Obstetric Literature Research Articles

Glycemic control during labor and delivery: a survey of academic centers in the United States

Significant controversy surrounds the management of blood glucose levels during labor and delivery. The American College of Obstetrics and Gynecology has recommended "tight" blood glucose control (<110 mg/dL). However, there is concern that tight control can increase the incidence of maternal hypoglycemia. Thus, there remains a lack of consensus regarding glycemic control during labor and delivery. To assess the current intrapartum glycemic management, we surveyed obstetrical residency programs in the United States. Questionnaires were distributed via email and if there was no response within 3 weeks, they were mailed to obstetrics/gynecology residency program directors. Of the 117 questionnaires distributed, 49 responses (41.9%) were received, but one was excluded, as it was incomplete. Although 85% of responders reported having a written protocol in place regarding intrapartum BG management, there was significant variation in target blood glucose levels, maintenance of those levels, monitoring of glucose levels, and fluid management during labor and delivery. The key finding of our survey is that there is significant variation in blood glucose management during labor and delivery. This survey identifies areas for improvement as well as areas for future research. Given the sparse obstetrical literature, properly conducted trials are necessary to assess all aspects of optimal intrapartum glucose management.

Increasing Timely and Available Prenatal Studies by Electronic Health Records

The government is encouraging the adoption of electronic medical records (EMRs). There is little information about using EMRs in the obstetric literature and none about using them in family medicine residencies. Our purpose was to assess if using an EMR was associated with improvement in the ordering and availability of prenatal tests. A retrospective chart review comparing the rate at which prenatal laboratory values were present on the chart, ordered on time, and recorded on a prenatal flow sheet. Comparison of charts before and after implementation of an EMR showed statistically significant improvement in the percent of patients with all first trimester (87.5% vs 96.0%; P=.0025), quadruple screening tests (91.1% vs 98.1%; P=.012), and second trimester screening results (93.5% vs 100%; P=.044) in their charts; first trimester laboratory tests (91.6% vs 99.5%; P=.001) and second trimester ultrasounds (90.9% vs 97.3%; P=.027) being ordered on time; and first trimester results (88.2% vs 95.5%; P=.009), quad screen results (93.1% vs 98.0%; P=.0495), and second trimester ultrasounds (93.5% vs 100%; P=.003) being recorded on the American Congress of Obstetricians and Gynecologists flow sheet. Adopting an EMR was associated with an improved rate at which prenatal tests were ordered on time, present on the chart, and recorded on a prenatal flow sheet.

SEIZURES IN WOMEN WITH PREECLAMPSIA: MECHANISMS AND MANAGEMENT

Eclampsia is defined in the obstetrical literature as the occurrence of unexplained seizure during pregnancy in a woman with preeclampsia. In the Western world, the incidence of eclampsia is ~1 per 2000 to 1 per 3000 pregnancies, but the incidence is 10-fold higher in tertiary referral centers and undeveloped countries where there is poor prenatal care, and in multi-fetal gestations. Nearly 1 in 50 women with eclampsia die as do 1 in 14 of their offspring, and mortality rates are considerably higher in undeveloped countries. Eclampsia is also associated with significant life-threatening complications, including neurological events. Seizure acutely can cause stroke, haemorrhage, oedema and brain herniation and thus lead to epilepsy and cognitive impairment later in life.

Demystifying the ED to Integrate Palliative Care Programs (507)

