Takotsubo cardiomyopathy in pregnancy.

BACKGROUND: Takotsubo cardiomyopathy is a cardiac condition associated with the acute onset of chest pain, abnormalities in cardiac enzymes and electrocardiogram, and a distinct pattern of left ventricular dysfunction on echocardiography. This case evaluates an obstetric patient diagnosed with Takotsubo cardiomyopathy during her 23rd week of pregnancy. CASE: A woman (G3P2002) at 23 weeks in an intrauterine pregnancy was admitted with chest pain. ST-segment elevation was noted on electrocardiogram with elevated cardiac enzymes. Subsequent tracings showed resolution of ST elevation with conservative management. Echocardiography was consistent with Takotsubo cardiomyopathy. She delivered through spontaneous vaginal delivery at term after a complete resolution of her cardiomyopathy. CONCLUSION: Although uncommon, physicians who manage cardiac complications should be familiar with the diagnosis and management of Takotsubo cardiomyopathy.

Comparative analysis of 5-mm trocars: dilating tip versus non-shielded bladed.

STUDY OBJECTIVE: To examine whether there are statistically significant differences in multiple variables evaluated at different times in the course of surgery and postoperative period when using 5-mm dilating-tip trocars (DTTs) and 5-mm non-shielded-bladed trocars (NSBTs) at randomly selected right or left lateral entry sites on the same patient. DESIGN: Randomized, single-blinded, controlled trial (Canadian Task Force classification I). SETTING: Center for Women's Care and Reproductive Surgery (CWCRS), Atlanta, Georgia. PATIENTS: Ninety-four women, median age 45, undergoing laparoscopic surgery at CWCRS for benign gynecologic conditions were randomly assigned to placement of a DTT to the right or left laparoscopic entry site. The NSBT was placed on the contralateral side of the same patient. INTERVENTION: Each patient had 2 lateral trocars placed, 1 of which was a DTT and the other of which was an NSBT. MEASUREMENTS AND MAIN RESULTS: Comparisons between the sites accessed with the DTT and the NSBT were made by the surgeons at the time of surgery and at the 2-week follow-up, by nurses at 1 and 4 hours after surgery, and by patients at the 2-week follow-up. The nurses and the patients were blinded as to the side of each trocar placement. A visual analog score of 1 to 5 was used for the assessment of 17 studied variables. Questionnaires were standardized and explained to examiners. Wilcoxon's signed-rank test was used for the analysis of time-specific data collected by the same examiner (evaluation by the nurses at 1 and 4 hours after surgery). Friedman's test was applied for analysis of the remaining data. Statistically significant differences were established in ease of placement (chi(2) = 4.691, p = .030) and displacement rate (chi(2) = 7.264, p = .007), in which the NSBT obtained the better results. No statistically significant differences were found in bleeding at the time of placement or removal of the trocars, hematoma/bruising formation, pain, or cosmetic results as assessed by surgeons, nurses, and patients at corresponding stages of intra- and postoperative care. CONCLUSIONS: When used for lateral laparoscopic access in gynecologic surgery, NSBTs were easier to place and had a smaller rate of displacement than DTTs. Despite substantial differences in the design of the trocars, no statistically significant differences in bleeding risk, hematoma/bruising formation, pain, or cosmetic results were established. Individual goals of the surgery and conditions specific to each patient appear to be the best criteria for selection of 1 or the other trocar.

Role of C825T polymorphism of GNbeta3 gene in preeclampsia.

OBJECTIVE: The main objective of the study was to understand the role of C825T polymorphism that generates a splice variant in the beta3 subunit of heterotrimeric G-protein in preeclampsia. RESULTS: We analyzed genomic DNA of 151 women with preeclampsia (72 Caucasians and 79 African-Americans) and 198 women with normal delivery (102 Caucasians and 96 African-Americans) for C825T polymorphism of GNbeta3 gene. The T-allele frequency in Caucasian women with preeclampsia was 0.42 as compared to 0.25 in normal pregnant women (p = 0.0004) and in African-American women with preeclampsia was 0.82 as compared to 0.68 in normal pregnant women (p = 0.0028). CONCLUSIONS: Results of these experiments show that the allele frequency of C825T polymorphism is significantly different in women with preeclampsia compared with women with normal delivery in Caucasian as well as African-American population.

Gestational diabetes is associated with depressed adiponectin levels.

