The construction and utility of an amniocentesis trainer.

OBJECTIVE: Our goal was to design an inexpensive amniocentesis trainer for instruction and practice with ultrasonography-assisted needle guidance and the freehand technique. STUDY DESIGN: The amniocentesis trainer was constructed from a commercially available 5.3-L storage box (No. 5805; Rubbermaid Incorporated, Wooster, Ohio). Sonodense sperical targets 2.3 cm in diameter were taped to the bottom, and the box was filled with a gelatin mixture. The box was covered with a rubber membrane from a pelviscopy trainer (United States Surgical Corp, Norwalk, Conn). After the gelatin mixture set overnight at 40 degreesF, the amniocentesis trainer was ready for use. RESULTS: When a needle is introduced through the membrane into the gelatin, the ultrasonographic image is a reasonable simulation of an amniocentesis. The trainer improved the ability of an operator to perform a freehand amniocentesis, orient the ultrasound transducer, follow a needle with continuous ultrasonographic guidance, and hit a 2-cm target. The gelatin also allows for evaluation of improvement between amniocentesis attempts because a faint image of the needle track from prior attempts remains visible. Once basic amniocentesis skills are mastered, the trainer is easily modifiable so that obstacles can be added that could simulate umbilical cord and fetal extremities. CONCLUSIONS: We were able to construct an inexpensive amniocentesis trainer that facilitates instruction in the freehand amniocentesis technique. This trainer enables an operator to master the skills necessary to perform the technique of freehand ultrasonography-guided amniocentesis under direct ultrasonographic visualization without putting a patient through the discomfort of participating in the learning curve.

Characteristics of successful claims for payment by the Florida Neurologic Injury Compensation Association Fund.

OBJECTIVES: Our purpose was to examine the obstetric characteristics of claims paid by the State of Florida after the birth of a neurologically impaired child. STUDY DESIGN: The Florida Birth Related Neurological Injury Compensation plan is a no-fault alternative to litigation for compensation after a catastrophic neurologic birth injury. The plan has specific criteria for inclusion. We retrospectively analyzed claims for compensation that were accepted and paid (n = 64) after a birth-related neurologic injury. Simple description statistics were compiled for the relative frequencies of various obstetric correlates found in successful claims for payment. RESULTS: Seventy percent of infants (45) were delivered by cesarean section and 15 of 19 vaginal deliveries (79%) were operative (forceps or vacuum), yielding a 94% operative delivery rate. A persistent nonreassuring fetal heart rate tracing was seen before delivery in all cases. The 5-minute Apgar score was < or = 6 in 91% of deliveries and the 10-minute Apgar score was < 6 in 86% of deliveries. When first examined in the labor and delivery suite, 17 women had a nonreassuring fetal heart rate, and a nonreassuring tracing developed in labor in 47. Nine attempts at vaginal birth after a cesarean section led to a uterine rupture. Seven of these deliveries were either inductions or augmentations against an unfavorable cervix. Forty-five percent (27) of deliveries were associated with meconium-stained amniotic fluid, including 17 infants with meconium aspiration syndrome. There were three shoulder dystocias and four infants with group B streptococcal sepsis. In eight cases (12.5%), there appeared to be a breach of the published standard of care, which contributed to the poor outcome. CONCLUSION: Most of these cases should not have been eligible for compensation in a traditional tort-based system because the applicable standard of care was not breached. Meeting the published standard for perinatal care failed to prevent these devastating neurologic injuries. Obviously, not all intrapartum injuries can be prevented; however, if we are to prevent similar injuries in the future, we will need to examine the clinical management in these or similar case for clues to develop novel strategies to respond to intrapartum emergencies. An unexpected finding was the frequency of catastrophic birth injuries after an attempted vaginal birth after cesarean section with the predominance of these deliveries associated with oxytocin stimulation against an unripe cervix. It is apparent that the push to lower cesarean section rates is not without some risk.

Persistent patent urachus with allantoic cyst: a case report.

Patent urachus results when there is a persistence of an allantois remnant which normally undergoes atresia during embryological development. It can lead to an abdominal wall defect similar in appearance on ultrasound to an omphalocele. A 34-year-old primigravida presented at 19 weeks' gestation for evaluation of a cystic mass arising at the umbilical cord insertion. The initial impression of the referring physician was an omphalocele. The mass arose from the abdominal wall and the umbilical cord inserted into the membranous covering of the mass, which appeared to be fluid-filled and separate from but contiguous with the urinary bladder. Serial sonography followed the progression of the abdominal wall mass. At term, the patient underwent primary Cesarean section with delivery of a 4494-g male infant. The infant underwent repair and closure of the patent urachus and plastic reconstruction of the abdominal wall. When the urachus remains patent, it can lead to a urinary fistula which mimics the ultrasound appearance of an omphalocele. However, patent urachus is associated with a much lower rate of abnormalities than omphalocele, yielding a better fetal prognosis.

Hypercalcemic crisis in pregnancy associated with excessive ingestion of calcium carbonate antacid (milk-alkali syndrome): successful treatment with hemodialysis.

Severe hypercalcemia, a potentially life-threatening condition, has been reported rarely during pregnancy. A patient with hypercalcemic crisis associated with excessive ingestion of absorbable calcium antacid was treated successfully with hemodialysis as well as other therapeutic measures, such as saline diuresis. This acute therapy resulted in long-term normalization of maternal calcium levels. The fetus, who exhibited a low biophysical score during the initial admission, was delivered a month later and had an uncomplicated neonatal course. Acute hemodialysis can be an effective, rapid, and safe method of lowering serum calcium levels in pregnant patients with severe hypercalcemia unresponsive to other medical therapies.

Vasa previa.

Diagnosis of vasa previa requires a high index of suspicion. Vasa previa must be included in the differential diagnosis of all cases of third trimester bleeding. When pulsatile vessels are palpated preceding the fetal vertex, vasa previa should be considered along with cord prolapse. Early diagnosis and intervention result in a favorable fetal outcome in this rare condition.

Landry-Guillain-Barré-Strohl syndrome in pregnancy. A report of two cases.

Landry-Guillain-Barré-Strohl syndrome (LGBS) in pregnancy is a rare event previously reported on only 29 times. Both cases reported on here were associated with cytomegalovirus infection. The fetus did not appear to be affected by the paralyzing agent in LGBS, although sequelae of the cytomegalovirus could occur later. Aggressive, long-term care is necessary to minimize maternal morbidity.

Septic shock with renal failure after chorionic villus sampling.

A report of septic shock and renal failure after a chorionic villus sampling is presented. Uterine evacuation, antibiotics, and vasopressor therapy were unsuccessful in reversing hypotension, coagulopathy, and anuria. The patient's condition improved only after exploratory laparotomy and removal of the uterus, ovaries, and fallopian tubes. The incidence of such serious complications must be determined.