Perinatal and maternal outcome following abruptio placentae.

OBJECTIVE: To characterize the maternal and fetal presentation of abruptio placentae and associated maternal and fetal morbidity and mortality by mode of delivery and fetal status on admission. STUDY DESIGN: Perinatal data (gestational age > 24 weeks) from women with abruptio placentae at a tertiary referral center were analyzed. For the purpose of evaluating fetal morbidity and mortality, group 1 included women with hypertensive disorders of pregnancy (preeclampsia or chronic hypertension), PROM, cocaine abuse, and > 20% abruptio placentae without regard to fetal status on admission (reassuring, nonreassuring, or stillborn). In group 1, either umbilical artery pH < 7.0, Apgar < 3(5), or base excess > 12 mmol/L represented perinatal hypoxia for this evaluation. Group 2 included women with stillborn fetuses on admission without regard to etiology or size of abruptio placentae. Comparisons between groups were made with one-way analysis of variance, Kruskal-Wallis, or chi2 tests; p < 0.05 was considered significant. RESULTS: Group 1 was comprised of 342 women; 58.4% of fetuses had abnormal fetal heart rate tracings. Overall, the sensitivity of an abnormal fetal heart rate tracing to predict perinatal hypoxia was 87.2%, specificity was 33.9%, positive predictive value was 22.2%, and negative predictive value was 92.5%. Of parameters suggestive for perinatal hypoxia, 17.3% of neonates had Apgar < 3(5), 13.0% had umbilical artery pH < 7.0, and 9.9% had base excess > 12 mmol/L. Overall, neonatal survival was 84.7%; 12.0% of fetuses were stillborn. For those fetuses alive on admission, cesarean delivery was associated with a significant reduction in neonatal mortality: odds ratio of 0.10 (95% confidence interval: 0.05-0.20) and p = 0.0001. Group 2 was comprised of 61 women. Women presenting with a stillborn infant on admission were more likely to require transfusions and suffer the complications (disseminated intravascular coagulopathy, acute renal failure, and acute respiratory distress syndrome) than women presenting with a live fetus. CONCLUSION: Cesarean delivery appeared to reduce neonatal mortality. Whether emergent cesarean delivery resulted in the birth of compromised fetus cannot be evaluated from this study. Composite maternal morbidity is increased when a stillborn fetus is present on admission.

Postpartum stroke: a twenty-year experience.

OBJECTIVE: The aim of this study was to characterize the clinical presentation, etiology, and acute and subsequent outcomes of postpartum stroke. STUDY DESIGN: This 20-year, single-center, retrospective review included 20 women without previous neurologic deficit with clinical and neuroimaging diagnoses of postpartum stroke. RESULTS: Eight of 20 women (40%) were delivered abdominally. Conduction anesthesia was induced in 9 of 20 women (45%). Causes of stroke included cerebral infarction (n = 13; 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced, 1 anatomic malformation), cerebritis (n = 1), and cerebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemiparesis were the most common presenting findings but were neither specific to the underlying pathologic condition nor predictive of ultimate maternal outcome. There were 2 maternal deaths, both caused by severe intracerebral hemorrhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurologic deficit. There was no correlation between a trial of labor (P =.4; odds ratio, 0.4; 95% confidence interval, 0.01-6.5) or vaginal versus cesarean mode of delivery (P =.6; odds ratio, 1.3; 95% confidence interval 0.1-16.8) and ultimate neurologic diagnosis (cerebral infarction or intracerebral hemorrhage). However, the incidence of cesarean delivery was greater in the cohort of women with postpartum stroke than in the overall obstetric population (P =.015; odds ratio, 3.2; 95% confidence interval, 1.2-8.5). One of the 20 women received methergine; 1 received bromocriptine. All women were either normotensive or had well-controlled hypertension at postpartum discharge. New-onset hypertension or exacerbation of existing hypertension occurred after the acute neurologic insult; subsequent mean (+/-SD) arterial blood pressure was 128.9 +/- 24.0 mm Hg. CONCLUSION: Postpartum stroke is a multifactorial, uncommon, and nonpreventable complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. However, this study refutes any etiologic association between conduction anesthesia and postpartum stroke.

