Dexamethasone compared with betamethasone for glucocorticoid treatment of postpartum HELLP syndrome.

OBJECTIVES: To compare the efficacy of dexamethasone and betamethasone to ameliorate the course of postpartum hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. METHODS: A prospective, mixed randomized/non-randomized clinical investigation of patients with postpartum HELLP syndrome. Treatment with either dexamethasone or betamethasone was continued until there was evidence of disease recovery. RESULTS: Baseline characteristics of both the dexamethasone (n=18) and betamethasone (n=18) groups were similar. Although the time to discharge from the obstetrical recovery room was not statistically significant between groups, reduction in mean arterial blood pressure was more pronounced in the dexamethasone group as compared with the betamethasone group (-15.3+/-1.4 mmHg vs. -7.5+/-1.4 mmHg, respectively, P<0.01). Patients in the dexamethasone group required less antihypertensive treatment than the betamethasone group (6% vs. 50%, P=0.01) and also had a decreased need for readmission to the obstetrical recovery room (0% vs. 22%, P=0.03). CONCLUSION: This investigation supports the use of dexamethasone as the superior glucocorticoid to use for patients with postpartum HELLP syndrome.

Repeat postpartum magnesium sulfate administration for seizure prophylaxis: is there a patient profile predictive of need for additional therapy?

OBJECTIVE: To profile patients with hypertensive disorders of pregnancy who require reinstitution of magnesium sulfate therapy for disease exacerbation. STUDY DESIGN: A prospective clinical trial enrolling gravidas with pre-eclampsia. The length of postpartum magnesium sulfate seizure prophylaxis was determined by individual patient characteristics. Patients with exacerbation of their disease after discontinuation of magnesium sulfate received a second course of magnesium sulfate lasting 24 h. RESULTS: Of a total of 503 patients, 38 (7.6%) required reinstitution of postpartum magnesium sulfate therapy for an additional 24-h period. Patients with chronic hypertension complicated by superimposed pre-eclampsia were most likely to require further therapy (11/61, 18.0%), when compared with other hypertensive disorders. Additionally, patients who required reinstitution of magnesium therapy had significantly shorter gestations (32.4 +/- 4.2 weeks versus 36.3 +/- 4.2 weeks, respectively; p < 0.001), and higher mean arterial pressure during the initial magnesium course (113.2 +/- 11.2 versus 105.6 +/- 11.3 mmHg; p < 0.001). CONCLUSION: Patients with chronic hypertension complicated by superimposed pre-eclampsia, patients delivered prior to 35 weeks' gestation and patients requiring a longer initial magnesium prophylaxis are at higher risk for the need of reinstitution of seizure prophylaxis postpartum.

A prospective, randomized trial comparing the efficacy of dexamethasone and betamethasone for the treatment of antepartum HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.

OBJECTIVE: This study was undertaken to determine whether dexamethasone or betamethasone is superior for the antepartum treatment of HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. STUDY DESIGN: This prospective, randomized, clinical investigation compared intravenously administered dexamethasone and intramuscularly administered betamethasone in the treatment of gravid women with HELLP syndrome. Efficacy end points included laboratory values (platelet count, lactate dehydrogenase activity, aspartate aminotransferase activity) and clinical parameters (mean arterial pressure, urinary output). RESULTS: Forty patients were enrolled in the study, 19 in the dexamethasone arm and 21 in the betamethasone arm. The adjusted time-averaged changes from baseline were significant for aspartate aminotransferase activity (dexamethasone, -20.4 +/- 9.6 U/L; betamethasone, 9.9 +/- 8.9 U/L; P =.029), mean arterial pressure (dexamethasone, -15.6 +/- 1.4 mm Hg; betamethasone, -8.1 +/- 1.4 mm Hg; P <.001), and urinary output (dexamethasone, 12.9 +/- 8.6 mL/h; betamethasone, -11.9 +/- 8.2 mL/h; P =.043). CONCLUSION: Intravenously administered dexamethasone appears to be more effective than intramuscularly administered betamethasone for the antepartum treatment of mothers with HELLP syndrome.

Change in platelet count predicts eventual maternal outcome with syndrome of hemolysis, elevated liver enzymes and low platelet count.

