The influence of gestational weight gain on the development of gestational hypertension in obese women.

OBJECTIVE: The objective of this study was to examine the influence of gestational weight gain on the development of gestational hypertension/preeclampsia (GHTN/PE) in women with an obese prepregnancy body mass index (BMI). METHODS: Obese women with a singleton pregnancy enrolled at < 20 weeks were studied. Data were classified according to reported gestational weight gain (losing weight, under-gaining, within target, and over-gaining) from the recommended range of 11 to 9.7 kg and by obesity class (class 1 = BMI 30-34.9 kg/m(2), class 2 = 35-39.9 kg/m(2), class 3 = 40-49.9 kg/m(2), and class 4 ≥ 50 kg/m(2)). Rates of GHTN/PE were compared by weight gain group overall and within obesity class using Pearson chi-square statistics. RESULTS: For the 27,898 obese women studied, rates of GHTN/PE increased with increasing class of obesity (15.2% for class 1 and 32.0% for class 4). The incidence of GHTN/PE in obese women was not modified with weight loss or weight gain below recommended levels. Overall for obese women, over-gaining weight was associated with higher rates of GHTN/PE compared with those with a target rate for obesity classes 1 to 3 (each p < 0.001). CONCLUSION: Below recommended gestational weight gain did not reduce the risk for GHTN/PE in women with an obese prepregnancy BMI. These data support a gestational weight gain goal ≤ 9.7 kg in obese gravidas.

Cervicoisthmic cerclage: transabdominal vs transvaginal approach.

OBJECTIVE: We sought to compare the outcomes of cervicoisthmic (CI) cerclage using traditional transabdominal (TA) approach vs the lesser used transvaginal (TV) approach. STUDY DESIGN: We conducted a retrospective cohort study of women who underwent placement of a CI cerclage. RESULTS: Before CI placement, the abdominal group had a total of 100 pregnancies that continued beyond the first trimester and had 27 (27%) surviving infants. After cerclage placement, there were 34 pregnancies and 24 (71%) surviving infants. Before cerclage placement, the vaginal group had a total of 90 pregnancies that continued beyond the first trimester and had 11 (12%) surviving infants. After cerclage placement, there were 29 pregnancies and 20 (69%) surviving infants. The vaginal cerclage group had a significantly shorter mean operative time of 33 vs 69 minutes, and shorter hospital stay of 0.5 vs 3.2 days. CONCLUSION: Both TV and TA CI cerclage offers select patients with cervical insufficiency improved neonatal survival. The TV placement of a CI has less morbidity than the TA approach with a comparable neonatal survival.

Latency and infectious complications after preterm premature rupture of membranes: impact of body mass index.

OBJECTIVE: Obesity has been associated with chronic inflammation. We hypothesized that body mass index may be inversely related to latency and directly related to infectious complications after preterm premature rupture of membranes. STUDY DESIGN: This secondary analysis of a randomized trial of antibiotics for preterm premature rupture of membranes had information available for 562 subjects. We analyzed the association between body mass index and latency, the occurrence of chorioamnionitis, endometritis, and maternal infectious morbidity after controlling for gestational age at rupture and treatment group. Survival analysis, regression, and test of proportions were used as appropriate. RESULTS: When evaluated as a categorical or continuous variable, body mass index did not reveal any significant associations. Latency to delivery was affected by gestational age at rupture of membrane and antibiotic therapy but not by body mass index group. CONCLUSION: Body mass index was not associated with latency or the occurrence of maternal infectious complications during conservative management of premature rupture of membranes before 32 weeks' gestation.

Management of pregnancies complicated by anti-E alloimmunization.

