A Case of Papillary Fibroelastoma of the Aortic Valve Causing an Embolic Ischemic Stroke.

Papillary fibroelastomas (PFEs) are the second most common primary cardiac tumors after myxomas. They are typically located on the aortic valve and comprise a short pedicle with multiple papillary fronds. PFEs are benign but highly friable in nature. Patients can be asymptomatic or present with severe thromboembolic complications. Echocardiography is the modality of choice for the diagnosis of these masses and surgical resection is indicated even in asymptomatic patients. Here, we have presented a case of a 53-year-old male who presented with a stroke after embolization of a PFE.

A Rare Case of Dilated Cardiomyopathy, Focal Segmental Glomerulosclerosis, and Bell's Palsy in a 29-Year-Old Male After Coxsackievirus Infection.

Dilated cardiomyopathy (DCM) is a severe myocardial disease with diversified etiologies. Coxsackievirus serotype B (CV-B) is a known cause of infectious myocarditis that leads to DCM. The pathogenesis of CV-B myocarditis is complex and involves a combination of tissue destruction from viral proliferation and host immune response. Diagnosis is based on clinical findings and the presence of post-infection elevated titers of IgM antibodies to CV-B. Echocardiography is an important imaging modality that plays a key role in diagnosing DCM. Rare complications of coxsackievirus infection may include facial paralysis and chronic kidney disease with nephrotic syndrome. Here we present a rare case of a 29-year-old-male with recent Bell's palsy who presented with new-onset heart failure with left ventricular ejection fraction of 5% and focal segmental glomerulosclerosis nephrotic syndrome in the setting of elevated antibodies to CV-B.

Mitral Leaflet Flail as a Late Complication of Infective Endocarditis: A Case Report.

Infective Endocarditis (IE) refers to an infection of the endocardial surface of the heart which leads to a wide array of complications, including heart failure, perivalvular abscess, metastatic infection, septic embolization, mycotic aneurysms, neurological and renal complications. Mitral leaflet flail (MLF), defined as a failure of leaflet coaptation with the rapid systolic movement of the involved leaflet into the left atrium, is a rare complication of IE which can lead to severe mitral regurgitation. Echocardiography plays a key role in making its diagnosis with transesophageal echocardiograms (TEE), providing greater sensitivity and specificity compared to transthoracic echocardiograms (TTE). MLF is often misdiagnosed, or diagnosis is delayed due to its presentation with non-specific cardiac symptoms. However, early diagnosis with echocardiography and prompt surgical correction leads to improved long-term survival. Here we have presented a case of a 71-year-old female with a past medical history of IE nine years ago who was referred to the cardiology clinic for one month of exertional dyspnea. TTE showed severe mitral regurgitation, and subsequent TEE confirmed flail mitral leaflet.

Amniotic fluid embolism syndrome: analysis of the Unites States International Registry.

BACKGROUND: Incidence, risk factors, and perinatal morbidity and mortality rates related to amniotic fluid embolism remain a challenge to evaluate, given the presence of differing international diagnostic criteria, the lack of a gold standard diagnostic test, and a significant overlap with other causes of obstetric morbidity and mortality. OBJECTIVE: The aims of this study were (1) to analyze the clinical features and outcomes of women using the largest United States-based contemporary international amniotic fluid embolism registry, and (2) to investigate differences in demographic and obstetric variables, clinical presentation, and outcomes between women with typical versus atypical amniotic fluid embolism, using previously published and validated criteria for the research reporting of amniotic fluid embolism. MATERIALS AND METHODS: The AFE Registry is an international database established at Baylor College of Medicine (Houston, TX) in partnership with the Amniotic Fluid Embolism Foundation (Vista, CA) and the Perinatology Research Branch of the Division of Intramural Research of the NICHD/NIH/DHHS (Detroit, MI). Charts submitted to the registry between August 2013 and September 2017 were reviewed, and cases were categorized into typical, atypical, non-amniotic fluid embolism, and indeterminate, using the previously published and validated criteria for the research reporting of AFE. Demographic and clinical variables, as well as outcomes for patients with typical and atypical AFE, were recorded and compared. Student t tests, χ2 tests, and analysis of variance tables were used to compare the groups, as appropriate, using SAS/STAT software, version 9.4. RESULTS: A total of 129 charts were available for review. Of these, 46% (59/129) represented typical amniotic fluid embolism and 12% (15/129) atypical amniotic fluid embolism, 21% (27/129) were non-amniotic fluid embolism cases with a clear alternative diagnosis, and 22% (28/129) had an uncertain diagnosis. Of the 27 women misclassified as an amniotic fluid embolism with an alternative diagnosis, the most common actual diagnosis was hypovolemic shock secondary to postpartum hemorrhage. Ten percent (6/59) of the women with typical amniotic fluid embolism had a pregnancy complicated by placenta previa, and 8% (5/61) had undergone in vitro fertilization to achieve pregnancy. In all, 66% (49/74) of the women with amniotic fluid embolism reported a history of atopy or latex, medication, or food allergy, compared to 34% of the obstetric population delivered at our hospital over the study period (P < .05). CONCLUSION: Our data represent a series of women with amniotic fluid embolism whose diagnosis has been validated by detailed chart review, using recently published and validated criteria for research reporting of amniotic fluid embolism. Although no definitive risk factors were identified, a high rate of placenta previa, reported allergy, and conceptions achieved through in vitro fertilization was observed.