morbidity and mortality in extremely low birthweight infants. 2. Examine legal decisions in resuscitation at the threshold of viability and in cases of neonatal medical futility. 3. Evaluate current practice in neonatal palliative care and appraise opportunities for perinatal hospice. Neonatal viability invokes passionate opinions and ethical debate within the medical community. This session will serve to build judgment more rooted in a framework of evidence, ethics, and legal responsibility, while accounting for the psychosocial values of parents. The principles of distributive justice, beneficence, autonomy, and nonmaleficence will provide the framework to review the clinical circumstances facing providers who care for the extremely low birthweight (ELBW) infant. The threshold of viability is defined as infants born at 22e25 weeks gestation by the American Academy of Pediatrics. Resuscitation guidelines for this period of viability range dramatically. In considering this variation, published morbidity, mortality, and neurodevelopmental outcomes often drive the intensive care decision making for these critical neonates. The NICHD Neonatal Research Network has demonstrated 54% of 500e750 gram infants survive, with only 37% showing evidence of a morbidity-free life. The EPICure Study illustrated 48% of survivors exhibit disability at 30months of age. Recent studies reflect that decision making to resuscitate the ELBW infant is rooted in parental autonomy; however, despite consistent prenatal counseling by neonatologists regarding clinical concerns, there is tremendous disparity when discussing social andethicalmatters. Paradigm legal cases including the Sydney Miller Case in Houston Texas have helped define legal implications in emergency decision making for the high-risk neonate. Such legislation as the Born-Alive Infants Protection Act, as well as obstetric literature that cites inaccurate gestational dating, indicate that distinct barriers exist regarding the accuracy of predicting neonatal outcomes. Diagnostic criteria for palliative care referrals in the neonatal ICU primarily includes extreme prematurity or catastrophic illness. Reasons for consultations often focus on the organization of home hospice and facilitation of medical options. These factors establish a considerable need for perinatal palliative care and hospice in the care of neonates at the threshold of viability. Domain Physical Aspects of Care; Ethical and Legal Aspects of Care

Malignant gastrointestinal stromal tumor presenting with hemoperitoneum in puerperium: report of a case with review of the literature

BackgroundGastrointestinal stromal tumors (GISTs) are mesenchymal tumors that develop in the wall of the gastrointestinal tract and their diagnosis during pregnancy or puerperium is extremely rare.CaseA 28-year old patient presented with acute abdomen due to hemoperitoneum from a large mass arising of the small intestine with distended vessels on its top and a ruptured superficial vessel bleeding into the peritoneal cavity. The patient was at the tenth postpartum day of her first pregnancy. The preoperative diagnosis was a possible ovarian or uterine mass. After an emergency exploratory laparotomy a segmental bowel resection was performed, removing the tumor with a part of 3-cm of the small intestine. Histology revealed GIST with maximum diameter of 13 cm and mitotic rates more than 5 mitoses per 50 high power fields with some atypical forms, indicating a high risk malignancy. Immunohistochemical staining of the tumor tissue demonstrated strongly positive reactivity to CD 117 (c-kit) and CD34 in almost all the tumor cells. The patient was treated with oral imatinib mesylate (Gleevec) 400 mg daily for one year. Three years after surgery, the patient was alive without evidence of metastases or local recurrence.ConclusionConsidering that only few patients with gastrointestinal stromal tumors have been reported in the obstetrical and gynecological literature, the awareness of such an entity by the obstetricians-gynecologists is necessary in order to facilitate coordinated approach with the general surgeons and oncologists for the optimal care of the patients.

Less Is More: The Recent History of Neuraxial Labor Analgesia

Labor analgesia researchers have pursued better and safer ways to provide pain relief in labor. Although some pharmacologic investigations have focused on alternative mechanisms to target and medications to employ, a large part of the recent obstetric anesthesiology literature has contributed toward the safety and efficacy of techniques dependent on traditional therapeutics, specifically local anesthetics given through a neuraxial anesthetic technique. Investigators have worked to demonstrate and remove doubts that neuraxial anesthesia can be a safe method of labor analgesia. Pharmacodynamic studies during the last 3 decades have revealed ways to achieve adequate analgesia with minimal doses and correspondingly minimal risks. Dose-sparing opiate adjuncts to local anesthetics are now commonplace. To avoid excessive dosages, clinical up-down sequential allocation experiments identified the minimum amounts of local analgesia needed. Modifications to the administration of drug allowed total doses to be further reduced. This historical overview highlights some of these important advances in the present and recent past of neuraxial labor analgesia, and it traces how desired outcomes are being achieved with less and less total drug.

