Management of preeclampsia when diagnosed between 34-37 weeks gestation: deliver now or deliberate until 37 weeks?

OBJECTIVE: To evaluate maternal-newborn outcomes with immediate or expectantly managed preeclampsia first diagnosed at 34-37 weeks. METHODS: Late preterm patients with preeclampsia without severe features were randomly assigned to immediate delivery (n=94) or expectant management (n = 75) until 37 weeks gestation or earlier if severe features developed. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if p < 0.05. RESULTS: The two groups were similar at presentation. 41% of those expectantly managed developed severe features of preeclampsia within 72 hours versus 3% in the immediately delivered group (p < 0.001). Immediate delivery did not significantly increase cesarean delivery or neonatal morbidity. CONCLUSION: Immediate delivery of the late preterm patient with preeclampsia significantly lessens her development of severe features without significantly increasing newborn risks. For the expectantly managed late preterm patient with preeclampsia, close surveillance for the first 72 hours following diagnosis and twice weekly thereafter appears prudent.

A multicenter assessment of 1,177 cases of shoulder dystocia: lessons learned.

The purposes of this review were to describe deliveries complicated by shoulder dystocia (SD) at three tertiary centers and discern the differences between SD with and without brachial plexus injury (BPI). The inclusion criteria for this multicenter, retrospective study were singletons, delivered vaginally with SD. To discern the risk factors for SD with and without injury, a case (SD and BPI) versus control (3 SD without injury at the same institution) design was used. Multiple linear regression was employed. Over a 7-year period, among 46,637 vaginal deliveries, SD occurred in 1,177 cases (2.5%) and BPI was noted in 11%. The results of multiple regression indicate that gestational age, operative delivery, and the number of maneuvers and concomitant fracture (4%) were statistically associated with BPI following SD (p < 0.001). SD was not associated with BPI in 89% and 88% of the cases that were resolved with McRoberts maneuver and suprapubic pressure, whereas only 0.2% of cases were litigated.

Risk factors for a prolonged third stage of labor and postpartum hemorrhage.

OBJECTIVES: To determine the effect of a third stage of labor ≥15 minutes on bleeding after delivery and other risk factors for a postpartum hemorrhage (PPH). METHODS: This was a case-control study of women undergoing vaginal delivery with placental delivery ≥15 minutes matched by gestational age to the next delivery with placental delivery <15 minutes. Multiple risk factors were evaluated for association with delayed placenta and with PPH. RESULTS: There were 226 pregnancies ≥15 minutes (cases) versus 226 whose placental time was <15 minutes (controls). The best-fit model identified placental delivery ≥15 minutes, history of retained placenta, nulliparity, and increased length of first stage of labor as significant factors for PPH. CONCLUSIONS: The best risk model for PPH includes placental delivery ≥15 minutes, history of retained placenta, nulliparity, and longer first stage of labor.

Postpartum thrombotic microangiopathic syndrome.

OBJECTIVE: Characterization of syndromes for patients with life-threatening, progressively worsening hemolysis-elevated-liver-enzymes-and-platelet (HELLP) syndrome-like diseases and with thrombotic microangiopathies. RETROSPECTIVE STUDY DESIGN: Patients who underwent postpartum plasma-exchange (PPEX) for preeclampsia-related, and microangiopathy/coagulopathy illnesses unresponsive to medical therapy between 1994 and 2008 in our center and elsewhere. RESULTS: Nine patients were treated with PPEX in our center with 78% maternal survival. Treatment with PPEX increased platelet levels (p=0.048), decreased serum lactic dehydrogenase (p=0.0012) and aspartate aminotransferase (p=0.0001). CONCLUSION: Nineteen patients from publications combined with our patients suggest five categories of postpartum thrombotic microangiopathy syndrome that exhibit HELLP syndrome criteria and respond to PPEX.

Effect of antenatal tocolysis on neonatal outcomes.

