Risks and benefits of conservative management in severe pre-eclampsia

This prospective study was designed to detect whether conservative management in cases of severe pre-eclampsia is possible or not and to avoid prematurity and its related complications. This prospective case controlled study was conducted at Ain Shams University Maternity Hospital, over two years from April 2003 to April 2005, to detect whether conservative management in cases of severe pre-eclampsia is possible or not and to avoid prematurity and its related complications. Eighty five [85]: patients with severe pre-eclampsia [PET] were included in this prospective case controlled study. All patients included in this study were primigravida, not in labor, had a living fetus and had documented evidence of pre-eclampsia. The gestational age of the patients included in this study was more than 30 weeks gestation. Patients with maternal or fetal indications necessitating immediate delivery on admission were excluded from this study. All patients were admitted to the MICU of Ain Shams University Maternity Hospital. Before starting conservative management, patients and their relatives were informed about the management plan and possible maternal or fetal risks and benefits. If the patient agreed to continue conservative management, she signed a consent form. After counseling, forty five [45] patients refused the conservative management were included in the first group of this study [severe pre-eclampsia with immediate TOP], and conservative management was accepted by forty patients [40], included in the second of this study [severe pre-eclampsia managed conservatively]. The goal of the conservative management was to prolong pregnancy until 36 completed weeks [to avoid prematurity and to decrease the chance of neonatal incubation] or until the onset of either maternal or fetal complications [impending eclampsia or fetal distress]. The management was started immediately following admission with: bed rest, magnesium sulfate and an antihypertensive [methyldopa or nifedipine +/- hydralazine]. After control of blood pressure and prevention of convulsions, either TOP was started in the first group or conservative management in the second group. All patients in the second group received dexamethasone 12 mg IM every 12 hours for 48 hours and dexamethasone therapy was repeated weekly till delivery. 24 hours urinary total protein [UTP], Blood urea, creatinine, uric acid, SCOT, SGPT and platelet count were determined in all cases on admission. These laboratory investigations were repeated weekly for patients in the second group. Patients of the second group were monitored by senior obstetrician and senior anaesthiologist managing the MICU every day. Monitoring included inquiry about any complaints, blood pressure measurement 4 times daily, fetal heart sound auscultation 4 times daily, fetal growth monitoring, assessment of fetal wellbeing twice weekly and repetition of other tests whenever necessary. Patients were instructed to report the development of features such as persistent headaches, visual disturbances, epigastric pain, uterine contractions, vaginal bleeding, ruptured membranes or decreased fetal movement. TOP was based on both maternal and fetal indications. All patients were discharged after delivery with stable blood pressure levels and absent or + I urinary albumin. There was a high significant difference between the two groups of this study as regards the gestational age at TOP which was 32.4 weeks +/- 2.5 in the first group with immediate TOP compared with 35.4 weeks +/- 6.2 in the second group managed conservatively. Although, the first group with immediate TOP had shorter hospital stay before TOP [0.25 days +/- 0.5] than the second group managed conservatively [20.5 days +/- 4.5], the same group with immediate TOP had longer hospital stay after TOP [7.5 days +/- 3.5] titan the second group managed conservatively [5.0 days +/- 1.5]. The two groups of this study were matched with no significant difference as regards the mean systolic and diastolic blood pressure on admission, but the mean systolic blood pressure on TOP was significantly lower in the second group managed conservatively 140.8 mmHg +/- 12.5 compared with 155.5 mmHg +/- 22.5 in the first group with immediate TOP, also, the mean diastolic blood pressure on TOP was significantly lower in the second group managed conservatively 101.5 mmHg +/- 10.5 compared with 112.5 mmHg +/- 15.5 in the first group with immediate TOP. In the