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Objective The aim of this study was to identify changes in protein expression in normal pregnancy compared with preterm labor by using 3 proteomic methods. Study Design Serum was collected from 25 nonpregnant (n = 5) and pregnant women at 24–40 weeks' gestation (n = 20) who had preterm labor resulting in preterm delivery (n = 5), preterm labor with term delivery (n = 5), term labor resulting in delivery (n = 5), or at term with contractions (n = 5). Undepleted serum was used for surface-enhanced laser desorption ionization and immune-depleted serum for matrix-assisted laser desorption ionization and 2-dimensional electrophoresis. Results Surface-enhanced laser desorption ionization identified significantly different peaks between preterm labor resulting in preterm delivery vs term labor resulting in delivery and preterm labor resulting in preterm delivery vs preterm labor with term delivery using 4 surfaces. In preterm labor resulting in preterm delivery vs preterm labor with term delivery, a peak of 7783.2 m/z was significantly up-regulated and at 3164 m/z down-regulated on 3 surfaces. By using 2-dimensional electrophoresis, protein 5364 was significantly different between preterm labor resulting in preterm delivery and term labor resulting in delivery. In preterm labor resulting in preterm delivery, 6 proteins showed decreasing trend and 1 showed increasing trend vs preterm labor with term delivery. Matrix-assisted laser desorption ionization showed a striking difference at 55,000 m/z between preterm labor resulting in preterm delivery and term labor resulting in delivery. Conclusion Surface-enhanced laser desorption ionization identified 2 proteins fulfilling the criteria of putative biomarkers. Biomarker identification may aid in identifying women with preterm labor who will deliver preterm.

Publisher Summary The precise pathogenesis of convulsions with the preeclampsia syndrome is enigmatic, the two prevailing schemes are vasospasm with ischemia and hypertensive encephalopathy. Eclampsia prevention can be primary by preventing worsening of preeclampsia; it can be secondary by using agents to prevent convulsions in women with established preeclampsia; and it can be tertiary by preventing recurrent convulsions in women with eclampsia. The decision to use secondary prophylaxis would in some regards depend on the likelihood of eclamptic convulsions in women with preeclampsia. Thus the use Magnesium Sulfate is used in mild and severe preeclampsia. The primary objective of magnesium sulfate prophylaxis in women with preeclampsia is to prevent or reduce the rate of eclampsia and associated complications. Other benefits include reduced maternal and perinatal mortalities and morbidities. In addition, in women with mild preeclampsia, a secondary benefit might include a decreased rate of progression to severe preeclampsia.

OBJECTIVE To assess the associations among maternal obesity, uterine contraction frequency, and spontaneous preterm birth in women at risk for spontaneous preterm birth. METHODS In a secondary analysis, we analyzed data from 253 women at risk for spontaneous preterm birth (prior spontaneous preterm birth, vaginal bleeding) enrolled in a multicenter observational study of home uterine activity monitoring at 11 centers. All women wore a uterine activity monitor twice daily from 22 weeks through 34 weeks of gestation. Mean and maximal contractions/hour at 22-24, 25-26, 27-28, 29-30, 31-32 weeks, and at or after 33 weeks of gestation were compared between overweight/obese women (a body mass index [BMI] at 22-24 weeks greater than 25 kg/m) and normal/underweight women (a BMI of 25 kg/m or less) at each gestational age interval. Multivariable analysis evaluated the influences of BMI, contractions, fetal fibronectin, and transvaginal cervical length on spontaneous preterm birth before 35 weeks. RESULTS Obese/overweight women (n=156) were significantly less likely to experience spontaneous preterm birth before 35 weeks (8.3% compared with 21.7%, P

Objective The purpose of this study was to determine if antioxidant supplementation during pregnancy reduces the incidence of premature rupture of the membranes (PROM). Study Design A placebo-controlled, double-blind trial was conducted. PROM and preterm PROM (PPROM) were planned secondary outcomes of the trial. Women between 120/7 and 196/7 weeks of gestation and diagnosed to have chronic hypertension or a prior history of preeclampsia were randomized to daily treatment with both vitamin C (1000 mg) and E (400 IU) or placebo. Results Outcome data for PROM were available for 697 of 739 patients. The rates of PROM (37/349 [10.6%] vs 19/348 [5.5%]; adjusted risk ratio [RR] 1.89 [95.42% CI, 1.11-3.23]; P = .015), and PPROM (16/349 [4.6%] vs 6/348 [1.7%]; RR 2.68 [1.07-6.71]; P = .025) were increased in the antioxidant group. Conclusion Contrary to expectations, vitamins C and E supplementation in this dose combination may be associated with an increased risk of PROM and PPROM.

Preeclampsia is a major cause of maternal and perinatal mortality and morbidities worldwide, and its etiology remains unknown. The reported incidence of preeclampsia in healthy nulliparous women is approximately 6%, with 93% of cases developing at ≥34 weeks gestation.1 Knowledge about the pathogenesis of preeclampsia has changed significantly over the past decade by virtue of increased recognition of the heterogenous nature of this syndrome. Patients with preeclampsia can present with a wide spectrum of clinical manifestations in the mother and fetus. The degree of maternal hypertension, the amount of proteinuria, and the presence or absence of laboratory abnormalities are highly variable (ranging from mild to severe), with a variable time of onset.2 The manifestations of preeclampsia can develop at

Objective We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. Study Design Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. Results There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. Conclusion TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelets syndrome are major obstetric disorders that are associated with substantial maternal and perinatal morbidities. As a result, it is important that clinicians make timely and accurate diagnoses to prevent adverse maternal and perinatal outcomes associated with these syndromes. In general, most women will have a classic presentation of preeclampsia (hypertension and proteinuria) at20 weeks of gestation and/or48 hours after delivery. However, recent studies have suggested that some women will experience preeclampsia withoutor = 1 of these classic findings and/or outside of these time periods. Atypical cases are those that develop at20 weeks of gestation and48 hours after delivery and that have some of the signs and symptoms of preeclampsia without the usual hypertension or proteinuria. The purpose of this review was to increase awareness of the nonclassic and atypical features of preeclampsia-eclampsia. In addition, a stepwise approach toward diagnosis and treatment of patients with these atypical features is described.

