Postpartum Patients Research Articles

Findings From Severe Maternal Morbidity Surveillance and Review in Maryland

In the US, more than 50 000 women experience severe maternal morbidity (SMM) each year, and the SMM rate more than doubled during the past 25 years. In response, professional organizations called for birthing facilities to routinely identify and review SMM events and identify prevention opportunities. To examine SMM levels, primary causes, and factors associated with the preventability of SMM using Maryland's SMM surveillance and review program. This cross-sectional study included pregnant and postpartum patients at 42 days or less after delivery who were hospitalized at 1 of 6 birthing hospitals in Maryland between August 1, 2020, and November 30, 2021. Hospital-based SMM surveillance was conducted through a detailed review of medical records. Hospitalization during pregnancy or within 42 days post partum. The main outcomes were admission to an intensive care unit, having at least 4 U of red blood cells transfused, and/or having COVID-19 infection requiring inpatient hospital care. A total of 192 SMM events were identified and reviewed. Patients with SMM had a mean [SD] age of 31 [6.49] years; 9 [4.7%] were Asian, 27 [14.1%] were Hispanic, 83 [43.2%] were non-Hispanic Black, and 68 [35.4%] were non-Hispanic White. Obstetric hemorrhage was the leading primary cause of SMM (83 [43.2%]), followed by COVID-19 infection (57 [29.7%]) and hypertensive disorders of pregnancy (17 [8.9%]). The SMM rate was highest among Hispanic patients (154.9 per 10 000 deliveries), primarily driven by COVID-19 infection. The rate of SMM among non-Hispanic Black patients was nearly 50% higher than for non-Hispanic White patients (119.9 vs 65.7 per 10 000 deliveries). The SMM outcome assessed could have been prevented in 61 events (31.8%). Clinician-level factors and interventions in the antepartum period were most frequently cited as potentially altering the SMM outcome. Practices that were performed well most often pertained to hospitals' readiness and adequate response to managing pregnancy complications. Recommendations for care improvement focused mainly on timely recognition and rapid response to such. The findings of this cross-sectional study, which used hospital-based SMM surveillance and review beyond the mere exploration of administrative data, offers opportunities for identifying valuable quality improvement strategies to reduce SMM. Immediate strategies to reduce SMM in Maryland should target its most common causes and address factors associated with preventability identified at individual hospitals.

Management of May Thurner Syndrome in Pregnant Patients.

May Thurner Syndrome contributes to thromboembolic disease and can cause significant morbidity in pregnant patients secondary to exaggerated anatomic relationships and physiologic changes in the hematologic system favoring thrombogenesis. Because this condition is both underrecognized and underreported, management in pregnant and postpartum patients is based on expert opinion without any formal evidence-based guidance. Herein, we review five pregnancies in four patients with May Thurner Syndrome and general management strategies. Through collaborative and multidisciplinary care, patients with May Thurner Syndrome can be safely and successfully managed during pregnancy and the postpartum period with appropriate anticoagulation.

Application of Breast Care to Fulfill the Pain Comfort in Post Partum Mothers with Swollen Breasts

Objective: The purpose of this study was to provide postpartum health care through breastfeeding (ASI) to increase milk production for mothers after giving birth. Method: The method used is descriptive and based on a case study approach. with the random sampling technique. The sample elements examined in this case study were postpartum patients with inefficient breastfeeding problems, using data collection techniques such as interviews, observations, physical examinations, and documentation studies. Result: The findings of the study indicated that the diagnosis was established, namely that breastfeeding was not successful due to insufficient milk supply. Procedures and procedures are breast care or breast care to improve blood flow and prevent blockage of the milk ducts to facilitate milk production. Conclusion: Maternity care for postpartum clients with ineffective breastfeeding problems is an insurmountable problem. As a result, after 3 days of undergoing breast care, the patient breastfeeds quite profusely.

Contribution of fetal microchimeric cells to maternal wound healing in sickle cell ulcers.

