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Antiphospholipid antibodies are associated with a spectrum of pregnancy complications, including preeclampsia and small for gestational age (SGA) fetuses. We sought to assess anticardiolipin and anti-beta2-glycoprotein I (anti-beta2-GPI) IgG and IgM antibody prevalence and the relationship of these antibodies to pregnancy complications in women with the Factor V Leiden (FVL) mutation. The study comprised a secondary analysis of a multicenter, prospective observational study of FVL prevalence among 5188 asymptomatic pregnant women. A subset of 362 women (117 FVL heterozygotes, 245 matched controls) had serum collected at the time of the original study and underwent serum analysis for anticardiolipin and anti-beta2-GPI IgG and IgM as a part of this analysis. The primary outcome was preeclampsia and/or SGA (10%). The overall prevalence of anticardiolipin and anti-beta2-GPI IgG and IgM antibodies was low and did not vary with FVL status. Forty-seven women (13.0%) developed preeclampsia and/or SGA. There were no differences in primary outcome rates between women with and without aPL antibodies, regardless of FVL mutation status. Among FVL carriers, the presence of antiphospholipid antibodies does not appear to contribute to adverse pregnancy outcome.

Gastrointestinal complications of pre-eclampsia can occur and have the risk of being life-threatening for the mother and fetus. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of pre-eclampsia for decades. Pregnancies complicated by this syndrome require a well-formulated management plan, including assessing and stabilizing the maternal condition as well as evaluating fetal well-being. Patients with HELLP syndrome should receive anti-seizure prophylaxis with magnesium sulfate, treatment for severe hypertension, and correction of coagulopathy, if present. The potential benefits of expectant management of HELLP syndrome in those remote from term and the use of corticosteroids to improve maternal outcome remain experimental. Computed tomography or ultrasound of the abdomen should be performed if a subcapsular hematoma of the liver is suspected. If a ruptured hematoma is confirmed, massive transfusions and laparotomy are indicated. Ischemia associated with pre-eclampsia cannot only damage the liver but also the pancreas and gallbladder.

There are many obstetric, medial, and surgical disorders that share many of the clinical and laboratory findings of patients with severe pre-eclampsia-eclampsia. Imitators of severe pre-eclampsia-eclampsia are life-threatening emergencies that can develop during pregnancy or in the postpartum period. These conditions are associated with high maternal and perinatal mortalities and morbidities, and survivors may face long-term sequelae. The pathophysiologic abnormalities in many of these disorders include vasospasm, platelet activation or destruction, microvascular thrombosis, endothelial cell dysfunction, and reduced tissue perfusion. Some of these disorders include acute fatty liver of pregnancy, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome, acute exacerbation of systemic lupus erythematosus, and disseminated herpes simplex and sepsis syndromes. Differential diagnosis may be difficult due to the overlap of several clinical and laboratory findings of these syndrome. It is important that the clinician make the accurate diagnosis when possible because the management and complications from these syndromes may be different. Because of the rarity of these conditions during pregnancy and postpartum, the available literature includes only case reports and case series describing these syndromes. This review focuses on diagnosis, management, and counseling of women who develop these syndromes based on results of recent studies and my own clinical experience.

The objective of the study was to evaluate the indications for late preterm birth and compare outcomes by gestational age among late preterm (34-36 weeks) and term (or = 37 weeks) neonates at our institution.This was a retrospective analysis of delivery indications and short-term neonatal outcomes in women who delivered at the University Hospital between January 1, 2005 and Dec. 31, 2006. Data were analyzed using chi(2), Student's t-test, analysis of variance, and post hoc Tukey tests.One hundred forty-nine late preterm (n = 49 for 34, n = 50 for 35, n = 50 for 36 weeks) and 150 term infants (n = 50 for 37, n = 50 for 38, n = 50 for 39 weeks or longer) were evaluated. Differences among groups (ie, 34 vs 35 vs 36 vs 37, etc) as well as combinations of differences between 2 groups (ie, 34-36 weeks vsor = 37 oror = 38 weeks) were analyzed. Spontaneous labor and/or rupture of membranes were the most common indications for late preterm delivery (92%). Compared with term, late preterm infants had longer hospital stays (5 days vs 2.4 days; P.001) and higher rates of neonatal intensive care unit (NICU) admissions (56% vs 4%; P.001), feeding problems (36% vs 5%; P.001), hyperbilirubinemia (25% vs 3%; P.001), and respiratory complications (20% vs 5%; P.001). Neonatal complications were minimal at 38 weeks or longer.Rates of neonatal intensive care unit admission, length of stay, and neonatal morbidities are significantly higher in late preterm as compared with term births.

Objective This study was undertaken to compare uterine contraction frequency in twins versus singletons and to determine if contraction frequency can be an efficient predictor of spontaneous preterm birth in twin gestations. Study design Fifty-nine twin and 306 singleton gestations were enrolled between 22 and 24 weeks at 11 centers. Contraction frequency was recorded with a home uterine activity monitor (HUAM) 2 or more times per day on 2 or more days per week until delivery or 36-6/7 weeks. Masked HUAM data were interpreted according to standard protocol. Repeated measures analyses were used to determine whether mean or maximum uterine contraction frequency per hour differed between singleton and twin gestations across gestational age, by time of day, and by delivery before 35 weeks or beyond. Uterine contraction frequency was also evaluated by logistic regression and receiver operator characteristic (ROC) curves as tests to predict spontaneous preterm birth. Results There were 34,908 hours of HUAM data recorded by the 306 singleton gestations and 5,427 hours by the 59 women with twins. Uterine contraction frequency was significantly greater in twins ( P = .002) compared with singletons, regardless of gestational age. Contraction frequency in twins increased significantly with gestational age and time of day (1600-0359 hours); but was not associated with spontaneous preterm birth. Maximum uterine contraction frequency was associated with preterm birth less than 35 weeks but only in the morning (am) recording (0400-1559) and at the 29- to 30-week gestational age interval. This relationship was modest (odds ratio 1-2) and not consistent across gestational age or between the am and afternoon/evening (pm) monitoring sessions. ROC analysis revealed no contraction frequency that efficiently identified twins who delivered prematurely at any 2-week gestational age interval. Conclusion Mean uterine contraction frequency was significantly higher for twin gestations than singletons throughout the latter half of pregnancy and between 1600 and 0359 hours but was not higher among twins who delivered less than 35 weeks' gestation. Neither maximum am or pm contraction frequency predicted spontaneous preterm birth less than 35 weeks' gestation in twin pregnancies.

Objective This study was undertaken to compare success rates of vaginal birth after cesarean (VBAC) delivery, and uterine rupture as well as maternal/perinatal outcomes between women with preterm and term pregnancies undergoing trial of labor (TOL), and to compare maternal and neonatal morbidities in those women with preterm pregnancies undergoing a TOL versus repeat cesarean delivery without labor (RCD). Study design Prospective 4-year observational study of women with a singleton gestation and a prior cesarean delivery at 19 academic centers. Clinical characteristics, maternal complications and VBAC delivery success for those with a preterm (24 0 -36 6 weeks) TOL, preterm RCD and term TOL (≥37 weeks) were analyzed. Results Among 3119 preterm pregnancies with prior cesarean delivery, 2338 (75%) underwent a TOL. 15,331 women undergoing TOL at term were also analyzed as a control group. TOL success rates for preterm and term pregnancies were similar (72.8% vs 73.3%, P = .64). Rates of uterine rupture (0.34% vs 0.74%, P = .03) and dehiscence (0.26% vs 0.67%, P = .02) were lower in preterm compared with term TOL. Thromboembolic disease, coagulopathy and transfusion were more common in women undergoing a preterm TOL than those at term. Among women undergoing a preterm TOL, rates of uterine dehiscence, coagulopathy, transfusion, and endometritis were similar to those having a preterm RCD. After controlling for gestational age at delivery and race, neonatal outcomes such as Neonatal Intensive Care Unit (NICU) admission, intraventricular hemorrhage, sepsis, and ventilatory support were similar in both groups except for a higher rate of respiratory distress syndrome in those delivered after a TOL. Conclusion The likelihood of VBAC success after TOL in preterm pregnancies is comparable to term gestations, with a lower risk of uterine rupture. Perinatal outcomes are similar with preterm TOL and RCD. TOL should be considered as an option for women undergoing preterm delivery with a history of prior cesarean delivery.

