Diabetic ketoacidosis complicating pregnancy.

BACKGROUND: Although diabetic ketoacidosis (DKA) in pregnancy can result in significant adverse consequences for both mother and fetus, the response to treatment, time course of recovery, and perinatal outcomes have not been well studied in pregnancy. OBJECTIVE: We examined the precipitating factors, laboratory abnormalities, treatment strategies, and clinical recovery in pregnancies complicated by DKA. STUDY DESIGN: This is a retrospective cohort study of pregnancies complicated by DKA between October 1999 and June 2015. The diagnosis was verified by hyperglycemia; anion gap >12 mEq/L, pH <7.3, HCO3 <15 mEq/L; and the presence of ketones. Each episode of DKA was reviewed and subsequent perinatal outcomes analyzed. RESULTS: During this period, we identified 33 women with 40 admissions (incidence: 0.2%). The majority of women had type 1 diabetes (67%), and almost all presented with nausea and vomiting (97%). Over half had poor compliance with prescribed insulin. The initial mean blood glucose was 380 mg/dL, within 6 hours, it was <200 mg/dL. By 12 hours, the acidosis had resolved in 90% of patients. CONCLUSION: Nausea and vomiting is a prominent presenting feature of DKA in pregnancy. With aggressive insulin and resuscitation, hyperglycemia and acidosis improve rapidly. With current treatment, good perinatal outcomes can be expected.

Appendicitis complicating pregnancy.

Thirty-four pregnant women with acute appendicitis presented at Parkland Memorial Hospital during a 15-year period. Abdominal pain, usually accompanied by nausea with or without vomiting, was the most common presenting symptom. Anorexia was less constant, and its occurrence decreased with advancing gestation. Physical findings usually included direct abdominal tenderness and, less often, rebound tenderness. Leukocytosis and/or a "left shift" were common laboratory findings, and the urinalysis was normal in most cases. Diagnosis was increasingly difficult as gestation progressed. This was reflected both by the increasing severity of the disease process found at surgery and by increasing fetal loss. If the diagnosis of appendicitis is suspected in the gravid patient, immediate surgical intervention is indicated to prevent the catastrophic complications associated with procrastination in diagnosis and treatment.

Acute focal pyelonephritis (lobar nephronia) complicating pregnancy.

Lobar nephronia, although initially indistinguishable from acute pyelonephritis, is characterized by a prolonged febrile course. The diagnosis is established radiographically using computed tomography. Treatment involves continuation of antimicrobials until the patient has been afebrile for 48 hours. Lobar nephronia has not been previously reported with pregnancy.

Short-term versus continuous antimicrobial therapy for asymptomatic bacteriuria in pregnancy.

Asymptomatic bacteriuria was identified in 300 pregnant women prior to the 28th week of gestation. In one group of 200 women short-term treatment with either nitrofurantoin or sulfamethizole was given for 14 days, and in another group of 100 women continuous therapy with one of these drugs was given for the remainder of gestation. Weekly urine cultures were obtained from all the women. Of the women treated with short-term therapy, 65% were abacteriuric for the remainder of pregnancy following one course of therapy, 24% became abacteriuric but subsequently relapsed, 2% had reinfection after becoming abacteriuric, and 9% demonstrated no response. Following treatment with a second course of short-term therapy, another 19% of these women were cured for the remainder of their pregnancy, and 3.5% responded to a third course. In the continuous therapy group, 88% of the women became abacteriuric for the remainder of the gestation, 3% demonstrated relapse, 2% developed reinfection, and 7% had no response to the first drug given. These data demonstrate that short-term administration of antimicrobials, when combined with surveillance for recurrent bacteriuria, is effective for the management of the pregnant woman with asymptomatic bacteriuria.

The bacterial pathogenesis of infection following cesarean section.