OBJECTIVE: Detail adverse neonatal effects in pregnancies treated with indomethacin (I), magnesium sulfate (M) or nifedipine (N). METHODS: Women in acute preterm labor with cervical dilatation 1-6 cm were randomized to receive one of three first-line tocolytic drugs. RESULTS: There were 317 neonates (I = 103, M = 95, N = 119) whose mothers were treated with tocolytic therapy. There was no difference in gestational age at randomization (average 28.6 weeks' gestation) or at delivery (31.6 weeks' gestation, p = 0.551), birth weight (p = 0.871) or ventilator days (p = 0.089) between the three groups. Neonatal morbidity was not different between the three groups; respiratory distress syndrome (p = 0.086), patent ductus arteriosus (p = 0.592), sepsis (p = 0.590), necrotizing enterocolitis (p = 0.770), intraventricular hemorrhage (p = 0.669) and periventricular leukomalacia (p = 0.124). CONCLUSIONS: There were no statistically significant differences between the three tocolytics as far as composite neonatal morbidity or mortality was concerned.

A high LDH to AST ratio helps to differentiate pregnancy-associated thrombotic thrombocytopenic purpura (TTP) from HELLP syndrome.

OBJECTIVE: Differentiating between pre-eclampsia/HELLP syndrome and pregnancy-associated thrombotic thrombocytopenic purpura (TTP) is difficult but important in order to undertake timely and potentially life-saving plasma exchange (PEX) therapy for TTP recovery. We review our institutional experience with pregnancy-associated TTP and determine if the ratio of LDH to AST reliably distinguishes patients with TTP from those with HELLP syndrome. STUDY DESIGN: This is a retrospective case control study of all pregnant/puerperal patients with TTP from a single tertiary care center during 1986-2006. Laboratory findings in patients with TTP were compared to patients who met all criteria for class 1 or 2 HELLP syndrome within the first 24 hours of hospital admission during 2000-2007. RESULTS: Thirteen pregnant (n = 10) or puerperal (n = 3) patients with TTP were identified; 11 cases were primary, 2 were recurrent. TTP laboratory findings included LDH to AST ratios of 77 ± 42.17; Patients with HELLP syndrome (N = 83) had significantly lower LDH to AST ratios of 20.04 ± 2.13. Based on an ROC analysis, an LDH/AST ratio ≥ 22.12 discriminates well between TTP and antenatal HELLP subjects (AUC = 0.99). CONCLUSION: A high LDH to AST ratio >22.12 suggests that TTP is a more likely diagnosis than HELLP syndrome in the third trimester pregnant patient, presenting with findings that could be compatible with either diagnosis. In these circumstances, it is advisable to obtain hematology consultation and to consider PEX implementation.

Standardized Mississippi Protocol treatment of 190 patients with HELLP syndrome: slowing disease progression and preventing new major maternal morbidity.

OBJECTIVE: To evaluate the effectiveness of the Mississippi Protocol (MP) to treat HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. METHODS: Uniform early initiation of MP (corticosteroids, magnesium sulfate, systolic blood pressure control) was studied prospectively in patients admitted with severe preeclampsia/class 1 or class 2 HELLP syndrome. RESULTS: One hundred and ninety patients between 2000 and 2007 received MP without suffering maternal death, stroke, or liver rupture. Only 39 of 163 patients (24%) not class 1 when MP began progressed to class 1 disease; only 18.2% of class 1 and 2.4% of class 2 subsequently developed major maternal morbidity. CONCLUSION: Early initiation of MP inhibits HELLP syndrome disease progression and severity.

Impedance cardiography facilitates differentiation of severe and superimposed preeclampsia from other hypertensive disorders.

OBJECTIVE: To determine if hemodynamic profiling using noninvasive impedance cardiography (ICG) reliably identifies the patient with severe (SPRE) or superimposed (SuPRE) preeclampsia. METHODS: Late gestation hypertensive pregnant patients underwent immediate ICG evaluation. Findings were compared between patients subsequently achieving or not achieving American College of Obstetricians and Gynecologists criteria for SPRE or SuPRE. RESULTS: Patients with severe disease were more likely to have depressed cardiac function and higher systolic blood pressure, mean arterial blood pressure, systemic vascular resistance, and thoracic fluid content compared to nonsevere hypertensive disease. CONCLUSION: ICG hemodynamic profiling of late gestation hypertensive patients can rapidly and reliably identify those with SPRE or SuPRE.

