Successful pregnancy outcome in a patient with Gaucher's disease and antiphospholipid syndrome.

Gaucher's disease is characterized by increased incidence of several autoantibodies, but autoimmune phenomena are rare in Gaucher patients. We report the first occurrence of Gaucher's disease and antiphospholipid syndrome in the same patient. A 27-year-old woman with hepatosplenomegaly and thrombocytopenia who was diagnosed as having Gaucher's disease with the genotype 1226G/1226G developed Coombs'-positive hemolytic anemia, recurrent abortions, and a high titer of IgG and IgM anticardiolipin antibodies constituting the diagnosis of antiphospholipid syndrome. A successful pregnancy outcome was achieved by combined therapy with aspirin, low-molecular-weight heparin, prednisone, and enzyme replacement therapy with imiglucerase. The possible pathogenicity of antiphospholipid antibodies found in the sera of many asymptomatic Gaucher patients should be further clarified.

Low molecular weight heparin and warfarin in the treatment of patients with antiphospholipid syndrome during pregnancy.

Fifty-seven pregnancies in women with antiphospholipid syndrome (APS) are presented. These were treated with s.c. enoxaparin and low dose aspirin. In fourteen pregnancies warfarin was prescribed between weeks 15-34 (warfarin group). The decision to switch to warfarin depended on a morbidity score, and the patient's consent. Neither teratogenicity nor significant maternal, fetal or neonatal hemorrhage was observed. Despite the higher pretreatment morbidity score of the warfarin group, the live birth rate was high in both groups: 86% in the warfarin group and 87% in the non-warfarin group. There was no significant difference in week of delivery, birth weight, or incidence of thrombosis between the groups. The study demonstrates the efficacy and safety of anticoagulants during pregnancy. The use of LMWH in pregnant women with APS not being moot, warfarin might be justified in selected patients.

Effect of very advanced maternal age on pregnancy outcome and rate of cesarean delivery.

OBJECTIVE: To determine outcomes of pregnancies in women at least 44 years of age and to determine factors predicting cesarean delivery in these patients. METHODS: Between January 1988 and December 1995, 109 women at least 44 years old delivered in our medical center. These women were matched to a group of 309 women 20-29 years of age. Multiple logistic regression analysis was used to evaluate the association between maternal age and outcome variables, controlling for possible confounding factors. Based on the logistic regression, a predictive model was calculated for cesarean delivery and validated prospectively in a separate group of 30 consecutive women at least 44 years old, who delivered during the first 8 months of 1996. RESULTS: Very advanced maternal age, compared with younger age, was associated with a significantly higher rate of medical complications (hypertensive disorder and diabetes) (odds ratio [OR] 2.5; 95% confidence interval [CI] 1.5, 4.1; P < .001), instrument-assisted vaginal delivery (OR 7.5; 95% CI 2.2, 25.0; P < .004), and cesarean delivery (OR 7.3; 95% CI 2.2, 16.7; P < .001). The incidences of preterm labor, premature rupture of membranes, emergency cesarean delivery, meconium-stained amniotic fluid, small for gestational age newborns, and 5-minute Apgar scores of 7 or lower were not influenced by maternal age. The regression model showed an increased risk for cesarean delivery associated with age of at least 44 years (OR 7.3; 95% CI 2.2, 16.7), primiparity (OR 3.5; 95% CI 1.3, 9.8), infertility treatment (OR 3.6; 95% CI 1.5, 8.8), and egg donation (OR 19.5; 95% CI 6.1, 62.2), with positive and negative predictive values of 94 and 86%, respectively. CONCLUSION: Maternal age of at least 44 years is associated with medical complications in pregnancy and more interventions during labor. However, overall pregnancy outcomes are favorable. Cesarean delivery can be predicted accurately based on maternal age, parity, and infertility treatment.

Outcome of pregnancy in three patients with primary antiphospholipid syndrome after stroke.

OBJECTIVE: Ischemic stroke is the most common neurological manifestation in patients with antiphospholipid syndrome (APS). Pregnancy in APS patients markedly increases the risk of thrombosis. There is no data on pregnancy outcome in patients with APS with a history of an ischemic stroke. We report our experience with three APS patients with a history of stroke who had successful pregnancies and deliveries. PATIENTS: Three patients with APS and previous stroke were treated with small doses of aspirin and anticoagulants during pregnancy. RESULTS: The patients remained free of attacks of cerebral ischemia during their pregnancies and at follow-up periods of 1 to 4 years. CONCLUSIONS: Successful pregnancy and delivery is possible in APS patients with a history of stroke, treated with low-dose aspirin and anticoagulants. A previous episode of cerebral ischemia should not be considered an absolute contraindication for an APS patient to become pregnant.

Role of renal ultrasonography in the management of pyelonephritis in pregnant women.

