Vertebral Osteomyelitis in Pregnancy from a Methicillin-resistant Staphylococcus Aureus Vulvar Abscess. A Case Report.

BACKGROUND: Osteomyelitis is a rare problem in pregnancy but can present challenges for diagnosis and treatment. This case report describes a patient with a history of vulvar abscess who developed methicillin-resistant Staphylococcus aureus (MRSA) bacteremia and osteomyelitis during pregnancy. CASE: A 20-year-old woman, gravida 1, at 33 weeks' gestation, developed sepsis from MRSA bacteremia after a vulvar abscess drainage. She developed acute respiratory distress syndrome (ARDS) and was found to have osteomyelitis on her thoracic spine level 7. The diagnosis of osteomyelitis was based on clinical findings and magnetic resonance imaging. An emergent cesarean section was undertaken due to worsening ARDS. The osteomyelitis was treated with intravenous daptomycin with symptomatic improvement. However, back pain returned and the patient was readmitted and required a spinal brace and 6 weeks of intravenous vancomycin. CONCLUSION: Osteomyelitis in pregnancy is a rare complication and a challenging diagnosis that requires a high index of suspicion. The treatment of osteomyelitis in pregnancy versus nonpregnancy is the same. This case is unique because this pregnant patient developed osteomyelitis secondary to a vulvar abscess.

Airway pressure release ventilation and respiratory failure during pregnancy. A report of three cases.

BACKGROUND: Acute respiratory distress syndrome is a rare complication during pregnancy but remains dificult to manage, with a high incidence of maternal mortality. CASES: We present 3 cases of respiratory failure and severe pulmonary disease managed with airway pressure release ventilation, among other ventilatory modes, with improved ventilation. CONCLUSION: Airway pressure release ventilation may be an important option as a ventilatory mode for management of maternal respiratory failure during pregnancy.

Evaluating ventricular function with B-type natriuretic peptide in obstetric patients.

OBJECTIVE: To determine if a rapid serum assay for B-type natriuretic peptide (BNP) provides information regarding ventricular function in obstetric patients with acute dyspnea. STUDY DESIGN: A review of 17 charts for 15 patients was undertaken. Seven patients had preeclampsia, 3 had preterm labor treated with aggressive tocolysis, and 5 had underlying cardiac and/or pulmonary disease. Each presented with signs and symptoms consistent with acute dyspnea. Serum BNP levels were obtained and other standard diagnostic procedures performed. Each patient was treated based on the findings of the standard diagnostic procedures. RESULTS: For the 7 patients with preeclampsia, elevated serum BNP levels correlated with acute ventricular overload that responded to volume management and diuresis. Two patients had marked elevation of serum BNP levels and were found to have significant left ventricular dysfunction that was not apparent by standard clinical evaluation. For preterm labor patients on tocolysis and patients with underlying cardiac or pulmonary disease, serum BNP levels were elevated for 5 of 6 patients with evidence of acute volume overload. CONCLUSION: Serum BNP levels provided useful information for the clinical evaluation and management of obstetric patients with acute dyspnea. In 2 patients, more serious cardiac dysfunction was detected with BNP than with clinical evaluation alone.

Hyperemesis gravidarum: outcomes and complications with and without total parenteral nutrition.

OBJECTIVE: To evaluate the obstetric and medical complications with hyperemesis gravidarum, comparing those who were supported with total parenteral nutrition (TPN group) and those who did not receive TPN (non-TPN group). STUDY DESIGN: The medical records of women with a diagnosis of hyperemesis gravidarum (ICD-9 code 643) admitted to Crouse Hospital, Syracuse, New York, between January 1995 and December 1998, were reviewed. A total of 166 subjects were identified and 192 admissions reviewed. Information was gathered for age, gestational age, gravity and parity, marital status, length of stay and number of admissions, and a review of electrolyte, albumin and thyroid function was performed. An assessment of pregnancy complications and outcomes was undertaken. RESULTS: Of the cases reviewed, 16% (27/166) were treated with TPN. The 2 groups were similar regarding incidence of pregnancy-related and maternal medical complications. The groups were similar when comparing objective measures, such as serum potassium, bicarbonate, albumin and thyroid function. The TPN group had a significantly increased incidence of complications directly attributable to parenteral therapy. Among multiparous patients in both groups, 69% had a prior pregnancy that had ended in spontaneous or induced abortion. CONCLUSION: The TPN group had a marked and significant increase in serious complications directly related to TPN use. These data suggest that great care should be taken to assess the need for parenteral therapy in patients with hyperemesis gravidarum. A history of loss in the antecedent pregnancy may be a risk factor for a subsequent pregnancy complicated by hyperemesis gravidarum.

Poorly differentiated large cell adenocarcinoma of the lung metastatic to the placenta: a case report.

BACKGROUND: Cancer is an uncommon diagnosis during pregnancy. Advanced disease is unusual; metastasis to the placenta is exceptionally rare. Primary cancers that have been reported to produce placental metastasis include melanoma, breast, hematologic and lung. CASE: A 41-year-old, Caucasian woman, para 4014, at 35 4/7 weeks' gestational age with a singleton pregnancy, presented with weight loss, nausea, vomiting, diarrhea and a nonproductive cough. A detailed evaluation revealed widely metastatic disease with a suspected lung origin. Biopsy of a supraclavicular lymph node revealed poorly differentiated large cell adenocarcinoma. Due to the patient's rapidly deteriorating condition and suspected asymmetric intrauterine growth restriction, induction of labor was undertaken. A female infant, Apgar scores 8 and 9, weight 1,885 g, was delivered vaginally. Pathologic evaluation of the placenta revealed metastatic poorly differentiated large cell adenocarcinoma within the intravillous spaces. The placental tumor appeared to be identical to the tumor identified on the lymph node biopsy. The patient's condition continued to deteriorate, and she died a few weeks after the delivery. The infant was doing well 6 months after birth. CONCLUSION: Placental metastasis is a rare complication among women with widely metastatic large cell adenocarcinoma of the lung. Vaginal delivery can be successful for seriously compromised patients with widespread malignant disease.