HELLP syndrome with and without eclampsia.

We assessed pregnancy outcomes for patients with HELLP syndrome (hemolysis; elevated liver enzymes; low platelet count) with and without concurrent eclampsia. We performed a retrospective investigation of data spanning three decades of patients with class 1 or 2 HELLP syndrome with concurrent eclampsia (HELLP + E) and patients with HELLP syndrome without eclampsia. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if P < 0.05. During 1981 to 1996 and 2000 to 2006, there were 693 patients with class 1 or 2 HELLP syndrome; altogether, 70 patients had HELLP + E. The only demographic difference was greater nulliparity in HELLP + E patients. Otherwise, inconsistent and clinically insignificant differences were observed between groups. Despite the relatively large size of the study groups, we were unable to detect a significant worsening of maternal or perinatal outcome in HELLP + E patients compared with HELLP patients. In our experience, eclampsia does not appear to contribute a significant adverse impact upon the course or outcome of HELLP syndrome pregnancies.

17-Hydroxyprogesterone blunts the hypertensive response associated with reductions in uterine perfusion pressure in pregnant rats.

OBJECTIVE: Reduction in uteroplacental perfusion (RUPP) in pregnant rats is associated with hypertension, elevated cytokines, and activation of the endothelin (ET-1) system. Our objective was to determine whether the antiinflammatory properties of 17-alpha-hydroxyprogesterone caproate (17 OHP) reduce cytokine-stimulated vasoactive pathways that are associated with hypertension in response to placental ischemia. STUDY DESIGN: Mean arterial pressure (MAP), tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, and renal ET-1 were measured in the following: pregnant controls, pregnant controls plus 17 OHP (6.6 mg/kg), RUPP rats, and RUPP rats plus 17 OHP. RESULTS: MAP increased 29 mm Hg in RUPP rats compared with pregnant controls (P < .001), whereas in RUPP plus 17 OHP rats, MAP increased only 19 mm Hg (P < .05). TNF-alpha and IL-6 increased 2- to 3-fold, respectively, in response to placental ischemia but was normalized in RUPP rats treated with 17 OHP. ET-1 increased 3-fold in RUPP rats but was markedly less in RUPP plus 17 OHP rats. CONCLUSION: 17 OHP blunts hypertension associated with RUPP, possibly via suppression of cytokine-stimulated ET-1 activation.

Effects of 17-hydroxyprogesterone on tumor necrosis factor-alpha-induced hypertension during pregnancy.

BACKGROUND: Inflammatory cytokines such as tumor necrosis factor-alpha (TNF-alpha) may be an important link between placental ischemia and hypertension in preeclampsia. We examined the effect of 17-hydroxyprogesterone caproate (17-OHP) on TNF-alpha-stimulated endothelin (ET) production and hypertension during pregnancy. METHODS: TNF-alpha-stimulated ET was examined from endothelial cells cultured in the presence and absence of progesterone. Blood pressure and tissue ET-1 were measured in the following groups of pregnant rats: controls, 17-OHP (3.32 mg/kg), TNF-alpha treated (50 ng/day), TNF-alpha treated+17-OHP. RESULTS: Progesterone abolished TNF-alpha-stimulated ET-1 from endothelial cells. TNF-alpha-induced hypertension was associated with significant increases in renal and placental ET-1. Administration of 17-OHP attenuated TNF-alpha-induced hypertension and decreased renal ET-1. CONCLUSION: Progesterone directly abolished TNF-alpha-stimulated ET-1 and attenuated TNF-alpha-induced hypertension, possibly via suppression of the renal ET-1 system. These data suggest that treatment with progesterone of hypertension associated with elevated cytokines during pregnancy may be worthy of further consideration.