Postpartum Hemorrhage Leading to Renal Infarction

A 19-year-old G1P0 with insignificant past medical history was admitted at 39w1d gestation for induction of labor after having category 2 fetal heart tones. Her induction was unremarkable aside from bradycardia in the second stage of labor requiring a vacuum-assisted delivery and episiotomy. Immediate postpartum course was complicated by a hemorrhage with a total estimated blood loss of 1450 cc. A CT scan was obtained to rule out retroperitoneal bleeding given her significant blood loss with downtrending hemoglobin. CT showed a wedge-shaped hypoattenuation concerning for multiple renal infarcts vs pyelonephritis. Etiology was suspected to be due to hypoperfusion during episodes of significant hypotension. Postpartum hemorrhage is not a causative event typically associated with acute renal infarction. The most commonly cited risk factors include cardiovascular disease, renovascular injury, and hypercoagulability – none of which were applicable to this patient. Although the patient in our report was without symptoms, renal infarction can present as acute abdominal or flank pain, and sometimes hypertension. There have been rare case reports associating a postpartum hemorrhage with a renal infarction, but given its rarity it is not a complication typically considered by obstetric providers in the setting of a hemorrhage. Evidence such as this may prompt clinicians to have greater suspicion for this sequela of postpartum hemorrhage if a patient suddenly develops the symptoms described above or signs of acute kidney injury without alternative explanation.https://scholarlycommons.henryford.com/merf2019caserpt/1058/thumbnail.jp

Evans Syndrome in Pregnancy: A Case Report

Evans syndrome is a chronic autoimmune disease characterized by autoimmune hemolytic anemia (AIHA) along with immune thrombocytopenic purpura (ITP), caused by autoantibodies against red blood cells and platelets. The prevalence of ITP alone is 12/100,000 in U.S. adults, and Evans syndrome has been diagnosed in 1.8-10% of patients with ITP. Few case reports of Evans syndrome in pregnancy have been published, and guidelines for treatment are not well-defined due to the lack of information available in literature. We present a case of Evans syndrome in pregnancy, her clinical course, treatment, and complications postpartum. Evans syndrome is known to be a chronic condition with remissions and relapses. There is some evidence that Evans syndrome may have a more favorable course in pregnancy. More studies are needed to understand the clinical course, treatment options, and neonatal outcome of Evans syndrome in pregnancy.https://scholarlycommons.henryford.com/merf2020caserpt/1127/thumbnail.jp

Evans Syndrome Associated with Pregnancy and COVID-19 Infection

Background: Evans syndrome (ES) is a chronic autoimmune disease characterized by autoimmune hemolytic anemia along with immune thrombocytopenic purpura. Few case reports of ES in pregnancy have been published, and ES may be difficult to distinguish from other diagnoses more common in pregnancy. Guidelines for treatment of ES are not well-defined. Case: A 23-year-old multigravid woman in active labor was found to have severe anemia and thrombocytopenia. She was diagnosed with ES and started on immunosuppressive treatments for persistent immune thrombocytopenic purpura. In the postpartum period, she was found to have coronavirus (COVID-19) infection and acute pulmonary embolism. Conclusion: Evans syndrome is a challenge to diagnose in pregnancy and poses important considerations for intrapartum and postpartum management

Benign Recurrent Intrahepatic Cholestasis in Pregnancy: Fetal Death at 36 Weeks of Gestation

Introduction: Benign recurrent intrahepatic cholestasis is a rare hepatologic disorder characterized by recurrent, self-limited episodes of severe pruritus, jaundice, and elevated bile acids. While there are guidelines for the management of intrahepatic cholestasis of pregnancy, the literature regarding benign recurrent intrahepatic cholestasis and pregnancy is limited. Case: A 29-year-old G1P0 woman, with history of liver toxicity, had elevated total serum bile acid levels and liver enzymes documented at 8 weeks of gestation and throughout her pregnancy. She had a reactive nonstress test just 3 days prior to her induction. Fetal demise was noted when she presented at 36 weeks for her induction. Conclusion: We recommend that women with elevated total serum bile acid early in pregnancy due to a separate entity relative to intrahepatic cholestasis of pregnancy be managed in a more individualized approach

COVID-19 is associated with early emergence of preeclampsia: results from a large regional collaborative

