Midwifery co-management of hyperemesis gravidarum.

Hyperemesis gravidarum is an infrequent, yet significant, maternal complication of pregnancy. Beginning with the frequently experienced nausea and vomiting of pregnancy, symptoms can progress to hyperemesis, a debilitating condition affecting maternal and fetal well-being. A basic understanding of the pathophysiology of the disease process and an awareness of the therapeutic interventions that are available will facilitate midwifery planning for either the collaborative care or the potential referral to medical management, both of which may be required with this clinical entity. The diagnosis and initial management of hyperemesis is within the purview of midwifery care. As certain critical features of duration and severity evolve, medical collaboration and ultimate hospitalization may be required. For those few individuals requiring the most intense level of care, the critical support and encouragement afforded by midwifery participation will contribute to timely resolution of this debilitating condition. This article discusses the continuum from differential diagnosis to ultimate care of the woman who has excessive nausea and vomiting of pregnancy. Collaboration among health care providers will allow all to exercise their respective skills in achieving the optimum in safe therapy and support for their patients.

Is the obstetric guideline of 30 minutes from decision to incision for Cesarean delivery clinically significant?

A Cesarean delivery may be critical to the health and wellbeing of a newborn. The time required to extract an infant from a hostile in utero environment is a frequent issue in medical negligence cases. The American College of Obstetricians and Gynecologists and the American Academy of Pediatrics suggest a time guideline of 30 minutes from decision for Cesarean delivery to the beginning (incision) of the procedure. This time frame is based on survey data from hospitals throughout the United States and is not based on clinical outcomes or the pathophysiology of obstetric events. This review focuses on specific Cesarean indications as noted by the specialty groups and analyzes them from an outcome point of view. The authors conclude that specific high-risk factors do indeed warrant delivery in as expedient a fashion as possible; however, compliance with the 30-minute guideline does not necessarily lead to a difference in outcome as far as the neonate is concerned.

The role of placental examination and its pathology in obstetric risk management.

The placenta is a marker of biologic events that occur during pregnancy. Placental pathologic examination gives insight to pregnancy-related insults, which affect the newborn at and after birth. Clinicians and risk managers can use this information to identify the cause of newborn complications in cases suggested to be birth-related injuries.

Management of moderate to severe trauma in pregnancy.

Severe trauma to an obstetric patient is truly an injury of double magnitude. While being cognizant of the fetus and its well-being, all expediency must be employed to accomplish a thorough evaluation of the injured patient and allow for the prompt employment of appropriate therapeutic measures. The best key to fetal survival is successful maternal therapy.

Preliminary study of the tryptase levels in the synovial fluid of patients with inflammatory arthritis.

This study examined levels of tryptase, a specific mast cell product, in synovial fluid. Samples of synovial fluid from eight patients with rheumatoid arthritis and ten with other arthritides were measured in solid-phase immunoradiometric assays. Elevated concentrations of tryptase were present in samples from three patients with rheumatoid arthritis, one with psoriasis, and one with Reiter's syndrome. The data support the theory that mast cell activation is involved in the pathogenesis in some inflammatory joint diseases, but activation does not appear to be disease specific.

Asynchronous multiple birth. A report of five cases.

The feasibility of prolonging the delivery interval of the fetus or fetuses in multiple gestations after the preterm delivery of one fetus has been demonstrated. Five clinical reports and a literature review served as the database for this study. Pregnancy was extended in each of five patients with multiple gestations after the extreme preterm delivery of one fetus. Four of the six remaining infants survived. The literature reviewed shows successful survival in 42 of 52 (81%) such asynchronously delivered infants. Use of tocolytic therapy, broad-spectrum antibiotics and cerclage allows pregnancy extension when delivery occurs asynchronously in multiple gestations. The patient's strong desire and full understanding of the potential risks are mandatory before such an endeavor is attempted.

Salsalate-induced pancytopenia in a patient with systemic lupus erythematosus.

