Obstetrics

Cesarean scar ectopic pregnancy (CSEP) is a challenging diagnosis that warrants consideration when performing ultrasound on a pregnant patient with a previous history of cesarean delivery. It is suspected when ballooning of the lower uterine segment is noted on ultrasound,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).²

Ectopic Pregnancy

Ectopic pregnancy affects approximately 2% of all pregnancies and is the leading cause of first-trimester maternal mortality.³ As front-line care providers, it is imperative that emergency physicians (EPs) recognize cases of ectopic implantation to avoid devastating outcomes. 

The majority of ectopic pregnancies (97%) are located in the fallopian tubes; however, many other locations are possible, including implantation in the scar from a previous cesarean delivery.^1,4 The frequency of such ectopic pregnancies is on the rise, consistent with the increasing number of cesarean deliveries performed worldwide.⁵ These cases present a special diagnostic challenge because patients often present asymptomatically or with painless vaginal bleeding; moreover, visualization via bedside ultrasound can be deceiving,⁵ and it is easy to mistake a CSEP for a viable intrauterine pregnancy.

Case

A 22-year-old woman with type 1 diabetes mellitus (DM) presented to the ED complaining of 3 days of worsening nausea and elevated blood glucose levels. She stated that although she had been taking her insulin regimen as prescribed, her symptoms progressively worsened. On the day of presentation, she developed moderate diffuse nonradiating dull abdominal pain and had several episodes of nonbloody, nonbilious emesis. She denied being pregnant and stated that her last menstrual period was 14 days ago; she further denied any vaginal discharge or bleeding. A review of her systems was otherwise benign.

In addition to type 1 DM, the patient also had a history of migraine headaches and an obstetric history of gravida 3, para 3, aborta 0. Each birth was via cesarean delivery and without complication. Her current medications included insulin glargine (Lantus) 25 units subcutaneously every night at bedtime; insulin aspart (Novolog) 7 units subcutaneously three times a day; zolpidem (Ambien) 10 mg orally every night at bedtime. A chart review was notable for several presentations of diabetic ketoacidosis (DKA) secondary to noncompliance with her diabetes regimen. 

Physical examination was notable for a well-developed, well-nourished 22 year old that appeared uncomfortable but in no acute distress. Her abdomen was soft and nondistended, with diffuse moderate tenderness to palpation but no rebound or guarding. The remainder of the physical 

The initial workup revealed DKA and pregnancy. Significant laboratory values included: finger-stick blood glucose, 441 mg/dL; serum ketones, 2.1 mmol/L (normal range, 0.0-0.5); anion gap, 15; and urinalysis 4+ glucose, 2+ ketones; and quantitative β-human chorionic gonadotropin (β-HCG), 5,282 IU/L (normal range, 0-5.0 IU/L ).examination was otherwise benign. 

After receiving insulin, intravenous (IV) fluids, pain medication, and antiemetics, the patient stated she felt much better. She was then admitted to the inpatient floor for management of DKA and discharged uneventfully several days later. Emergency bedside transabdominal and transvaginal ultrasounds were performed by the emergency staff and identified an intrauterine gestational sac and yolk sac. The EP ordered a consultation with an obstetrician-gynecologist (OB-GYN), who saw the patient in the ED and agreed with the findings, and noted the gestational sac was consistent with a date of 5 weeks, 1 day.

Six days after discharge, however, she returned to the ED complaining of several days of weakness, vomiting, and lower abdominal pain. Significant laboratory values included: urinalysis with 4+ ketones, 1+ bacteria, + nitrites; and quantitative β-HCG 25,925 IU/L (expected range, 0-5.0); serum glucose 206 mg/dL; serum ketones 0.8 (expected range, 0-0.5); and anion gap, 12.

An emergency ultrasound identified a gestational sac, yolk sac, fetal pole, and fetal heart tones; an OB-GYN ultrasound had consistent findings, with an estimated gestational age of 6 weeks, 6 days. The patient responded well to IV fluids and antiemetics, and was asymptomatic when she was admitted to the ED observation unit for continued monitoring, fluids, and antiemetics as needed. Several hours later she again began to complain of nausea, vomiting, and poorly localized abdominal discomfort. As these symptoms persisted, the OB-GYN team returned to reevaluate the patient. 

Discussion

Cesarean scar ectopic pregnancy was first described in the obstetric literature in 1978 and originally thought to be an exceedingly rare occurrence.^5,6 With both the increasing number of cesarean deliveries performed and improvement in imaging technology, it is now believed that uterine scar ectopic pregnancy makes up as much as 6.1% of ectopic pregnancies in patients with a prior cesarean delivery.⁷ This diagnosis is well-documented in the obstetric and radiology literature, yet has never been discussed in an emergency medicine publication. Searching through both Pubmed and EMBase using the terms “cesarean” and “ectopic” yields no EM literature on the topic of CSEP. This is concerning because ultrasound of the pregnant patient is now a routine function of EPs.

Clinical history can be helpful in differentiating CSEP from alternative diagnoses. Patients undergoing spontaneous abortion are more likely to have lower abdominal cramping and experience greater loss of blood. While there is no correlation between the number of cesarean deliveries a woman has had and the likelihood of developing a CSEP, factors that impede myometrial healing (eg, preterm cesarean, cesarean after arrest of first stage of labor, chorioamnionitis) do, however, increase a patient’s risk of developing CSEP.⁵

Similar to tubal ectopic pregnancy, CSEP oftentimes presents early with mild, nonspecific symptoms. Thirty-nine percent of cases present with light, painless vaginal bleeding while only 25% present with abdominal pain. Moreover, 37% of cases are asymptomatic at the time of diagnosis.⁵

One study by found the mean gestational age at diagnosis to be 7.5 weeks.⁵ Delayed diagnosis places the patient at risk for uterine rupture, hemorrhage, and maternal death, making suspicion and prompt diagnosis by bedside ED ultrasound essential.^7,8

Regardless of one’s clinical suspicion, the diagnosis is made (or ruled out) through ultrasound. Uterine scar ectopic pregnancy is suspected when ballooning of the lower uterine segment is noted,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).² As seen with this patient, the diagnosis is challenging as a uterine scar ectopic pregnancy can easily be mistaken for an intrauterine pregnancy. The clinician must make every effort to ensure that the pregnancy is surrounded by appropriate myometrium. It is much easier to diagnose an ectopic pregnancy far removed from the uterus, where the uterus and pregnancy are easily visualized and independent. 

Management of patients with CSEP remains outside of the scope of EM, and there is no consensus among our colleagues in OB-GYN on optimal management of these patients. Options include systemic or local injection of methotrexate and potassium chloride, or minimally invasive surgery for removal.⁵

As bedside ultrasound by EPs becomes standard of care for first-trimester pregnancies, a greater awareness of emergent obstetric pathologies becomes necessary. Vigilance and proper ultrasound technique will enable the EP to make the diagnosis of CSEP, minimizing maternal morbidity and mortality.

Drs Haight and Watkins are residents in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri. Dr Kane is a clinical instructor in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri.

Cesarean scar ectopic pregnancy (CSEP) is a challenging diagnosis that warrants consideration when performing ultrasound on a pregnant patient with a previous history of cesarean delivery. It is suspected when ballooning of the lower uterine segment is noted on ultrasound,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).²

Ectopic Pregnancy

Ectopic pregnancy affects approximately 2% of all pregnancies and is the leading cause of first-trimester maternal mortality.³ As front-line care providers, it is imperative that emergency physicians (EPs) recognize cases of ectopic implantation to avoid devastating outcomes. 

The majority of ectopic pregnancies (97%) are located in the fallopian tubes; however, many other locations are possible, including implantation in the scar from a previous cesarean delivery.^1,4 The frequency of such ectopic pregnancies is on the rise, consistent with the increasing number of cesarean deliveries performed worldwide.⁵ These cases present a special diagnostic challenge because patients often present asymptomatically or with painless vaginal bleeding; moreover, visualization via bedside ultrasound can be deceiving,⁵ and it is easy to mistake a CSEP for a viable intrauterine pregnancy.

Case

A 22-year-old woman with type 1 diabetes mellitus (DM) presented to the ED complaining of 3 days of worsening nausea and elevated blood glucose levels. She stated that although she had been taking her insulin regimen as prescribed, her symptoms progressively worsened. On the day of presentation, she developed moderate diffuse nonradiating dull abdominal pain and had several episodes of nonbloody, nonbilious emesis. She denied being pregnant and stated that her last menstrual period was 14 days ago; she further denied any vaginal discharge or bleeding. A review of her systems was otherwise benign.

In addition to type 1 DM, the patient also had a history of migraine headaches and an obstetric history of gravida 3, para 3, aborta 0. Each birth was via cesarean delivery and without complication. Her current medications included insulin glargine (Lantus) 25 units subcutaneously every night at bedtime; insulin aspart (Novolog) 7 units subcutaneously three times a day; zolpidem (Ambien) 10 mg orally every night at bedtime. A chart review was notable for several presentations of diabetic ketoacidosis (DKA) secondary to noncompliance with her diabetes regimen. 

