Management of gestational hypertension - the impact of HYPITATa.

AIMS: The objective of this study was to examine the impact of one trial (the HYPITAT trial) on management of gestational hypertension. STUDY DESIGN: This is a retrospective cohort study of 5077 patients delivered at our institution from 7/1/2008 to 6/15/2011. "Pre-HYPITAT" was defined as 7/1/2008-9/30/2009 and "Post-HYPITAT" as 10/1/2009-6/15/2011. The primary outcome is the rate of delivery intervention for gestational hypertension. Secondary maternal and neonatal outcomes were analyzed in patients with gestational hypertension only. Statistical analyses included the χ2-test, Fisher's exact test, and the two-sample t-test. RESULTS: The rate of delivery intervention Pre-HYPITAT was 1.9%, compared to 4% Post-HYPITAT (P<0.001). There was no significant change in secondary outcomes. CONCLUSION: There was a statistically significant increase in delivery intervention for gestational hypertension at our institution after the publication of the HYPITAT trial. There was no significant change in immediate maternal or neonatal outcomes for patients with gestational hypertension.

Advanced oral tongue cancer in a 22-year-old pregnant woman.

OBJECTIVES: Oral squamous cell carcinoma generally occurs in older men and is associated mostly with tobacco and alcohol as the primary risk factors. The incidence of oral squamous cell carcinoma in younger patients has increased. We report a case of a young woman, 25 weeks pregnant, who presented with stage IV carcinoma of the oral tongue. METHODS: The following is a case presentation and literature review. RESULTS: The patient presented with T4 N3 M0 oral tongue cancer. A team consisting of a head and neck surgeon, a radiation oncologist, a medical oncologist, and a maternal-fetal medicine specialist was assembled. The patient initially refused surgery. Chemotherapy was initiated until 32 weeks' gestation. After an infant boy was delivered via cesarean section, the patient began concurrent irradiation and chemotherapy, which induced complete regression of the primary tongue neoplasm with a partial response of the neck nodes. The patient underwent bilateral neck dissection followed by hemiglossectomy for recurrence. CONCLUSIONS: Management of advanced oral carcinoma in pregnancy presents a unique set of challenges. Few studies have described chemotherapy and radiotherapy during pregnancy, and long-term results are needed. Care must be taken to balance appropriate and adequate treatment of disease and to ensure the safety of the patient and the fetus.

Successful use of argatroban during the third trimester of pregnancy: case report and review of the literature.

Direct thrombin inhibitors are commonly used anticoagulants in patients with known or suspected heparin-induced thrombocytopenia (HIT). All three direct thrombin inhibitors available in the United States-argatroban, bivalirudin, and lepirudin-are pregnancy category B drugs based on animal studies, but little data are available on the safety of these agents during human pregnancy. Whereas several case reports support the safe use of lepirudin, only one case report has been published with argatroban and none with bivalirudin. We describe a 26-year-old pregnant woman with portal vein thrombosis and thrombocytopenia treated with argatroban for possible HIT during her last trimester. An argatroban infusion was started at 2 microg/kg/minute during her 33rd week of pregnancy, with the dosage titrated based on the activated partial thromboplastin time; infusion rates ranged from 2-8 microg/kg/minute. Treatment continued until her 39th week of pregnancy, when labor was induced. Argatroban therapy was discontinued 7 hours before epidural anesthesia. The patient successfully delivered a healthy male newborn, devoid of any known adverse effects from argatroban. The infant was found to have a small ventricular septal defect and patent foramen ovale at birth, but it is unlikely that these were caused by argatroban since organogenesis occurs in the first trimester. Even though the cause of this patient's thrombocytopenia was later determined to be idiopathic thrombocytopenic purpura, this is an important case that adds to the literature on use of argatroban during pregnancy.

Preconceptional health: risks of adverse pregnancy outcomes by reproductive life stage in the Central Pennsylvania Women's Health Study (CePAWHS).

