AJP Reports最新文献

Background: Guidelines recommend a 3-day follow-up for severe hypertensive disorders of pregnancy (HDP) and a 7- to 10-day follow-up for nonsevere HDP, but implementation varies.

Objective: To improve adherence to guideline-recommended postpartum follow-up by targeting provider discharge recommendations. A risk stratification tool incorporating HDP severity, maternal symptoms, and discharge blood pressure guided providers to recommend telehealth follow-up at 3, 5, or 7 days. We aimed to maintain 3-day recommendations for severe HDP and reduce unnecessary 3-day recommendations for nonsevere HDP.

Study design: This quality improvement project was conducted at a single urban academic institution. The risk stratification tool was integrated into discharge workflows, and demographic, clinical, and telehealth follow-up data for pre- and post-intervention cohorts were abstracted from the electronic medical record and compared using summary statistics and bivariate analyses.

Results: Cohorts were similar at baseline. After implementation, all patients with severe HDP continued to receive 3-day follow-up instructions. Among patients with nonsevere HDP patients, 3-day recommendations decreased from 100 to 31.1% ( p  < 0.001), with a corresponding decrease in 3-day telehealth scheduling. Scheduling for severe HDP did not improve.

Conclusion: The tool improved guideline-aligned provider recommendations for postpartum HDP. Scheduling changes were limited, suggesting future efforts should target workflow and system processes.

Background: Thyroid storm is a rare, life-threatening endocrine emergency in pregnancy with significant maternal and neonatal implications. Clinical symptoms may mimic those of hypertensive disorders in pregnancy. Prompt diagnosis and multidisciplinary management are critical for reducing maternal and neonatal morbidity and mortality.

Case: A 31-year-old woman with a dichorionic diamniotic twin pregnancy, chronic hypertension, short cervix, and poorly controlled Graves' disease presented at 22 weeks' gestation with vaginal bleeding and severe-range blood pressures. She was diagnosed with thyroid storm and admitted to the intensive care unit. She failed to respond to maximal medical management, ultimately requiring plasmapheresis. She later developed preterm labor and spontaneously delivered periviable twins. She eventually underwent total thyroidectomy for definitive management of thyroid storm.

Conclusion: This case illustrates the severe consequences of poorly controlled Graves' disease in pregnancy. Although thyroid storm can mimic preeclampsia, abnormal thyroid function tests, persistent tachycardia, fevers, and hypertension with wide pulse pressures may help distinguish it. Timely recognition and multidisciplinary care are imperative to decrease morbidity and mortality associated with thyroid storm.

Background: Poikiloderma with neutropenia is an autosomal recessive condition characterized by postinflammatory poikiloderma and chronic neutropenia. To date, there is no published literature reporting on the impact of pregnancy on this rare genetic disorder.

Case: This case highlights a successful pregnancy outcome in a 26-year-old gravida 1 para 0 female with poikiloderma with neutropenia. Her pregnancy was complicated by thrombocytopenia, low fetal fraction, and high-risk cell-free DNA result.

Discussion: The findings of low fetal fraction and high-risk aneuploidy were unexpected given normal neonatal outcome. It is not yet well understood whether these findings are related to the genetic condition itself or use of medications used to manage her condition.

Objective: This study aimed to identify factors related to the successful induction of labor (IOL) among pregnancies complicated with fetal growth restriction (FGR).

Methods: We performed a retrospective cohort study between January and December 2024 at Orléans University Hospital, Orléans, France. The study enrolled all singleton pregnancies complicated by FGR and underwent IOL. Logistic regression was used to reveal the associated factors relating to the success of IOL, following two criteria, including Bishop score after IOL greater than 7 points (criterion 1) and vaginal birth (criterion 2).

Results: Bishop score had a negative correlation with IOL duration. This study did not find statistically significant clinical factors related to the success of the Bishop score change of more than 7 points. However, absence of Doppler abnormalities and IOL at term, more than 37 weeks, were related to the success rate of vaginal delivery (OR [95% CI]: 22.5 [3.240-156.269] and OR [95% CI]: 22.5 [3.240-156.269], respectively; p  < 0.05).

Conclusion: Bishop score before IOL helps in reducing the duration of IOL. In FGR pregnancies with a normal Doppler ultrasound scan and gestational age at IOL greater than 37 weeks, these are good prognostic factors for vaginal delivery; however, further research is needed to explore more associated factors.

Group B Streptococcus (GBS) is the leading cause of sepsis, pneumonia, and/or meningitis in neonates. Insertion of an umbilical catheter (UC) is a common practice in neonatal intensive care for primary central vascular access in extreme premature neonates. UC is used for the administration of intravenous medications, parenteral nutrition, blood samplings, and continuous central blood pressure monitoring. Malposition or migration of UC tends to occur in extreme premature infants with risks of multiple complications. We present a case of an extreme premature neonate who developed fatal GBS sepsis with autopsy findings of multiple cardiac abscesses in the myocardium but not in any other organ. GBS sepsis with isolated multifocal myocardial abscesses leading to sudden fatal clinical deterioration has not been described previously. In this review, we describe the plausible pathological mechanism of this rare presentation. Intracardiac migrated UC, in conjunction with rhythmic heart contractions and intracardiac blood flow dynamics, can cause direct trauma to the endocardium. Damaged endocardium can be a potential nidus for bacterial overgrowth and abscess formation that ultimately may lead to cardiac failure. Therefore, the correct aseptic technique of securing and management of UC, and daily assessment of UC position are recommended to prevent complications associated with catheter migration.