Physical examination was notable for a well-developed, well-nourished 22 year old that appeared uncomfortable but in no acute distress. Her abdomen was soft and nondistended, with diffuse moderate tenderness to palpation but no rebound or guarding. The remainder of the physical 

The initial workup revealed DKA and pregnancy. Significant laboratory values included: finger-stick blood glucose, 441 mg/dL; serum ketones, 2.1 mmol/L (normal range, 0.0-0.5); anion gap, 15; and urinalysis 4+ glucose, 2+ ketones; and quantitative β-human chorionic gonadotropin (β-HCG), 5,282 IU/L (normal range, 0-5.0 IU/L ).examination was otherwise benign. 

After receiving insulin, intravenous (IV) fluids, pain medication, and antiemetics, the patient stated she felt much better. She was then admitted to the inpatient floor for management of DKA and discharged uneventfully several days later. Emergency bedside transabdominal and transvaginal ultrasounds were performed by the emergency staff and identified an intrauterine gestational sac and yolk sac. The EP ordered a consultation with an obstetrician-gynecologist (OB-GYN), who saw the patient in the ED and agreed with the findings, and noted the gestational sac was consistent with a date of 5 weeks, 1 day.

Six days after discharge, however, she returned to the ED complaining of several days of weakness, vomiting, and lower abdominal pain. Significant laboratory values included: urinalysis with 4+ ketones, 1+ bacteria, + nitrites; and quantitative β-HCG 25,925 IU/L (expected range, 0-5.0); serum glucose 206 mg/dL; serum ketones 0.8 (expected range, 0-0.5); and anion gap, 12.

An emergency ultrasound identified a gestational sac, yolk sac, fetal pole, and fetal heart tones; an OB-GYN ultrasound had consistent findings, with an estimated gestational age of 6 weeks, 6 days. The patient responded well to IV fluids and antiemetics, and was asymptomatic when she was admitted to the ED observation unit for continued monitoring, fluids, and antiemetics as needed. Several hours later she again began to complain of nausea, vomiting, and poorly localized abdominal discomfort. As these symptoms persisted, the OB-GYN team returned to reevaluate the patient. 

Discussion

Cesarean scar ectopic pregnancy was first described in the obstetric literature in 1978 and originally thought to be an exceedingly rare occurrence.^5,6 With both the increasing number of cesarean deliveries performed and improvement in imaging technology, it is now believed that uterine scar ectopic pregnancy makes up as much as 6.1% of ectopic pregnancies in patients with a prior cesarean delivery.⁷ This diagnosis is well-documented in the obstetric and radiology literature, yet has never been discussed in an emergency medicine publication. Searching through both Pubmed and EMBase using the terms “cesarean” and “ectopic” yields no EM literature on the topic of CSEP. This is concerning because ultrasound of the pregnant patient is now a routine function of EPs.

Clinical history can be helpful in differentiating CSEP from alternative diagnoses. Patients undergoing spontaneous abortion are more likely to have lower abdominal cramping and experience greater loss of blood. While there is no correlation between the number of cesarean deliveries a woman has had and the likelihood of developing a CSEP, factors that impede myometrial healing (eg, preterm cesarean, cesarean after arrest of first stage of labor, chorioamnionitis) do, however, increase a patient’s risk of developing CSEP.⁵

Similar to tubal ectopic pregnancy, CSEP oftentimes presents early with mild, nonspecific symptoms. Thirty-nine percent of cases present with light, painless vaginal bleeding while only 25% present with abdominal pain. Moreover, 37% of cases are asymptomatic at the time of diagnosis.⁵

One study by found the mean gestational age at diagnosis to be 7.5 weeks.⁵ Delayed diagnosis places the patient at risk for uterine rupture, hemorrhage, and maternal death, making suspicion and prompt diagnosis by bedside ED ultrasound essential.^7,8

Regardless of one’s clinical suspicion, the diagnosis is made (or ruled out) through ultrasound. Uterine scar ectopic pregnancy is suspected when ballooning of the lower uterine segment is noted,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).² As seen with this patient, the diagnosis is challenging as a uterine scar ectopic pregnancy can easily be mistaken for an intrauterine pregnancy. The clinician must make every effort to ensure that the pregnancy is surrounded by appropriate myometrium. It is much easier to diagnose an ectopic pregnancy far removed from the uterus, where the uterus and pregnancy are easily visualized and independent. 

Management of patients with CSEP remains outside of the scope of EM, and there is no consensus among our colleagues in OB-GYN on optimal management of these patients. Options include systemic or local injection of methotrexate and potassium chloride, or minimally invasive surgery for removal.⁵

As bedside ultrasound by EPs becomes standard of care for first-trimester pregnancies, a greater awareness of emergent obstetric pathologies becomes necessary. Vigilance and proper ultrasound technique will enable the EP to make the diagnosis of CSEP, minimizing maternal morbidity and mortality.

Drs Haight and Watkins are residents in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri. Dr Kane is a clinical instructor in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri.

Cesarean scar ectopic pregnancy (CSEP) is a challenging diagnosis that warrants consideration when performing ultrasound on a pregnant patient with a previous history of cesarean delivery. It is suspected when ballooning of the lower uterine segment is noted on ultrasound,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).²

Ectopic Pregnancy

Ectopic pregnancy affects approximately 2% of all pregnancies and is the leading cause of first-trimester maternal mortality.³ As front-line care providers, it is imperative that emergency physicians (EPs) recognize cases of ectopic implantation to avoid devastating outcomes. 

The majority of ectopic pregnancies (97%) are located in the fallopian tubes; however, many other locations are possible, including implantation in the scar from a previous cesarean delivery.^1,4 The frequency of such ectopic pregnancies is on the rise, consistent with the increasing number of cesarean deliveries performed worldwide.⁵ These cases present a special diagnostic challenge because patients often present asymptomatically or with painless vaginal bleeding; moreover, visualization via bedside ultrasound can be deceiving,⁵ and it is easy to mistake a CSEP for a viable intrauterine pregnancy.

Case

A 22-year-old woman with type 1 diabetes mellitus (DM) presented to the ED complaining of 3 days of worsening nausea and elevated blood glucose levels. She stated that although she had been taking her insulin regimen as prescribed, her symptoms progressively worsened. On the day of presentation, she developed moderate diffuse nonradiating dull abdominal pain and had several episodes of nonbloody, nonbilious emesis. She denied being pregnant and stated that her last menstrual period was 14 days ago; she further denied any vaginal discharge or bleeding. A review of her systems was otherwise benign.

In addition to type 1 DM, the patient also had a history of migraine headaches and an obstetric history of gravida 3, para 3, aborta 0. Each birth was via cesarean delivery and without complication. Her current medications included insulin glargine (Lantus) 25 units subcutaneously every night at bedtime; insulin aspart (Novolog) 7 units subcutaneously three times a day; zolpidem (Ambien) 10 mg orally every night at bedtime. A chart review was notable for several presentations of diabetic ketoacidosis (DKA) secondary to noncompliance with her diabetes regimen. 

Physical examination was notable for a well-developed, well-nourished 22 year old that appeared uncomfortable but in no acute distress. Her abdomen was soft and nondistended, with diffuse moderate tenderness to palpation but no rebound or guarding. The remainder of the physical 

The initial workup revealed DKA and pregnancy. Significant laboratory values included: finger-stick blood glucose, 441 mg/dL; serum ketones, 2.1 mmol/L (normal range, 0.0-0.5); anion gap, 15; and urinalysis 4+ glucose, 2+ ketones; and quantitative β-human chorionic gonadotropin (β-HCG), 5,282 IU/L (normal range, 0-5.0 IU/L ).examination was otherwise benign. 

After receiving insulin, intravenous (IV) fluids, pain medication, and antiemetics, the patient stated she felt much better. She was then admitted to the inpatient floor for management of DKA and discharged uneventfully several days later. Emergency bedside transabdominal and transvaginal ultrasounds were performed by the emergency staff and identified an intrauterine gestational sac and yolk sac. The EP ordered a consultation with an obstetrician-gynecologist (OB-GYN), who saw the patient in the ED and agreed with the findings, and noted the gestational sac was consistent with a date of 5 weeks, 1 day.

Six days after discharge, however, she returned to the ED complaining of several days of weakness, vomiting, and lower abdominal pain. Significant laboratory values included: urinalysis with 4+ ketones, 1+ bacteria, + nitrites; and quantitative β-HCG 25,925 IU/L (expected range, 0-5.0); serum glucose 206 mg/dL; serum ketones 0.8 (expected range, 0-0.5); and anion gap, 12.

An emergency ultrasound identified a gestational sac, yolk sac, fetal pole, and fetal heart tones; an OB-GYN ultrasound had consistent findings, with an estimated gestational age of 6 weeks, 6 days. The patient responded well to IV fluids and antiemetics, and was asymptomatic when she was admitted to the ED observation unit for continued monitoring, fluids, and antiemetics as needed. Several hours later she again began to complain of nausea, vomiting, and poorly localized abdominal discomfort. As these symptoms persisted, the OB-GYN team returned to reevaluate the patient. 

Discussion

Cesarean scar ectopic pregnancy was first described in the obstetric literature in 1978 and originally thought to be an exceedingly rare occurrence.^5,6 With both the increasing number of cesarean deliveries performed and improvement in imaging technology, it is now believed that uterine scar ectopic pregnancy makes up as much as 6.1% of ectopic pregnancies in patients with a prior cesarean delivery.⁷ This diagnosis is well-documented in the obstetric and radiology literature, yet has never been discussed in an emergency medicine publication. Searching through both Pubmed and EMBase using the terms “cesarean” and “ectopic” yields no EM literature on the topic of CSEP. This is concerning because ultrasound of the pregnant patient is now a routine function of EPs.

