Common obstetrics and gynecologic topics in critical care: A narrative review.

The fields of Obstetrics and Gynecology and Critical Care often share medically and surgically complex patients. Peripartum anatomic and physiologic changes can predispose or exacerbate certain conditions and rapid action is often needed. This review discusses some of the most common conditions responsible for the admission of obstetrical and gynecological patients to the critical care unit. We will consider both obstetrical and gynecologic concepts including postpartum hemorrhage, antepartum hemorrhage, abnormal uterine bleeding, preeclampsia and eclampsia, venous thromboembolism, amniotic fluid embolism, sepsis and septic shock, obstetrical trauma, acute abdomen, malignancies, peripartum cardiomyopathy, and substance abuse. This article aims to be a primer for the Critical Care provider.

A Simulator for Breech Extraction of the Second Twin.

BACKGROUND: Breech extraction of a second twin is a skill useful for any health care provider planning on undertaking vaginal delivery of twins. However, training opportunities in this skill may be limited. METHOD: Using readily available supplies, a reusable model neoprene uterus can be constructed, as can a balloon model to simulate a fetus in the amniotic cavity. EXPERIENCE: The model allowed demonstration of skills expected of trainees and is easy to construct. A simulated vagina addition increased extraction difficulty and increased the probability of balloon (amniotic sac) rupture during simulation. A hysterotomy addition enhanced model applicability for use at simulated cesarean delivery of the breech fetus. CONCLUSION: This educational device for simulation of breech extraction realistically simulates a fetus suspended in an amniotic cavity and challenges learners to use tactile cues for prompt and proper identification, grasping, and delivery of the fetal foot or feet.

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.

Periurethral cystic mass misdiagnosed: a case report.

BACKGROUND: Periurethral cystic masses, including Skene's duct cyst and urethral diverticula, are rare and are often misdiagnosed for more common vulvovaginal cysts. Given their proximity to the urethra, correct diagnosis is needed for appropriate referral and surgical management to prevent complications, including fistula formation. CASE: A 36-year-old woman was diagnosed by her primary care physician with a Bartholin's gland cyst, which was confirmed on MRI. She was referred to a gynecologist for incision and drainage. However, on examination the cyst was noted to be more anterolateral on the vagina and more concerning for a Skene's duct cyst or a urethral diverticulum. She was referred to Urogynecology. The images were reviewed with the radiologist, who agreed that the lesion was more consistent with a Skene's duct cyst. She underwent successful excision of the cyst. The patient had an uncomplicated postoperative course and has normal bladder and urethral function. CONCLUSION: Although imaging modalities are useful to assist in diagnosis of vulvovaginal lesions, clinical examination finding is also key in distinguishing periurethral cystic masses from their more common vulvovaginal counterparts.

Successful in utero intervention for bilateral renal agenesis.

BACKGROUND: We report a case of bilateral renal agenesis treated with serial amnioinfusion in which the newborn survived the newborn period and was able to undergo peritoneal dialysis as a bridge to planned renal transplantation. CASE: A 34-year-old woman, gravida 1 para 0, presented at 23 1/7 weeks of gestation with a diagnosis of anhydramnios and bilateral renal agenesis. The patient underwent weekly serial amnioinfusion with the goal of improving fetal pulmonary development. At 28 weeks of gestation, the patient delivered a live newborn who required minimal respiratory support. The neonate is currently 9 months old and is undergoing daily peritoneal dialysis. CONCLUSION: Serial amnioinfusion appears to have mitigated the severe pulmonary compromise that has, in the past, led to the death of newborns with bilateral renal agenesis.

Developing a program, a curriculum, a scenario.

Simulation in obstetrics and maternal-fetal medicine is an educational tool that can be employed to address local and national learning objectives for residents and fellows. Simulation may also be incorporated as part of a comprehensive patient safety program to improve maternal and neonatal outcomes. Our objective is to identify steps in designing an effective simulation program, curricula, and scenario using available evidence and drawing on experience. Identification of needs, leadership, and financial and logistic resources is the first step in program design. An appropriate curriculum may be crafted with the intended audience and clear learning objectives in mind. Simulation scenario design is best achieved in a stepwise, layered fashion and must incorporate time for debriefing, feedback, and didactics. Simulation programs of any size, budget, and scope can be successfully implemented at the local, regional, and national levels to enhance education and improve patient safety.

Perinatal detection of familial adenomatous polyposis.

BACKGROUND: Hepatoblastoma is an uncommon fetal neoplasm that may represent an isolated malignancy or a component of a familial cancer or syndromic diagnosis. CASE: A large fetal liver mass was detected on routine ultrasound examination of a 23-year-old woman with thyroid nodules and hypertension. Inferior vena cava compression prompted delivery; postnatal biopsy revealed hepatoblastoma. Maternal thyroid biopsy revealed papillary carcinoma. Neonatal and maternal cytomolecular analysis revealed APC gene disruption at 5q22.2. Pedigree analysis exposed multigenerational colon cancer and thyroid cancer, which in conjunction with genetic testing is consistent with familial adenomatous polyposis. CONCLUSION: This is a novel means of familial adenomatous polyposis diagnosis. Obstetricians and perinatologists should be alert for familial cancer or syndromic diagnoses presenting as fetal neoplasms.

Fatal aortic dissection in a patient with a family history of Marfan syndrome.

BACKGROUND: Marfan syndrome has great genotypic and phenotypic variability. Marfan syndrome patients face an increased risk of maternal and fetal complications during and after pregnancy. CASE: A 5-ft, 4-in-tall 40-year-old gravida 4 para 2 with a family history of Marfan syndrome presented 4 days after spontaneous vaginal delivery with sudden onset of shortness of breath, air hunger, syncope, and collapse, with resultant asystole. Resuscitation attempts were unsuccessful, and postmortem findings showed dissection and cystic medial necrosis of the aorta. CONCLUSION: Regardless of physical appearance, any patient reporting a family history of Marfan syndrome should undergo and have documented a thorough multidisciplinary evaluation of the skeletal, ocular, cardiovascular, pulmonary, and skin/integumentary systems and dura, in addition to genetic counseling.