Pregnancy-related mortality in the United States, 2003-2016: age, race, and place of death.

BACKGROUND: Pregnancy-related deaths in the United States are increasing. Medical, social, economic, and cultural issues have all been implicated in this trend, but few data exist to differentiate the relative contributions of these various factors. OBJECTIVE: The objective of the study was to examine trends in US pregnancy-related mortality by place of death and maternal race and age. We hypothesized that such an analysis may allow some distinction between deaths related to medical performance and those more closely related to social, cultural, or environmental issues. STUDY DESIGN: We conducted a retrospective, cross-sectional study for the years 2003-2016 using multiple cause-of-death mortality data provided by the Centers for Disease Control and Natality Data provided by National Vital Statistics System of the National Center for Health Statistics. Temporal trends analyses for the place of death, race/ethnicity, and age at the time of death were performed using joinpoint regression over the study period. RESULTS: Approximately one third of pregnancy-related deaths occurred outside a medical facility. The fraction of maternal deaths occurring in inpatient facilities fell by 20% over the study period, from 53% to 44% of all maternal deaths (P < .0001). Maternal deaths in an outpatient facility or emergency room demonstrated a similar decline (24%) in relative frequency (P < .0001). In contrast, there was a significant increase in the relative frequency of maternal mortality in other settings, particularly within the descendant's home, with a doubling over this time period. However, overall pregnancy-related deaths continued to increase in all settings. These increases were particularly striking in non-Hispanic black and white women and among women in the youngest and oldest age groups. CONCLUSION: Against a background of rising US pregnancy-related mortality, stratification of such deaths by place of death and maternal age and race highlights both the need for ongoing improvements in the quality of medical care and the potential contribution of events occurring outside a medical facility to the overall morality ratio. Current trends in pregnancy-related mortality in the United States are, in part, driven by social, cultural, and financial issues beyond the direct control of the medical community.

Utilization and outcomes of massive transfusion protocols in women with and without invasive placentation.

Objective: Our objective was to compare women with and without invasive placentation for whom the massive transfusion protocol (MTP) was activated. In addition, we evaluated the differences in clinical management and blood product utilization between the two groups and described the activation of MTP over time.Study design: This is a retrospective cohort study of women for whom the MTP was activated from January 2012 through July 2016. Two groups were compared, those with invasive placentation (accreta, increta, percreta) and those without.Results: We identified 87 women for whom the MTP was activated, the majority (62.1%) did not have invasive placentation. Women with invasive placentation were more likely to have had a prior cesarean delivery and placenta previa (both p < .001). Women with invasive placentation were more likely to undergo hysterectomy, experience more blood loss, and receive cell salvage (all p ≤ .04). Blood product utilization was similar between the two groups, with the exception of cell-salvage, which was more commonly used for women with invasive placentation. The proportion of deliveries necessitating MTP activation ranged from 1.4 to 2.6 per 1000 deliveries.Conclusion: Invasive placentation accounts for less than half of the cases complicated by activation of an MTP. Cases with invasive placentation were more likely to result in a vertical uterine and skin incision or a hysterectomy. With the exception of cell-salvage, blood product utilization was similar.