To estimate the success rates and risks of an attempted vaginal birth after cesarean delivery (VBAC) according to the number of prior successful VBACs.From a prospective multicenter registry collected at 19 clinical centers from 1999 to 2002, we selected women with one or more prior low transverse cesarean deliveries who attempted a VBAC in the current pregnancy. Outcomes were compared according to the number of prior VBAC attempts subsequent to the last cesarean delivery.Among 13,532 women meeting eligibility criteria, VBAC success increased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%, and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively (P.001). The rate of uterine rupture decreased after the first successful VBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%, 0.52% (P=.03). The risk of uterine dehiscence and other peripartum complications also declined statistically after the first successful VBAC. No increase in neonatal morbidities was seen with increasing VBAC number thereafter.Women with prior successful VBAC attempts are at low risk for maternal and neonatal complications during subsequent VBAC attempts. An increasing number of prior VBACs is associated with a greater probability of VBAC success, as well as a lower risk of uterine rupture and perinatal complications in the current pregnancy.II.

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 To study whether antioxidant supplementation will reduce the incidence of preeclampsia among patients at increased risk. METHODS A randomized, placebo-controlled, double-blind clinical trial was conducted at four Brazilian sites. Women between 12 0/7 weeks and 19 6/7 weeks of gestation and diagnosed to have chronic hypertension or a prior history of preeclampsia were randomly assigned to daily treatment with both vitamin C (1,000 mg) and vitamin E (400 International Units) or placebo. Analyses were adjusted for clinical site and risk group (prior preeclampsia, chronic hypertension, or both). A sample size of 734 would provide 80% power to detect a 40% reduction in the risk of preeclampsia, assuming a placebo group rate of 21% and alpha=.05. The alpha level for the final analysis, adjusted for interim looks, was 0.0458. RESULTS Outcome data for 707 of 739 randomly assigned patients revealed no significant reduction in the rate of preeclampsia (study drug, 13.8% [49 of 355] compared with placebo, 15.6% [55 of 352], adjusted risk ratio 0.87 [95.42% confidence interval 0.61-1.25]). There were no differences in mean gestational age at delivery or rates of perinatal mortality, abruptio placentae, preterm delivery, and small for gestational age or low birth weight infants. Among patients without chronic hypertension, there was a slightly higher rate of severe preeclampsia in the study group (study drug, 6.5% [11 of 170] compared with placebo, 2.4% [4 of 168], exact P=.11, odds ratio 2.78, 95% confidence interval 0.79-12.62). CONCLUSION This trial failed to demonstrate a benefit of antioxidant supplementation in reducing the rate of preeclampsia among patients with chronic hypertension and/or prior preeclampsia. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov, www.ClinicalTrials.gov, NCT00097110 LEVEL OF EVIDENCE I.

OBJECTIVE To determine whether human immunodeficiency virus (HIV)-infected women have a higher rate of postcesarean morbidity and mortality compared with women without HIV infection. METHODS A secondary analysis was performed of women with singleton gestations undergoing cesarean delivery with known HIV status. Data were collected as part of a prospective 4-year (1999-2002) observational study and analyzed using logistic regression. Women were surveyed for a large number of intraoperative complications, common perioperative morbidities, and uncommon maternal complications. RESULTS There were 378 HIV-infected and 54,281 uninfected women who met criteria. Patients infected with HIV were more likely to have postpartum endometritis (11.6% compared with 5.8%, P

The objective of this study was to determine whether intraumbilical injection of oxytocin shortens the third stage of labor. A randomized, double-blind, placebo-controlled trial was used to assess the effectiveness of an intraumbilical injection of oxytocin on the duration of the third stage. Following randomization, each of 79 women received 30 mL of saline ( N = 40) or 20 U of oxytocin in 30 mL of saline ( N = 39). The primary outcome of interest was the effect on the duration of the third stage. Secondary outcomes examined were change in hemoglobin and percentage of undelivered placenta after 15 minutes. There was no difference in the duration of the third stage between the two groups (7.8 +/- 6.1 min in the saline-only group versus 5.9 +/- 2.6 min in the oxytocin group). The change in hemoglobin was significantly lower in the oxytocin group (1.3 +/- 0.9 g/dL in the oxytocin group versus 1.8 +/- 0.9 g/dL in the saline-only group). The percentage of undelivered placentas beyond 15 minutes was significantly lower in the oxytocin group (0% in the oxytocin group versus 12.5% in the saline-only group). The study concluded that intraumbilical vein injection of oxytocin reduced the rate of placentas remaining undelivered beyond 15 minutes and subsequent blood loss.

The obstetrical management of women with renal disease is complicated and associated with increased fetal and maternal morbidity. However, maternal serum screening is an integral part of obstetrical care and should be offered to all women. We found that maternal serum levels of α-fetoprotein and human chorionic gonadotropin did not significantly change as a result of hemodialysis, whereas levels of unconjugated estriol were markedly decreased following hemodialysis. Maternal serum screening should be limited to α-fetoprotein analysis in women undergoing hemodialysis until the effects of hemodialysis on all serum analytes are better delineated.

A recent review of the literature on thrombophilia and adverse pregnancy outcome reveals contradictory findings. There are retrospective and prospective studies that recommend testing for genetic and acquired markers of thrombophilia for those with the enumerated adverse pregnancy outcome. Based on our review, routine screening for thrombophilias in women with a history of adverse pregnancy outcome (preeclampsia, abruptio placenta, intrauterine growth restriction, and fetal loss) is not justified. Based on data from observational studies and few randomized trials with inadequate number of subjects, there is consensus that women with true antiphospholipid antibody syndrome should receive low-dose aspirin plus adjusted-dose heparin in subsequent pregnancies. Some authors also recommend heparin prophylaxis in subsequent pregnancies in women with genetic thrombophilia with previous adverse pregnancy outcome. However, this recommendation is not based on randomized trials. Hence, a randomized double-blind, controlled trial is urgently needed to evaluate the benefit of heparin during pregnancy in women with a history of adverse pregnancy outcome in association with genetic thrombophilia.

