Corticosteroids for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP): what evidence?

The fundamental premise that has governed the proposal relative to the use of corticosteroids for the purpose of disease modification in Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) syndrome was that pre-eclampsia is a condition characterized by an inappropriate maternal systemic inflammatory response and possibly immune-mediated impairment in maternal-fetal communication, while corticosteroids have the capacity to exercise anti-inflammatory and immunosuppressive effects. The present article reviews the evidence behind this proposal, concluding that corticosteroids administration, either antepartum or postpartum, does not improve the outcome of pregnancies affected by HELLP syndrome. The risks associated with such an approach, especially in fetuses manifesting growth restriction and absent end-diastolic flow, are also discussed. The literature published in English between 1990 and 2006 was searched for papers dealing with corticosteroids treatment for disease modification in pre-eclampsia and HELLP syndrome, using a combination of keywords including ''HELLP syndrome '', ''pre-eclampsia'', ''corticosteroids'', and ''maternal and fetal outcomes''. The MEDLINE bibliographic database yielded 9 studies relevant to this topic, including one retrospective analysis, 7 randomized trials, and one meta-analysis. Until more convincing data become available, corticosteroids for disease modification in women with HELLP syndrome should not be used outside the setting of an approved investigational protocol.

Loss of heterozygosity in Wilms' tumour involves two distinct regions of chromosome 11.

Pairs of tumour and normal DNA samples from 38 Wilms' tumour patients have been investigated for loss of heterozygosity using 12 probes from chromosome 11. Allele loss was detected in only 11 cases (31%). Densitometric analysis showed that allele loss was not due to non-disjunction or hemizygous deletion, but rather to mitotic recombination or non-disjunction plus reduplication. Although the development of homozygosity sometimes involved the whole of the short arm of chromosome 11, in a few tumours allele loss was restricted to band 11p15 or 11p13 and distal sequences. This suggests mutations in two distinct regions play an important role in Wilms' tumorigenesis. There was no apparent correlation between loss of heterozygosity and tumour stage, age of presentation, or prior exposure to chemotherapy.

Preferential loss of maternal alleles in sporadic Wilms' tumour.

Loss of heterozygosity at loci on the short arm of chromosome 11 has been reported in 31% (11/38) of Wilms' tumours in our series. Lymphoblastoid cell lines were prepared from the parents of 10/11 of the patients showing allele loss in their tumours. In 9 of the cases, where the parental origin of the alleles could be followed, it was the paternal alleles which were retained in the tumour. This preferential loss of the maternal alleles implies a role for genomic imprinting in the pathogenesis of Wilms' tumour.

Validation of the 1988 ACOG forceps classification system.

In February 1988, an ACOG Committee Opinion substantially revised the classification of forceps operations. The revision addressed two significant shortcomings of the old system: Outlet forceps had been defined too narrowly and midforceps too imprecisely. We now report the results of a prospective study of 357 forceps deliveries classified using each system. Allowing up to 45 degrees of rotation in an outlet forceps delivery did not increase morbidity measured by any criterion. Dividing the old midforceps group by precisely identifying station and rotation permitted greater stratification of the risks of short-term neonatal and maternal morbidity. We conclude that our results validate the 1988 classification scheme.

Meconium in the amniotic fluid and fetal acid-base status.

Of 323 pregnancies with meconium-stained amniotic fluid at 36-42 weeks' gestation, 68 (21%) had a pH less than 7.20 in umbilical arterial blood, 21 (7%) had a pH less than 7.15, and only three newborns (0.9%) had true metabolic acidemia. At birth, of the 74 newborns with normal electronic fetal heart rate (FHR) tracings, eight (11%) had an umbilical arterial pH less than 7.20. There was a significantly higher frequency of acidemia (defined as pH less than 7.20) in newborns with both baseline and periodic FHR abnormalities. Although there was a significant difference (P less than .05) in the frequency of meconium found below the cords in these neonates with an umbilical artery pH less than 7.20 compared with those with values exceeding 7.20, there was no significant difference in the frequency of clinical meconium aspiration syndrome. We conclude that meconium-stained amniotic fluid correlates poorly with infant condition at birth as reflected by umbilical cord acid-base measurements.

Early repair of episiotomy dehiscence.

Early repair of episiotomy dehiscence was performed in 22 women with an initial fourth-degree episiotomy, four with third-degree episiotomy, and five with a mediolateral episiotomy. Early complications were limited to development of a pinpoint rectovaginal fistula in two women, both subsequently repaired by a rectal mucosal flap procedure. Of the 27 women now 1 year or more post-repair, all are completely continent and report resumption of normal coital activity.

Prenatal corticosteroid therapy to prevent respiratory distress syndrome.

Recently, an editor observed that the number of clinical trials has multiplied and that several trials of the same treatment may be published serially over a span of 10 years or more. He was not discussing antenatal CS therapy, was he? He added that meta-analysis should decide whether characteristics of patients, their therapies, and outcomes in each trial are comparable. Were they? Neither controlled trials in large numbers nor meta-analysis of these trials have swayed obstetricians toward routine use of antenatal CS as a single intervention. Perhaps the data from studies of combined hormonal therapy or of prenatal-postnatal therapy, or of a combination of both of these approaches will increase the use of antenatal CS. Ironically, maybe a retrospective study will provide the stimulus. Time will tell.

