Gravid hysterectomy: a decade of experience at an academic referral center.

OBJECTIVE: To evaluate the incidence of gravid hysterectomy (GH) and to examine the indications as well as risk factors and complications associated with the procedure at an academic perinatal referral center. STUDY DESIGN: Retrospective chart review of all patients who underwent GH from 1991 to 2001. Demographics, obstetric history, delivery information, complications and outcome were analyzed. RESULTS: There were 34 GHs out of 19,491 deliveries (1.74/1000). The preoperative indications were hemorrhage associated with atony (32.4%), placenta accreta (20.6%) and uncontrolled bleeding (17.6%). Of the patients, 87.5% were parous and 53.1% had previous cesarean section. GH was performed prior to viability in 3. GH followed cesarean delivery in 24 (68.6%). Uterine and/or hypogastric artery ligation were performed in 11 (32.4%). Postoperative complications included surgical re-exploration for recurrent hemorrhage in 5, transfusion of blood products in 30, disseminated intravascular coagulopathy in 15, prolonged (> 24 hours) ventilation in 10 and admission to the SICU for prolonged intensive care in 12. There were 2 maternal deaths (5.9%). A significant rise in GH rate from 1/800 to 1/299 occurred over the past 5 years despite constant cesarean rates (chi2, p < 0.05). CONCLUSION: Rates of GH increased over the period examined. Placenta accreta associated with previous cesarean section is the predominant risk factor for GH.

Screening for postpartum depression with the Edinburgh Postnatal Depression Scale in an indigent population: does a directed interview improve detection rates compared with the standard self-completed questionnaire?

BACKGROUND: The Edinburgh Postnatal Depression Scale (EPDS) is a well-validated screening tool for the detection of patients at risk for postpartum depression. It was postulated that screening utilizing the EPDS in a directed interview would increase the detection rate compared with a self-completed EPDS in an indigent population. OBJECTIVE: To compare the results of a self-completed EPDS with those of a directed interview utilizing the EPDS in the identification of patients at increased risk for postpartum depression. METHODS: All patients undergoing a 6-week postpartum evaluation in the obstetric clinic at a community teaching hospital between November 1, 2003 and March 31, 2004 were screened for postpartum depression using the self-completed EPDS. This was followed by a directed interview, which consisted of a verbally administered EPDS by a social worker blinded to the results of the self-completed EPDS. A positive screen was defined as an EPDS score of > or =12 by either method. The number of patients with a positive screen to either the self-completed EPDS, the directed interview EPDS, or both were recorded. The two techniques were compared by the McNemar Chi-square test. The self-completed and directed interview EPDS scores were compared by Pearson's correlation coefficient to examine differences in screening techniques. Demographic data and characteristics in each group were examined. RESULTS: Among the 134 patients evaluated, 24 (17.9%) screened positively for being at an increased risk of having postpartum depression. The self-completed EPDS and the directed interview EPDS screening detection rates were not different, identifying 23 (17.2%) and 22 (16.4%) patients, respectively (p = 1.0). The use of the self-completed EPDS and the directed interview EPDS in parallel detected one additional subject (0.7%; p = 0.99). The self-completed EPDS and directed interview EPDS scores correlated significantly (r = 0.94; p = 0.01). The demographics and characteristics of patients with a positive screen were not different from those with a negative screen. CONCLUSIONS: The self-completed EPDS and directed interview EPDS are equivalent screening techniques for postpartum depression. There is no evidence to suggest that parallel screening improves detection. Either technique should be incorporated into the postpartum visit to screen for postpartum depression.

Analysis of disease in the obstetric intensive care unit at a university referral center: a 24-month review of prospective data.