Caring for the Pregnant Woman With Neurofibromatosis

Neurofibromatosis (NF) is one of the most common inherited single-gene disorders in humans, and is expressed as two distinct types: Type I (von Recklinghausen disease) and Type II, which occurs much less frequently. When it was first reported in the obstetric literature in 1906 by Brickner, neurofibromatosis was called "fibroma moluscum contagiosum." This article presents a case of a 20-year-old woman with NF Type I who became pregnant. The clinical challenges of NF and pregnancy are explored through the collaborative relationships between the patient and two clinical nurse specialists from obstetric and neuroscience nursing. The case study provides valuable information for nurses who want to provide evidence-based care.

‘Decision to delivery’– assessment of maternity staff communication with anaesthetists in preparation for emergency caesarean sections

Guidelines exist for audit standards for emergency caesarean section delivery times. There is little in the obstetric literature focussing on communication with anaesthetists in preparation for emergency caesareans. This audit assessed two areas: the time the anaesthetist was notified about the caesarean after the obstetrician’s decision; and the person notifying the anaesthetist. Fifty-two emergency caesareans were assessed over a calendar month. A questionnaire was completed per delivery by the obstetric, midwifery and anaesthetic staff involved. Data analysis was via Excel spreadsheets. For category-1 deliveries, 100% of cases were communicated with the anaesthetist within 2 min of the decision to deliver. For category-2 deliveries, the anaesthetist was informed within 2 min for only 50% of cases. The mean (range) communication times was 6.3 min (0–28 min). The person communicating with the anaesthetist should ideally be an obstetrician of appropriate seniority. In category-1 sections, this was only achieved in 33% of cases. Category-2 sections achieved this in 38% of cases. This audit shows that anaesthetists are not promptly notified regarding emergency caesarean sections, and are often not notified by an obstetrician of appropriate seniority when these cases arise. After the decision is made to deliver a woman by caesarean section, the most senior obstetrician should contact the duty anaesthetist promptly [1]. This will allow discussion of the patient’s clinical issues, and improve anaesthetic assessment and management.

Low Molecular Weight Heparin to Achieve Live Birth Following Unexplained Pregnancy Loss: A Meta-Analysis.

Abstract 489 The management of recurrent pregnancy loss is uncertain. Some cohort studies have identified an association between inherited thrombophilias and recurrent or late-nonrecurrent pregnancy loss which has prompted investigators to evaluate the benefit of low molecular weight heparin to achieve live birth. A similar benefit for low molecular weight heparin has also been proposed independent of thrombophilia status. A recent Cochrane Review on this topic included the results of a single randomized trial in their analysis. As there are several recent randomized trials using low molecular weight heparin in women with recurrent pregnancy loss published in the obstetrical literature, we performed a meta-analysis to evaluate the benefit of low molecular weight heparin in women who experienced unexplained recurrent or late-nonrecurrent pregnancy loss. Methods: We conducted a meta-analysis of randomized controlled trials investigating the benefit of low molecular weight heparin versus a non-anticoagulant control arm in women with a history of ≥2 early pregnancy losses or ≥1 late pregnancy loss; we excluded women with antiphospholipid antibodies and those with an underlying cause of recurrent fetal loss, except for the hereditary thrombophilias. We planned to use random-effects analysis as the primary summary model due to the anticipated variations in enrollment criteria and interventions between the studies. Results: A total of 757 women were enrolled in five studies that satisfied the eligibility criteria. Using the random effects model, the risk ratio of fetal loss for low molecular weight heparin versus control was 0.49 (0.25-0.97 95% CI, P=0.04). There was significant heterogeneity observed between studies (Q-value was 15.59, P=0.004, and I2=74.33%). A priori, we identified the presence or absence of a hereditary thrombophilia as a potential source of heterogeneity. However, subgroup analysis of the studies according to the inclusion or exclusion of women with hereditary thrombophilia did not resolve the observed heterogeneity between studies. Exclusion of the only trial that enrolled women following a non-recurrent pregnancy loss improved the observed heterogeneity but diminished the apparent benefit of low molecular weight heparin (0.63, 95% CI 0.34-1.16, P=0.14). In this trial, the observed birth rate in the control arm was significantly lower than in the other two trials included in this meta-analysis with aspirin-only controls (29% versus 84% or 87% in aspirin-only arms, P&lt;0.001). Conclusion: There is a trend for increased live births when using low molecular weight heparin for the prevention of recurrent pregnancy loss. However, considering the observed heterogeneity across studies, there is insufficient evidence to support the routine use of low molecular weight heparin to improve pregnancy outcomes in women with a history of pregnancy loss. Disclosures: Off Label Use: low molecular weight heparin to prevent pregnancy loss. Bauer:Bayer Healthcare: Consultancy, Honoraria, Membership on an entity's Board of Directors or advisory committees; GSK: Speakers Bureau; GTC Biotherapeutics: Membership on an entity's Board of Directors or advisory committees. Zwicker:Sanofi-Aventis: Research Funding.

