Pregnancy, labour and puerperium in patient after replacement of the descending thoracic aorta with a synthetic graft for aneurysm

Aortic aneurysms occurs very rarely in young women. They usually accompany congenital heart diseases, Marfan's syndrome, bicuspid aortic valve and coarctation. What is more, they may be the consequence of syphilis and trauma, however less frequently. Despite their rare incidence, aortic aneurysms seem to be an important problem due to high maternal mortality during gestation. Hemodynamic changes which occur in pregnancy favour the appearance of this pathology, deteriorating the prognosis even further--half of the cases of aortic ruptures in women aged below 40 years are associated with pregnancy. Until recently only a few cases of aneurysm repairs during pregnancy have been reported. Also, only one pregnancy and one delivery in a patient after the repair of aortic aneurysm have been described in the literature. In our research we wish to report the successful management of a pregnancy, ended by vaginal route, 8 years after the replacement of descending thoracic aorta with a synthetic graft for aneurysm.     

Clinical observations and lessons learned in the treatment of patients with thoracoabdominal aortic aneurysms

Thoracoabdominal aortic aneurysms can be repaired successfully with acceptable rates of morbidity and mortality. Twenty-three men and seven women (an average age of 67 years) underwent 23 elective and seven emergency operations. Pulmonary complications were the most common, but renal insufficiency and paraplegia were the most serious postoperative problems. The average time of suprarenal aortic occlusion was 47 minutes, but neither renal insufficiency nor paraplegia was directly related to suprarenal clamp time. Four deaths occurred after elective procedures, two from postoperative bleeding (one death from a technical error) and two deaths from multisystem organ failure. Four late deaths were caused by myocardial infarction. The remaining patients are alive at two to 79 months after infarction. DeBakey's technique (multiple sidearm grafts from the main aortic graft) was used in the first three procedures, and the graft inclusion technique of Crawford, in the remainder. The graft inclusion technique reduced operating time and loss of blood by 50 per cent and intraoperative fluid requirements by 33 per cent. Hypothermia was minimized by extraperitoneal, rather than intraperitoneal, abdominal aortic exposure, heated ventilation and warmed intravenous fluids. Selective renal cooling was performed by catheter perfusion of the renal arteries. Extreme care must be taken in making openings and attaching grafts to visceral arteries to avoid troublesome hemorrhage. In contrast with patients with infrarenal aneurysms, those with thoracoabdominal aneurysms require prolonged ventilatory support and have considerably higher fluid requirements. Precise surgical technique is mandatory.     

Management of a False Aneurysm with Arteriovenous Fistula of the Aorta in a Pregnant Woman

Although prompt surgical intervention of traumatic great vessel false aneurysms is recommended when diagnosed, additional factors must be considered in the pregnant patient. This communication represents the first report describing the successful vaginal delivery of a term infant in a patient presenting with a false aortic aneurysm and arteriovenous fistula.     

Chronic Kidney Disease and Pregnancy. Guideline of the DGGG,OEGGG, DGfN (S2k Level,AWMF Registry No. 015 – 090)

Aim As diagnostic and therapeutic options have improved in recent years, women with limited renal function of varying etiologies are now able to become pregnant. Depending on the extent of disease and the patientsʼ comorbidities, the care of these women can be especially challenging. This guideline aims to improve the interdisciplinary care offered to pregnant women with kidney disease. Methods A selective literature search was carried out. This S2k guideline was then compiled using a structured consensus-based process which included representatives from different medical specialties and professional societies. Recommendations Recommendations for the care of pregnant women with renal disease were developed to cover preconception counseling, the recording of risks, special aspects of prenatal care and prenatal screening, as well as the specific treatment options for the underlying disease in women wanting to have children and pregnant women. Key words: chronic kidney disease, pregnancy, complications, renal function, preconception counseling, guideline     

Ethical and legal approaches to 'the fetal patient'.

The concept of fetuses being 'patients' can serve a benign protective, cautionary purpose, alerting healthcare providers and pregnant women to the implications that medical treatment can have for fetuses. The concept allows women to provide the children they intend to deliver with the care they consider appropriate. A negative effect occurs, however, if healthcare providers decide to treat pregnant women according to providers' own views of the best interests of fetuses, and compromise patients' care and self-determination without their informed consent. Some activists advocate rights of fetuses for the purpose of limiting pregnant women's self-determination. Recognition that fetuses have legitimate interests, rather than rights, is common, and opens a way to balancing various competing interests without compromising patients' rights to decide on their medical care. Courts of law generally favor this approach, and tend to allow few limits on women's choice of indicated medical care while pregnant.     