Maternal and Fetal Death on Weekends.

BACKGROUND: Higher mortality rates have been reported in patients admitted to the hospital on weekends. This study aimed to compare maternal mortality ratio (MMR), fetal mortality ratio, and other maternal and neonatal outcomes by day of death or delivery in the United States. METHODS: Our database consisted of a population-level analysis of live births and maternal and fetal deaths between 2004 and 2014 in the United States from the Centers for Disease Control and Prevention's National Center for Health Statistics. We also examined the relationship between these deaths and various documented maternal and fetal clinical conditions. RESULTS: A total of 2,061 maternal deaths occurred on weekends and 5,510 deaths on weekdays. During the same period of time, 65,063 and 210,851 cases of fetal demise were delivered on weekends and on weekdays, respectively. Maternal mortality was significantly higher on weekends than weekdays (22.9 vs. 15.3/100,000 live births, p < 0.001) as was fetal mortality (7.21 vs. 5.85/100,000, p < 0.001), despite a lower frequency of serious comorbidities among women delivering on weekends. CONCLUSION: Our data demonstrate a significant increase in the U.S. MMR and stillbirth delivery on weekends. Relative representation of antepartum, intrapartum, and postpartum deaths cannot be ascertained from these data.

Health Care Disparity and Pregnancy-Related Mortality in the United States, 2005-2014.

OBJECTIVE: To quantitate the contribution of various demographic factors to the U.S. maternal mortality ratio. METHODS: This was a retrospective observational study. We analyzed data from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) from 2005 to 2014 that contains mortality and population counts for all U.S. counties. Bivariate correlations between the maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P<.05) in the univariate analysis to deal with multicollinearity among the existing variables. RESULTS: The United States has experienced an increase in maternal mortality ratio since 2005 with rates increasing from 15 per 100,00 live births in 2005 to 21-22 per 100,000 live births in 2013 and 2014. (P<.001) This increase in mortality was most pronounced in non-Hispanic black women, with ratios rising from 39 to 49 per 100,000 live births. A significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population was demonstrated. Cesarean deliveries, unintended births, unmarried status, percentage of deliveries to non-Hispanic black women, and four or fewer prenatal visits were significantly (P<.05) associated with the increased maternal mortality ratio. CONCLUSION: The current U.S. maternal mortality ratio is heavily influenced by a higher rate of death among non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability and access or utilization by underserved populations are important issues faced by states seeking to decrease maternal mortality.

Cyanotic congenital heart disease following fertility treatments in the United States from 2011 to 2014.

OBJECTIVE: To examine the risk for cyanotic congenital heart diseases (CCHDs) among live births in the USA, resulting from various forms of infertility treatments. METHODS: This study is a cross-sectional analysis of live births in the USA from 2011 to 2014. Infertility treatments are categorised into two of the following groups on birth certificates: assisted reproductive technology (ART) fertility treatment (surgical egg removal; eg, in vitro fertilisation and gamete intrafallopian transfer) and non-ART fertility treatment (eg, medical treatment and intrauterine insemination). We compared the risk for CCHD in ART and non-ART fertility treatment groups with those infants whose mothers received no documented fertility treatment and were naturally conceived (NC). RESULTS: Among 14 242 267 live births from 2011 to 2014, a total of 101 494 live births were in the ART and 81 242 resulted from non-ART fertility treatments. CCHD prevalence in ART, non-ART and NC groups were 393/100 892 (0.39%), 210/80 884 (0.26%) and 10 749/14 020 749 (0.08%), respectively. As compared with naturally conceiving infants, risk for CCHD was significantly higher among infants born in ART (adjusted relative risk (aRR) 2.4, 95% CI 2.1 to 2.7) and non-ART fertility treatment groups (aRR 1.9, 95% CI 1.6 to 2.2). Absolute risk increase in CCHD due to ART and non-ART treatments were 0.03% and 0.02%, respectively. A similar pattern was observed when the analysis was restricted to twins, newborns with birth weights under 1500 g and gestational age of less than 32 weeks. CONCLUSIONS: Our findings suggest an increased risk for CCHD in infants conceived after all types of infertility treatment.