Angioedema hereditario en mujer embarazada con parto normal

There are few publications on hereditary angioedema (HAE) in the obstetrics literature. Hormone alterations can trigger a crisis and pregnancy affects the frequency of attacks. Familiarity with the diagnosis and treatment of this disease is vital because it does not respond to the routine management of allergic edema (adrenaline, antihistamines or steroids), and it can affect the glottis and cause death. The treatment of choice is infusion of complement C1 inhibitor protein.

Evaluation of Logistic Regression Reporting in Current Obstetrics and Gynecology Literature

Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan (Sokol) 2Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, Washington Hospital Center, Washington, DC (Kudish) Financial Disclosure The author has no potential conflicts of interest to disclose.

Evaluation of Logistic Regression Reporting in Current Obstetrics and Gynecology Literature

Evaluation of Logistic Regression Reporting in Current Obstetrics and Gynecology Literature

Update on the Use of Antihypertensive Drugs in Pregnancy

As the most common medical disorder of pregnancy, hypertension is reported to complicate 1 in 10 pregnancies1,2 and affects an estimated 240 000 women in the United States each year.3 Antihypertensive treatment rationale in this group represents a departure from the nonpregnant adult Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure guidelines.4 First, during pregnancy, the priority regarding hypertension is in making the correct diagnosis, with the emphasis on distinguishing preexisting (chronic) from pregnancy induced (gestational hypertension and the syndrome of preeclampsia). Second, much of the obstetric literature distinguishes blood pressure (BP) levels as either mild (140 to 159/90 to 109 mm Hg) or severe (≥160/110 mm Hg), rather than as stages (as in Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; Table 1). Third, in contrast to hypertension guidelines in adults, which emphasize the importance of systolic BP, much of the obstetric literature focuses on diastolic rather than systolic BP, in part because of the lack of clinical trials to support one approach versus another. The focus of treatment is the 9 months of pregnancy, during which untreated mild-to-moderate hypertension is unlikely to lead to unfavorable long-term maternal outcomes. In this setting, antihypertensive agents are mainly used to prevent and treat severe hypertension; to prolong pregnancy for as long as safely possible, thereby maximizing the gestational age of the infant; and to minimize fetal exposure to medications that may have adverse effects. During pregnancy, the challenge is in deciding when to use antihypertensive medications and what level of BP to target. The choice of antihypertensive agents is less complex, because only a small proportion of currently available drugs have been adequately evaluated in pregnant women, and many others …

Evaluation of Logistic Regression Reporting in Current Obstetrics and Gynecology Literature

To evaluate the quality of logistic regression reporting in the obstetrics and gynecology literature. All original papers published in 2005 and 2006 in four leading obstetrics and gynecology journals were manually searched for the use of logistic regression. One hundred four articles that used logistic regression were randomly selected (13 from each journal and each year) and evaluated according to previously established criteria for reporting logistic regression analyses. Rates of compliance with these criteria were calculated separately for each journal and weighted according to the number of articles using logistic regression in each of the journals in the same period to obtain an overall estimate. Logistic regression was used in 34.2% of all original research articles (724 of 2,234) in the four journals for the study period. Statistical significance of estimates was reported in 96% of examined articles. Criteria of variable selection for the logistic regression model were reported in 76% of articles, and coding of variables was described in 83%. Overfitting (models with too many variables for the number of outcome events) occurred in 57% of studies. The majority of examined articles insufficiently reported information for the remaining criteria-testing for interactions (18%), conformity to a linear gradient of continuous variables (9%), goodness of fit (3.6%), assessment of multi-collinearity (0.46%), and validation of the model (0%). Logistic regression has become a standard statistical method in obstetrics and gynecology literature. Although some standards are mostly fulfilled, there is still considerable room for improvement. III.