Objective The objective of the study was to estimate whether midpregnancy genitourinary tract infection with Chlamydia trachomatis is associated with an increased risk of subsequent preterm delivery. Study design Infection with C. trachomatis was determined using a ligase chain reaction assay (performed in batch after delivery) of voided urine samples collected at the randomization visit (16 0/7 to 23 6/7 weeks' gestation) and the follow-up visit (24 0/7 to 29 6/7 weeks) among 2470 gravide women with bacterial vaginosis or Trichomonas vaginalis infection enrolled in 2 multicenter randomized antibiotic treatment trials (metronidazole versus. placebo). Results The overall prevalence of genitourinary tract C. trachomatis infection at both visits was 10%. Preterm delivery less than 37 weeks' or less than 35 weeks' gestational age was not associated with the presence or absence of C. trachomatis infection at either the randomization (less than 37 weeks: 14% versus 13%, P =.58; less than 35 weeks: 6.4% versus 5.5%, P =.55) or the follow-up visit (less than 37 weeks: 13% versus 11%, P =.33; less than 35 weeks: 4.4% versus 3.7, P =.62). Treatment with an antibiotic effective against chlamydia infection was not associated with a statistically significant difference in preterm delivery. Conclusion In this secondary analysis, midtrimester chlamydia infection was not associated with an increased risk of preterm birth. Treatment of chlamydia was not associated with a decreased frequency of preterm birth.

The syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) has been described in women with preeclampsia for several decades. For the past 50 years, it has been recognized that the presence of all these laboratory abnormalities in preeclampsia-eclampsia is usually associated with increased rates of maternal complications (Table). The rate of these complications will depend on the criteria used to establish the diagnosis of HELLP syndrome, the population studied (hospital based or tertiary referral center), and the presence of associated medical, surgical, or obstetric complications (abruption placentae, eclampsia, peripartum hemorrhage). More than 2 decades since the term HELLP syndrome was first coined by Weinstein and after the publication of extensive literature in which the term HELLP syndrome has been described, there is still considerable disagreement with regard to the diagnosis and treatment of this syndrome. This disagreement is due in part to a lack of uniform diagnostic criteria for this syndrome and in part to a lack of well-designed, randomized studies for the treatment of this syndrome. The diagnostic criteria for HELLP syndrome, and its subclasses, are not as rigorous as one thinks and have varied among investigators from the same country and even between countries. For example, a significant percentage of published reports on the subject include

Objective The purpose of this study was to define independent risk factors for uterine atony after primary cesarean delivery, and to assess their overall association with atony in the study cohort. Study design This was a 13–university center prospective observational study. All women who underwent primary cesarean from January 1, 1999 to December 31, 2000 were eligible. Trained and certified research nurses performed systematic data abstraction. The definition of atony required both the clinical diagnosis and the use of methergine or a prostaglandin preparation. Risk factors for uterine atony were assessed in univariable and multivariable logistic regression analyses, and these analyses then used to inform an assessment of the association of the various risk factors with the occurrence of uterine atony in the overall cohort. Results Twenty-three thousand, three hundred and ninety pregnancies were analyzed. Uterine atony occurred in 1416 women (6%). Several variables were independently associated with atony in a multivariable model, including multiple gestation (odds ratio [OR] 2.40, 95% CI 1.95-2.93), maternal Hispanic race (2.21, 1.90-2.57), induced or augmented labor for >18 hours (2.23, 1.92-2.60), infant birth weight >4500 g (2.05, 1.53-2.69), and clinically diagnosed chorioamnionitis (1.80, 1.55-2.09). However, because the various risk factors were not very powerful, approximately half of the cases of atony were associated with the 2/3 of women lacking a given risk factor or combination of risk factors. Conclusion Although certain risk factors and uterine atony were clearly associated, the associations are of limited practical clinical use.

Pregnancies complicated by hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome require a well-formulated management plan. The development of this syndrome after 34 weeks' gestation or with documentation of maternal or fetal compromise is an indication for delivery. Acute fatty liver of pregnancy, hemolytic uremic syndrome, and thrombotic thrombocytopenic purpura may present with signs, symptoms, and laboratory abnormalities that may be confused with HELLP syndrome. Thorough investigation is warranted because of the differences in proper management among these various complications of pregnancy. Expectant management in patients with HELLP syndrome remote from term and the use of corticosteroids to improve postpartum maternal outcome remain experimental.

The purpose of this study was to evaluate placental lesions found in women with preeclampsia compared with normotensive control subjects and to determine whether the presence of these lesions are related to gestational age at delivery.Placental disease of women with preeclampsia at 24 to 42 weeks of gestation was compared with the placental disease of normotensive gestational age-matched control subjects. The placental lesions that were studied specifically included decidual arteriolopathy, thrombi in the fetal circulation, central infarction, intervillous thrombi, and hypermaturity of villi. Data analysis involved the chi(2) test, the Student t test, and logistic regression; odds ratios and CIs were estimated.Placentas from women with preeclampsia (n=158) and normotensive control subjects (n=156) were evaluated. Among women with preeclampsia, 67% had severe disease. Placental lesions were studied according to gestational age at delivery:28, 28 to 32, 33 to 36, andor=37 weeks of gestation. Of the placental lesions that were studied, decidual arteriolopathy (odds ratio, 23.8, 95% CI 10.0-57.0), hypermaturity of villi (odds ratio, 12.4; 95% CI 5.3-29.2), intervillous thrombi (odds ratio, 1.95;95% CI 1.0-3.7), central infarction (odds ratio, 5.9; 95% CI 3.1-11.1), and thrombi in the fetal circulation (odds ratio, 2.8; 95% CI 1.2-6.6) were found to have significantly higher rates in the preeclamptic group. In contrast, the rate of chorioamnionitis was significantly lower in the preeclamptic group (odds ratio, 0.2; 95% CI 0.1-0.4). The rates of abruptio placentae and meconium staining were not different between the two groups. Within the preeclamptic group, the rates of decidual arteriolopathy (P.0001), central infarction (P=.0001), and hypermaturity of villi (P.0001) were higher the earlier the gestational age at delivery.Placentas in women with preeclampsia have increased amounts of disease. The rate is increased with lower gestational ages at the time of delivery for women with preeclampsia.