Effect of advanced maternal age on maternal and neonatal outcomes in assisted reproductive technology pregnancies.

OBJECTIVES: To compare maternal and neonatal outcomes between women with assisted reproductive technologies pregnancy aged <40, 40-44, 45-49, and ≥50 years. STUDY: Design In a population-level analysis study, all live births by ART identified on birth certificate between 2011 and 2014 were extracted (n=101,494) using data from the Center for Disease Control and Prevention-National Center for Health Statistics (CDC-NCHS). We investigated and compared maternal and neonatal outcomes based on conditions routinely listed on birth certificates. RESULTS: Of 101,494 ART live births, 79,786 (78.6%), 16,186 (15.9%), 4637 (4.6%), and 885 (0.9%) were delivered by women aged <40, 40-44, 45-49, and ≥50 years, respectively. Comparing to women aged <40years, women aged 40-44, 45-49, and ≥50 years were at increased risk for gestational hypertension (aRR: 1.26, 1.55, and 1.61, respectively), gestational diabetes (aRR: 1.23, 1.40, and 1.31, respectively), eclampsia (aRR: 1.49, 1.51, and 2.37, respectively), unplanned hysterectomy (aRR: 2.55, 4.05, and 3.02, respectively), and ICU admission (aRR: 1.64, 2.06, and 2.04, respectively). The prevalence of preterm delivery was slightly higher in women aged 45 and older. (35%, 36.9%, and 40.2% in women aged <40 years, 45-49 years, and ≥50 years, respectively) CONCLUSIONS: Advanced age ART was significantly associated with higher rates of maternal morbidities. Except for preterm delivery, neonatal outcomes were similar between ART pregnancies in women aged ≥45 years and younger women. These data should be interpreted with caution because of potential confounding by potentially higher use of donor eggs by older women, the exact rates for which we were unable to ascertain from the available data.

A survey of honor-related practices among US obstetricians and gynecologists.

OBJECTIVE: To assess patterns of honor-related practices-including virginity testing, virginity restoration, and female genital mutilation (FGM)-among US obstetrician-gynecologists (OBGYNs). METHODS: Between June 1 and August 31, 2016, 1000 members of the American College of Obstetricians and Gynecologists were invited by email to complete an anonymous online survey. The survey comprised 42 questions evaluating the demographic and practice characteristics of the respondents. RESULTS: Overall, 288 of the 909 practicing US OBGYNs with functioning email addresses completed the survey (31.7% response rate). In the 12 months before the survey, 168 (58.3%) respondents had provided care to one or more patients who had previously undergone FGM. Care was also provided for patients who requested virginity testing or virginity restoration by 29 (10.1%) and 16 (5.6%) respondents, respectively. Ten (3.5%) respondents performed virginity testing on request, whereas 3 (1.0%) performed virginity restoration. CONCLUSION: Some respondents performed honor-related practices, which indicated a need to educate all practicing US OBGYNs about their ethical and legal obligations in the care of such patients.

Ethical issues in fetal therapy.

The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.

Reproductive decisions after the diagnosis of amniotic fluid embolism.

OBJECTIVE: This study aims to describe the subsequent reproductive outcomes in women who either correctly or incorrectly were diagnosed with amniotic fluid embolism (AFE). STUDY DESIGN: Medical records were obtained, abstracted and reviewed by authors with extensive experience in critical care obstetrics. Telephone interviews of all survivors were conducted to determine obstetrical and contraceptive history. A subgroup underwent further telephone interview to address subsequent reproductive decisions. RESULTS: By November 2015, 116 medical records of patients diagnosed with AFE were reviewed. Patients who had undergone hysterectomy (n=26), died (n=9), or developed Sheehan's syndrome (n=1) at the time of the original event were excluded from the present analysis. Of the remaining 80 women, 30% (24/80) had subsequently conceived and 32.5% (26/80) patients or their partners had undergone permanent sterilization. At the time of this report, 66% (21/32) of registry participants were categorized to have had AFE and 34% (11/32) as not likely AFE or indeterminate. CONCLUSIONS: The syndrome of AFE is over-diagnosed. Women diagnosed with AFE who survive conceive another pregnancy less frequently than US women over similar time intervals and often choose a permanent sterilization method, whether or not they actually had AFE, largely out of fear of AFE recurrence.

