A randomized clinical trial comparing vaginal misoprostol versus cervical Foley plus oral misoprostol for cervical ripening and labor induction.

We compared labor induced by vaginal misoprostol versus a supracervical Foley catheter and oral misoprostol. Singleton pregnancies at > or = 24 weeks' gestation were randomized to either an initial 25-microg dose of intravaginal misoprostol, followed by 50-microg intravaginal doses at 3- to 6-hour intervals, or a supracervical Foley balloon and 100 microg of oral misoprostol at 4- to 6-hour intervals. Primary outcome was time from induction to delivery. One hundred twenty-six women were randomized to vaginal misoprostol alone (group I) and 106 women to Foley and oral misoprostol (group II). The groups were similar in age, weight, gestational age, parity, indication for induction of labor, and oxytocin use. Cesarean delivery rates at 37% and cesarean indications were similar ( P = 0.25). The time from induction to delivery in group II (12.9 hours) was significantly shorter than that in group I (17.8 hours, P < 0.001). Uterine tachysystole occurred less often in the vaginal misoprostol group (21% versus 39%, P = 0.015). Compared with vaginal misoprostol, delivery within 24 hours was significantly more likely with a Foley balloon and oral misoprostol. The use of terbutaline and peripartum outcomes were similar in the two groups.

Stroke and severe preeclampsia and eclampsia: a paradigm shift focusing on systolic blood pressure.

OBJECTIVE: To identify important clinical correlates of stroke in patients with preeclampsia and eclampsia. METHODS: The case histories of 28 patients who sustained a stroke in association with severe preeclampsia and eclampsia were scrutinized with particular attention to blood pressures. RESULTS: Stroke occurred antepartum in 12 patients, postpartum in 16. Stroke was classified as hemorrhagic-arterial in 25 of 27 patients (92.6%) and thrombotic-arterial in 2 others. Multiple sites were involved in 37% without distinct pattern. In the 24 patients being treated immediately before stroke, systolic pressure was 160 mm Hg or greater in 23 (95.8%) and more than 155 mm Hg in 100%. In contrast, only 3 of 24 patients (12.5%) exhibited prestroke diastolic pressures of 110 mm Hg or greater, only 5 of 28 reached 105 mm Hg, and only 6 (25%) exceeded a mean arterial pressure of 130 mm Hg before stroke. Only 3 patients received prestroke antihypertensives. Twelve patients sustained a stroke while receiving magnesium sulfate infusion; 8 had eclampsia. Although all blood pressure means after stroke were significantly higher than prestroke, only 5 patients exhibited more than 110 mm Hg diastolic pressures. In 18 of 28 patients, hemolysis, elevated liver enzymes, low platelets syndrome did not significantly alter blood pressures compared with non-hemolysis, elevated liver enzymes, low platelets. Mean systolic and diastolic changes from pregnancy baseline to prestroke values were 64.4 and 30.6 mm Hg, respectively. Maternal mortality was 53.6%; only 3 patients escaped permanent significant morbidity. CONCLUSION: In contrast to severe systolic hypertension, severe diastolic hypertension does not develop before stroke in most patients with severe preeclampsia and eclampsia. A paradigm shift is needed toward considering antihypertensive therapy for severely preeclamptic and eclamptic patients when systolic blood pressure reaches or exceeds 155-160 mm Hg. LEVEL OF EVIDENCE: III.

Obstetric implications of antepartum corticosteroid therapy for HELLP syndrome.

OBJECTIVE: We reviewed the impact of intravenous high-dose corticosteroid administration for preterm hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome on vaginal delivery rate and degree of clinically significant thrombocytopenia. METHODS: Retrospective analysis of 1991-2000 HELLP syndrome (platelets < 100,000/uL, lactate dehydrogenase > 600 IU/L, aspartate aminotransferase and/or alanine aminotransferase > 70 IU/L) data focusing on labor inductions for gestations of less than 34 weeks and increase in platelet count sufficient to permit regional anesthetic techniques. RESULTS: Antepartum high-dose corticosteroid use increased from 32% (1991-1995) to 67% (1996-2000) for 350 patients studied (n = 199, < 34 weeks; n = 151, > 34 weeks). Corresponding vaginal delivery rates were 32% for gestations of less than 30 weeks, 61% at 30-31 weeks, and 62% at 32-33 weeks. Similarly, 27% of patients with a platelet count of less than 75,000/uL and 52% with a platelet count of less than 100,000/uL who received high-dose corticosteroids during the study interval subsequently achieved a 100,000/uL threshold in time to perform regional anesthesia for delivery. CONCLUSION: Administration of intravenous high-dose corticosteroids for preterm HELLP syndrome increases probability of successful labor induction and candidacy for regional anesthesia. LEVEL OF EVIDENCE: II-3.

Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial.

OBJECTIVE: The purpose of this prospective study was to determine whether the timing of prophylactic antibiotics at cesarean delivery influences maternal/neonatal infectious morbidity. STUDY DESIGN: In this double-blind placebo-controlled trial, cefazolin was given at skin incision (group A) or at cord clamping (group B). Patients were eligible for the trial if they had labored and required a cesarean delivery. RESULTS: Over a 30-month period 303 patients with singleton pregnancies entered the trial; 153-group A, 149-group B. Demographics, indication for cesarean delivery (P = .54), and operative time (P = .999), as well as rates of endometritis (RR 0.67, 95% CI 0.42-1.07), wound infection (RR 0.84, 95% CI 0.45-1.55), neonatal sepis (RR 1.28, 95% CI 0.91-1.79), and NICU admissions (RR 1.28, 95% CI 0.91-1.79) were similar between the 2 groups. CONCLUSION: There was no difference in maternal infectious morbidity whether antibiotics were given before skin incision or at cord clamping.

Maternal benefit of high-dose intravenous corticosteroid therapy for HELLP syndrome.

OBJECTIVE: We compared maternal outcomes for patients with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome treated with or without high-dose corticosteroids to ameliorate maternal disease. STUDY DESIGN: An analysis of data for patients with HELLP syndrome (platelets, or=600 IU/L; aspartate aminotransferase and/or alanine aminotransferase level, >or=70 IU/L) who were treated during the 7-year epochs before and after the clinical trials in 1992 and 1993 demonstrated maternal benefit with high-dose dexamethasone. RESULTS: Corticosteroid use increased from 16% (39/246 patients) for fetal indication from 1985 to 1991 to 90% (205/228 patients) for maternal-fetal indications from 1994 to 2000. Significantly reduced composite maternal disease from 1994 to 2000 was evidenced by improvements in laboratory parameters, disease progression to class 1 HELLP syndrome, the degree of hypertension, the need for antihypertensive therapy, the use of transfusion, and the presence of maternal morbidity (P<.05). Indices of postpartum recovery also were shortened significantly (P<.001). CONCLUSION: Routine early initiation of high-dose intravenous corticosteroids for patients with HELLP syndrome significantly lessened maternal disease, reduced maternal morbidity, and expedited recovery.