Patients In Third Trimester Research Articles

Cluster of differentiation 4/cluster of differentiation 8 ratio of T-lymphocyte subsets in Egyptian patients with severe pre-eclampsia

This study was designed to evaluate the immunological role of CD4+Tcells, CD8+ T cells in the pathogenesis of severe pre-eclampsia. Consequently, we estimated their blood levels and the CD4+/CD8+Tcells ratio among patients with pre-eclampsia. The study included 50 primigravid patients in third trimester, recruited from El-Shatby Maternity University Hospital. After obtaining informed written consents, they were divided into two groups: Group A included 25 patients with severe pre-eclampsia, and Group B included 25 normal pregnant women. All patients underwent thorough history taking, complete clinical examination and ultrasound evaluation for fetal condition. Then the percentages of blood CD4+ T cells and CD8+ T cells were estimated via flow cytometry and CD4+/CD8+ T cells ratio was calculated. Patients with severe pre-eclampsia in Group A revealed an increase in CD4+ T cells and a decrease of CD8+ T cells together with an increase in CD4+/CD8+ T cells ratio in comparison with the normal pregnancy (Group B). These differences were statistically significant (p=0.041, p=0.0001 and, p=0.0001, respectively). In addition, there was a positive correlation of blood CD4+ T cells, CD8+ T cells, CD4/CD8 T cells ratio and severe pre-eclampsia. In conclusion, estimation of the percentage of CD4+ T cells, CD8+ T cells and their ratio may be used as a marker to predict pre-eclampsia and confirm its severity.

Placental apoptotic index on COVID-19 and non-COVID-19 cases: a cross sectional study

Backgrounds: Rare cases of COVID-19 vertical transmission are reported, even though abnormal findings on placenta histopathology are frequently reported on SARS-CoV-2 infected pregnancies. However, no publications report the impact of COVID-19 infection on the placental apoptotic index. Apoptosis is a physiological process of cell regeneration. SARS-CoV-2 infection during pregnancy may disturb the respiration system, causing hypoxia, thus altering placental perfusion. COVID-19 infection also increases inflammatory mediators, producing reactive oxygen species and affecting placenta tissue in viremia cases. These processes can cause caspase cleavage, resulting in programmed cell death and apoptosis. This study aims to know whether COVID-19 infection with various degrees of symptoms affects placental apoptosis. Methods: This is a retrospective, cross sectional study. We conduct a study on 34 placenta blocks of COVID-19 pregnancy and 31 placenta blocks of non-COVID-19 pregnancy. The PCR of nasopharyngeal swabs performed on third-trimester patients in Dr. Soetomo Hospital meets the inclusion and exclusion criteria. Those placenta samples were processed into slides and painted with a TUNEL assay kit. Slides are then examined and rated for apoptotic index. Results: The majority of these patients are multiparous women. Sixty-five patients were included in the study, 2 died, and 63 others lived. Comparison between COVID-19 positive and non-COVID-19 placental apoptotic index shows a significant difference between both groups (p=0.001). Conclusion: From this study, we can conclude that there is a significant difference in the apoptotic index of the placenta between COVID-19-positive and negative pregnancies.

Intrahepatic Cholestasis in Pregnancy: Increased Surveillance and the Role of Bile Acids in a Patient with History of Fetal Demise

Intrahepatic cholestasis of pregnancy (ICP) is a known risk for fetal demise and premature delivery. We describe the case of a third-trimester patient with ICP that would have gone unnoticed based on laboratory reporting. Symptoms presented two weeks after laboratory values consistent with ICP were obtained, and serial labs fell below the threshold despite persistent symptoms. The diagnosis was further complicated when the types of bile acids and the ranges for normal varied between facilities. We emphasize the importance of assessing lab values objectively and investigating the causes of pregnant patients' itching.