OBJECTIVE: To evaluate risks for intraoperative or post-operative packed red blood cell transfusion in womenwho underwent cesarean delivery.METHODS: This was a 19-university prospective obser-vational study. All primary cesarean deliveries from Jan-uary 1, 1999, to December 31, 2000, and all repeatcesareans from January 1, 1999, to December 31, 2002,were included. Trained, certified research nurses per-formed systematic data abstraction. Primary and repeatcesareandeliverieswereanalyzedseparately.Univariableanalyses were used to inform multivariable analyses.RESULTS: A total of 23,486 women underwent primarycesarean delivery, of whom 762 (3.2%) were transfused(median 2 units, 25th% to 75th% 2–3 units). A total of33,683 women underwent primary cesarean delivery, and735 (2.2%) were transfused (median 2 units, 25th% to75th% 2–4 units). Among primary cesareans, generalanesthesia (odds ratio [OR] 4.2, 95% confidence interval[CI] 3.5–5.0), placenta previa (OR 4.8, CI 3.5–6.5) andsevere (hematocrit less than 25%) preoperative anemia(OR 17.0, CI 12.4–23.3) increased the odds of transfusion.Among repeat cesareans, the risk was increased by gen-eral anesthesia (OR 7.2, CI 5.9–8.7), a history of five ormore prior cesareans (OR 7.6, CI 4.0–14.3), placentaprevia (OR 15.9, CI 12.0–21.0), and severe preoperativeanemia (OR 19.9, CI 14.5–27.2).CONCLUSION: Overall, the risk of transfusion in asso-ciation with cesarean is low. However, both severepreoperative maternal anemia and placenta previa areassociated with markedly increased risks. The formerargues for optimizing maternal antenatal iron status toavoid severe anemia and the latter for careful perioper-ative planning when previa complicates cesarean.

Preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome remain as major obstetric problems that plague a large percentage of women resulting in an equally large percentage of maternal and perinatal morbidities. It is important that a clinician makes the most accurate diagnosis possible to prevent these adverse maternal and perinatal outcomes. In general, most women will have a classical presentation of preeclampsia (hypertension and proteinuria) at >20 weeks gestation and

To measure decision-to-incision intervals and related maternal and neonatal outcomes in a cohort of women undergoing emergency cesarean deliveries at multiple university-based hospitals comprising the National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network.All women undergoing a primary cesarean delivery at a Network center during a 2-year time span were prospectively ascertained. Emergency procedures were defined as those performed for umbilical cord prolapse, placental abruption, placenta previa with hemorrhage, nonreassuring fetal heart rate pattern, or uterine rupture. Detailed information regarding maternal and neonatal outcomes, including the interval from the decision time to perform cesarean delivery to the actual skin incision, was collected.Of the 11,481 primary cesarean deliveries, 2,808 were performed for an emergency indication. Of these, 1,814 (65%) began within 30 minutes of the decision to operate. Maternal complication rates, including endometritis, wound infection, and operative injury, were not related to the decision-to-incision interval. Measures of newborn compromise including umbilical artery pH less than 7 and intubation in the delivery room were significantly greater when the cesarean delivery was commenced within 30 minutes, likely attesting to the need for expedited delivery. Of the infants with indications for an emergency cesarean delivery who were delivered more than 30 minutes after the decision to operate, 95% did not experience a measure of newborn compromise.Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased.II-2.

Objective The purpose of this study was to determine if weekly corticosteroids improve neonatal outcome without undue harm. Study design Women 23 to 32 weeks receiving 1 course of corticosteroids 7 to 10 days prior were randomized to weekly betamethasone or placebo. Results The study was terminated by the independent data and safety monitoring committee with 495 of the anticipated 2400 patients enrolled. There was no significant reduction in the composite primary morbidity outcome (8.0% vs 9.1%, P = .67). Repeated courses significantly reduced neonatal surfactant administration ( P = .02), mechanical ventilation ( P = .004), CPAP ( P = .05), pneumothoraces ( P = .03). There was no significant difference in mean birth weight or head circumference. The repeat group had a reduction in multiples of the birth weight median by gestational age (0.88 vs 0.91) ( P = .01) and more neonates weighing less than the 10th percentile (23.7 vs 15.3%, P = .02). Significant weight reductions occurred for the group receiving ≥4 courses. Conclusion Repeat antenatal corticosteroids significantly reduce specific neonatal morbidities but do not improve composite neonatal outcome. This is accompanied by reduction in birth weight and increase in small for gestational age infants.

Intrauterine growth restriction (IUGR) and preeclampsia differ in their association with maternal disease but share a similar placental pathology. Moreover, mothers who have had pregnancies complicated by preeclampsia or IUGR are at elevated later-life cardiovascular risk. Why, then, do some women develop IUGR and others develop preeclampsia? In this clinical opinion, based on a review of the literature, we hypothesize that both women experiencing preeclampsia and IUGR enter pregnancy with some degree of endothelial dysfunction, a lesion that predisposes to shallow placentation. In our opinion, preeclampsia develops when abnormal placentation, through the mediator of elevated circulating cytokines, interacts with maternal metabolic syndrome, comprised of adiposity, insulin resistance/hyperglycemia, hyperlipidemia, and coagulopathy. IUGR develops in the absence of antenatal metabolic syndrome. Among these women, the baby is affected by shallow placentation but the mother does not develop clinically apparent disease. This conceptualization provides a testable framework for future etiologic studies of preeclampsia and IUGR.

Objective We sought to estimate the rate of spontaneous resolution of asymptomatic Chlamydia trachomatis in pregnancy and to evaluate factors associated with its resolution. Methods A cohort of women enrolled in a large multicenter randomized bacterial vaginosis antibiotic trial (metronidazole versus placebo) that, when randomly allocated, had asymptomatic C trachomatis diagnosed by urine ligase chain reaction (from frozen archival specimens) between 16(0/7) and 23(6/7) weeks were included. The urine ligase chain reaction is a highly accurate predictor of genital tract chlamydial infection. A follow-up ligase chain reaction was performed between 24(0/7) and 29(6/7) weeks. Results A total of 1,953 women were enrolled in the original antibiotic trial; 1,547 (79%) had ligase chain reaction performed both at randomization and follow-up. Women receiving antibiotics effective against Chlamydia between randomization and follow-up or having symptomatic Chlamydia infection were excluded (26 women). Of the 140 women (9%) who were diagnosed as positive via the initial ligase chain reaction assay, 61 (44%) had spontaneous resolution of Chlamydia by the follow-up ligase chain reaction assay. Factors associated with spontaneous resolution included older age (P = .02), more than 5 weeks from randomization to follow-up (P = .02), and a greater number of lifetime sexual partners (P = .02). Using a logistic regression model, maternal age and a greater-than-5-week follow-up interval remained significant; for every 5-year increase in maternal age, the odds of a positive result on the ligase chain reaction test at follow-up decreased by 40% (odds ratio 0.6; 95% confidence interval 0.4-0.9). Race, substance abuse, parity, and treatment with metronidazole were not associated with spontaneous resolution. Gram stain score and vaginal pH at randomization and follow-up also were not associated. Conclusion The prevalence of asymptomatic C trachomatis in pregnancy was 9%; infection resolved spontaneously in almost half of these women. The association of older age and increasing time interval to spontaneous resolution of Chlamydia is consistent with a host immune-response mechanism.