Clinical history can be helpful in differentiating CSEP from alternative diagnoses. Patients undergoing spontaneous abortion are more likely to have lower abdominal cramping and experience greater loss of blood. While there is no correlation between the number of cesarean deliveries a woman has had and the likelihood of developing a CSEP, factors that impede myometrial healing (eg, preterm cesarean, cesarean after arrest of first stage of labor, chorioamnionitis) do, however, increase a patient’s risk of developing CSEP.⁵

Similar to tubal ectopic pregnancy, CSEP oftentimes presents early with mild, nonspecific symptoms. Thirty-nine percent of cases present with light, painless vaginal bleeding while only 25% present with abdominal pain. Moreover, 37% of cases are asymptomatic at the time of diagnosis.⁵

One study by found the mean gestational age at diagnosis to be 7.5 weeks.⁵ Delayed diagnosis places the patient at risk for uterine rupture, hemorrhage, and maternal death, making suspicion and prompt diagnosis by bedside ED ultrasound essential.^7,8

Regardless of one’s clinical suspicion, the diagnosis is made (or ruled out) through ultrasound. Uterine scar ectopic pregnancy is suspected when ballooning of the lower uterine segment is noted,¹ when a trophoblast is seen at a presumed cesarean scar beneath the utero-vesicular fold, and when myometrium between the gestational sac and bladder wall is thin (<8 mm).² As seen with this patient, the diagnosis is challenging as a uterine scar ectopic pregnancy can easily be mistaken for an intrauterine pregnancy. The clinician must make every effort to ensure that the pregnancy is surrounded by appropriate myometrium. It is much easier to diagnose an ectopic pregnancy far removed from the uterus, where the uterus and pregnancy are easily visualized and independent. 

Management of patients with CSEP remains outside of the scope of EM, and there is no consensus among our colleagues in OB-GYN on optimal management of these patients. Options include systemic or local injection of methotrexate and potassium chloride, or minimally invasive surgery for removal.⁵

As bedside ultrasound by EPs becomes standard of care for first-trimester pregnancies, a greater awareness of emergent obstetric pathologies becomes necessary. Vigilance and proper ultrasound technique will enable the EP to make the diagnosis of CSEP, minimizing maternal morbidity and mortality.

Drs Haight and Watkins are residents in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri. Dr Kane is a clinical instructor in the division of emergency medicine, Washington University School of Medicine, Saint Louis, Missouri.

Case

A 35-year-old woman underwent an elective hysteroscopic myomectomy to remove a symptomatic 2.7-cm uterine leiomyoma. The procedure was uncomplicated, and the patient awoke in the postanesthesia care unit (PACU) in good condition. Two hours later, however, she developed severe shortness of breath and required bilevel positive airway pressure ventilation. Her vital signs in the PACU were: blood pressure (BP), 110/70 mm Hg; heart rate, 90 beats/minute; respiratory rate, 12 breaths/minute; temperature, 98.4°F. Oxygen saturation was 94% on room air. She was diaphoretic and tachycardic on physical examination, but her pulmonary, abdominal, and gynecologic examinations were normal. During the examination, she complained of nausea, vomited, and then became increasingly lethargic and confused. 

How can this patient’s clinical presentation be explained?

Uterine fibroids are the most common pelvic tumor in women.¹ Hysteroscopic myomectomy is a minimally invasive surgical procedure commonly performed to resect submucosal fibroids. The procedure takes about 60 minutes, and is often performed on an outpatient basis under general anesthesia. During the procedure, an electrosurgery device called a resectoscope is inserted through the cervix. The uterine cavity is then distended with a large volume of irrigating solution. Maneuvering the resectoscope, the surgeon then shaves the protruding fibroid layer-by-layer until it aligns with the surrounding myometrium.

Surgical complications of hysteroscopic myomectomy may produce life-threatening effects. Excessive resection of the myometrium may increase blood loss, which can cause chest pain, shortness of breath, diaphoresis, lethargy, and confusion. Uterine perforation may produce hypotension, abdominal pain and distention, infection, and vaginal bleeding.

Venous Thromboembolism

Venous thromboembolism (VTE) is a common postoperative complication, with pulmonary embolism accounting for the most common preventable cause of hospital death in the United States.² Gynecologic surgery, especially brief procedures, are associated with among the lowest rates of VTE, however, making this an unlikely explanation in this case.³ Additionally, VTE is not expected to produce the neurological findings observed in this patient.

Negative Pressure Pulmonary Edema

An uncommon but life-threatening complication for patients undergoing general anesthesia is negative pressure pulmonary edema, or “postextubation pulmonary edema,” which is estimated to occur in up to 1 in 1,000 procedures involving mechanical ventilation. During extubation, forced inspiration against a closed glottis causes intravascular fluid to be drawn into the interstitial space leading to pulmonary edema.⁴

Hyponatremia

An unusual but well described complication of endoscopic surgery is hyponatremia from systemic absorption of the irrigating fluid. Fluid overload may result in pulmonary edema, and dilutional hyponatremia may cause altered mental status or seizures.

Case Continuation

A chest X-ray performed after the patient became symptomatic revealed mild bilateral pulmonary edema. Her postoperative laboratory values were: sodium, 112 mEq/L; potassium, 3.3 mEq/L; chloride, 81 mEq/L; bicarbonate, 25 mEq/L; blood urea nitrogen, 18 mg/dL; creatinine, 0.6 mg/dL. Her ammonia level was 24 mmol/L (normal range, 11-35 mmol/L). An endotracheal tube was placed after her level of consciousness declined further. Her neurological examination revealed bilateral fixed and dilated pupils. An emergent computed tomography (CT) scan of the brain revealed severe generalized swelling of the brain.

What is the cause of this patient’s hyponatremia?

Monopolar electrosurgical devices such as the resectoscope cannot be used with electrolyte-containing irrigation fluids (eg, isotonic saline or lactated Ringer’s solution).  Nonconductive, nonelectrolyte solutions such as glycine 1.5%, sorbitol 3%, or mannitol 5%, are the most common irrigating fluids employed to dilate the operating field and to wash away debris and blood.⁵

A dilutional hyponatremia can occur when the irrigating fluid is absorbed systemically. As it was first described following transurethral resection of the prostate procedures in the 1950s, the syndrome is referred to as “TURP” syndrome. Since then, several hundred life-threatening and even fatal cases of TURP syndrome have been reported.⁶ The syndrome occurs with other operations including transcervical resection of the endometrium (TCRE).⁵ The irrigating fluid is most frequently absorbed directly into the vascular system when a vein has been severed during the electrosurgery, particularly when the infusion pressure exceeds the venous pressure.⁶ Additionally, extravasation of the irrigating fluid into the intraperitoneal space can occur after instrument perforation of the uterine wall in TCRE, or via the fallopian tubes.⁶

What are the signs and symptoms of TURP syndrome?

Mild-to-moderate TURP syndrome occurs in 1% to 8% of TURP procedures performed.  Fluid absorption is slightly more common during TCRE, and occurs more often during the resection of fibroids.⁶ The dilutional hyponatremia can result in brain edema, as well as pharmacological effects specific to the irrigant solutes. 

Symptoms of TURP syndrome are primarily neurological, with nausea being the earliest sign of a mild syndrome. A “mini” mental-status test may show transient confusion with smaller absorption volumes.⁷ As the fluid absorption increases, the hyponatremia worsens, resulting in cerebral edema. This manifests as encephalopathy, which includes disorientation, twitching, and seizures. Hypotension is uncommon, since the fluid is being absorbed intravascularly.⁶ Shortness of breath, uneasiness, chest pain, and pulmonary edema may develop from systemic fluid overload. The intra-abdominal extravasation of fluid can result in abdominal pain. Other symptoms are specific to the irrigant.

Glycine

Glycine 1.5% is the most common irrigant solution used; as such, it produces the highest incidence of TURP syndrome.⁸ This solution is hypoosmotic (osmolality of 200 mosm/kg) compared with the normal serum (osmolality of 280 to 296 mosm/kg).⁵ In addition, glycine may cause visual disturbances.⁸ The metabolism of glycine produces ammonia, serine, and oxalate (Figure), and 10% of patients who absorb glycine show a marked hyperammonemia, further exacerbating the neurological effects^.9,10

Sorbitol and mannitol

Sorbitol and mannitol irrigation fluids are used less frequently than glycine. Sorbitol 3% is metabolized to fructose and glucose, and has an osmolality of 165 mosm/kg.⁶ When absorbed systemically, sorbitol’s effects are similar to those of glycine, except that it does not induce visual symptoms. Mannitol 5% solution has the advantage of being isosmotic (275 mosm/kg). It is not metabolized and is excreted entirely in the urine. The excretion of mannitol creates an osmotic diuresis, thereby preventing hyponatremia from occurring.⁹Sorbitol and Mannitol

What are the treatment options for TURP Syndrome? Can it be prevented?

Patients with TURP syndrome in its mildest form can be asymptomatic, but severe cases can be life threatening or fatal. Unlike the treatment for hyponatremia caused by psychogenic polydipsia or the syndrome of inappropriate antidiuretic hormone, which calls for fluid restriction, plasma volume expansion is indicated in TURP syndrome, as hypovolemia and low-cardiac output develop as soon as irrigation is discontinued.