Leg ulcers are a major complication of sickle cell disease (SCD). They are particularly challenging to treat and innovative therapies are needed. We previously showed that the healing of SCD ulcers is delayed because of decreased angiogenesis. During pregnancy, fetal microchimeric cells (FMC) transferred to the mother are recruited to maternal wounds and improve angiogenesis. After delivery, FMC persist in maternal bone marrow for decades. Here, we investigated whether fetal cells could also improve SCD ulcers in the post-partum setting. We found that skin healing was similarly improved in post-partum mice and in pregnant mice, through increased proliferation and angiogenesis. In a SCD mouse model that recapitulates refractory SCD ulcers, we showed that the ulcers of post-partum SCD mice healed more quickly than those of virgin mice. This was associated with the recruitment of fetal cells in maternal wounds where they harbored markers of leukocytes and endothelial cells. In a retrospective cohort of SCD patients, using several parameters we found that SCD women who had ever had a baby had less of a burden related to leg ulcers compared to nulliparous women. Taken together, these results indicate that healing capacities of FMC are maintained long after delivery and may be exploited to promote wound healing in post-partum SCD patients.

Critical care in obstetrics: Clinical audit in the Republic of Ireland, 2014–2016

IntroductionAdmission to an Intensive Care Unit (ICU) in obstetrics is often used as a proxy for maternal near miss/severe maternal morbidity (MNM/SMM) events. Understanding incidence and management of pregnant or postpartum patients requiring critical care (CC) is thus important for continued improvement of maternity care. This study aims to describe provision of critical care in obstetrics in the Republic of Ireland. Material and methodsThe national clinical audit on critical care included 15 of 19 maternity units in Ireland (2014–2016). 960 pregnant or postpartum (within 42 days) individuals who required CC were included. Data were reported on all cases requiring level 2 or level 3 CC. We calculated basic descriptive statistics for diagnosis and process of care variables, and compared characteristics of women requiring level 2 care to those requiring level 3. Outcomes included diagnoses necessitating critical care; additional complications; level of care required; care process outcomes such as length of stay, consultation with non-obstetric specialties, location of maternal critical care, and neonatal care provision. ResultsOverall, the rate of critical care in obstetrics for these hospitals was 1 in 131 live births; 900 of the 960 cases required level 2 care only. Hypertensive disorders contributed to the need for critical care for 1 in 242; hemorrhage, 1 in 422; and infections, 1 in 926. A substantial minority (15.7%) had more than one diagnosis, accounting for 40% of level 3 care. Serious complications were rare (eg, hysterectomy, 1 in 3846). Parity, hospital size, and identification as high-risk antenatally (<50% cases) were associated with requiring level 3 care. Critical care was provided in multiple locations, including ICUs, HDUs, and operating theatres. Only 23.8% of patients received CC in an ICU, suggesting ICU admission is not an ideal method for identifying severe maternal morbidity. ConclusionsWe reported rates of critical care admission and primary diagnoses within the range of other published estimates, but huge variability exists in the literature, and within our data. ICU admission in and of itself iss not a reliable proxy for having received level 2 or 3 obstetric critical care in Ireland.

Dyadic Care Mobile Units: A Collaborative Midwifery and Pediatric Response to the COVID-19 Pandemic.

Often dubbed the fourth trimester, the first 6 weeks of the postpartum period is a critical time that sets the stage for future health outcomes for both women and children. Leading maternal and child health advocates agree that intervention in the first 6 weeks of life is crucial. Although most new parents prioritize their newborn's well-care, many postpartum patients do not attend appointments for themselves, missing critical opportunities for identification and treatment of leading causes of maternal morbidity and mortality. Racial disparities in rates of postpartum complications highlight the increased importance of close postpartum follow-up for women of color. Barriers to attending routine postpartum visits were exacerbated by the coronavirus disease 2019 (COVID-19) pandemic. Additionally, in traditional models of care, maternal-infant dyads experience fragmented care across multiple departments and patient care settings and only 1 to 2 routine visits for the postpartum patient. To address the challenges of providing in-person postpartum care during the COVID-19 pandemic in Boston, the Midwifery Service, and the Pediatrics Department of Boston Medical Center partnered to launch a mobile postpartum clinic that provided comprehensive, high-touch, dyadic care to postpartum patients and newborns in the first 6 weeks of life. Integrative mobile visits catered to the interplay of maternal and newborn health in the early postpartum period, providing an average of 3 visits to each dyad. This novel clinic concept addresses structural inequities by decreasing barriers to care and reimagines an ideal state of postpartum dyadic care with frequent visits addressing the complete needs of each postpartum patient and newborn. For more than 2 decades, maternal health advocates have been calling for change from health care birth systems to improve health care outcomes. This collaborative, interdepartmental initiative-conceived in the context of a pandemic-is an answer to that call.