The purpose of this study was to determine which factors influence the likelihood of successful trial of labor (TOL) after 1 previous cesarean delivery (CD).We performed a multicenter 4-year prospective observational study (1999-2002) of all women with previous CD undergoing TOL. Women with term singleton pregnancies with 1 previous low transverse CD or unknown incision were included for analysis.Fourteen thousand five hundred twenty-nine women underwent TOL, with 10,690 (73.6%) achieving successful VBAC. Women with previous vaginal birth had an 86.6% success rate compared with 60.9% in women without such a history (odds ratio [OR] 4.2; 95% CI 3.8-4.5; P.001). TOL success rates were affected by previous indication for CD, need for induction or augmentation, cervical dilation on admission, birth weight, race, and maternal body mass index. Multivariate logistic regression analysis identified as predictive of TOL success: previous vaginal delivery (OR 3.9; 95% CI 3.6-4.3), previous indication not being dystocia (CPD/FTP) (OR 1.7; 95% CI 1.5-1.8), spontaneous labor (OR 1.6; 95% CI 1.5-1.8), birth weight4000 g (OR 2.0; 95% CI 1.8-2.3), and Caucasian race (OR 1.8, 95% CI 1.6-1.9) (all P.001). The overall TOL success rate in obese women (BMIor = 30) was lower (68.4%) than in nonobese women (79.6%) (P.001), and when combined with induction and lack of previous vaginal delivery, successful VBAC occurred in only 44.2% of cases.Previous vaginal delivery including previous VBAC is the greatest predictor for successful TOL. Previous indication as dystocia, need for labor induction, or a maternal BMIor = 30 significantly lowers success rates.

Objective The purpose of this study was to determine recurrence risk and pregnancy outcome in 23 women with a history of stroke. Study design We conducted a descriptive study of 23 women (35 pregnancies) with a history of stroke. Charts were reviewed from 1990 through 2002. The data were analyzed for the antenatal treatment strategies, recurrence risk for stroke, and pregnancy outcome. Results There were 23 study patients with 35 subsequent pregnancies. Associated risk factors of the stroke were thrombophilia (5 women), sickle cell disease (3 women), maternal cardiac malformations (3 women), hypertension (3 women), oral contraceptive use (2 women), cerebral arteriovenous malformations (2 women), head trauma (1 woman), meningitis (1 woman), endocarditis (1 woman), and idiopathic reason (2 women). Four women with 9 subsequent pregnancies had a stroke that was associated with a previous pregnancy or postpartum incident. Two of these 9 pregnancies received anticoagulation (heparin, 1 pregnancy; heparin plus aspirin, 1 pregnancy). Nineteen women with 26 subsequent pregnancies had a stroke before pregnancy. Nine of these 26 pregnancies received anticoagulation (heparin, 5 pregnancies; aspirin, 3 pregnancies; heparin plus aspirin, 1 pregnancy). The remaining pregnancies did not receive prophylactic anticoagulation. Overall, there were 21 term deliveries, 8 preterm deliveries, 5 miscarriages, and 1 fetal death. Three of 34 pregnancies (9%) were small for gestational age infants. There were no recurrent thrombotic episodes during pregnancy or after delivery. Maternal complications included admission to the intensive care unit for uncontrolled hypertension in 1 patient. Conclusion Women with a history of stroke have a low risk of recurrent stroke (0%). This information is useful for the prepregnancy counseling of such individuals. The need for prophylactic anticoagulation in patients with a previous stroke cannot be answered by this study.

Objective Preeclampsia affects 6% to 8% of pregnancies. There are few data regarding hypertensive disorders that are diagnosed in the postpartum period. Our purpose was to determine the demographics, outcomes, and treatment of this complication. Study design This was a multicenter retrospective study of women who had received a diagnosis of hypertension/preeclampsia in the postpartum period. Inclusion criteria were readmission of a patient with this diagnosis (≤6 weeks after the delivery). Results Data from 151 women were studied. Complications included 24 cases (15.9%) of eclampsia, 9 cases (5.9%) of pulmonary edema, 6 cases (3.9%) of endomyometritis, 2 cases (1.3%) of thromboembolism, and 1 case of maternal death. Seventy-eight patients required antihypertensive medications on discharge. Subanalysis performed between the eclamptic and non-eclamptic women showed no difference among groups. Conclusion Delivery does not eliminate the risk for preeclampsia and its complications. Efforts should be directed at the continued monitoring, reporting, and evaluating of the symptoms of preeclampsia during the postpartum period.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of preeclampsia-eclampsia for decades. Recognition of this syndrome in women with preeclampsia is increasing because of the frequency of blood test results that reveal unexpected thrombocytopenia or elevated liver enzymes. The diagnosis of HELLP syndrome requires the presence of hemolysis based on examination of the peripheral smear, elevated indirect bilirubin levels, or low serum haptoglobin levels in association with significant elevation in liver enzymes and a platelet count below 100,000/mm(3) after ruling out other causes of hemolysis and thrombocytopenia. The presence of this syndrome is associated with increased risk of adverse outcome for both mother and fetus. During the past 15 years, several retrospective and observational studies and a few randomized trials have been published in an attempt to refine the diagnostic criteria, to identify risk factors for adverse pregnancy outcome, and to treat women with this syndrome. Despite the voluminous literature, the diagnosis and management of this syndrome remain controversial. Recent studies suggest that some women with partial HELLP syndrome may be treated with expectant management or corticosteroid therapy. This review will emphasize the controversies surrounding the diagnosis and management of this syndrome. Recommendation for diagnosis, management, and counseling of these women is also provided based on results of recent studies and my own clinical experience.