Investigation of transvaginal and transabdominal ultrasound and bladder fullness in the evaluation of cervical length in low-risk pregnant women

Objective Cervical length is an important ultrasonographic marker used to predict cervical insufficiency and preterm labor. Our aim in this study was to compare TA and TV cervical lengths in three trimesters and to investigate the effect of bladder fullness on TA measurements. Methods This study was planned as a prospective cross-sectional study and low-risk pregnant women between 11–37 weeks who presented to the hospital were included in the study. The patients were divided into three groups according to their trimesters, and the cervical lengths of the patients were assessed first with TA and then TV ultrasound with a full bladder and then an empty bladder. Results The mean cervical length was 45.6±7.0 cm in first-trimester patients, 42.8±7.0 cm in second-trimester patients, and 41.0±8.5 cm in third-trimester patients. Although TV cervical length was longer in all three trimesters, no statistically significant difference was found between TV and TA ultrasound with a full bladder (p>0.05). When TA ultrasound with empty bladder and TV ultrasound were compared, the TV measurements were found to be statistically significantly longer in each trimester (p<0.05). It was shown that parity number, fetal presentation, and obesity did not affect TV or TA assessment with a full bladder (p>0.05). Conclusion TV and TA assessment with a full bladder were found similar in all three trimesters. TA ultrasound with a full bladder can be safely used for cervical length measurement in low-risk patients in every trimester.

Bone Health Assessed by Calcaneal Quantitative Ultrasound among Cohort of Pregnant Egyptian Women.

Aim:The aim was to assess the risk of osteopenia and osteoporosis and to identify possible risk factors affecting bone density (BD) during pregnancy as parity, body mass index (BMI), Vitamin D, and calcium supplementation using quantitative ultrasound (QUS) of the calcaneus among first- and third-trimester pregnant women.Methods:It is a case–control study conducted at Ain Shams Maternity Hospital, Egypt, from May 7 to December 14, 2015. One hundred and thirty-two women in the third trimester and 33 matched controls in the first trimester were screened for BD at the calcaneus by QUS. Stiffness index (SI), QUS-T, and Z scores were measured.Results:Comparing both the groups regarding QUS-T score, Z score, and SI showed a statistically significant difference between both groups. Third-trimester participants had lower scores (−0.72 ± 1.0, −0.63 ± 0.99, and 88.53 ± 14.81, respectively) compared to their matched controls (1.05 ± 0.89, 1.16 ± 0.91, and 113.79 ± 12.49, respectively). According to QUS-T scores, 82 women (62.1%) in the third-trimester group were assessed as having normal BD, whereas 47 women (35.6%) were at risk of being osteopenic and 3 women (2.3%) were at risk of being osteoporotic. All women of the first trimester were assessed as having normal BD. Logistic regression was performed to identify possible risk factors affecting BD among third-trimester patients. BMI was the only statistically significant predictor for changes in bone health in those women (P = 0.001, odds ratio: 0.857, 95% confidence interval: 0.786–0.936).Conclusion:With one-unit rise in BMI, a 14% reduction in risk of decreased bone health is obtained.

Serum uric acid level between normotensive and pre-eclamptic patients in third trimester of pregnancy and perinatal outcome

Background : Preeclampsia is associated with maternal and neonatal complications. It has been indicated that increased uric acid might have a predictive role on preeclampsia. Several studies have demonstrated a relation between elevated maternal serum uric acid levels and adverse maternal and fetal outcome. The aim of this study was to find out the association of serum uric acid level between normotensive and pre-eclamptic (PE) patients in third trimester of pregnancy and perinatal outcome.
 Methodology : A case control study was conducted in the department of the Obstetrics and Gynaecology in Dhaka Medical College Hospital from July 2017 to June 2018. A total number of 100 pregnant women in third trimester of pregnancy attending in Obstetrics and Gynaecology department of Dhaka Medical College Hospital were selected purposively as study subjects. Among them 50 diagnosed cases of preeclampsia were selected as cases with age range of 18-35 years and 50 normal healthy age matched pregnant women as controls. Pregnant women with pre-existing hypertension, diabetes mellitus and renal disease were excluded from the study by history, clinical examination and relevant laboratory investigations.
 Results : The mean serum uric acid level was found 4.49±1.72 mg/dl in normotensive group and 7.03±1.89 mg/dl in preeclampsia group. Serum uric acid was significantly higher (p<0.05) in pre-eclampsia group than normotensive group. Regarding outcome take home as alive neonate was found 48(96.0%) in normotensive group and 41(82.0%) in preeclampsia group. Early neonatal death was 1(2.0%) in normotensive and 4(8.0%) in pre-eclampsia group. Still birth was 1(2.0%) and 5(10.0%) in normotensive and pre-eclampsia group respectively.
 Conclusion : Hyperuricemia is most basic and reliable observations in pre-eclamptic pregnancies. While elevated concentrations of circulating uric acid are not uniformly increased in every woman with PE. But hyperuricemia is found in a subset of pre-eclamptic women who had higher risk for maternal and fetal complications. Therefore, measurement of serum uric acid concentration seems to be a useful test to predict maternal and fetal complications in a women with preeclampsia.
 Northern International Medical College Journal Vol. 11 No. 1 July 2019, Page 419-422