Objective: The objective of the study was to evaluate the efficacy of gentamicin and clindamycin given once daily versus the more common 8-hour dosing regimen for the treatment of postpartum endometritis. Study Design: In a prospective, placebo-controlled, double-blinded study, patients who had postpartum endometritis diagnosed were randomly selected to receive 1.5 mg/kg gentamicin and 900 mg clindamycin phosphate administered every 8 hours versus gentamicin 5 mg/kg and clindamycin phosphate 2700 mg administered as a single-daily dose. The single-dose group received an infusion of gentamicin and clindamycin, followed by an administration of intravenous placebo 8 and 16 hours later to maintain blinding. Treatment success was defined as absence of fever 72 hours after initiation of antibiotic therapy. Results: One hundred ten patients were enrolled. The daily-dose group (n = 55) and the thrice-daily dose group (n = 55) were similar with respect to age, gravidity, parity, gestational age, and maternal weight. Clinical characteristics (including maximum temperature, presence of predelivery chorioamnionitis, white blood cell count, and mode of delivery) were also similar. There was no difference in the mean time from initiation of therapy until becoming afebrile in the daily-dose group (27.4 ± 24.9 hours) compared with the thrice-daily dose group (32.9 ± 26.3 hours). Forty-five of 56 (82%) patients in the daily-dose group and 38 of 55 (69%) patients in the thrice-daily dose group had treatment success ( P = .12). Conclusion: Once-daily dosing with gentamicin and clindamycin in women with postpartum endometritis has a similar success rate as the standard every 8-hour dosing schedule. (Am J Obstet Gynecol 2003;188:149-52.)

Objective: The purpose of this study was to determine whether there is a shift in the timing of eclampsia in relation to delivery and whether traditional symptoms precede impending postpartum eclampsia. Study Design: A multicenter analysis of data from patients with eclampsia from March 1996 through February 2001 at the University of Cincinnati, the University of Tennessee, Memphis, and Central Baptist Hospital, Lexington. Data were collected regarding the relationship of the patient's first seizure to delivery, prodromal symptoms, neuroimaging studies, use of magnesium sulfate, antihypertensive therapy, and follow-up medical care. The analysis focused on women who had late postpartum eclampsia. Results: During the study period, 89 patients were diagnosed with eclampsia. Twenty-nine women (33%) had postpartum eclampsia, of whom 23 women (79%) had late onset (>48 hours). Interestingly, only 5 of these 23 women (22%) had been previously diagnosed with preeclampsia. Twenty-one patients (91%) with late postpartum eclampsia had at least 1 prodromal symptom, and 12 patients (52%) had >1 symptom that heralded the seizure: 20 women (87%) had headache; 10 women (44%) had visual changes; 5 women (22%) had nausea or vomiting; and 2 women (9%) experienced epigastric pain. Only 7 of these 21 women (33%) sought care for their symptoms, of whom 6 women (86%) had clinical evidence of preeclampsia that was not considered by the treating physician. Among all patients with eclampsia, there were 7 cases of aspiration pneumonia, 3 cases of pulmonary edema, 3 cases of pleural effusion, 2 cases of disseminated intravascular coagulation, and no cases of maternal death. Conclusion: Current obstetric treatment in the United States has resulted in a shift of eclampsia toward the postpartum period, with most cases being seen as late post partum. To reduce the rate of late postpartum eclampsia, efforts should be directed to the education of the health care providers and patients regarding the importance of prompt reporting and evaluation of symptoms of preeclampsia during the postpartum period. (Am J Obstet Gynecol 2002;186:1174-7.)

Traditionally, 2-dimensional ultrasound parameters have been used for the diagnosis of a suspected morbidly adherent placenta previa. More objective techniques have not been well studied yet.The objective of the study was to determine the ability of prenatal 3-dimensional power Doppler analysis of flow and vascular indices to predict the morbidly adherent placenta objectively.A prospective cohort study was performed in women between 28 and 32 gestational weeks with known placenta previa. Patients underwent a two-dimensional gray-scale ultrasound that determined management decisions. 3-Dimensional power Doppler volumes were obtained during the same examination and vascular, flow, and vascular flow indices were calculated after manual tracing of the viewed placenta in the sweep; data were blinded to obstetricians. Morbidly adherent placenta was confirmed by histology. Severe morbidly adherent placenta was defined as increta/percreta on histology, blood loss2000 mL, and2 units of PRBC transfused. Sensitivities, specificities, predictive values, and likelihood ratios were calculated. Student t and χThe following results were found: (1) 50 women were studied: 23 had morbidly adherent placenta, of which 12 (52.2%) were severe morbidly adherent placenta; (2) 2-dimensional parameters diagnosed morbidly adherent placenta with a sensitivity of 82.6% (95% confidence interval, 60.4-94.2), a specificity of 88.9% (95% confidence interval, 69.7-97.1), a positive predictive value of 86.3% (95% confidence interval, 64.0-96.4), a negative predictive value of 85.7% (95% confidence interval, 66.4-95.3), a positive likelihood ratio of 7.4 (95% confidence interval, 2.5-21.9), and a negative likelihood ratio of 0.2 (95% confidence interval, 0.08-0.48); (3) mean values of the vascular index (32.8 ± 7.4) and the vascular flow index (14.2 ± 3.8) were higher in morbidly adherent placenta (P.001); (4) area under the receiver-operating characteristic curve for the vascular and vascular flow indices were 0.99 and 0.97, respectively; (5) the vascular index ≥21 predicted morbidly adherent placenta with a sensitivity and a specificity of 95% (95% confidence interval, 88.2-96.9) and 91%, respectively (95% confidence interval, 87.5-92.4), 92% positive predictive value (95% confidence interval, 85.5-94.3), 90% negative predictive value (95% confidence interval, 79.9-95.3), positive likelihood ratio of 10.55 (95% confidence interval, 7.06-12.75), and negative likelihood ratio of 0.05 (95% confidence interval, 0.03-0.13); and (6) for the severe morbidly adherent placenta, 2-dimensional ultrasound had a sensitivity of 33.3% (95% confidence interval, 11.3-64.6), a specificity of 81.8% (95% confidence interval, 47.8-96.8), a positive predictive value of 66.7% (95% confidence interval, 24.1-94.1), a negative predictive value of 52.9% (95% confidence interval, 28.5-76.1), a positive likelihood ratio of 1.83 (95% confidence interval, 0.41-8.11), and a negative likelihood ratio of 0.81 (95% confidence interval, 0.52-1.26). A vascular index ≥31 predicted the diagnosis of a severe morbidly adherent placenta with a 100% sensitivity (95% confidence interval, 72-100), a 90% specificity (95% confidence interval, 81.7-93.8), an 88% positive predictive value (95% confidence interval, 55.0-91.3), a 100% negative predictive value (95% confidence interval, 90.9-100), a positive likelihood ratio of 10.0 (95% confidence interval, 3.93-16.13), and a negative likelihood ratio of 0 (95% confidence interval, 0-0.34). Intrarater and interrater agreements were 94% (P.001) and 93% (P.001), respectively.The vascular index accurately predicts the morbidly adherent placenta in patients with placenta previa. In addition, 3-dimensional power Doppler vascular and vascular flow indices were more predictive of severe cases of morbidly adherent placenta compared with 2-dimensional ultrasound. This objective technique may limit the variations in diagnosing morbidly adherent placenta because of the subjectivity of 2-dimensional ultrasound interpretations.