Preeclampsia is a multisystem disorder that complicates 6% to 8% of pregnancies, with higher rates in women with preexisting hypertension, diabetes mellitus, or previous history of preeclampsia. Recent large randomized trials, including two large trials conducted by members of the Maternal-Fetal Medicine Network, have not shown a benefit in reducing the rate of preeclampsia or perinatal outcome from the use of low-dose aspirin. Secondary analysis from these trials revealed that the onset of mild gestational hypertension or mild preeclampsia at or near term was associated with minimal to low neonatal and maternal morbidities. During review of the medical records we found considerable differences among the various centers regarding the definitions of both mild and severe preeclampsia. These differences were more prevalent in those women with pre-existing hypertension or diabetes mellitus. The majority of adverse pregnancy outcomes occurred in women who developed severe gestational hypertension-preeclampsia prior to 35 weeks' gestation and in those women with previous preeclampsia and/or pre-existing vascular disease. We also found that epidural anesthesia is safe in parturients receiving low-dose aspirin in pregnancy and in women with severe preeclampsia.

The first objective was to assess the association of renal function with maternal and fetal pregnancy outcome in women with diabetic nephropathy. The second objective was to examine the feasibility of a multicenter surveillance program to determine the rates of maternal and fetal pregnancy complications in women with diabetic nephropathy, and to study the effect of pregnancy on the natural history of diabetic renal disease.In order to address the first objective, we analyzed data from women with type 1 diabetes and nephropathy enrolled in the Diabetes in Pregnancy Program at our institution. Women were assigned to one of three groups according to enrolment serum creatinine concentration:or = 1.0 mg/dl,1.0 to 1.5 mg/dl and1.5 mg/dl. A pilot surveillance program at six centers included women experiencing pregnancy complicated by diabetic nephropathy. In both studies, medical and obstetric history, and maternal and neonatal outcomes, were recorded. Statistical analysis included chi2, logistic regression and analysis of variance.There were 72 pregnancies in 58 women with diabetic nephropathy who enrolled in the pregnancy program. High serum creatinine concentration at enrolment was associated with delivery before 32 weeks' gestation, very low birth weight and increased incidence of neonatal hypoglycemia, independent of quantity of total urinary protein excretion and glycemic control in any trimester. To date, pilot surveillance data have been obtained from six centers on 16 women. Serum creatinine concentrations ranged from 0.4 to 1.1 mg/dl and creatinine clearance from 32 to 317 m/min. Gestational age at delivery ranged from 22 to 39 weeks.High serum creatinine concentration at enrolment is a risk factor for adverse maternal and neonatal outcome, independent of quantity of total urinary protein excretion and glycemic control during any trimester. A multicenter surveillance program is needed, in order to study less frequent maternal and neonatal outcomes as well as the long-term effects of pregnancy on the natural course of diabetic renal disease.

To provide a review of the use and safety of insulin lispro during pregnancy.This is a review of the available literature on the use of insulin lispro in pregnancy. A MEDLINE search was performed which included published manuscripts and abstracts in the English language to June 2001.The extensive search revealed that data on insulin lispro use during pregnancy are limited. Most of the reports on the use of insulin lispro during pregnancy demonstrated improvement of glycemic control, an increase in patient satisfaction, decreased hypoglycemic episodes, improved maternal and neonatal outcomes, and no deterioration in retinal status. However, there were two reports where it was suggested that there was an association with the use of insulin lispro in pregnancy and increased risk for the development of congenital anomalies and/or development or progression of diabetic retinopathy.Preliminary data suggest that insulin lispro does not have adverse maternal or fetal effects during pregnancy in women with diabetes. The use of insulin lispro during pregnancy results in improved glycemic control, fewer hypoglycemic episodes, improved patient satisfaction, improved maternal and neonatal outcomes and no deterioration in retinal status. There is no evidence that the use of insulin lispro during pregnancy results in an increased rate of congenital malformations. A prospective randomized clinical trial is imperative for further evaluation of any possible association with the use of insulin lispro during pregnancy and an increased rate of congenital malformations or change in retinal status.

The current literature emphasizes increased risk of adverse outcomes in the presence of proteinuria and hypertension. The objective of this study was to compare the frequency of adverse fetal outcomes in women who developed hypertensive disorders with or without proteinuria.The study design was a secondary analysis of data from women who had preeclampsia in a previous pregnancy (n = 598) who were enrolled in a multicenter trial of aspirin for the prevention of preeclampsia. The women had no history of chronic hypertension or renal disease and were normotensive at study inclusion. The maternal and perinatal outcome variables assessed were preterm delivery at37 and35 weeks of gestation, rate of small-for-gestational-age infants, and abruptio placenta. Data were analyzed by using the chi-square test, and women who remained normotensive or who had mild gestational hypertension were considered as a single group because they had similar outcomes.As compared to mild preeclampsia, women who developed severe gestational hypertension (without proteinuria) had higher rates of both preterm delivery at37 weeks of gestation and small-for-gestational-age infants. In addition, when compared to women with mild preeclampsia, for women with severe gestational hypertension, gestational age and birth weight were significantly lower at delivery (P.003 for both age and birth weight). Moreover, women who developed severe gestational hypertension had higher rates of preterm delivery at37 weeks of gestation (54.2% vs 17.8%, P =.001) and at35 weeks of gestation (25.0% vs 8.4%, P =.0161), and delivery of small-for-gestational-age infants (20.8% vs 6.5%, P =.024) when compared to women who remained normotensive or those who developed mild gestational hypertension. There were no statistically significant differences in perinatal outcomes between the normotensive/mild gestational hypertension and the mild preeclampsia groups. Overall, women who had severe gestational hypertension had increased rates of preterm delivery and delivery of small-for-gestational-age infants than women with mild gestational hypertension or mild preeclampsia. In the presence of severe hypertension, proteinuria did not increase the rates of preterm delivery or delivery of small-for-gestational-age infants.In women who have gestational hypertension or preeclampsia, increased rates of preterm delivery and delivery of small-for-gestational-age infants are present only in those with severe hypertension. In these women, the presence of proteinuria does not influence perinatal outcome.