Hypertonic saline is indicated for neurological symptoms, or if the serum sodium concentration is <120mEq/L.⁶ Although furosemide has been used to treat acute pulmonary edema, no studies support its routine use in the treatment of fluid absorption,⁶ and its use may aggravate hyponatremia and hypovolemia. 

Bipolar electrosurgical systems, unlike monopolar systems, permit the use of electrolyte solutions such as isotonic saline, thereby significantly reducing the risk of hyponatremia. For hysteroscopic procedures, the American College of Obstetricians and Gynecologists recommends the use of an automated fluid pump and monitoring system, thus minimizing the fluid pressure and halting or terminating the procedure before absorption thresholds are exceeded.¹¹

Case Conclusion

The patient was immediately given a 1 mL/kg bolus of hypertonic saline. Two hours later, her serum sodium improved to 114 mEq/L and serum sodium concentration normalized over the next 24 hours. Her cardiovascular and neurological examinations worsened, however, and she required vasopressors. Her pupils remained fixed and dilated, and she lost her corneal and gag reflexes. A repeat CT of the brain showed persistent cerebral edema with signs of herniation, and she did not recover.

Dr Nguyen is a medical toxicology fellow in the department of emergency medicine at New York University Langone Medical Center. Dr Nelson, editor of “Case Studies in Toxicology,” is a professor in the department of emergency medicine and director of the medical toxicology fellowship program at the New York University School of Medicine and the New York City Poison Control Center. He is also associate editor, toxicology, of the EMERGENCY MEDICINE editorial board.

Case

A 35-year-old woman underwent an elective hysteroscopic myomectomy to remove a symptomatic 2.7-cm uterine leiomyoma. The procedure was uncomplicated, and the patient awoke in the postanesthesia care unit (PACU) in good condition. Two hours later, however, she developed severe shortness of breath and required bilevel positive airway pressure ventilation. Her vital signs in the PACU were: blood pressure (BP), 110/70 mm Hg; heart rate, 90 beats/minute; respiratory rate, 12 breaths/minute; temperature, 98.4°F. Oxygen saturation was 94% on room air. She was diaphoretic and tachycardic on physical examination, but her pulmonary, abdominal, and gynecologic examinations were normal. During the examination, she complained of nausea, vomited, and then became increasingly lethargic and confused. 

How can this patient’s clinical presentation be explained?

Uterine fibroids are the most common pelvic tumor in women.¹ Hysteroscopic myomectomy is a minimally invasive surgical procedure commonly performed to resect submucosal fibroids. The procedure takes about 60 minutes, and is often performed on an outpatient basis under general anesthesia. During the procedure, an electrosurgery device called a resectoscope is inserted through the cervix. The uterine cavity is then distended with a large volume of irrigating solution. Maneuvering the resectoscope, the surgeon then shaves the protruding fibroid layer-by-layer until it aligns with the surrounding myometrium.

Surgical complications of hysteroscopic myomectomy may produce life-threatening effects. Excessive resection of the myometrium may increase blood loss, which can cause chest pain, shortness of breath, diaphoresis, lethargy, and confusion. Uterine perforation may produce hypotension, abdominal pain and distention, infection, and vaginal bleeding.

Venous Thromboembolism

Venous thromboembolism (VTE) is a common postoperative complication, with pulmonary embolism accounting for the most common preventable cause of hospital death in the United States.² Gynecologic surgery, especially brief procedures, are associated with among the lowest rates of VTE, however, making this an unlikely explanation in this case.³ Additionally, VTE is not expected to produce the neurological findings observed in this patient.

Negative Pressure Pulmonary Edema

An uncommon but life-threatening complication for patients undergoing general anesthesia is negative pressure pulmonary edema, or “postextubation pulmonary edema,” which is estimated to occur in up to 1 in 1,000 procedures involving mechanical ventilation. During extubation, forced inspiration against a closed glottis causes intravascular fluid to be drawn into the interstitial space leading to pulmonary edema.⁴

Hyponatremia

An unusual but well described complication of endoscopic surgery is hyponatremia from systemic absorption of the irrigating fluid. Fluid overload may result in pulmonary edema, and dilutional hyponatremia may cause altered mental status or seizures.

Case Continuation

A chest X-ray performed after the patient became symptomatic revealed mild bilateral pulmonary edema. Her postoperative laboratory values were: sodium, 112 mEq/L; potassium, 3.3 mEq/L; chloride, 81 mEq/L; bicarbonate, 25 mEq/L; blood urea nitrogen, 18 mg/dL; creatinine, 0.6 mg/dL. Her ammonia level was 24 mmol/L (normal range, 11-35 mmol/L). An endotracheal tube was placed after her level of consciousness declined further. Her neurological examination revealed bilateral fixed and dilated pupils. An emergent computed tomography (CT) scan of the brain revealed severe generalized swelling of the brain.

What is the cause of this patient’s hyponatremia?

Monopolar electrosurgical devices such as the resectoscope cannot be used with electrolyte-containing irrigation fluids (eg, isotonic saline or lactated Ringer’s solution).  Nonconductive, nonelectrolyte solutions such as glycine 1.5%, sorbitol 3%, or mannitol 5%, are the most common irrigating fluids employed to dilate the operating field and to wash away debris and blood.⁵

A dilutional hyponatremia can occur when the irrigating fluid is absorbed systemically. As it was first described following transurethral resection of the prostate procedures in the 1950s, the syndrome is referred to as “TURP” syndrome. Since then, several hundred life-threatening and even fatal cases of TURP syndrome have been reported.⁶ The syndrome occurs with other operations including transcervical resection of the endometrium (TCRE).⁵ The irrigating fluid is most frequently absorbed directly into the vascular system when a vein has been severed during the electrosurgery, particularly when the infusion pressure exceeds the venous pressure.⁶ Additionally, extravasation of the irrigating fluid into the intraperitoneal space can occur after instrument perforation of the uterine wall in TCRE, or via the fallopian tubes.⁶

What are the signs and symptoms of TURP syndrome?

Mild-to-moderate TURP syndrome occurs in 1% to 8% of TURP procedures performed.  Fluid absorption is slightly more common during TCRE, and occurs more often during the resection of fibroids.⁶ The dilutional hyponatremia can result in brain edema, as well as pharmacological effects specific to the irrigant solutes. 

Symptoms of TURP syndrome are primarily neurological, with nausea being the earliest sign of a mild syndrome. A “mini” mental-status test may show transient confusion with smaller absorption volumes.⁷ As the fluid absorption increases, the hyponatremia worsens, resulting in cerebral edema. This manifests as encephalopathy, which includes disorientation, twitching, and seizures. Hypotension is uncommon, since the fluid is being absorbed intravascularly.⁶ Shortness of breath, uneasiness, chest pain, and pulmonary edema may develop from systemic fluid overload. The intra-abdominal extravasation of fluid can result in abdominal pain. Other symptoms are specific to the irrigant.

Glycine

Glycine 1.5% is the most common irrigant solution used; as such, it produces the highest incidence of TURP syndrome.⁸ This solution is hypoosmotic (osmolality of 200 mosm/kg) compared with the normal serum (osmolality of 280 to 296 mosm/kg).⁵ In addition, glycine may cause visual disturbances.⁸ The metabolism of glycine produces ammonia, serine, and oxalate (Figure), and 10% of patients who absorb glycine show a marked hyperammonemia, further exacerbating the neurological effects^.9,10

Sorbitol and mannitol

Sorbitol and mannitol irrigation fluids are used less frequently than glycine. Sorbitol 3% is metabolized to fructose and glucose, and has an osmolality of 165 mosm/kg.⁶ When absorbed systemically, sorbitol’s effects are similar to those of glycine, except that it does not induce visual symptoms. Mannitol 5% solution has the advantage of being isosmotic (275 mosm/kg). It is not metabolized and is excreted entirely in the urine. The excretion of mannitol creates an osmotic diuresis, thereby preventing hyponatremia from occurring.⁹Sorbitol and Mannitol

What are the treatment options for TURP Syndrome? Can it be prevented?

Patients with TURP syndrome in its mildest form can be asymptomatic, but severe cases can be life threatening or fatal. Unlike the treatment for hyponatremia caused by psychogenic polydipsia or the syndrome of inappropriate antidiuretic hormone, which calls for fluid restriction, plasma volume expansion is indicated in TURP syndrome, as hypovolemia and low-cardiac output develop as soon as irrigation is discontinued.

Hypertonic saline is indicated for neurological symptoms, or if the serum sodium concentration is <120mEq/L.⁶ Although furosemide has been used to treat acute pulmonary edema, no studies support its routine use in the treatment of fluid absorption,⁶ and its use may aggravate hyponatremia and hypovolemia. 

Bipolar electrosurgical systems, unlike monopolar systems, permit the use of electrolyte solutions such as isotonic saline, thereby significantly reducing the risk of hyponatremia. For hysteroscopic procedures, the American College of Obstetricians and Gynecologists recommends the use of an automated fluid pump and monitoring system, thus minimizing the fluid pressure and halting or terminating the procedure before absorption thresholds are exceeded.¹¹

Case Conclusion

The patient was immediately given a 1 mL/kg bolus of hypertonic saline. Two hours later, her serum sodium improved to 114 mEq/L and serum sodium concentration normalized over the next 24 hours. Her cardiovascular and neurological examinations worsened, however, and she required vasopressors. Her pupils remained fixed and dilated, and she lost her corneal and gag reflexes. A repeat CT of the brain showed persistent cerebral edema with signs of herniation, and she did not recover.

