Carbon Monoxide Exposure During Pregnancy.

IMPORTANCE: Carbon monoxide (CO) is the leading cause of poisoning in the United States and is associated with high maternal and fetal mortality rates. Given the nonspecific signs and symptoms of toxicity, cases may go unsuspected or attributed to other etiologies. As CO adversely affects both mother and fetus, it is important for practitioners to recognize and treat poisoning in a timely manner. OBJECTIVE: We seek to assist practitioners with understanding the physiology and recognizing the presentations of both acute and chronic CO poisoning, as well as provide information on diagnosis and treatment options. We also conducted a review of cases described in the literature during the past half century to show varying presentations and treatment methodologies. EVIDENCE ACQUISITION: A qualitative literature search was conducted using PubMed and Google Scholar for articles published between 1970 and 2014 that assessed cases of CO poisoning during pregnancy. Excluded studies were not in English or contained nonhuman subjects. RESULTS: Nineteen published reports of CO poisoning during pregnancy described in varying levels of detail were found in the literature from 1971 to 2010. CONCLUSIONS AND RELEVANCE: Carbon monoxide poisoning requires a high degree of suspicion. Diagnosis is made based on initial history and physical evaluation and assessment of environmental CO levels; presenting carboxyhemoglobin levels may be poor indicators of severity of disease. Oxygen therapy should be initiated promptly in all possible cases with consideration of hyperbaric oxygen therapy in cases of significant maternal exposure. Treatment requires a longer duration for fetal CO elimination than in the nonpregnant patients. Importantly, practitioners should educate pregnant patients on prevention.

Maternal influenza vaccination: evaluation of a patient-centered pamphlet designed to increase uptake in pregnancy.

We developed and tested a theoretically-based pamphlet entitled 'Influenza in Pregnancy,' specifically designed to increase pregnant women's knowledge, reduce barriers to maternal vaccination, and subsequently improve vaccine uptake. A randomized control trial was conducted on pregnant women (n = 135) at three locations in Connecticut during the 2011-2012 season to evaluate the impact of the patient-centered pamphlet. The women were randomized to one of three groups: the pamphlet; pamphlet/benefit statement (vaccinating the pregnant woman also benefits the young infant); or control. A Chi square analysis compared the intervention with control using the primary outcome of vaccination. A secondary outcome of the perceptions of health beliefs of maternal vaccination were measured through General Linear Model/ANOVA model for repeated measures. Overall 66.9% (89/133) were vaccinated. Both the pamphlet group 72.9% (35/48) (χ² = 6.81, df = 1 p = .009), and the pamphlet/benefit statement group 86.1% (31/36) (χ² = 13.74, df = 1, p < .001), had significantly higher vaccine uptake than the control group 46.9% (23/49). The potential barrier, perception of vaccine safety (F = 4.973, df = 2, p < .01), and benefit of vaccination to mother and infant (F = 6.690, df = 2, p < .01) significantly improved for the intervention groups compared to control group. The pamphlet significantly increased the pregnant women's perceptions of the safety and benefit of the vaccine, and the overall uptake.

Hereditary persistence of alpha-fetoprotein: a rare cause for unexplained alpha-fetoprotein elevations in pregnancy.

Markedly elevated maternal serum alpha-fetoprotein (MSAFP) levels were found in a 26 year old healthy, nulliparous Polish woman during pregnancy. No fetal abnormalities were identified on targeted ultrasound and amniocentesis revealed normal amniotic fluid alpha-fetoprotein (AFP) values. Maternal ultrasound screening for liver and ovarian germ cell malignancies were also negative. The mother delivered a live, healthy female at term and a repeat maternal serum AFP postpartum remained markedly elevated, suggestive of hereditary persistence of alpha-fetoprotein.

Reasons why women accept or reject the trivalent inactivated influenza vaccine (TIV) during pregnancy.

