<strong>Objective: </strong><span><span><span style="font-family:""><span style="font-family:Verdana;">To review a case series of 12 women with unexpected h...<strong>Objective: </strong><span><span><span style="font-family:""><span style="font-family:Verdana;">To review a case series of 12 women with unexpected heart and lung disorders that occurred during pregnancy and the puerperium, describing for teaching purposes the pitfalls in practice and the lessons learned from this experience. </span><b><span style="font-family:Verdana;">Materials & Methods: </span></b><span style="font-family:Verdana;">We reviewed case files of women with medical and/or hypertensive complications of pregnancy that were evaluated </span><span style="font-family:Verdana;">for medicolegal defense purposes by the first author between 1986-2015.</span> <span style="font-family:Verdana;">Twelve women in these case files experienced unexpected cardiovascular</span><span style="font-family:Verdana;"> and/or cardiopulmonary complications late in pregnancy or early in the puerperium. For each case, the pertinent medical record information was extracted. Im</span><span style="font-family:Verdana;">portant concepts as lessons learned are summarized and referenced for</span><span style="font-family:Verdana;"> teaching purposes. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> Five women had undetected preexisting heart disease which acutely deteriorated during the third trimester, four women developed postpartum heart failure related to pregnancy and delivery, and three women </span><span style="font-family:Verdana;">suffered an intrapartum cardiac arrest;none survived. Their case presenta</span><span style="font-family:Verdana;">tions illustrate the importance of obstetric health care professionals being alert to the signs/symptoms of developing cardiopulmonary disease late in pregnancy and following delivery so that timely evaluation and intervention can be accomplished to potentially avoid morbidity and mortality. Diagnostic categories include peripartum heart failure, high-risk chronic hypertension, superimposed preeclampsia, amniotic fluid embolism, pulmonary embolism and Raynaud’s with occult pulmonary hypertension. </span><b><span style="font-family:Verdana;">Conclusion: </span></b><span style="font-family:Verdana;">These cases illustrate the diversity of ways that cardiovascular disease can suddenly complicate pregnancy and the early postpartum period. A major part of any effort to enhance safer motherhood is a heightened awareness by obstetric specialists to consider the possibility of heart disease in all maternity patients so that appropriate consultation and collaboration with other specialists might help avoid major maternal morbidity or mortality.</span></span></span></span>展开更多
<strong>OBJECTIVE:</strong> <span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">To determine the types o...<strong>OBJECTIVE:</strong> <span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">To determine the types of major maternal-perinatal morbidity associated with prolonged, acute-onset severe systolic hypertension during pregnancy and postpartum.</span></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">METHODS: </span></b></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">A medicolegal database retaining only medical record data was created from all cases involving women with medical/hypertensive disorders of pregnancy evaluated by the first author between 1986-2015. Case files of women that experienced severe systolic hypertension (SSH) sustained for many hours to days were identified for study. </span><b><span style="font-family:Verdana;">RESULTS: </span></b><span style="font-family:Verdana;">Sixty six pregnant/postpartum women met study criteria. Stroke secondary to intracranial hemorrhage or thrombosis (65.2) and acute pulmonary edema (33%) were the leading causes of maternal morbidity and mortality, most often antepartum as a component of early-onset preeclampsia (</span></span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">≤</span><span style="font-family:Verdana;">34 weeks). Eclampsia, abruptio placenta and injury to heart, liver and/or kidneys were other frequent co-morbidities. Seven postpartum women developed sudden new-onset postpartum SSH and suffered a stroke 4</span></span></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">-</span></span></span><span><span><span style="font-family:""> </span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">13 days after delivery. Maternal mortality (54.6%) and morbidity as persistent disability (24.2%) were high in this cohort. </span><b><span style="font-family:Verdana;">CONCLUSION: </span></b><span style="font-family:Verdana;">Failure to rapidly respond, reduce and sustain at a safe level acute-onset SSH poses a significant threat to the wellbeing of mothers and babies, before and in the weeks following delivery. Systems to implement safe practices to identify and emergently treat severe maternal hypertension are needed.</span></span></span></span>展开更多
