American journal of perinatology
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Comparative Study
Conflicts between physicians and patients in non-elective cesarean delivery: incidence and the adequacy of informed consent.
A study was undertaken in 372 consecutive patients undergoing non-elective cesarean delivery to explore the incidence and nature of conflicts between physician and patient surrounding the decision to undergo non-elective cesarean delivery; to examine the adequacy of informed consent at the time of non-elective cesarean delivery; and to describe the importance of a preventive ethics approach to non-elective cesarean delivery. During a 6-month interval, all patients who underwent non-elective cesarean delivery and their physicians were asked to take part in a survey in the early postpartum period concerning their response to recommendations for cesarean delivery. The survey included demographics as well as questions pertaining to informed consent and the presence and nature of patient-physician conflict. ⋯ Our findings suggest that even though the incidence of physician-patient conflict about non-elective cesarean delivery was quite low, a significant number of patients (1 in 12) may have reservations concerning the informed consent process at the time of non-elective cesarean delivery. Patients with reservations are more likely to have greater concerns with regard to maternal and fetal risks, suggesting that a more detailed risk disclosure prior to the procedure is warranted for all pregnant patients. Perhaps by incorporating the preventive strategies discussed, the adequacy of informed consent and therefore the patient's autonomy could be enhanced, thus diminishing patient reservations and preventing physician-patient conflict in the intrapartum period.
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Multiple gestations have a significantly increased incidence of preterm labor and preterm rupture of membranes. This leads to an increase in neonatal morbidity and mortality due to prematurity. In this case, a 30-year-old woman achieved a triplet pregnancy by ovulation induction and intrauterine inseminations. ⋯ This is the first reported case of delayed delivery of the two remaining fetuses of a triplet pregnancy, after spontaneous preterm delivery of the presenting triplet, without surgical intervention. Although the first fetus expired 48 hours after delivery secondary to complications of prematurity, the other fetuses were subjected to tocolysis, bed rest, and steroids. This case illustrates that conservative management of a triplet pregnancy after preterm delivery of the presenting triplet may have a good outcome.
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Review Case Reports
Surgery for pancreatic tumors during pregnancy: a case report and review of the literature.
Seven cases of surgery of pancreatic tumors during pregnancy have been reported in the literature. Six of the cases resulted in live term births. The patient discussed herein, a 37-year-old para 2-0-0-2 white female, had surgery for the removal of a pancreatic mass at 20 2/7 weeks' gestation. ⋯ Three days after admission, the fetus was noted to have poor biophysical testing and a caesarean delivery was performed. The infant was found to have a large intracerebral hemorrhage, which most likely occurred antenatally, and life support was discontinued shortly after birth. We conclude from this that surgery for a pancreatic mass in pregnancy should be approached cautiously, and the risk to both the mother and fetus should be considered.
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Comparative Study
Advantages of larger volume, less frequent intrauterine red blood cell transfusions for maternal red cell alloimmunization.
Larger volume intravascular transfusions to manage severe maternal red cell alloimmunization in pregnancy may prolong the interval between procedures without increasing maternal, fetal, or neonatal complications. A retrospective cohort study compared the management and outcome of 19 patients with severe red cell alloimmunization managed at two facilities with different intravascular transfusion protocols. The volume of blood transfused, pre- and post-transfusion fetal hematocrit, and interval (days) between intravascular transfusions were compared. ⋯ The adverse outcomes, complication rates, and neonatal outcomes were otherwise similar in both management protocols. It is possible to significantly increase the interval between intravascular transfusions with larger transfusion volumes for the management of severe maternal red cell alloimmunization without undue risk. The overall risk for the fetus and mother may be reduced by performing fewer transfusions and avoiding additional blood product exposures.
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Case Reports
Doppler echocardiographic findings of indomethacin-induced occlusion of the fetal ductus arteriosus.
We present an unusual case of indomethacin-induced occlusion of the fetal ductus arteriosus, which occurred in one of twins. In fetal echocardiography, the characteristic findings, a to and fro regurgitation pattern at pulmonary valve and postvalvular dilation of the main pulmonary artery, were obtained in addition to right ventricular dilation and hypertrophy, tricuspid regurgitation, right atrium dilation, and pericardial effusion. This fetus developed fetal distress and was delivered by an emergency cesarean section at 35 weeks' gestation. We suggest that these fetal echocardiographic findings may be the end-stage signs of the fetal ductal occlusion as well as the signs for emergent delivery.