866 Meeting the Challenge of Analgesia in a Pregnant Woman with Burn Injury Using Subanesthetic Ketamine: A Case Report

Abstract Introduction Burn injury is the fourth most common form of trauma worldwide, requiring unique management considerations and a collaborative approach to treatment. Thermal injuries sustained during pregnancy add considerably to case complexity. Overall, there is a low incidence of burns in gravid women living in developed countries, making management guidelines in this patient population scarce. Despite few data, it is recognized that early intervention and inter-disciplinary treatment are critical to optimize maternal and fetal outcomes. Thus, interventions including fluid resuscitation, excision and grafting, routine debridement and dressing changes, antibiotic administration, and early mobilization are the cornerstones of management. Effective pain management is crucial in allowing patients to tolerate these often-painful procedures, engage in rehabilitation, and to prevent pain-related morbidity. Methods The patient is a 34-year-old G5P3013 in her third trimester of pregnancy, who sustained partial and full thickness burns to 18% of total body surface area in a grease fire. She was brought to the ED approximately 2 hours post-injury by EMS. During her hospital stay, Acute Pain Management Service (APMS) was consulted for a comprehensive pain management plan. APMS recommendations included IV acetaminophen, hydromorphone PCA, gabapentin, and ketamine infusion with a reduced dose bolus for procedural analgesia. Risks and benefits of these medications were explained to patient and her family by the APMS, Maternal-Fetal Medicine, and the Burn team, stressing the importance of tolerating routine burn care to decrease morbidity. Although human data are limited, it was explained that low doses (as outlined in our regimen) present little fetal risk in animal models. Results The patient was discharged at hospital day 11 and seen for burn follow-up after 2 weeks post-discharge (35 weeks gestation) with returning color, no evidence of hypertrophy, and overall excellent wound healing. Patient reported no pain, and her pain regimen was discontinued. Patient demonstrated significant improvement in her injuries, and had a normal spontaneous vaginal delivery of a live born male 7 weeks post discharge, with APGAR scores of 8 and 9 at 1 and 5 minutes, respectively. Additionally, the patient brought her infant to the office visit and conveyed that the child was consistently reaching pediatric milestones. Conclusions Ketamine may be considered as an adjunct for procedural and background analgesia during the third trimester, as part of a multi-modal strategy in a short-term, monitored setting after a thorough and complete analysis of risks and benefits and careful patient selection. Applicability of Research to Practice Procedural pain management in a third-trimester burn patient.

Comparison between abdominal ultrasound and nuclear magnetic resonance imaging detection of placenta accreta in the second and third trimester of pregnancy

This study is to determine accuracy of abdominal ultrasound and nuclear magnetic resonance imaging (MRI) for placenta accreta in the second and third trimester of pregnancy and to define the most relevant features of abdominal ultrasound and MRI for placenta accreta prediction.Between September 2012 and September 2018, 245 high risk of placenta accreta in the second trimester of pregnancy were prenatal diagnosed by abdominal ultrasound and MRI and they were followed up until the end of pregnancy.Forty-six patients at the second trimester of pregnancy and 40 patients at the third trimester of pregnancy were confirmed as placenta accreta. For the second and third trimester of pregnancy, the sensitivity (Se), specificity (Sp), positive and negative predictive value (PPV and NPV) of abdominal ultrasound were 95.65% versus 97.50%, 91.78% versus 90.70%, 88% versus 83%, and 97% versus 99%, respectively, while the Se, Sp, PPV, and NPV of MRI were 89.13% versus 92.50%, 87.67% versus 8721%, 82% versus 77%, and 93% versus 96%, respectively. Five features having significant statistical differences between normal placentation women and placenta accreta patients in second or third trimester of pregnancy, including loss of the normal retroplacental clear space, thinning or disappearance of the myometrium, increased vascularization at the uterine serosa-bladder wall interface, and vascularization perpendicular to the uterine wall on abdominal ultrasound, and uterine bulging and dark intraplacental bands on MRI.Abdominal ultrasound and MRI for placenta accreta in the second and third trimester of pregnancy could provide meaningful imaging evidences.

