North American Fetal Therapy Network: Maternal Outcomes in Fetal Aqueductal Stenosis.

INTRODUCTION: Fetal aqueductal stenosis (AS) affects approximately 1:1,000 pregnancies. Obstruction of cerebral spinal fluid circulation occurs at the aqueduct of Sylvius, leading to progressive hydrocephalus and macrocephaly, which often necessitates cesarean section (CS). The purpose of this study was to describe maternal outcomes associated with fetal AS. METHODS: This study is conducted through the North American Fetal Therapy Network (NAFTNet). Subjects with a prenatal diagnosis of severe fetal central nervous system ventriculomegaly were recruited and followed longitudinally. Maternal events around the delivery of fetuses with AS were recorded and analyzed. RESULTS: Thirty-seven subjects with fetal AS confirmed by neonatal neuroimaging were analyzed. The average gestational age at delivery was 36.7 weeks. Overall, 86% were delivered by CS, and 62% of these were elective. Ninety-one percent of CSs were performed through a Pfannenstiel abdominal incision. A classical uterine incision was required in 13% of cesarean deliveries. The peripartum complication rate was 27%. CONCLUSION: Women carrying a fetus with AS were at risk for preterm birth, cesarean delivery, a classical uterine incision, and peripartum complications. These data highlight the maternal morbidity associated with fetal AS and the potential benefit of in utero therapy not only for neonatal outcomes but also for maternal outcomes.

Iatrogenic Wernicke encephalopathy in a patient with severe hyperemesis gravidarum.

BACKGROUND: Hyperemesis gravidarum complicates 0.5-2.0% of pregnancies and may lead to substantial nutritional deficiencies. Total parenteral nutrition can be used in severe cases in an attempt to avoid such deficiencies. Rarely, thiamine deficiency resulting in Wernicke encephalopathy occurs, with significant maternal morbidity. CASE: We present the case of a 30-year-old woman with hyperemesis gravidarum at 13 4/7 weeks of gestation treated with prolonged total parenteral nutrition that lacked thiamine supplementation, resulting in iatrogenic Wernicke encephalopathy. After high-dose intravenous thiamine repletion, she experienced slow resolution of her symptoms. CONCLUSION: Pregnancies complicated by hyperemesis gravidarum treated with total parenteral nutrition represent potential high-risk clinical scenarios for thiamine deficiency. Compositions of total parenteral nutrition are not standardized. Thus, physicians must confirm repletion of all essential components to avoid significant morbidity.

Effect of rotation on perineal lacerations in forceps-assisted vaginal deliveries.

OBJECTIVE: To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput-anterior before delivery. METHODS: We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008 to 2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. χ and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. RESULTS: Of 148 forceps-assisted deliveries, 81 delivered occiput-anterior after either manual or forceps rotation, 10 delivered in the occiput-posterior or occiput-transverse position after an unsuccessful rotation, and 57 delivered occiput-posterior without attempted rotation. No significant differences were found among demographic, obstetric, and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations was found in the occiput-posterior nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy, and birth weight, forceps-assisted vaginal delivery in the occiput-posterior position without rotation remained significantly more likely to be associated with severe lacerations (odds ratio 3.67, 95% confidence interval 1.42-9.47). CONCLUSION: Forceps-assisted vaginal delivery after rotation of an occiput-posterior position to an occiput-anterior position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the occiput-posterior position. LEVEL OF EVIDENCE: II.

Physiologic adaptations to pregnancy.

Pregnancy leads to diverse physiologic changes to accommodate the demands of the developing fetoplacental unit, which affect many major organ systems. Understanding these physiologic adaptations to pregnancy is important for all clinicians because they have important implications for the diagnosis and management of various disorders. This article provides a brief overview of the most notable of these adaptations, including cardiovascular, hematologic, respiratory, renal, immunologic, and gastrointestinal. Clinical correlate of pharmacokinetics and a patient case study are included.

Rapid detection of group B streptococcus and Escherichia coli in amniotic fluid using real-time fluorescent PCR.

OBJECTIVE: To establish reliability and validity of real-time fluorescent PCR for early detection of bacterial invasion of the amniotic cavity. METHODS: Amniotic fluid samples from 40 patients undergoing mid-trimester genetic amniocentesis were incubated for 6 h at 37 degrees C and were cultured on media specific for group B streptococcus (GBS) and E. coli. Concurrently, samples were analyzed with real-time fluorescent PCR (Roche LightCycler) using DNA primers and probes designed to detect the CAMP factor encoding cfb gene and uidA gene of GBS and E. coli, respectively. For positive control and to simulate amniotic fluid colonization, 104 cfu/ml of GBS and E. coli were inoculated on sterile amniotic fluid and incubated for 6 h. Bacterial genomic DNA for the two organisms was extracted and purified via the two-step precipitation method using a commercial kit. The real-time PCR assays were also tested against 25 non-GBS and non-E. coli bacterial species. The lower limit of detection for each pathogen was established using serial dilution of bacterial genomic DNA. RESULTS: All patient samples were negative for evidence of GBS and E. coli with both culture and real-time PCR methods. Amniotic fluid samples inoculated with GBS and E. coli were positive with real-time PCR whereas the 25 bacterial species other than GBS or E. coli tested negative with the assay. Average total sample processing time including the pre-enrichment step was 7 h 40 min. The average cost for DNA extraction and PCR testing was 8.50 dollars per test. CONCLUSION: Real-time fluorescent PCR is a valid and reliable method for detection of specific pathogens in amniotic fluid. This technique is sensitive for low inoculation levels. Real-time fluorescent PCR has potential to impact clinical management as a rapid, reliable detection method for GBS and E. coli in chorioamnionitis.