Hemostatic dysfunction with acute fatty liver of pregnancy.

OBJECTIVE: To estimate the frequency of disseminated intravascular coagulation (DIC); elucidate the genesis of hemostatic dysfunction; and characterize associated hemolysis in women with acute fatty liver of pregnancy. METHODS: Hemostatic function was measured in 51 women. Disseminated intravascular coagulation was assessed using the International Society of Thrombosis and Haemostasis DIC score. Hepatic and hemostatic function was quantified with measurement of fibrinogen, fibrin-fibrinogen split products, cholesterol, and coagulation testing. As a comparison of fibrinogen synthesis, these women were compared with 25 women with placental abruption. Hemolysis was assessed indirectly by quantification of reticulocytosis and nucleated red blood cells with determination of erythrocyte morphotypes. RESULTS: Eighty-percent of women were classified as having unequivocal DIC (mean score 5.9±1.8) at delivery, which persisted 4-5 days postpartum. Fibrinogen regeneration with placental abruption was rapid, whereas it remained depressed for 4-5 days with acute fatty liver of pregnancy; fibrin-fibrinogen split products were also cleared more rapidly after abruption than women with acute fatty liver (P<.001 for interaction for both using random effects modeling). Kaplan-Meier survival analysis of fibrinogen recovery to a set point of 280 mg/dL after delivery was also different between the two cohorts (median 1.7 compared with 4.2 days, P=.046). Continuing hepatic dysfunction with acute fatty liver of pregnancy was exemplified by diminished procoagulant production. Reticulocytosis, nucleated red blood cells, and elevated serum bilirubin levels reflected ongoing hemolysis. CONCLUSIONS: Hemostatic dysfunction with acute fatty liver of pregnancy persists 4-5 days postpartum and results from substantive ongoing DIC in concert with reduced procoagulant synthesis and clinically significant hemolysis. LEVEL OF EVIDENCE: : III.

Acute fatty liver of pregnancy: clinical outcomes and expected duration of recovery.

OBJECTIVE: Our aim was to provide a description of clinical and laboratory finding: pregnancy outcomes in women with acute fatty liver of pregnancy (AFLP). We also characterize the duration of recovery of multiorgan system dysfunction that begins after delivery. STUDY DESIGN: All women who were admitted to Parkland Hospital with AFLP were identified; their clinical and laboratory findings, pregnancy outcomes, and postpartum resolution of AFLP were reviewed. RESULTS: Between 1975 and 2012, there were 51 women who were identified to have AFLP. The most common complaints were persistent nausea and vomiting (57%), hypertension (57%), and abdominal pain (53%). More than 90% of these women had at least 1 of these findings or combinations thereof. A combination of hepatic and renal dysfunction was nearly universal, but with variable severity. Procoagulant synthesis was impaired in more than three-fourths of the women, which served to intensify obstetric hemorrhage for which 50% of the 51 women received blood and component transfusions. The stillbirth rate was 120 of 1000 pregnancies, and there were 2 maternal deaths. Composite recovery times of various markers of hepatic and renal function indicated normalization of most laboratory values within 7-10 days after delivery. CONCLUSION: The clinical features and laboratory findings of women with AFLP derive from the central pathologic process: liver failure. After delivery, clinical recovery typically is seen within 3-4 days; however, laboratory abnormalities can persist for much longer.

Postpartum contraceptive preferences of HIV-infected women in the era of highly active antiretroviral therapy (HAART) and scheduled cesarean deliveries.

BACKGROUND: We sought to determine if postpartum tubal ligation among HIV-infected women changed with the introduction of highly active antiretroviral therapy (HAART) and scheduled cesarean delivery. METHODS: Retrospective cohort study of HIV-infected women delivered before (Pre-HAART) and after (Post-HAART) the introduction of HAART and scheduled cesarean delivery. Rates of the primary outcome, postpartum tubal ligation (PPTL), were compared by univariable and multivariable analyses. RESULTS: We found that 34.5% (60/174) of women in the Post-HAART period chose PPTL, compared to 22.0% (18/82) in the Pre-HAART period [unadjusted OR=1.87 (95% CI 1.02-3.44), p=.04]. When stratified by mode of delivery, rates of PPTL were not significantly different between the two periods. Similarly, in multivariable analysis controlling for confounders, rates of PPTL were not different between the two periods [adjusted OR=1.40 (95% CI=0.66-2.99), p=.39]. CONCLUSIONS: HIV-infected women on HAART are overall more likely to have PPTL, but cesarean delivery appears to be the facilitator of this choice.

Estrogen and progesterone metabolism in the cervix during pregnancy and parturition.