ASSESSMENT OF GESTATIONAL AGE

Objective: To compare correct assessment of gestational age betweenTranscerebeller diameter versus femur length in third trimester (28-40) using first day of lastmenstrual period for actual period of gestation. Study Design: Cross-sectional descriptive study.Place and Duration of Study: Department of Obstetrics and Gynecology, Bahawal VictoriaHospital, Bahawalpur from Jun 2012 to Dec 2012. Methodology: This study was performed on327 patients in third trimester of pregnancy from 28-40 weeks fulfilling the inclusion criteria.Ultrasound measurements of transcerebellar diameter (TCD) and femur (FL) were made withcommercially available real time ultrasound equipment Toshiba Nemio-10 model 2009,Transducer frequency 50/60 Hz. Collected data was analyzed by SPSS version 10. Results: Outof 327 patients, TCD was found to give correct assessment corresponding to the gestational ageby LMP in 262 (80.1%) patients, while in 232 (70.9%) patients FL was found to give correctassessment corresponding to the gestational age by LMP. Conclusions: Transcerebellardiameter is more reliable method of gestational age determination in third trimester of pregnancythan femur length. TCD can be used as a tool to assist in the assessment of gestational age inthird trimester.

The Coagulation Profile on Pregnancy Induced Hypertensive Patients in Third Trimester of Pregnancy – The Prospective and Observational Study

The Coagulation Profile on Pregnancy Induced Hypertensive Patients in Third Trimester of Pregnancy – The Prospective and Observational Study

Neonatal and maternal outcome in oligohydramnios: a prospective study

Background: Oligohydramnios presents a threat to the fetus and has been correlated with increased risk of intrauterine growth retardation, meconium aspiration syndrome, severe birth asphyxia, low APGAR scores and congenital abnormities. It is associated with perinatal morbidity and mortality and maternal morbidity in a significant number of cases. Therefore, early detection of oligohydramnios and its management is important. Aim of this study was to know the fetal and maternal outcome in oligohydramnios.Methods: 90 patients in third trimester of pregnancy with Oligohydramnios were selected after satisfying inclusion and exclusion criteria. A detailed history and examination were done. All required investigation done. Oligohydramnios confirmed by measuring Amniotic fluid index (AFI).Results: Mean maternal age-26.1 years. Incidence of oligohydramnios was more in primipara (64.4%) in our study. And operative morbidity was also more in primipara (51.7%). Most common cause of Oligohydramnios was idiopathic (44.44%). Operative morbidity was significantly higher in Non-reassuring FHR (80%) than reassuring FHR (32%). 7 patients (7.78%) were found with fetoplacental insufficiency on Doppler study.Conclusions: Oligohydramnios is frequent occurrence and demands intensive fetal surveillance and proper antepartum and intrapartum care so that perinatal morbidity and mortality and maternal morbidity can be reduced.

Levels of alloantibodies to human platelet antigen in relation to blood dyscrasia occurring at various trimesters of pregnancy