Sociologic aspects of pregnancy.

Increasingly, social factors are recognized as having a major impact on pregnancy, childbearing, and prenatal care. This review examines some of the more recent societal developments that have influenced health care for pregnant women. Although human gestation is a biologic phenomena, it exists with the social context of personal needs, family, and community of the pregnant women. This social fabric determines the perception, management, and outcome of that gestation. Significant influences to examine include pregnant women in the work force; malpractice concerns of health care providers; issues related to the cost of health care in pregnancy; the legal rights of the pregnant woman versus the legal rights of the fetus; pregnancy and occupational health; and the role of stress in pregnancy outcome.     

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.     

Cardiac screening for pregnant intravenous drug abusers

We performed screening two-dimensional and M-mode echocardiograms on 23 pregnant intravenous drug abusers who had systolic murmurs that clinically appeared physiologic. Although no patient had symptoms or a history of cardiac disease, all but two of the women were evaluated as having unexpected cardiac valvular changes. The majority of morphologic valvular findings on echocardiography consisted of either a mitral valve prolapse or valvular leaflet thickening. However, two of these 21 women were identified as having a previously undiagnosed aortic or tricuspid vegetation for which they subsequently received prophylactic antibiotic therapy during labor and delivery. Notably, two additional women among the group with morphologic valvular changes ultimately developed subacute bacterial endocarditis. Atypically, the clinical illness occurred antenatally for one of the two women with a mitral valve prolapse and 18 months postpartum for another women with unexplained valvular thickening. On the basis of these observations, a more liberal use of echocardiography in the care of the pregnant intravenous drug abuser population is suggested for evaluation of otherwise seemingly innocuous systolic murmurs.     

Perspectives of Family Physicians on the Care of Uninsured Pregnant Women

ObjectiveNo official provisions are made for the medically uninsured under provincial public health programs in Canada. Studies have shown that uninsured pregnant women have inadequate access to prenatal and obstetrical services that favour healthy maternal and child outcomes. This qualitative study aimed to explore the perspectives of family physicians who provided care to uninsured pregnant women.MethodsEight family physicians affiliated with two Montreal-based primary-care clinics and one tertiary care hospital between 2004 and 2007 were interviewed using a semi-structured interview guide. Data were assessed using thematic analysis.ResultsUninsured pregnant patients were characterized by physicians as socially vulnerable, with precarious immigration status that limited their access to health services. Uninsured patients were thought not to benefit from the same standard of perinatal care as their insured counterparts. Care of uninsured women was generally thought to be a professional obligation, regardless of the woman’s ability to pay. Caring for this population was considered by family physicians to be challenging, engendering psychological stress, increased workload, and occasional tensions with other health care providers.ConclusionIn the present context, family physicians are left to negotiate the health care system in an attempt to provide adequate perinatal care for uninsured pregnant patients. This situation has repercussions for physicians, for patients and, ultimately, for infants. Leadership is required to ensure that all pregnant women in Canada have access to appropriate health care during the perinatal period.     

Maternal hemodynamics and aortic diameter in normal and hypertensive pregnancies

The aortic diameters of 89 normotensive pregnant women were compared with those of nine rigorously defined preeclamptic women and 59 women who required antihypertensive therapy. Over the course of normal pregnancy, the diameter increased significantly; it was larger in preeclamptic than in normotensive women throughout pregnancy. The aortic diameter in women with high-resistance hypertension was smaller than that in normotensive women and in those with high-output, low-resistance hypertension, but it was larger in women with low-resistance hypertension than in normotensive women. The aortic diameter increased after treatment of high-resistance hypertension with hydralazine, but decreased after treatment of high-output, low-resistance hypertension.     

Impact of pregnancy on the size of small cerebral aneurysm

Objective: Because the management of cerebral aneurysms during pregnancy remains controversial, the objective of this study was to perform a retrospective review of pregnant women with cerebral aneurysms to determine whether pregnancy is a risk factor for aneurysm rupture.

Methods: The change in size of aneurysms during pregnancy was examined by performing repeat magnetic resonance angiography in five pregnant women with cerebral aneurysms between 2005 and 2013. The outcome examined was development of subarachnoid hemorrhage.

Results: Among the five pregnancies, there were eight cerebral aneurysms. Subarachnoid hemorrhage did not developed during any pregnancy. In four of the pregnancies, the cerebral aneurysms did not change in size during pregnancy, remaining 2–5?mm. Although in one pregnancy, the aneurysm increased from 6 to 7?mm during the third trimester, it returned to its original size in the postpartum period.