The purpose of this study was to compare the efficacy of different routes of misoprostol administration for cervical ripening and the induction of labor.Three hundred thirty women ator = 32 weeks gestation with a Bishop scoreor = 6 and an indication for induction were randomized to 1 of 3 double-blinded groups: (1) 25 microg orally administered misoprostol plus 25 microg vaginally administered misoprostol, (2) orally administered placebo plus 25 microg vaginally administered misoprostol, or (3) 25 microg orally administered misoprostol plus vaginally administered placebo. Doses were repeated every 4 hours until onset of labor or a maximum of 12 doses were given. The primary outcome of the trial was vaginal delivery within 24 hours of the initiation of induction. Secondary outcomes were the time from induction to delivery, need for oxytocin augmentation, mode of delivery, frequency of side effects, and neonatal and maternal outcome. Analysis of variance, chi-square test, and logistic regression were used for analysis.There were no significant differences in maternal characteristics or indications for induction. The percentage of women who achieved vaginal delivery within 24 hours was highest in the vaginally administered misoprostol group: 67% compared with 53% in the oral-plus-vaginal group (P.05) and 36% in the oral group (P.05). The median time to vaginal delivery was shorter in the vaginal and oral-plus-vaginal misoprostol groups, 13.5 hours and 14.3 hours, respectively, when compared with 23.9 hours in the oral group (P.05). The rate of cesarean delivery was lowest in the vaginal misoprostol group (17% compared with 30% in the oral-plus-vaginal group and 32% in the oral group; P.05). Uterine tachysystole occurred least frequently in the oral misoprostol group (10% compared with 32% in the vaginal group and 34% in the oral-plus-vaginal group; P.05). Uterine hyperstimulation also occurred least frequently in the oral misopro-stol group (4% compared with 15% in the vaginal group and 22% in the oral-plus-vaginal group; P.05).At the doses studied, induction of labor with vaginally administered misoprostol is more efficacious than either oral-plus-vaginal or oral-only route of administration.

Objective: This study was undertaken to address the role of oxidative stress in preeclampsia. Study Design: We measured urinary 8,12- iso -iPF 2 α -VI, a chemically stable, free-radical catalyzed product, in a case control study of severe preeclampsia nested within the trial of Calcium for Preeclampsia Prevention. Cases included 29 women who developed severe preeclampsia and from whom urine had been obtained 10 to 20 weeks before the diagnosis of preeclampsia, 3 to 9 weeks before, and 1 day before through delivery. Controls did not develop hypertension or proteinuria and were matched to cases by center, gestational age at each of 3 corresponding urine collections, and date of enrollment. Results: Urinary 8,12- iso -iPF 2 α -VI did not differ significantly between cases and controls before or at diagnosis of preeclampsia, nor did it vary with gestational age. Conclusions: These results call into question the importance of oxidative stress in the disease and the biochemical rationale for clinical trials of antioxidants to prevent and treat preeclampsia. (Am J Obstet Gynecol 2001;185:572-8.)

Hypertensive disorders are the most common medical disorders during pregnancy. Their presence is associated with increased adverse maternal and fetal outcomes both acute and long-term. Antihypertensive agents are widely used in the treatment of these pregnancies despite absent evidence of either benefits or harms from this therapy. Multiple agents are available and various guidelines recommend different agents and various doses and regimens in the absence of information about the pharmacokinetics, disposition, and pharmacodynamic effects of these drugs in pregnancy. Randomized trials comparing antihypertensive therapy to a placebo are lacking and the available data have not shown clinical benefits because of inadequate sample size to rule out even moderate to large effects on perinatal outcome. In addition, data on teratogenic effects, adverse fetal-neonatal effects, and long-term infant outcome are also scant. These problems resulted from lack of interest and support by the government and pharmaceutical companies to conduct research in pregnant women because of regulatory and medical-legal concerns. Consequently, there is an urgent need to conduct clinical research in this area.

Objective: The aim of this study was to determine whether positive results of tests for any of 5 antiphospholipid antibodies are associated with recurrent preeclampsia among women with a history of preeclampsia in a previous pregnancy. Study Design: Second-trimester serum samples were obtained from 317 women with preeclampsia in a previous pregnancy who were being followed up in a prospective treatment trial. The serum samples were measured by enzyme-linked immunoassay for immunoglobulin G and immunoglobulin M antibodies against 5 phospholipids. Positive results were analyzed with regard to preeclampsia, severe preeclampsia, intrauterine growth restriction, and preterm delivery. Results: Sixty-two of the 317 women (20%) had recurrent preeclampsia develop, 19 (6%) had severe preeclampsia, and 18 (5.8%) were delivered of infants with growth restriction. Positive results of tests for immunoglobulin G or immunoglobulin M antiphospholipid antibodies were not associated with recurrent preeclampsia. Positive results for immunoglobulin G or immunoglobulin M antibodies at the 99th percentile were also not associated with preterm delivery. Positive results at the 99th percentile for immunoglobulin G antiphosphatidylserine antibody were associated with severe preeclampsia, and positive results at the 99th percentile for immunoglobulin G anticardiolipin, antiphosphatidylinositol, and antiphosphatidylglycerol antibodies were associated with intrauterine growth restriction. The positive predictive values for these outcomes all were approximately 30%. Conclusion: Positive results of testing for antiphospholipid antibodies in the second trimester were not associated with recurrent preeclampsia among women at risk because of a history of preeclampsia. Positive results for immunoglobulin G antiphosphatidylserine antibody were associated with severe preeclampsia, and positive results for immunoglobulin G anticardiolipin, antiphosphatidylinositol, and antiphosphatidylglycerol antibodies were associated with intrauterine growth restriction. However, the positive predictive values for all these associations were modest. Testing for antiphospholipid antibodies during pregnancy is of little prognostic value in the assessment of the risk for recurrent preeclampsia among women with a history of preeclampsia. (Am J Obstet Gynecol 2001;184:825-34.)

Elevated amounts of circulating fetal deoxyribonucleic acid in maternal plasma have recently been detected in pregnancies complicated by preeclampsia. We attempted to confirm this finding and simultaneously examined the quantity of maternal circulating deoxyribonucleic acid.Circulating deoxyribonucleic acid was measured by realtime quantitative polymerase chain reaction in plasma samples obtained from 44 women with preeclampsia and a matched cohort of 53 normotensive pregnant women.We confirmed that circulating fetal deoxyribonucleic acid levels were significantly elevated in pregnancies complicated by preeclampsia (3194.6 vs 332.8 copies/mL; P.001). We also showed for the first time that circulating maternal deoxyribonucleic acid levels are also elevated (219,023.9 vs 20,235.8 copies/mL; P.001). The increases in these deoxyribonucleic acid levels corresponded to the severity of the disorder, and values were correlated with each other in pregnancies complicated by preeclampsia (r = 0.556; P.001) but not normotensive pregnancies (r = 0.046; P = .747).The releases of both free fetal and maternal deoxyribonucleic acid were found to be affected in preeclampsia.

Pre-eclampsia remains one of the major obstetrical problems in less-developed countries. The causes of this condition are still unknown, thus effective primary prevention is not possible at this stage. Research in the past decade has identified some major risk factors for pre-eclampsia, and manipulation of these factors might result in a decrease in its frequency. In the early 1990s aspirin was thought to be the wonder drug in secondary prevention of pre-eclampsia. Results of large trials have shown that this is not the case: if there is an indication for using aspirin it is in the patient at a very high risk of developing severe early-onset disease. The calcium story followed a more or less similar pattern, with the difference that existing evidence shows that women with a low dietary calcium intake are likely to benefit from calcium supplementation. Proper antenatal care and timed delivery are of utmost importance in tertiary prevention of pre-eclampsia. There is evidence to suggest that the intrinsic direct effect of moderate degrees of maternal hypertension is beneficial to the fetus. Severe hypertension needs treatment. If antihypertensive is indicated, there is no clear choice of a drug. Hydralazine should no longer be thought of as the primary drug, most studies show a preference for calcium channel blockers.

