Septic shock in pregnancy.

OBJECTIVE: To evaluate the etiology, management, and maternal and perinatal outcome in patients with septic shock during pregnancy. METHODS: In 18 patients with septic shock during pregnancy, the criteria for the diagnosis were sepsis-induced hypotension unresponsive to adequate fluid resuscitation and requirement for vasopressors. RESULTS: Causes of shock were pyelonephritis (n = 6), chorioamnionitis (n = 3), postpartum endometritis (n = 2), toxic shock (n = 2), and one each of septic abortion, ruptured appendix, ruptured ovarian abscess, necrotizing fasciitis, and bacterial endocarditis. Five women (28%) died. Comparing medians of the initial laboratory data for the 13 survivors with those of the five nonsurvivors revealed significant differences for hematocrit (26 compared with 35%; Z = -2.267, P = .023), aspartate aminotransferase (30 compared with 287 U/L; Z = -2.068, P = .042), total bilirubin (1.6 compared with 5.8 mg/dL; Z = 2.046, P = .045), arterial carbon dioxide pressure (30 compared with 19 mmHg; Z = -2.384, P = .013), and arterial oxygen pressure (62 compared with 104 mmHg; Z = -2.004, P = .048). Comparing medians of the hemodynamic data showed differences in blood pressure (88 compared with 70 mmHg; Z = -2.439, P = .013), stroke volume (74 compared with 52 mL; Z = -2.041, P = .038), and left ventricular stroke work index (42 compared with 12 g.m.m2; Z = -1.929, P = .052). Sixty-four percent of survivors and 80% of nonsurvivors had depressed left ventricular function (Fisher exact test, P > .99). Locating the source of infection was difficult and delayed in eight patients. CONCLUSION: In women with septic shock, progression to death can be dramatically rapid. Because vascular permeability is increased, it may be appropriate to administer vasopressors early during resuscitation. An initial low cardiac output is a poor prognostic sign.

A comparison of labetalol plus hospitalization versus hospitalization alone in the management of preeclampsia remote from term.

Two hundred primigravid women with mild preeclampsia at 26-35 weeks' gestation were randomly allocated to treatment with hospitalization alone or combined with labetalol. There were no differences between the two groups in mean systolic or diastolic pressures, mean gestational age, or initial laboratory findings at time of entry. Patients in the labetalol group demonstrated a statistically significant (P less than .005) decrease in blood pressure during treatment. No such decrease occurred in the hospitalization-alone group. Both groups exhibited significant deterioration in proteinuria, creatinine, and uric acid. The average days of pregnancy prolongation (mean +/- SD) were 21.3 +/- 13 and 20.1 +/- 14 days in the hospitalization and labetalol groups, respectively. There were no differences between the groups regarding any of the following: gestational age at delivery, birth weight, number of infants admitted to the special care unit, or cord blood gas measurements. However, the incidence of small-for-gestational-age infants was significantly higher in the labetalol group (19 versus 9%, P less than .05). There were no stillbirths, but one neonatal death in the labetalol group. Treatment of maternal blood pressure in preeclamptic pregnancies with labetalol did not improve perinatal outcome, and was associated with a higher frequency of fetal growth retardation.

Chronic hypertension in pregnancy.

The course and outcome of 169 pregnancies in 156 women with chronic hypertension were studied. Antihypertensive medications were given if the diastolic blood pressure exceeded 90 mmHg. A number of major associated medical problems were found. Left ventricular hypertrophy, a serum creatinine greater than 1.0 mg%, and a diastolic pressure greater than 100 mmHg at less than 20 weeks' gestation were high-risk indicators. The overall perinatal mortality was 28.4 of 1000 (versus hospital of 25.6 of 1000). Despite antihypertensive therapy, one-third of the patients developed superimposed preeclampsia. The poorest outcome occurred in patients with superimposed preeclampsia necessitating delivery at 27 to 34 weeks' gestation (perinatal mortality = 238 of 1000). Antepartum fetal heart rate testing was abnormal in 10% of the patients with intrauterine growth retardation occurring in 15%. The incidence of fetal growth retardation was fourfold higher (20 versus 5%) in patients treated with antihypertensive drugs, particularly methyldopa as a single agent. However, this may have been related more to the study design than to a detrimental effect of the drug. The perinatal outcome in this study is similar to the outcome of studies in which antihypertensive therapy was withheld. This indicates that controlling the blood pressure is merely one aspect of the management of chronic hypertension in pregnancy. Accurate dating, attention to associated medical problems, antenatal fetal assessment by ultrasound and heart rate monitoring, and carefully timed delivery are additional important factors.