To further define the bacterial pathogenesis of infections following cesarean section, amnionic fluid was obtained transabdominally at the time of surgery from 56 women whose membranes were ruptured for more than 6 hours. In all specimens, bacterial growth was demonstrated, and 53 of these women developed postoperative myometritis. A mean of 2.5 pathogenic bacteria was isolated from each specimen. More than 90% of the amnionic fluid specimens had polymicrobial anaerobic/aerobic growth (63%) or anaerobes only (30%). Aerobic and anaerobic streptococci accounted for 72% of all bacterial isolates; Bacteroides and Escherichia coli were the next most commonly recovered species. In women treated for myometritis and who subsequently developed a wound or pelvic abscess, cultures from these wounds or abscesses were positive for 1-3 organisms present in amnionic fluid. These data indicate that ascending colonization of flora from the lower genital tract and inoculation into surgically traumatized tissues usually result in polymicrobial pelvic infection with a predominance of anaerobic pathogens. Moreover, abscess development in these women is probably associated with organisms identified in amnionic fluid. Bacterial isolates from these women are remarkably similar to those from women with other pelvic infections.

Evaluation of cefamandole nafate for the treatment of acute gonococcal salpingitis.

Eighty-six women with suspected acute salpingitis were treated with parenteral cefamandole. From 53 (62%) of these Neisseria gonorrhoeae was recovered from an anogenital site(s) at admission. These women were younger, of lower parity, had pain for a shorter period of time, responded more rapidly to therapy, and required less antimicrobial agent for clinical cure than those from whom N gonorrhoeae was not recovered. The clinical success observed in these women was 94%, and only 2% of 122 gonococcal isolates were resistant to cefamandole in vitro.

Pregnancy and sickle cell hemoglobinopathies: results with and without prophylactic transfusions.

Maternal morbidity and perinatal outcome in 108 pregnancies complicated by sickle cell anemia (hemoglobin SS disease), sickle cell-hemoglobin C disease (hemoglobin SC disease), or sickle cell-beta-thalassemia disease were analyzed. Women given prophylactic red cell transfusions (1973-1982) during pregnancy were matched with historic controls whose care was almost identical except that blood was not given unless indicated (1955 to 1972). In women with hemoglobin SS disease who received prophylactic red cell transfusions, there was a sevenfold reduction in perinatal mortality and negligible maternal morbidity. In pregnancies complicated by hemoglobin SC disease during which transfusions were given, there were no perinatal losses, whereas there were in 18% of women not given transfusions. Maternal morbidity in women given transfusions was negligible; however, half of those not transfused experienced morbidity and, importantly, pulmonary complications were common. Transfusion-related complications included hepatitis and alloimmunization. From these experiences the authors conclude that prophylactic red cell transfusions reduce maternal morbidity and perinatal mortality appreciably, although perinatal morbidity is not eliminated. Transfusion therapy is justifiably started early in pregnancy for women with hemoglobin SS disease; however, transfusions may be withheld until the end of the second trimester for women with hemoglobin SC or sickle cell-beta-thalassemia disease.

Further observations on the nature of pressor responsivity to angiotensin II in human pregnancy.

The pressor dose of infused angiotensin II was determined before and after rapid volume expansion with 800 to 1075 ml of high-hematocrit blood. There was no remarkable change in sensitivity to infused angiotensin demonstrated except in two instances in which transient volume overload developed. The data support the hypothesis that increased angiotensin sensitivity observed in patients with pregnancy-induced hypertension is the consequence of increased vascular responsivity.

Hypothyroidism complicating pregnancy.

Hypothyroidism rarely complicates pregnancy because most affected women are anovulatory. In this report, we describe 28 complicated pregnancies cared for over a ten-year period at Parkland Memorial Hospital. In the group of 16 pregnancies in 14 overtly hypothyroid women, maternal complications were common and included anemia (31%), preeclampsia (44%), placental abruption (19%), postpartum hemorrhage (19%), and cardiac dysfunction. Perinatal morbidity and mortality were also high mainly because of placental abruption, and reflected frequent low birth weight (31%) and fetal death (12%). In a group of 12 women with subclinical hypothyroidism, these complications were less impressive. We speculate that overt thyroid deficiency is associated with adverse pregnancy outcome related to preeclampsia and placental abruption. Thyroxine replacement probably improves these outcomes even if subclinical hypothyroidism persists.

Magnetic resonance imaging in human pregnancy.