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

ContextAlthough shortened cervical length has been consistently associated with spontaneous preterm birth, it is not known when in gestation this risk factor becomes apparent.ObjectiveTo determine whether sonographic cervical findings between 16 weeks' and 18 weeks 6 days' gestation predict spontaneous preterm birth and whether serial evaluations up to 23 weeks 6 days' gestation improve prediction in high-risk women.Design, Setting, and ParticipantsBlinded observational study performed between March 1997 and November 1999 at 9 university-affiliated medical centers in the United States in 183 women with singleton gestations who previously had experienced a spontaneous birth before 32 weeks' gestation.ObservationCertified sonologists performed 590 endovaginal sonographic examinations at 2-week intervals. Cervical length was measured from the external os to the functional internal os along a closed endocervical canal. Funneling and dynamic cervical shortening were also recorded.Main Outcome MeasureSpontaneous preterm birth before 35 weeks' gestation, analyzed by selected cutoff values of cervical length.ResultsForty-eight women (26%) experienced spontaneous preterm birth before 35 weeks' gestation. A cervical length of less than 25 mm at the initial sonographic examination was associated with a relative risk (RR) for spontaneous preterm birth of 3.3 (95% confidence interval [CI], 2.1-5.0; sensitivity = 19%; specificity = 98%; positive predictive value = 75%). After controlling for cervical length, neither funneling (P = .24) nor dynamic shortening (P = .054) were significant independent predictors of spontaneous preterm birth. However, using the shortest ever observed cervical length on serial evaluations, after any dynamic shortening, the RR of a cervical length of less than 25 mm for spontaneous preterm birth increased to 4.5 (95% CI, 2.7-7.6; sensitivity = 69%; specificity = 80%; positive predictive value = 55%). Compared with a single cervical measurement at 16 weeks' to 18 weeks 6 days' gestation, serial measurements at up to 23 weeks 6 days significantly improved the prediction of spontaneous preterm birth in a receiver operating characteristic curve analysis (P = .03).ConclusionsCervical length assessed by endovaginal sonography between 16 weeks' and 18 weeks 6 days' gestation, augmented by serial evaluations, predicts spontaneous preterm birth before 35 weeks' gestation in high-risk women.

In large, prospective studies of pregnancy conducted in the 1960s, women reported very accurately whether or not they smoked. However, in the 1990s, pregnant women who smoke are often pressured to reduce or quit smoking, and the incentive to misreport may be greater than in the past. To assess the accuracy of reported smoking, the authors compared self-reported smoking with cotinine in the serum and/or urine of 105 women who participated in the Calcium for Pre-eclampsia Prevention pilot study in 1992. Cotinine confirmed the report of 84.6% of women who reported smoking and 94.5% of women who denied smoking. These fractions are virtually identical to those obtained in a pregnancy cohort from the 1960s. The authors conclude that in the setting of two obstetrical research studies not specifically focused on smoking, the accuracy of self-reported cigarette smoking did not change substantially from the 1960s to the 1990s.

Objective: Limited information is available regarding the progression of disease in women with mild gestational hypertension. Our purpose was to describe the prognostic signs in the natural course of mild gestational hypertension and pregnancy outcomes in women who were remote from term with mild gestational hypertension that was expectantly managed. Study Design: Women with mild gestational hypertension participating in an outpatient hypertension monitoring program were studied. Inclusion criteria were patients with a singleton pregnancy between 24 and 35 weeks' gestation who had no proteinuria by dipstick (0 or trace) on the first 2 days of program participation. Progression to preeclampsia was the primary outcome. The rate of progression to severe preeclampsia, obstetric complications, and neonatal outcomes were secondary measures. Data were compared by independent Student t and Fisher exact tests where applicable. Results: A total of 748 patients were studied during the observation period; preeclampsia (persistent proteinuria ≥1+) developed in 343 (46%), and 72 (9.6%) had antepartum progression to severe preeclampsia. No significant differences in maternal age, race, marital status, or tobacco use were observed between those women in whom persistent proteinuria developed and those in whom it did not develop. Gestational age of the infants at delivery (36.5 ± 2.4 vs 37.4 ± 2.0 weeks), birth weight (2752 ± 767 vs 3038 ± 715 g), incidence of small-for-gestational-age newborns (24.8% vs 13.8%), and duration of neonatal hospital stay (7.1 ± 10 vs 5.0 ± 9.3 days) differed significantly in the patients with versus those without proteinuria ( P Conclusions: In patients with mild gestational hypertension remote from term, 46% ultimately had preeclampsia, with progression to severe disease in 9.6%. The development of proteinuria is associated with an earlier gestational age at delivery, lower birth weight, and an increased incidence of small-for-gestational age newborns. (Am J Obstet Gynecol 2001;184:979-83.)

Objective: The objective of this analysis was to prospectively determine the effects of nutrient intakes on the incidences of preeclampsia and pregnancy-associated hypertension among women enrolled in the Calcium for Preeclampsia Prevention study. Study Design: This was a prospective observational cohort study of women in a randomized clinical trial that included women seeking prenatal care at university medical centers and affiliated clinics and hospitals in 5 US communities. A total of 4589 nulliparous women were recruited between 13 and 21 weeks' gestation. Preeclampsia and pregnancy-associated hypertension were the main outcome measures. Results: Preeclampsia was noted in 326 (7.6%) of the 4314 women with known pregnancy outcomes followed up until ≥20 weeks' gestation, and pregnancy-associated hypertension was noted in 747 (17.3%). As previously reported, there was no significant difference in these outcomes between cohorts randomly assigned to supplementation with calcium or placebo. By means of logistic regression a baseline risk model was constructed for preeclampsia and pregnancy-associated hypertension. After adjustment for treatment and clinical site, body mass index >26 kg/m 2 and race were significantly associated with an increased risk of preeclampsia. Body mass index ≥35 kg/m 2 , race, and never smoking were significantly associated with an increased risk of pregnancy-associated hypertension. After adjustment for baseline risks, none of the 28 nutritional factors analyzed were significantly related to either preeclampsia or pregnancy-associated hypertension. Conclusion: We found no evidence in this study for a significant association of hypertensive disorders of pregnancy with any of the 23 nutrients measured. (Am J Obstet Gynecol 2001;184:643-51.)