OBJECTIVE: The objective of this study was to determine the usefulness of renal ultrasonography in pregnant women with pyelonephritis. STUDY DESIGN: A retrospective review was done of hospital records of 171 consecutive pregnant women admitted to the hospital over a 7-year period with the diagnosis of pyelonephritis. RESULTS: Urine cultures were positive in all but one of the women and intravenous antibiotics were administered in all cases. Renal ultrasonography was done in 75 (43.9%) of the women and results found to be normal in 26 (34.7%) of them. The renal pelvis was dilated mildly (6 to 10 mm) in 25 (33.3%), moderately (11 to 15 mm) in 16 (21.3%), and severely (> or = 16 mm) in 8 (10.7%) patients. Duplicated collecting systems and renal calculi were each found in 2 (2.7%) patients. All patients were treated conservatively with no need for ureteral stents. Three of the patients with severe hydronephrosis were first seen at term and delivery was therefore induced. There was no difference in maternal characteristics and outcome of pregnancy between women who underwent renal ultrasonography and those who did not. However, the duration of hospitalization was significantly longer (p < 0.02) for women in whom renal ultrasonography was performed (mean +/- SD, 5.8 +/- 1.7 vs 4.1 +/- 1.3 days). CONCLUSION: Renal ultrasonography is of limited benefit in pregnant women with pyelonephritis, because these imaging studies only rarely modify management and do not significantly affect pregnancy outcome.

A prospective cohort study of oxytocin plus ergometrine compared with oxytocin alone for prevention of postpartum haemorrhage.

OBJECTIVE: To determine the safety and efficacy of intramuscular oxytocin plus ergometrine compared to intravenous oxytocin for prevention of postpartum haemorrhage, and the significance of administration at the end of the second stage of labour compared with that after the third stage. DESIGN: A prospective cohort study. SETTING: A university affiliated tertiary medical centre. PARTICIPANTS: Two thousand one hundred and eighty-nine women delivering singletons during 40 consecutive weeks. MAIN OUTCOME MEASURES: Postpartum haemorrhage (> 500 ml), prolonged third stage (> 30 min), retained placenta (> 60 min), elevated blood pressure (systolic > 150 mmHg, diastolic > 100 mmHg). RESULTS: The rate of postpartum haemorrhage was not significantly different for oxytocin-ergometrine compared with oxytocin, when administered at the end of the second stage of labour (odds ratio 1.10, 95% confidence interval (CI) 0.75-1.61) or after the third stage (odds ratio 0.95, 95% CI 0.68-1.34). The patients receiving oxytocics at the end of the second stage of labour had significantly lower rates of postpartum haemorrhage, for both oxytocin-ergometrine (odds ratio 0.69, 95% CI 0.49-0.98) and oxytocin (odds ratio 0.60, 95% CI 0.41-0.87), compared with those treated after the third stage. CONCLUSION: Administration of oxytocin alone is as effective as the use of oxytocin plus ergometrine in the prevention of postpartum haemorrhage, but associated with a significantly lower rate of unpleasant maternal side effects. Oxytocics administered after delivery of the fetal head compared with after the placental expulsion are associated with a significantly lower rate of postpartum haemorrhage.

Early oral feeding after cesarean delivery.

OBJECTIVE: To assess the gastrointestinal function and patient acceptability of early initiation of oral feeding after cesarean delivery. METHODS: Two hundred twenty-one healthy women delivered by cesarean were assigned in an alternating manner to receive either a high-protein, low-residue pudding initiated within 6 hours of delivery and given every 6 hours thereafter (n = 108), or a standard postoperative diet, consisting of sips of water 12 hours after surgery and a liquid diet permitted only after bowel sounds returned and flatus passed (n = 113). RESULTS: Compared with the control group, the early-feeding group had a shorter mean (+/- standard deviation) duration of intravenous fluid administration, 18.6 +/- 6.3 versus 30.5 +/- 8.1 hours (P < .001); more rapid return to regular oral diet, 26.8 +/- 6.3 versus 39.7 +/- 8.8 hours (P < .001); and a shorter time to first bowel movement, 30.0 +/- 10.0 versus 43.3 +/- 11.7 hours (P < .001). There was no significant increase in gastrointestinal morbidity: 17.4 versus 15.6%, respectively. CONCLUSION: Early feeding after cesarean delivery was well tolerated and was associated with a more rapid return to a normal diet. This approach may facilitate early hospital discharge.

Low-molecular-weight heparin during pregnancy and delivery: preliminary experience with 41 pregnancies.

OBJECTIVE: To describe experience with 41 pregnancies treated with the low-molecular-weight heparin enoxaparin. METHODS: The medical charts of 34 women (a total of 41 pregnancies) treated between January 1992 and March 1995 with the low-molecular-weight heparin enoxaparin were reviewed. Most patients (87.5%) received one daily 40-mg injection. In all cases, treatment was continued throughout labor, delivery, and the immediate postpartum period. RESULTS: Therapy was administered for 5-280 days (median 91). One case of a thromboembolic event was recorded during treatment. No systemic or local side effects were reported. During pregnancy, only one patient had mild vaginal bleeding, which resolved spontaneously while therapy was continued. There was no excessive intrapartum bleeding in any of these patients, whether delivered vaginally or abdominally. During treatment, 19 of the 34 patients underwent 24 surgical procedures, including 13 cesarean deliveries, without excessive bleeding. Epidural anesthesia was used during labor in nine of the patients, with no specific complications. The corrected perinatal mortality rate, (ie, the rate of fetal death after 24 weeks' gestation plus neonatal death, excluding a neonate with multiple anomalies) for those neonates delivered after 24 weeks' gestation was 2.7%. There were no cases of intraventricular hemorrhage in any of the neonates. CONCLUSION: This preliminary series, the largest reported to date, demonstrates the relative safety and efficacy of low-molecular-weight heparin therapy in pregnancy and delivery.