OBJECTIVE: To profile the rates of change for platelets and lactate dehydrogenase (LDH) in patients with the syndrome of hemolysis, elevated liver enzymes and low platelet count (HELLP) to reflect and possibly predict disease severity. METHODS: Serial determinations of the platelet count and serum LDH were analyzed retrospectively for 545 patients with HELLP syndrome and 94 severely pre-eclamptic patients. A repeated measures (mixed model) analysis of variance (ANOVA) was utilized to estimate the rates of change for LDH and platelets in each group. RESULTS: Patients who developed class 1 or 2 HELLP syndrome exhibited a rapid deterioration in platelet count of 45-50,000/microl per day compared to 30,000/microl per day for class 3 and non-HELLP severe pre-eclampsia. For LDH, values increased at a rate of approximately 1400 IU/l per day, 600 IU/l per day, 300 IU/l per day and 200 IU/l per day for patients with classes 1, 2 and 3 and for non-HELLP severe pre-eclampsia, respectively. CONCLUSION: The rate of change of platelets and LDH appeared to correlate well with eventual syndrome severity and this can be used to enhance patient assessment beyond the value of a single test for either laboratory parameter.

Pregnancy outcome in women with preterm labor symptoms without cervical change.

OBJECTIVE: This study was undertaken to determine pregnancy outcome in women who have preterm labor symptoms without cervical change according to fetal fibronectin status. STUDY DESIGN: Patients who were examined at the obstetric emergency department with symptoms of preterm labor but without cervical change underwent fetal fibronectin collection. Pregnancy outcome and fetal fibronectin results were analyzed after delivery. RESULTS: Of the 235 patients sampled, 20% (n = 48) had positive fetal fibronectin results. The mean +/- SD gestational age at delivery was lower in women with positive fetal fibronectin results (34.2 +/- 4.1 vs 37.7 +/- 2.3 weeks; P <.001); these women were more likely to deliver preterm as a result of preterm labor than women with other obstetric indications (46% vs 19%; P <.001). Infants born to these women demonstrated lower birth weight (2317 +/- 895 g vs 2877 +/- 557 g; P =.003), were more likely to be admitted to the neonatal intensive care unit (42% vs 14%; P <.001), and were more likely to die in the neonatal period (11% vs 0%; P <.001). CONCLUSION: Patients with symptoms of preterm labor but without cervical change who have negative fetal fibronectin results are less likely to deliver preterm. Therefore in women with symptoms but without cervical change fetal fibronectin should be considered for risk assessment.

Single umbilical artery is associated with an increased incidence of structural and chromosomal anomalies and growth restriction.

The objective to characterize neonatal outcome associated with ultrasonographic identification of a single umbilical artery. Pregnancies diagnosed with single umbilical artery antenatally were identified. All prenatal/antenatal and pediatric records were reviewed for maternal demographics, associated anomalies, karyotypic analysis, pregnancy complications, and neonatal outcome. Twenty-seven pregnancies complicated by fetal single umbilical artery were identified. Of the 27 pregnancies, 5 (18.5%) underwent pregnancy termination and 1 (3.7%) experienced fetal demise. Of the 21 liveborn infants, 4 (19%) died within the first year of life. Sixty-seven percent of fetuses had an associated structural anomaly. Sixteen of the 27 pregnancies underwent amniocentesis and 7 of these were chromosomally abnormal. All of the karyotypically abnormal fetuses had a structural defect in addition to the single umbilical artery. Of the six fetuses without any associated structural or chromosomal anomalies, three (50%) demonstrated growth restriction. Single umbilical artery is relatively rare finding. When a single umbilical artery is identified, a vigilant search for associated anomalies should be undertaken. Pregnancies identified as having fetuses with associated structural anomalies should be offered amniocentesis. Pregnancies with isolated single umbilical artery should be carefully monitored for evidence of fetal growth restriction.

Randomized trial of intermittent or continuous amnioinfusion for variable decelerations.

OBJECTIVE: To determine whether continuous or intermittent bolus amnioinfusion is more effective in relieving variable decelerations. METHODS: Patients with repetitive variable decelerations were randomized to an intermittent bolus or continuous amnioinfusion. The intermittent bolus infusion group received boluses of 500 mL of normal saline, each over 30 minutes, with boluses repeated if variable decelerations recurred. The continuous infusion group received a bolus infusion of 500 mL of normal saline over 30 minutes and then 3 mL per minute until delivery occurred. The ability of the amnioinfusion to abolish variable decelerations was analyzed, as were maternal demographic and pregnancy outcome variables. Power analysis indicated that 64 patients would be required. RESULTS: Thirty-five patients were randomized to intermittent infusion and 30 to continuous infusion. There were no differences between groups in terms of maternal demographics, gestational age, delivery mode, neonatal outcome, median time to resolution of variable decelerations, or the number of times variable decelerations recurred. The median volume infused in the intermittent infusion group (500 mL) was significantly less than that in the continuous infusion group (905 mL, P =.003). CONCLUSION: Intermittent bolus amnioinfusion is as effective as continuous infusion in relieving variable decelerations in labor. Further investigation is necessary to determine whether either of these techniques is associated with increased occurrence of rare complications such as cord prolapse or uterine rupture.

