis. Prompt recognition and treatment is essential to minimize complications to mother and fetus. Presentation: Thursday, June 15, 2023

An Unusual Cause of Neck Pain and Headache in Pregnancy.

A previously healthy 21-year-old Caucasian female G1P0 at 32 weeks gestation presented to the ED for an episode of syncope. She also complained of headaches, neck pain, and blurry vision. Physical examination revealed a healthy pregnant female. Neurological examination demonstrated Grade III papilledema but was otherwise unremarkable. CT brain revealed hydrocephalus and intraventricular hemorrhage of unclear etiology MRI of the head was negative for a mass lesion. MRA/MRV of the head was negative, ruling out cavernous sinus thrombosis. Lumbar puncture was bloody but negative for infection. Infectious workup, including HSV, toxoplasmosis, and neurocysticercosis, was negative. An intraventricular drain was placed for hydrocephalus. While in the hospital, she developed sudden left-sided weakness, prompting an emergency C-section. Further workup with CT angio of the brain and neck revealed an arteriovenous malformation (AVM) involving the anterior spinal artery and adjacent venous plexus. Digital subtraction angiography showed a C2-3 pial AVM with a partially thrombosed nidal aneurysm. She was transferred to an outside hospital for embolization. Embolization obliterated the aneurysm, but residual flow remained in the AVM. Blood products are visible on sagittal MRI after embolization. At hospital discharge, her left-sided weakness had resolved, and her neurological examination was normal. The hydrocephalus had resolved.