Our purpose was to determine whether the onset of the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome in women ator =28.0 weeks' gestation is associated with an increased risk of adverse maternal and perinatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age.Sixty-four patients with either the HELLP syndrome (n = 32) or severe preeclampsia but absent HELLP syndrome laboratory test results (n = 32), admitted ator =28.0 weeks' gestation between July 1, 1992, and April 30, 1999, were studied. Maternal and perinatal outcomes were compared between the 2 groups. Statistical analysis was performed by the Student t test and the Fisher exact test.There were no significant differences between the 2 groups regarding African-American race (59% vs 75%), nulliparity (50% vs 56%), or the use of corticosteroids (59% vs 78%). There were no maternal deaths. One woman with the HELLP syndrome had a liver hematoma. The rate at which transfusion of blood products was required was significantly greater in women with the HELLP syndrome than in those with severe preeclampsia only (25% vs 3%; P.05). There were no significant differences between the 2 groups with respect to eclampsia (16% vs 13%), abruptio placentae (6% vs 9%), disseminated intravascular coagulopathy (13% vs 0%), pulmonary edema (13% vs 6%), acute renal failure (3% vs 0%), pleural effusion (3% vs 3%), or ascites (6% vs 16%). No significant differences were found between the 2 groups with respect to neonatal death (11% vs 17%), respiratory distress syndrome (78% vs 86%), or composite neonatal morbidity.Except for the need for transfusion of blood products in women with the HELLP syndrome, onset ator =28.0 weeks' gestation is not associated with an increased risk of adverse maternal or neonatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age.

Objective: The purpose of this study was to compare the rates of indicated and spontaneous preterm delivery among women with chronic hypertension or pregestational diabetes mellitus with the rates among healthy women. Study Design: This was a secondary analysis of data from healthy women with singleton gestations enrolled in a prospective observational study for prediction of preterm delivery (control group, n=2738), women with pregestational diabetes mellitus requiring insulin therapy (n = 461), and women with chronic hypertension (n = 761). The two latter groups were enrolled in a randomized multicenter trial for prevention of preeclampsia. The main outcome measures were rates of preterm delivery, either spontaneous (preterm labor or rupture of membranes) or indicated (for maternal or fetal reasons), and neonatal outcomes. Results: The overall rates of preterm delivery were significantly higher among women with diabetes mellitus (38%) and hypertension (33.1%) than among control women (13.9%). Rates were also significantly higher for delivery at Conclusion: The increased rate of preterm delivery among women with chronic hypertension relative to control women was primarily an increase in indicated preterm delivery, whereas the rates of both spontaneous and indicated preterm delivery were increased among women with pregestational diabetes mellitus. (Am J Obstet Gynecol 2000;183:1520-4.)

Objective: The aim of this study was to characterize the clinical presentation, etiology, and acute and subsequent outcomes of postpartum stroke. Study Design: This 20-year, single-center, retrospective review included 20 women without previous neurologic deficit with clinical and neuroimaging diagnoses of postpartum stroke. Results: Eight of 20 women (40%) were delivered abdominally. Conduction anesthesia was induced in 9 of 20 women (45%). Causes of stroke included cerebral infarction (n = 13; 7 venous, 6 arterial), intracerebral hemorrhage (n = 5; 1 cocaine-induced, 1 anatomic malformation), cerebritis (n = 1), and cerebral atrophy (n = 1). The median time at onset of stroke was 8 days post partum (range, 3-35 days). Headache, seizures, visual change, and hemiparesis were the most common presenting findings but were neither specific to the underlying pathologic condition nor predictive of ultimate maternal outcome. There were 2 maternal deaths, both caused by severe intracerebral hemorrhage. Intracerebral hemorrhage was associated with the poorest outcome (2 deaths and 1 residual neurologic deficit). Eight women had residual neurologic deficit. There was no correlation between a trial of labor ( P =.4; odds ratio, 0.4; 95% confidence interval, 0.01-6.5) or vaginal versus cesarean mode of delivery ( P =.6; odds ratio, 1.3; 95% confidence interval 0.1-16.8) and ultimate neurologic diagnosis (cerebral infarction or intracerebral hemorrhage). However, the incidence of cesarean delivery was greater in the cohort of women with postpartum stroke than in the overall obstetric population ( P =.015; odds ratio, 3.2; 95% confidence interval, 1.2-8.5). One of the 20 women received methergine; 1 received bromocriptine. All women were either normotensive or had well-controlled hypertension at postpartum discharge. New-onset hypertension or exacerbation of existing hypertension occurred after the acute neurologic insult; subsequent mean (±SD) arterial blood pressure was 128.9 ± 24.0 mm Hg. Conclusion: Postpartum stroke is a multifactorial, uncommon, and nonpreventable complication of pregnancy. There was an association between postpartum stroke and hypertensive disorders of pregnancy and cesarean delivery. However, this study refutes any etiologic association between conduction anesthesia and postpartum stroke. (Am J Obstet Gynecol 2000;183:83-8.)

Our purpose was to evaluate the outcome of infants who underwent successful resuscitation after initial Apgar scores of 0 at both 1 and 5 minutes.Eligible infants were identified through the perinatal database at the University of Tennessee, Memphis. Hospital records and long-term outcomes, where available, of babies who met the above criteria occurring between January 1986 and February 1999 were reviewed.Thirty-three of 81,603 infants (0.4/1000 births) met our study criteria. Twenty-two (67%) babies died during hospitalization. Mortality decreased significantly from 100% for babies with a birth weight of750 g to 38% for those weighingor =2500 g at birth (P =.03). All 6 babies delivered before 26 weeks' gestation died. The incidence of 10-minute Apgar scores0 was significantly higher among survivors than among those who subsequently died (82% vs 33%, P.05). Nine survivors had hypoxic-ischemic encephalopathy diagnosed before discharge. Of the 7 infants with available follow-up, 4 had significant persisting morbidity. Two infants had normal neurologic examinations at follow-up.Survival in babies born with 1- and 5-minute Apgar scores of 0 is predicted by birth weight, gestational age, and 10-minute Apgar score. Long-term sequelae are common but not ensured.

Objective: This study was undertaken to identify risk factors associated with adverse maternal outcome in pregnancies complicated by eclampsia. Study Design: This was a descriptive study of 399 consecutive women with eclampsia whose cases were managed at one perinatal center between August 1977 and July 1998. Data were collected. Risk factors studied included maternal age, race, parity, preexisting medical complications, and clinical and laboratory findings. Outcome variables were maternal morbidities. Data were analyzed by either χ2 analysis or the unpaired Student t test as appropriate. Results: In the entire cohort of women with eclampsia major maternal complications included abruptio placentae (10%), HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome (11%), disseminated intravascular coagulopathy (6%), neurologic deficits and aspiration pneumonia (7%), pulmonary edema (5%), cardiopulmonary arrest (4%), acute renal failure (4%), and death (1%, n = 2 patients with antepartum onset). Women with antepartum eclampsia had significantly higher incidences of abruptio placentae (12% vs 6%; P < .05) and HELLP syndrome (14% vs 4%; P = .005) than did those in whom eclampsia developed post partum. In contrast, women with postpartum eclampsia were more likely to have neurologic deficits develop (9% vs 2%; P = .0006) than were those with antepartum eclampsia. In addition, women in whom eclampsia developed at ≤32 weeks’ gestation had significantly higher incidences of abruptio placentae (17% vs 8%; P = .01), HELLP syndrome (20% vs 7%; P = .0005), and acute renal failure (8% vs 2%; P = .01) than did those in whom eclampsia developed later. Conclusion: Eclampsia remains a significant complication of pregnancy that carries high maternal mortality and morbidity rates. Antepartum onset carries greater risks, and onset at ≤32 weeks’ gestation is particularly dangerous to both mother and fetus. (Am J Obstet Gynecol 2000;182:307-12.)

