Prenatal sonographic diagnosis of vasa previa: ultrasound findings and obstetric outcome in ten cases.

OBJECTIVE: To assess the specificity of sonographic diagnosis of vasa previa and pregnancy outcome in sonographically diagnosed cases. METHODS: We prospectively collected cases of vasa previa diagnosed by color Doppler sonography. Delivery by elective Cesarean section after demonstration of fetal pulmonary maturity and prior to the onset of labor was recommended unless obstetric complications supervened. Data regarding maternal obstetric courses and newborn status were collected. RESULTS: Eleven cases of vasa previa without placenta previa were diagnosed among 33 208 women over an 8-year period. Ten patients had confirmation of the diagnosis by the delivering obstetrician and/or placental examination, giving a specificity of diagnosis of 91%. Among the 10 patients with confirmed vasa previa, two were delivered at 31.5 and 35.5 weeks' gestation prior to demonstration of lung maturity, and the remainder were delivered at 34-37.5 weeks, after lung maturity. All infants had normal Apgar scores and survived. One baby had Scimitar syndrome, which was not suspected from sonography. CONCLUSIONS: The specificity of sonographic diagnosis of vasa previa at our center was 91%. Antenatal diagnosis permitted us to prevent the catastrophic outcomes commonly associated with vasa previa.

Splenectomy for hairy cell leukemia in pregnancy.

OBJECTIVE: Hairy cell leukemia is a rare hematologic malignant disease characterized by pancytopenia and splenomegaly. Its occurrence during pregnancy limits treatment with standard chemotherapeutic agents. A woman was found to have hairy cell leukemia and massive splenomegaly late in the second trimester. A review of the literature did not provide a carefully formulated treatment plan. It was believed that splenectomy (the historic therapy for hairy cell leukemia) would likely result in improved hematologic values and allow the pregnancy to progress. STUDY DESIGN: Case report with literature review. RESULTS: Preoperative laboratory studies revealed platelet count 65,000/mm3, hematocrit 28.6%, white blood cell count 4000/mm3, and hairy cell index 0.06 to 0.07. At 24 weeks' gestation, the patient underwent splenectomy with resolution of thrombocytopenia and normal progression of pregnancy without complication. Repeat cesarean section at 38 weeks produced a 2875 gm healthy male infant with Apgar scores of 9 and 9. CONCLUSION: If antepartum management of hairy cell leukemia is warranted, splenectomy is a safe and effective treatment option during the second trimester.

Does Doppler-detected fetal movement decrease the incidence of nonreactive nonstress tests?

OBJECTIVE: To determine whether a decreased incidence of nonreactive nonstress tests (NSTs) in antepartum testing was attributable to the addition of fetal movement detection to the standard NST. METHODS: Monitors with standard fetal heart rate recording capabilities were used, as were new monitors producing a Doppler-detected recording of fetal movement (NST-fetal movement). Cross-sectional retrospective analysis of NST results was carried out by chi 2. RESULTS: Comparison of the 10-month period before fetal movement detection to the 10 months including NST-fetal movement monitoring showed a significant decrease in nonreactive NSTs from 5.7% to 3.3% (chi 2 = 61.7, 95% confidence interval [CI] 0.97-0.98). This reduction in nonreactive tests disappeared (3.3% to 5.1%) when the NST-fetal movement-capable monitors were no longer available (chi 2 = 24.2, 95% CI 1.01-1.03). CONCLUSIONS: Nonreactive NSTs decreased by 58% with the introduction of fetal movement monitoring in our antepartum testing center and increased when the NST-fetal movement-capable monitors were removed. A reduced incidence of nonreactive NSTs associated with NST-Doppler-detected fetal movements should effect a savings in both time and resources.

Emergency peripartum hysterectomy and associated risk factors.

OBJECTIVE: Peripartum hysterectomy at Los Angeles County-University of Southern California Medical Center was reviewed and associated risk factors were identified. STUDY DESIGN: Retrospective descriptive and cohort analysis from January 1985 to June 1990 was carried out. Adjusted relative risks for hysterectomy with 95% confidence intervals for identified risk factors were calculated where possible. RESULTS: There were 123 cases of emergency peripartum hysterectomy (incidence of 1.3/1000 births). Indications for hysterectomy were primarily placenta accreta (n = 61), uterine atony (n = 25), unspecified uterine bleeding (n = 19), and uterine rupture (n = 14). The relative risk of emergency hysterectomy was 95.5 (95% confidence interval 66.7 to 136.9) for cesarean delivery, 10.78 (95% confidence interval 7.56 to 15.37) for prior cesarean delivery, and 97.29 (95% confidence interval 70.28 to 134.70) for placenta previa. CONCLUSIONS: Cesarean delivery, prior cesarean delivery, placenta previa, placenta accreta, and uterine atony were identified risk factors for emergency peripartum hysterectomy.

Subarachnoid hemorrhage at an inner-city hospital.

We evaluated the clinical manifestations, treatment, and outcome of a group of inner-city patients with subarachnoid hemorrhage. Twenty-one patients had surgical therapy and sixteen patients were managed with supportive measures. Patients were graded according to their clinical condition on initial presentation. Those with a favorable outcome tended to be in better condition initially. The surgical mortality was 14% and decreased substantially for the group of patients in optimal clinical condition. Cerebral vasospasm was more frequent with a poor clinical state and was associated with an unfavorable outcome. Inner-city patients with subarachnoid hemorrhage seemed to fare no worse than the general population.