Conclusions: We suggest that if the cerebral aneurysm is small (≤?5?mm), it is likely to remain unchanged despite the increase in circulating blood volume during pregnancy. Cerebral aneurysms greater than 5?mm but without blebs, irregular shape, high-risk location, or increased aspect ratio are also at low risk of rupture and are not likely to change during pregnancy.     

After-hours telephone calls to obstetrician-gynecologists

OBJECTIVE: To characterize the pattern, content, and management of after-hours telephone interactions between obstetrician-gynecologists and patients. METHODS: In a prospective observational study, 12 resident and nine private physicians practicing obstetrics and gynecology completed data cards for after-hours telephone interactions with patients. Chief complaints were categorized as related to either women's health or primary care and on whether women were pregnant, postpartum, or not pregnant. Triage dispositions (evaluate now, office follow-up, or home care) were compared between groups. Women also were asked what they would have done if they had been unable to contact their physicians by telephone. RESULTS: One hundred ninety-two of 276 calls evaluated (69. 6%) were from pregnant women, 20 (7.2%) were from postpartum women, and 64 (23.3%) were from nonpregnant women. Calls were related to primary care health issues in 24.1% (n = 45) of pregnant women, 40% (n = 8) of postpartum women, and 28.1% (n = 18) of nonpregnant women. There were no differences between residents and private physicians in the proportion of women triaged to immediate evaluation for pregnancy (35.1% [n = 40] versus 41.9% [n = 31], P =.74) or postpartum (11.1% [n = 1] versus 10% [n = 1],P =.96) problems. Among 139 women triaged to office follow-up, 41% (n = 57) would have come to the hospital for emergency evaluation if they had been unable to reach their physicians. CONCLUSION: Resident and private obstetrician-gynecologists provide primary care and women's health care advice during after-hours telephone calls from patients. More than one third of after-hours telephone calls from pregnant women are triaged to immediate evaluation.     

Telephone social support for low-income pregnant women

OBJECTIVE: To assess whether social support can be provided to low-income pregnant women by telephone. DESIGN: A qualitative pilot study. SETTING: Nonurban prenatal clinics. PARTICIPANTS: Convenience sample of 20 pregnant women who were eligible for Medicaid, spoke English, were at least 24 weeks gestation, and had a telephone or access to a telephone. RESULTS: The Baby-Beep pilot program provides strong evidence that a telephone social support intervention is feasible and highly acceptable to a group of low-income pregnant women. Through the use of the telephone, a strong rapport appeared to develop between the health care provider and the women because nonverbal cues were eliminated. The study also found that collaboration between mental health nurses and prenatal care providers could help create safe, cost-effective psychosocial care for pregnant women. CONCLUSION: The Baby-Beep pilot study provides important information about one way to deliver social support to low-income women who may have little or no social support and feel alienated in a clinical setting.     

Evidence-based prenatal care visits: when less is more

Traditionally, low-risk pregnant women in the United States who participate in prenatal care have been scheduled for approximately 14-16 prenatal visits, which is the schedule recommended by the American College of Obstetricians and Gynecologists. In 1989, an expert panel convened by the United States Department of Health and Human Services proposed a reduced frequency prenatal visit schedule for low-risk, healthy women based on the timing of specific tests or events that occur in pregnancy. Available evidence shows no adverse effect on maternal or neonatal outcomes for low-risk pregnant women who follow a reduced visit schedule, making it a highly important consideration for pregnant women and their health care providers. Other important aspects of prenatal care, especially related to adequacy and content, will be explored in-depth in a future segment of this series on evidence-based prenatal care.     

Nursing care for pregnant adolescents

Although the physical care of pregnant adolescents is similar to that required by adult women, adolescents have additional unique needs. Adolescents often need more support and extensive teaching during pregnancy and the postpartum. Moreover, adolescents often have fewer life experiences than do adult women, making them less able to cope with the life changes they are experiencing related to pregnancy and birth. Nonjudgmental and developmentally appropriate interactions are essential to the care of pregnant adolescents. This article explores nursing care for the physical, emotional, and educational needs of adolescents during the prenatal, intrapartum, and postpartum periods.     