Predictors of neonatal outcome in women with severe preeclampsia or eclampsia between 24 and 33 weeks' gestation.

OBJECTIVE: We sought to characterize predictors of neonatal outcome in women with severe preeclampsia or eclampsia who were delivered of their infants preterm. STUDY DESIGN: We performed a retrospective analysis of 195 pregnancies delivered between 24 and 33 weeks' gestation because of severe preeclampsia or eclampsia. Multiple logistic regression and univariate chi(2) analysis were performed for the dependent outcome variables of survival and respiratory distress syndrome by use of independent fetal and maternal variables. A P value of <.05 was considered significant. RESULTS: In the multivariate analysis, respiratory distress syndrome was inversely related to gestational age at delivery (P =.0018) and directly related to cesarean delivery (P =.02), whereas survival was directly related to birth weight (P =.00025). There was no correlation in the multivariate analysis between respiratory distress syndrome or survival and corticosteroid use, composite neonatal morbidity, mean arterial pressure, eclampsia, or abruptio placentae. In the univariate analysis respiratory distress syndrome was associated with cesarean delivery (odds ratio, 7.19; 95% confidence interval, 2. 91-18.32). The incidence of intrauterine growth restriction increased as gestational age advanced. Furthermore, intrauterine growth restriction decreased survival in both the multivariate (P =. 038; odds ratio, 13.2; 95% confidence interval, 1.16-151.8) and univariate (P =.001; odds ratio, 5.88; 95% confidence interval, 1. 81-19.26) analyses. CONCLUSION: The presence of intrauterine growth restriction adversely affected survival independently of other variables. Presumed intrauterine stress, as reflected by the severity of maternal disease, did not improve neonatal outcome.

Presentation of venous thromboembolism during pregnancy.

OBJECTIVE: We sought to characterize the presentation, recurrence, and outcome of venous thromboembolism during pregnancy. STUDY DESIGN: We performed a 12-year, single-center, retrospective review of 38 patients with venous thromboembolism during pregnancy. The independent variables were subjected to univariate analysis (unpaired t test for normally distributed continuous variables and Fisher exact test for discrete variables). P <.05 was considered significant. RESULTS: There was no significant difference for the following variables according to time of presentation (antepartum vs post partum): gestational age at delivery (37.4 +/- 6.6 wk vs 38.1 +/- 2.4 wk; P =.7), birth weight (3257 +/- 458 g vs 3093 +/- 719 g; P =.3), and mode of delivery (2 vs 4 cesarean deliveries; P =.15). There were 2 maternal deaths. All 3 women with antepartum recurrent venous thromboembolism (despite heparin prophylaxis) had findings of protein C deficiency, protein S deficiency, and lupus anticoagulant-anticardiolipin antibody, respectively. CONCLUSION: The gestational age at presentation appears more equally distributed throughout gestation than previously reported. Notwithstanding limited numbers, the recurrence of venous thromboembolism despite use of prophylactic heparin therapy suggests the need to reexamine the current recommendations for heparin dosing.

Risk factors for abruptio placentae and eclampsia: analysis of 445 consecutively managed women with severe preeclampsia and eclampsia.

OBJECTIVE: Our purpose was to characterize the clinical presentation or laboratory variables predictive of either abruptio placentae or eclampsia in women with severe preeclampsia. STUDY DESIGN: Prospective collection of perinatal data from 445 consecutively managed women with severe preeclampsia and eclampsia. Univariate analysis was used to determine which of the independent variables were significantly different between the groups (abruptio placentae vs no abruptio placentae; eclampsia vs no eclampsia). Those with significant differences were then entered into multiple logistic regression analysis to determine those characteristics that were independently related to the outcome variable (abruptio placentae or eclampsia). Before multivariate analysis, the independent variables with an interval scale of measurement were converted to a dichotomous scale, with the receiver-operator characteristic curve used to determine a cutoff level. RESULTS: Univariate analysis revealed statistical significance for the following variables associated with eclampsia: uric acid concentration, > 8.1 mg/dL; proteinuria (>3+); headache; visual symptoms; deep tendon reflexes >3+; serum albumin concentration, <3 mg/dL; and serum creatinine concentration, >1.3 mg/dL. However, with subsequent multivariate analysis, only headache and deep tendon reflexes >3+ remained significant. Univariate analysis for variables associated with abruptio placentae revealed an association between bleeding and platelet count <60,000/mm3. There was no association between abruptio placentae and eclampsia and systolic, diastolic, or mean arterial pressure, quantitative proteinuria, epigastric pain, bleeding, gestational age at delivery, history of preeclampsia, or chronic hypertension. CONCLUSION: Quantitative proteinuria and degree of blood pressure elevation were not predictive of either abruptio placentae or eclampsia, as has previously been suggested. The greatest morbidity associated with eclampsia occurred in women with preterm gestations not receiving medical attention.

