Pregnancy outcome after ultrasound diagnosis of fetal intra-abdominal umbilical vein varix.

OBJECTIVES: Fetal intra-abdominal umbilical vein (FIUV) varix is a focal dilatation of the intra-abdominal portion of the umbilical vein, which has been reported to be associated with intrauterine death and other anomalies. Our aim was to examine our experience with this diagnosis at a single tertiary-care center and to correlate it with clinical outcome. METHODS: This was a retrospective case series study. Our ultrasound database was searched for all cases with a diagnosis of FIUV varix identified at our facility between 1997 and 2007. We reviewed all ultrasound examinations, maternal antenatal records, delivery records and newborns' medical records. RESULTS: We identified 52 cases of FIUV among a population of approximately 68,000. Three cases of trisomy 21 were identified, all of which were accompanied by other anomalies. There was intrauterine death of one fetus with trisomy 21 at 35 weeks of gestation. We did not find an association between FIUV varix and other obstetric complications. CONCLUSIONS: The outcome of pregnancies with FIUV varix is generally favorable. The finding of a FIUV varix should prompt the search for other anomalies, especially markers of aneuploidy.

Comparison of two oxytocin regimens to prevent uterine atony at cesarean delivery: a randomized controlled trial.

OBJECTIVE: To determine if high-dose oxytocin reduces the need for additional uterotonic agents at cesarean. METHODS: A randomized, double-masked trial of two oxytocin regimens was performed to prevent postpartum uterine atony in laboring women. The pharmacy prepared sequentially numbered oxytocin solutions containing either 10 U/500 mL or 80 U/500 mL of lactated Ringer's solution infused over 30 minutes after cord clamping. The need for additional uterotonic agents was determined by the surgical team. Hypotension was diagnosed and treated with crystalloid or a pressor agent. To detect a 50% decrease in the need for additional uterotonic agents and considering a beta error of 0.2, 220 patients would be required in each group (alpha = 0.05, two-tailed chi(2) test). RESULTS: The low-dose group (n = 163) received 333 mU/min, and the high-dose group (n = 158) received 2667 mU/min of oxytocin. The groups were similar with respect to risk factors for atony. Women in the low-dose group received additional uterotonic medication significantly more often than those in the high-dose group (39% compared with 19%, P <.001, relative risk 2.1, 95% confidence interval 1.4, 3.0). Moreover, more women in the low-dose group received methylergonovine, 15-methyl prostaglandin F(2alpha) or both (9% compared with 2%, relative risk 4.8, 95% confidence interval 1.4, 16) after additional oxytocin (median 20 U) had been added to the study solution. The incidence of hypotension was similar in both groups. CONCLUSION: Compared with an infusion rate of 333 mU/min, oxytocin infused at 2667 mU/min for the first 30 minutes postpartum reduces the need for additional uterotonic agents at cesarean delivery.

Prenatally diagnosed hypoplastic left heart syndrome--outcomes after postnatal surgery.

OBJECTIVE: To identify prenatally diagnosed cases of hypoplastic left heart syndrome (HLHS) and then to determine postnatal outcomes after surgical interventions. METHODS: An ultrasound and pediatric cardiology database was used to identify all fetuses diagnosed prenatally from 1991-1996 with HLHS. Fetal karyotypes were performed on cultured amniocytes. After diagnosis, parents were given several management options: pregnancy termination before 22 weeks, postnatal hospice care, or surgery using the Norwood procedure or cardiac transplantation. Ultrasound and echocardiography findings were later compared to karyotype results and postnatal outcome data. RESULTS: Fifteen fetuses with HLHS were identified. Two (16%) chromosome abnormalities and three (20%) structural defects were detected. Three mothers (20%) opted for pregnancy termination, two (13%) chose postnatal hospice care, and one aneuploid fetus had an intrauterine death. Nine parents (60%) chose surgery for their infants; however, one infant was not an appropriate surgical candidate due to a coexisting diaphragmatic hernia. Eight infants underwent surgery and two survived (25%). Of the four infants scheduled to undergo the Norwood procedure, one died preoperatively, two died intraoperatively, and one infant survived and is doing well at age 8 months. Of the four infants scheduled for cardiac transplantation, two died awaiting transplant and one died postoperatively. One infant survived cardiac transplantation but has microcephaly and developmental delay at age two. CONCLUSIONS: In prenatally diagnosed HLHS at our institution, the survival rate following surgery for infants felt to be the best candidates was only 25%.

Pneumonia as a complication of pregnancy.

OBJECTIVE: To identify risk factors for the development of antepartum pneumonia and to describe maternal and perinatal outcome in pregnant women with pneumonia. METHODS: The study group consisted of 59 women with antepartum pneumonia. Pneumonia was defined by the presence of lower respiratory tract symptoms, radiographic findings, no other source of infection, and at least two of the following: oral temperature > or =38 degrees C, white blood cell count > or =15,000/ml, auscultatory findings, and/or positive sputum cultures. For comparison, a control group (n = 118) of pregnant women was formed by selecting the first mother who delivered immediately before and after an index study subject. RESULTS: Mothers in the study group were significantly more likely than women in the control group to have either a history of asthma (P = 0.022) or an admission hematocrit < or =30% (P < 0.001). Women with pneumonia were also more likely to receive a tocolytic agent (P < 0.001) and/or beta-methasone to enhance fetal lung maturity (P < 0.001). In addition, study subjects delivered at an earlier mean gestational age (P = 0.002) and had infants who weighed significantly less (P = 0.003) than mothers in the control group. Multivariate analysis indicated that women with asthma or anemia had more than a five-fold increase in the risk of developing pneumonia during pregnancy (P = 0.013), and mothers with pneumonia were significantly more likely to deliver before 34 weeks gestation (P = 0.04). CONCLUSIONS: Pneumonia during pregnancy was associated with maternal anemia and asthma. In addition, preterm labor with tocolysis and/or beta-methasone was more common in women with pneumonia, and these women were more likely to deliver preterm and have low birthweight infants compared to women without pneumonia.

Intraoperative hypothermia and post-cesarean wound infection.

OBJECTIVE: To determine whether intraoperative hypothermia during cesarean delivery is a risk factor for wound infection. METHODS: Eighteen cases with wound infection and 18 controls matched for age, weight, presence of gestational hypertension, and surgery length were selected from a cohort of 900 women who underwent cesarean delivery and who were assessed for wound infection according to strict criteria. Because immediate postoperative temperatures reflect intraoperative temperature nadir accurately and were available universally, we compared the mean immediate postoperative temperatures between cases and controls. RESULTS: In addition to the intentionally matched factors, the groups were well-matched for race, parity, presence of labor, presence of meconium, and duration of membrane rupture. The mean initial postoperative temperatures were similar between the two groups (36.3+/-0.9C versus 36.6+/-1.0C, respectively; P=.8). This study had a power of 90% to detect an intergroup difference of 1C. CONCLUSION: In this case-control study of cesarean delivery, intraoperative hypothermia was not a risk factor for wound infection.

The antiphospholipid antibody syndrome: an overview.

The antiphospholipid antibody syndrome is characterized by the presence of maternal anticardiolipin antibodies and/or the lupus anticoagulant in association with recurrent pregnancy loss, thrombotic events, and/or thrombocytopenia. This disorder occurs rarely, but pregnant patients with antiphospholipid antibodies are at risk for adverse maternal and perinatal outcomes. This article reviews the antiphospholipid antibody syndrome, including its pathophysiology, clinical sequelae, diagnostic criteria, medical treatment, and nursing care.