Introduction: The literature is limited regarding the use of recombinant tissue plasminogen activator (r-tPA) in premature infants. We describe the use of r-tPA to treat life-threatening intra- and extracardiac thrombi in a very low birth weight patient born at 23 weeks of gestational age.

Case report: An extremely premature infant was diagnosed with multiple thrombi at 4 weeks of age. The acute phase of treatment was managed with an infusion of r-tPA followed by unfractionated heparin, then low-molecular-weight heparin for continued anticoagulation. The patient did not experience any side effects associated with the therapies and was discharged home.

Conclusion: Thrombotic events in neonates, though rare, are being increasingly identified due to improved survival of premature infants, enhanced diagnostic modalities, and the widespread use of central venous catheters. Heparin remains the standard of care in neonates for anticoagulation. Thrombolytic therapy with agents such as r-tPA, though less frequently employed, may be lifesaving in certain instances, such as the one presented in this case report.

Objective: During pregnancy, total blood volume increases by about 40%. As gestation advances, blood volume to the pelvic region increases significantly. Due to the enlarging uterus, the venous return from the lower body decreases with advancing gestational age. The pooling and stasis of blood in the lower body can lead to the formation of varices, affecting the lower extremity, vulva, and vaginal regions. Varicosities in the lower extremities and vulva are not uncommon and often asymptomatic. Vulvar varicosities are more common in women with varicosities in the lower extremities. On the other hand, vaginal varicosities are extremely rare and mentioned only in case reports. Although asymptomatic, vaginal varicosities could become a concern for hemorrhage risk during vaginal delivery. There is little information in the current medical literature about the diagnosis and management of large vaginal varicosities during pregnancy.

Study: Design We present a case of a primigravida with very large prolapsing vaginal varicosities that presented as a large external mass at 36 weeks of gestation.

Results: The patient was managed expectantly during the antenatal period. She was delivered via an elective scheduled cesarean section. An almost complete resolution of the vaginal varices was noted at 6 hours postoperatively, with complete resolution reported on postoperative day 22.

Conclusion: Due to the rarity of the condition, we hope to add our experience to the literature.

Neonatal Echovirus 11 (E-11) infection acquired perinatally often manifests as a severe, sepsis-like illness with rapid clinical deterioration within the first week of life. The infection is characterized by fulminant multiorgan failure, commonly involving severe hepatitis with coagulopathy, myocarditis, and meningoencephalitis. Adverse outcomes are strongly associated with prematurity and vertical transmission from a mother with an acute peripartum infection, which precludes the transfer of protective serotype-specific antibodies. We present a fatal case of E-11 sepsis in a late preterm neonate following maternal peripartum illness.

Background: Noonan syndrome (Online Mendelian Inheritance in Man #163950) is a RASopathy caused by germline mutations in the RAS/RAF/mitogen-activated protein kinase signaling pathway and characterized by distinctive facial features, musculoskeletal abnormalities, and congenital heart defects. A subset of patients with RIT1 mutations present with hypertrophic cardiomyopathy and generalized lymphatic anomalies. While sirolimus, a mammalian target of rapamycin inhibitor (mTOR), has been shown to suppress lymphangiogenesis, its efficacy in Noonan syndrome remains unclear.

Case presentation: We report the case of an infant with Noonan syndrome and RIT1 mutation who developed recurrent refractory chylothorax and edema. Despite multiple interventions, including corticosteroids, octreotide, thoracic duct ligation, and pleurodesis, the patient's condition remained critical and refractory. Skin biopsy revealed lymphatic malformations. Sirolimus (0.6 mg/day) was initiated at 220 days of age, but was discontinued due to a markedly elevated serum level (88.2 ng/mL) and a lack of therapeutic effect. The patient died of Escherichia coli sepsis at 235 days of age.

Conclusion: Although sirolimus was ineffective in this case, initiation of treatment at a lower dose may be advisable for patients with compromised hepatic function or concurrent infections. Further studies are warranted to clarify the appropriate indications, dosage, and timing of sirolimus therapy for Noonan syndrome.

Background: Small-cell carcinoma of the ovary, hypercalcemic type (SCCOHT) is a rare, aggressive, and highly fatal gynecologic malignancy with few treatment guidelines offered in nonpregnant patients.

Case report: A 32-year-old woman presented for initial prenatal care at 9 weeks and her dating ultrasound was notable for a large complex adnexal mass. Magnetic resonance imaging performed 2 weeks later revealed accelerated interval growth with possible malignant etiology. She underwent surgical evaluation with salpingo-oophorectomy. Pathology noted signature features of SCCOHT. The patient desired expectant management and declined termination of pregnancy or chemotherapy. Four weeks later, she developed severe abdominal pain, nausea, and vomiting, and she was diagnosed with extensive metastatic disease. After multidisciplinary and multi-institutional counseling, she elected for continuation of her pregnancy and 6-agent chemotherapy including Vinblastine, Cisplatin, Cyclophosphamide, Bleomycin, Doxorubicin, Etoposide (VPCBAE) with close antepartum surveillance. The patient completed multiple rounds of chemotherapy and subsequently delivered via primary cesarean at 27 ^2/7 weeks due to maternal sepsis and nonreassuring fetal status. Maternal and neonatal death occurred approximately 1-week postpartum.

Conclusion: This is the first known case of SCCOHT in which the pregnancy was continued through an aggressive chemotherapy regimen.