Context Thrombocytopenia is major complication in complicated and uncomplicated pregnancies. Aims The aim of this study was to determine the incidence of thrombocytopenia in pregnancy and determine possible immune thrombocytopenia correlates with blood dyscrasia involving other cellular components of blood. Settings and design The study was an institution-based cross sectional study. Participants and methods The full blood count of 200 women attending an antenatal center was determined. Sera of 73 (36.5%) thrombocytopenic women defined by a platelet count less than 80×10 9 /l and inadequate platelet in the peripheral blood film were evaluated for circulating antiplatelet antibody directed against platelet membrane glycoprotein GPIIb/llla. Statistical analysis Pearson and Kendall's tau-b correlation analysis was carried out on data using the SPSS (PASW version 18) statistical package. Results The antibody was detected in two (3%), 13 (17%), and 44 (60%) of the subset of patients in the first, second, and third trimester, respectively. Fourteen (20%) of the women had no detectable antiplatelet antibody. The idiopathic immune thrombocytopenia observed in the patients was associated with anemia and leukopenia in four (9%) patients in the third trimester of pregnancy. A significant correlation was observed between thrombocytopenia and the red cell count, hemoglobin concentration, and packed cell volume of the women. Irregular attendance at an antenatal clinic and nonutilization of hematinic were evident in groups of thrombocytopenic and anemic women. There was a negative correlation between the occurrence of antiplatelet antibody and the severity of thrombocytopenia. Conclusion There is a need to distinguish immune thrombocytopenia from gestational thrombocytopenia and assess other blood parameters in pregnancy for a proper clinical intervention.

Atraumatic Subdural Hematoma in a Third-Trimester Gravid Patient.

Acute atraumatic subdural hematoma is a rare occurrence and there exist few case studies which describe suspected cases and causes for this condition. We present a case of a 36-year-old female at 32-week gestation who initially presented to the emergency department for evaluation of lower extremity cellulitis but had acute neurologic change while being in the ED. Computed tomography revealed a right subdural hematoma with midline shift and mass effect. The primary cause for the patient's subdural hematoma is unknown; however, this patient had several risk factors for developing an atraumatic subdural hematoma.

A quantitative investigation of hemodynamic adaptation to pregnancy using uterine artery Doppler ultrasonography and finger photoplethysmography

Objective: Normal pregnancy is characterized by maternal hemodynamic adaptations of cardiovascular system and uterine artery. We aimed to investigate quantitatively the relationship between uterine artery Doppler (Ut AD) ultrasonography and finger photoplethysmography (PPG) in each of the three trimesters. Methods: Eighty normal pregnancy subjects were recruited from the nulliparous women with uncomplicated singleton pregnancy presenting for a routine ultrasound scan and divided into three groups according to their trimester. Comparative analysis were conducted between Ut AD ultrasonography and finger PPG within and across trimesters, particularly with focus on the relationship between Uterine Artery Resistance Index (UtA RI) and photoplethysmographic reflection index (PPG RI) throughout pregnancy. Additional 10 preeclampsia patients in third trimester were enrolled for comparison. Results: Both UtA RI and PPG RI were markedly decreased with gestation in normal pregnancy and generally consistent with each other in trend. The preeclampsia patients of third trimester were significantly higher in both indices, even more than normal pregnancy subjects of first trimester. Conclusions: The results of this study revealed clear relationship between UtA RI and PPG RI throughout pregnancy which could be exploited to enhance the potential ability in early recognition of pathophysiologic process in maternal adaptation and prediction of complicated pregnancy.

Maternal and fetal outcome in oligohydramnios- Study of 100 cases

Background: Decrease in amniotic fluid volume or Oligohydramnios has been correlated with increased risk of intrauterine growth retardation, meconium aspiration syndrome, severe birth asphyxia, low APGAR scores and congenital abnormities. Early detection of oligohydramnios and its management may help in reduction of perinatal morbidity and mortality one side and decreased caesarean deliveries on the other side. Aims & Objective: (1) To study affects Oligohydramnios on fetal outcome in form of (a) Fetal distress (b) Growth retardation (c) NICU admission (2) To study APGAR scores of newborn babies in relation to Oligohydramnios (3) To study incidence of congenital malformation (4) To study early neonatal morbidity and mortality (5) To study maternal morbidity in form of operative delivery and induced labour. Material and Methods: Present study was done over a period from May 2009 to November 2011. 100 patients in third trimester of pregnancy with Oligohydramnios selected randomly after satisfying inclusion and exclusion criteria. A detailed history and examination were done. All required investigation done. Oligohydramnios confirmed by measuring AFI. Results: Mean maternal age-23.66 years. Incidence of oligohydramnios was more in primipara (52%) in our study. And operative morbidity was also more in primipara. Most common cause of Oligohydramnios is idiopathic (52%). Second commonest cause is PIH (25%). Operative morbidity is highest in PIH (60%). Operative morbidity was significantly higher in NST (non-stress test) non-reactive (3.12 ± 75=78.12%) group than NST reactive (26.47%) group. Most common reason to perform caesarean was fetal distress which was either due to cord compression or IUGR. 7% patients were found with fetoplacental insufficiency on Doppler study. Oligohydramnios was related to higher rate of growth retardation and NICU (neonatal intensive care unit) admission. Conclusion: Oligohydramnios is frequent occurrence and demands intensive fetal surveillance and proper antepartum and intrapartum care. Due to intrapartum complication and high rate of perinatal morbidity and mortality, rates of caesarean section are rising, but decision between vaginal delivery and caesarean section should be well balanced so that unnecessary maternal morbidity prevented and other side timely intervention can reduce perinatal morbidity and mortality.