AWHONN postpartum discharge education: patient knowledge and sustainability

ObjectiveThe objective is to evaluate whether the implementation of the Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN) postpartum discharge educational initiative is associated with improved patient knowledge of...

Increasing effective postpartum care in an obstetric clinic using ACOG's postpartum toolkit.

Approximately 69% of maternal mortality occurs in the postpartum period. Contributing factors include the absence of preparation of pregnant women for the postpartum period during the antenatal period, postpartum follow-up care not being scheduled until 6weeks after childbirth, and the lack of further care coordination. The aim of this project was to increase the frequency of effective postpartum care visits to 80% in 8 weeks at an urban obstetric clinic. A quality improvement project was conducted through four Plan-Do-Study-Actcycles over 8weeks. Postpartum Readiness & Awareness Tools (PRATs) were reviewed with patients during their late third trimester, to review postpartum warning signs that warrant further evaluation. A population health registry was created to manage early follow-up for newly postpartum patients, to ensure their recovery was progressing normally. A note template was created and implemented to guide the completion of comprehensive postpartum visits. Over 8weeks, 188 patients received 1of the 3standardized interventions. Effective postpartum visits increased to 88%. The PRATs increased patient postpartum warning sign knowledge, with a project mean risk factor knowledge score of 6 (Goal = 5). The population health registry drove right care by ensuring early postpartum patients were recovering as expected, as seen by a project mean right-care score of 16 (Goal = 12). The note template increased the effectiveness of postpartum visits, with a mean effective postpartum care score of 10 (Goal = 10). The PRATs, population health registry, and note template collectively increased the quality and effectiveness of postpartum care.

PO46 Presentation Time: 4:45 PM: MRI-Guided Adaptive External Beam Radiotherapy for Cervical Cancer

Cervical cancer is the fourth most common cancer in women worldwide. Traditionally, bulky cervical tumors or those with clinical nodal involvement are treated with definitive chemoradiation therapy. Pelvic or extended field radiation has traditionally been delivered using 3-dimensional conformal radiotherapy with fields that are not altered during treatment. However, there is an emerging role for intensity modulated radiotherapy as well as adaptive planning. Although MRI-based linear accelerators have recently been used for image guidance during brachytherapy, to our knowledge, there are no reports of adaptive planning for cervical cancer cases using MRI-based linear accelerators. We present a case of a postpartum patient with a bulky cervical adenocarcinoma who underwent replanning twice during treatment due to uterine and tumor shrinkage. The use of a MRI-based linear accelerator facilitated both replanning and tumor assessment.

PENERAPAN KOMPRES DINGIN (ICE GEL) TERHADAP PENURUNAN NYERI LUKA EPISIOTOMI PADA PASIEN POST PARTUM DI RSUD Dr. SOESELO KABUPATEN TEGAL

This study aims to determine the application of cold compress (ice gel) to reduce episiotomy wound pain in post partum patients at RSUD Dr. Soeselo Tegal Regency. This research method is a descriptive method with the research design being a case study. The results of the case study study with cold compress therapy (ice gel) had a significant influence in reducing the scale of pain in post partum patients with episiotomy wound pain. There was a decrease in the pain scale of the two respondents, namely the level of the pain scale before being given cold compress therapy (ice gel) in patient 1 pain scale 6 and patient 2 pain scale 7, after being given cold compress therapy (ice gel) for 3 days to both patients the pain scale dropped to 2. The application of cold compress (ice gel) is recommended to be done 3 times a day for 3 days with a duration of 5-10 minutes at a temperature of 15o C to reduce pain. In conclusion, cold compress therapy (ice gel) can reduce episiotomy wound pain in post partum patients.Keywords : Pain, Episiotomy, Cold Compress.