Does asphyxia cause cerebral palsy?

The incidence of cerebral palsy is 1 per 1,000, whereas the proportion caused by perinatal asphyxia is only 8% to 10%. The purpose of this article is to review the relationship between asphyxia and cerebral palsy. Only a minority of cases, those involving severe pathological fetal academia, are consistently associated with neonatal encephalopathy and an increased risk of cerebral palsy.

Group A beta-hemolytic Streptococcus as a cause of toxic shock syndrome. A case report.

Group A beta-hemolytic Streptococcus (pyogenes) has been associated recently with toxic-shock-like syndrome similar to staphylococcal toxic shock as described originally in 1978. A group A beta-hemolytic streptococcal infection occurred in a recent postpartum patient and clinically resembled staphylococcal toxic shock.

Amniotic cavity accumulation of magnesium with prolonged magnesium sulfate tocolysis.

In seven women, continuous intravenous tocolysis with magnesium sulfate for 4-28 days resulted in high amniotic fluid magnesium levels (10.54 mg% +/- 1.83 SD). In all cases the amniotic fluid magnesium level greatly exceeded the maternal serum level in a sample collected simultaneously. Additionally, when amniorrhexis and delivery occurred within one hour of each other, the fetal magnesium levels uniformly exceeded the maternal levels in paired maternal and cord blood samples.

Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity.

OBJECTIVE: To review the management of puerperal vulvovaginal hematomas and report on the use of closed system drainage in cases in which operative intervention was used. STUDY DESIGN: A retrospective review of medical records for a five-year period was conducted. The charts of all patients in whom puerperal vulvovaginal hematomas occurred were reviewed and data extracted regarding possible etiologic factors, details of delivery, characterization of the hematoma, surgical intervention and type of drain used. Also recorded was length of stay and postoperative complications. RESULTS: Eleven patients with hematomas were identified, for an incidence of 1/526. All patients received antibiotics; transfusion was required in eight patients. Drains were used in nine patients: Penrose in four and closed system drainage in five. All drains were brought through a separate site distant from the repair. There was one postoperative abscess, which resolved with wound care, resulting in no long-term morbidity. CONCLUSION: Puerperal vulvovaginal hematomas may be a life-threatening event. Review of the literature and our experience suggests that aggressive operative management and the use of drains are beneficial in the management of these patients. Closed system drainage may be an effective adjunct in the management of vulvovaginal hematomas.

Karyotypic abnormalities and hydramnios. Role of amniocentesis.

Hydramnios complicates up to 1.6% of pregnancies, with major fetal malformations found in an average of 20% of patients with hydramnios. Chromosomal abnormalities, although associated with some conditions in which hydramnios is present, have not been reported to complicate a significant percentage of hydramnios cases. Data from 45 patients admitted during the period January 1, 1985-May 31, 1990, were analyzed. All patients had hydramnios sufficiently severe to merit hospitalization for diagnosis and/or treatment. Amniocentesis was performed at the discretion of the attending physician and not under a specific protocol. The incidence of major fetal structural malformations was 36%. Of patients in whom amniocentesis was performed, 22% were found to have karyotypic abnormalities, none of which was specifically suspected prior to the amniocenteses. Neither the estimated gestational age nor the assessment of the amount of amniotic fluid differed between those with karyotypic abnormalities and those with normal chromosome complements. This information suggests that both advanced ultrasound studies and amniocentesis are beneficial in the evaluation of hydramnios.

Teaching the Laufe-Piper forceps technique at cesarean delivery.

OBJECTIVE: To present a method of teaching forceps technique during cesarean delivery of breech-presenting infants using Laufe-Piper forceps and to evaluate its usefulness. STUDY DESIGN: For several years, residents at the University of Texas Medical Branch, Galveston, have learned and practiced Piper forceps technique during cesarean delivery. To assess their experience with this method, we mailed questionnaires to third- and fourth-year residents and recent graduates of the Galveston program. The same surveys were mailed to a control group of residents and recent graduates of two other programs where this teaching exercise is not practiced routinely. RESULTS: Responses were received from 32 (74%) study subjects and 63 (71%) controls. Demographic characteristics and experience with vaginal breech delivery were similar between the two groups. Respondents from the Galveston program noted greater annual use of forceps for vaginal delivery of cephalic-presenting infants (P = .012). They also rated themselves as more comfortable (P = .023) and more skilled (P = .006) with Piper forceps than controls. Of 53 respondents who had had previous experience with this teaching method, 47 noted that it provided a great or moderate educational benefit, and 36 strongly or moderately believed it gave them more confidence in using Piper forceps during vaginal breech delivery. Using multiple regression analysis, sex, overall level of experience, Piper forceps experience during vaginal delivery and overall forceps use were stronger determinants of self-rated comfort and skill than was experience with Laufe-Piper forceps during cesarean. CONCLUSION: Laufe-Piper forceps can be used for cesarean delivery of breech-presenting infants. This practice promotes confidence and skill for their use at vaginal delivery.

