American journal of obstetrics and gynecology
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Am. J. Obstet. Gynecol. · Jan 2020
Amniotic fluid embolism: principles of early clinical management.
Amniotic fluid embolism is an uncommon, but potentially lethal, complication of pregnancy. Because amniotic fluid embolism usually is seen with cardiac arrest, the initial immediate response should be to provide high-quality cardiopulmonary resuscitation. We describe key features of initial treatment of patients with amniotic fluid embolism. ⋯ Blood pressure support with vasopressors is preferred over fluid infusion in the setting of severe right ventricular compromise. Amniotic fluid embolism-related coagulopathy should be managed with hemostatic resuscitation with the use of a 1:1:1 ratio of packed red cells, fresh frozen plasma, and platelets (with cryoprecipitate as needed to maintain a serum fibrinogen of >150-200 mg/dL). In cases that require prolonged cardiopulmonary resuscitation or, after arrest, severe ventricular dysfunction refractory to medical management, consideration for venoarterial extracorporeal membrane oxygenation should be given.
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The mainstay of the management of opioid use disorder in pregnancy is with methadone or buprenorphine medication-assisted treatment. Methadone and buprenorphine are opioid agonist drugs. Naltrexone, an opioid antagonist, is also a medication-assisted treatment option; however, to date, only a few retrospective studies have reported its use in pregnancy. ⋯ These study data demonstrate that, in pregnant women who choose to completely detoxify off opioid drugs during gestation, naltrexone, as a continued form of medication-assisted treatment, is a viable option for some pregnant patients who experience opioid use disorder. Naltrexone crosses the placenta, and maternal and fetal levels are concordant. Because naltrexone clears quickly from the maternal circulation, this rapid clearance needs to be addressed with patients. This is important because maternal relapse could occur in a short time-period if the oral drug is discontinued without the knowledge of their healthcare providers. Nonetheless, the drug is well-tolerated by both mother and fetus, and newborn infants do not experience symptoms of neonatal abstinence syndrome if naltrexone medication-assisted treatment is maintained to delivery.
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Am. J. Obstet. Gynecol. · Jan 2020
Evaluating the discordant relationship between Tarlov cysts and symptoms of pudendal neuralgia.
Pudendal neuralgia is a painful neuropathic condition involving the pudendal nerve dermatome. Tarlov cysts have been reported in the literature as another potential cause of chronic lumbosacral and pelvic pain. Notably, they are often located in the distribution of the pudendal nerve origin at the S2, S3, and S4 sacral nerve roots and it has been postulated that they may cause similar symptoms to pudendal neuralgia. Literature has been inconsistent on the clinical relevance of the cysts and if they are responsible for symptoms. ⋯ The increased prevalence of Tarlov cysts is likely not the etiology of pudendal neuralgia, yet both could be due to similar pathogenesis from part of a focal or generalized condition.
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Am. J. Obstet. Gynecol. · Jan 2020
Should women with gestational diabetes be screened at delivery hospitalization for type 2 diabetes?
Less than one-half of women with gestational diabetes mellitus are screened for type 2 diabetes postpartum. Other approaches to postpartum screening need to be evaluated, including the role of screening during the delivery hospitalization. ⋯ A normal oral glucose tolerance test during the delivery hospitalization appears to exclude postpartum type 2 diabetes mellitus. However, the results of the immediate postpartum oral glucose tolerance test were mixed when including impaired fasting glucose or impaired glucose tolerance. As a majority of women do not return for postpartum diabetic screening, an oral glucose tolerance test during the delivery hospitalization may be of use in certain circumstances in which postpartum follow-up is challenging and resources could be focused on women with an abnormal screening immediately after the delivery hospitalization.
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Am. J. Obstet. Gynecol. · Jan 2020
Pelvic floor muscle strength and the incidence of pelvic floor disorders after vaginal and cesarean delivery.
Pelvic floor disorders (including urinary and anal incontinence and pelvic organ prolapse) are associated with childbirth. Injury to the pelvic floor muscles during vaginal childbirth, such as avulsion of the levator ani muscle, is associated with weaker pelvic floor muscle strength. As weak pelvic floor muscle strength may be a modifiable risk factor for the later development of pelvic floor disorders, it is important to understand how pelvic floor muscle strength affects the course of pelvic floor disorders over time. ⋯ After vaginal delivery, but not cesarean delivery, the cumulative incidence of pelvic organ prolapse, stress incontinence, and overactive bladder is associated with pelvic muscle strength, but the associations attenuate when adjusting for genital hiatus and body mass index.