Acute heart failure associated with toxic shock syndrome due to methicillin-susceptible Staphylococcus aureus during the postpartum period: case report and systematic literature review

BackgroundToxic shock syndrome (TSS) caused by Staphylococcus aureus in the postpartum period is a rare but life-threatening disease. We present a case of acute heart failure as the initial presentation of TSS due to methicillin-susceptible Staphylococcus aureus (MSSA) and describe its clinical characteristics with a systematic literature review.Case presentationA 34-year-old woman, 8 days after a normal vaginal delivery presented to our hospital with dyspnea and fever. She had jugular venous distension, bilateral leg edema, and erythema. Laboratory examinations revealed elevated NT-pro-BNP level of 3,233 pg/mL. Transthoracic echocardiography showed elevated tricuspid regurgitation peak gradient, with decreased respiratory variability of the inferior vena cava diameter and bilateral pleural effusions. The patient was hospitalized with suspicion of congestive heart failure. MSSA positive for toxic shock syndrome exotoxin-1 was detected in the culture of the perineal incision wound, and we diagnosed TSS caused by MSSA. Intravenous diuretics were administered, along with eventual cefazolin plus clindamycin. After 2 weeks of antimicrobial therapy, the patient showed improvement and was discharged. No recurrence was observed at the 24-month follow-up.ConclusionThis is a rare case report of acute heart failure being the initial manifestation of TSS due to MSSA in the postpartum period. Clinicians should consider TSS as a possibility in postpartum patients with acute heart failure. This systematic review provides insights into its clinical features, treatment regimens, and prognosis of TSS by S. aureus in the postpartum period. TSS requires an appropriate, prompt diagnosis, because delayed treatment can be fatal.

A Qualitative Study of Perceptions, Strengths, and Opportunities in Cardiometabolic Risk Management During Pregnancy and Postpartum in a Georgia Safety-Net Hospital, 2021.

Despite the strong link between cardiometabolic pregnancy complications and future heart disease, there are documented gaps in engaging those who experience such conditions in recommended postpartum follow-up and preventive care. The goal of our study was to understand how people in a Medicaid-insured population perceive and manage risks during and after pregnancy related to an ongoing cardiometabolic disorder. We conducted in-depth qualitative interviews with postpartum participants who had a cardiometabolic conditions during pregnancy (chronic or gestational diabetes, chronic or gestational hypertension, or preeclampsia). We recruited postpartum participants from a single safety-net hospital system in Atlanta, Georgia, and conducted virtual interviews during January through May 2021. We conducted a content analysis guided by the Health Belief Model and present themes related to risk management. From the 28 interviews we conducted, we found that during pregnancy, advice and intervention by the clinical care team facilitated management behaviors for high-risk conditions. However, participants described limited understanding of how pregnancy complications might affect future outcomes, and few described engaging in postpartum management behaviors. Improving continuity and content of care during postpartum may improve uptake of preventive behaviors among postpartum patients at risk of heart disease.

Development and Validation of a Turkish Version of Obstetric Quality of Recovery-10.

