The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department: lessons from 4 tertiary hospitals.

OBJECTIVE: We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. STUDY DESIGN: Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. RESULTS: There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. CONCLUSION: TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Does peripartum infection increase the incidence of cerebral palsy in extremely low birthweight infants?

OBJECTIVES: This study was undertaken to determine the perinatal predictors of cerebral palsy in extremely low birthweight infants (<1000 g). STUDY DESIGN: A case control study of infants with birthweight of less than 1000 g (19 with cerebral palsy and 38 controls) who survived beyond 18-22 months of corrected age was performed. Outcome variables included maternal demographics, obstetric complications, and neonatal outcome (gestational age at delivery, birthweight, Apgar scores, intrauterine growth restriction, respiratory distress syndrome, intraventricular hemorrhage, and neonatal sepsis). Data analysis consisted of t tests, chi2, and analysis of variance when appropriate. RESULTS: There were no significant differences between cerebral palsy and control groups with regard to mode of delivery, Apgar scores, preeclampsia, antenatal vaginal bleeding, or the use of magnesium sulfate. However, male gender (odds ratio 3.70; 95% CI 1.05-12.5), primigravid status (odds ratio 5.52; 95% CI 1.67-18.3), early neonatal sepsis (odds ratio 12.9; 95% CI 2.94-57.2) and chorioamnionitis, both clinical and histologic (odds ratio 3.71; 95% CI 1.16-11.9) were significantly associated with the development of cerebral palsy. The strong association between cerebral palsy and chorioamnionitis, as well as early neonatal sepsis, remain significant after adjustment for primigravid status and male gender. CONCLUSION: In extremely low birthweight infants, cerebral palsy was strongly associated with chorioamnionitis, early neonatal sepsis, male gender, and primigravid status.

Diagnosis and management of women with stroke during pregnancy/postpartum.

Although the incidence of stroke is extremely low, the complications are serious. Maternal mortality has been reported to be as high as 26%. It is important for doctors to be aware of the causes, diagnostic techniques, and management strategies for stroke in order to achieve the best outcome for the mother and fetus. Recurrence risk appears extremely low, so women should feel confident in future positive pregnancy outcomes.

Expression of phosphodiesterase 5 in maternal and fetal sheep.

OBJECTIVE: Ovine pregnancy is associated with elevated levels of nitric oxide. Nitric oxide stimulates cyclic guanosine monophosphate (cGMP), which results in vascular smooth muscle relaxation/vasodilation. Phosphodiesterase type 5 regulates cGMP in the urogenital track. The present study was designed to determine message expression of phosphodiesterase type 5 in the myometrium, uterine vessels, and placentome of the sheep and phosphodiesterase type 5 protein expression in the maternal and fetal placentome. STUDY DESIGN: Tissue was collected from 5 nonpregnant and 5 pregnant anesthetized animals (gestational day = 134 +/- 4) and frozen at -80 degrees C. Optimized reverse transcription-polymerase chain reaction was performed on all tissues, and immunohistochemistry was performed on the placentome only. RESULTS: Phosphodiesterase type 5 messenger ribonucleic acid levels were significantly higher in the myometrium and placentome, compared with the maternal blood vessels. Phosphodiesterase type 5 protein was immuno-localized to the vascular smooth muscle of the maternal vessels, stroma, and placental capsule only. CONCLUSION: Although phosphodiesterase type 5 messenger ribonucleic acid was present in the fetal placenta, phosphodiesterase type 5 protein was expressed only in maternally derived placental tissue. This suggests that regulation of cGMP levels and vascular tone in the umbilical circulation differs from the uterine circulation.

Acute fatty liver of pregnancy in 3 tertiary care centers.