Counseling for women with preeclampsia or eclampsia.

Preconception counseling may address issues such as nutrition, prevention and prediction of preeclampsia, utility of prenatal visits and fetal surveillance, risk of superimposed preeclampsia, recurrence risks for future gestation, diagnosis of underlying predisposing factors, and potential impact on future maternal and fetal health. Although certainty is lacking in medicine, it appears that minimal risk to either mother or fetus is attributable to mild chronic hypertension complicating pregnancy. Increased maternal and fetal morbidity is associated with superimposed preeclampsia. Unfortunately, we are unable to predict which of these gravidas will have superimposed preeclampsia and thus suffer added morbidity. There appears to be a greater than 50% chance of maternal or fetal morbidity for those women entering pregnancy with severe chronic hypertension in association with other renocardiovascular complications. Unfortunately, for the majority of women whose medical condition falls between these two extremes, the current predictive value remains vague. The best option is to review the existing literature with patients in a nondirective manner, allow them their decisions, and provide them the best available prenatal care.

Magnesium sulfate therapy in preeclampsia and eclampsia.

OBJECTIVE: To review the available evidence regarding efficacy, benefits, and risks of magnesium sulfate seizure prophylaxis in women with preeclampsia or eclampsia. DATA SOURCES: The English-language literature in MEDLINE was searched from 1966 through February 1998 using the terms "magnesium sulfate," "seizure," "preeclampsia," "eclampsia," and "hypertension in pregnancy." Reviews of bibliographies of retrieved articles and consultation with experts in the field provided additional references. METHODS OF STUDY SELECTION: All relevant English-language clinical research articles retrieved were reviewed. Randomized controlled trials, retrospective reviews, and observational studies specifically addressing efficacy, benefits, or side effects of magnesium sulfate therapy in preeclampsia or eclampsia were chosen. TABULATION, INTEGRATION, AND RESULTS: Nineteen randomized controlled trials, five retrospective studies, and eight observational reports were reviewed. The criteria used for inclusion were as follows: randomized controlled trials evaluating use of magnesium sulfate in eclampsia, preeclampsia, and hypertensive disorders of pregnancy; nonrandomized studies of historical interest; "classic" observational studies; and recent retrospective studies evaluating efficacy of magnesium sulfate therapy, using relative risk and 95% confidence intervals where applicable. Magnesium sulfate therapy has been associated with increased length of labor, increased cesarean delivery rate, increased postpartum bleeding, increased respiratory depression, decreased neuromuscular transmission, and maternal death from overdose. A summary of randomized, controlled trials in women with eclampsia reveals recurrent seizures in 216 (23.1%) of 935 women treated with phenytoin or diazepam, compared with recurrent seizures in only 88 (9.4%) of 932 magnesium-treated women. Randomized controlled trials in women with severe preeclampsia collectively revealed seizures in 22 (2.8%) of 793 women treated with antihypertensive agents, compared with seizures in only seven of 815 (0.9%) magnesium-treated women. CONCLUSION: The evidence to date confirms the efficacy of magnesium sulfate therapy for women with eclampsia and severe preeclampsia. However, there is a need for a randomized controlled trial to determine efficacy of magnesium sulfate therapy for women with mild preeclampsia and gestational hypertension.

Peripartum cardiomyopathy: a longitudinal echocardiographic study.