Objective: The aim of this study was to determine whether plasma concentrations of vascular endothelial growth factor and placental growth factor are altered in women with severe preeclampsia. Study Design: We performed a case-control study to compare plasma concentrations of vascular endothelial growth factor and placental growth factor between women with severe preeclampsia and normotensive women admitted for delivery. Twenty-one women with severe preeclampsia were matched for gestational age and ethnicity with 21 normotensive women. Vascular endothelial growth factor and placental growth factor concentrations were measured with a specific antigen-capture enzyme-linked immunosorbent assay. Results: Women with severe preeclampsia demonstrated significantly lower plasma concentrations of both vascular endothelial growth factor (6.36 ± 3.96 pg/mL vs 18.65 ± 5.98 pg/mL; P

Objective: This study was undertaken to compare baseline characteristics and pregnancy outcomes between normotensive women who did and those who did not have a rise in diastolic blood pressure of ≥15 mm Hg in association with proteinuria. Study Design: We studied 4302 healthy nulliparous women from the Calcium for Preeclampsia Prevention trial who were delivered at ≥20 weeks’ gestation. We selected as the study group normotensive women who developed proteinuria within 7 days of a rise in diastolic blood pressure of ≥15 mm Hg with respect to baseline on 2 occasions 4 to 168 hours apart. Baseline blood pressure was the mean of measurements at 2 clinic visits before 22 weeks’ gestation. Other normotensive women used for comparison were those who did not develop gestational hypertension or a rise in diastolic blood pressure of ≥15 mm Hg in association with proteinuria. Results: Except for greater weight (P < .001), body mass index (P < .001), and systolic blood pressure (P = .05) the baseline characteristics of the 82 women with a rise in diastolic blood pressure of ≥15 mm Hg in association with proteinuria did not differ significantly from those of the other normotensive women. Although they had a greater rate of weight gain (P < .005), larger babies (P = .06), and a 2-fold increase in abdominal delivery (P < .001), there was little other evidence of adverse pregnancy outcomes among these women. Conclusion: During normotensive pregnancy a rise in diastolic blood pressure of ≥15 mm Hg in association with proteinuria appears to be benign and is not a useful clinical construct. (Am J Obstet Gynecol 2000;183:787-92.)

This study was undertake to determine risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.Maternal medical records of pregnancies complicated by HELLP syndrome managed between July 1, 1992, and April 30, 1999, were reviewed. Risk factors evaluated included maternal age, parity, race, previous preeclampsia, chronic hypertension, gestational age at diagnosis, mean arterial blood pressure, nadir blood platelet count (50,000 cells/microL vsor =50,000 cells/microL), and peak serum levels of aspartate aminotransferase and lactate dehydrogenase. Maternal outcome variables analyzed included eclampsia, abruptio placentae, disseminated intravascular coagulopathy, pulmonary edema, pleural effusion, ascites, acute renal failure, liver hematoma, need for transfusion of blood products, cesarean delivery, and death. Statistical analysis was performed with the Student t test, the chi(2) test, and logistic regression analysis.A total of 183 women with HELLP syndrome were studied. Eclampsia was present in 6%, abruptio placentae was present in 10%, and disseminated intravascular coagulopathy was present in 8%. Forty-one women (22%) required transfusion of blood products. Incidence of eclampsia significantly decreased with increasing gestational age, from 16% ator =28 weeks' gestation to 3% at32 weeks' gestation (P.05) and was higher among African American patients than among white patients (12% vs 3%; P.05). Logistic regression analysis showed an independent relationship between eclampsia and race (P.05). Incidence of abruptio placentae was higher among women with previous preeclampsia than among women without this clinical history (26% vs 5%; P.05). Disseminated intravascular coagulopathy was significantly associated with abruptio placentae (P.0001) and acute renal failure (P.0001). A nadir platelet count of50, 000/microL, a peak serum aspartate aminotransferase level of150 U/L, and a peak serum lactate dehydrogenase level of1400 U/L were not independent risk factors for adverse outcome.Among women with HELLP syndrome, African American race is a risk factor for eclampsia. Both acute renal failure and abruptio placentae are associated with disseminated intravascular coagulopathy. Laboratory parameters of HELLP syndrome are not independent risk factors for adverse maternal outcome.

This study was designed to evaluate the efficacy and safety of the oxytocin receptor antagonist atosiban in the treatment of preterm labor.A multicenter, double-blind, placebo-controlled trial with tocolytic rescue was designed. Five hundred thirty-one patients were randomized to receive, and 501 received, either intravenous atosiban (n = 246) or placebo (n = 255), followed by subcutaneous maintenance with the assigned agent. Standard tocolytics as rescue tocolysis were permitted after 1 hour of either placebo or atosiban if preterm labor continued. The primary end point was the time from the start of study drug to delivery or therapeutic failure. Secondary end points were the proportion of patients who remained undelivered and did not receive an alternate tocolytic at 24 hours, 48 hours, and 7 days.No significant difference was found in the time from start of treatment to delivery or therapeutic failure between atosiban and placebo (median, 25.6 days vs 21.0 days, respectively; P =.6). The percentages of patients remaining undelivered and not requiring an alternate tocolytic at 24 hours, 48 hours, and 7 days were significantly higher in the atosiban group than in the control group (all Por =.008). A significant treatment-by-gestational age interaction existed for the 48-hour and 7-day end points. Atosiban was consistently superior to placebo at a gestational age ofor =28 weeks. Fourteen atosiban-treated patients and 5 placebo-treated patients were randomized at24 weeks; the incidence of fetal-infant deaths was higher for the atosiban group at24 weeks. Maternal-fetal adverse events were similar except for injection-site reactions, which occurred more often with atosiban.In this trial the treatment of patients in preterm labor with atosiban resulted in prolongation of pregnancy for up to 7 days for those at a gestational ageor =28 weeks, and this occurred with a low rate of maternal-fetal adverse effects. In addition, at a gestational ageor =28 weeks, the infant morbidity and mortality of atosiban-initiated standard care were similar to those with placebo-initiated standard care. Given that all patients in this study were eligible for tocolysis and that, in practice, nearly all patients who are eligible for a tocolytic receive one, the benefit of using atosiban is the placebo-like maternal-fetal side effect profile. These observations support the use of this oxytocin receptor antagonist in the treatment of patients in preterm labor with intact membranes. Efficacy and infant outcome data at28 weeks are inconclusive.