OBJECTIVE: The purpose of this study was to determine the demographics, clinical presentation, and maternal and neonatal outcomes in patients who were diagnosed with acute fatty liver of pregnancy over a 10-year period. STUDY DESIGN: This was a multicenter retrospective study of women with the diagnosis of acute fatty liver of pregnancy. Records were reviewed for symptoms, laboratory findings, clinical course, and maternal and perinatal outcomes. RESULTS: Sixteen cases of acute fatty liver of pregnancy were identified. Three of the 16 cases had multiple gestations (18%). Eleven of the 16 cases were diagnosed in the antepartum period, and 5 cases were diagnosed within 4 days after delivery. Nausea and vomiting were the most common symptoms (75%). There were 2 maternal deaths (12.5%) and 3 fetal deaths (15%). CONCLUSION: We recommend that patients with persistent nausea, vomiting, or epigastric pain in the third trimester receive evaluation of liver enzymes, renal function, and a complete blood count to rule out the diagnosis of acute fatty liver of pregnancy.

Severe preeclampsia and delivery outcomes: is immediate cesarean delivery beneficial?

OBJECTIVE: This study was designed to determine whether immediate cesarean delivery for patients with severe preeclampsia confers any benefit to the mother or neonate. STUDY DESIGN: This retrospective chart review included all deliveries complicated by severe preeclampsia between July 1, 1999, and June 30, 2000. Cesarean deliveries performed for malpresentation, previous classic incision, multiple gestation, placenta previa, and herpetic outbreak were not included. Demographic variables, maternal outcomes, and neonatal outcomes were collected. RESULTS: Of 114 patients, 93 had an option regarding route of delivery. Thirty-four had an immediate cesarean section and 59 had induction of labor. Thirty-seven of 59 were delivered vaginally and 22 of 59 underwent cesarean delivery. Pulmonary complications in the mother and neonate were more common in cesarean delivery (P <.05). No morbidity was decreased by cesarean delivery. Bishop score and gestational age did not affect the labor induction success rate. CONCLUSION: Immediate cesarean delivery confers no benefit to patients with severe preeclampsia.

Maternal and perinatal outcome in women with a history of stroke.

OBJECTIVE: The purpose of this study was to determine recurrence risk and pregnancy outcome in 23 women with a history of stroke. STUDY DESIGN: We conducted a descriptive study of 23 women (35 pregnancies) with a history of stroke. Charts were reviewed from 1990 through 2002. The data were analyzed for the antenatal treatment strategies, recurrence risk for stroke, and pregnancy outcome. RESULTS: There were 23 study patients with 35 subsequent pregnancies. Associated risk factors of the stroke were thrombophilia (5 women), sickle cell disease (3 women), maternal cardiac malformations (3 women), hypertension (3 women), oral contraceptive use (2 women), cerebral arteriovenous malformations (2 women), head trauma (1 woman), meningitis (1 woman), endocarditis (1 woman), and idiopathic reason (2 women). Four women with 9 subsequent pregnancies had a stroke that was associated with a previous pregnancy or postpartum incident. Two of these 9 pregnancies received anticoagulation (heparin, 1 pregnancy; heparin plus aspirin, 1 pregnancy). Nineteen women with 26 subsequent pregnancies had a stroke before pregnancy. Nine of these 26 pregnancies received anticoagulation (heparin, 5 pregnancies; aspirin, 3 pregnancies; heparin plus aspirin, 1 pregnancy). The remaining pregnancies did not receive prophylactic anticoagulation. Overall, there were 21 term deliveries, 8 preterm deliveries, 5 miscarriages, and 1 fetal death. Three of 34 pregnancies (9%) were small for gestational age infants. There were no recurrent thrombotic episodes during pregnancy or after delivery. Maternal complications included admission to the intensive care unit for uncontrolled hypertension in 1 patient. CONCLUSION: Women with a history of stroke have a low risk of recurrent stroke (0%). This information is useful for the prepregnancy counseling of such individuals. The need for prophylactic anticoagulation in patients with a previous stroke cannot be answered by this study.

Delayed postpartum preeclampsia: an experience of 151 cases.

OBJECTIVE: Preeclampsia affects 6% to 8% of pregnancies. There are few data regarding hypertensive disorders that are diagnosed in the postpartum period. Our purpose was to determine the demographics, outcomes, and treatment of this complication. STUDY DESIGN: This was a multicenter retrospective study of women who had received a diagnosis of hypertension/preeclampsia in the postpartum period. Inclusion criteria were readmission of a patient with this diagnosis (