Evaluation of Amniotic Fluid Volume among Sudanese Diabetic Patients in Third Trimester Using Ultrasound

Assessment of amniotic fluid volume in diabetic pregnancies is important for maternal and fetus health judgment and pregnancy outcome and for this reason the purpose of this study is relevant using two ultrasonographic methods. The study included 49 Sudanese pregnant women with diabetes mellitus and 20 subjects as control group .The study was conducted at Omdurman Military hospital and Al -Saudi hospital in the period from December 2011 to April 2012. Ultrasound was done by using Mindray 6600, 2200 ultrasound machine fitted with 3.5 MHZ convex probe. Amniotic fluid volume (AFV) was measured by largest pocket and Amniotic fluid index (AFI) .The mean AFI for control group was found to be (16.6±2.4) and the largest pocket was (6.6±0.7),for diabetic sample AFI was (20.3±5.6), largest pocket was (7.4±1.9).T-test showed that AFI was found to be 4.66 at p <0.001, largest pocket was 2.93 at p-value 0.005. There is significant difference between AFI measurements and largest pocket for diabetic pregnant ladies compared to the control group.Measurements of AFV using ultrasound compared with type of diabetic and diabetic status is of great value to categorize the relative risk of complications related to diabetes.

Surgical Management of Acute Right Lower-Quadrant Pain in Pregnancy: A Prospective Cohort Study

The etiology of right lower-quadrant pain in pregnant patients is a challenge in diagnosis. We discuss the surgical issues among pregnant patients with right lower-quadrant pain and demonstrate the method to diagnosis. This was a prospective cohort study with enrollment during 2 years. Pregnant patients presenting with acute right lower-quadrant abdominal pain and requiring surgical consult were included. Demographics, gestational age, symptoms, workup, operative results, and pathology were recorded. One-hundred patients were enrolled, 38 had nonspecific abdominal pain, 15 of whom were admitted. There were no differences in temperature, leukocyte count, and neutrophil shift among the admitted and nonadmitted patients. Forty-one patients underwent surgery and had a substantially higher gestational age, leukocyte count, and neutrophil shift than those who did not. Ultrasound was performed considerably more often on first-trimester patients (81.6%) compared with second- (58.1%) and third-trimester (57.9%) patients, and CT scan was used considerably less in the first trimester compared with the second and third trimesters, and considerably less than ultrasound for the first trimester. Sensitivity of ultrasound for appendicitis was inversely correlated to fetal gestational age, and CT scan retained high sensitivity and specificity throughout pregnancy. This is one of the first prospective studies assessing diagnoses and workup of pregnant patients with right lower-quadrant pain. We recommend abdominal ultrasound be the first imaging modality for patients for whom surgical consultation is necessary, thereby determining if the pathology is obstetric. If inconclusive, a CT scan is necessary to guide treatment.