<strong>OBJECTIVE:</strong> <span><span><span><span style="font-family:""><span style="font-family:Verdana;">HELLP syndrome is a severe preeclampsia s...<strong>OBJECTIVE:</strong> <span><span><span><span style="font-family:""><span style="font-family:Verdana;">HELLP syndrome is a severe preeclampsia spectrum disorder diagnosed when laboratory evidence of hemolysis, liver dysfunction and thrombocytopenia are present. The presence of epigastric pain with laboratory criteria for HELLP syndrome may indicate higher maternal-fetal risk. Thus we explored maternal outcomes in 42 pregnant/postpartum women that had HELLP syndrome by laboratory criteria in addition to sudden severe epigastric pain. </span><b><span style="font-family:Verdana;">METHODS: </span></b><span style="font-family:Verdana;">A database was constructed from the medical files of all patients with medical/hypertensive disorders evaluated by the first author from 1986-2015 for medicolegal purposes. All patient files of women who presented to their physicians with a diagnosis of presumptive HELLP syndrome were examined. </span><b><span style="font-family:Verdana;">RESULTS: </span></b><span style="font-family:Verdana;">Fifty</span></span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">-</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">eight pregnant/postpartum women fulfilled study inclusion criteria;they presented to physicians for evaluation usually in non-tertiary care hospital settings. Clinical presentation and care including lab data and details of pregnancy outcome were evaluated. A correct diagnosis of HELLP syndrome was verified for 42 women (72.4%);others were determined to have AFLP-Acute Fatty Liver of Pregnancy (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">8) or TTP-aHUS-Thrombotic thrombocytopenic purpura-adult/atypical hemolytic uremic syndrome (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">8). All 42 HELLP women (100%) in our cohort had severe epigastric pain. Treatment modalities for maternal HELLP syndrome included magnesium sulfate (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">35, 83%), antihypertensives (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span><span><span><span style="font-family:""><span style="font-family:Verdana;">17, 40%);corticosteroids (CORT) for HELLP were not utilized. Major maternal morbidity (21 strokes, 9 liver ruptures/hematomas) affected 41 HELLP women (98%);22 died, 7 were permanently disabled. </span><b><span style="font-family:Verdana;">CONCLUSION: </span></b><span style="font-family:Verdana;">HELLP syndrome patients presenting with sudden, severe epigastric pain in this </span></span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">highly </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">select</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">ed</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"> cohort experienced very high maternal morbidity and mortality. Laboratory evidence of HELLP syndrome in association with epigastric pain is a dangerous combination that portends great danger to safe motherhood. We speculate that the absence of CORT use in this cohort contributed to poor maternal outcome (word count = 280 as modified for reviewers)</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">.</span></span></span></span>展开更多
文摘<strong>Objective: </strong><span><span><span style="font-family:""><span style="font-family:Verdana;">To review a case series of 12 women with unexpected heart and lung disorders that occurred during pregnancy and the puerperium, describing for teaching purposes the pitfalls in practice and the lessons learned from this experience. </span><b><span style="font-family:Verdana;">Materials & Methods: </span></b><span style="font-family:Verdana;">We reviewed case files of women with medical and/or hypertensive complications of pregnancy that were evaluated </span><span style="font-family:Verdana;">for medicolegal defense purposes by the first author between 1986-2015.</span> <span style="font-family:Verdana;">Twelve women in these case files experienced unexpected cardiovascular</span><span style="font-family:Verdana;"> and/or cardiopulmonary complications late in pregnancy or early in the puerperium. For each case, the pertinent medical record information was extracted. Im</span><span style="font-family:Verdana;">portant concepts as lessons learned are summarized and referenced for</span><span style="font-family:Verdana;"> teaching purposes. </span><b><span style="font-family:Verdana;">Results:</span></b><span style="font-family:Verdana;"> Five women had undetected preexisting heart disease which acutely deteriorated during the third trimester, four women developed postpartum heart failure related to pregnancy and delivery, and three women </span><span style="font-family:Verdana;">suffered an intrapartum cardiac arrest;none survived. Their case presenta</span><span style="font-family:Verdana;">tions illustrate the importance of obstetric health care professionals being alert to the signs/symptoms of developing cardiopulmonary disease late in pregnancy and following delivery so that timely evaluation and intervention can be accomplished to potentially avoid morbidity and mortality. Diagnostic categories include peripartum heart failure, high-risk chronic hypertension, superimposed preeclampsia, amniotic fluid embolism, pulmonary embolism and Raynaud’s with occult pulmonary hypertension. </span><b><span style="font-family:Verdana;">Conclusion: </span></b><span style="font-family:Verdana;">These cases illustrate the diversity of ways that cardiovascular disease can suddenly complicate pregnancy and the early postpartum period. A major part of any effort to enhance safer motherhood is a heightened awareness by obstetric specialists to consider the possibility of heart disease in all maternity patients so that appropriate consultation and collaboration with other specialists might help avoid major maternal morbidity or mortality.</span></span></span></span>