Guidelines for establishing a maternal serum alpha-fetoprotein screening program.

Maternal serum alpha-fetoprotein (MSAFP) screening of all pregnant women between 15 and 20 weeks gestational age is generally recognized as a standard of care in current obstetric practice. There are many factors to consider when deciding to establish MSAFP testing as an in-house procedure versus ship-out testing by a reference laboratory at fee-for-service cost. In this report, we review clinical and analytical aspects of MSAFP testing, along with appropriate guidelines for establishing an on-site MSAFP screening program.

Theoretic considerations regarding slow cooling and vitrification during cryopreservation.

This review presents the methodology of using theoretic models for development of cryopreservation protocols by designing specific cooling profiles and selecting appropriate external conditions to optimize cryopreservation survival. Biophysical events during the processes of cryopreservation were examined and corresponding theoretic equations were used to simulate cryopreservation procedures under various slow cooling conditions for rat zygotes in the presence of DMSO, using a 0.25-mL plastic straw as the container. Simulation revealed three regions with their own characteristics and cryopreservation relevance. In addition, this review discusses vitrification cryopreservation using two-step additions. The effects of exposure durations and exposure temperatures on cell survival and subsequent development rates were examined in a series of cryopreservation experiments. Values of accumulative osmotic damage were used to quantitatively examine the magnitude of the associated osmotic damage during cryoprotective agent (CPA) additions and dilutions. In these investigations, oocyte blastocyst rates were highly correlated with the values of accumulative osmotic damage in the processes of CPA additions/dilutions. This review emphasizes the most essential step of the selection of the cell container in the process of cryopreservation, and provides practical suggestions and guidelines for optimizing slow cooling protocols. The review stresses that conducting CPA addition steps at 25 °C would be preferable for vitrification. It also suggests that the final dilution process needs more systematic research to optimize vitrification procedures.

Etoposide (VP16) in the treatment of multisystem Langerhans cell histiocytosis (histiocytosis X).

Ten children with Langerhans cell histiocytosis (histiocytosis X) either resistant to or intolerant of corticosteroids received etoposide (VP16). Nine responded. In one instance, partial diabetes insipidus was temporarily reversed. There was no major toxicity. Etoposide should be seriously considered as therapy for patients with LCH in whom the toxicity/benefit ratio of steroid therapy is unacceptably high.

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.

Efficacy of bulb versus DeLee suction at deliveries complicated by meconium stained amniotic fluid.

A combined obstetric-pediatric approach to the management of deliveries complicated by meconium-stained amniotic fluid has been recommended to decrease the incidence of meconium aspiration syndrome. Although pharyngeal suction with a DeLee catheter is generally recommended, many obstetricians prefer to use a bulb syringe for suction at the perineum. A thorough review of the literature reveals no prospective studies in humans comparing the two techniques. In the present study, these two techniques of pharyngeal suction were prospectively compared at deliveries complicated by meconium-stained amniotic fluid. Of the total 2874 deliveries, 127 (4%) were complicated by moderate or thickly meconium-stained amniotic fluid, and 107 of these were included in the study. There were 53 infants in the DeLee-suctioned group and 54 in the bulb-suctioned group. Of the 107 studied infants, four (4%) developed meconium aspiration syndrome, three in the DeLee group and one in the bulb group. There was no significant difference in the amount of meconium found below the vocal cords, comparing pharyngeal DeLee suction to bulb suction (0.22 cc versus 0.24 cc; p = NS). In conclusion, the data fail to support a significant difference in efficacy between bulb and DeLee suction in clearing the naso- and oropharynx of the neonate of meconium in cephalic-presenting vaginal or cesarean delivery.

Emergent cerclage.

Emergent cerclage may be defined as that performed in the setting of advanced cervical dilation with bulging or "hourglass" membranes. During a five year period, 15 patients with bulging or hourglass membranes and marked cervical dilation in the second trimester were treated with emergent cerclage. Included were two triplet gestations. Complications were limited to intraoperative rupture of fetal membranes in two patients and chorioamnionitis either in the early postoperative period (two) or later in pregnancy (three). Pregnancy was prolonged for a sufficient time to deliver viable fetuses in 11 of 15 patients. Eleven of 13 neonates of a gestational age of 24 weeks or more survived. The lack of significant maternal morbidity combined with the results for the fetus-infant supports further efforts in this area.

Umbilical arterial and venous acid-base and blood gas values and the effect of chorioamnionitis on those values in a cohort of preterm infants.

Umbilical arterial and venous acid-base and blood gas values in uncomplicated premature births are similar to values that are reported in term infants and are unaffected by birth weight or gestational age. In this group of patients chorioamnionitis had no significant effects on umbilical arterial acid-base or blood gas values or on the percentage of patients that were born with acidemia. Apgar scores were significantly lower in the group with chorioamnionitis in spite of a virtual absence of acidemia, which again suggests that low Apgar scores alone do not confirm a diagnosis of birth asphyxia.