Atypical Hemolytic-Uremic Syndrome Following Obstetric Hemorrhage in the Setting of Fetal Demise and Placenta Accreta: A Case Report.

Multiple disease processes can contribute to coagulopathy in the setting of intrauterine fetal demise. A 34-year-old woman with multiple prior uterine surgeries presented for dilation and evacuation of a fetal demise at 17 weeks. Her case was complicated by significant hemorrhage and coagulopathy requiring massive transfusion and hysterectomy. She developed atypical hemolytic-uremic syndrome postoperatively. Pathology identified a focal placenta accreta. While not known to present together, fetal demise, placenta accreta, and atypical hemolytic-uremic syndrome can occur in the same patient with an overlapping presentation. Early hematology consultation is recommended in the setting of ongoing hemolysis and renal dysfunction.

Suture Compared With Staple Closure of Skin Incision for High-Order Cesarean Deliveries.

OBJECTIVE: To compare wound complication rates in tertiary or higher-order cesarean delivery based on wound closure technique. METHODS: We performed a retrospective cohort study of all tertiary or higher-order cesarean deliveries performed by one group practice in a large academic medical center from 2005 to 2017. We excluded patients with a vertical skin incision. Although the study was not randomized, wound closure type was relatively uniform in this practice and based on time period: before 2011, the preferred closure was staple closure; after 2011, subcuticular suture closure was preferred. All patients received preoperative antibiotics and closure of subcutaneous tissue 2 cm deep or greater. The primary outcome was a wound complication, defined as a wound infection requiring antibiotics or a wound separation requiring wound packing or reclosure any time up to 6 weeks after delivery. Regression analysis was used to control for any significant differences at baseline between the groups. RESULTS: There were 551 patients with tertiary or higher-order cesarean delivery, 192 (34.8%) of whom had staple closure and 359 (65.2%) of whom had suture closure. Suture closure was associated with a significantly lower rate of wound complication (4.7% [17/359, 95% CI 3.0%-7.5%] vs 11.5% [22/192, 95% CI 7.7%-16.7%], P=.003). On regression analysis controlling for the number of prior cesarean deliveries and the participation of a resident in the closure, suture closure remained independently associated with a lower risk of a wound complication (adjusted odds ratio 0.44, 95% CI 0.23-0.86). CONCLUSION: For women undergoing their third or higher-order cesarean delivery, suture closure is associated with a lower rate of wound complications.

Risk factors for cesarean delivery in twin pregnancies attempting vaginal delivery.

OBJECTIVE: The purpose of this study was to estimate independent risk factors for cesarean delivery in patients with twin pregnancies who attempt vaginal delivery. STUDY DESIGN: This was an historic cohort of twin pregnancies that were delivered in 1 practice from June 2005 to February 2014. Baseline characteristics were compared between women who delivered vaginally and women who underwent cesarean delivery in labor. Logistic regression analysis was performed to estimate independent risk factors for cesarean delivery. RESULTS: Two hundred eighty-six women with twin pregnancies who had attempted vaginal delivery were included in the study. The overall modes of delivery were vaginal delivery (82.2%), cesarean delivery (17.8%), and combined vaginal-cesarean delivery (0%). The most common indication for cesarean delivery in labor was an arrest disorder (82.4%). The risk factors that were associated independently with cesarean delivery were nulliparity (adjusted odds ratio, 5.78; 95% confidence interval, 2.24-14.88) and advanced maternal age of ≥35 years (adjusted odds ratio, 2.36; 95% confidence interval, 1.16-4.80). The patients at highest risk for cesarean delivery (nulliparous, advanced maternal age, induced labor) still had a 48.6% likelihood of vaginal delivery. CONCLUSION: In patients with twin pregnancies who attempt labor, nulliparity and advanced maternal age are associated independently with cesarean delivery in labor. However, even the patients at highest risk for cesarean delivery have nearly a 50% likelihood of successful vaginal delivery and therefore should be allowed to attempt vaginal delivery if it is desired and not otherwise contraindicated.

The effect of maternal obesity on outcomes in patients undergoing tertiary or higher cesarean delivery.