CONTEXT: Experimental and clinical studies in a variety of nonprimate species demonstrate that progesterone withdrawal leads to changes in gene expression that initiate parturition at term. Mice deficient in 5alpha-reductase type I fail to undergo cervical ripening at term despite the timely onset of luteolysis and progesterone withdrawal in blood. OBJECTIVE: Our objective was to test the hypothesis that estrogen and progesterone metabolism is regulated in cervical tissues during pregnancy, even in species in which parturition is not characterized by progesterone withdrawal in blood. DESIGN: Estradiol and progesterone metabolism was quantified in intact cervical tissues from nonpregnant and pregnant women at term before or after labor. SETTING: The study was conducted at a university hospital. PATIENTS: Tissues were obtained from five nonpregnant and 21 pregnant women (nine before labor and 12 in labor). MAIN OUTCOME MEASURES: Enzyme activity measurements, Northern blot analysis, quantitative real-time RT-PCR, and immunohistochemistry were used to quantify steroid hormone metabolizing enzymes in cervical and myometrial tissues. RESULTS: During pregnancy, 17beta-hydroxysteroid dehydrogenase type 2 was induced in glandular epithelial cells to catalyze the conversion of estradiol to estrone and stroma-derived 20alpha-hydroxyprogesterone to progesterone. During parturition, 17beta-hydroxysteroid dehydrogenase type 2 was down-regulated in endocervical cells, thereby creating a microenvironment favorable for cervical ripening. CONCLUSIONS: Together, the data indicate that cervical ripening during parturition involves localized regulation of estrogen and progesterone metabolism through a complex relationship between cervical epithelium and stroma, and that steroid hormone metabolism in cervical tissues from pregnant women is unique from that in mice.

Magnetic resonance signal characteristics of the cervix as pregnancy advances.

The objective of this study is to describe magnetic resonance (MR) signal intensity (SI) changes in the cervix during pregnancy. This is an observational cohort study of women with a history of preterm delivery. MR imaging sequences were performed every 3 to 4 weeks. Using 8 regions of interest, the SIs are quantified and analyzed with respect to gestational age. Twenty-seven MR studies were performed on a cohort of 8 women. The SIs of the external os are significantly greater than those of the internal os ( P = .035). Similarly, the SIs of the outer stroma are greater than those of the inner stroma (P = .002). As gestational age advances, the inner to outer stromal SI ratio increases, primarily because of a decreasing SI in the outer stromal layer (P = .03). The MR SIs of the cervical stromal zones display variability during pregnancy and decrease with advancing gestation.

Effect of coitus on recurrent preterm birth.

OBJECTIVE: To estimate the impact of sexual behavior on the risk of recurrent spontaneous preterm birth at less than 37 weeks of gestation. METHODS: This is a secondary analysis of a multicenter, blinded observational study of endovaginal sonographic examinations performed at 16-18 weeks of gestation on 187 women with singleton gestations who were at high risk for recurrent spontaneous preterm birth (prior spontaneous preterm birth at < 32 weeks of gestation). At the time of enrollment, each woman was interviewed by a research nurse with regard to her sexual history. The patient was asked about the number of sexual partners in her lifetime, the number of sexual partners since the start of her pregnancy, and, on average, the frequency of intercourse per week in the preceding month. RESULTS: A total of 165 pregnancies were available for this analysis. The population incidence of spontaneous preterm birth at less than 37 weeks of gestation in the study pregnancy was 36%. An increasing number of sexual partners in a woman's lifetime was associated with an increased risk of spontaneous preterm delivery (one partner 19%, 2-3 partners 29%, >or= 4 partners 44%, P = .007), whereas the number of sexual partners since the start of pregnancy was not (P = .42). Women who reported infrequent sexual intercourse during early pregnancy had an incidence of recurrent spontaneous preterm birth of 28% compared with 38% in those women who reported some intercourse (P = .35). CONCLUSION: Self-reported coitus during early pregnancy was not associated with an increased risk of recurrent preterm delivery. There was an association between increasing number of sexual partners in a woman's lifetime and recurrent preterm delivery. LEVEL OF EVIDENCE: II-2.

Hospitalization for women with arrested preterm labor: a randomized trial.

