Risk factors for obstetric admissions to the intensive care unit in a tertiary hospital: a case-control study.

OBJECTIVE: The objective was to review all obstetric admissions to the intensive care unit (ICU) at the Royal Free Hospital, London, UK, and to identify the risk factors for obstetric admissions to the ICU. METHOD: We carried out a retrospective case-control study. The cases consisted of women admitted to the ICU during pregnancy and up to 42 days postpartum between 1 January 1993 and 31 December 2003. Controls were women who delivered immediately before and after the indexed case. Demographic data, medical and surgical histories, pregnancy, and intrapartum and postpartum data were collected. Statistical analysis was done using SPSS software. RESULTS: Thirty-three obstetric patients were admitted to the ICU, representing 0.11% of all deliveries. The ICU utilization rate was 0.81%. Eighty percent of the admissions were postpartum. The main indications for admission were hypertensive disorders (39.4%), and obstetric haemorrhage (36.4%). There was no difference between cases and controls in, age, parity, smoking and employment status. Compared with controls, women admitted to the ICU were significantly more likely to be black (P<0.05), have a shorter mean duration of pregnancy (36.6 vs. 39.2 weeks; P=0.006), delivered by emergency caesarean section (P<0.001), and have higher mean blood loss at delivery (1,173 vs. 296 ml; P<0.001). The risk factors for obstetric ICU admission were black race (odds ratio [OR] =2.8, 95% confidence interval [CI] 1.05-6.28), emergency caesarean section (OR=14.9, 95% CI 5.38-41.45) and primary postpartum haemorrhage (OR=5.4, 95% CI 1.79-4.35). CONCLUSION: Women of black race, those delivered by emergency caesarean section and those with primary postpartum haemorrhage are more likely to be admitted to the ICU.

Aneurysmal subarachnoid haemorrhage in pregnancy.

Although uncommon, aneurysmal subarachnoid haemorrhage (SAH) in pregnancy can be devastating for both mother and baby. It is the leading cause of other indirect maternal death in England and Wales accounting for 60 deaths in the decade 1988-1999. No single obstetric or neurosurgical unit has sufficiently large database or experience in managing this condition in pregnancy. With significant improvements in antenatal care and management of deliveries, non-obstetric causes of maternal death such as aneurysmal subarachnoid haemorrhage are likely to become increasingly significant. The clinical features of aneurysmal subarachnoid haemorrhage closely resemble those of other commoner conditions seen in pregnancy. It is therefore imperative that awareness by obstetricians and other frontline staff is increased so that a high index of suspicion is maintained when pregnant women present with unique headaches. Prompt neurosurgical referral is vital and early involvement of an experienced neuroradiologist essential. It is only when an early diagnosis is made and an aggressive treatment instituted that the bleak case-fatality figure associated with aneurysmal subarachnoid haemorrhage in pregnancy can be improved. This review, by a multidisciplinary and multicenter team, provides a comprehensive update on the epidemiology, aetiology, clinical presentation, diagnosis and the complexities of the multidisciplinary management of this serious and potentially fatal condition when it occurs in pregnancy.

A clinico-pathological study of postcoital bleeding.

METHODS: To undertake a clinical study of postcoital bleeding (PCB) in a district general hospital we retrospectively reviewed the records of 248 patients referred to the gynaecology department over a 5-year period. RESULTS: 63% were in the 21-40-year age group and 80% were multiparous. Seventy per cent were referred to the gynaecology out patients' clinic and 28% to the colposcopy clinic. Associated symptoms included menstrual abnormalities (39%) and dyspareunia (13%). Twenty per cent had benign polyps, including endometrial polyps and 25% had cervical ectropion. Cervical intraepithelial neoplasia was detected in 6.8% of cases. There was no case of invasive cancer of the lower genital tract. CONCLUSIONS: This is the first report of associated endometrial polyps contributing to PCB. We conclude that CIN may not always be asymptomatic and the incidence of cervical or endometrial cancer is low in women with PCB.

