Melasma gravidarum (the mask of pregnancy) involves the forehead, the cheeks, and the bridge of the nose. Diabetes Care. This study evaluated offspring of women who participated in the Nurses’ Health Study II. A. Neisseria gonorrhea B. Chlamydia trachomatis C. Treponema pallidum D. Group B Streptococcus ANSWERS 12.1 B. Please match the following clinical vignette with the stage of the TTTS. See also intrauterine growth restriction asthma and, 394-395, 400 IUGR and, 272 stillbirth and restriction of, 303-304 fetal heart rate eclamptic seizure and, 176, 178-179 stillbirth and, 298 fetal hydrops, 472-473. CLINICAL CASES 187 Management of DIC DIC may complicate HELLP syndrome and is a perilous situation in which there is the simultaneous processes of accelerated formation and lysis of clots. The hemoglobin level is 12 g/dL and platelet count 120,000/mm3. 13. Cytomegalovirus (CMV) is the most common congenital viral infection. The latter occurs in 80% of women. 18. Postpartum blues are more mild and do not meet the same diagnostic criteria as postpartum depression. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. Baseline labs should include a completion of their preconception labs if not recently obtained including 24-hour urine, CBC, and early dating ultrasound as well as a repeat of the lupus anticoagulant and anticardiolipin antibodies if previously negative. Pregnancy- and lactation-associated breast cancer: mammographic and sonographic findings. There are conflicting and scant data about whether route of delivery impacts prognosis for the newborn with open spina bifida. Create lists, bibliographies and reviews: or Search WorldCat. . Brown et al found visual estimation of cervical dilation had a positive predictive 446 CASE FILES: High-Risk Obstetrics value of 86.5% and negative predictive value of 100%.13 Digital evaluation of cervix should be avoided; Lewis et al found that in PPROM patients gestational ages 24 to 35 weeks, who underwent digital vaginal examination, had a significantly decreased mean latency period (2.1 vs 11.3 days).14 Ultrasound evaluation of the gestational age, fetal weight, fetal presentation, placental location, and assessment of amniotic fluid index (AFI) are vital for treatment planning. Testing should be performed in women with a personal history of thrombosis. Following the steps outlined in the subsequent discussion will assist caregivers in achieving satisfactory results. Less common causes include systemic lupus erythematosus, antiphospholipid antibody syndrome, HIV-associated thrombocytopenia, thrombotic thrombocytopenic purpura (TTP), and medication use.1 In this patient who is normotensive with negative urine protein, the likelihood of preeclampsia or HELLP syndrome is low. iii. • Cyclophosphamide (Cytoxan) should be avoided (cleft lip, skeletal abnormalities). Salkind AR, Cuddy PG, Foxworth JW. Williams Obstetrics. ➤ Next step: Discontinue penicillin infusion, begin supportive measures, and administer epinephrine. There is rapid consumption of platelets in these patients (see Table 16-4 for blood product transfusion). J Matern Fetal Neonatal Med. 17. ➤ Next step: Initiate a well-planned sequence of maneuvers1 (see following discussion) designed to accomplish delivery of the infant. Obstet Gynecol. C. Has been shown to increase the risk of neonatal sepsis. Hepatology. Several authorities have voiced concern over the withholding of firsttrimester screening information from women found to have elevated risks. When an ovarian cyst is complex (and not hemorrhagic), the likelihood of neoplasm is increased. The combination of an H1 and an H2 blocker is superior to either one alone. Case 5 A 32-year-old G4P3003 Hispanic female with no prenatal care presents to the hospital at 40 weeks stating that her membranes ruptured the day before and her contractions began about 8 hours prior to this admission. Become familiar with the evaluation of stillbirth. Clinical Pearl ➤ Umbilical artery Doppler flow can be helpful in assessing possible IUGR, especially when the end-diastolic velocity is absent or there is reverse flow. Mahieu-Caputo D, Dommergues M, Delezoide AL, et al. 3. every 4-6 h, OR propranolol, 1-2 mg IV every 5 min for a total of 6 mg, then 1-10 mg IV every 4 h. • Phenobarbital, 30-60 mg po every 6-8 h PRN extreme restlessness. 2. Her only complaint was excessive weight gain of 25 lb to this point in pregnancy. Prompt diagnosis and aggressive treatment of associated complications may contribute to improved maternal outcome. Tape a red-top tube containing 2 to 3 cc of blood to the wall. Women are given a 50 g glucose load and plasma glucose levels are measured 1 hour after completion of the load. Crit Care Med. Acute chest syndrome is the second most common acute event, the clinical presentation of which has been discussed previously. This percentage is increased in women with preexisting renal dysfunction; as 40% of women with mild preexisting nephropathy and nearly 50% with significant disease will experience pregnancy-related hypertensive disease9 (Level II-2), women with diabetic retinopathy and chronic hypertension experience rates of preeclampsia as high as 60%2,3 (Level III). Release of histamine and other inflammatory 380 CASE FILES: High-Risk Obstetrics mediators causes spasm of the bronchial, gastrointestinal, and coronary artery smooth muscle, vasodilation, increased vascular permeability, and tachycardia. . 