After a patient with a history of systemic lupus erythematosus in remission was given salsalate, all of her hematologic elements, especially leukocytes, profoundly decreased within hours, although the patient was receiving steroids. She had been challenged with salsalate at an earlier date, with a similar but less impressive drop in blood counts. Granulocytotoxic antibodies persisted during this episode in contrast to declining lymphocytotoxic and anti-native DNA antibodies that accompanied a remission of systemic lupus. This is the first case of this kind occurring with salsalate therapy and may have represented preformed antibodies induced by salsalate.

Placenta previa.

A placenta previa, whether found fortuitously by ultrasound or with the clinical emergency of maternal hemorrhage, carries significant maternal and fetal risk. Accurate diagnosis, judicious expectant management with transfusion as required, and delivery at the time of fetal lung maturation can lead to the most favorable outcome. Anticipation of the clinical complication of placenta accreta may avoid some serious consequences. Clinical judgement and skill in the performance of cesarean sections, dilatation and curettage, and other forms of uterine invasive techniques may help to keep subsequent incidence of placenta previa at a reasonably low rate.

Amniography for confirming the diagnosis of monoamniotic twinning. A case report.

In a case of monoamniotic twinning, amniography was used to confirm the diagnosis. This modality, old but now employed infrequently, helps establish the absence of a dividing membrane and complements currently used ultrasound diagnostic methods. A successful outcome resulted. Amniography should be considered a useful diagnostic modality in the management of twin gestations and not be relegated to the past.

Subcapsular hematoma of the liver during pregnancy.

We have reported a case of subcapsular hematoma of the liver, diagnosed and observed by ultrasonography, in association with the HELLP syndrome. The patient's condition improved with conservative management, but the hematoma was clearly shown to last for more than 12 weeks, which shows the need for extended postpartum follow-up and appropriate patient consultation.

Sonography of the puerperal uterus.

Thirty-seven patients who delivered singleton pregnancies were followed by serial sonograms during the first 2 weeks of the puerperal period to evaluate uterine involution. Significant correlation was found between birthweight and uterine size during this period. No correlation was found between regressing uterine size and route of delivery, parity, or method of infant feeding. Variations in normal uterine, endometrial, and adnexal appearance are described as knowledge of these changes is necessary to appreciate pathologic conditions.

The physician's reaction to a malpractice suit.

A malpractice suit can have a devastating impact on a practitioner's professional and personal life. The physician's reaction to this event is profound, affecting his own life-style and that of family, colleagues, and patients. This commentary presents an analogy between the physician's reaction to a malpractice suit and the stages of grief described by Elisabeth Kübler-Ross: the sequence of denial, anger, bargaining, depression, and acceptance. Understanding the psychodynamics of this reaction can help physicians to cope with the problems inherent in a malpractice suit and to maintain a greater stability in their personal lives. Adverse effects on medical practice and private life-style, and on the legal proceedings, can be minimized.

Unexplained fetal baseline bradycardia in congenital panhypopituitarism.

An unexplained fetal baseline bradycardia apparently not secondary to uteroplacental insufficiency is reported. Congenital panhypopituitarism was diagnosed in the neonate. A common cause of both findings is speculated and a review of possible methods for antenatal diagnosis is given.

Sonographic evaluation of the adnexa during early pregnancy.

Of 3,918 obstetric patients who underwent scanning during the first 20 weeks of gestation, 94 had sonolucent adnexal masses identified. These represented predominantly the corpus luteum of pregnancy. The incidence of such a mass significantly declined after the tenth gestational week. This pattern of degeneration is physiologic and represents the normal course of events for the ovary in the first half of pregnancy. Characteristics of these masses and indications for operative intervention are discussed. The obstetric outcome for eight patients who underwent surgical treatment was uncomplicated. Guidelines for management of significant adnexal masses in pregnancy is similar to that of the nonpregnant state.