Cerebrovascular disorders complicating pregnancy--beyond eclampsia.

OBJECTIVE: Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium. STUDY DESIGN: Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded. RESULTS: The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure > or = 110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation. CONCLUSION: Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor.

Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

OBJECTIVE: Our purpose was to compare the maternal outcome of pregnancies complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, partial HELLP syndrome, or severe preeclampsia. STUDY DESIGN: In a retrospective cohort study we reviewed the maternal charts of 316 women with HELLP syndrome or severe preeclampsia managed at our perinatal center between July 1, 1992, and June 30, 1995. HELLP syndrome was strictly defined by previously published laboratory criteria. Women were divided into three groups: HELLP syndrome (n = 67), partial HELLP syndrome (one or two but not all three features of HELLP syndrome, n = 71), and severe preeclampsia (no features of HELLP syndrome, n = 178). Results were compared by chi 2 analysis and one-way analysis of variance. RESULTS: Mean gestational ages at delivery in the HELLP, partial HELLP, and severe preeclampsia groups were, respectively, 31.7, 32.7, and 34.5 weeks (p < 0.001 between HELLP and severe preeclampsia). There was one maternal death from intracerebral hemorrhage in the HELLP group. In women with HELLP syndrome there was a higher incidence of cesarean section (p < 0.05), disseminated intravascular coagulation (p < 0.001), and need for transfusion (p < 0.001) than in the other two groups. CONCLUSIONS: Higher incidences of maternal complications in women with HELLP syndrome stress the importance of strict criteria for the definition of HELLP syndrome. Women with partial HELLP syndrome should be studied and managed separately from women with complete HELLP syndrome.

Management of severe preeclampsia.

Preeclampsia affects two patients, the mother and the fetus. Traditionally, women with severe preeclampsia have been delivered without delay, regardless of fetal considerations. Although delivery is appropriate therapy for the mother, aggressive management with immediate delivery of a fetus remote from term leads to high neonatal mortality and morbidity resulting from prematurity. Recent studies have shown favorable neonatal outcomes after conservative management of severe preeclampsia. Candidates for conservative management should be selected carefully and managed with intensive maternal and fetal monitoring at a tertiary perinatal center.

Is fetal neurologic and physical development accelerated in preeclampsia?

OBJECTIVE: Our objective was to determine whether the Ballard score, a maturity score for neonatal neuromuscular and physical development, is more advanced in preterm infants of preeclamptic women than in controls. STUDY DESIGN: A matched cohort study design was used. One hundred women with strictly defined preeclampsia (new-onset hypertension, proteinuria, and hyperuricemia) were matched for gestational age, race, and gender to 100 normotensive women with preterm delivery. All patients had an assigned antenatal gestational age based on ultrasonography before 24 weeks. The gestational age, based on antenatal ultrasonography and last menstrual period, was compared with the Ballard score given at the time of neonatal physical examination within the first 12 hours after delivery. The difference in gestational age between the Ballard score and antenatal ultrasonography (Ballard score - ultrasonography) was calculated for each patient. Results are expressed as median and range and are compared with a Student t test. RESULTS: The mean gestational age at delivery by antenatal ultrasonography in patients with severe preeclampsia was 32.06 +/- 2.74 and 32.03 +/- 2.70 weeks, respectively. The median difference between scores in patients with severe preeclampsia and normal patient were 1.3 +/- 1.8 and 1.5 +/- 1.6 weeks, respectively (p = 0.41). CONCLUSION: On the basis of criteria defined by the Ballard score, preeclampsia was not associated with accelerated fetal neurologic and physical development.

Maternal adaptation to pregnancy.

Pregnancy is a time when significant maternal cardiovascular and hemodynamic changes occur. Such alterations may include blood volume, heart rate, stroke volume, cardiac output, and systemic vascular resistance. These physiologic changes are usually well tolerated by the pregnant patient, and they must be recognized and understood by the physician to distinguish them from what is abnormal. Changes begin early in gestation and continue as pregnancy advances, and are totally reversible after delivery. This review summarizes updates on cervical, hemodynamic, cardiovascular and endocrinologic changes during pregnancy.

Recurrent molar pregnancies in a family with extensive intermarriage: report of a family and review of the literature.

BACKGROUND: Familial recurrent molar pregnancies are exceedingly rare. The genetic basis for recurrent moles is not well understood, and its association with major human lymphocytic antigen histocompatibility is debatable. The purpose of this report is to present a family with extensive intermarriage and recurrent molar pregnancies with some emphasis on the result of the human lymphocytic antigen-typing. CASE: Two sisters, both married to first-degree cousins, had three and five pathologically confirmed molar pregnancies, respectively. A second-degree cousin, also married to her first-degree cousin, is also reported to have had five consecutive moles. Chromosomal analysis and human lymphocytic antigen-typing on the two sisters and their spouses was performed. Human lymphocytic antigen-typing was compared to a cross-sectional sample of our population. This showed a high incidence of unusual human lymphocytic antigens in these family members. CONCLUSION: In families with extensive intermarriage and recurrent molar pregnancies, patients and their spouses may have unusual human lymphocytic antigen histocompatibility, which supports the possibility of a strong genetic predisposition expressed at the level of major histocompatibility class I and II gene translation.

Dorsal column input to cochlear neurons in decerebrate-decerebellate cats.

In decerebrate-decerebellate cats with cervical spinal cuts sparing only the dorsal columns (DCs), activation of one DC modulates sound-evoked discharges of neurons in both dorsal cochlear nuclei. In a sample of 50 neurons, 34% were excited or facilitated, 12% were inhibited and 54% were not affected by DC stimulation. This modulation appears to be mediated through direct projections from the dorsal column nuclei to the dorsal cochlear nuclei.