OBJECTIVE: There is limited information published about anti-E alloimmunization. We review our experience at The Ohio State University to determine appropriate management strategies. METHODS: We reviewed records from June 1959 to April 2004 to identify pregnancies managed for anti-E alloimmunization. Information collected included antibody titers, DeltaOD450 values, Liley zones, middle cerebral artery peak systolic velocity, fetal and neonatal hemoglobin (Hb) and antigen typing, fetal and neonatal direct antiglobulin test, and outcomes. Pregnancies affected only by anti-E alloimmunization with a positive direct antiglobulin test or positive E antigen typing in the fetus or newborn were included. RESULTS: A total of 283 pregnancies were identified with anti-E. Of these, 32 pregnancies in 27 women were at risk for hemolytic disease of the fetus or newborn from anti-E only and had complete records. Sixteen of these pregnancies had titers greater than or equal to 1:32, with amniocenteses performed for DeltaOD450 in 15 pregnancies. Values of DeltaOD450 in zone IIB or zone III in combination with serologic titers identified all pregnancies with fetal or neonatal anemia. Five of 32 (15%) fetuses had Hb less than 10 g/dL and 1 fetus had hydrops fetalis due to anti-E alloimmunization. There was 1 perinatal death attributable to anti-E hemolytic disease of the fetus or newborn. Middle cerebral artery peak systolic velocity was measured in 2 cases and corroborated information obtained from amniocentesis. CONCLUSION: Anti-E alloimmunization can cause hemolytic disease of the fetus or newborn requiring prenatal intervention. Based on our population, clinical strategies developed for Rh D alloimmunization using maternal serology, amniotic fluid spectrophotometry, and fetal blood sampling are useful in monitoring E alloimmunization.

Monochorionic diamniotic infants without twin-to-twin transfusion syndrome.

BACKGROUND: Monochorionic-diamniotic twins (MoDi) occur in 0.3% of all pregnancies. Twin-to-twin transfusion syndrome (TTS) that occurs in 20% of MoDi pregnancies is associated with high perinatal morbidity and mortality. MoDi twins without TTS are more frequent (80%) but have been scarcely reported. OBJECTIVE: To study perinatal morbidity and mortality of 74 MoDi twin sets without TTS and to compare it to that of 38 sets of MoDi twins with TTS. METHODS: Chorionicity was determined by gender and placental examination. Gestational age (GA) was set by sonography and pediatric examination. TTS was diagnosed clinically and by sonography, discordance was defined by twins birth weight difference > or =20%, and fetal growth restriction was determined by using a twin-specific nomogram. RESULTS: MoDi twin pregnancies without and with TTS were similar in demographics, live births, history of preeclampsia, fetal distress and cesarean delivery. They were different (p<0.01) in discordant pregnancies (36 and 79%), GA at delivery (32 and 29 weeks) intrauterine growth restriction (39 and 89%) and neonatal mortality (12 and 36%). Concordant (47 sets) and discordant (27 sets) MoDi twins without TTS were clinically similar. CONCLUSIONS: MoDi twins without TTS have high rates of birth weight discordance, fetal growth restriction, fetal distress, prematurity and cesarean delivery. Although their perinatal mortality is low, the reported occurrence and the short- and long-term impacts of fetal and neonatal morbidities warrants attention.

Mean arterial pressure in concordant and discordant triplets during the first week of life.

OBJECTIVE: To retrospectively determine mean arterial pressure (MAP) for stable concordant and discordant triplets during the first 7 days of life. BACKGROUND: Morbidity and mortality for prematurely born triplets is high, therefore, MAP monitoring during the first day of life is important for their clinical management. MAP reference values for special populations such as triplets have not been published. Recently, we reported that in stable discordant twins MAP values during the first day of life were significantly lower in the smaller than in their larger siblings. Comparable information for triplets is not available. DESIGN: Retrospective cohort study. METHODS: We studied 30 sets of concordant and 29 sets of discordant (birth weight difference > or =20%) consecutively born triplets. Stable patients were defined as those having umbilical cord hemoglobin > or =13 g/dl, normal blood gases, who were never treated for hypotension, and survived at least 7 days. MAP (torr) were measured by oscillometry in 3410, and by transducer via an umbilical arterial catheter in 1251 instances. RESULTS: Concordant and discordant triplets were similar in demographics, history of preterm labor (63 and 63%), chorioamnionitis (10 and 10%), pre-eclampsia (53 and 48%), cesarean delivery (100 and 100%), antenatal steroids (77 and 73%), cord hemoglobin (16 and 16 g/dl), combined triplets birth weight (4922 and 4732 g), gestational age (32 and 33 weeks), normal head ultrasounds or Grade I intracranial hemorrhage (96 and 100%) and neonatal mortality (2 and 1%), but were different in the number of infants requiring mechanical ventilation (57 and 31%). A total of 80 (89%) concordant triplets and 77 (88%) discordant triplets were stable according to our definition. Concordant stable triplets, whether small, medium or large, had similar MAP at birth. Their MAP values increased noticeably from birth to 24 hours and more subtlely to 7 days. Triplets of < or =32 weeks GA had lower MAP throughout than those of > or =33 weeks GA. Discordant stable triplets were divided into 27 small (1382 g), 26 medium (1683 g) and 27 large (1969 g); during the first 24 hours, medium and smaller triplets had MAP values that were lower than those of their larger siblings. From the second to the seventh day of life, all MAP values and trends were similar. Among discordant triplets, 86% of the smallest, 13% of the medium and 13% of the largest infants had asymmetrical intrauterine growth restriction. CONCLUSION: In stable concordant and stable discordant triplets, MAP correlates with birth weight, gestational age and postnatal age. MAP values increase noticeably during the first 24 hours and more subtlely during the next 7 days. Concordant or discordant, small, medium, and large triplets have similar MAP values and trends to that of their siblings. Small and medium discordant triplets have lower MAP values during the first day of life than their larger siblings but by the second day there MAP trends and values were no longer different.

