Significant fetal bradycardia during antepartum heart rate testing

Selected neurologic complications of pregnancy

Many neurologic disorders, such as eclampsia, pseudotumor cerebri, stroke, obstetric nerve palsies, subarachnoid hemorrhage, pituitary tumors, and choriocarcinoma, can develop in the pregnant patient. Maternal mortality from eclampsia, which ranges from 0 to 14%, can be due to intracerebral hemorrhage, pulmonary edema, disseminated intravascular coagulation, abruptio placentae, or failure of the liver or kidneys. Associated fetal mortality ranges from 10 to 28% and is directly related to decreased placental perfusion. Pseudotumor cerebri can be associated with serious visual complications; thus, the therapeutic goal is to prevent loss of vision. The risk of stroke in the pregnant patient is 13 times the risk in the nonpregnant patient of the same age. The major causes of stroke in pregnant patients are arterial occlusion and cerebral venous thrombosis. Lumbar disk prolapse is common in pregnant patients, and lumbosacral plexus injuries can occur during labor or delivery. In addition, peripheral nerve compression or entrapment syndromes are thought to be caused by the retention of fluid during pregnancy. The incidence of subarachnoid hemorrhage during pregnancy is 1 in every 10,000 patients, a rate 5 times higher than in nonpregnant women. Because of a proliferation of prolactin-secreting cells, the pituitary gland can enlarge dramatically during pregnancy, a change that can disclose a previously unknown tumor or cause a known pituitary tumor to become symptomatic. The incidence of choriocarcinoma is 1 in 50,000 full-term pregnancies but 1 in 30 molar pregnancies. This malignant tumor has a high rate of cerebral metastatic lesions. In addition to these disorders that develop during pregnancy, the pregnant state can affect numerous preexisting neurologic conditions, including epilepsy, headaches, multiple sclerosis, myasthenia gravis, spinal cord injury, and brain tumors. We discuss advice for patients with such conditions who wish to become pregnant, recommendations for medical and surgical management, and surgical considerations for neurologic complications during pregnancy.

Second-trimester fetal monitoring and preterm delivery in pregnancies with systemic lupus erythematosus and/or circulating anticoagulant

Antepartum fetal monitoring was initiated at 19 to 26 weeks' gestation in 15 pregnancies: six (five with systemic lupus erythematosus, one with circulating anticoagulant) with a complicated antepartum course (group 1); three, all systemic lupus erythematosus, with a normal antepartum course (group 2); and six normal control pregnancies (group 3). Group 1 all exhibited nonperiodic fetal heart rate decelerations, without the classical appearance of early, late, or variable decelerations, and four of the six had fetal bradycardia. In three group 1 cases, there was no active intervention because of early gestational age, and fetal death occurred at 23, 27, and 27 weeks, respectively. The other three patients in group 1 received betamethasone and were delivered by cesarean section at 28 to 30 weeks. There were no cases of respiratory distress syndrome or neonatal death. Five of the six infants in group 1 were small for gestational age. The nonperiodic fetal heart rate decelerations were absent in both groups 2 and 3 who all had normal fetal outcomes at term. The abnormal finding of women with nonperiodic fetal heart rate decelerations at 20 to 28 weeks may detect the fetus at risk for intrauterine death in pregnancies complicated by systemic lupus erythematosus or circulating anticoagulant. Continued surveillance, steroid induction of lung maturity, and delivery should be considered in these cases.

Antepartum cardiotocography

Antepartum cardiotocography remains a valuable adjunct in the management of the high-risk gravida. Twice weekly use of NST coupled with real-time ultrasound assessment of amniotic fluid volume appear reasonable approaches to testing. More controversial is the use of testing in all pregnancies. Clearly, if one could reduce the perinatal mortality to 1-2/1000, such universal application of testing could be justified. However, more pragmatic concerns, such as personnel and cost constraints have all but prohibited the adoption of this policy. Secondly, in an attempt to improve the predictive reliability of antenatal testing additional evaluation of patients demonstrating diminished AFV or variable decelerations should be considered. More frequent testing or consideration for delivery are reasonable management plans. Finally, the use of acoustic stimulation to reduce the frequency of persistently non-reactive NSTs offers considerable promise. Investigations in this and other techniques of surveillance are ongoing. The best single method remains to be discovered, but utilization of current techniques offers the obstetrician a reliable technique by which to assess fetal well-being.