Group Prenatal Care for Women Receiving Medication‐Assisted Treatment for Opioid Use Disorder in Pregnancy: An Interprofessional Approach

Opioid use disorder among pregnant women is common and rapidly increasing nationwide. Group prenatal care is an innovative alternative to individual care for pregnant women and has been shown to improve women's and health care providers’ satisfaction and adherence to care. We describe a novel group prenatal care program colocated in an opioid treatment program that integrates prenatal care, substance use disorder counseling, and medication‐assisted treatment. Our interprofessional model draws on the unique contributions of physicians, midwives, nurses, and mental health professionals to address the complex needs of pregnant women with opioid use disorder. Participants reported increased trust and engagement with health care providers and peers, improved prenatal care and birth experience, and increased resilience for relapse prevention. Group prenatal care is an accepted and promising model for women with opioid use disorder in pregnancy and has the potential to improve outcomes for women and newborns.     

The impact of social factors on attendance at antenatal care services and the subsequent effect on mothers’ health, measured during the years of economic transition in Latvia

The goal of the study is to evaluate the risk factors having an impact on attendance at antenatal care services in Latvia during the years of economic transition as well as the impact of those factors on mothers and newborns’ health. Based on Latvian statistical data and published surveys, we analysed the possible impact of social and economic factors on attendance at antenatal care services. To illustrate the posed problems, we carried out a small pilot follow-up study, comparing social profiles, incidences of reproductive tract infections and HIV infection and pregnancy outcome on 200 consecutive unselected pregnant women who received antenatal care and 25 pregnant women who did not. Despite the fact that antenatal care is free of charge and the social security system facilitates the attendance of antenatal care visits, 4.6% of pregnant women in 1997 and 3.3% of pregnant women in 2002 did not attend antenatal care. Their perinatal outcome is significantly worse, as they are more likely to deliver preterm and growth-retarded babies and have a greater risk of perinatal mortality. Women delivering without previous antenatal care were characterised by poor socio-economic status and have limited access to health care and family planning services due to their low educational level, low income and high incidence of different addictions. More frequently, they were in the risk group having sexually transmitted and HIV infections. As a result, newborns had lower birth weight, were more likely to have intrauterine infection and intrauterine growth retardation. Low social class, high substance abuse, and a high rate of genital infections are associated with lack of antenatal care and compromised neonatal outcome. Improving the availability of primary health care and easy access to social and family planning services are priorities for the socially depressed during the reform period of the health care system in Latvia. Standard protocols for the management of women without previous antenatal care have to be developed.     

Maternal cytomegalovirus infection prevention: The role of Dutch primary care midwives

Objectiveto assess the knowledge of cytomegalovirus (CMV) infection among Dutch primary care midwives, and clinical approaches to informing women about CMV.Designcross-sectional study, using self-administered questionnaires.Participants330 Dutch primary care midwives.Settingprimary midwifery care practices across the Netherlands.Main outcomeMidwives׳ knowledge of CMV transmission routes and maternal symptoms, and clinical practice behaviours regarding CMV, the information typically provided or reasons for not informing pregnant women about CMV.Findingsthe overall median knowledge score was 8.0 out of a maximum possible score of 13.0. Of all participants, 10.6% reported always informing pregnant women about CMV infection prevention and 41.0% reported never informing pregnant women. The main reason indicated for not informing pregnant women was lack of knowledge about preventive methods (45.7%).ConclusionDutch primary care midwives have limited knowledge of CMV infection. Improvement in providing education to pregnant women about strategies to prevent CMV is necessary.     

Prenatal Care Outcomes in Women with Substance Use Disorders: A Retrospective Cohort Study

ObjectiveThis study sought to examine and compare the characteristics and prenatal care and pregnancy outcomes of women with and without substance use disorder (SUD). It also examined whether there were differences in prenatal care and pregnancy outcomes within the population of substance-using women based on the stability of their SUD during pregnancy.MethodsThis retrospective cohort study involved pregnant women with and without SUD who accessed care through the Maternity Centre of Hamilton between 2015 and 2017. Cases and controls were matched 1:1 for gravidity, parity, ethnicity, smoking status, and postal code.ResultsFifty-five pregnant women with SUD were identified and matched to 55 pregnant women without SUD. When analyzed by stability of substance use, women with stable SUD had similar outcomes to those of women without SUD. Women with unstable SUD received the poorest prenatal care and were more likely to have their infants removed from their care. There was significant movement towards stability of maternal substance use over the course of pregnancy in our integrated prenatal and addiction care model.ConclusionWomen with unstable SUD had poorer prenatal care and higher rates of custody loss than those with stable substance use disorders or those without substance use disorders. The disparate outcomes among women with unstable SUD may indicate a need to identify patients requiring greater support at entry into prenatal care and to target services accordingly. This integrated prenatal and addiction care model was effective in reducing maternal substance use in pregnancy.