OBJECTIVE: Our purpose was to determine echocardiographic trends after initial diagnosis of peripartum cardiomyopathy. STUDY DESIGN: Nine women diagnosed with peripartum cardiomyopathy were prospectively recruited for a longitudinal echocardiographic study. Severe myocardial dysfunction was defined as left ventricular end-diastolic dimension > or = 60 mm + fractional shortening < or = 21%, and mild dysfunction was defined as left ventricular end-diastolic dimension < 60 mm + fractional shortening 22% to 24%. Unpaired t tests were used to compare sample means and Fisher's exact test used to compare discrete variables. RESULTS: All women were seen initially for pulmonary edema. Echocardiography showed decreased systolic function in all women. The mean age at diagnosis was 33.0 +/- 6.9 years. All but one woman had a diagnosis of either chronic hypertension (n = 6) or preeclampsia (n = 2). Four women were first seen ante partum and five post partum (range 1 day to 2 months). Repeat echocardiography was performed in all nine women (median 8 months, range 6 weeks to 5 years). There was no correlation between antepartum or postpartum presentation and cardiovascular status on follow-up (p = 0.3). Values for initial left ventricular end-diastolic dimension, severe versus mild dysfunction (68.3 +/- 7.2 mm vs 55.0 +/- 4.2 mm, p = 0.046), follow-up left ventricular end-diastolic dimension, severe versus mild (68.7 +/- 4.1 mm vs 52.0 +/- 5.7 mm, p = 0.002), and follow-up fractional shortening, severe versus mild (14.6% +/- 5.0% vs 28.5% +/- 9.2%, p = 0.02) are significant. Six of the seven women with severe dysfunction had stable disease in follow-up and one is awaiting heart transplant. One of the two women with mild dysfunction had disease resolution and one had stable disease. CONCLUSION: Patients with severe myocardial dysfunction due to peripartum cardiomyopathy are unlikely to regain normal cardiac function on follow-up.

Asthma in pregnancy.

Asthma is the most common respiratory crisis complicating pregnancy. Asthma is a heterogeneous lung disease characterized by reversible airway obstruction, airway inflammation, and airway hyperresponsiveness. The cornerstone of management involves the use of inhaled beta2-receptor agonists and inhaled corticosteroids. Poor control and exacerbations of asthma during pregnancy may result in maternal hypoxia with resultant decreases in fetal oxygen saturation and fetal hypoxia, which has been associated with an increased incidence of low birth weight, intrauterine growth restriction, and cesarean delivery. Therefore, the goals of therapy are to maintain normal pulmonary function, control symptoms, prevent exacerbations, avoid adverse effects of medication, and deliver a healthy baby.

Cerebrovascular disorders complicating pregnancy--beyond eclampsia.

OBJECTIVE: Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium. STUDY DESIGN: Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded. RESULTS: The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure > or = 110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation. CONCLUSION: Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor.

The effect of magnesium sulfate therapy on the duration of labor in women with mild preeclampsia at term: a randomized, double-blind, placebo-controlled trial.

OBJECTIVE: The primary outcome was to determine whether magnesium sulfate therapy prolongs the duration of labor in women with mild preeclampsia. Secondary outcomes were to assess the side effects associated with magnesium sulfate therapy: hours and maximum dose of oxytocin, incidence of progression to severe preeclampsia, incidence of cesarean delivery, change in maternal hematocrit, incidence of postpartum hemorrhage, incidence of maternal infection, and Apgar scores. STUDY DESIGN: Women with a diagnosis of mild preeclampsia at term were randomized to receive standard therapy during labor and for 12 hours post partum with either magnesium sulfate (n = 67) or a matching placebo solution (n = 68). RESULTS: There was no difference between magnesium sulfate and placebo with respect to the primary outcome variables: total length of labor (median 17.8 hours vs 16.5 hours, p = 0.7) and length of the active phase of labor (median 5.4 hours vs 6.0 hours, p = 0.5). In addition, no difference was observed in the secondary outcome variables: hours of oxytocin use, change in hematocrit, frequency of maternal infection, progression to severe preeclampsia, incidence of cesarean delivery, and Apgar scores. Although not statistically significant, the incidence of postpartum hemorrhage was approximately fourfold greater in the magnesium sulfate group (relative risk 4.1, 95% confidence interval 0.5 to 35.4). There was a significant difference in the maximum dose of oxytocin used (13.9 +/- 8.6 mU/min with magnesium sulfate vs 11.0 +/- 7.6 mU/min with placebo, p = 0.036). CONCLUSION: The use of magnesium sulfate during labor in women with mild preeclampsia at term does not affect any component of labor but did necessitate a higher dose of oxytocin.