Objective: To examine the relationship between COVID-19 and preeclampsia (PreE) in a large, diverse population. Study Design: The COVID-19 in Pregnancy and The Newborn: State of Michigan Collaborative established a database of pregnant patients admitted to 14 institutions in Southern Michigan. Patients with COVID-19 (cases) were matched to 2 or 3 non-COVID patients (controls) on the same unit within 30 days of each case. Relative Risks (RR) were calculated using robust Poisson regression models with adjustment for covariates. Chi-squared test for trend was used to assess the increase in risk with the severity of disease. Results: 369 cases and 1,090 controls were delivered between March - October 2020. An increased risk of PreE (RR=1.8), driven almost entirely by an increase in preterm PreE (pretermPreE) (RR=2.85) was observed in COVID pregnancies (Table 1), with a dose-response relationship with symptomatology and severity (Table 2). The associations between COVID-19 disease and PreE or pretermPreE were independent of other risk factors, as demonstrated by the minimal changes in RR after adjustment for confounders (Table 1). However, African American (AA) COVID patients experienced pretermPreE 1.9 times more than COVID patients of other races (10.1 vs 5.3), an increase not observed in control patients. The strength of the association for COVID with PreE was comparable to the association of PreE with chronic hypertension and nulliparity (data not shown). Increasing symptoms and severity of COVID-19 were associated with an increased risk for PreE with placental lesions, even after adjustment for relevant covariates (Tables 1 & 2). Non-PreE COVID patients had an increased trend of placental lesions compared to non-COVID patients, reaching significance for intravillous thrombin. Conclusion: COVID-19 is significantly associated with early emergence of PreE, independent of known risk factors other than AA race. Our study shows that among patients predisposed to PreE, COVID-19 impacts PreE severity in that it leads to pretermPreE. Further studies on COVID-19 and PreE, with a focus on racial disparities, is warranted

Maternal SARS-COV-2 infection and prematurity: the Southern Michigan COVID-19 collaborative

OBJECTIVE: COVID-19 has been reported to increase the risk of prematurity, however, due to the frequent absence of unaffected controls as well as inadequate accounting for confounders in many studies, the question requires further investigation. We sought to determine the impact of COVID-19 disease on preterm birth (PTB) overall, as well as related subcategories such as early prematurity, spontaneous, medically indicated preterm birth, and preterm labor (PTL). We assessed the impact of confounders such as COVID-19 risk factors, a-priori risk factors for PTB, symptomatology, and disease severity on rates of prematurity. METHODS: This was a retrospective cohort study of pregnant women from March 2020 till October 1st, 2020. The study included patients from 14 obstetric centers in Michigan, USA. Cases were defined as women diagnosed with COVID-19 at any point during their pregnancy. Cases were matched with uninfected women who delivered in the same unit, within 30 d of the delivery of the index case. Outcomes of interest were frequencies of prematurity overall and subcategories of preterm birth (early, spontaneous/medically indicated, preterm labor, and premature preterm rupture of membranes) in cases compared to controls. The impact of modifiers of these outcomes was documented with extensive control for potential confounders. A p value \u3c.05 was used to infer significance. RESULTS: The rate of prematurity was 8.9% in controls, 9.4% in asymptomatic cases, 26.5% in symptomatic COVID-19 cases, and 58.8% among cases admitted to the ICU. Gestational age at delivery was noted to decrease with disease severity. Cases were at an increased risk of prematurity overall [adjusted relative risk (aRR) = 1.62 (1.2-2.18)] and of early prematurity (\u3c34 weeks) [aRR = 1.8 (1.02-3.16)] when compared to controls. Medically indicated prematurity related to preeclampsia [aRR = 2.46 (1.47-4.12)] or other indications [aRR = 2.32 (1.12-4.79)], were the primary drivers of overall prematurity risk. Symptomatic cases were at an increased risk of preterm labor [aRR = 1.74 (1.04-2.8)] and spontaneous preterm birth due to premature preterm rupture of membranes [aRR = 2.2(1.05-4.55)] when compared to controls and asymptomatic cases combined. The gestational age at delivery followed a dose-response relation with disease severity, as more severe cases tended to deliver earlier (Wilcoxon p \u3c .05). CONCLUSIONS: COVID-19 is an independent risk factor for preterm birth. The increased preterm birth rate in COVID-19 was primarily driven by medically indicated delivery, with preeclampsia as the principal risk factor. Symptomatic status and disease severity were significant drivers of preterm birth