Magnetic resonance imaging is a new noninvasive diagnostic technique that involves no ionizing radiation, has no known significant adverse biologic effects, and produces high resolution cross-sectional body images. When compared with sonography and x-ray computed axial tomography, magnetic resonance imaging may have several advantages. To investigate its clinical role in obstetrics, magnetic resonance imaging was used to examine 11 women with abnormal pregnancies. Prior ultrasound examination showed abnormal appearing fetuses in five, abnormalities of the amnionic fluid volume in five, and one each with a large adnexal mass and a molar pregnancy. Examples of images obtained from these women are presented and described. Maternal anatomy was well visualized in all women studied. Based on the preliminary experience, the authors believe that magnetic resonance imaging will be a useful adjunct for diagnostic visualization of normal and abnormal maternal anatomy. Detailed fetal imaging was also possible, and it is anticipated that magnetic resonance imaging will prove useful for fetal evaluation, especially fetal intracranial anatomy and fetal anatomy in pregnancies complicated by oligohydramnios. Because fetal subcutaneous fat is prominently depicted with magnetic resonance imaging, this technology may be useful for assessment of fetal nutritional status.

Management of pregnancy-induced hypertension in the nullipara.

Three hundred and forty-six nulliparous women with pregnancy-induced hypertension prior to term were monitored in a high-risk pregnancy unit while awaiting fetal maturity. Management included ambulation as desired, regular hospital diet without salf restriction, blood pressure measured 4 times daily, weight and urine protein determined 3 times each week, creatinine clearance determined weekly, and serial sonography to monitor fetal growth. Sedation and antihypertensive agents were not prescribed. Delivery was delayed until term unless hypertension persisted or recurred following an initial salutary response. Factors other than hypertension that contributed to the decision to effect delivery were 1) rapid weight gain, 2) decreasing creatinine clearance, 3) appearance of significant proteinuria, 4) suspected fetal growth retardation, and 5) the development of severe headache or scotomata. With this method of management the perinatal mortality rate was 9/1000. Only 5 infants developed the respiratory distress syndrome and all survived. There were 26 women who left the unit against medical advice. Severe hypertension subsequently developed in 7 of these women and 4 of their fetuses were stillborn. The perinatal mortality rate among this group of patients was 154/1000. It is concluded that the nulliparous patient with pregnancy-induced hypertension prior to term can be safely managed by hospitalization and close observation as a viable alternative to prompt delivery.

Transient renal dysfunction associated with acute pyelonephritis of pregnancy.

Endogenous creatinine clearance was measured in 220 pregnant women with acute pyelonephritis and the results compared to data obtained from 167 pregnant control patients without acute pyelonephritis. These data showed that an appreciable number of patients with pyelonephritis occurring during pregnancy demonstrated a transient but definite diminution in renal function during the acute attack. Causes of this temporary renal dysfunction are discussed.

The national impact of ritodrine hydrochloride for inhibition of preterm labor.

Ritodrine hydrochloride is a beta 2-receptor agonist that relaxes uterine smooth muscle. It was developed specifically for treatment of preterm labor and was approved for this indication in 1980 by the Food and Drug Administration. Estimates of ritodrine usage in the United States were calculated based upon annual sales, and these were examined in relation to the incidence of births in 500-g weight categories less than 2500 g. We estimate that more than 100,000 women with preterm labor are treated with ritodrine annually, but this has had minimal if any impact on the incidence of low birth weight in this country.

Puerperal seizures after post-dural puncture headache.

OBJECTIVE: To describe eight cases of postpartum women who developed seizures associated with post-dural puncture headache. METHODS: Between the years 1982-1991, more than 19,000 women at our institution underwent subarachnoid analgesia for delivery or puerperal tubal sterilization. In eight of these women, grand mal seizures developed after spinal headache. RESULTS: In all eight women, typical post-dural puncture headaches were followed by visual disturbances that progressed to cortical blindness in three. These headaches and visual disturbances culminated in generalized tonic-clonic seizures 2-7 days after dural puncture. Although some of these women had transient hypertension at the time of seizure, none had preeclampsia. In three of the women evaluated, there was evidence of regional blood flow changes; two had diffuse cerebral artery vasospasm seen on angiography, and the third had diminished blood flow detected by a xenon-flow study. CONCLUSION: We propose that cerebral vasoconstriction is the mechanism for post-dural puncture headaches and seizures. Anatomic brain displacement may incite this vasospasm. This mechanism could also be the cause of cranial nerve palsies that have been described after dural puncture.