Health Care Disparity and State-Specific Pregnancy-Related Mortality in the United States, 2005-2014.

OBJECTIVE: To investigate factors associated with differential state maternal mortality ratios and to quantitate the contribution of various demographic factors to such variation. METHODS: In a population-level analysis study, we analyzed data from the Centers for Disease Control and Prevention National Center for Health Statistics database and the Detailed Mortality Underlying Cause of Death database (CDC WONDER) that contains mortality and population counts for all U.S. counties. Bivariate correlations between maternal mortality ratio and all maternal demographic, lifestyle, health, and medical service utilization characteristics were calculated. We performed a maximum likelihood factor analysis with varimax rotation retaining variables that were significant (P<.05) in the univariate analysis to deal with multicollinearity among the existing variables. RESULTS: The United States has experienced a continued increase in maternal mortality ratio since 2007 with rates of 21-22 per 100,000 live births in 2013 and 2014. This increase in mortality was most dramatic in non-Hispanic black women. There was a significant correlation between state mortality ranking and the percentage of non-Hispanic black women in the delivery population. Cesarean deliveries, unintended births, unmarried status, percentage of non-Hispanic black deliveries, and four or less prenatal visits were significantly (P<.05) associated with increased maternal mortality ratio. CONCLUSION: Interstate differences in maternal mortality ratios largely reflect a different proportion of non-Hispanic black or unmarried patients with unplanned pregnancies. Racial disparities in health care availability, access, or utilization by underserved populations are an important issue faced by states in seeking to decrease maternal mortality.

Trends in the delivery route of twin pregnancies in the United States, 2006-2013.

OBJECTIVES: To determine the trends of cesarean delivery rate among twin pregnancies from 2006 to 2013. STUDY DESIGN: This is a population-based, cross-sectional analysis of twin live births from United State birth data files of the National Center for Health Statistics for calendar years 2006 through 2013. We stratified the population based on the gestational age groups, maternal race/ethnicity, advanced maternal age (AMA) which was defined by age more than 35 years and within the standard birth weight groups (group 1: birth weight 500-1499g, group 2: birth weight 1500-2499g and group 3: birth weight >2500g). We also analyzed the effect of different risk factors for cesarean delivery in twins. RESULTS: There were 1,079,102 infants born of twin gestations in the U.S. from 2006 to 2013, representing a small but significant increase in the proportion of twin births among all births (3.2% in 2006 versus 3.4% in 2013). The rate of cesarean delivery in twin live births peaked at 75.3% in 2009, and was significantly lower (74.8%) in 2013. The rate of the twin live birth with the breech presentation increased steadily from 26.3% in 2006 to 29.1% in 2013. For the fetus of the twin pregnancy presented as breech, the cesarean delivery rate peaked at 92.2% in 2010, falling slightly but significantly in the ensuing 3 years. The results demonstrated that the decrease in cesarean delivery rate was due to fewer cesareans in non-Hispanic white patients; all other ethnic subgroups showed increasing rates of cesarean delivery throughout the study. Gestational diabetes, gestational hypertension, previous cesarean delivery and breech presentation were all significant risk factors for cesarean delivery during the entire study period. Induction of labor and premature rupture of the membranes were associated with lower rates of cesarean delivery in twins. CONCLUSION: The recent decrease in the cesarean delivery rate in twin gestation appears to be largely attributable to a decline in cesarean among pregnancies complicated by breech presentation in non-Hispanic white women, and may reflect a health care disparity that deserves further research.

Twin anemia polycythemia sequence: a single center experience and literature review.

Twin anemia polycythemia sequence (TAPS) is defined by significant intertwin hemoglobin discordance without the amniotic fluid discordance that characterizes twin-twin-transfusion syndrome (TTTS) in monochorionic twin pregnancies. TAPS is an uncommon condition which can either occur spontaneously, or following fetoscopic laser ablation for TTTS. This complication is thought to result from chronic transfusion through very small placental anastomoses; however, the pathogenesis of TAPS remains unknown. Consequently, there is no consensus in the management of TAPS. In this article, three cases of TAPS are described and we review the literature on this uncommon pregnancy complication.