Hypertension in pregnancy: current concepts of preeclampsia.

Hypertensive disorders (gestational hypertension, preeclampsia, chronic hypertension, superimposed preeclampsia) are the most common medical complications of pregnancy and constitute a major cause of maternal and perinatal morbidity and mortality. Prediction of those women destined to develop preeclampsia remains elusive. The benefits of calcium supplementation for prevention of preeclampsia are encouraging; however, the definitive study is not yet complete. Aspirin therapy for high-risk has not been helpful; results of therapy for high-risk women are pending. More experience is being gained with antihypertensive therapy and expectant management in severe preeclampsia. Conservative management of severe preeclampsia, when performed in a tertiary care center, may benefit a select group of women and their fetuses.

Peripartum cardiomyopathy: an ominous diagnosis.

OBJECTIVE: Our purpose was to review and characterize the initial presentation, etiology, and prognosis of peripartum cardiomyopathy. STUDY DESIGN: Cases of peripartum cardiomyopathy confirmed by echocardiography were prospectively collected between 1986 and 1994. RESULTS: A total of 28 patients without an antecedent history of heart disease were diagnosed with peripartum cardiomyopathy. Common associated disorders included preeclampsia or chronic hypertension (19), alcohol abuse (2), family history (2), and multiple tocolytic therapy (2). Five deaths occurred (18% mortality), 3 patients received heart transplants (11%), 18 continued with cardiac impairment (64%), and only 2 patients (7%) had regress on of cardiomyopathy. The perinatal mortality rate was 36 per 1000 births. Six patients had seven subsequent pregnancies; 4 patients decompensated earlier in the subsequent pregnancy, 1 patient remained well compensated on medical therapy in spite of poor systolic function and a dilated left ventricle, and 1 patient had two subsequent pregnancies without recurrence of cardiac compromise. CONCLUSION: The unique hemodynamic stresses of pregnancy unmask previously undiagnosed cardiomyopathy in otherwise medically stable individuals. The prognosis for these patients is guarded.

Septic pelvic thrombophlebitis or refractory postpartum fever of undetermined etiology.

The objective of this study was to review and characterize the presentation, diagnostic dilemmas, management, and prognosis of postpartum septic pelvic thrombophlebitis. Medical records of postpartum women with the diagnosis of septic pelvic thrombophlebitis were reviewed for the 8-year period 1986-1994. Cases of documented ovarian vein thrombosis or those with other pelvic pathology on imaging study were excluded. Thirty-one women, four following vaginal delivery and 27 following cesarean delivery, with a final diagnosis of septic pelvic thrombophlebitis were identified. All patients demonstrated refractory febrile morbidity (mean 5.5 +/- 1.9 days prior to instituting heparin therapy) despite multiagent antimicrobial therapy with ampicillin, gentamicin, and clindamycin. Imaging studies (CT and/or ultrasound) were performed in 20 women and revealed no pelvic pathology. The patients required an average of 4.7 +/- 2.1 days (median 5, range 1-9 days) of heparin therapy before defervescence. Heparin levels were therapeutic at a mean of less than 24 h (range 6-24 h). The average dose of heparin required was 16.0 +/- 3.0 U/kg/h. Nine women had 13 subsequent pregnancies without recurrent thromboembolic complications. Currently available imaging studies cannot diagnose the entity we now define as septic pelvic thrombophlebitis (once cases of ovarian vein thrombosis are excluded). Our findings do not support the time-honored rule that septic pelvic thrombophlebitis responds within 24-48 h to therapeutic anticoagulation with heparin. Therefore, criteria other than imaging studies or immediate defervescence following heparin therapy are necessary for diagnosis of septic pelvic thrombophlebitis. A more appropriate terminology for septic pelvic thrombophlebitis should be refractory postpartum fever of undetermined etiology.