Erythropoietin in pregnancies complicated by pyelonephritis.

OBJECTIVE: To determine whether antepartum pyelonephritis causes an acute or delayed alteration in erythropoietin production. METHODS: Serum erythropoietin concentrations were determined prospectively using an enzyme-linked immunosorbent technique in 36 pregnant women admitted to Parkland Hospital with pyelonephritis. Healthy nonanemic pregnant women served as controls. RESULTS: Serum erythropoietin levels in women with antepartum pyelonephritis were not different from those measured in normal pregnant women. Specifically, there were no differences in erythropoietin levels in women who had anemia at admission (n = 6; 13.8 mU/mL), hemolysis (15.4 versus 12.9 mU/mL), or renal insufficiency (14.5 versus 12.9 mU/mL) secondary to renal infection as compared to controls. CONCLUSION: We conclude that antepartum pyelonephritis does not alter erythropoietin production either acutely or within several days of infection. Because erythropoietin production was not decreased, we suggest that hemolysis is the major factor contributing to anemia associated with renal infection.

Cerebrovascular accidents complicating pregnancy and the puerperium.

The decreasing incidence of direct causes of maternal death over the past half century has led to a heightened awareness of nonobstetric factors responsible for maternal mortality. For example, cerebrovascular accidents are an important nonobstetric cause of maternal morbidity and mortality. During the 6.5-year period from 1984 to mid-1990, we encountered 15 women in whom pregnancy or the puerperium was complicated by an acute cerebrovascular accident. Six of these women had hemorrhagic strokes and nine had ischemic strokes. During this same time, approximately 90,000 women were delivered at Parkland Memorial Hospital, and thus the incidence of stroke was about one in 6000 pregnancies. Chronic hypertension or preeclampsia was causative in three cases of hemorrhagic stroke. It is important that 20% of the women died as a result of stroke, and of the 12 survivors, 40% have residual neurologic deficits. An aggressive work-up to define the etiology of stroke is necessary in order to implement cause-specific management, with subsequent reduction in morbidity and mortality.

The long-term consequences of thrombotic microangiopathy (thrombotic thrombocytopenic purpura and hemolytic uremic syndrome) in pregnancy.

OBJECTIVE: To characterize perinatal outcomes and long-term maternal complications from thrombotic microangiopathy manifested during pregnancy, and to review the clinical course and long-term follow-up of pregnant women with this condition at our institution over the past 25 years. METHODS: We identified prospectively pregnant women who met clinical and laboratory criteria for thrombotic thrombocytopenic purpura or hemolytic uremic syndrome. Their clinical and laboratory findings, response to treatment, perinatal outcomes, and long-term sequelae were then analyzed. RESULTS: Between 1972 and 1997, 11 women had 13 pregnancies complicated by thrombotic microangiopathy, representing an incidence of one per 25,000 births. In three pregnancies (23%), severe and refractory disease developed before midpregnancy. In ten other pregnancies, disease developed either peripartum (62%) or several weeks postpartum (15%). In only two pregnancies with peripartum or postpartum onset of disease was there a clinical picture of severe preeclampsia. In general, the response to treatment was prompt. One woman died of her initial disease in early pregnancy, and mean follow-up of nine survivors was 8.7 years. Disease recurred at least once in 50% of these, two during a subsequent pregnancy. There was at least one serious long-term sequela in all but two survivors; these included recurrence of thrombotic microangiopathy, renal failure, severe hypertension, chronic blood-borne infections, and death. CONCLUSION: Thrombotic microangiopathy complicating pregnancy is rare, and with careful evaluation, it should not be confused with atypical preeclampsia. With prompt and aggressive treatment including plasma exchange, the likelihood of immediate survival is high; however, long-term morbidity and mortality are common.

Takayasu's syndrome in pregnancy.

Two cases of Takayasu's syndrome in pregnancy are presented. The obstetric courses of these women are compared with those of 7 others described in the literature. Symptoms of this rare condition may respond variably during pregnancy. Of the 9 women, 5 had worsening of their symptoms during gestation while 4 had milder symptoms than they had had prior to pregnancy. The best therapy is rest. Vaginal delivery is recommended and cesarean section should be reserved for obstetric indications.