Blood transfusion trends in women with abnormal uterine bleeding

INTRODUCTION: Blood transfusion continues to pose serious risks to recipients. The role of blood transfusion in management of women presenting with abnormal uterine bleeding is unclear and has not been studied before. The goal of this study is to determine the predictors of existing blood transfusion practice in women with abnormal uterine bleeding. METHODS: Retrospective chart review of women who presented to Emergency room between 2011 and 2013 with abnormal uterine bleeding and received blood transfusion. Patients with pregnancy, critical illness, cancer, bleeding diathesis and religious beliefs precluding transfusion were excluded. RESULTS: A total of 212 charts were reviewed. Of the women who received transfusion for abnormal uterine bleeding, 163 were between 24-60 yrs (73%), 141 were not on any hormonal therapy for bleeding (67%), 121 had no previous procedures performed (57%). 78 (37%) women were orthostatic, 21 (10%) had a hemoglobin less than ± gm/dL, 170 (80%) had hemoglobin between 6-8 gm/dL. Patients with cardiac comorbidities were few (8%). Most women were African American (79%) and the most common etiology was Fibroids (71%). 164 (77%) women had chronic bleeding (6 months or more) and 48 (23%) had acute bleeding. 79 (37%) women had no insurance. CONCLUSION: Blood transfusion trends in women with abnormal uterine bleeding in the existing practice appear to be liberal. There is a need for prospective studies for implementing blood transfusion guidelines for women with abnormal bleeding and comparing outcomes of liberal versus restrictive transfusion practice in this clinical situation

Outcome Comparison Before & After New Protocol of DVT Chemoprophylaxis for Cesarean Section Patients [11L]

INTRODUCTION: Venous thromboembolism is one of the leading causes of maternal morbidity and mortality. After careful review of the available literature and discussion of the recommendations of multiple national organizations (American College of Obstetricians and Gynecologists, RCOG, American College of Chest Physicians, etc.), the Quality and Safety Committee at our hospital changed the protocol for VTE prophylaxis for obstetric patients. The new policy advocates a more aggressive VTE prophylaxis of 7500U heparin BID for all Cesarean section patients starting 12 hours post-operation. One year has passed since the implementation of the new chemoprophylaxis protocol and this comparison will allow us to analyze if the benefits outweigh the potential risks. METHODS: Retrospective chart review of one year before and one year implementation of new DVT chemoprophylaxis protocol for benefits and complications. Rates of wound infections, hematomas, dehiscence, ER visits, readmissions, DVT, and PE were studied. Initial records were collected from February 2015 through January 2016. 288 patients before protocol implementation and 296 patients after were studied. Cohorts were uniform in regards to age, race, BMI, gravidity, parity. RESULTS: No statistical significance noted at ± months with respect to wound complications, ED visits, readmission rates, DVT, or PE from before protocol implementation to after protocol implementation. CONCLUSION: Six month data suggest no statistical significance between the before and after protocol implementation groups. Additional data has been collected and is being analyzed out to the one year mark to determine if the policy change has benefited or adversely affected patients

Postpartum bilateral lung transplantation in COVID-19 associated respiratory failure

In critically ill patients with COVID-19, established therapies in the setting of respiratory failure include invasive mechanical ventilation and extracorporeal membrane oxygenation (ECMO). This case report describes a pregnant woman in her 30s who was hospitalised at 35 weeks gestation with moderate COVID-19 disease. Her condition worsened following delivery, and she required intubation, maximum ventilatory support and ECMO. Because of the severe and irreversible nature of her lung disease, she ultimately underwent bilateral lung transplantation. This case showcases lung transplantation as an alternative life-saving option for patients with severe COVID-19 associated respiratory failure refractory to ECMO and mechanical ventilation. Further studies are needed to develop a multidisciplinary approach for patient selection for transplantation within the context of COVID-19 and to assess long-term outcomes

Recurrence Rate for Isolated Elevated Maternal Serum Alpha-Fetoprotein Levels and Pregnancy Outcomes

Objective: To examine the rate of recurrence for elevated isolated maternal serum alpha-fetoprotein (MSAFP) and its associated adverse outcomes during a subsequent pregnancy. Materials and Methods: A retrospective cohort study of pregnant multiparous women who had elevated MSAFP levels during an initial and a subsequent pregnancy between 1994 and 2020. Results: Twenty-seven out of 344 (7.8%) women with elevated MSAFP had recurrent elevated MSAFP in a subsequent pregnancy. Four women were excluded due to missing data. Of the 23 women included, 5 (22%) had fetal growth restriction (FGR), 2 (9%) had pre-eclampsia, 9 (35%) had preterm births, and 2 (9%) had fetal death/miscarriage in their subsequent pregnancy. Looking at individual outcomes, 60% of women had recurrence of preterm labor, 33% had recurrence of fetal death, and 25% had recurrence of FGR. Conclusion: Women with elevated MSAFP levels during an initial pregnancy should be informed during preconception counseling about their risk of recurring elevated MSAFP and its associated adverse outcomes risks