Extensive thrombosis and first-trimester pregnancy loss caused by sticky platelet syndrome.

BACKGROUND: Sticky platelet syndrome is an autosomal-dominant thrombophilia characterized by platelet hyperaggregability in the presence of adenosine diphosphate or epinephrine. The result clinically can be widespread thromboses, often arterial, in patients without apparent risk factors for thrombotic disease. Limited data exist regarding its role in adverse pregnancy outcomes. CASE: A gravid woman with two previous first-trimester miscarriages presented at 11 weeks of gestation with a deep venous thrombosis. Despite anticoagulation, she developed extensive and progressive arterial and venous thromboses and suffered a fetal demise. A thrombophilia panel was unremarkable, but platelet aggregometry demonstrated hyperactive platelets in the presence of adenosine diphosphate and epinephrine consistent with sticky platelet syndrome. CONCLUSION: Sticky platelet syndrome causes arterial thromboses and may be an underappreciated etiology for adverse pregnancy outcomes.

The prognosis for spontaneous labor in women with uncomplicated term pregnancies: implications for cesarean delivery on maternal request.

OBJECTIVE: To assess the prognosis for vaginal delivery in women with entirely normal pregnancies who began spontaneous labor at term. METHODS: Between January 1, 1988, and October 31, 2006, a total of 278,164 women delivered newborns at our hospital. A subset of women with uncomplicated pregnancies and spontaneous labor between 37 and 41 weeks of gestation then were identified for analysis of maternal and neonatal outcomes. The outcomes we studied included admission-to-delivery intervals, use of epidural analgesia, maternal perineal trauma, route of delivery, and several potential indices of neonatal condition at birth. RESULTS: There were 103,526 (37%) women who delivered at our hospital during the study period who had normal term pregnancies and entered labor spontaneously. Overall, 96% of these women had vaginal deliveries, and adverse neonatal outcomes were rare. For example, perinatal deaths occurred in 0.3 of every 1,000 women. CONCLUSION: Approximately one third of pregnant women have entirely normal pregnancies and enter spontaneous labor at term. Virtually all such women can anticipate safe vaginal deliveries for themselves and their infants. LEVEL OF EVIDENCE: III.

Fetal magnetic resonance imaging in isolated diaphragmatic hernia: volume of herniated liver and neonatal outcome.

OBJECTIVE: We sought to use magnetic resonance (MR) imaging (MRI) to estimate percentage of fetal thorax occupied by lung, liver, and other abdominal organs in pregnancies with congenital diaphragmatic hernia (CDH). STUDY DESIGN: This was a retrospective study of pregnancies with isolated CDH referred for MRI between August 2000 and June 2006. Four regions of interest were measured in the axial plane by an investigator blinded to neonatal outcome, and volumes were then calculated. The percentages of thorax occupied by lung, liver, and all herniated organs were then compared with neonatal outcomes. RESULTS: Fifteen CDH fetuses underwent MRI at a median gestational age of 29 weeks. Liver herniation was found in 93%. When the liver occupied > 20% of the fetal thorax, neonatal deaths were significantly increased. Percentages of lung and other herniated organs were not associated with outcome. CONCLUSION: In our MR series of isolated CDH, neonatal deaths were significantly increased when > 20% of the fetal thorax was occupied by liver.

Conservative management of placenta percreta: experiences in two cases.

BACKGROUND: The management of an abnormally invaded placenta presents a challenging obstetric problem. Recent reports have suggested that a conservative approach to the treatment of this condition is appropriate in selected cases. We present the courses of two women with suspected placenta percreta who were managed conservatively and the complications that ensued. CASES: Two multiparous women underwent elective repeat cesarean deliveries and were found to have clinical evidence of placenta percreta with bladder invasion. In both cases, the placenta was left in situ and medical management was attempted with methotrexate. Both women developed significant delayed complications requiring reoperation and hysterectomy, and both required multiple transfusions. CONCLUSION: Conservative management of the abnormally invaded placenta should be undertaken with caution, and complications should be anticipated.

The metabolism and transplacental transfer of oseltamivir in the ex vivo human model.

UNLABELLED: Oseltamivir phosphate is extensively metabolized in the ex vivo human placenta model, and the transplacental passage of the metabolite oseltamivir carboxylate is incomplete. OBJECTIVE: To evaluate the metabolism and transplacental transfer of oseltamivir (Tamiflu) in the ex vivo human placental model. STUDY DESIGN: Perfusion studies were performed in six placentas from term, uncomplicated deliveries. Concentrations of oseltamivir phosphate (OP) that were 5-6 fold, 20-30 fold, and 600-800 fold above the therapeutic peak were tested, as neither OP nor its active metabolite, oseltamivir carboxylate (OC), could be detected at near-therapeutic concentrations. The transplacental transfer and accumulation of OC were assessed using the (14)C antipyrine reference method. RESULTS: OP was extensively metabolized to OC. In the 4 placentas with the highest concentration of OP, OC had a mean clearance index of 0.13 +/- 0.08, suggesting that transplacental passage occurs at a relatively low rate. Measurable fetal accumulation occurred in the two placentas with the highest initial concentrations. CONCLUSIONS: Oseltamivir phosphate was extensively metabolized in the ex vivo model. Transplacental transfer of the metabolite was incomplete and accumulation was minimal.

Advanced extrauterine pregnancy: diagnostic and therapeutic challenges.

OBJECTIVE: The objective of the study was to identify women with advanced extrauterine pregnancy, specifically assessing the problems encountered with their diagnosis and management, preoperative evaluation, and surgical removal. STUDY DESIGN: This was a case series including women diagnosed with an extrauterine pregnancy of 18 weeks' gestation or greater at our institution from 1980 to 2005. RESULTS: We identified 10 women with advanced extrauterine pregnancies during the study period. Diagnosis was not optimal, and only 6 were discovered preoperatively. Despite the fact that only 3 of 10 women met diagnostic criteria for an abdominal pregnancy, surgical dissection was universally difficult, and hemorrhage was common with 9 of 10 patients requiring blood transfusions. In 2 women, the placenta was left in situ, and both developed serious complications. All 5 viable fetuses survived, but their courses were long and complicated. CONCLUSION: Irrespective of placental implantation site, an advanced extrauterine pregnancy is a serious condition. The currently accepted definition of abdominal pregnancy is too exclusive.