Proximity of magnesium exposure to delivery and neonatal outcomes.

BACKGROUND: In infants delivered preterm, magnesium sulfate reduces cerebral palsy in survivors. The benefit of magnesium given remote from delivery is unclear. OBJECTIVE: Our objective was to evaluate the association of time from last exposure to magnesium with cerebral palsy. STUDY DESIGN: This was a secondary analysis of a multicenter trial evaluating magnesium for neuroprotection. For this study, we included women with live, nonanomalous, singleton gestations who received magnesium. Pregnancies with missing information at the 2 year follow-up were excluded. Women were divided into 2 groups based on exposure timing: last infusion of magnesium <12 hours and last infusion of magnesium ≥12 hours prior to delivery. The primary outcome was cerebral palsy of any severity at 2 years of life. Secondary outcomes were moderate/severe cerebral palsy and moderate/severe cerebral palsy or death. A χ(2) test, Student t test, and Mann-Whitney U test were used for bivariate associations. We fit a multivariable logistic regression model to adjust for confounders. RESULTS: A total of 906 infants were analyzed. Five hundred sixty-eight were last exposed to magnesium <12 hours prior to delivery and 338 were last exposed ≥12 hours. Cerebral palsy occurred in 28 offspring (3%), 2.3% of those last exposed <12 hours vs 4.4% last exposed ≥12 hours prior to delivery (P = .07). On adjusted analyses, last exposure to magnesium <12 hours prior to delivery was associated with a significant reduction in cerebral palsy compared with last exposure ≥12 hours (adjusted odds ratio, 0.41, 95% confidence interval, 0.18-0.91, P = .03). There was no difference in secondary outcomes. CONCLUSION: Exposure to magnesium proximal to delivery (<12 hours) is associated with a reduced odds of cerebral palsy compared with more remote exposure. This highlights the importance of the timing of magnesium for neuroprotection for women at risk of preterm delivery.

Obstetric Recommendations in American Congress of Obstetricians and Gynecologists Practice Bulletins versus UpToDate: a comparison.

OBJECTIVE: To compare the obstetric recommendations in American Congress of Obstetricians and Gynecologists (ACOG) practice bulletins (PB) with similar topics in UpToDate (UTD). STUDY DESIGN: We accessed all obstetric PB and cross-searched UTD (May 1999-May 2013). We analyzed only the PB which had corresponding UTD chapter with graded recommendations (level A-C). To assess comparability of recommendations for each obstetric topic, two maternal-fetal medicine (MFM) subspecialists categorized the statement as similar, dissimilar, or incomparable. Simple and weighted kappa statistics were calculated to assess agreement between the two raters. RESULTS: We identified 46 ACOG obstetric PB and 86 UTD chapters. There were 50% fewer recommendations in UTD than in PB (181 vs. 365). The recommendations being categorized as level A, B, or C was significantly different (p < 0.001) for the two guidelines. While the overall concordance rate between the two MFM subspecialists was 83% regarding the recommendations for the same topic as similar, dissimilar, or incomparable, the agreement was moderate (kappa, 0.56; 95% confidence intervals, 0.48-0.65). CONCLUSION: Though obstetricians have two sources for graded recommendations, incongruity among them may be a source of consternation. Congruent recommendations from ACOG and UTD could enhance compliance and potentially optimize outcomes.

Hypertensive crisis during pregnancy and postpartum period.

Hypertension affects 10% of pregnancies, many with underlying chronic hypertension, and approximately 1-2% will undergo a hypertensive crisis at some point during their lives. Hypertensive crisis includes hypertensive urgency and emergency; the American College of Obstetricians and Gynecologists describes a hypertensive emergency in pregnancy as persistent (lasting 15 min or more), acute-onset, severe hypertension, defined as systolic BP greater than 160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia. Pregnancy may be complicated by hypertensive crisis, with lower blood pressure threshold for end-organ damage than non-pregnant patients. Maternal assessment should include a thorough history. Fetal assessment should include heart rate tracing, ultrasound for growth and amniotic assessment, and Doppler evaluation if growth restriction is suspected. Initial management of hypertensive emergency (systolic BP >160 mmHg or diastolic BP >110 mmHg in the setting of pre-eclampsia or eclampsia) generally includes the rapid reduction of blood pressure through the use of intravenous antihypertensive medications, with goal systolic blood pressure between 140 mmHg and 150 mmHg and diastolic pressure between 90 mmHg and 100 mmHg. First-line intravenous drugs include labetalol and hydralazine, but other agents may be used, including esmolol, nicardipine, nifedipine, and, as a last resort, sodium nitroprusside. Among patients with hypertensive urgency, slower blood pressure reduction can be provided with oral agents. The objective of this article is to review the current understanding, diagnosis, and management of hypertensive crisis during pregnancy and the postpartum period.