The 10-item Obstetric Quality-of-Recovery 10 scale is a validated patient-reported outcome questionnaire that measures the quality of recovery following delivery. This study aims to develop a Turkish version of the Obstetric Quality of Recovery 10 to evaluate its validity, reliability, and clinical feasibility. Term parturients who underwent vaginal delivery or elective caesarean delivery were asked to complete a Turkish version of Obstetric Quality-of-Recovery 10 scoring tool and EuroQol 5-dimension 3L scores (including a global health visual analogue scale) 24 hours after delivery. To validate the Obstetric Quality of Recovery 10-Turkish, we assessed validity, reliability, and clinical feasibility and compared it with the EQ-5D-3L questionnaires. One hundred parturients completed the questionnaire in 24 hours (100% response rate). Obstetric Quality of Recovery 10-Turkish correlated highly with EQ-5D-3L score (r=-0.611) and global health visual analogue scale score (r = 0.652) at 24 hours and discriminated well between good versus poor recovery (global health visual analogue scale score ≥70 vs <70; median interquartile range were 86 [80-90] and 68 [59-75] (P < .001), respectively). Scores were similar for caesarean and vaginal deliveries, 83 (76-89) and 82.5 (69-90), respectively (P = .5). Twenty-four-hour Obstetric Quality of Recovery 10-Turkish scores did not correlate with any baseline demographic and clinical data parameters. Internal consistency was good (Cronbach's alpha=0.87 and inter-item correlation=0.41), and split-half reliability was very good (Spearman-Brown prophesy reliability estimate=0.86). Test-retest reliability was excellent (intra-class correlation coefficient=0.99). No floor or ceiling effects were demonstrated. The Obstetric Quality of Recovery 10-Turkish is a valid, reliable, and clinically feasible measure of inpatient postpartum recovery following caesarean and vaginal delivery modes.

Successful treatment of aortic arch mural thrombosis with low-dose, ultra-slow-flow thrombolysis: a case report and literature review

Aortic arch thrombosis represents a severe condition which usually requires surgical treatment in specialized centers. Treatments described in literature are mostly surgery or sodium heparin infusion. Here we describe an off-label use of alteplase in aortic arch thrombosis in a patient in whom sodium heparin treatment failed and surgery was not possible due to the site of thrombus. We report the case of a 34-year-old postpartum patient who was admitted to our hospital for aortic arch thrombosis. She had no genetic disorders for hypercoagulability, only a family history for ischemic cerebrovascular accident. As treatment with sodium heparin failed and surgery was not possible due to the site of thrombus, she received a low-dose, ultra-slow-flow treatment with alteplase for 75 hours with successful removal of the thrombus. No side effects from alteplase were observed. Considering the safety and efficacy in this patient, as well as the easiness by which it can be reproduced in the majority of clinical settings, this treatment may be a viable option in cases of aortic arch thrombosis when conventional treatments are not applicable or available.

Variations in Postpartum Opioid Prescribing Practices among Obstetrician-Gynecologists.

There have been many efforts to combat the United States opioid crisis that has been occurring for the past two decades, specifically with postpartum patients that often were prescribed opioids. Prior studies described how accounting for usage of inpatient opioids on the day prior to discharge had an impact on how much discharge opioids were prescribed on the day of discharge. These studies provided a guideline to use the inpatient opioid amount from the day before discharge to determine discharge opioid quantity and minimize how much was being prescribed. In July 2018, the American College of Obstetrics and Gynecologists (ACOG) published Committee Opinion 742, guidelines for obstetricians-gynecologists about post-partum pain management. Prescription pain medications (including opioids, if necessary) require a shared decision-making approach between the physician and patient to determine the medication type and quantity. This study aimed to determine if there were differences in prescribing practices based on the specific post-operative day that opioid prescriptions were written, and if there were differences in the prescribing practices for cesarean deliveries following the publication of ACOG Committee Opinion 742. This retrospective chart review included patients who had a live cesarean birth at one rural Midwest facility anytime between July 1, 2017 and February 28, 2021. This study excluded those with chorioamnionitis and those discharged after more than four days. Opioid amounts were converted to oral morphine milligram equivalents (MME) for comparison, and total MME was calculated for each prescription. Patients were stratified into two groups based on the day that their discharge opioid medication prescriptions were written (i.e., a day prior to discharge or the day of discharge). Patients were also stratified based on date of delivery, before or after the publication of ACOG Committee Opinion 742. Of 411 cesarean patients, 93.9% (n = 386) had opioids prescribed at discharge, 86% (n = 330) of whom received a prescription written on the day of discharge. There was no difference in the quantity of MMEs, doses per day, or dosage from discharge prescriptions between those written on the day of discharge and those written on a prior day. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 (63.9%, n = 263) received discharge prescriptions with fewer average MMEs (159.53 ± 61.64) than those whose deliveries occurred before the publication (36%, n = 148; 187.35 ± 53.42; χ2 (1, N = 411) = 17.71; p < 0.001), and they were prescribed fewer doses per day. After cesarean sections, the specific post-operative day did not seem to impact the prescribing trends as there were no differences in MMEs, doses per day, or dosage between prescriptions that were written on the day of discharge and before the day of discharge. Patients whose deliveries occurred after the publication of ACOG Committee Opinion 742 received discharge prescriptions with fewer MMEs, fewer doses per day, and the same dosage than those whose deliveries occurred before the publication, reflecting the overall national trend of decreasing prescription opioids over these years.