Objective: We sought to characterize the presentation, recurrence, and outcome of venous thromboembolism during pregnancy. Study Design: We performed a 12-year, single-center, retrospective review of 38 patients with venous thromboembolism during pregnancy. The independent variables were subjected to univariate analysis (unpaired t test for normally distributed continuous variables and Fisher exact test for discrete variables). P Results: There was no significant difference for the following variables according to time of presentation (antepartum vs post partum): gestational age at delivery (37.4 ± 6.6 wk vs 38.1 ± 2.4 wk; P = .7), birth weight (3257 ± 458 g vs 3093 ± 719 g; P = .3), and mode of delivery (2 vs 4 cesarean deliveries; P = .15). There were 2 maternal deaths. All 3 women with antepartum recurrent venous thromboembolism (despite heparin prophylaxis) had findings of protein C deficiency, protein S deficiency, and lupus anticoagulant–anticardiolipin antibody, respectively. Conclusion: The gestational age at presentation appears more equally distributed throughout gestation than previously reported. Notwithstanding limited numbers, the recurrence of venous thromboembolism despite use of prophylactic heparin therapy suggests the need to reexamine the current recommendations for heparin dosing. (Am J Obstet Gynecol 1999;181:1118-21.)

HELLP syndrome without proteinuria or hypertension is rare. We present the case of a 33-year-old primigravid who initially was diagnosed with pulmonary embolism. The patient was readmitted with a diagnosis of subcapsular hematoma and eventually diagnosed with HELLP syndrome with a sequela of hepatic rupture.

Preeclampsia is a multisystem disorder of unknown etiology. During the past 2 decades, numerous clinical reports and randomized trials described the use of various methods to prevent or reduce the incidence and severity of preeclampsia. These methods were used in an attempt to correct certain abnormalities such as biochemical imbalance, a pathophysiologic mechanism, or a dietary deficiency. There are at least 15 randomized trials evaluating the use of various antihypertensive drugs including diuretics for the prevention of preeclampsia. Results of these trials reveal no such benefit. There are few randomized trials evaluating magnesium (n = 2), zinc (n = 2), or fish oil supplementation (n = 3) to prevent preeclampsia. The majority of these trials had limited sample size; however, results reveal minimal-to-no benefit. There are 7 placebo-controlled trials evaluating calcium supplementation during pregnancy. Findings of these trials reveal that calcium supplementation does not reduce the incidence of preeclampsia in healthy nulliparous women. The majority of randomized trials for the prevention of preeclampsia have used low-dose aspirin. Results of early single-center trials demonstrated an average reduction of preeclampsia of 70% with low-dose aspirin. However, results of recent large multicenter trials (n = 7) that included >27,000 women revealed minimal-to-no benefit. Until the pathogenesis of preeclampsia is well defined, prevention of this syndrome with any modality remains unlikely. (Am J Obstet Gynecol 1998;179:1275-8.)

Objective: Our goal was to identify risk factors for the development of preeclampsia in nulliparous women enrolled in a multicenter trial comparing calcium supplementation to a placebo. Study Design: A total of 4589 women from five centers was studied. Analysis of risk factors for preeclampsia was performed in 4314 who carried the pregnancy to >20 weeks. Baseline systolic and diastolic blood pressure, demographic characteristics, and findings after randomization were examined for the prediction of preeclampsia. Preeclampsia was defined as hypertension (diastolic blood pressure ≥90 mm Hg on two occasions 4 hours to 1 week apart) and proteinuria (≥300 mg/24 hours, a protein/creatinine ratio ≥0.35, one dipstick measurement ≥2+ or two dipstick measurements ≥1+ at an interval as specified for diastolic blood pressure). Results: Preeclampsia developed in 326 women (7.6%). The first analysis treated each risk factor as a categoric variable in a univariate regression. Maternal age, blood group and Rh factor, alcohol use, previous abortion or miscarriage, private insurance, and calcium supplementation were not statistically significant. Risk factors initially found to be significant were body mass index, systolic blood pressure, diastolic blood pressure, non-white race (African-American and other), clinical center, and smoking. Adjusted odds ratios computed with a Iogistic regression model revealed that body mass index (odds ratio 3.22 for ≥35 kg/m 2 vs 2 ), systolic blood pressure (odds ratio 2.66 for ≥120 vs p Conclusion: These risk factors should be of value in counseling women regarding preeclampsia and should aid in understanding the pathophysiologic characteristics of this syndrome.

OBJECTIVE: Our purpose was to determine whether a protocol for outpatient induction is safe and effective for initiating labor. STUDY DESIGN: A randomized, double-blind, a placebo-controlled trial was performed with 100 low-risk patients having well-dated pregnancies. Women with a Bishop score ≤6 at 38 to 40 weeks' gestation were administered either 2 mg of intravaginal prostaglandin E 2 gel or placebo for 5 consecutive days as outpatients while undergoing fetal monitoring. RESULTS: The median interval from randomization to delivery was 4 days in the prostaglandin E 2 group (range 0 to 28 days) and versus 10 days in the placebo group (range 0 to 26 days, p=0.002). Twenty-seven of 50 patients (54%) in the prostaglandin E 2 group were admitted for labor during the dosing interval compared with 10 placebo-treated patients (20%, p = 0.001). The mean gestational age at delivery was significantly reduced in the treatment group (39.9 ± 1.0 weeks vs 40.5 ± 0.99 weeks, p = 0.003) as was the incidence of postdates pregnancy (40% vs 66%, p = 0.016). Hyperstimulation was observed in one prostaglandin E 2 -treated patient, but no intervention was required. CONCLUSIONS: Outpatient low-dose prostaglandin E 2 gel administration is effective for initiating labor in patients with an unfavorable cervix and appears safe if performed with adequate monitoring.

Our purpose was to determine the impact of early and late amniotomy on labor induction with continuous oxytocin infusion at term.A total of 209 women admitted for labor induction were randomized to early or late amniotomy. The early amniotomy group (n = 106) had membranes ruptured as soon as it was deemed safe and feasible. The late amniotomy group (n = 103) had membrane rupture performed ator = 5 cm dilatation. The first 103 women received a continuous oxytocin infusion with incremental adjustments at 60-minute intervals as required. The next 106 women had adjustments every 30 minutes as required. Statistical analysis was confined to concurrent groups.Early amniotomy was associated with shorter labor (13.3 vs 17.8 hours, p = 0.001), chorioamnionitis (22.6% vs 6.8%, p = 0.002), and significant fetal umbilical cord compression (12.3% vs 2.9%, p = 0.017). The benefit regarding shortening of labor was limited to women having oxytocin increments every 30 minutes as required (13.3 vs 17.8 hours, p = 0.001). Alternatively, the increase in chorioamnionitis was confined to the 60-minute group (39% vs 11%, p0.001), which also demonstrated a trend toward increased moderate and severe variable decelerations (19.6% vs 6.4%, p = 0.08).When a protocol of 60-minute increments in oxytocin infusion rate is desired, amniotomy should be performed late in labor to reduce chorioamnionitis and significant umbilical cord compression. Alternatively, if early amniotomy is necessary, oxytocin should be adjusted every 30 minutes as tolerated.