Postcoital vaginal cuff rupture 10 months after a total vaginal hysterectomy. A case report.

BACKGROUND: Transvaginal evisceration following total vaginal hysterectomy secondary to coitus is extremely rare. CASE: A woman presented 10 months following a total vaginal hysterectomy with complaints of progressive postcoital abdominal and shoulder pain as well as a pinkish vaginal discharge. Examination revealed a 3-cm defect at the left edge of the vaginal cuff. Corrective surgery followed overnight observation with pain management. CONCLUSION: Postcoital vaginal cuff disruption is rare, and complications can range from bowel evisceration to hemorrhage. Management should be tailored to the severity of the complications.

New gestational weight gain guidelines: an observational study of pregnancy outcomes in obese women.

In 2009, the Institute of Medicine (IOM) revised their pregnancy weight gain guidelines, recommending gestational weight gain of 11-20 pounds for women with prepregnancy BMI >30 kg/m(2). We investigated the potential influence of the new guidelines on perinatal outcomes using a retrospective analysis (n = 691), comparing obese women who gained weight during pregnancy according to the new guidelines to those who gained weight according to traditional recommendations (25-35 pounds). We found no statistical difference between the two weight gain groups in infant birth weight, cesarean delivery rate, pregnancy-related hypertension, low birth weight infants, macrosomia, neonatal intensive care unit admissions, or total nursery days. Despite showing no evidence of other benefits, our data suggest that obese women who gain weight according to new IOM guidelines are no more likely to have low birth weight infants. In the absence of national consensus on appropriate gestational weight gain guidelines, our data provide useful data for clinicians when providing evidence-based weight gain goals for their obese patients.

Steroid-induced myopathy in the ICU.

OBJECTIVE: To report a case of steroid-induced myopathy resulting from prolonged administration of corticosteroids in an asthmatic patient in a medical intensive care unit. CASE SUMMARY: A 30-year-old white man presented with status asthmaticus requiring intubation for respiratory failure. His hospital course was complicated by the need for reintubation and the development of "quadriplegia." Electromyography does not identify neuropathy. After rapid tapering of systemic steroids, the patient quickly regained muscle strength, was extubated, and was transferred to a rehabilitation facility for prolonged physical therapy. DISCUSSION: Steroid-induced myopathy is a rare occurrence in the intensive care setting. Cases of myopathy that have been reported have been associated with prolonged and combined use of corticosteroids with neuromuscular blocking agents or aminoglycosides. Corticosteroids are thought to produce deleterious effects through 1 or all of 3 main pathways: altered electrical excitability of muscle fibers, loss of thick filaments, and/or inhibition of protein synthesis. All of these pathways are believed to increase the rate of muscle catabolism and result in loss of muscle movement. CONCLUSIONS: Steroid-induced myopathy is a complication of high-dose steroid use. Unfortunately, in this patient, initial treatment of status asthmaticus required intravenous steroids in high doses to adequately treat the presenting illness. Clinicians should be aware of neuromuscular findings and act aggressively to appropriately eliminate systemic steroids from the treatment regimen.