Telemedicine may increase visit completion rates in postpartum patients with preeclampsia.

Postpartum cardiovascular (CV) evaluation of women with preeclampsia is recommended to screen for and treat modifiable risk factors to reduce lifetime CV risk. However, attendance at in-person postpartum obstetric and cardiology clinic visits is low. The aim of this study was to compare the completion rate of new patient telemedicine visits to in-person office visits for patients with preeclampsia referred for postpartum hypertension management and CV risk assessment at a single center. There were 236 unique new patient visits scheduled during the study period. The average age was 30.3 years, 73.7% patients were Black, and 56.7% had Medicaid insurance. The completion rate was 32% for in-person clinic visits and 70% for telemedicine visits. Women who did not complete an office visit were more likely to be Black (87% vs. 56%, p < 0.01) and younger (29.1 vs. 31.4 years, p = 0.04) compared to those who completed a visit. Notably, this difference was not seen with telemedicine visits. Telemedicine may provide a novel opportunity to improve the care for blood pressure management and CV risk reduction in a vulnerable population at risk of premature CV disease.

Factors associated with postpartum contraceptive planning in New Zealand

ObjectiveTo identify factors associated with contraceptive planning in the immediate postpartum period. Study designSurvey of those receiving inpatient postpartum care in two tertiary hospitals/associated birthing units (Auckland, New Zealand). Multivariable analyses using logistic regression examined independent predictors of contraceptive planning. ResultsOf 571 participants, those who recalled both antenatal and postpartum contraception discussions were more likely to have a contraceptive plan than those who recalled neither (aOR 5.6(2.8–11.5)). ConclusionBoth antenatal and postpartum contraceptive discussions are associated with postpartum contraceptive planning. ImplicationsBoth antenatal and postpartum discussions around contraception were independently associated with increased rates of established contraceptive plan postpartum, however patients who recalled both were more likely to have made a plan. Clinicians should provide multiple opportunities for discussing contraception throughout pregnancy and post-pregnancy to facilitate informed decision making.

Relationship between cardiovascular symptoms, health status assessment and cardiomyopathy in the obstetric population