OBJECTIVE: To estimate the association between maternal obesity and adverse outcomes in patients without placenta previa or accreta undergoing a tertiary or higher cesarean delivery. STUDY DESIGN: Retrospective cohort of patients cared for by a single MFM practice undergoing a tertiary or higher cesarean delivery from 2005 to 2013. Patients attempting vaginal delivery and patients with placenta accreta and/or placenta previa were excluded. We estimated the association of maternal obesity (prepregnancy BMI ≥ 30 kg/m(2)) and maternal outcomes. The primary outcome was a composite of severe maternal morbidity (uterine rupture, hysterectomy, blood transfusion, cystotomy requiring repair, bowel injury requiring repair, intensive care unit admission, thrombosis, re-operation, or maternal death). RESULTS: Three hundred and forty four patients met inclusion criteria, 73 (21.2%) of whom were obese. The composite outcome was significantly higher in the obese group (6.8% versus 1.8%, p = 0.024, aOR 4.36, 95% CI 1.21, 15.75). The incidence of several individual adverse outcomes were also increased in obese women, including blood transfusion (4.1% versus 0.7%, p = 0.033, aOR 7.36, 95% CI 1.19, 45.34), wound separation or infection (20.5% versus 5.9%, p < 0.001, aOR 4.05, 95% CI 1.75, 9.36) and 1-min Apgar score less than 7 (6.8% versus 1.9%, p = 0.024, aOR 4.40, 95% CI 1.21, 15.94). CONCLUSIONS: In patients undergoing a tertiary or higher cesarean delivery without placenta previa or accreta, obesity increases the risk of adverse outcomes. Obese patients are at risk for blood transfusion, low 1-min Apgar scores and postoperative wound complications.

Outcomes of emergency or physical examination-indicated cerclage in twin pregnancies compared to singleton pregnancies.

OBJECTIVE: To report the obstetrical outcomes in patients with twin pregnancies who underwent an emergency/physical exam-indicated cerclage and to compare them to patients with singleton pregnancies undergoing the same procedure. STUDY DESIGN: Patients who underwent emergency/physical exam-indicated cerclage in the second trimester in one maternal-fetal medicine practice from July 1997 to March 2012 were reviewed. We defined an emergency/physical exam-indicated cerclage as any cerclage placed in a patient with a dilated cervix on examination or membranes visible at the external cervical os on speculum examination. We compared outcomes between patients with singleton and twin pregnancies using non-parametric testing. RESULTS: There were 43 patients (12 twin and 31 singleton pregnancies) who underwent emergency/physical exam-indicated cerclage placement. The median gestational age at cerclage placement, cervical dilation, maternal age, and cerclage type were similar between the groups. Comparing twins to singletons, the median time from cerclage placement to delivery was similar (92 vs. 106 days, p=0.330), as was the median gestational age at delivery (33.5 vs. 35.0 weeks, p=0.244). The likelihood of delivery at >32 weeks (75.0% vs. 71.0%, p>0.999) and the likelihood of neonatal survival to discharge (83.3% vs. 83.9%, p>0.999) were also similar. CONCLUSIONS: Emergency/physical exam-indicated cerclage in twin pregnancies can be associated with favorable outcomes, including a high likelihood of delivery at >32 weeks and a high likelihood of survival. Their outcomes appear similar to singleton pregnancies. Cerclage should be considered an option for patients with twin pregnancies and a dilated cervix in the second trimester.

Active second-stage management in twin pregnancies undergoing planned vaginal delivery in a U.S. population.

OBJECTIVE: To estimate neonatal morbidity and delivery outcomes according to planned mode of delivery in twin pregnancies with active second-stage management. METHODS: This was an historic cohort of twin pregnancies delivered in one practice between June 2005 and September 2009 using a strict protocol of second-stage management, including breech extraction of a second noncephalic twin and internal version of a nonengaged cephalic second twin followed by breech extraction. Primary outcome was a 5-minute Apgar score less than 7 for twin B. Secondary outcomes were 5-minute Apgar score less than 7 for twin A and 1-minute Apgar score less than 7 and arterial cord pH below 7.20 for each twin. RESULTS: A total of 287 twin pregnancies were included. There were 157 patients (54.7%) in the planned cesarean group and 130 patients (45.3%) in the planned vaginal delivery group. There was no significant difference in the rates of twin B having a 5-minute Apgar score lower than 7 or an arterial cord pH below 7.20. Among the patients in the planned vaginal delivery group, the cesarean delivery rate was 15.4%. No patients had a vaginal delivery of twin A followed by cesarean delivery of twin B. Among the patients in the planned vaginal delivery group, patients who had a successful vaginal delivery were more likely to be younger (31.56+/-6.6 compared with 36.88+/-6.1 years, P=.001) and were more likely to have a prior vaginal delivery (47.3% compared with 15.0%, P=.007). CONCLUSION: Planned vaginal delivery of twin pregnancies seems to be associated with neonatal outcomes similar to those with planned cesarean delivery. Active second-stage management is associated with good neonatal outcomes and a low risk of combined vaginal-cesarean delivery. LEVEL OF EVIDENCE: II.

