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1/388. dexamethasone-facilitated postponement of delivery of an extremely preterm pregnancy complicated by the syndrome of hemolysis, elevated liver enzymes, and low platelets.

    OBJECTIVE: patients with severe preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets (hellp syndrome) are at increased risk for perinatal and maternal morbidity, especially in very preterm gestations. When this condition affects a pregnancy on the cusp of viability, a therapeutic intervention to prolong gestation without undue risk to the mother or fetus could be beneficial. METHOD: A single case report and review of the literature. Result: We report a patient with hellp syndrome in whom antenatal administration of high-dose dexamethasone helped achieve disease stabilization and delivery postponement for 9 days of a very preterm fetus estimated to weight less than 600 g. Both mother and infant did well postpartum. CONCLUSION: Administration of antenatal high-dose dexamethasone can be used in carefully selected preterm patients with hellp syndrome to delay delivery while in utero fetal maturation is accelerated and the maternal condition is optimized. This can be beneficial in carefully selected pregnancies without apparent adverse maternal or perinatal impact. ( info)

2/388. Delayed interval delivery in multiple gestations.

    The incidence of higher-order gestations is increasing primarily as a result of menstrual cycle manipulation, with concomitant increased risk in maternal and fetal complications. perinatal mortality rates range between 47 and 120 per 1000 births for twins and 93 to 203 per 1000 births for triplets. The critical period of perinatal mortality and morbidity is between weeks 23 and 28 of gestation. attention has recently turned to methods of delaying the birth of second and higher order fetuses to improve newborn survival and decrease neonatal morbidity in these high-risk pregnancies. We report two cases of delayed interval delivery. Neither pregnancy involved a monochorionic/monoamniotic gestation. The first case was a twin gestation delivered at 21 weeks with an interval of 5 days and extreme prematurity of both twins. The second case was a triplet gestation delivered at 21 weeks with an interval of 5 days. Triplet A was stillborn; triplets B and C succumbed in extreme prematurity. Preterm labor in multiple gestations usually results in delivery of all fetuses. On occasion, the uterus will spontaneously cease to contract after the birth of one or more premature infants. review of the literature now reports 48 twin pregnancies exposed to delayed interval delivery with 40 surviving infants of 96 fetuses. Whereas delaying the delivery of remaining fetuses improves their prognosis, there is currently no consensus regarding technique nor is there statistical significance in techniques currently used. Furthermore, study is indicated to reduce preterm birth and associated costs. ( info)

3/388. anaphylaxis in labor secondary to prophylaxis against group B streptococcus. A case report.

    BACKGROUND: Two strategies have been recommended by the Centers for disease Control and Prevention and approved by the American College of obstetrics and gynecology to help prevent group B streptococcal disease in the newborn. Both involve using penicillin in labor. However, the potential for allergic and even anaphylactic reactions to penicillin exists. CASE: A patient was treated for risk factors for group B streptococcus in labor and suffered a serious anaphylactic reaction to penicillin; it resulted in an emergency cesarean section. Although the patient and infant were eventually discharged, the patient developed disseminated intravascular coagulation and suffered acute tubular necrosis that required dialysis. CONCLUSION: Prophylaxis against group B streptococcal sepsis is of proven benefit, but the possible harm to the mother and fetus from treatment with penicillin must be recognized. ( info)

4/388. Transient hypertrophic cardiomyopathy in the newborn following multiple doses of antenatal corticosteroids.

    Postnatal exposure to steroids has been associated with hypertrophic cardiomyopathy (HCM) in the newborn. Such an effect has not been described in infants born to mothers who received antenatal steroids. We report three newborns whose mothers were treated with betamethasone prenatally in different doses, duration of time, and who developed various degrees of HCM diagnosed by echocardiography. There was no maternal evidence of diabetes except for one infant whose mother had a normal fasting and post-prandial blood glucose prior to steroid therapy, but an abnormal one hour postprandial glucose after 8 weeks of betamethasone therapy, with a normal HbA1 C level. There was no family history of HCM, no history of maternal intake of other relevant medications, and no hypertension in all three newborns. Follow-up echocardiography revealed complete resolution of the HCM changes in all infants. We suggest that repeated antenatal maternal steroid intake may cause changes of HCM in the newborn. These changes appear to be dose- and duration-related and are mostly reversible. Further prospective controlled studies to evaluate these observations and to investigate potential mechanisms are warranted. ( info)

5/388. Preterm labor and accidental hemorrhage after disopyramide therapy in pregnancy. A case report.