2006;29:445-455 (Level III). Am J Obstet Gynecol 2002;186(1):66-71. Importantly, women with a prior preterm, live birth associated with growth restriction have a stillbirth rate (21.8 per 1000) in a subsequent pregnancy that is higher than those with a prior stillbirth.1 Women with a prior stillbirth also have an increased risk of fetal growth restriction, abruption, and preterm birth in subsequent pregnancies. . Parvovirus B19 (B19) is the virus with the strongest association with stillbirth. ➤ Idiopathic polyhydramnios has an up to 28% chance of neonatal abnormality, and should prompt a careful newborn examination (Level II-3). As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. An abdominal ultrasound can be performed to evaluate the liver. . The ultrasound finding of oligohydramnios is usually confirmatory. Miller J, Turan S, Baschat AA. Like CMV, the fetus is most likely to be infected if maternal infection occurs in the third trimester; however, fetuses infected in the first trimester are associated with the greatest risk of injury10 (Level III). Babies born to mothers with suboptimal glycemic control experience increased rates of congenital anomalies8 (Level III). In a retrospective review of greater than 500 singletons with a diagnosis of IUGR, the mean GA at delivery correlated with Doppler studies: • Normal Doppler studies: 37 weeks at delivery • AEDF: 31 weeks at delivery • REDF: 29 weeks at delivery Similarly, the perinatal mortality increases as Doppler indices worsen: • Normal Doppler studies: 1.3% perinatal mortality rate • AEDF: 25% perinatal mortality rate • REDF: 54% mortality rate CLINICAL CASES 275 Some investigators advocate the addition of venous Doppler studies in evaluating the fetus with suspected IUGR. Acute cholestasis is not usually associated with hypertension. A comparison of glyburide and insulin in women with gestational diabetes mellitus. 1993;168:108-113. Within 2 weeks of the stillbirth 80% to 90% of women will enter labor spontaneously. More than 40 years ago, obstetricians at Parkland Hospital developed transfusion guidelines for the management of hypovolemia secondary to hemorrhage.5 These guidelines, referred to as the “30-30 rule,” called for transfusion to maintain the woman’s hematocrit at or close to 30% and her urine output at ≥ 30 mL/h. The authors comment on the biologic plausibility of this finding as low oxygen tension is normally present in early pregnancy. ➤ In cases of Kell sensitization, the critical titer is lower, usually 8, because severe fetal anemia can occur at lower antibody titers than in cases of Rh alloimmunization (Level III). Other causes of pain, fever, and worsening anemia must be excluded. D. Postpartum depression affects approximately 1% to 3% of postpartum women. The majority will not result in stillbirth with intrauterine transfusion. Acute renal failure in pregnancy. Louik C, Lin A, Werler M, Hernandez-Diaz S, Mitchell A. For trisomy 18, the detection rate was 91% with a 2% FPR. JAMA. b. Speculum examination: The vagina should be inspected for lesions, discharge, estrogen effect (well-rugated vs atrophic), and presence of a cystocele or a rectocele. During pregnancy CO is increased tremendously. Combined oral contraceptives do not affect the course of SCD, but some recommend against their use because of the potential for thrombosis related to the estrogen component. The main goal of management in the presence of ARDS is to provide respiratory support while the underlying condition is treated and/or resolved and the acute lung injury healed. Molecular testing for the most common mutation, E474Q, and known genetic variants are available for women who develop AFLP, their partner, or their infants. Obstet Gynecol Clin N Am. Goldenberg RL, Thompson C. The infectious origins of stillbirth. It is one of the most common hematologic complications of pregnancy. The mature cystic teratoma is the most common benign ovarian neoplasm to be diagnosed in pregnancy. Seventy-nine of heterozygous mothers developed AFLP or HELLP syndrome while carrying fetuses with Glu474Gln mutation (Level II-2). Other placental/umbilical cord abnormalities that can cause stillbirth include placental abruption (10%-20% cases), placental infarction, umbilical cord thrombosis, cord prolapse, velamentous cord insertion, vasa previa, and amniotic band syndrome. Case 39 A 22-year-old G1 P0 with a monochorionic diamniotic twin gestation is seen in your office at 24 weeks for follow-up sonogram. SECTION How to Approach Clinical Problems ➤ Part 1. She has no jugular venous distention, and her heart is regular in rhythm, without murmurs, rubs, or gallop. Her platelet count is 160,000/mm3. Carroll SG, Papiaoannou S, Nicolaides KH. . See chorionic villus sampling cystadenomas, 459 cysts, 457-458. ➤ Next step: Immediate volume replacement with typed and screened or O−(do not wait for cross match) blood and crystalloid. A. Dietary supplementation with omega-3 polyunsaturated fatty acids has been associated with reduced production of inflammatory mediators, and a randomized trial of omega-3 supplements undertaken in women at risk of preterm birth showed a reduction in the preterm birth rate as did a randomized trial of supplemental fish oil. CLINICAL CASES 367 Clinical Pearls See US Preventive Services Task Force Study Quality levels of evidence in Case 1 ➤ Respiratory adaptations of pregnancy that promote increased oxygen availability and facilitate CO2 elimination also make pregnant women particularly susceptible to respiratory failure (Level III). It would be appropriate second-line therapy for those with similar platelet counts who have not shown improvement following 2 to 4 weeks of prednisone treatment. Am J Clin Nutr. Maternal factors include hypertension (HTN), cardiac disease, respiratory diseases, renal disease, anemia, toxic habits, and malnutrition. Immediate delivery via cesarean section. ANALYSIS Objectives 1. ANALYSIS Objectives 1. See acute fatty liver of pregnancy age. For these women, low-dose oxytocin and transcervical Foley bulb are reasonable alternatives. On rare occasions such as this, nonspecific symptoms may represent a serious and potentially lifethreatening condition. APPROACH TO Thrombophilia In general, inherited thrombophilias in pregnancy increase the risk of thrombosis in either the maternal, fetal, or placental venous systems. 2. 2005;33:269S-278S. This intramembranous pathway may explain the observation that in upper GI tract obstruction in the human fetus with no fetal swallowing, only 40% develop polyhydramnios. Sometimes TTTS can develop not necessary to calculate the estimated delivery 23 clinical cases 14.2 ( )... With PPROM ( Level II-3 ) exclusion of causes other than vaso-occlusion, hydration, administer magnesium and... 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