The aim of the study was to gain an in-depth understanding of the reasons why pregnant women accept or reject the seasonal influenza vaccine. The qualitative descriptive design used a face-to-face semi-structured interview format. Sixty pregnant and postpartum women at two hospitals in the Northeastern United States participated. Content analysis was the inductive method used to code the data and identify emergent themes. Six themes emerged from the data: differing degrees of influence affect action to vaccinate; two-for-one benefit is a pivotal piece of knowledge that influences future vaccination; fear if I do (vaccinate), fear if I don't; women who verbalize 'no need' for the vaccine also fear the vaccine; a conveniently located venue for vaccination reduces barriers to uptake; H1N1-a benefit and barrier to the seasonal vaccine. Our study supports previous findings and reveals a deeper understanding and interpretation of the behavior and decision-making to accept or reject the influenza vaccine. Understanding the reasons behind the behavior of vaccine rejection gives us the chance to change it.

Challenges in the diagnosis and treatment of congenital syphilis.

Despite the advent of effective antibiotic treatment of Treponema pallidum, syphilis continues to be present in our population and recently has been increasing in frequency. The consequences can be especially dire in the setting of an untreated infection in pregnancy. This case report describes a case of congenital syphilis in a dichorionic-diamniotic twin pregnancy that resulted in a stillbirth of one twin and the characteristic findings of congenital syphilis in the surviving twin. This report demonstrates a number of challenges to the clinician in the effective and timely diagnosis and treatment of syphilis in pregnancy.

Influenza vaccination during pregnancy and factors for lacking compliance with current CDC guidelines.

BACKGROUND: The Center for Disease Control and Prevention (CDC) and the American College of Obstetricians and Gynecologists (ACOG) recommend influenza vaccination for all pregnant women during the influenza season. However, the actual rate of vaccination is substantially below the target levels. Given the recent emergence of novel influenza strains, there is an important need to address knowledge gaps in women and their healthcare providers to improve vaccination coverage for pregnant women during inter-pandemic and pandemic periods. This study attempted to identify potentially remediable attitudinal factors among women and their physicians that may present barriers to influenza vaccination and then assess the impact of interventions to increase the influenza vaccination rate in pregnant women. METHODS: This prospective study initially analyzed patient and physician knowledge regarding the influenza vaccine in pregnancy and then examined the impact of several interventions aimed to increase immunization rates implemented over the following year. Influenza vaccination rates were assessed before and after the interventions. RESULTS: Five hundred twenty patients were enrolled in the study during the influenza season 2007/2008. Only 19% of those patients reported receiving the influenza vaccination and only 28% recalled that the vaccine was offered. Following this, in the summer and fall of 2008, we performed a physician education program and distributed posters advertising the influenza vaccine to all offices offering prenatal care in our area in order to increase patient awareness of the need for the vaccine. In the following influenza season, we again reassessed the vaccination rate and patient's knowledge and awareness of the vaccine in 480 postpartum women. Influenza vaccination rates increased from 19% to 31%. After the intervention, 51% of patients recalled that the vaccine was offered to them during the pregnancy as opposed to only 28% the year prior. CONCLUSION: Understanding the specific barriers to vaccination that our population faced was helpful in designing the interventions to improve knowledge and acceptance of influenza vaccination in pregnancy, which led to an increased vaccination rates in women.

Cytomegalovirus infection in pregnancy: should all women be screened?

Cytomegalovirus (CMV) is the most common cause of congenital infection and complicates approximately 1% of all live births. Primary maternal CMV infection carries a 30% to 40% risk of vertical transmission to the fetus. In cases where maternal CMV infection is suspected, it is important to evaluate the risk to the fetus to provide appropriate counseling and guidance to parents. This article reviews the published literature and summarizes current diagnostic and management recommendations to help answer the question, should all women be screened for CMV infection in pregnancy?

Prenatal diagnosis of an umbilical vein aneurysm: a case report.

Aneurysm of the umbilical vessels is a rare abnormality and has seldom been diagnosed prenatally. We report a case in which dilatation of the intra-amniotic umbilical cord was seen on prenatal ultrasound at 34-weeks gestation. This was believed to represent an umbilical vein aneurysm and was confirmed on subsequent pathological examination after delivery. A review of the literature concerning these uncommon vascular abnormalities of the umbilical cord is presented.