OBJECTIVE: To determine the current spectrum of disease in an obstetric population resulting in admission to the intensive care unit (ICU) at a tertiary care hospital. STUDY DESIGN: Analysis of data from obstetric patients admitted for critical care management at the University of Maryland Medical Center over a 24-month period. RESULTS: Critical care admission was required for 34 (1.3%) of 2,565 women admitted for deliveries; 38.5% of patients were delivered during their ICU admission. Preexisting medical conditions were present in 67.6% (76.5% were in the antenatal period vs. 23.5% in the postpartum period). Conditions leading to ICU admission included organ system failure, respiratory failure, central nervous system disease, cardiac failure, preeclampsia and postpartum hemorrhage. The median Acute Physiology and Chronic Health Evaluation II (APACHE II) score overall was 11.0 (antenatal 12.0, postpartum 10.5). Although the predicted maternal mortality rate was 12.9% (14.6% in the antenatal period and 12.1% in the postpartum period), the actual mortality rate was 0%. CONCLUSION: In this population, the antenatal period now accounts for the majority of ICU admissions. Respiratory failure (mainly from infectious etiologies) has surpassed obstetric hemorrhage as the primary reason for ICU admission. Finally, the APACHE II scoring system is inaccurate for use in an obstetric population.

Trauma in pregnancy.

Trauma is the leading nonobstetric cause of maternal mortality. The basic tenets of trauma evaluation and resuscitation should be applied in maternal trauma. Aggressive resuscitation of the mother is the best management for the fetus. Care must be taken to keep the patient in the left lateral decubitus position to avoid compression of the inferior vena cava and resultant hypotension. Radiographic studies should be used with care. Noninvasive diagnostics should be used when available. Cardiotocographic monitoring of a viable gestation should be initiated as soon as possible in the emergency department to evaluate fetal well-being. Urgent cesarean section should be considered if fetal distress is present or if the presence of the fetus is contributing to maternal instability.

Persistent fetal hemoglobin in maternal circulation complicating the diagnosis of fetomaternal hemorrhage.

BACKGROUND: Transplacental hemorrhage can be life threatening to a fetus and has important maternal treatment implications. In contrast, hereditary persistence of fetal hemoglobin is a condition that has little consequence. The Kleihauer-Betke test, which is routinely used to document transplacental hemorrhage, will be positive in either case. CASES: We report two cases in which maternal persistence of fetal hemoglobin was unknown and led to the erroneous diagnosis of fetomaternal hemorrhage. These cases highlight both the limitations of the Kleihauer-Betke test and the role of flow cytometry in diagnosing fetomaternal hemorrhage. CONCLUSION: The use of flow cytometry can clarify Kleihauer-Betke test results when there is known maternal persistence of fetal hemoglobin and can more precisely quantify a fetomaternal hemorrhage for accurate Rh immune globulin dosing.

Kleihauer-betke testing is important in all cases of maternal trauma.

BACKGROUND: In maternal trauma, the Kleihauer-Betke (KB) test has traditionally been used to detect transplacental hemorrhage (TPH), so that Rh-negative women could receive appropriate Rh immune prophylaxis. Reasoning that the magnitude of TPH would reflect uterine injury, we evaluated Kleihauer-Betke testing as an independent predictor of preterm labor (PTL) after maternal trauma. METHODS: Admissions to the Shock Trauma Center, University of Maryland, from January 1996 to January 2002, were reviewed. Of 30,362 trauma patients admitted, 166 were pregnant, and 93 of these underwent electronic fetal monitoring. Their records were abstracted for demographics, injury type, three separate trauma scores, documented uterine contractions, PTL (contractions with progressive cervical change), and serious perinatal complications. In 71 cases, transplacental hemorrhage was assessed by maternal KB test. RESULTS: TPH, defined as KB-positive for greater than 0.01 mL of fetal blood in the maternal circulation, occurred in 46 women. Forty-four had documented contractions (25 had overt PTL) and 2 had no contractions. In 25 women with a negative KB test, none had uterine contractions. All patients with contractions or PTL had positive KB tests. By logistic regression, KB test result was the single risk factor associated with PTL (p < 0.001; likelihood ratio, 20.8 for positive KB test). Compared with other sites, abdominal trauma was associated more often with uterine contractions (p < 0.001), PTL (p = 0.001), and a positive KB test (p < 0.001, chi). None of the trauma scoring systems predicted PTL. CONCLUSION: Kleihauer-Betke testing accurately predicts the risk of preterm labor after maternal trauma. Clinical assessment does not. With a negative KB test, posttrauma electronic fetal monitoring duration may be limited safely. With a positive KB test, the significant risk of PTL mandates detailed monitoring. KB testing has important advantages to all maternal trauma victims, regardless of Rh status.