Anaphylaxis from medroxyprogesterone acetate.

BACKGROUND: More than 30 million women in more than 90 countries use depot medroxyprogesterone acetate as an injectable contraceptive agent, and it is thought to be very safe. However, it should be recognized that serious and potentially life-threatening adverse effects can occur. CASE: A 40-year-old para 2 went into anaphylactic shock after receiving 150 mg of depot medroxyprogesterone acetate intramuscularly. She was not taking any other medication, and there was no history of allergy to food or cosmetics. She responded fully to immediate resuscitation. A repeat episode occurred when she received another dose 12 weeks later. CONCLUSION: Although thought to be very safe, life-threatening adverse effects can occur with depot medroxyprogesterone acetate, and practitioners should be prepared for such eventuality.

Pregnancy outcomes following the diagnosis of interstitial cystitis.

OBJECTIVE: To describe the outcome of pregnancy in patients treated for interstitial cystitis. METHODS: Over a 4-year period, 12 patients with interstitial cystitis who had one course of intravesical dimethyl sulphoxide (DMSO) therapy for interstitial cystitis were studied. Information on the effects of the treatment-to-conception interval, symptom control during pregnancy and immediately post partum, other pregnancy events and pregnancy outcome were collected. RESULTS: The mean age was 32 years (SD = 5.4), and 6 (50%) were nulliparous. Fifty-eight percent of the women presented with combined urinary and pain symptoms, 25% with a pain symptom only and 17% with a urinary symptom only. Eleven women had 1 course (6 doses) of DMSO therapy. Symptom relief was maintained during pregnancy in almost all the women. The mean interval from diagnosis of interstitial cystitis to the first day of the last menstrual cycle preceding all pregnancies beyond 28 weeks was 19.3 months (SD = 14.7). This interval was 6 months or less for 2 pregnancies that were terminated on account of symptoms attributable to interstitial cystitis. Thirteen healthy babies were delivered. CONCLUSION: Pregnancy outcomes appear good following treatment for interstitial cystitis with 1 course of intravesical DMSO.

Review: spontaneous rupture of splenic artery aneurysm in pregnancy.

Splenic artery aneurysms (SAA) occur predominantly in women and a majority of the aneurysms are asymptomatic until rupture. Over half of those that rupture occur during pregnancy or in women who have had children. Rupture during pregnancy is associated with a very high maternal and fetal mortality rate. Although this condition is uncommon, good materno-fetal outcome can only be achieved by early diagnosis and prompt treatment. It is therefore important to increase awareness of this condition so that obstetricians and other frontline staff can entertain the diagnosis of a ruptured splenic artery aneurysm in any pregnant woman who presents with severe upper abdominal pain. This article reviews the aetiology, clinical features, diagnosis and treatment of this potentially lethal condition.

Randomised clinical trial of suture compared with adhesive strip for skin closure after HRT implant.

To determine which method of skin closure was associated with less bleeding, 250 women were randomly allocated to have either a suture closure (3-0 Dexon II) or an adhesive strip closure (Steri-Strip) following subcutaneous insertion of hormone (HRT) implants. Data were collected via a tested questionnaire and analysed. Significantly, more women in the adhesive strip group recorded postprocedure bleeding (RR = 2.26; 95% CI 1.42-3.60) and considered the bleeding excessive (RR = 4.17; 95% CI 1.18-14.76) and unacceptable (RR = 12.52; 95% CI 1.63-96.19). Pain scores and symptoms of local infection were similar in both groups. Routine use of adhesive strips for implant skin incision closure is not recommended.

Uterine rupture after a single vaginal 2 mg prostaglandin gel application in a primiparous woman.

We report a case of a primiparous woman who was induced for post-term pregnancy with 2mg intravaginal prostaglandin gel. She developed hyperstimulation and ruptured her uterus. The pathogenesis and treatment of hyperstimulation is discussed.