Peripartum Cardiomyopathy: Experience at a Tertiary Care Center in Puerto Rico.

OBJECTIVE: Peripartum cardiomyopathy is a rare type of heart failure to which only pregnant women are susceptible. In Puerto Rico there is a paucity of information regarding this condition. In this report we describe our experience with peripartum cardiomyopathy. METHODS: This was a descriptive retrospective study. We conducted a chart review of all the patients with peripartum cardiomyopathy managed at our institution from January 2006 through December 2012. A total of 12 patients qualified for our analysis. RESULTS: The mean age of our population was 27 (± 8) years. Eight of the twelve (67%) patients were multigravid women, with a mean parity of 2.6 (± 1.6). Most patients (75%) showed clinical evidence of anemia while pregnant, and more than half (58%) delivered prematurely. Six patients (50%) had a prior history of preeclampsia. Cardiac imaging detected a mean ejection fraction of 35% (± 8%) at the time of diagnosis. Only 1 maternal death was documented. CONCLUSION: Our study cohort was very similar to those in most case series in which the same condition has been studied. In order to better understand the pathophysiology of this entity and, thus, improve treatment for these patients, prospective studies are needed.

Rapid Resolution of Polyhydramnios Foretells Circulatory Collapse for the Donor Twin in Feto-Fetal Transfusion Syndrome.

Feto-fetal transfusion syndrome is a pathological process unique to diamniotic monochorionic pregnancies. It is the consequence of an unbalanced fetal blood flow through communicating vessels within a shared placenta. When it occurs, a polyuric, hypervolemic recipient twin co-exists with a hypovolemic oliguric donor. The presence of polyhydramnios or oligohydramnios is considered a poor prognostic indicator, whereas normal amniotic fluid volumes indicate a lack of clinically significant twintwin transfusion. In addition, the spontaneous normalization of amniotic fluid volume is usually seen as a favorable prognostic sign. Here, however, we present a case of feto-fetal transfusion in a 31 year-old primigravida at 19 week, in which the spontaneous normalization of amniotic fluid volume in the recipient twin preceded the death of the donor.

Pregnancy after liver transplantation.

UNLABELLED: Several reports on liver transplantation and pregnancy have been published recently. Uncertainty remains regarding appropriate management of these patients. METHODS: The study included pregnant women of all ages with liver transplant referred to our center. A total of eight patients were identified and qualified for our study. The following variables were obtained: age, date of liver transplantation, date of conception, reasons for liver transplantation, type of immunosuppressive therapy, complications during pregnancy, gestational age at birth, birth weight, mode of delivery, the interval of time from liver transplantation to conception and co-morbidity. RESULTS: The mean age of our population was 24 years. Four of the eight were nulliparous. The mean time interval from transplantation to pregnancy was eight years. The indication for liver transplantation in 75% of patients was autoimmune hepatitis. Two cases were associated with viral hepatitis. Combination therapy with more than one immunosuppressant was given to 75% of patients. The most prevalent complication was pyelonephritis in (38%), followed by gestational thrombocytopenia and preeclampsia. Most deliveries (75%) were vaginal and at term (88%). The median for gestational age was 39 weeks. The median birth weight was 2,898 grams. CONCLUSIONS: This study proves that successful and uneventful pregnancies are likely in liver transplant patients under optimal obstetric management.

Effectiveness and safety of lidocaine in the induction of fetal cardiac asystole for second trimester pregnany termination.

UNLABELLED: The presence of a major congenital anomaly is a frequent indication for late termination of pregnancy. The possibility of the fetus being born alive is significant, thus, feticide prior to the procedure is desirable. The purpose of this study was to assess the safety and efficacy of lidocaine 1% as a feticidal agent prior to second trimester termination of pregnancy. METHODS: We conducted a chart review of all patients who underwent a second trimester termination of pregnancy at our institution between March 2009 and June 2012. We collected data regarding the indication for the termination procedure, gestational age, site of lidocaine injection, dosage of lidocaine, need for additional to produce asystole, and maternal complications. RESULTS: We identified 54 patients who underwent second trimester termination following injection with lidocaine. Forty-six cases (85%) were done for major fetal anomalies and 8 cases (15%) were for maternal indications. The mean gestational age was 22 weeks (SD = 2.3). The mean volume of lidocaine 1% injected was 10.1 mL (range: 5-40 mL). Asystole was achieved in 1-2 minutes following intracardiac administration. Intracardiac injection was successful in 45/46 (98%) of cases. Intrathoracic administration was successful in 5/6 (83%). This approach was chosen when cardiac puncture was not effective. Two fetuses receiving an initial intraabdominal or umbilical vein injection required additional doses of intracardiac lidocaine to produce asystole. There were no maternal complications. CONCLUSIONS: Intracardiac administration of lidocaine is an effective method to induce cardiac asystole for second trimester pregnancy termination. Extra-cardiac injection, however, is less effective.

Prenatal diagnosis of a vein of Galen aneurysmal malformation using color Doppler ultrasound: a case report.

Vein of Galen aneurysms are a rare and complex vascular malformation of the brain. Their prevalence is somewhat less than 1 in 25,000 deliveries. Common associated anomalies include ventriculomegaly, cardiomegaly secondary to high cardiac output and enlarged neck vessels, the later being an almost pathognomonic sign. The prognosis for these neonates is poor with a mortality rate of 50% and a high risk for neurologic sequelae. Color flow Doppler studies of the fetal brain vasculature are a reliable method for diagnostic purposes. In this paper we present a case of a vein of Galen malformation diagnosed prenatally at 33 weeks of gestation using both 2D and color Doppler ultrasound modalities.