Dr Nguyen is a medical toxicology fellow in the department of emergency medicine at New York University Langone Medical Center. Dr Nelson, editor of “Case Studies in Toxicology,” is a professor in the department of emergency medicine and director of the medical toxicology fellowship program at the New York University School of Medicine and the New York City Poison Control Center. He is also associate editor, toxicology, of the EMERGENCY MEDICINE editorial board.

Case

A 35-year-old woman underwent an elective hysteroscopic myomectomy to remove a symptomatic 2.7-cm uterine leiomyoma. The procedure was uncomplicated, and the patient awoke in the postanesthesia care unit (PACU) in good condition. Two hours later, however, she developed severe shortness of breath and required bilevel positive airway pressure ventilation. Her vital signs in the PACU were: blood pressure (BP), 110/70 mm Hg; heart rate, 90 beats/minute; respiratory rate, 12 breaths/minute; temperature, 98.4°F. Oxygen saturation was 94% on room air. She was diaphoretic and tachycardic on physical examination, but her pulmonary, abdominal, and gynecologic examinations were normal. During the examination, she complained of nausea, vomited, and then became increasingly lethargic and confused. 

How can this patient’s clinical presentation be explained?

Uterine fibroids are the most common pelvic tumor in women.¹ Hysteroscopic myomectomy is a minimally invasive surgical procedure commonly performed to resect submucosal fibroids. The procedure takes about 60 minutes, and is often performed on an outpatient basis under general anesthesia. During the procedure, an electrosurgery device called a resectoscope is inserted through the cervix. The uterine cavity is then distended with a large volume of irrigating solution. Maneuvering the resectoscope, the surgeon then shaves the protruding fibroid layer-by-layer until it aligns with the surrounding myometrium.

Surgical complications of hysteroscopic myomectomy may produce life-threatening effects. Excessive resection of the myometrium may increase blood loss, which can cause chest pain, shortness of breath, diaphoresis, lethargy, and confusion. Uterine perforation may produce hypotension, abdominal pain and distention, infection, and vaginal bleeding.

Venous Thromboembolism

Venous thromboembolism (VTE) is a common postoperative complication, with pulmonary embolism accounting for the most common preventable cause of hospital death in the United States.² Gynecologic surgery, especially brief procedures, are associated with among the lowest rates of VTE, however, making this an unlikely explanation in this case.³ Additionally, VTE is not expected to produce the neurological findings observed in this patient.

Negative Pressure Pulmonary Edema

An uncommon but life-threatening complication for patients undergoing general anesthesia is negative pressure pulmonary edema, or “postextubation pulmonary edema,” which is estimated to occur in up to 1 in 1,000 procedures involving mechanical ventilation. During extubation, forced inspiration against a closed glottis causes intravascular fluid to be drawn into the interstitial space leading to pulmonary edema.⁴

Hyponatremia

An unusual but well described complication of endoscopic surgery is hyponatremia from systemic absorption of the irrigating fluid. Fluid overload may result in pulmonary edema, and dilutional hyponatremia may cause altered mental status or seizures.

Case Continuation

A chest X-ray performed after the patient became symptomatic revealed mild bilateral pulmonary edema. Her postoperative laboratory values were: sodium, 112 mEq/L; potassium, 3.3 mEq/L; chloride, 81 mEq/L; bicarbonate, 25 mEq/L; blood urea nitrogen, 18 mg/dL; creatinine, 0.6 mg/dL. Her ammonia level was 24 mmol/L (normal range, 11-35 mmol/L). An endotracheal tube was placed after her level of consciousness declined further. Her neurological examination revealed bilateral fixed and dilated pupils. An emergent computed tomography (CT) scan of the brain revealed severe generalized swelling of the brain.

What is the cause of this patient’s hyponatremia?

Monopolar electrosurgical devices such as the resectoscope cannot be used with electrolyte-containing irrigation fluids (eg, isotonic saline or lactated Ringer’s solution).  Nonconductive, nonelectrolyte solutions such as glycine 1.5%, sorbitol 3%, or mannitol 5%, are the most common irrigating fluids employed to dilate the operating field and to wash away debris and blood.⁵

A dilutional hyponatremia can occur when the irrigating fluid is absorbed systemically. As it was first described following transurethral resection of the prostate procedures in the 1950s, the syndrome is referred to as “TURP” syndrome. Since then, several hundred life-threatening and even fatal cases of TURP syndrome have been reported.⁶ The syndrome occurs with other operations including transcervical resection of the endometrium (TCRE).⁵ The irrigating fluid is most frequently absorbed directly into the vascular system when a vein has been severed during the electrosurgery, particularly when the infusion pressure exceeds the venous pressure.⁶ Additionally, extravasation of the irrigating fluid into the intraperitoneal space can occur after instrument perforation of the uterine wall in TCRE, or via the fallopian tubes.⁶

What are the signs and symptoms of TURP syndrome?

Mild-to-moderate TURP syndrome occurs in 1% to 8% of TURP procedures performed.  Fluid absorption is slightly more common during TCRE, and occurs more often during the resection of fibroids.⁶ The dilutional hyponatremia can result in brain edema, as well as pharmacological effects specific to the irrigant solutes. 

Symptoms of TURP syndrome are primarily neurological, with nausea being the earliest sign of a mild syndrome. A “mini” mental-status test may show transient confusion with smaller absorption volumes.⁷ As the fluid absorption increases, the hyponatremia worsens, resulting in cerebral edema. This manifests as encephalopathy, which includes disorientation, twitching, and seizures. Hypotension is uncommon, since the fluid is being absorbed intravascularly.⁶ Shortness of breath, uneasiness, chest pain, and pulmonary edema may develop from systemic fluid overload. The intra-abdominal extravasation of fluid can result in abdominal pain. Other symptoms are specific to the irrigant.

Glycine

Glycine 1.5% is the most common irrigant solution used; as such, it produces the highest incidence of TURP syndrome.⁸ This solution is hypoosmotic (osmolality of 200 mosm/kg) compared with the normal serum (osmolality of 280 to 296 mosm/kg).⁵ In addition, glycine may cause visual disturbances.⁸ The metabolism of glycine produces ammonia, serine, and oxalate (Figure), and 10% of patients who absorb glycine show a marked hyperammonemia, further exacerbating the neurological effects^.9,10

Sorbitol and mannitol

Sorbitol and mannitol irrigation fluids are used less frequently than glycine. Sorbitol 3% is metabolized to fructose and glucose, and has an osmolality of 165 mosm/kg.⁶ When absorbed systemically, sorbitol’s effects are similar to those of glycine, except that it does not induce visual symptoms. Mannitol 5% solution has the advantage of being isosmotic (275 mosm/kg). It is not metabolized and is excreted entirely in the urine. The excretion of mannitol creates an osmotic diuresis, thereby preventing hyponatremia from occurring.⁹Sorbitol and Mannitol

What are the treatment options for TURP Syndrome? Can it be prevented?

Patients with TURP syndrome in its mildest form can be asymptomatic, but severe cases can be life threatening or fatal. Unlike the treatment for hyponatremia caused by psychogenic polydipsia or the syndrome of inappropriate antidiuretic hormone, which calls for fluid restriction, plasma volume expansion is indicated in TURP syndrome, as hypovolemia and low-cardiac output develop as soon as irrigation is discontinued.

Hypertonic saline is indicated for neurological symptoms, or if the serum sodium concentration is <120mEq/L.⁶ Although furosemide has been used to treat acute pulmonary edema, no studies support its routine use in the treatment of fluid absorption,⁶ and its use may aggravate hyponatremia and hypovolemia. 

Bipolar electrosurgical systems, unlike monopolar systems, permit the use of electrolyte solutions such as isotonic saline, thereby significantly reducing the risk of hyponatremia. For hysteroscopic procedures, the American College of Obstetricians and Gynecologists recommends the use of an automated fluid pump and monitoring system, thus minimizing the fluid pressure and halting or terminating the procedure before absorption thresholds are exceeded.¹¹

Case Conclusion

The patient was immediately given a 1 mL/kg bolus of hypertonic saline. Two hours later, her serum sodium improved to 114 mEq/L and serum sodium concentration normalized over the next 24 hours. Her cardiovascular and neurological examinations worsened, however, and she required vasopressors. Her pupils remained fixed and dilated, and she lost her corneal and gag reflexes. A repeat CT of the brain showed persistent cerebral edema with signs of herniation, and she did not recover.

Dr Nguyen is a medical toxicology fellow in the department of emergency medicine at New York University Langone Medical Center. Dr Nelson, editor of “Case Studies in Toxicology,” is a professor in the department of emergency medicine and director of the medical toxicology fellowship program at the New York University School of Medicine and the New York City Poison Control Center. He is also associate editor, toxicology, of the EMERGENCY MEDICINE editorial board.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

Share your thoughts on this article! Send your Letter to the Editor to [email protected]. Please include your name and the city and state in which you practice.

CASE: McRobert’s maneuver fails
You are attempting an early term vaginal delivery of a 31-year-old G2P1 woman with type 2 diabetes mellitus and an estimated fetal weight of 4,100 g. The fetal head has delivered but retracted against the perineum, producing the “turtle sign.”