The Shaken Baby Syndrome: An Odyssey -II Origins and Further Hypotheses-

Subdural bleeding in the so-called "shaken baby syndrome" is recognized as a hallmark of this syndrome, and is often noted as chronic in nature, indicating an earlier time of origin than clinical presentation. In infants and neonates, the timeframe for generating such chronic intracranial bleeding is therefore limited. Neurosurgical, obstetric, and pediatric literature all recognize the significance of birth trauma in the generation of intracranial bleeding. This possibility is explored further here, with emphasis on features peculiar to Homo sapiens predisposing to intracranial bleeding during this timeframe. Encephalization and bipedalism combine to render the infant and mother susceptible to injury at birth.

Simulation and simulator technology in obstetrics: past, present and future

Healthcare has come to appreciate the value of simulation and its role in education, training, evaluation and research. This article reviews simulator technology and the role of simulation in obstetrics. The scope and nature of the obstetric literature published between January 1950 and July 2007 were reviewed. A total of 84 out of the 305 articles identified met criteria for inclusion in this review, most (59/84) having been published since 2000. The field of obstetrical simulation has grown substantially over the past decade. Thus far, the literature supports simulation as an essential tool for practicing routine and critical events, and improving technical proficiency and teamwork. Simulation can serve as a strategy for improving procedural and behavioral skills, potentially mitigating adverse perinatal events. More research is needed to determine whether obstetrical simulation leads to a significant reduction in the risk of birth-related injury and improved birth outcomes.

Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation: a cautionary case

Massive hemorrhage from abnormal placentation is a leading cause of postpartum maternal death and hysterectomy after cesarean section. The endovascular surgeon and radiologist are increasingly asked to assist in the management of these complex patients with the placement of bilateral internal iliac artery balloon catheters. We report the case of a 27-year-old woman with placenta percreta with preemptive bilateral internal iliac artery balloons who had iliac artery thrombosis and acute limb ischemia develop 7 hours after cesarean hysterectomy. This is the first report of iliac artery thrombosis in this setting. A review of the vascular and obstetrical literature reveals divergent recommendations for the use of this technique in patients with abnormal placentation. No guidance from rigorous prospective evidence is available and thus we offer recommendations for the cautious use of this modality.