Knowledge of chlamydia trachomatis assessed in a Puerto Rican medical student population.

OBJECTIVE: The knowledge of medical students in Puerto Rico with regard to the Chlamydia trachomatis infection has not been formally assessed. The purpose of this study was to make such an assessment as it is the members of this group who will eventually educate and inform patients about this and other health-care issues. METHODS: The sample was drawn from a population of students enrolled in a four-year medical school program in Puerto Rico. Data were collected via a self-administered one-page questionnaire and took approximately 5 minutes to complete. The questionnaire was a 9-item inventory composed mostly of knowledge items. A frequency count for each item was calculated. The SPSS program was used for the statistical analysis. RESULTS: A final response rate of 76% (338/455) was obtained for the analysis. The sources of chlamydial information were college (73.4%), high school (59.8%), friends (28.1%), press media (21.6%), and family members (15.4%). Asked to identify the etiology of the infection, participants responded that it was bacterial (78.1%), viral (16.9%), parasitic (3.8%), or fungal (1.2%). Knowledge about the existence of a cure for the infection resulted in 85.5% of the respondents answering in the affirmative, that a cure exists; the rest either did not know or were uncertain about the existence of a cure for Chlamydia. Knowledge regarding the mode of transmission resulted in 98.2% stating that it is transmitted sexually, while public bathrooms as a source of infection accounted for 2.4%; kissing (1.5%) was also identified as a method of transmission. Statistics for the symptoms and the consequences of chlamydia resulted in pelvic inflammatory disease (PID) (81.1%), infertility (75.1%), abnormal vaginal secretions (79.6%), burning sensation upon urination (49.6%), ectopic pregnancies (44.9%), abnormal vaginal bleeding (13.9%), and cervical cancer (8.9%). CONCLUSION: Our data suggest that members of this population understand this infection only partially and that there is indeed a lack of knowledge regarding infection of sexually transmitted Chlamydia trachomatis. Without accurate knowledge of chlamydial infection, medical students and physicians are unable to identify its presence and, subsequently, educate their patients regarding both the management and the serious complications of this infection. There are serious implications for women's health, and thus knowledge is important to reduce the burden of chlamydial infection.

Antenatal screening for Down syndrome with special considerations in the Puerto Rican population.

Down syndrome is the most studied chromosomal abnormality, and the risk of having a child with Down syndrome increases as maternal age increases. The prevalence of Down syndrome has been increasing in the last decade because more women older than 35 years of age are having children. In recent decades, the rate of identification of fetal anomalies in the uterus has substantially increased. Diagnostically speaking, serious concerns yet remain within the obstetrical community regarding who should be recommended for invasive procedures. The FASTER, SURUSS, and BUN studies have attempted to address this issue. In the United States, the quadruple screen for Down syndrome (hcG, AFP, estriol, and inhibin-A) is the most commonly used test today. During the first trimester, the nuchal translucency measurement combined with serum markers hcG and PAPP-A (pregnancy-associated plasma protein-A) results in high detection rates and low false-positive rates. For Down syndrome screening, new methods of evaluation have been proposed; among these are integrated, sequential, and contingent modalities. Different trials have demonstrated that first-trimester screening for Down syndrome is very effective, but all conclude that combining screening during both trimesters allows for lower false-positive values and higher detection rates. In Puerto Rico, in spite of the fact that a large proportion of the population undergoes serum screening, the rate of Down syndrome live births remains steady. One important aspect that appears to limit prenatal diagnosis of Down syndrome in our population is a poor acceptance rate of diagnostic testing techniques such as amniocentesis. Also, a limited efficiency in the implementation of these screening methods as well as their diagnostic success has been observed for our patient population.

Seasonal variations in the incidence of some congenital anomalies in Puerto Rico based on the timing of conception.

BACKGROUND: Birth defects represent one of the main causes of infant mortality and morbidity around the world. OBJECTIVE: The purpose of this study is to identify seasonal changes in the incidence of various congenital anomalies in our population. METHODS: We identified all cases of open neural tube defects, cardiac anomalies, cleft lip and palate and gastroschisis of children born in Puerto Rico and reported to the Health's Department Birth Registry Program between January 1995 and December 2005. The conception dates were determined by estimation based on the reported last menstrual period. All deliveries during this same period were recorded and their conception dates estimated in the same manner. The data for each anomaly was separated into 4 groups for each year studied corresponding to the four seasons. The sample was stratified based on the type of anomaly detected and the season when conception took place. RESULTS: There is a seasonal pattern in the rate of conceptions in Puerto Rico with the highest incidence during the winter and lowest during the summer months. We detected a statistically significant increase in the incidence and relative risk during the summer months (using winter as a reference) of conceiving a child with open neural tube defects (1.03/1000, RR:1.33), cardiac anomalies (5.22/1000, RR:1.39), or cleft lip and palate (1.68/1000, RR:1.89). Gastroschisis did not show a statistically significant difference in the rate of conceptions, but there was a tendency towards a higher incidence during spring (0.39/1000, RR:1.67). CONCLUSIONS: The reported seasonal variation in the incidence of open neural tube defects, cardiac anomalies, and cleft lip and palate may be secondary to the effect of yet to be identified teratogens acting on the population at large, or, more likely, to changes in activity and dietary patterns of the population.