    BACKGROUND: Treatment of arrhythmias during pregnancy is complicated by concerns about the safety of antiarrhythmic therapy. This is the first case report of preterm labor and abruptio placentae following the administration of disopyramide during pregnancy. CASE: A 26-year-old woman, gravida 2, para 1, was diagnosed as having wolff-parkinson-white syndrome during the third trimester of pregnancy. Recurrent episodes of supra-ventricular tachycardia were refractory to medical therapy and required repeated direct current cardioversion. Administration of disopyramide led to the initiation of painful uterine contractions and accidental hemorrhage. CONCLUSION: Caution must be exercised during the use of disopyramide during pregnancy, and intensive monitoring should be instituted to avoid adverse maternal and fetal effects. ( info)

6/388. Pelvic abscess in the second half of pregnancy after oocyte retrieval for in-vitro fertilization: case report.

    We describe a very late manifestation of pelvic abscesses after oocyte retrieval for in-vitro fertilization (IVF). In a twin pregnancy achieved after intracytoplasmic sperm injection, rupture of bilateral ovarian abscesses occurred at the end of the second trimester. An emergency laparotomy was necessary because of an acute abdomen. This complication led to severe maternal and neonatal morbidity, preterm birth and neonatal death. The rare occurrence of acute abdomen in pregnancy due to pelvic infection and the non-specific symptoms of a pelvic abscess after oocyte retrieval for IVF are discussed. ( info)

7/388. pica: sorting it out.

    pica, a culture-bound illness, has occurred for centuries. The ingestion of nonfood substances such as starch, cornstarch, clay, dirt, and other material is fairly common, although the distribution of the condition varies by cultural and socioeconomic factors. The underlying cause of pica is not known, although the condition often is associated with pregnancy. There is conflicting evidence about the association of nutrient deficiencies and pica. This article presents a clinical example of pica in a pregnant 33-year-old African American woman. Implications for culturally appropriate care are discussed. ( info)

8/388. Neonatal end-stage renal failure associated with maternal ingestion of cyclo-oxygenase-type-1 selective inhibitor nimesulide as tocolytic.

    Cyclo-oxygenase-type-2 (COX-2) enzyme is fundamental for nephrogenesis, upregulated on fetal membranes and myometrium at parturition. Fetal COX-2 inhibition, due to maternal nimesulide assumption, can be responsible for neonatal chronic renal failure. ( info)

9/388. Intrapartum drainage of fetal pleural effusion.

    Our objective was to describe our experience with intrapartum thoracocentesis in fetuses with severe bilateral pleural effusion. We describe the outcome of four consecutive cases of fetal pleural effusion due to chylothorax that were managed by intrapartum thoracocentesis. These fetuses were not candidates for pleuro-amniotic shunting either because of the need for prompt delivery (three fetuses) or because of advanced gestational age (one fetus). Thoracocentesis was performed in the operating theatre under ultrasound guidance prior to Caesarean delivery. gestational age at the time of diagnosis and thoracocentesis ranged between 26-34 weeks and 31-34 weeks respectively. Bilateral thoracocentesis was performed in two fetuses and unilateral in the remaining two fetuses. All four infants were born in a relatively good condition; however, all eventually required intubation, ventilation and chest tubes. chest tubes were introduced between 2 h and 5 days after delivery in three infants, and immediately after birth in one infant who was hydropic. Two infants survived and are developing normally. One infant died from sepsis following successful pleurodesis and one from aspiration on day 51. Our conclusions are that intrapartum thoracocentesis seems to be a relatively simple procedure, that allows newborns with pleural effusion, to breathe spontaneously or be more easily ventilated. This in turn, reduces the need to introduce chest tubes in an emergency situation. ( info)

10/388. Fatal course of veno-occlusive disease of the liver (endophlebitis hepatica obliterans) in a preterm infant.

    We describe the fatal course of a preterm infant of 34 weeks' gestation with veno-occlusive disease of the liver and refractory ascites. Despite aggressive medical management, the baby died twenty-two hours post partum because of cerebral haemorrhage before potentially life-saving organ transplantation could take place. At autopsy, paucity of lymphoid tissue in lymph nodes, thymus, spleen, and gastrointestinal tract were also seen. To our knowledge, this is the youngest infant with veno-occlusive disease of the liver reported in the literature. ( info)
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