Amniotic fluid volume estimation and the biophysical profile: a confusion of criteria.

The biophysical profile (BPP) can be used as an initial test of fetal health and as a secondary back-up assessment of fetuses at risk of adverse outcomes when preliminary evaluations are not reassuring. The BPP evaluates five characteristics: fetal movement, tone, breathing, heart reactivity, and amniotic fluid (AF) volume estimation. Three of the most frequently used obstetric textbooks define adequate AF volume differently. In two of the three, the stated method of evaluating AF volume differs from that actually used by the referenced authors. We reviewed articles by Manning and found that his methodology changed from a 1-cm pocket in one plane to a 1-cm pocket in two perpendicular planes, and finally to a 2-cm vertical pocket with a 1-cm horizontal measurement. The 2 x 2-cm pocket is a fourth methodology that has been introduced recently. It is not known how often and in which groups each of the four methods has been used to evaluate abnormal AF volumes. The relevance and importance of determining precisely the ultrasound measurement actually used for investigations are emphasized by looking at women with AF indices < or = 5. Fifty-three percent of those women had a 2 x 2 pocket, 72% had a 2 x 1 pocket, and 95% had a 1 x 1 pocket. The diagnosis of low fluid can lead to additional testing, hydration, and intervention, so the importance of a universal definition linked with pregnancy outcomes cannot be overemphasized.

Lack of utility of standard labor curves in the prediction of progression during labor induction.

OBJECTIVE: This study was undertaken to determine whether patients undergoing labor induction can be reliably evaluated by means of standard labor assessment curves. STUDY DESIGN: In this retrospective chart review of 123 patients who underwent cervical ripening and induction of labor, Friedman's standard labor curves were used for comparison. Statistical analysis was performed with the Student t test. RESULTS: Nulliparous and parous patients undergoing cervical ripening spent more time in active-phase labor than standard expectations of labor progression would indicate (12.7 +/- 7.8 vs 5. 9 +/- 3.4 hours for nulliparous women, P <.001; 7.9 +/- 6.4 vs 2.5 +/- 1.5 hours for parous women, P <.001). Nulliparous and parous patients who were delivered vaginally spent more time in active labor than did their respective standard historical control populations (10.3 +/- 8.0 vs 5.9 +/- 3.4 hours for nulliparous women, P <.001; 7.0 +/- 6.0 vs 2.5 +/- 1.5 hours for parous women, P <. 001). CONCLUSION: Standard methods for the evaluation of labor adequacy and prediction of the likelihood of vaginal delivery may not apply to patients undergoing cervical ripening.

Cardiopulmonary morbidity as a complication of severe preeclampsia HELLP syndrome.

OBJECTIVE: To profile the types and frequencies of cardiopulmonary morbidity encountered in patients with severe preeclampsia with or without hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). STUDY DESIGN: We initiated a retrospective study of 979 patients with severe preeclampsia with and without HELLP syndrome. Types of cardiopulmonary morbidity were analyzed among the three classes of HELLP syndrome and severe preeclampsia without HELLP syndrome. RESULTS: Cardiopulmonary morbidity occurred in 7.6% of study patients. As a group, patients with cardiopulmonary complications were more likely to have cesareans (11% vs 6%, p = 0.019) earlier in gestation (1366 +/- 700 gm birth weight versus 1734 +/- 892 gm birth weight, p = 0.021), with higher peak postpartum blood pressures (< 0.001) and with more abnormal laboratory values indicative of multisystem disease, compared with patients without this complication. Patients with cardiopulmonary complications required almost twice as long to achieve diuresis as comparison patients (22 +/- 23 hours versus 12 +/- 11 hours, p < 0.001). CONCLUSION: The probability of cardiopulmonary complications increases significantly when patients develop class 1 HELLP syndrome. Of all cardiopulmonary complications, acute lung injury/acute respiratory distress syndrome is most specific to class 1 HELLP syndrome. Transient renal dysfunction is closely related to cardiopulmonary morbidity.

Maternal mortality associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

OBJECTIVE: The aim of this study was to determine factors contributing to deaths among women with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome. STUDY DESIGN: Information from multiple sources was scrutinized to distinguish and profile maternal deaths associated with HELLP syndrome. RESULTS: Information was available regarding 54 maternal deaths. According to HELLP syndrome classification 60.0% had class 1 disease, 35.6% had class 2 disease, and 4.4% had class 3 disease. Events associated with maternal deaths included cerebral hemorrhage (45%), cardiopulmonary arrest (40%), disseminated intravascular coagulopathy (39%), adult respiratory distress syndrome (28%), renal failure (28%), sepsis (23%), hepatic hemorrhage (20%), and hypoxic ischemic encephalopathy (16%). Delay in diagnosis of HELLP syndrome was implicated in 22 of 43 patients' deaths (51.1%). CONCLUSIONS: It appears that (1) most maternal deaths occurred among women with class 1 HELLP syndrome, (2) delay in diagnosis was associated with mortal consequences, and (3) hemorrhage in the hepatic or central nervous system or vascular insult to the cardiopulmonary or renal system were associated with increased mortality risk.

