RESUMEN
We present a case of a vein of Galen aneurysmal malformation (VGAM), a rare congenital arteriovenous malformation, in one fetus of a monochorionic-diamniotic twin pregnancy. The diagnosis was made with color Doppler ultrasonography at 28 weeks and the affected fetus was found to have worsening cardiomegaly on subsequent fetal echocardiograms. She was emergently delivered at 32 weeks for abnormal fetal heart rate tracing of the affected twin. Magnetic resonance imaging of the brain findings after delivery demonstrated severe neurological injury; therefore, postnatal embolization was not performed. The neonate died on day of life 9. The cotwin survived without neurological complications. This is the first case in the literature of a VGAM diagnosed prenatally in a monochorionic-diamniotic twin pregnancy and demonstrates the challenge of delivery timing with prenatal diagnosis in a twin pregnancy.
RESUMEN
The optimal gestational age for delivery of twin gestations balances the risk to the mother with the risks to the fetus and newborn. Primary considerations should include chorionicity and the presence or absence of other obstetrical complications such as fetal growth restriction or hypertensive disorders of pregnancy. More than half of twin gestations will deliver preterm, and a significant portion will be due to spontaneous labor or medical indications, such that the timing of delivery for twins is typically less determined by the provider discretion. Future studies are needed to assist in clarifying the optimal timing for delivery of twin pregnancies.
Asunto(s)
Embarazo Gemelar , Gemelos , Femenino , Humanos , Recién Nacido , Embarazo , Feto , Edad Gestacional , Madres , Resultado del Embarazo , Estudios RetrospectivosRESUMEN
Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2, has led to a global health crisis. The virus can cause varying severity of liver injury, but the mechanism has not yet been elucidated, especially in pregnancy. We present a morbidly obese 30-year-old woman with COVID-19 at 28 weeks' gestation complicated by significant transaminitis with peak liver enzymes levels of 501/1,313 (aspartate aminotransferase/alanine aminotransferase). Liver biopsy showed reactive changes consistent with medication effect and mild steatosis. Significant transaminitis has been found in both pregnant and nonpregnant patients with COVID-19. Our case demonstrates the multifactorial nature of liver injury in COVID-19 patients including mild underlying liver steatosis combined with possible viral potentiation of medication effect.
RESUMEN
OBJECTIVES: The aim of the study is to evaluate how current management of Category II fetal heart rate tracings compares with that suggested by a published algorithm and whether these differences lead to disparate neonatal outcomes. STUDY DESIGN: This is a retrospective observational study from the resident service at an academic-community tertiary care center from 2013 to 2018. We reviewed archived fetal heart rate tracings from patients with cesarean delivery performed for nonreassuring fetal heart rate tracing and interpreted tracings against the algorithm. We assigned tracings to one of three categories: Group A-consistent; Group B-inconsistent too early (algorithm permits the patient to labor longer); Group C-inconsistent too late (algorithm suggests performing the cesarean delivery sooner). Maternal demographics, features of labor, and neonatal outcomes were compared. RESULTS: Of the 110 cases, 27 (24.5%) had a cesarean delivery performed in group A, 49 (44.5%) in group B, and 34 (30.9%) in group C. Baseline characteristics were similar. Of the 49 in group B, 46 (93.9%) violated the algorithm at the same branchpoint. In group C, cesarean deliveries would have been performed on average 244 minutes earlier had the algorithm been used. Neonatal outcomes were not significantly different among the groups, including 5-minute Apgar <7, pH <7.1, and NICU admit. CONCLUSION: Our retrospective application of the algorithm showed that 44.5% of patients who have cesarean delivery for nonreassuring fetal heart rate tracing may be able to labor longer and that violation at a common decision point on the algorithm (moderate variability or accelerations, but a lack of recurrent decelerations) is responsible for nearly all such cesarean deliveries. More studies are needed to evaluate if cesarean delivery rates for nonreassuring fetal heart rate tracing can be reduced without impacting neonatal outcomes using the algorithm. KEY POINTS: · There is a potential to further standardize management of Category II fetal heart rate tracings.. · In our practice, 25% of cesareans performed for fetal distress were consistent with the algorithm.. · A subset of patients (45%) with cesarean for fetal distress may have been able to labor longer..