This study used population-based data to examine how health status and risks vary by reproductive life stage, with particular focus on the proximal risks for preterm birth and low birthweight (LBW) infants in preconceptional and interconceptional women. Data are from the Central Pennsylvania Women's Health Study (CePAWHS), which included a telephone survey of a representative sample of 2,002 women ages 18-45 years residing in largely rural central Pennsylvania. Women were classified according to reproductive stage--preconceptional, interconceptional, and postconceptional--on the basis of pregnancy history and reproductive capacity. Multiple indicators of health status and health risks were examined by reproductive stage, stratified by age group (ages 18-34 and ages 35-45). Results show that many risk factors varied significantly by reproductive stage and by age group within reproductive stage. Preconceptional and interconceptional women exhibited several unhealthy behaviors (e.g., binge drinking, nutritional deficits, physical inactivity). Younger pre- and interconceptional women (ages 18-34) had more gynecologic infections, some less favorable health behaviors, and more psychosocial stress than older women (ages 35-45) in the same reproductive stages. Older preconceptional women were more likely to have chronic conditions (hypertension, high cholesterol) than younger preconceptional women. Results suggest how interventions could be tailored to women's reproductive stages.

Improving women's preconceptional health: long-term effects of the Strong Healthy Women behavior change intervention in the central Pennsylvania Women's Health Study.

PURPOSE: To investigate the long-term (6- and 12-month) effects of the Strong Healthy Women intervention on health-related behaviors, weight and body mass index (BMI), and weight gain during pregnancy. Strong Healthy Women is a small-group behavioral intervention for pre- and interconceptional women designed to modify key risk factors for adverse pregnancy outcomes; pretest-posttest findings from a randomized, controlled trial have been previously reported. The following questions are addressed: 1) were significant pretest-posttest changes in health-related behaviors (previously reported) maintained over the 12-month follow-up period; 2) did the intervention impact weight and BMI over the 12-month follow-up period; and 3) did the intervention impact pregnancy weight gain for those who gave birth during the follow-up period? METHODS: Data are from 6- and 12-month follow-up telephone interviews of women in the original trial of the Strong Healthy Women intervention (n = 362) and from birth records for singleton births (n = 45) during the 12-month follow-up period. Repeated measures regression was used to evaluate intervention effects. MAIN FINDINGS: At the 12-month follow-up, participants in the Strong Healthy Women intervention were significantly more likely than controls to use a daily multivitamin with folic acid and to have lower weight and BMI. The intervention's effect on reading food labels for nutritional values dropped off between the 6- and 12-month follow-up. Among those who gave birth to singletons during the follow-up period, women who participated in the intervention had lower average pregnancy weight gain compared with controls. Although the intervention effect was no longer significant when controlling for pre-pregnancy obesity, the adjusted means show a trend toward lower weight gain in the intervention group. CONCLUSION: These findings provide important evidence that the Strong Healthy Women behavior change intervention is effective in modifying important risk factors for adverse pregnancy outcomes and may improve an important pregnancy outcome, weight gain during pregnancy. Because the intervention seems to help women manage their weight in the months after the intervention and during pregnancy, it may be an effective obesity prevention strategy for women before, during, and after the transition to motherhood.

Chondroitin sulfate proteoglycan but not hyaluronic acid is the receptor for the adherence of Plasmodium falciparum-infected erythrocytes in human placenta, and infected red blood cell adherence up-regulates the receptor expression.

A low-sulfated chondroitin sulfate proteoglycan (CSPG) has been shown to be the receptor for the adherence of Plasmodium falciparum-infected red blood cells (IRBCs) in human placenta. Recently, hyaluronic acid (HA) has been suggested as an additional receptor even though IRBC binding to HA and the presence of HA at locations where IRBCs adhere in the placenta have not been established. In this study, we investigated whether HA is also a receptor for IRBC binding. IRBCs from infected placentas as well as those from different laboratory strains could bind to CSPG but not to HA. In a cell depletion assay, IRBCs from infected placentas could bind quantitatively to CSPG. Although CSPG is present both in the intervillous space and on the syncytiotrophoblast surface, HA is absent in these locations. These data conclusively demonstrate that CSPG, but not HA, is a receptor for IRBC adherence in the placenta. Our data also show, for the first time, that the IRBC-binding CSPG in the placenta is of fetal origin and that, in P. falciparum-infected placentas, the CSPG level is significantly increased, which could exacerbate IRBC adherence and placental pathogenesis. These results have important implications for the development of anti-IRBC adhesion-based vaccine for pregnancy-associated malaria.