Eclampsia is a life-threatening emergency that continues to be a major cause of serious maternal morbidity and is still the leading cause of maternal mortality worldwide. Complicated and mismanaged cases are responsible for many maternal deaths. Perinatal morbidity and mortality is also high if eclampsia occurs in the antepartum period. This article reviews eclampsia management with special emphasis on puerperal eclampsia. The complications associated with eclampsia are also discussed.

OBJECTIVE: Our purpose was to determine the frequency and safety of the use of epidural anesthesia and the correlation between bleeding time and maternal-neonatal bleeding complications in a group of pregnant women who participated in a multicenter trial of low-dose aspirin in pregnancy. STUDY DESIGN: Data regarding type of anesthesia used for labor and delivery were available in 1629 nulliparous women who were randomly assigned at 13 to 27 weeks to receive 60 mg/day aspirin or a placebo. A total of 891 (55%) received epidural anesthesia, and the remaining 738 did not. RESULTS: Among the 891 women known to have received epidural anesthesia, 451 were assigned to low-dose aspirin and 440 to placebo. There was no instance of bleeding related to epidural use. In addition, there were no differences in maternal and neonatal complications between those receiving or not receiving epidural anesthesia. Within the group receiving epidural anesthesia there were no differences in bleeding complications between those assigned to aspirin on placebo. One of the five centers also obtained bleeding times in 303 women (149 received aspirin and 154 received placebo). The mean=SD bleeding time in women assigned to low-dose aspirin was significantly higher than in women assigned to placebo (6.99 ± 2.95 minutes vs 5.99 ± 2.43 minutes, p = 0.004). In addition, the frequency of women having a bleeding time > 10 minutes was higher in the aspirin group (14.1% vs 5.2%, p = 0.01). Interestingly, women who received an epidural anesthetic had a lower bleeding time than those not receiving an epidural ( p = 0.003), irrespective of the treatment used. CONCLUSIONS: In women assigned to low-dose aspirin there were no adverse effects related to epidural anesthesia. In spite of an increased bleeding time in a subset of pregnant women assigned to low-dose aspirin, maternal-neonatal bleeding complications were not increased.

OBJECTIVE: We conducted a large clinical trial to evaluate the effect of low-dose aspirin on the frequency of preeclampsia in nulliparous women. A secondary objective of the trial was to identify those clinical characteristics that might be predictive for the development of preeclampsia. STUDY DESIGN: A total of 2947 healthy women with a single fetus were prospectively followed up from randomization at 13 to 27 weeks' gestation to the end of pregnancy. Of these, 1465 women were assigned to low-dose aspirin and 1482 to placebo. Baseline maternal blood pressure and demographic characteristics were examined for the prediction of preeclampsia. RESULTS: Preeclampsia developed in 156 women (5.3%). Four characteristics predicted the development of preeclampsia: in order of improtance, systoloic blood pressure at entry, prepregnancy obesity (weight as a precentage of desirable weight), number of previous abortions or miscarriages, and smoking history. Contrary to previous reports, black race was not a risk factor for preeclampsia. Systolic blood pressure was a better predictor of preeclampsia than either diastolic or mean arterial blood presure. The greater the blood pressure or prepregnancy weight, the greater was the risk for preeclampsia. If the woman had never smoked or had never been previously pregnant, her risk was also higher than average. A multivariate logistic regression equation based on these four factors was able to define a tenth of the population at very high risk and another tenth at very low risk; the ratio of risk between these two groups was 12:1. The p value for each of the multivariate coefficients of the risk equation was systolic blood press ( p p p p CONCLUSIONS: These risk factors should be of value to practitioners counseling woman regarding preeclampsia. Moreover, such risk factors should be considered in the design of future studies dealing with preeclampsia.

OBJECTIVE: Our purpose was to determine whether there is an increased incidence of pulmonary maturity in premature fetuses of preeclamptic women compared with fetuses of matched controls. STUDY DESIGN: A matched cohort study design was used. One hundred twenty-seven strictly defined preeclamptic women who had undergone amniocentesis for pulmonary maturity assessment were matched for gestational age, race, and infant gender to non hypertensive women with preterm labor who had undergone the same procedure. Patients with multiple gestation, ruptured membranes, diabetes, or prior glucocorticoid treatment were excluded. Lung maturity was assessed with the Lumadex foam stability index test, the lecithin/sphingomyelin ratio, and the TD X fetal lung maturity assay. In addition, the occurrence of respiratory distress syndrome was assessed in 69 of the 127 matched pairs who were also matched for mode of delivery and amniocentesis-to-delivery interval. RESULTS: There was no significant difference in the incidence of an immature result between the preeclamptic and matched control groups (39.4% vs 38.6%). Likewise, women with mild ( n = 63) and severe ( n = 64) preeclampsia or with small-for-gestational-age ( n = 26) and appropriate-for-gestational-age ( n = 101) infants, when analyzed separately, showed no differences in comparison with their matched controls. When analyzed by gestational age subgroups, no specific gestational age range was associated with accelerated maturity. The incidence of respiratory distress syndrome in the 69 matched pairs was slightly, but not significantly, higher in the preeclampsia group (relative risk 1.43, 95% confidence interval 0.94 to 2.37). CONCLUSION: This study does not support the contention that fetuses of preeclamptic women exhibit accelerated lung maturation.

Objective: The use of prophylactic antibiotics in the management of preterm premature rupture of the membranes has not been adequately studied. The purpose of this study was to evaluate the efficacy of oral erythromycin therapy in the prolongation of latency and reduction of infectious morbidity after preterm premature rupture of membranes. Study Design: In this randomized, prospective, double-blind, placebo-controlled study, 220 women at 20 to 35 weeks' gestation were evaluated. Subjects received oral erythromycin 333 mg ( n = 106) or indistinguishable placebo ( n = 114) every 8 hours from randomization to delivery. Results: Prolongation of latency was identified with erythromycin therapy ( p = 0.02), particularly for those destined to have chorioamnionitis ( p = 0.003) and those with oligohydramnios ( p = 0.01 ). No decrease in the incidence of maternal or neonatal infectious morbidity was seen. Conclusions: Oral erythromycin delays, but does not prevent, the onset of clinical infection when administered to women with preterm premature rupture of membranes. This regimen does not decrease neonatal morbidity and mortality.