Antibiotic resistance and penicillin tolerance in ano-vaginal group B streptococci.

OBJECTIVES: We sought to determine the prevalence of group B streptococcus (GBS) colonisation and to characterise antibiotic resistance patterns. METHODS: Vaginal and ano-rectal cultures were evaluated for GBS colonisation, and antibiotic susceptibility profiles were determined to 15 antibiotics according to the guidelines of the National Committee for Clinical Laboratory Standards. RESULTS: Our GBS prevalence was 30%. All isolates were sensitive to amoxicillin/clavulanic acid, ampicillin, ampicillin/sulbactam, cefotaxime, ceftriaxone, cefuroxime-sodium, imipenem, linezolid, penicillin G and vancomycin. Thirty-two percent of the isolates were resistant to azithromycin, 21% to clindamycin, 25% to erythromycin and 23% to tetracycline. CONCLUSIONS: The relatively high rates of resistance to four of the 15 antibiotics tested confirm that for women allergic to penicillin and colonised with GBS, antibiotic sensitivities should be determined. We noticed increasing resistance to clindamycin over a 7-year period. Ongoing surveillance of local antibiotic resistance patterns at the institutional level is important in determining optimal prophylaxis as resistance patterns differ between institutions and are increasing.

Prenatal diagnosis of ectopic intrathoracic kidney in a fetus with a left diaphragmatic hernia.

Intrathoracic renal ectopia as a result of a congenital diaphragmatic hernia (CDH) is a rare congenital anomaly. We present a case in which the prenatal diagnosis of an ectopic intrathoracic kidney was made on routine anatomical survey at 28 weeks' gestation. Color doppler sonography imaging revealed the renal artery coursing into the infant's thorax and was consistent with CDH, but fetal MRI suggested an intact diaphragm. However, neonatal evaluation confirmed the diagnosis of intrathoracic kidney with posterior CDH, which was repaired without complication. In contrast to diaphragmatic hernia with liver or bowel herniation, infants with intrathoracic ectopic kidneys generally do well.

Lutheran b blood group alloimmunization: case series and literature review.

The Lutheran b blood antigen is a high prevalence antigen occurring in 99.8% of Caucasians. Consequently, antibody formation against Lutheran b is very rare. While this antibody can cause hemolytic reactions in adults, there is limited clinical information on its effects on the fetus and newborn. As a high prevalence antigen, it may be difficult to obtain Lutheran b-negative blood for possible maternal transfusion. We describe two cases of pregnancy complicated by Lutheran b alloimmunization. These cases highlight the potential fetal and maternal complications associated with this antibody and we review options to maximize perinatal outcome.

Late postpartum eclampsia as an obstetric complication seen in the ED.

Preeclampsia is a complication of pregnancy associated with hypertension and proteinuria. Preeclampsia may be associated with grand mal seizures and is termed eclampsia. Historically, eclampsia occurring more than 48 hours after delivery, known as late postpartum eclampsia, was thought to be uncommon; however, recent evidence suggests that its incidence is increasing. In addition, the presentation of late postpartum preeclampsia-eclampsia may differ from that occurring during the pregnancy. This contributes to difficulty in diagnosing late postpartum preeclampsia-eclampsia in an emergency department setting. We report 2 cases of late postpartum eclampsia presenting 8 days after delivery, which highlight the unique features of this disorder and discuss some of the difficulties in managing these patients. Greater awareness and knowledge of this disorder by ED physicians should improve outcomes in these potentially life-threatening cases.

Group B streptococcal antibiotic resistance patterns in pregnant women.

Group B Streptococcal (GBS) antibiotic susceptibility studies were performed in 95 pregnant women in Bridgeport, Connecticut. Testing for penicillin, ampicillin, cefazolin, and clindamycin sensitivity was performed. Resistance to clindamycin was seen in 5% of isolates. All isolates were susceptible to penicillin, ampicillin, and cefazolin. Clindamycin sensitivity testing should be performed in patients who are allergic to penicillin. GBS remained uniformly susceptible to penicillin and first generation cephalosporins during this study period.