Pulmonary edema associated with pregnancy: echocardiographic insights and implications for treatment.

OBJECTIVE: To evaluate the role of echocardiography in determining the cause of pulmonary edema in pregnancy and the impact this information has on management. METHODS: We studied prospectively 45 pregnant or recently postpartum women admitted to an obstetric intensive care unit with pulmonary edema during a 6-year period. Between 1 and 4 days after the onset of pulmonary edema, two-dimensional and M-mode echocardiography was performed, as was continuous, pulsed, and color Doppler echocardiography. The clinical diagnosis obtained from history, physical examination, chest radiograph, and laboratory data was compared with the echocardiographic diagnosis. RESULTS: Three therapeutically and prognostically distinct groups were identified by echocardiography: 1) those with decreased systolic function (N = 19), 2) those with normal systolic function but increased left ventricular mass and presumed diastolic dysfunction (N = 17), and 3) those with normal hearts (N = 9). During the study period, two patients with systolic dysfunction died and one underwent cardiac transplantation. Patients with systolic dysfunction required short- and long-term treatment with digoxin, diuretics, and angiotensin-converting enzyme inhibitors. Those with diastolic dysfunction received diuretics and long-term antihypertensive therapy. Women with normal hearts required acute therapy only. In 21 patients (47%), echocardiography demonstrated clinically unsuspected findings, which altered the long-term management in 16. CONCLUSION: Because clinical and roentgenographic findings do not accurately differentiate patients with respect to the presence and type of cardiac dysfunction, and because these subgroups differ with respect to treatment and probably prognosis, we recommend echocardiography to evaluate all pregnant women with pulmonary edema.

A comparative trial of labetalol and hydralazine in the acute management of severe hypertension complicating pregnancy.

Sixty peripartum patients with diastolic blood pressures (BP) 110 mmHg or higher were randomized in a 2:1 ratio to receive repeated intravenous injections of either labetalol (20-80 mg) or hydralazine (5 mg) until the diastolic BP was below 100 mmHg. There were four treatment failures in the labetalol group (N = 40) and none in the hydralazine group (N = 20). Hydralazine lowered mean arterial pressure (MAP) more than did labetalol (33.3 +/- 13.2 versus 25.5 +/- 11.2 mmHg; mean +/- SD), but labetalol had a more rapid effect. There was considerable interpatient variability in the dose of labetalol required to control BP, which could not be predicted by any clinical characteristic before therapy. The duration of action also varied in the labetalol group, with the shortest duration occurring in those patients who required the highest dosage for BP control. No significant fetal or neonatal problems ascribable to drug treatment were noted in the 13 instances in which labetalol was given before delivery. However, fetal distress occurred in two of the six cases involving antenatal hydralazine. We conclude that labetalol appears to be a safe and effective alternative to hydralazine for treating hypertension in the peripartum period, but serious rare side effects have not yet been quantified.

Sacroiliitis associated with pyelonephritis in pregnancy.

BACKGROUND: Sacroiliitis is a rare infection and an unusual cause of back pain during pregnancy. Because pregnancy and infections commonly associated with pregnancy are risk factors, this diagnosis should be considered in the gravida with sacroiliac pain. CASE: A 17-year-old woman at 24 weeks' gestation, with a history of illicit drug use, presented to a local emergency room with back and buttock pain. Bacteriuria and pyuria were diagnosed, and cefazolin was initiated. Blood cultures grew Staphylococcus aureus and Escherichia coli. Despite prolonged antibiotic therapy for possible endocarditis, she had persistent debilitating lower back and buttock pain. Radiographic studies detected sacroiliitis, and broadened antibiotic therapy effected cure. CONCLUSION: When sacroiliitis is suspected, diagnostic imaging with either computed axial tomography, or, preferably, magnetic resonance imaging may be helpful. Antibiotic therapy should be tailored to the specific organism involved and continued for 3-6 weeks.

The epidemiology and pathology of maternal mortality: Charity Hospital of Louisiana in New Orleans, 1965-1984.

Eighty-nine maternal deaths occurred at Charity Hospital of New Orleans between 1965 and 1984, for an overall rate of 60.8 per 100,000 live births. The mortality rate increased with increasing maternal age, was greater with cesarean than vaginal delivery, and has not continued to decline over the 20-year interval. Of those decedents delivered abdominally, more than half of the deaths were attributable to operative complications, including anesthesia, rather than to an underlying disease. Although the majority of obstetric deaths were attributable to complications of hypertension, hemorrhage, and infection, the single most common cause at autopsy was pulmonary edema. Potentially preventable pulmonary edema was responsible for one-third of the obstetric deaths from hypertension and hemorrhage.