Abstract Background Pregnancy related cardiomyopathy is a significant cause of maternal morbidity and mortality globally. A presumed overlap between normal pregnancy-associated symptoms and clinical symptoms of cardiomyopathy contributes to delays in diagnosis and increased risk of maternal mortality. Purpose We sought to evaluate the association between patient-reported cardiovascular symptoms and the presence of cardiomyopathy among pregnant and postpartum patients. We hypothesize that individual cardiovascular symptoms are unrelated to the presence of cardiomyopathy. We also evaluated the use of a novel adaptation of a validated health status questionnaire in relation to cardiomyopathy. Methods We enrolled 48 pregnant (&amp;gt;13 weeks) and postpartum (up to 12 months) participants in a prospective study between October 2021 and February 2022. All study participants completed a baseline questionnaire, which included current cardiovascular symptoms, an assessment of health status using an adapted version of the Kansas City Cardiomyopathy Questionnaire (KCCQ-12), followed by a resting transthoracic echocardiogram on the same day. We defined cardiomyopathy as a left ventricular ejection fraction (LVEF) &amp;lt;50% based on 2-D echocardiography. Fisher's exact and Wilcoxon rank-sum tests were employed to evaluate the association between reported cardiovascular symptoms, the adapted KCCQ-12 (KCC-A) score, and cardiomyopathy. Results At the time of enrollment, 67% were pregnant and 33% postpartum. Forty-eight percent identified as White, 31% as Black, 10% as Asian, and 10% as other race. The median age was 31 years (Q1: 28, Q3: 35) and 6% had an LVEF &amp;lt;50%. We found no statistically significant association between four reported cardiovascular symptoms (shortness of breath, orthopnea, fast breathing, and episodes of “asthma” that did not improve with inhalers or other treatment) and cardiomyopathy or medial E/e' ratio. KCC-A scores were low in the study population overall (median 52; Q1:40, Q3: 61). We demonstrated a significantly lower KCC-A score among women with LVEF &amp;lt;50% (median 24; Q1: 15, Q3: 44) compared to women with LVEF ≥50% (median 54; Q1: 44, Q3: 61) p=0.02. Conclusions We showed no significant association between individual cardiovascular symptoms and cardiomyopathy in an obstetric population. However, we demonstrate for the first time that an adapted KCCQ-12 questionnaire for health status assessment could potentially identify women with a high-likelihood of cardiomyopathy during the peripartum period who may benefit from additional evaluation including echocardiography. Larger studies are needed to validate this finding. Funding Acknowledgement Type of funding sources: Foundation. Main funding source(s): This study was funded by a research grant from the Miami Heart Research Institute, Florida Heart Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health

Unusual cause of acute respiratory compromise in a postpartum patient.

Unusual cause of acute respiratory compromise in a postpartum patient.

S2972 Disseminated Herpes Simplex Virus: A Diagnostic Enigma

Introduction: Disseminated Herpes Simplex Virus (HSV) is rare but is associated with up to 50% mortality, especially in immunocompromised patients and pregnant women in whom the diagnosis is often missed. In pregnant women, it can cause fulminant liver failure and can lead to fetal demise in some cases. We describe a case of disseminated HSV in a pregnant woman with no known active disease prior to pregnancy. Case Description/Methods: A 28-year-old healthy female presented at 26 weeks gestation with fever, chills and back pain. Initial labs were concerning for pyelonephritis and antibiotics were initiated. Despite broad spectrum antibiotics, she had persistent fever and workup for infectious etiology was broadened to include HIV, CMV, EBV, toxoplasma, syphilis, which were all negative. She developed worsening transaminases with AST 384 U/L and ALT 220 U/L. Viral hepatitis serologies and, due to her recent travel to Lyme endemic area, arbovirus serology was tested, which were all negative. She subsequently developed thrombocytopenia and worsening hypertension raising concern for HELLP syndrome and underwent emergent cesarean section. Postpartum course was complicated by persistent fevers and concern for chorioamnionitis; however, she continued to have worsening transaminases (AST 2632, ALT 1000). Computed tomography abdomen found numerous liver lesions concerning for abscesses or metastases. Liver biopsy found microvesicular steatosis consistent with HELLP syndrome. She developed worsening thrombocytopenia, coagulopathy (INR 2) and rising LDH, which was concerning for disseminated intravascular coagulation. She was started on plasma exchange and N-acetylcysteine. HSV PCR serology was tested which returned positive for HSV-2 and she was started on acyclovir. Lumbar puncture returned positive for HSV confirming disseminated HSV. Her course was complicated by encephalopathy that eventually improved and she was able to be discharged on a 21-day course of acyclovir. Transaminases and coagulopathy improved with treatment of disseminated HSV. Discussion: Disseminated HSV has a high mortality in pregnancy but can be missed due to the rarity of the condition. Early diagnosis and administration of acyclovir decreases mortality. A high index of suspicion is necessary, and it should remain in the differential diagnosis in pregnant and postpartum patients with acute hepatitis and even considered in patients with elevated transaminases without any overt history or skin lesions concerning for HSV as in this patient.