Evidence for the clinical management of chorioamnionitis.

Acute chorioamnionitis or intra-amniotic infection is defined by maternal fever in association with at least one additional clinical criterion including maternal or fetal tachycardia, maternal leukocytosis, uterine tenderness, or foul amniotic fluid odor. In clinically uncertain cases, the diagnosis can be augmented by routine laboratory studies (e.g. white blood cell count and differential count and acute phase reactants) and assays done on amniotic fluid. In general, the clinical management of chorioamnionitis is based on observational or cohort studies; only a few randomized controlled trials have been done. Prompt administration of antibiotics and delivery decrease maternal and neonatal morbidity. The most commonly used antibiotic regimen is ampicillin and gentamicin. Recent evidence supports daily rather than three-times-daily dosing of gentamicin for greater efficacy and decreased fetal toxicity. There is no evidence demonstrating harm with the administration of corticosteroids (to promote fetal lung maturity) in women with acute chorioamnionitis. Cesarean delivery should be reserved for standard obstetric indications.

Risk factors for preterm delivery with placenta previa.

AIMS: To identify factors associated with preterm delivery in cases of sonographically identified placenta previa. METHODS: Pregnancies with sonographic evidence of placenta previa at ≥ 28 weeks were identified. Demographic information, antepartum course, and delivery information were extracted from electronic medical records. Statistical analysis was performed with Fisher's exact test, Mann-Whitney U, Spearman's ρ (correlation), and logistic regression. Continuous data are presented as median (interquartile range). RESULTS: Of 113 singleton pregnancies with placenta previa, 54 (48%) delivered at term and 59 (52%) delivered preterm. Fifty-one (45%) experienced antepartum bleeding at a median gestational age of 31 weeks (29-33 weeks) with a median interval of 20 days (11-33 days) between first bleeding episode and delivery. Women with antepartum bleeding were more likely to be delivered for hemorrhage (36 of 51 vs. 8 of 62, P<0.001) and delivered emergently (40 of 51 vs. 14 of 62, P<0.001). Antepartum bleeding before 34 weeks had a positive predictive value of 88% for preterm birth and 83% for emergent delivery. CONCLUSION: In pregnancies with placenta previa, antepartum bleeding is a strong predictor of preterm delivery.

Risk factors for emergent preterm delivery in women with placenta previa and ultrasound findings suspicious for placenta accreta.

AIM: To identify factors associated with emergent preterm delivery in women with placenta previa and suspected accreta. METHODS: Pregnancies with placenta previa and ultrasound findings suspicious for accreta were identified. Demographic information and obstetric and neonatal outcomes were obtained from electronic medical records. Mann-Whitney U, Fisher's exact test, and Kaplan-Meier analysis were used. Continuous data are expressed as median (interquartile range). RESULTS: Twenty-one patients with placenta previa and suspicion for accreta delivered at a median of 34 weeks [32-37]. Fourteen bled prior to delivery, 10 at <32 weeks. Fifty-seven percentage of deliveries were planned at a median gestational age of 36.5 weeks [34-37] vs. 32 weeks [29.5-32.5] for emergent deliveries (P<0.001). Emergent delivery was associated with transfusion of a median of nine units packed red blood cells (PRBCs) [4-16] compared to 4.5 units [1-7] with planned delivery (P=0.05). CONCLUSION: Planned late perterm delivery is reasonable and likely women with placenta previa and ultrasound findings suspicious for placenta accreta who do not experience antepartum bleeding. Those women with multiple episodes of antepartum bleeding or bleeding prior to 32 weeks gestation are at increased risk of emergent preterm delivery.

Parvovirus-mediated fetal cardiomyopathy with atrioventricular nodal disease.

Acute parvovirus B19 infection (API) in pregnancy has been associated with fetal anemia and hydrops fetalis. Direct myocardial damage from API in a fetus and an infant has been described. This report presents a case of fetal second-degree heart block and cardiomyopathy secondary to API. A 19-year-old G4P1112 (gravida 4 para 2 with 1 term delivery, 1 preterm delivery, 1 termination, and 2 living children) was referred at 20 weeks gestation for fetal bradycardia. A 2:1 atrioventricular block was identified by fetal echocardiography at 23 weeks. Hydrops developed at 25 weeks. Amniocentesis and percutaneous umbilical blood sampling demonstrated API. At 31 weeks, the patient presented with preterm labor and delivered a viable female infant, who died of poor cardiac function and arrhythmia on the first day of life. In addition to fetal anemia and hydrops fetalis, API in pregnancy may cause direct fetal myocardial damage and conduction system disease.