OBJECTIVE: Adiponectin is a 29-kd adipocyte-secreted protein that has been linked to insulin resistance in obesity and diabetes. The aim of the present study was to evaluate adiponectin levels in the insulin-resistant state of diabetes in gestation. METHODS: Term, gravid subjects with diabetes (n = 31; age, 30.0 +/- 0.9 years; weight, 98.8 +/- 4.6 kg) and healthy, term, gravid subjects (n = 27; age, 26.1 +/- 1.1 years; weight, 91.2 +/- 3.78 kg) were examined. The diabetes group consisted of 11 class A1, 11 class A2, and nine class B subjects. Plasma insulin, glucose, adiponectin, and leptin were measured on samples obtained immediately before Cesarean or vaginal delivery. Data were presented as means +/- SE, and significance is set at P < or = .05. RESULTS: We observed decreased adiponectin levels in class A2 (4.93 +/- 0.58 microg/mL; P = .013) and class B diabetics (3.33 +/- 0.56 microg/mL; P = .001) as compared to controls (8.17 +/- 0.82 microg/mL), while a nonsignificant decrease was also observed in class A1 (6.58 +/- 1.13 microg/mL; P = .213). When grouping all gravid subjects, we observed that non-Caucasian subjects (n = 42) (5.51 +/- 0.51 microg/mL; P = .003) had lower adiponectin levels than Caucasian subjects (n = 16) (8.88 +/- 1.11 microg/mL). Within the non-Caucasian group, we found significantly lower adiponectin levels in diabetic gravid subjects (class A2: 4.24 +/- 0.75 microg/mL; P = .044; and class B: 3.33 +/- 0.56 microg/mL; P = .005) compared with nondiabetic gravid subjects (7.05 +/- 0.80 microg/mL). CONCLUSION: Class A2 and B gestational diabetes are associated with suppressed levels of adiponectin, similar to that found in other insulin-resistant states (type II diabetes and obesity).

Septic pelvic thrombophlebitis and preeclampsia are related disorders.

OBJECTIVE: To elicit factors associated with the postpartum development of septic pelvic thrombophlebitis in a single large referral tertiary patient population. METHODS: A nine-year single institution retrospective case review of all patients with enigmatic fever and septic pelvic thrombophlebitis was analyzed. RESULTS: A total of 55 patients with septic pelvic thrombophlebitis were provided care during the study interval. The average gestational age at delivery was 36.8 +/- 4.3 weeks. The most prevalent concurrent medical complication of pregnancy was preeclampsia (45%) while chorioamnionitis affected only 13%. The average length of ruptured membranes was 22.8 +/- 56.8 hours (median 10.5, 95% confidence interval [CI] 7.0-38.7 hours), with 22% of patients undergoing amnion rupture at the time of cesarean delivery. Prolonged (>24 hours) amnion rupture occurred in only 9% of patients. Most affected patients were delivered abdominally (91%) but a minority delivered vaginally (9%). Antibiotic therapy for presumed infection was initiated at 27.4 +/- 24.6 hours postpartum. Subsequently intravenous heparin therapy was initiated 128.9 +/- 54.2 hours thereafter enigmatic fever defervesed 37.2 +/- 36.8 hours later (median 34.0, 95% CI 27.2-47.3 hours). Patients received 6.3 +/- 1.8 days of heparin therapy. CONCLUSION: In this series, septic pelvic thrombophlebitis was frequently preceded by cesarean delivery and commonly associated with preeclampsia. Unexpectedly, a small number of patients suffered prolonged rupture of membranes or chorioamnionitis. We speculate that the cesarean delivery of a population of at-risk patients with preeclampsia may predispose them to develop septic pelvic thrombophlebitis.

The importance of parity to major maternal morbidity in the eclamptic mother with HELLP syndrome.