Labor outcomes after Shirodkar cerclage.

OBJECTIVE: To describe labor outcomes in women who had a Shirodkar cerclage placed during pregnancy and removed before labor. METHODS: A review was conducted of 69 patients with a singleton pregnancy and a Shirodkar cervical cerclage placed before 24 weeks' gestation. Indications for cerclage were history indicated, ultrasound indicated or physical examination indicated. RESULTS: The mean time from cerclage removal to delivery was 9.4 +/- 8.8 days. The overall cesarean delivery rate was 18.8%, with the majority (9 of 13) being for fetal indications. Two (2.9%) patients had a uterine rupture of an unscarred uterus and 2 (2.9%) patients had an umbilical cord prolapse. Four (5.8%) patients had a cervical laceration requiring repair. CONCLUSION: Patients with a Shirodkar cerclage placed and removed during the index pregnancy appear to have a higher than expected rate of cesarean delivery for fetal indications and complications associated with significant neonatal morbidity including uterine rupture and cord prolapse.

Anti-factor Xa plasma levels in pregnant women receiving low molecular weight heparin thromboprophylaxis.

OBJECTIVE: To report the incidence of prophylactic, subprophylactic, and supraprophylactic anti-factor Xa activity in pregnant patients receiving low molecular weight heparin for venous thromboembolism prophylaxis, and to evaluate whether maternal weight, body mass index, age, gestational age, or the low molecular weight heparin dose correlated with anti-factor Xa levels. METHODS: We reviewed 321 anti-factor Xa levels in 77 patients from one Maternal-Fetal Medicine faculty practice. All patients were administered low molecular weight heparin that subsequently was adjusted based upon serial assessment of peak plasma (at 4 hours postinjection) anti-factor Xa levels at less than 36 weeks gestation. Targeted prophylactic range of peak plasma anti-factor Xa level was 0.2-0.4 units/mL. RESULTS: Only 59% of anti-Xa concentrations were in the prophylactic range, whereas 26% were subprophylactic, and 15% were supraprophylactic. Anti-Xa values were not significantly more likely to be prophylactic in early compared with late pregnancy, obese compared with nonobese patients, or in patients receiving a weight-based minimal dose compared with patients receiving less than a weight-based minimal dose. Anti-factor Xa levels did not correlate with maternal age, weight, body mass index, or gestational age, but there was a positive correlation with the percent of the minimal weight-based dose. CONCLUSION: Even with enhanced low molecular weight heparin dosing, 26% of patients have subprophylactic anti-factor Xa levels. Serial anti-factor Xa assessment for dose adjustment should be considered for all pregnant women receiving low molecular weight heparin.

Shigellosis complicating preterm premature rupture of membranes resulting in congenital infection and preterm delivery.

BACKGROUND: The association of chorioamnionitis with preterm birth is well established. Intra-amniotic infection complicates 13-60% of preterm premature rupture of membranes (PROM) with enteric gram-negative pathogens accounting for 20-40% of recoverable organisms. However, the source of enteric pathogens leading to premature birth has been poorly characterized. CASE: A 36-year-old multiparous woman presented at 2567 weeks with preterm PROM. She reported a 5-day history of bloody, mucous diarrhea. A fourth cesarean delivery was performed secondary to the onset of labor. Fetal blood, placental membrane, and vaginal pool cultures revealed the presence of Shigella sonnei. With appropriate antibiotic therapy, the patient was discharged home on postoperative day 5. Neonatal stool cultures revealed evidence of in utero fetal transmission. CONCLUSION: It is prudent to treat pregnant patients with clinical symptoms suggestive of shigellosis because this pathogen can result in preterm PROM and preterm delivery. Neonatal testing is indicated if maternal disease is suspected before delivery.