You call a shoulder dystocia emergency and request help. In sequence, you tell the mother to stop pushing, check for a nuchal cord, and cut a mediolateral episiotomy. Working seamlessly with your nurse, you place the patient at the edge of the bed, perform the McRobert’s maneuver, provide suprapubic pressure and apply gentle downward guidance to the fetal head. Unfortunately, with these maneuvers the baby does not deliver.

What is your next obstetric maneuver?

With alacrity, move on to an advanced maneuver. In this article, I outline your options for this advanced maneuver and describe the technique for execution. First, however, I discuss the amount of time you have to work with.

How long do you have to perform advanced maneuvers?
In managing a difficult shoulder dystocia, critical goals are to avoid permanent injury to the newborn, including brachial plexus injury, fetal asphyxia, central nervous system injury, and death. Many experts believe that the accoucheur has approximately 4 or 5 minutes to deliver the impacted fetus before the risk of these adverse outcomes rises substantially.^1-3 In one study, a head-to-body delivery interval of less than 5 minutes and 5 minutes or longer were associated with rates of hypoxic ischemic encephalopathy of 0.5% and 24%, respectively.²

Stay calm, move on. Given the time pressure for management, it is important to initiate an advanced maneuver, such as rotation of the fetal body or delivery of the posterior arm, when the initial sequence of McRobert’s maneuver, suprapubic pressure, and gentle downward guidance on the fetal head do not result in delivery. Repetitively repeating these initial maneuvers will increase the risk of an adverse fetal outcome. Stay calm and quickly move on to an advanced maneuver.

Advanced maneuvers
The two advanced shoulder dystocia maneuvers that often result in a successful birth are:

• rotation of the fetal shoulders
• delivery of the posterior arm.^4,5

In a prior editorial, I described in detail the Woods and Rubin rotational maneuvers.⁶ In this editorial, I focus on the technique for delivery of the posterior arm.

Delivery of the posterior arm
This maneuver to resolve difficult shoulder dystocia deliveries has been in the armamentarium of obstetricians since at least the mid-18th Century.⁷ The delivery of the posterior arm reduces the presenting fetal diameter from the larger bisacromial diameter to the smaller axilloacromial diameter. Experts estimate that this change results in a 2-cm decrease in the presenting fetal diameter, thereby facilitating delivery.^8,9

In describing posterior arm delivery, it is important to clearly define the anatomy of the upper extremity. The arm is the portion of the upper extremity from the shoulder to the elbow joint.  The long bone of the arm is the humerus. The forearm is the portion of the upper extremity from the elbow to the wrist. The long bones of the forearm are the radius and ulna.

Descriptions of how to deliver the posterior arm range from concise to detailed. A concise description recommends “inserting a hand in the vagina, grasping the fetal arm, and sweeping it across the chest.”⁹

These detailed instructions are provided by Dr. John Rodis, Chief of Obstetrics and Gynecology at St. Francis Hospital in Hartford Connecticut, in UpToDate:

Additional technical guidance. After grasping the fetal wrist and hand, pull the upper extremity against the fetal chest. Approaching the vaginal introitus, pull the wrist and hand toward the fetal ear nearest the maternal symphysis pubis.¹¹ These maneuvers may result in a fracture to the humerus, but this complication is acceptable given the risk of fetal asphyxia and death.

Approaches to grasping the posterior arm
The posterior arm may be in one of three positions, and your approach to each position will be different.

Fetal hand near the chin. Delivery of the posterior arm is relatively easy when the fetal hand is in this position. Grasp the wrist gently and guide it out of the vagina. The fetal wrist should be pulled toward the fetal ear closest to the maternal symphysis.

Fetal hand on the abdomen. In this position, the operator can exert pressure on the antecubital fossa with the index and middle fingers, resulting in flexion of the forearm at the elbow. This will bring the fetal hand and wrist to the upper chest. The wrist then can be grasped and pronated over the fetal chest. The wrist and forearm are then pulled upward along the chest toward the fetal ear closest to the maternal symphysis. 

Fetal upper extremity is extended with the hand next to the thigh. The most challenging situation is when the upper extremity of the fetus is extended along the trunk or behind the buttocks. In this situation the hand and wrist may be near the fetal thigh and very difficult to reach. In addition, the upper extremity may be tightly pinned between fetal trunk and maternal tissues, making it impossible to flex the forearm by gentle pressure on the antecubital fossa.

In this situation the operator’s hand must reach the fetal wrist and distal forearm, grasp these structures, and pull hard across the trunk to free the pinned upper extremity. The fetal wrist and distal forearm can be securely grasped using techniques pictured in the Figure. It can take 30 to 90 seconds for the operator to place a hand in the vagina, identify the posterior shoulder, follow the extended arm to the hand, and secure the wrist. Given the amount of time that it may take to accomplish the first steps of the maneuver, the nurse in the room should call out the time elapsed since the birth of the head at regular intervals to assist the obstetrician in pacing the speed of the intervention.

___________________________________________________________________________________________________

		Figure. When the fetal upper extremity is extended and the hand is near the fetal thigh the fetal upper extremity may be tightly pinned between maternal and fetal tissues. Gentle pressure in the antecubital fossa may not cause the forearm to flex toward the vaginal introitus. In this situation it may be very difficult to grasp the fetal wrist or forearm. The operator should be prepared to place their entire hand and forearm into the vagina to reach the fetal wrist (Top left). Two options for grasping the fetal wrist are with the index finger and middle finger (Top right), or by encircling the wrist with the thumb and index finger (Bottom left). For many obstetricians, the index and middle fingers extend much further from their wrist than the thumb. Consequently, when the fetal wrist and hand are against the fetal thigh it may be easier to reach the fetal wrist with the operator’s index and middle finger. However, many obstetricians find that the thumb and index finger provide a more secure grip of the fetal wrist.

______________________________________________________________________________________________________

When the posterior arm is fully extended and pinned between fetal trunk and maternal tissues it can be very difficult to reach the fetal wrist. To help successfully complete the maneuver, the obstetrician should visualize placing his or her hand and entire forearm up to the elbow in the vagina to reach the fetal wrist. It may not be necessary to insert the entire forearm in the vagina, but the operator should visualize this step so he or she is prepared for the possibility.Surprisingly, the hollow of the sacrum often provides sufficient space for inserting the hand and entire forearm of the operator. In this process the operator’s hand and forearm may be strongly compressed by maternal and fetal tissues, cutting off circulation to the upper extremity. The operator’s upper extremity may quickly become numb, resulting in a reduction in tactile sensation and strength.

If the posterior arm is positioned behind the back of the fetus, maneuvers similar to those described above can be used to grasp the wrist and pull the arm to the anterior side of the fetal trunk, followed by delivery of the posterior arm.

Practice, practice, and practice some more
Obstetric emergencies create a rush of adrenaline and great stress for the obstetrician. This may adversely impact motor performance, decision-making, and communication skills.¹² Low- and high-fidelity simulation exercises permit the obstetrics team to practice the sequence of maneuvers necessary to successfully resolve a shoulder dystocia, thereby reducing stress and improving performance when the emergency actually occurs.¹³ Simulating obstetric emergencies and visualizing the steps necessary to resolve an emergency are good approaches to prepare obstetricians for the most challenging emergencies. For the difficult to resolve shoulder dystocia, my recommendation is: “Deliver the posterior arm.”

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Pregnant women who used an interactive computer program to help them decide whether to undergo prenatal testing were 55% less likely to choose invasive testing than women who received standard prenatal care, even when they were offered free testing, researchers reported online Sept. 23 in JAMA.

Women who used the computer program also were more likely to correctly estimate the risks of amniocentesis-related miscarriage and fetal trisomy 21, said Miriam Kuppermann, Ph.D., of the University of California, San Francisco, and her associates. “

If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing,” the investigators said.

©Kativ/iStockphoto

The multicenter study included 710 English- or Spanish-speaking women who were at 20 weeks’ gestation or less.

A bilingual actress narrated the computer program, emulating a “warm and knowledgeable friend” and emphasizing “the personal nature of prenatal testing decisions,” said the researchers.

The control group received prenatal care based on current guidelines, and did not receive financial support for prenatal tests beyond their own insurance plans, the investigators added (JAMA 2014 Sept. 23 [doi:10.1001/jama.2014.11479]).

Medical record reviews showed that the intervention group was significantly less likely to pursue amniocentesis or chorionic villi sampling than was the control group (5.9% vs. 12.3%; odds ratio, 0.45; 95% confidence interval, 0.25 to 0.80). In addition, computer program users were more than three times as likely to forego testing altogether and more than twice as likely to elect screening alone than to choose screening followed by invasive testing.

Although the computer program did not address cell-free DNA testing, the findings should extend to these tests because they cover the same conditions, the researchers said.

The intervention group also was more likely to correctly estimate the risk of amniocentesis-related miscarriage (73.8% vs. 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and the age-adjusted chance of fetal trisomy 21 (58.7% vs. 46.1%; OR, 1.66 [95% CI, 1.22-2.28]) than the control group, Dr. Kuppermann and her associates reported.

The National Institutes of Health and the March of Dimes Foundation funded the study. Dr. Kuppermann reported receiving research support from Ariosa Diagnostics, Verinata Health, and Natera. Two coauthors reported receiving funding or stock options from Verinata Health, Natera, Ariosa Diagnostics, and Cellscape. The authors disclosed no other financial conflicts.