Modern obstetric management and outcome of infants with gastroschisis.

OBJECTIVE: To determine whether outcomes of infants with gastroschisis differed by mode or site of delivery, diagnostic method, or when maternal-fetal medicine consultation was given. METHODS: Charts of 32 infants born at the University of Mississippi Medical Center or admitted to the neonatal intensive care unit between September 1992 and June 1998 were reviewed for maternal demographic characteristics and neonatal outcomes. Statistical analysis was done using Student t test, analysis of variance, chi2, and Kruskal-Wallis test with P<.05 considered statistically significant. RESULTS: There were no statistically significant differences in neonatal outcomes by method or site of delivery, diagnostic method, or maternal-fetal medicine consultation before delivery. Infants delivered vaginally had higher Apgar scores at 1 and 5 minutes (9 versus 7 and 9 versus 8, respectively, P<.05). Vaginally delivered infants required more days of antibiotic therapy than those delivered abdominally (10 versus 3 days, P<.05) but had a shorter interval to enteral feedings (15 versus 30 days, P<.05). CONCLUSION: Outcomes of infants with isolated gastroschisis were not significantly affected by method or site of delivery, diagnostic method, or maternal-fetal surveillance. Although the findings of this investigation were largely negative and the statistical power limited due to the rarity of this fetal disruption, small series of cases of gastroschisis need to be analyzed to resolve current controversies surrounding optimal treatment of gastroschisis.

Pathogenesis of neurological signs associated with bovine enteric coccidiosis: a prospective study and review.

Various hypotheses have been proposed for the pathogenesis of the neurological signs associated with bovine enteric coccidiosis. We undertook a prospective study of cases of bovine enteric coccidiosis with and without nervous signs to test the validity of these hypotheses and explore other possible pathophysiological mechanisms. Clinical, pathological and toxicological data from 12 calves with, and 15 calves without, neurological signs were compared. Calves with neurological signs had a lower liver Cu concentration (p less than 0.01) and a higher plasma glucose concentration (p less than 0.05) than did calves without neurological signs. Hyperglycemia and Cu deficiency may increase the susceptibility to central nervous system damage, but are not likely to account for the onset of neurological signs in calves with enteric coccidiosis. The results of the study suggest that the following are not involved in the pathogenesis of "nervous coccidiosis": disturbance of serum Na, K, Ca, P, or Mg concentration, vitamin A deficiency, thiamine deficiency, anemia, lead intoxication, uremia, Haemophilus somnus meningoencephalitis, severity of coccidial infection, gross alterations in intestinal bacterial flora and hepatopathy.

Characteristics of the labile neurotoxin associated with nervous coccidiosis.

Reported are the results of preliminary attempts to characterize the molecular weight, heat sensitivity and other features of a labile neurotoxin identified in the serum of calves exhibiting neurological signs in association with coccidial enteritis. The labile neurotoxin activity is heat labile (60 degrees C for 30 min) and is lost upon exposure to acidic pH (5.5) and cysteine (1.75 g/100 mL serum). Activity can be recovered from the precipitate of a 30% wt/vol solution of (NH4)2SO4 in serum. Ultrafiltration trials suggest that labile neurotoxin activity may be linked to a molecule of over 300,000 MW.

Labile neurotoxin in serum of calves with "nervous" coccidiosis.

Mouse inoculation was used to test for the presence of a toxin in the serum, cerebrospinal fluid, and intestinal contents collected from cases of bovine enteric coccidiosis, with and without neurological signs, and from control calves. Intravenous inoculation of mice with 10 mL/kg of serum from calves showing nervous signs caused effects significantly different from those caused by the inoculation of serum from calves not showing nervous signs and from control calves. The effect was particularly evident in female mice. At this dosage severe neurological signs such as loss of righting reflex, seizures and death occurred only with serum from calves with "nervous coccidiosis". The results suggest that serum from the calves with neurological signs contains a neurotoxin. This toxin appears to be highly labile. It was not present in the cerebrospinal fluid at levels comparable to those in the serum. The significance of this labile neurotoxin with respect to the pathogenesis of the neurological signs associated with bovine enteric coccidiosis is unknown.