文摘<strong>OBJECTIVE:</strong> <span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">To determine the types of major maternal-perinatal morbidity associated with prolonged, acute-onset severe systolic hypertension during pregnancy and postpartum.</span></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><b><span style="font-family:Verdana;">METHODS: </span></b></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">A medicolegal database retaining only medical record data was created from all cases involving women with medical/hypertensive disorders of pregnancy evaluated by the first author between 1986-2015. Case files of women that experienced severe systolic hypertension (SSH) sustained for many hours to days were identified for study. </span><b><span style="font-family:Verdana;">RESULTS: </span></b><span style="font-family:Verdana;">Sixty six pregnant/postpartum women met study criteria. Stroke secondary to intracranial hemorrhage or thrombosis (65.2) and acute pulmonary edema (33%) were the leading causes of maternal morbidity and mortality, most often antepartum as a component of early-onset preeclampsia (</span></span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">≤</span><span style="font-family:Verdana;">34 weeks). Eclampsia, abruptio placenta and injury to heart, liver and/or kidneys were other frequent co-morbidities. Seven postpartum women developed sudden new-onset postpartum SSH and suffered a stroke 4</span></span></span></span><span><span><span style="font-family:""> </span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">-</span></span></span><span><span><span style="font-family:""> </span></span></span><span><span><span style="font-family:""><span style="font-family:Verdana;">13 days after delivery. Maternal mortality (54.6%) and morbidity as persistent disability (24.2%) were high in this cohort. </span><b><span style="font-family:Verdana;">CONCLUSION: </span></b><span style="font-family:Verdana;">Failure to rapidly respond, reduce and sustain at a safe level acute-onset SSH poses a significant threat to the wellbeing of mothers and babies, before and in the weeks following delivery. Systems to implement safe practices to identify and emergently treat severe maternal hypertension are needed.</span></span></span></span>
文摘<strong>OBJECTIVE:</strong> <span><span><span><span style="font-family:""><span style="font-family:Verdana;">HELLP syndrome is a severe preeclampsia spectrum disorder diagnosed when laboratory evidence of hemolysis, liver dysfunction and thrombocytopenia are present. The presence of epigastric pain with laboratory criteria for HELLP syndrome may indicate higher maternal-fetal risk. Thus we explored maternal outcomes in 42 pregnant/postpartum women that had HELLP syndrome by laboratory criteria in addition to sudden severe epigastric pain. </span><b><span style="font-family:Verdana;">METHODS: </span></b><span style="font-family:Verdana;">A database was constructed from the medical files of all patients with medical/hypertensive disorders evaluated by the first author from 1986-2015 for medicolegal purposes. All patient files of women who presented to their physicians with a diagnosis of presumptive HELLP syndrome were examined. </span><b><span style="font-family:Verdana;">RESULTS: </span></b><span style="font-family:Verdana;">Fifty</span></span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">-</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">eight pregnant/postpartum women fulfilled study inclusion criteria;they presented to physicians for evaluation usually in non-tertiary care hospital settings. Clinical presentation and care including lab data and details of pregnancy outcome were evaluated. A correct diagnosis of HELLP syndrome was verified for 42 women (72.4%);others were determined to have AFLP-Acute Fatty Liver of Pregnancy (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">8) or TTP-aHUS-Thrombotic thrombocytopenic purpura-adult/atypical hemolytic uremic syndrome (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">8). All 42 HELLP women (100%) in our cohort had severe epigastric pain. Treatment modalities for maternal HELLP syndrome included magnesium sulfate (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">35, 83%), antihypertensives (n</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">=</span></span></span></span><span><span><span><span style="font-family:""> </span></span></span></span><span><span><span><span style="font-family:""><span style="font-family:Verdana;">17, 40%);corticosteroids (CORT) for HELLP were not utilized. Major maternal morbidity (21 strokes, 9 liver ruptures/hematomas) affected 41 HELLP women (98%);22 died, 7 were permanently disabled. </span><b><span style="font-family:Verdana;">CONCLUSION: </span></b><span style="font-family:Verdana;">HELLP syndrome patients presenting with sudden, severe epigastric pain in this </span></span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">highly </span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">select</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">ed</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"> cohort experienced very high maternal morbidity and mortality. Laboratory evidence of HELLP syndrome in association with epigastric pain is a dangerous combination that portends great danger to safe motherhood. We speculate that the absence of CORT use in this cohort contributed to poor maternal outcome (word count = 280 as modified for reviewers)</span></span></span></span><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;"><span style="font-family:Verdana;">.</span></span></span></span>