Pregnant women who used an interactive computer program to help them decide whether to undergo prenatal testing were 55% less likely to choose invasive testing than women who received standard prenatal care, even when they were offered free testing, researchers reported online Sept. 23 in JAMA.

Women who used the computer program also were more likely to correctly estimate the risks of amniocentesis-related miscarriage and fetal trisomy 21, said Miriam Kuppermann, Ph.D., of the University of California, San Francisco, and her associates. “

If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing,” the investigators said.

©Kativ/iStockphoto

The multicenter study included 710 English- or Spanish-speaking women who were at 20 weeks’ gestation or less.

A bilingual actress narrated the computer program, emulating a “warm and knowledgeable friend” and emphasizing “the personal nature of prenatal testing decisions,” said the researchers.

The control group received prenatal care based on current guidelines, and did not receive financial support for prenatal tests beyond their own insurance plans, the investigators added (JAMA 2014 Sept. 23 [doi:10.1001/jama.2014.11479]).

Medical record reviews showed that the intervention group was significantly less likely to pursue amniocentesis or chorionic villi sampling than was the control group (5.9% vs. 12.3%; odds ratio, 0.45; 95% confidence interval, 0.25 to 0.80). In addition, computer program users were more than three times as likely to forego testing altogether and more than twice as likely to elect screening alone than to choose screening followed by invasive testing.

Although the computer program did not address cell-free DNA testing, the findings should extend to these tests because they cover the same conditions, the researchers said.

The intervention group also was more likely to correctly estimate the risk of amniocentesis-related miscarriage (73.8% vs. 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and the age-adjusted chance of fetal trisomy 21 (58.7% vs. 46.1%; OR, 1.66 [95% CI, 1.22-2.28]) than the control group, Dr. Kuppermann and her associates reported.

The National Institutes of Health and the March of Dimes Foundation funded the study. Dr. Kuppermann reported receiving research support from Ariosa Diagnostics, Verinata Health, and Natera. Two coauthors reported receiving funding or stock options from Verinata Health, Natera, Ariosa Diagnostics, and Cellscape. The authors disclosed no other financial conflicts.

Pregnant women who used an interactive computer program to help them decide whether to undergo prenatal testing were 55% less likely to choose invasive testing than women who received standard prenatal care, even when they were offered free testing, researchers reported online Sept. 23 in JAMA.

Women who used the computer program also were more likely to correctly estimate the risks of amniocentesis-related miscarriage and fetal trisomy 21, said Miriam Kuppermann, Ph.D., of the University of California, San Francisco, and her associates. “

If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing,” the investigators said.

©Kativ/iStockphoto

The multicenter study included 710 English- or Spanish-speaking women who were at 20 weeks’ gestation or less.

A bilingual actress narrated the computer program, emulating a “warm and knowledgeable friend” and emphasizing “the personal nature of prenatal testing decisions,” said the researchers.

The control group received prenatal care based on current guidelines, and did not receive financial support for prenatal tests beyond their own insurance plans, the investigators added (JAMA 2014 Sept. 23 [doi:10.1001/jama.2014.11479]).

Medical record reviews showed that the intervention group was significantly less likely to pursue amniocentesis or chorionic villi sampling than was the control group (5.9% vs. 12.3%; odds ratio, 0.45; 95% confidence interval, 0.25 to 0.80). In addition, computer program users were more than three times as likely to forego testing altogether and more than twice as likely to elect screening alone than to choose screening followed by invasive testing.

Although the computer program did not address cell-free DNA testing, the findings should extend to these tests because they cover the same conditions, the researchers said.

The intervention group also was more likely to correctly estimate the risk of amniocentesis-related miscarriage (73.8% vs. 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and the age-adjusted chance of fetal trisomy 21 (58.7% vs. 46.1%; OR, 1.66 [95% CI, 1.22-2.28]) than the control group, Dr. Kuppermann and her associates reported.

The National Institutes of Health and the March of Dimes Foundation funded the study. Dr. Kuppermann reported receiving research support from Ariosa Diagnostics, Verinata Health, and Natera. Two coauthors reported receiving funding or stock options from Verinata Health, Natera, Ariosa Diagnostics, and Cellscape. The authors disclosed no other financial conflicts.

WASHINGTON – Options and opportunity are the keys to navigating the 2014-2015 flu season, according to a panel of experts at a press conference sponsored by the National Foundation for Infectious Diseases.

“The easier we make it for people to get vaccinated, the more likely they are to get vaccinated,” said CDC Director Thomas Frieden, who received his flu shot at the press conference.

In interviews at the conference, Dr. Frieden, Dr. Paul A. Offit of the Children’s Hospital of Philadelphia; Dr. Laura E. Riley of Massachusetts General Hospital, Boston; and Dr. William Schaffner of Vanderbilt University, Nashville, Tenn., discussed making the most of opportunities to vaccinate patients, offering reassurance about vaccine safety (especially for pregnant women), setting an example in your practice by getting vaccinated yourself, and ensuring that everyone who works in your office receives a flu vaccine as well. 

[email protected]

WASHINGTON – Options and opportunity are the keys to navigating the 2014-2015 flu season, according to a panel of experts at a press conference sponsored by the National Foundation for Infectious Diseases.

“The easier we make it for people to get vaccinated, the more likely they are to get vaccinated,” said CDC Director Thomas Frieden, who received his flu shot at the press conference.

In interviews at the conference, Dr. Frieden, Dr. Paul A. Offit of the Children’s Hospital of Philadelphia; Dr. Laura E. Riley of Massachusetts General Hospital, Boston; and Dr. William Schaffner of Vanderbilt University, Nashville, Tenn., discussed making the most of opportunities to vaccinate patients, offering reassurance about vaccine safety (especially for pregnant women), setting an example in your practice by getting vaccinated yourself, and ensuring that everyone who works in your office receives a flu vaccine as well. 

[email protected]

WASHINGTON – Options and opportunity are the keys to navigating the 2014-2015 flu season, according to a panel of experts at a press conference sponsored by the National Foundation for Infectious Diseases.

“The easier we make it for people to get vaccinated, the more likely they are to get vaccinated,” said CDC Director Thomas Frieden, who received his flu shot at the press conference.

In interviews at the conference, Dr. Frieden, Dr. Paul A. Offit of the Children’s Hospital of Philadelphia; Dr. Laura E. Riley of Massachusetts General Hospital, Boston; and Dr. William Schaffner of Vanderbilt University, Nashville, Tenn., discussed making the most of opportunities to vaccinate patients, offering reassurance about vaccine safety (especially for pregnant women), setting an example in your practice by getting vaccinated yourself, and ensuring that everyone who works in your office receives a flu vaccine as well. 

[email protected]

BARCELONA – Women with mechanical heart valves who become pregnant face a very-high-risk pregnancy, with a 58% rate of an uncomplicated pregnancy resulting in a live birth, according to international registry data collected since 2007.

Pregnant women at high risk because of a mechanical heart valve need management by a multidisciplinary team at a referral center that focuses on these cases, a type of care that many of these women do not receive today, Dr. Jolien W. Roos-Hesselink said at the annual congress of the European Society of Cardiology.

Mitchel Zoler/ Frontline Medical News

“We believe management of these women needs to be better structured and organized,” said Dr. Roos-Hesselink, professor and head of the department of congenital cardiology at Erasmus Medical Center in Rotterdam, the Netherlands. “Pregnancy is a time of risk for any woman with structural heart disease, but for those with a mechanical valve are really high-risk patients,” she said in an interview.

“Most of these women are now cared for by a general cardiologist. They need a specialist in obstetric cardiology,” as well as care from other experts with experience in the types of complications these woman develop, said Dr. Roger J.C. Hall, professor of cardiology at Norfolk and Norwich (U.K.) University Hospital.

The data also showed that physicians around the world used any one of seven different anticoagulant regimens during these pregnancies, a strikingly high number that highlights uncertainty about which regimen is best, although heparin use during the first trimester was linked with a higher rate of valve thrombosis. The various regimens use different combinations of periods of treatment with unfractionated heparin, low-molecular-weight heparin, or a vitamin K antagonist drug during the first trimester, during weeks 14-36, and during the last weeks of pregnancy.

Mitchel Zoler/ Frontline Medical News

“We found large differences in management among different countries, physicians, and among individual patients. All the regimens have advantages and disadvantages” and are based on expert opinion with no prospect for a randomized, controlled trial, said Dr. Roos-Hesselink. For now, the numbers of women receiving each of the seven regimens remains too small for statistical analysis, but the researchers hope that eventually larger numbers may start to reveal which regimens work best, said Dr. Hall.

However, the available data showed two clear trends: Treatment with vitamin K antagonists was tied to an increased rate of miscarriages, and treatment with heparin during the first trimester was associated with an increased rate of valve thrombosis, noted Dr. Roos-Hesselink.

One other notable finding was that the risks faced by women with mechanical heart valves far exceeded the risk seen in women with tissue valves, and in women with other forms of mechanical heart disease but no valve prostheses. Adolescents and young women who need a heart valve should be part of a shared decision process that reviews the pros and cons of a mechanical and tissue valve, said Dr. Roos-Hesselink and Dr. Hall. A tissue valve is less durable, and so typically requires replacement sooner than does a mechanical valve. But in the current study, the pregnancy loss and complication rates among the 134 women with a tissue valve roughly matched the rates among the 2,620 women with no valve prosthesis, while the rates among 212 women with a mechanical valve ran much higher.

