Time advantage of HemoCue versus traditional complete blood count during cordocentesis.

OBJECTIVES: During cordocentesis, a significant risk factor for adverse outcome is procedure length. One of the greatest contributors to total procedure length is the time that elapses between obtaining a fetal sample and receiving the results of the complete blood count (CBC) from the hospital laboratory. We aimed to evaluate whether there is an advantage to using a point of care hemoglobinometer (HemoCue) compared with traditional CBC during cordocentesis, measured in time elapsing between obtaining fetal sample, and available result. Secondarily we aimed to compare accuracy of HemoCue in relation to traditional CBC. METHODS: A prospective cohort study was conducted on women undergoing cordocentesis and fetal transfusion for suspected fetal anemia from July 2016 to July 2018 at an urban academic medical center. Fetal blood samples were obtained during cordocentesis, and concurrently sent for traditional CBC, as well as immediately analyzed at bedside using a HemoCue machine. The time elapsing between the obtained fetal sample and availability of results with HemoCue versus traditional CBC were recorded. Primary outcome was time elapsed between obtaining fetal sample and result available for HemoCue versus traditional CBC. Secondary outcome was comparison of HemoCue and CBC hemoglobin values for accuracy. RESULTS: Forty-five fetal samples were compared using CBC and HemoCue. Sixteen cordocentesis procedures were performed on 10 patients during the study period. Use of HemoCue was associated with a significantly shorter time to yield a fetal hemoglobin result, compared to traditional CBC (1.5 versus 5.5 min, p = .0001). Results yielded by the HemoCue highly correlated to those yielded by traditional CBC (R = 0.96). CONCLUSIONS: Use of HemoCue during cordocentesis is associated with a 4-min time advantage over traditional CBC. Hemoglobin results yielded by HemoCue and traditional CBC are highly correlated.KEY MESSAGEUse of a point-of-care hemoglobinometer is associated with a time advantage of 4 min over traditional complete blood count during cordocentesis. This represents a potentially modifiable risk factor for procedure length, and thus procedure complications.

The worst of both worlds-combined deliveries in twin gestations: a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study.

OBJECTIVE: The reported incidence of combined twin delivery (vaginal delivery of twin A followed by cesarean delivery for twin B) ranges between 5% and 10%. These estimates are based mostly on small studies or retrospective data. We aimed to evaluate to incidence and risk factors for and outcomes of combined twin deliveries, using a subanalysis of the Twin Birth Study, a randomized, controlled, prospective study. STUDY DESIGN: The Twin Birth Study included women with twin gestation between 32+0 and 38+6 weeks, with the first twin in vertex presentation at randomization. Women were randomized to planned cesarean delivery or planned vaginal delivery. For the purpose of this subanalysis, we included women who had a vaginal delivery of twin A. Women who had a combined delivery (cesarean delivery for twin B) were compared with women who had a vaginal delivery of both twins. Our primary objective was to identify risk factors for combined twin deliveries. Our secondary objective was to assess the rate of fetal/neonatal death or serious neonatal morbidity in combined deliveries. RESULTS: Of the 2786 women included in the original study, 842 women delivered twin A by a vaginal delivery and were included in the current analysis, of whom 59 (7%) had a combined delivery. Women in the combined delivery group had a lower rate of nulliparity (22.0% vs 34.7%, P = 0.047) and higher rates of noncephalic presentation of twin B at delivery (61.0% vs 27.3%, P < 0.001) and spontaneous version from presentation at randomization of twin B (72.9% vs 44.3%, P < 0.0001). In a multivariable model, the only risk factor significantly associated with a combined delivery was transverse/oblique lie of twin B following delivery of twin A (adjusted odds ratio, 47.7; 95% confidence interval, 15.4-124.5). Twins B in the combined delivery group had a higher rate of fetal/neonatal death or serious neonatal morbidity (13.6% vs 2.3%, P < 0.001), 5-minute Apgar score <7, neonatal intensive care unit admission, abnormal level of consciousness, and assisted ventilation. CONCLUSION: Transverse/oblique lie of twin B following vaginal delivery of twin A is a risk factor for combined delivery. Combined delivery is associated with higher risk of adverse neonatal outcomes of twin B. These data may be used to better counsel women with twin gestation who consider a trial of labor.

Review of familial hemiplegic migraine, successful outcome in a pregnant patient.

As the field of neurogenetics is expanding rapidly and variant classification criteria evolve, genetic variants in databases are re-evaluated overtime allowing updated classifications of pathogenicity predication. When caring for patients with genetic disorders, it is important to obtain the original genetic report and also consider an updated reanalysis.

Nonsteroidal Antiinflammatory Drug Administration and Postpartum Blood Pressure in Women With Hypertensive Disorders of Pregnancy.

OBJECTIVE: To evaluate whether postpartum nonsteroidal antiinflammatory drug (NSAID) administration is associated with increased blood pressure in women with hypertensive disorders of pregnancy and to estimate the association between NSAID administration and use of opioid medication. METHODS: We conducted a retrospective cohort study of women with hypertensive disorders of pregnancy. Patients were analyzed in two groups according to whether they received NSAIDs postpartum. Study participants were women delivered at a tertiary care center from 2008 to 2015. The primary outcome was change in mean arterial pressure during the postpartum period. Secondary outcomes were postpartum pain scores, cumulative postpartum opioid requirement, initiation or dose escalation of antihypertensive agents, and adverse postpartum outcomes including acute renal failure, change in hematocrit, and maternal readmission for hypertensive disorder. RESULTS: Two hundred seventy-six women with hypertensive disorders of pregnancy were included (129 NSAID-unexposed and 147 NSAID-exposed). Postpartum NSAID administration was not associated with a statistically significant change in mean arterial pressure compared with no NSAID administration (-0.7 vs -1.8; mean difference 1.10, 95% CI -1.44 to 3.64). Similarly, no difference was observed between the cohorts in terms of need for initiation or escalation in dose of antihypertensive agents or maternal readmission for hypertensive disorder. The study was underpowered to determine whether NSAID administration was associated with any difference in less frequent secondary outcomes (eg, incidence of acute renal insufficiency, need for postpartum transfusion) or cumulative opioid use. CONCLUSION: Nonsteroidal antiinflammatory drug administration to postpartum patients with hypertensive disorders of pregnancy is not associated with a change in blood pressure or requirement for antihypertensive medication.

Gestational Alloimmune Liver Disease: A Devastating Condition Preventable With Maternal Intravenous Immunoglobulin.

BACKGROUND: Gestational alloimmune liver disease, a form of profound liver failure in the newborn, is the main underlying cause of the entity formerly known as neonatal hemochromatosis. Antepartum maternal intravenous immunoglobulin (IVIG) has been shown to prevent gestational alloimmune liver disease, which otherwise has a recurrence risk above 90% in subsequent pregnancies. CASE: A 30-year-old woman, gravida 3 para 0120, presented early in gestation. Her previous pregnancy had been complicated by fetal growth restriction, oligohydramnios, and ultimately fatal fulminant neonatal liver failure. With gestational alloimmune liver disease recognized as the primary diagnosis for the liver failure, we began maternal weekly IVIG therapy. She delivered a healthy newborn at term without evidence of hepatic dysfunction. CONCLUSION: Recognition of gestational alloimmune liver disease enables antepartum treatment that dramatically alters the course of disease.