A diagnosis not to miss: Pheochromocytoma during pregnancy

Sirs: Pheochromocytoma during pregnancy is a life-threatening situation for both mother and fetus. Its diagnosis is too often missed [1, 2], mainly due to three reasons. Firstly, pheochromocytoma is extremely rare with an estimated prevalence in full-term pregnancies of 1 in 54,000 [3]; secondly, it has the ability to mimic a huge number of acute, insidious clinical syndromes and the tumor has been correctly termed the “Great Masquerader” [1]; thirdly, pheochromocytoma can be asymptomatic until delivery. Classic attacks include acute hypertension, headache, sweating and tachycardia. However, patients can be completely free of manifestations between attacks. Thus, diagnosis of pheochromocytoma during pregnancy remains a great challenge, but is essential to prevent disastrous complications for both mother and fetus [2, 4]. Although a few recent reports exist in the obstetric and anesthetic literature on this condition, curiously, to our knowledge there are no reports in recent neurological literature. A 30-year previously healthy woman in the 26th week of her first pregnancy was referred from her gynecologist because of new-onset headache. Symptoms had started six weeks earlier with pain in the neck, lightheadedness, nausea and vomiting after prolonged sunbathing. While all symptoms vanished with bed rest, a stabbing neck pain persisted, which during the next two weeks evolved into a daily occipital squeezing headache of mild intensity, intermingled with periodic pulsating neck pain. Subsequently, she developed episodic frontal throbbing headaches of moderate to severe intensity, accompanied by nausea, vomiting and hyperventilation. Episodes occurred up to five times daily and lasted from a few minutes to one hour. On two occasions the patient had noted a scintillating scotoma in the left visual field. She had no history of migraine. Since proteinuria and edema were absent, preeclampsia had been ruled out by her gynecologist prior to referral. Neurological examination, including fundoscopy, was unremarkable. The patient had no fever and blood pressure was 130/85 mmHg in both arms. Routine laboratory testing revealed mild leucocytosis and trombocytosis, slightly increased C-reactive protein and liver enzymes, but normal thyroid function and blood glucose. While the initial symptoms were consistent with aseptic meningitis secondary to heat stroke and prolonged sunbathing, the subsequent complaints were neither fully compatible with migraine nor with any other primary headache syndrome. MRI of the head including MR angiography and a lumbar puncture were normal and thus, cerebral venous thrombosis, vascular malformations, vasculitis, hemorrhagic and ischemic cerebrovascular accidents, infectious or neoplastic processes, and sinusitis were ruled out. However, on day three after admission the patient was observed during a severe headache with marked tachycardia, sweating, pallor, tremor and anxiety. Blood pressure was 220/110 mmHg, pulse rate 115 beats/min. A working diagnosis of pheochromocytoma was made. Repeated 24 hour urinary catecholamine testing revealed increased levels of norepinephrine (3,200–20,000 nmol; reference interval 62–560 nmol), epinephrine (240–620 nmol; 9–101 nmol), metanephrines (32–115 μmol; 5–7 μmol), aldosterone (260–280 nmol; 11–56 nmol) and vanillylmandelic acid (85–280 μmol; < 34 μmol). MRI of the abdomen showed a 6x6 cm solid right adrenal mass (Fig. 1). The patient’s family history was unremarkable for neuroendocrine tumors. Genetic testing of the patient for mutations of RET, VHL, SDHB and SDHD genes was negative. Using a multidisciplinary approach involving endocrinologists, anesthetists, surgeons and neonatologists, it was decided to treat the patient with phenoxybenzamine (α-adrenoceptor antagonist) and await fetal maturity. Headaches vanished completely. In the 31st week of pregnancy the patient underwent an uncomplicated caesarean section combined with removal of the adrenal mass. Microscopic evaluation confirmed the diagnosis of pheochromocytoma. Pheochromocytoma is a catecholamine-producing tumor arising from the adrenal medulla in 85 % of cases and in the remaining patients from chromaffin cells in or about sympathetic ganglia in the abdomen, pelvis, and rarely in the chest or neck [1]. Tumors with a comparable biochemical and clinical profile include some chemodectomas derived from the carotid body and neuroblastomas; the LETTER TO THE EDITORS

Nitrofurantoin Neuropathy

Nitrofurantoin is a widely prescribed antibiotic used to treat uncomplicated lower urinary tract infections. Unknown in the obstetric and gynecologic literature is the complication of peripheral neuropathy as an adverse effect. We describe a patient who developed a severe sensory neuropathy after taking nitrofurantoin intermittently and then continuously over a 7-year period. She recovered almost completely after its discontinuation. Peripheral neuropathy is a rare and potentially reversible adverse effect, unreported in the obstetric and gynecologic literature, and commonly unrecognized by physicians who prescribe it.

Anaesthesia for caesarean section in a patient with acute generalised pustular psoriasis

We describe a 30-year-old parturient with acute generalised pustular psoriasis who presented for urgent caesarean section. A multidisciplinary team was involved and general anaesthesia was used successfully. Management of this condition is discussed and the literature reviewed. While generalised pustular psoriasis or impetigo herpetiformis is well recognised in pregnancy, it has not hitherto been reported in obstetric anaesthesia literature. The purpose of this article is to delineate the clinical picture of this disease, its treatment, and the effect on the mother and the fetus.