first group with immediate TOP, the serum uric acid was significantly decreased from 6.8 mg/dL +/- 1.73 on admission to 5.5 mg/dL +/- 0.35 on TOP, also, the SCOT was significantly decreased from 38.0 IU/L +/- 1.5 on admission to 31.2 IU/L +/- 3.58 on TOP and the SGPT was significantly decreased from 42.0 IU/L +/- 7.21 on admission to 20.0 IU/L +/- 5.7 on TOP. In the second group managed consewatively, the blood urea level was significantly decreased from 37.25 mg/dL +/- 7.32 on admission to 34.30 mg/dL +/- 5.67 on TOP, and the serum creatinine was significantly decreased from 1.35 mg/dL +/- 0.56 on admission to 1.24 mg/dL +/- 1.1 on TOP. Also, in the second group, the SCOT was significantly decreased from 40.50 IU/L +/- 3.5 on admission to 29.85 IU/L +/- 8.36 on TOP, and the SGPT was significantly decreased from 41.62 IU/L +/- 10.2 on admission to 19.8 IU/L +/- 7.35 on TOP, but there was a significant increase in the level of uric acid from 7.2 mg/dL +/- 1.12 on admission to 7.5 mg/dL +/- 0.87 on TOP and a significant decrease in the Platelet count from 192.907 x 1000/mm3 +/- 93.25 on admission to 156.484 x 1000/mm3 +/- 77.387 on TOP. The incidence of accidental hemorrhage was significantly higher in the first group of this study with immediate TOP [two patients = 0.44%], compared with the second group managed conservatively [one patient = 0.25%] and the incidence of antepartum eclampsia was signifantly higher in the second group managed consematively [3 patients = 0.75%] compared with the first group with immediate TOP [two patients - 0.44%]. In the second group of this study, The consewative management was successful and was continued till 36 weeks gestation in 22 patients out of 40 [55.0%]. 23 patients [57.5%] delivered vaginally in the second group managed conservatively compared with 21 patients [46.67%] in the first group with immediate TOP [P < 0.05 S.] and the number of the patients delivered by cesarean section was 24 out of 45 [53.33%] in the first group with immediate TOP and was 17 out of 40 [42.5%] in the second group managed conse-rvatively [P < 0.001, H.S.]. Also, there was a significant difference between the two groups of this study as regards fetal birth weight, which was 1.890 Kg +/- 0.850 in the first group with immediate TOP versus 2.425 Kg +/- 1.55 in the second group managed conservatively [P < 0.001, H.S.]. The number of the infants admitted to the NNICU was 29 out of 45 [64.4%] in the first group with immediate TOP compared with 12 out of 40 [30.0%] in the second group managed conservatively [P < 0.001, H.S.]. The neonatal deaths were significantly higher in the first group with immediate TOP [12 neonates - 26.7%] compared with the second group managed conservatively [3 neonates = 0.75%] [P < 0.001]. The duration of admission to NNICU was significantly longer in the first group with immediate TOP [37.5 days +/- 9.0] compared with the second group managed conservatively [19.0 days +/- 11.5] [P < 0.001]. The postpartum complications were significantly higher in the first group with immediate TOP compared with the second group managed conservatively. Two patients [0.44%] in the first group developed post-partum hemorrhage, while no cases of post-partum hemorrhage recorded in the second group [P < 0.001], also, one patient [0.22%] developed post-partum renal failure in the first group, while no cases of post-partum renal failure recorded in the second group [P < 0.05]. Six patients [13.4%] developed post-partum eclampsia in the first group compared with 3 patients [0.75%] in the second group [P < 0.001] and two patients [0.44%] developed HELLP syndrome in the first group compared with one patient [0.25%] in the second group [P < 0.05]. Consewative treatment with continuous monitoring and supervision is possible in selected cases of severe pre-eclampsia, in order to improve the fetal outcome in developing countries where NNICU is not available, without increasing the maternal risk

False negative cytology and colposcopy in cervical condyloma

In this study of 150 young women attending the Early Cancer Detection Unit at Ain Shams University Hospital, 70.6% of cases had histologically proven cervical HPV associated disease. Cervical cytology reported HPV with or Without dyskaryosis in 57.5% of cases, while cotpics colposcopy was sensitive in only 58.4%. The reliability of diagnosis increased to 75.4% when the two methods were used in conjunction. We recommend another more, sensitive methods for detection of cervical human papilloma virus