Biopsy specimens were obtained under direct vision at the time of cesarean section from 47 patients (35 with preeclampsia and 12 normotensive patients) and from four women with cesarean section hysterectomies (all normotensive) as an extension of previous work. Tissues were obtained from the myometrium near the placental bed and from the opposite side of the uterus. Skin biopsies were also obtained from eight women with preeclampsia and liver biopsies were obtained from two patients with acute microvesicular fatty change of pregnancy (one with and one without concomitant preeclampsia). Specimens were examined histologically and by electron microscopy. Mitochondrial changes in small vessels, principally venules, in myometrial smooth muscle, myometrial interstitial cells, circulating leukocytes, epidermal and dermal cells, and hepatocytes were examined and compared between women with preeclamptic and normotensive pregnancies. These findings were then compared with mitochondria from 500 biopsies over the same 3-year interval to assess the possible role of delay in tissue fixation. There were 12 other biopsies from nonpregnant women of childbearing age. As further control on artifact, other specimens were initially sampled immediately in the operating room and then serially for up to 2 hours later. Artifact as a basis for the mitochondrial changes was ruled out by these procedures. Normal mitochondria undergo a morphologic conformational sequence with physiologic changes in substrate, oxygen consumption, adenosine diphosphate, and respiratory rate. The mitochondria of preeclamptic tissues show a central disruption that is outside this normal sequence or cycle. This disruption occurs more often and is more severe in preeclampsia than in normotensive pregnancies. In addition, the hypertrophic smooth muscle of the pregnant uterus has a complex of cytoplasmic organelles in a paranuclear location, usually apical, that contains a variable mixture of glycogen, the Golgi apparatus, endoplasmic reticulum, mitochondria, and small unidentified microvesicles. This complex has the location and appearance suggestive of a myometrial "power pack" of significance in metabolism and contraction. The presence of similar mitochondrial changes in a limited sample of nonuterine tissues is suggestive of a systemic metabolic disorder as an important feature of preeclampsia.

Pharmacokinetic parameters of oral labetalol were studied in eight women with pregnancy-induced hypertension in the third trimester of pregnancy. Labetalol exhibited rapid absorption; peak serum concentrations of 881 +/- 219 ng/ml occurred at 20 minutes after labetalol ingestion. The terminal elimination half-life (mean, 1.7 +/- 0.27 hours) was found to be shorter than that reported for normotensive volunteers or nonpregnant hypertensive patients (mean, 6 to 8 hours). A mean apparent oral elimination clearance of 21.8 ml/min/kg compared favorably with that seen in other pregnant and nonpregnant populations. Food delayed the time to peak serum concentration to approximately 60 minutes. Labetalol was detected in fetal cord samples and amniotic fluid samples at concentrations approximately 50% and 16% that of simultaneous maternal vein samples, respectively.

A three-bed intensive care unit was opened in the labor and delivery area of a city-county hospital having approximately 7500 deliveries annually. The utilization rate of 0.9% and the severity of illness were sufficient to justify such a unit. Main indications for admission were hypertensive disorders (46%), massive hemorrhage (10%), and medical problems of pregnancy (44%). Identifiable benefits of the unit were as follows: (1) Intensive observation and organization allowed for prevention or early recognition and treatment of complications; (2) familiarity with invasive monitoring permitted personnel to exert prompt, rational treatment of hemodynamically unstable patients; (3) continuity of care was improved before and after delivery; (4) residents and fellows learned a great deal about intensive care and the management of rare medical complications of pregnancy. We conclude not only that critically ill pregnant women can be managed successfully in an obstetric intensive care unit but also that critical care is a bona fide part of obstetric practice and has been incorporated into our training program. (Ann J OBSTET GYNECOL 1990;162:1-4.)

OBJECTIVE: We sought to evaluate the relationship between skin incision, transverse or vertical, and the development of wound complications in women with morbid obesity requiring primary cesarean delivery (CD). STUDY DESIGN: Morbidly obese women (body mass index � 40 kg/m 2 ) undergoing primary CD at � 24 weeks’ gestation were studied in a secondary analysis of a multicenter registry. Clinical characteristics and outcomes were compared between women who had transverse vs vertical skin incision. The primary outcome was composite wound complication (infection, seroma, hematoma, evisceration, fascial dehiscence) and composite adverse maternal outcome (transfusion, hysterectomy, organ injury, coagulopathy, thromboembolic event, pulmonary edema, death). Multivariable logistic regression analyses were performed to adjust for confounding factors. RESULTS: In all, 3200 women were studied: 2603 (81%) had a transverse incision and 597 (19%) had a vertical incision. Vertical skin incision was associated with lower risk for wound complications (adjusted odds ratio, 0.32; 95% confidence interval, 0.17e0.62; P

Objective Antenatal corticosteroids (ACS) decrease respiratory distress syndrome in singleton gestations. Twin data are less clear. Obesity and body mass index (BMI) also affect medication distribution volume. We evaluated whether maternal or neonatal cord betamethasone concentrations differed in twin gestations or obese patients. Study Design Participants receiving betamethasone in a randomized controlled trial of weekly ACS were identified. We analyzed maternal delivery and cord serum betamethasone concentrations comparing singletons with twins and obese (BMI ≥30 kg/m 2 ) with nonobese women. Results Fifty-five maternal and 45 cord blood samples were available. Unadjusted median maternal serum concentrations appeared paradoxically higher in both twin gestations and the obese. However, after controlling for confounders, there were no differences in betamethasone concentrations in maternal serum or cord blood between singletons and twins ( P = .61 vs P = .14) or nonobese and obese women ( P = .67 vs .12). Conclusion Maternal and umbilical cord blood serum betamethasone concentrations are not different in twin gestations or obese women.

Objective To evaluate subsequent pregnancy outcome and impact of gestational age at onset of HELLP on long-term prognosis after HELLP over an average follow-up of 5 years Study Design One hundred twenty-eight patients with a history of HELLP filled out questionnaires and sent their medical records. Hemolysis, elevated liver enzymes, and low platelets data were stratified according to gestational age at onset of HELLP ≤28 weeks and >28 weeks. Results Fifty-three patients had subsequent pregnancies with 24% complicated by HELLP and 28% by preeclampsia. During follow-up, 33% of the patients had new onset hypertension develop, 32% had depression develop, 26% had anxiety develop, and 2.4% required dialysis. There was no significant difference in long-term outcome between comparison groups. Conclusion Patients with a history of HELLP are at increased risk for preeclampsia and HELLP as well as long-term morbidities as depression and chronic hypertension. Gestational age at the onset of HELLP could be a predictor for long-term outcome.

Objective The objective of the study was to assess the prognostic value of ejection fraction (EF) at index and subsequent pregnancy on long-term outcome in patients with peripartum cardiomyopathy (PPCM). Study Design Seventy PPCM patients met inclusion criteria. Patients had echocardiography evaluations at the index pregnancy, at interval follow-up (F/U) or at the beginning of a subsequent pregnancy and the last F/U study available. Outcome data were echocardiographic parameters and the subsequent need for cardiac transplant. Results Patients were categorized on the basis of their initial EF into EF of 25% or less and EF greater than 25% and stratified on the basis of their pregnancy into the following groups: group 1 (n = 33), no subsequent pregnancy; group 2 (n = 16), subsequent pregnancy with early termination; and group 3 (n = 21), successful subsequent pregnancy. F/U from index pregnancy to final F/U was 3.4±1.9 (range, 1-6 years). Groups 1 and 2 had persistent left ventricular dysfunction at all echocardiographic evaluations. In group 3, despite a mean EF greater than 40% at a subsequent pregnancy, 29% had worsening cardiac symptoms. Among 28 patients with EF of 25% or less, 16 (57%) had end-stage cardiac disease. One had a transplant and 15 were on a transplant list. All 16 had a baseline EF 25% or less at index pregnancy: 4 had improved (EF greater than 40%) at interval F/U and 3 at last F/U available. Conclusion Women with a history of PPCM had a higher rate of progression of symptoms of heart failure in a subsequent pregnancy. A baseline left ventricular EF 25% or less at index pregnancy is associated with a higher rate of cardiac transplant.