Laparoscopy: a safe approach to appendicitis during pregnancy

The aim of this study was to evaluate laparoscopic versus open surgery for suspected appendicitis during pregnancy. A hospital-based retrospective review of 65 consecutive pregnant patients who underwent surgery for suspected appendicitis from 1999 to 2008 was performed. Significance was determined by Pearson's chi(2) test, Fisher's exact test, Mann-Whitney test, and Kruskal-Wallis test. Of the 65 patients, 48 cases were laparoscopic and 17 open. Use of the laparoscopic versus open approach was significantly increased in the first (100% vs. 0%, p < 0.001) and second trimesters (73% vs. 27%, p < 0.001). The open approach was used more frequently in third-trimester patients (71% vs. 29%, p = NS). Significance was demonstrated in mean length of hospital stay in the laparoscopic versus open group (3.4 vs. 4.2 days, p = 0.001). No maternal mortalities occurred. Follow-up of fetal outcome was achieved in 89% of patients. No difference was demonstrated in fetal loss (1 in laparoscopic group), APGAR score, birth weight, and preterm delivery rate by operative approach. Adverse outcome was associated with maternal temperature greater than 38 degrees C, leukocytosis greater than 16 x 10(9)/l, or more than 48 h between onset of symptoms and emergency room presentation. This article is the largest hospital-based series evaluating the laparoscopic versus open approach for pregnant patients with presumed acute appendicitis. While methodological limitations preclude a definitive recommendation, laparoscopy appears to be a safe, feasible, and efficacious approach for pregnant patients with presumed acute appendicitis. We conclude that it is likely not the surgical approach but the underlying diagnosis combined with maternal factors that determine the risk for pregnancy complications. A benefit of laparoscopy is the diagnostic ability to identify other intra-abdominal pathology which may mimic appendicitis and harbor pregnancy risks.

The Feasibility of Adding Fetal Heart Rate to the Nocturnal Polysomnogram

To demonstrate that fetal heart rate measured by ultrasound can be successfully captured and monitored throughout the nocturnal polysomnogram. Fetal heart rate by ultrasound using an abdominal belt (Hewlett Packard Fetal Monitor 8040A) was measured during 1 overnight polysomnogram in volunteers in late pregnancy and added to a digitized polysomnography system (Alice 4, Respironics). In 6 women with a single fetus in their third trimester, the fetal heart rate monitor band only infrequently needed to be readjusted. Fetal kicks and movements resulted in signal loss, usually with subsequent recapture without having to awaken the mother. Fetal heart rate, 1 of the classic signals of fetal distress, can be added to the nocturnal polysomnogram with minimal disruption of maternal sleep and with signal capture throughout the night.

Laparoscopic management of a nonobstetric emergency in the third trimester of pregnancy

Laparoscopic management of nonobstetric acute abdominal pain during pregnancy remains controversial. A gestational age of 26 to 28 weeks has been considered the upper limit for laparoscopy by some authors. A case series of nonobstetric surgery in advanced pregnancy is reported. Third-trimester patients who underwent surgery between 1997 and 2006 were reviewed. Laparoscopic surgery was performed for nonobstetric emergencies during the third trimester for 11 patients. Four patients underwent open surgery. The laparoscopic surgery group included five cholecystectomies, four appendectomies, and two adenexal surgeries. The laparoscopic surgery procedure was successfully completed for 10 patients. Of these 10 patients, 9 had no complications and went on to deliver a healthy term infant. One patient went into preterm labor after a laparoscopic appendectomy for perforated acute appendicitis with purulent peritonitis and delivered a viable infant at 34 weeks. Another patient at 29 weeks of gestation underwent a diagnostic laparoscopy for abdominal pain. Adenexal torsion of a large multicystic ovarian mass led to a laparotomy (obstetrician preference) and right salpingo-oophrectomy. Her postoperative course was complicated by an episode of sudden syncope, hypotension, and fetal distress on postoperative day 3. An emergent laparotomy showed hemoperitoneum attributable to bleeding from the ovarian pedicle. A cesarean section delivery of a preterm infant requiring neonatal resuscitation was performed. The open surgery group included four patients. Two of the patients underwent appendectomies at 35 and 33 weeks, respectively, followed by a term delivery. The remaining two patients underwent emergent colectomies with a cesarean section delivery at 31 and 38 weeks, respectively. This study demonstrated that laparoscopic surgery in the third trimester of pregnancy is feasible and can be performed safely with an acceptable risk to the fetus and the mother. Access to the pregnant abdomen is easily obtained. Space generally is not a problem, and there is minimal uterine manipulation.