Circulatory congestion in obese hypertensive women: a subset of pulmonary edema in pregnancy.

We describe four obese, chronically hypertensive women presenting with antepartum pulmonary edema in whom invasive hemodynamic monitoring showed elevated wedge pressure, normal to high cardiac index, and normal systemic vascular resistance. Echocardiography revealed large chambers, thick walls, and increased left ventricular mass with normal systolic but abnormal diastolic function. These findings are indicative of intrinsic volume overload occurring in the presence of impaired left ventricular relaxation, a combination resulting in high filling pressures and pulmonary congestion. Diuretic therapy is indicated in this subset of patients, who could not be recognized by the usual clinical parameters such as history and physical examination, chest x-ray, and arterial blood gas.

The benefit of cesarean section in acute myocardial infarction complicated by premature labor.

A 42-year-old woman with no known risk factors had an acute myocardial infarction at 32 weeks' gestation and went into premature labor. She required invasive hemodynamic monitoring and inotropic support. Congestive heart failure improved dramatically after cesarean section. During the acute infarction, ventricular dysfunction was out of proportion to the ultimate ventricular damage. The concept of the stunned myocardium is used to explain this finding and to justify early cesarean section. Another complication of her infarction, left ventricular thrombosis, has not previously been described in pregnancy.

A placebo-controlled comparative trial of various prenatal vitamin formulations in pregnant women.

The iron-delivery characteristics of three commercially available prenatal vitamin-mineral supplements were studied in a placebo-controlled, randomized cross-over comparison in 40 low-risk women during their second and third trimesters of pregnancy. Each formulation was ingested immediately after a standardized meal. The serum iron concentration was measured at one, three, and six hours after administration. With two of the supplements (Stuart-natal 1 + 1 and Stuart Prenatal tablets), the mean serum iron level at six hours was significantly higher than the mean level at three hours. In contrast, Materna gave the same mean serum level at three hours and at six hours. Calculations of the mean total number of milligrams of iron absorbed after a single dose were 5.7 for Stuart Prenatal, 5.2 for Stuartnatal 1 + 1, and 4.4 for Materna. The results from this study indicate that Stuartnatal 1 + 1, when administered correctly, does provide substantially more iron than the accepted daily requirement during pregnancy.

Fluorescein angiography in toxaemia of pregnancy.

The clinical and fluorescein angiographic findings in 2 cases of retinal detachment occurring in toxaemia of pregnancy are presented. Both cases showed angiographic evidence of abnormal choroidal leakage of dye unassociated with signs of retinal angiospasm. Both cases also showed angiographic evidence of delayed filling of the choriocapillaris. We believe this finding has not previously been reported. These observations provide further clinical evidence that retinal detachment in toxaemia of pregnancy is secondary to choroidal damage.

Acute fatty liver of pregnancy.

AFLP is a syndrome that occurs in the last trimester or postpartum, characterized by jaundice, coagulopathy, and central nervous system disturbances. Renal insufficiency is common. Clinical and laboratory findings are nonspecific. Diagnosis is based primarily on histologic examination of the liver. The cause of AFLP is unknown. The illness has been associated with a high maternal and fetal mortality; with increased awareness and more liberal use of liver biopsy, however, milder forms of the disease are now recognized. Some speculate that AFLP is part of the spectrum of preeclampsia. Liver histology shows microvesicular fat and little or no inflammation or hepatocellular necrosis. Treatment consists of expeditious delivery and maximal supportive care, which may include intensive care unit monitoring, blood component therapy, glucose infusion, sodium restriction, diuretic agents, mechanical ventilation, and dialysis. The role of hepatic transplantation in AFLP appears limited. The risk of mortality during AFLP must be compared with the short- and long-term morbidity and mortality associated with liver transplantation.

Hypertension.

This article reviews some of the salient points in the management of hypertension as recommended by the "Sixth Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure." New developments since publication of this 1997 report are also discussed.

Sudden chest pain and cardiac emergencies in the obstetric patient.

The differential diagnosis and work-up of a patient with chest pain during pregnancy is presented in this article. This is followed by discussions of cardiac emergencies including hypertensive crisis, pulmonary edema, arrhythmias, cardiopulmonary resuscitation, myocardial infarction, and aortic dissection.

Placenta previa.

