American journal of perinatology
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Case Reports
Brain death during pregnancy: tocolytic therapy and aggressive maternal support on behalf of the fetus.
We report a case of maternal brain death at 25 weeks gestation in which aggressive maternal hemodynamic, respiratory, and metabolic support and tocolytic drug therapy resulted in prolongation of pregnancy for 25 days. The indication for delivery was torulopsis giabrata amnionitis, which may have occurred due to transmembrane or transplacental route. ⋯ Premature labor may occur spontaneously after maternal brain death, and may be precipitated by infection or by maternal drug therapy. The myriad of hemodynamic and endocrine issues associated with maternal brain death complicate the choice of tocolytic drugs, but this case illustrates that uterine activity can be successfully blocked, potentially diminishing risks to the newborn, following the tragedy of maternal brain death during pregnancy.
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Trauma and/or accidental injury complicates 6-7% of all pregnancies. The management protocols for trauma in pregnancy are based largely on case reports and small series. The purposes of this study were to: describe the demographics of pregnant trauma patients at a tertiary care center and a large community hospital; identify variables predictive of fetal outcome including an examination of Kleihauer-Betke and nonstress testing; and recommend an evaluation and management protocol after trauma based on empirical data rather than anecdotal reports. ⋯ Given our findings that prolonged monitoring was not helpful in management of pregnant trauma patients, we support the recommendation that initial external fetal monitoring be performed for 4 hr, and, if reassuring, the patient may be sent home with precautions. We also recommend an Rh-immunoglobulin work-up for all Rh-negative pregnant trauma patients, but do not recommend Kleihauer-Betke testing for Rh-positive women. Given the frequency with which trauma affects pregnancy and the difficulty encountered with identifying variables predictive of pregnancy outcome, there may be great benefits of incorporating trauma prevention into routine prenatal care.
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Laerdal Infant Resuscitators (Laerdal Medical Co., NY) are commonly used as free-flow oxygen delivery devices during neonatal resuscitation in situations where oxygen but not mechanical ventilation is desired. This study evaluates the performance of these resuscitators as free-flow oxygen devices. Efficiency was measured by comparing oxygen flow entering the resuscitator to oxygen flow delivered by the resuscitator. ⋯ Simulated fiO2 ranged from 0.23 to 0.68 at 5 lpm oxygen flow. We conclude that use of the Laerdal Infant Resuscitator for the delivery of free-flow oxygen, even with the valve assembly removed, generates highly variable patient fiO2. The use of self-inflating bags for delivery of oxygen without manual ventilation should be reconsidered.
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Comparative Study
Corticosteroid binding globulin, total serum cortisol, and stress in extremely low-birth-weight infants.
Our objective was to determine if low levels of corticosteroid binding globulin (CBG) might explain the low serum total cortisol levels found in some extremely low-birth-weight (ELBW) infants. In a prospective study, serum total cortisol and CBG were measured in single blood samples from 31 ELBW infants, with a gestational age less than 28 weeks, in the first 8 days of life. Severity of illness was assessed using the Score for Neonatal Acute Physiology Perinatal Extension (SNAP-PE). ⋯ Estimated mean serum free cortisol concentrations in these five infants (0.76 mcg/dL) were comparable to estimated free cortisol levels diagnostic of adrenal insufficiency in sick adult patients. Our findings indicate that CBG levels are lower in ELBW infants than in term infants, but low CBG levels do not explain the low serum total cortisol levels found in some very sick infants. Low cortisol levels in small premature infants may be adequate to support growth if the infant is well, but may result in a syndrome of adrenal insufficiency in those with severe illnesses.
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We tested the hypothesis that in preterm infants, prolonged apneas (apneas > or = 20 sec) are not random events but are preceded by frequent and progressively longer respiratory pauses associated with changes in ventilatory variables. We studied 36 preterm infants with apnea [birth weight 1190 +/- 60 g (mean +/- SEM), study weight 1300 +/- 60 g, gestational age 28 +/- 1 weeks, and postnatal age 23 +/- 2 days]. A nosepiece with a flow-through system was used to measure ventilation and alveolar gases. ⋯ When the 1 min before prolonged apnea was compared with the 1 min of similar sleep state not having prolonged apnea, minute ventilation decreased, primarily due to a decrease in respiratory frequency. Oxygen saturation decreased and alveolar PCO2 did not change. These findings suggest that prolonged apnea is not a random event but is preceded by a disturbance of the respiratory control system characterized by (1) frequent apneas of progressive duration, (2) decrease in respiratory minute volume and frequency, and (3) decreased O2 saturation.