The intrapartum platelet count in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: is it predictive of later hemorrhagic complications?

OBJECTIVE: We wished to determine in patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) whether (1) there is an intrapartum threshold platelet count that is predictive of immediate or delayed hemorrhagic complications and (2) whether prophylactic platelet transfusion at delivery prevents these outcomes. STUDY DESIGN: In this retrospective, descriptive study, the peripartal courses of 132 patients with class 1 (< or = 50,000/microliters platelet nadir) and 160 patients with class 2 (> 50,000 but < or = 100,000/microliters platelet nadir) HELLP syndrome were reviewed with special attention to laboratory data, evidence of hemorrhage, and details of platelet transfusion therapy. RESULTS: A higher incidence of postpartum hemorrhagic complications (p < 0.001) occurred in class 1 versus class 2 HELLP pregnancies. The tendency to have postpartum incisional bleeding after abdominal or vaginal delivery was related to the degree of thrombocytopenia (p = 0.006). The antepartum threshold platelet count most predictive of subsequent postpartum hemorrhagic complications was < or = 40,000/microliters. The prophylactic administration of platelets does not appear to have either significantly decreased the incidence of postpartum hemorrhagic complications or significantly hastened normalization of the postpartum platelet count. CONCLUSIONS: Although bleeding in the gravid patient is related to more factors than platelet count alone, patients with HELLP syndrome in whom an intrapartum platelet count above 40,000/microliters maintained are unlikely to have clinically significant postpartum bleeding. Patients with intrapartum platelet counts < or = 40,000/microliters, however, are at significant risk for postpartum bleeding, but prophylactic platelet transfusion at delivery does not ensure a significantly lower incidence of postpartum hemorrhagic complications.

Ascites: a portent of cardiopulmonary complications in the preeclamptic patient with the syndrome of hemolysis, elevated liver enzymes, and low platelets.

OBJECTIVE: Maternal ascites is frequently found at cesarean delivery in patients with severe preeclampsia or eclampsia expressed as hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). We attempted to determine whether large-volume maternal ascites present at cesarean delivery in HELLP syndrome patients is correlated with disease severity or with any specific form of increased maternal morbidity. METHODS: For this retrospective case series, we reviewed the medical records of 190 patients and noted the presence or absence of large-volume maternal ascites, peripartum complications, laboratory data, and specific operative techniques. RESULTS: The incidence of large-volume ascites in patients with HELLP syndrome who underwent abdominal delivery was approximately 10% in classes 1, 2, and 3. Compared with HELLP syndrome patients without ascites, those with HELLP-associated ascites at surgery had a significant sixfold increase in the incidence of congestive heart failure and a ninefold increase in the incidence of adult respiratory distress syndrome, both of which usually became clinically apparent within 24 hours postpartum. Those HELLP syndrome patients without ascites at surgery developed congestive heart failure or adult respiratory distress syndrome infrequently, and more than 24 hours postoperatively. CONCLUSION: Cautious fluid administration and observation for cardiopulmonary deterioration are crucial in management of the critically ill, high-risk group of HELLP syndrome patients with large-volume ascites.

Pregnancy complicated by carcinoma of the colon above the rectum.

Although rare during pregnancy, colorectal carcinoma is one of the leading three types of cancer in women. In the medical literature, there are only 28 reports of carcinoma of the colon above the rectum concurrent with pregnancy. During the last 8 years in our community, four pregnant women have received care by us for this usually lethal disease. These cases are presented and the pertinent considerations of this pregnancy complication based on the entire collected experience are reviewed. The possibility of this disease must be considered in the obstetric as well as the gynecologic patient.

Correlation of vaginal hormonal cytograms with cervical mucus symptoms as observed by women using the ovulation method of natural family planning.

The first study was done in which vaginal hormonal cytograms were correlated with cervical mucus symptoms as charted by women using the ovulation method of natural family planning. Daily vaginal smears obtained by 67 women during 78 menstrual cycles provided the basis of the study. The women had used the ovulation method for at least three cycles and were not breast-feeding. All vaginal smears examined cytologically had a microbiologic diagnosis of lactobacilli. All the vaginal hormonal cytograms revealed ovulatory-type patterns. Karyopyknotic index (KPI) peak correlated with peak mucus day +/-2 days in 74, or 94.9%, of the cases, with a mean of peak mucus at +0.14 days. The average number of mucus days prior to the KPI peak was 6.1. Seven women also provided daily blood specimens for bioassay of luteinizing hormone (LH). KPI peaked with a mean of 0.7 days after the LH peak.

Correlation between divalent cation concentration and electrocardiogram in canine myocardial infarction.

Myocardial infarction is accompanied by changes in serum divalent cation concentrations. The effects of these changes on the electrical activity of the heart have not been fully determined. In six mongrel dogs, major coronary arteries were catheterized and occluded with metal beads; in five dogs the arteries were catheterized, but left patent. Serum magnesium concentrations ([Mg++]), zinc concentrations ([ZN++1]), copper concentrations ([Cu++]), calcium concentrations ([Ca++]), and ECGs were monitored in each dog at one, 24, 48, and 72 hours after surgery. Only dogs with coronary artery occlusion had ST segment changes (1.9 +/- 0.4 mm) in chest lead V4. Serum [Mg++] and [Zn++] decreased (approximately 20%) only after coronary artery occlusion and only at 24 hours after the procedure. Runs of ventricular tachycardia and premature beats were prevalent at this time. Serum [Cu++] was different in that it increased (approximately 30%) at 48 and 72 hours in the dogs with and without coronary artery occlusion. No changes were observed in serum [Ca++]. Decreases in serum [Mg++] and Zn++] coincided with the periods of dysrhythmia in the ischemic hearts. Elevation of serum [Cu++] was not specifically associated with myocardial ischemia and, within these physiologic limits, it appeared to be without effect on cardiac electrical activity.

Basic psychiatric literature. II. Articles and article sources.

Widely varying reading lists for general psychiatry residents were obtained from 140 three-year approved training programs. The material recommended for reading was listed on index cards, and the number of programs recommending each item was posted on the cards. Approximately 4,000 articles, 2,800 books, and 200 serials were recommended. A statistical evaluation of the book list appeared in a previous paper (3).(*) Part II is a similar evaluation of the article list and the limited editions and serials in which the articles appear.

Basic psychiatric literature. I. Books.

Widely varying recommended reading lists for psychiatry residents were obtained from 140 AMA-approved training programs. Approximately 4,000 articles, 2,800 books, and 200 serials were listed. The number of recommendations for each book was counted, and a rank-order determined. A second rank-order was determined from the lists of those eighty-seven programs which indicated that their material covered the "basic" literature; a third rank-order was determined from the number of residents using the lists. All rank-orders agreed on the "most recommended" book and the first eighteen books; there was a 92 percent correlation through the first 453 books. One-third of the "basic" recommendations were for the first 104 books; one-third for the next 349 books, and one-third for the remaining 1,994 books. The subject matter of the first 104 books indicated that the currently most popular subjects in psychiatry are psychoanalytic theories of personality, schizophrenia, psychotherapy, and child psychiatry. A list of the 104 most recommended books is appended.