The Registry of Pregnancy and Cardiac Diseases began in 2007 through an initiative of two interest groups of the European Society of Cardiology, the valve group and the congenital heart disease group (Eur. Heart J. 2013;34:657-65). By September 2014, the registry had enrolled more than 3,600 pregnancies. The current report focused on the first 2,966 women enrolled, with an average age of 29 years. Slightly more than half the enrolled women had congenital heart disease, slightly fewer than a third had valvular heart disease (usually because of rheumatic heart disease), 7% had cardiomyopathy, and smaller number of women had other etiologies.

Maternal mortality averaged 1.4% for women with mechanical valves, 1.5% for those with tissue valves, and 0.2% for everyone else. Miscarriage rates were 16% for mothers with mechanical valves and 2% for everyone else, including those with tissues valves. Fetal mortality was 3% among women with mechanical valves and less than 1% for everyone else. Thrombotic and hemorrhagic events occurred in about 29% of women with mechanical valves, compared with less than 6% in everyone else. Ten of the women with mechanical valves (5%) developed valve thrombosis. The live birth rate was 80% for women with mechanical valves and 95% or better for everyone else.

Dr. Roos-Hesselink and Dr. Hall had no disclosures.

[email protected]

On Twitter @mitchelzoler

BARCELONA – Women with mechanical heart valves who become pregnant face a very-high-risk pregnancy, with a 58% rate of an uncomplicated pregnancy resulting in a live birth, according to international registry data collected since 2007.

Pregnant women at high risk because of a mechanical heart valve need management by a multidisciplinary team at a referral center that focuses on these cases, a type of care that many of these women do not receive today, Dr. Jolien W. Roos-Hesselink said at the annual congress of the European Society of Cardiology.

Mitchel Zoler/ Frontline Medical News

“We believe management of these women needs to be better structured and organized,” said Dr. Roos-Hesselink, professor and head of the department of congenital cardiology at Erasmus Medical Center in Rotterdam, the Netherlands. “Pregnancy is a time of risk for any woman with structural heart disease, but for those with a mechanical valve are really high-risk patients,” she said in an interview.

“Most of these women are now cared for by a general cardiologist. They need a specialist in obstetric cardiology,” as well as care from other experts with experience in the types of complications these woman develop, said Dr. Roger J.C. Hall, professor of cardiology at Norfolk and Norwich (U.K.) University Hospital.

The data also showed that physicians around the world used any one of seven different anticoagulant regimens during these pregnancies, a strikingly high number that highlights uncertainty about which regimen is best, although heparin use during the first trimester was linked with a higher rate of valve thrombosis. The various regimens use different combinations of periods of treatment with unfractionated heparin, low-molecular-weight heparin, or a vitamin K antagonist drug during the first trimester, during weeks 14-36, and during the last weeks of pregnancy.

Mitchel Zoler/ Frontline Medical News

“We found large differences in management among different countries, physicians, and among individual patients. All the regimens have advantages and disadvantages” and are based on expert opinion with no prospect for a randomized, controlled trial, said Dr. Roos-Hesselink. For now, the numbers of women receiving each of the seven regimens remains too small for statistical analysis, but the researchers hope that eventually larger numbers may start to reveal which regimens work best, said Dr. Hall.

However, the available data showed two clear trends: Treatment with vitamin K antagonists was tied to an increased rate of miscarriages, and treatment with heparin during the first trimester was associated with an increased rate of valve thrombosis, noted Dr. Roos-Hesselink.

One other notable finding was that the risks faced by women with mechanical heart valves far exceeded the risk seen in women with tissue valves, and in women with other forms of mechanical heart disease but no valve prostheses. Adolescents and young women who need a heart valve should be part of a shared decision process that reviews the pros and cons of a mechanical and tissue valve, said Dr. Roos-Hesselink and Dr. Hall. A tissue valve is less durable, and so typically requires replacement sooner than does a mechanical valve. But in the current study, the pregnancy loss and complication rates among the 134 women with a tissue valve roughly matched the rates among the 2,620 women with no valve prosthesis, while the rates among 212 women with a mechanical valve ran much higher.

The Registry of Pregnancy and Cardiac Diseases began in 2007 through an initiative of two interest groups of the European Society of Cardiology, the valve group and the congenital heart disease group (Eur. Heart J. 2013;34:657-65). By September 2014, the registry had enrolled more than 3,600 pregnancies. The current report focused on the first 2,966 women enrolled, with an average age of 29 years. Slightly more than half the enrolled women had congenital heart disease, slightly fewer than a third had valvular heart disease (usually because of rheumatic heart disease), 7% had cardiomyopathy, and smaller number of women had other etiologies.

Maternal mortality averaged 1.4% for women with mechanical valves, 1.5% for those with tissue valves, and 0.2% for everyone else. Miscarriage rates were 16% for mothers with mechanical valves and 2% for everyone else, including those with tissues valves. Fetal mortality was 3% among women with mechanical valves and less than 1% for everyone else. Thrombotic and hemorrhagic events occurred in about 29% of women with mechanical valves, compared with less than 6% in everyone else. Ten of the women with mechanical valves (5%) developed valve thrombosis. The live birth rate was 80% for women with mechanical valves and 95% or better for everyone else.

Dr. Roos-Hesselink and Dr. Hall had no disclosures.

[email protected]

On Twitter @mitchelzoler

BARCELONA – Women with mechanical heart valves who become pregnant face a very-high-risk pregnancy, with a 58% rate of an uncomplicated pregnancy resulting in a live birth, according to international registry data collected since 2007.

Pregnant women at high risk because of a mechanical heart valve need management by a multidisciplinary team at a referral center that focuses on these cases, a type of care that many of these women do not receive today, Dr. Jolien W. Roos-Hesselink said at the annual congress of the European Society of Cardiology.

Mitchel Zoler/ Frontline Medical News

“We believe management of these women needs to be better structured and organized,” said Dr. Roos-Hesselink, professor and head of the department of congenital cardiology at Erasmus Medical Center in Rotterdam, the Netherlands. “Pregnancy is a time of risk for any woman with structural heart disease, but for those with a mechanical valve are really high-risk patients,” she said in an interview.

“Most of these women are now cared for by a general cardiologist. They need a specialist in obstetric cardiology,” as well as care from other experts with experience in the types of complications these woman develop, said Dr. Roger J.C. Hall, professor of cardiology at Norfolk and Norwich (U.K.) University Hospital.

The data also showed that physicians around the world used any one of seven different anticoagulant regimens during these pregnancies, a strikingly high number that highlights uncertainty about which regimen is best, although heparin use during the first trimester was linked with a higher rate of valve thrombosis. The various regimens use different combinations of periods of treatment with unfractionated heparin, low-molecular-weight heparin, or a vitamin K antagonist drug during the first trimester, during weeks 14-36, and during the last weeks of pregnancy.

Mitchel Zoler/ Frontline Medical News

“We found large differences in management among different countries, physicians, and among individual patients. All the regimens have advantages and disadvantages” and are based on expert opinion with no prospect for a randomized, controlled trial, said Dr. Roos-Hesselink. For now, the numbers of women receiving each of the seven regimens remains too small for statistical analysis, but the researchers hope that eventually larger numbers may start to reveal which regimens work best, said Dr. Hall.

However, the available data showed two clear trends: Treatment with vitamin K antagonists was tied to an increased rate of miscarriages, and treatment with heparin during the first trimester was associated with an increased rate of valve thrombosis, noted Dr. Roos-Hesselink.

One other notable finding was that the risks faced by women with mechanical heart valves far exceeded the risk seen in women with tissue valves, and in women with other forms of mechanical heart disease but no valve prostheses. Adolescents and young women who need a heart valve should be part of a shared decision process that reviews the pros and cons of a mechanical and tissue valve, said Dr. Roos-Hesselink and Dr. Hall. A tissue valve is less durable, and so typically requires replacement sooner than does a mechanical valve. But in the current study, the pregnancy loss and complication rates among the 134 women with a tissue valve roughly matched the rates among the 2,620 women with no valve prosthesis, while the rates among 212 women with a mechanical valve ran much higher.

The Registry of Pregnancy and Cardiac Diseases began in 2007 through an initiative of two interest groups of the European Society of Cardiology, the valve group and the congenital heart disease group (Eur. Heart J. 2013;34:657-65). By September 2014, the registry had enrolled more than 3,600 pregnancies. The current report focused on the first 2,966 women enrolled, with an average age of 29 years. Slightly more than half the enrolled women had congenital heart disease, slightly fewer than a third had valvular heart disease (usually because of rheumatic heart disease), 7% had cardiomyopathy, and smaller number of women had other etiologies.

Maternal mortality averaged 1.4% for women with mechanical valves, 1.5% for those with tissue valves, and 0.2% for everyone else. Miscarriage rates were 16% for mothers with mechanical valves and 2% for everyone else, including those with tissues valves. Fetal mortality was 3% among women with mechanical valves and less than 1% for everyone else. Thrombotic and hemorrhagic events occurred in about 29% of women with mechanical valves, compared with less than 6% in everyone else. Ten of the women with mechanical valves (5%) developed valve thrombosis. The live birth rate was 80% for women with mechanical valves and 95% or better for everyone else.

Dr. Roos-Hesselink and Dr. Hall had no disclosures.

[email protected]

On Twitter @mitchelzoler