OBJECTIVE: To determine if the rate of major morbidity from severe preeclampsia with/without hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome differs by parity. METHODS: Retrospective investigation of 970 gravidas with severe preeclampsia with and without HELLP syndrome analyzed according to parity. RESULTS: Altogether 609 (63%) patients were nulliparous and 361 (37%) parous. Between groups there was no significant difference in the incidence of overall major morbidity (21% vs. 19%, p=0.467), or specific morbidities including hematologic/coagulopathic (13.6% vs. 11.9%, p=0.442), cardiopulmonary (8.9% vs. 7.2%, p=0.362), CNS/visual (1.8% vs. 2.8%, p=0.319), or hepatorenal (0.8% vs. 2.2%, p=0.068). Although eclampsia was significantly more common in nulliparous (10.2%) than in parous patients (5.5%, p=0.012), the later significantly more often demonstrated major maternal morbidity associated with eclampsia (50%) than did nulliparous patients (25%, p=0.043). CONCLUSIONS: Unless parous patients with severe preeclampsia with or without HELLP syndrome develop eclampsia, their disease acuity does not differ significantly from their nulliparous counterparts.

Evaluation of a rat model of preeclampsia for HELLP syndrome characteristics.

OBJECTIVE: To determine whether a rat model of preeclampsia includes features consistent with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. METHODS: Preeclampsia was induced experimentally in timed-pregnant Sprague-Dawley rats using the reduced uterine perfusion pressure (RUPP) model. On day 14 of gestation, silver clips were placed around the aorta below the renal arteries and on the left and right uterine arcade at the ovarian artery. All animals were chronically instrumented to determine conscious blood pressure and to obtain blood samples for analysis of complete blood count, platelet count, liver function tests, uric acid, creatinine, and albumin. Blood samples were collected and animals sacrificed on day 19 of gestation, at which time placental and pup weight were obtained. A control group was analyzed similarly. Statistical analysis was performed with the Student t test. RESULTS: The RUPP model animals (n = 8), when compared with the normotensive controls (n = 9), did not show a statistically significant difference in hemoglobin, platelets, liver function tests, uric acid, creatinine, or albumin, although the mean arterial pressure was higher (mean +/- SD 131.9 +/- 17.1 mmHg versus 104.0 +/- 14.0 mmHg, respectively; P = .003) and pup number was lower (RUPP 6.6 +/- 2.4 versus control 13.8 +/- 2.3, P < .001). CONCLUSION: Although decreased uteroplacental perfusion induces changes similar to symptoms of preeclampsia, the RUPP rat model does not appear to express features of HELLP syndrome.

Postpartum seizure prophylaxis: using maternal clinical parameters to guide therapy.

OBJECTIVE: To use individual patient clinical parameters to signal cessation of postpartum magnesium sulfate seizure prophylaxis for the spectrum of pregnancy-related hypertensive disorders. METHODS: This was a prospective study using clinical symptoms (absence of headache, visual changes, epigastric pain) and signs (sustained blood pressure less than 150/100 without need for acute antihypertensive therapy, spontaneous diuresis more than 100 mL per hour for no less than 2 hours) to signal cessation of intravenous magnesium sulfate postpartum in gravidas diagnosed with preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome. Laboratory assessments (including proteinuria) were not used as criteria for drug discontinuation. RESULTS: Five hundred three patients were enrolled and classified according to American College of Obstetricians and Gynecologists criteria (mild preeclampsia, severe preeclampsia, chronic hypertension with superimposed preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome). Maternal age, gestational age, and hours of magnesium therapy before delivery were not statistically different among groups. There was no significant difference in the duration of postpartum magnesium sulfate therapy among groups with the median duration of therapy 4 hours (range 2-77 hours). No eclamptic seizures occurred after magnesium discontinuation. Thirty-eight patients (7.6%) required reinstitution of magnesium therapy for 24 hours because of exacerbation of blood pressure (sustained blood pressure more than 160/110) associated with headache or visual changes. CONCLUSION: Clinical criteria, when compared with arbitrary protocols, can be used successfully to shorten the duration of postpartum magnesium sulfate administration for seizure prophylaxis in patients with pregnancy-related hypertensive disorders.

Preeclampsia: pathophysiology and practice considerations for the consulting nephrologist.

Abnormal placental implantation presumed to be secondary to maternal genetic susceptibility or immune maladaptation is considered to be fundamental to the pathogenesis of preeclampsia. The reduced placental perfusion resulting in placental ischemia is hypothesized to cause the known endothelial dysfunction, which leads to the clinical manifestations of this disease. Oxidative stress is a postulated linking factor, an aberration that possibly has its genesis via cytokines released from the abnormally implanted and perfused placenta. Clearly the maternal pathophysiologic changes that subsequently produce what is recognized as preeclampsia are present long before the disease makes its clinical appearance.