OBJECTIVE: To determine if women with a history of a previous preterm cesarean delivery experienced an increased risk of subsequent uterine rupture compared with women who had a previous nonclassic term cesarean delivery. METHODS: A prospective observational study was performed in singleton gestations that had a previous nonclassic cesarean delivery from 1999 to 2002. Women with a history of a previous preterm cesarean delivery were compared with women who had a previous term cesarean delivery. Women who had both a preterm and term cesarean delivery were included in the preterm group. RESULTS: A prior preterm cesarean delivery was significantly associated with an increased risk of subsequent uterine rupture (0.58% compared with 0.28%, P

Our objective was to determine if maternal urinary calcium excretion is altered during treatment of mild preeclampsia remote from term with the calcium channel blocker nifedipine. One hundred forty-eight women with mild preeclampsia were randomly allocated to treatment with either bed rest alone (n=64) or in combination with nifedipine (n=84) at 26-36 weeks' gestation. All women had 24 hr urine samples collected for creatinine clearance and calcium excretion determination prior to therapy and during treatment. There was no difference in gestational age at the time of urine collection between the two groups. There were no differences in 24-hr creatinine clearance and calcium excretion between the groups prior to therapy. When followed longitudinally, there was a significant reduction in calcium excretion within each group (p=0.0005 control group, p

Objective To evaluate the etiology, management, and maternal and perinatal outcome in patients with septic shock during pregnancy. Methods In 18 patients with septic shock during pregnancy, the criteria for the diagnosis were sepsis-induced hypotension unresponsive to adequate fluid resuscitation and requirement for vasopressors. Results Causes of shock were pyelonephritis ( n = 6), chorioamnionitis ( n = 3), postpartum endometritis ( n = 2), toxic shock ( n = 2), and one each of septic abortion, ruptured appendix, ruptured ovarian abscess, necrotizing fasciitis, and bacterial endocarditis. Five women (28%) died. Comparing medians of the initial laboratory data for the 13 survivors with those of the five nonsurvivors revealed significant differences for hematocrit (26 compared with 35%; Z = −2.267, P = .023), aspartate aminotransferase (30 compared with 287 U/L; Z = −2.068, P = .042), total bilirubin (1.6 compared with 5.8 mg/dL; Z = 2.046, P = .045), arterial carbon dioxide pressure (30 compared with 19 mmHg; Z = −2.384, P = .013), and arterial oxygen pressure (62 compared with 104 mmHg; Z = −2.004, P = .048). Comparing medians of the hemodynamic data showed differences in blood pressure (88 compared with 70 mmHg; Z = −2.439, P = .013), stroke volume (74 compared with 52 mL; Z = −2.041, P = .038), and left ventricular stroke work index (42 compared with 12 g · m · m 2 ; Z = −1.929, P = .052). Sixty-four percent of survivors and 80% of nonsurvivors had depressed left ventricular function (Fisher exact test, P > .99). Locating the source of infection was difficult and delayed in eight patients. Conclusion In women with septic shock, progression to death can be dramatically rapid. Because vascular permeability is increased, it may be appropriate to administer vasopressors early during resuscitation. An initial low cardiac output is a poor prognostic sign.

OBJECTIVE: Our purpose was to review and characterize the initial presentation, etiology, and prognosis of peripartum cardiomyopathy. STUDY DESIGN: Cases of peripartum cardiomyopathy confirmed by echocardiography were prospectively collected between 1986 and 1994. RESULTS: A total of 28 patients without an antecedent history of heart disease were diagnosed with peripartum cardiomyopathy. Common associated disorders included preeclampsia or chronic hypertension (19), alcohol abuse (2), family history (2), and multiple tocolytic therapy (2). Five deaths occurred (18% mortality), 3 patients received heart transplants (11%), 18 continued with cardiac impairment (64%), and only 2 patients (7%) had regression of cardiomyopathy. The perinatal mortality rate was 36 per 1000 births. Six patients had seven subsequent pregnancies; 4 patients decompensated earlier in the subsequent pregnancy, 1 patient remained well compensated on medical therapy in spite of poor systolic function and a dilated left ventricle, and 1 patient had two subsequent pregnancies without recurrence of cardiac compromise. CONCLUSION: The unique hemodynamic stresses of pregnancy unmask previously undiagnosed cardiomyopathy in otherwise medically stable individuals. The prognosis for these patients is guarded. (Am J Obstet Gynecol 1997;176:182-8.)

To determine the degree of fetal endothelial involvement in preeclampsia by measuring fetal plasma concentrations of cellular fibronectin.In a prospective cohort study, fetal plasma was collected at delivery from the chorionic plate arteries and veins in a convenience sample of 28 pregnancies complicated by preeclampsia and in 28 normal pregnancies. Stored plasma was assayed for cellular fibronectin using a sensitive and specific enzyme immunoassay. On the basis of a desired power of 0.8, alpha of .05, and expected fetal plasma cellular fibronectin values of 4 +/- 2 micrograms/mL, 26 women were required in each group to detect a 40% difference between the groups. Results were compared using the unpaired Student t test, chi 2 analysis with Yates correction, and linear regression.There was no statistically significant difference in fetal plasma concentrations of cellular fibronectin in women with preeclampsia compared with normal pregnant women, either in arteries (3.2 +/- 1.1 and 2.9 +/- 1.5 micrograms/mL; P = .33) or veins (3.3 +/- 1.5 and 2.8 +/- 1.6 micrograms/mL; P = .18). Plasma cellular fibronectin concentrations in fetal arteries correlated significantly with those in fetal veins (r = 0.45, P.001), but not with those in maternal veins (r = 0.15, P = .27).Fetal plasma cellular fibronectin concentrations are similar in preeclamptic and normal pregnancies. We found no evidence that factors responsible for maternal endothelial involvement in preeclampsia are operative in the fetal circulation.