Placenta previa occurs in approximately one in 200 pregnancies. The cause is unknown, but endometrial damage due to prior pregnancy, cesarean section, and other factors predispose to it. Diagnosis is usually made by transabdominal ultrasonography. False-positive diagnoses are common in the second trimester and the term "potential placenta previa" has been proposed to describe this situation. Bleeding with placenta previa is usually associated with uterine contractions, thus the introduction of tocolysis. Placenta accreta is common in the patient with one or more previous cesarean sections and placenta previa in the current pregnancy. Management of placenta previa is expectant and involves avoidance of digital vaginal examination, delay of delivery until 36 weeks' gestation and/or documented fetal lung maturity, transfusion support to maintain maternal hematocrit greater than or equal to 30%, serial ultrasonography, antepartum fetal heart rate monitoring, glucocorticoids, tocolytic therapy, and elective delivery by cesarean section. Maternal mortality is rare with placenta previa. Perinatal mortality is currently 4% to 8% primarily related to complications of prematurity.

Hemodynamics of preeclampsia.

A review of the English literature reveals considerable disagreement regarding the cardiovascular hemodynamics of preeclampsia as measured by both noninvasive and invasive techniques. In the untreated patient, most of the data suggest the presence of low CO, low PCWP, and elevated SVR as compared to normotensive pregnancy. In contrast, in patients receiving treatment prior to the measurements, the majority of the data indicate the presence of normal to elevated CO, PCWP, and SVR. There is general agreement that plasma colloid oncotic pressure is markedly reduced in patients with severe disease, and this reduction is more dramatic in the postpartum period especially in those receiving excessive crystalloid therapy. As a result, these patients are at increased risk for pulmonary edema. Several studies recommended using plasma and plasma substitutes to correct the reduced plasma volume and PCWP prior to the use of vasodilator therapy in such pregnancies. This management requires the use of invasive hemodynamic monitoring, and its benefit is transient and not well established. Finally, the true cardiovascular hemodynamics of preeclampsia remain unknown.

Obstetric management of gastroenterologic complications of pregnancy.

Key elements in the management of gastroenterologic complications during pregnancy are knowledge of the natural history of the disease process, understanding the effects of pregnancy on the disease and of the disease on pregnancy, concern about fetal effects of medications, careful antepartum fetal assessment, and appropriate timing of the delivery. Vaginal delivery is preferred in most pregnancies complicated by gastrointestinal disease.

Management of acute severe hypertension and encephalopathy.

We still do not have an ideal drug to treat acute severe hypertension in pregnancy. Hydralazine and labetalol are the safest agents, but they are inadequate to control blood pressure in some women. Both hypertensive encephalopathy and eclampsia now appear to be forms of an acute process known as reversible posterior leukoencephalopathy syndrome.

Treatment in an obstetric intensive care unit.

A three-bed intensive care unit was opened in the labor and delivery area of a city-county hospital having approximately 7500 deliveries annually. The utilization rate of 0.9% and the severity of illness were sufficient to justify such a unit. Main indications for admission were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%). Identifiable benefits of the unit were as follows: (1) Intensive observation and organization allowed for prevention of early recognition and treatment of complications; (2) familiarity with invasive monitoring permitted personnel to exert prompt, rational treatment of hemodynamically unstable patients; (3) continuity of care was improved before and after delivery; (4) residents and fellows learned a great deal about intensive care and the management of rare medical complications of pregnancy. We conclude not only that critically ill pregnant women can be managed successfully in an obstetric intensive care unit but also that critical care is a bona fide part of obstetric practice and has been incorporated into our training program.

The central hemodynamics of severe preeclampsia.

Swan-Ganz hemodynamic monitoring in 49 antepartum patients with severe preeclampsia revealed a variable hemodynamic profile. The majority of patients had normal left ventricular filling pressure (8.4 +/- 0.2 mm Hg), normal to high cardiac index (4.4 +/- 0.1 L.min-1.m2), and upper normal to moderately elevated systemic vascular resistance (1226 +/- 37 dynes.sec.cm-5). Eight patients had pulmonary edema and their findings included high wedge pressure (18 +/- 1 mm Hg), upper normal to high cardiac index (4.9 +/- 0.5 L.min-1.m2), and normal systemic vascular resistance (964 +/- 50 dynes.sec.cm-5). Left ventricular function was hyperdynamic in 73% of the 49 patients. Patients with chronic hypertension and superimposed preeclampsia were hemodynamically indistinguishable from patients with preeclampsia alone. We conclude that, in general, preeclampsia is a high cardiac output state associated with an inappropriately high peripheral resistance. The normal wedge and central venous pressures suggest central redistribution of intravascular volume if the generally accepted reports of decreased plasma volume in preeclampsia are correct.