OBJECTIVE: To determine whether hospitalization of women with arrested preterm labor has an effect on delivery at 36 weeks or greater when compared with women discharged home. METHODS: All women with a singleton gestation and a diagnosis of arrested preterm labor with intact membranes between 24 and 33 weeks, 4 days of gestation were randomly assigned to home or hospital management. Upon completion of a dexamethasone course, women assigned to outpatient management were promptly discharged, and women in the inpatient group were advised to continue hospitalization until 34 weeks. Decreased activity was encouraged in both groups. Bed rest was not strictly enforced. The primary outcome was delivery at 36 weeks or greater. RESULTS: A total of 101 women of a planned 188 were enrolled at the time of an interim analysis. There was no difference in the primary study outcome between the 2 groups and the trial was terminated. Among the hospitalized women, 71% reached 36 weeks or greater, compared with 72% of those discharged home (P = .89). The mean cervical dilatation in hospitalized women was 2.7 +/- 0.5 cm, compared with 2.6 +/- 0.5 cm in women discharged home (P = .16). The overall length of hospital stay for the women allocated to hospitalization was 16 +/- 13 days. CONCLUSION: Compared with hospitalization, outpatient management of women with arrested preterm labor and intact membranes had no effect on the rate of preterm birth. LEVEL OF EVIDENCE: I.

A prospective observational study of domestic violence during pregnancy.

OBJECTIVE: To assess whether women reporting domestic violence are at increased risk for adverse pregnancy outcomes. METHODS: A screening questionnaire, previously validated for the identification of female victims of domestic violence, was offered to women presenting to our Labor and Delivery Unit. The survey prompted women to indicate whether her partner or family member physically hurt her, insulted or talked down to her, threatened her with harm, or screamed or cursed at her. The primary study outcome was to detect a 3-fold increase in low birth weight infants (< or = 2,500 g) in women reporting physical abuse, compared with those not reporting domestic violence. RESULTS: A total of 16,041 women were approached to be interviewed. Of these, 949 (6%) women responded affirmatively to one or more of the survey questions, and another 94 (0.6%) declined to be interviewed. The incidence of low birth weight infants was significantly increased in women who reported verbal abuse, compared with the no-abuse group (7.6% versus 5.1%, respectively, P = .002). Physical abuse was associated with an increased risk of neonatal death (1.5% versus 0.2%, P = .004). Interestingly, women who declined to be interviewed had significantly increased rates of low birth weight infants (12.8% versus 5.1%, P < .001), preterm birth at 32 weeks of gestation or less (5.3% versus 1.2%, P = .002), placental abruptions (2.1% versus 0.2%, P < .001), and neonatal intensive care admissions (7.4% versus 2.2%, P = .008) when compared with women in the no-abuse group, respectively. CONCLUSION: Women who declined to be surveyed regarding domestic violence were at increased risk for adverse pregnancy outcome. LEVEL OF EVIDENCE: II-2.

Number and gestational age of prior preterm births does not modify the predictive value of a short cervix.

OBJECTIVE: This study was undertaken to determine whether the number and gestational age of prior preterm deliveries modifies the significance of endovaginal sonographic cervical length less than 25 mm for the prediction of recurrent preterm birth less than 35 weeks' gestation. STUDY DESIGN: Secondary analysis of a multicenter, blinded, observational study. Endovaginal ultrasonographic examinations were scheduled at 2-week intervals between 16 and 23 weeks' gestation in singleton pregnancies of 181 gravid women with at least 1 prior spontaneous preterm birth between 16 and 32 weeks' gestation. RESULTS: The earliest prior preterm birth occurred before 23 weeks in 61 women and at 23.0 to 31 weeks in 115; 5 had missing gestational age data. Cervical length was not different between these 2 groups both at the initial scan (median 38 vs 37 mm, P=.54) and considering the shortest ever observed cervical length over the entire study period (median 30 vs 30 mm, P=.97). Cervical length less than 25 mm was associated with spontaneous preterm birth less than 35 weeks for both groups (positive predictive value 80% vs 71%, P>.99). There were 134 women with 1 prior preterm delivery (74%) and 47 with 2 or more. Cervical lengths were not different between these 2 groups at the initial scan (median 36.5 vs 37 mm, P=.52) or over the entire study period (median 30 vs 32 mm, P=.31). The positive predictive value of cervical length less than 25 mm for subsequent spontaneous premature birth was not significantly higher in gravid women with multiple prior preterm births (100% vs 73%, P>.99). CONCLUSION: Neither the number nor the gestational age of prior preterm births modify the predictive value of a cervical length less than 25 mm at 16 to 19 weeks for recurrent spontaneous preterm birth.

A hospital-sponsored quality improvement study of pain management after cesarean delivery.

OBJECTIVE: We undertook this study to systematically assess prevailing pain management regimes used at our hospital in women after cesarean delivery. STUDY DESIGN: Between August 1999 and July 2000, all women delivered by cesarean section at Parkland Hospital were assigned to 1 of 4 different pain management strategies: (1). intramuscular (IM) meperidine, (2). patient-controlled analgesia (PCA) meperidine, (3). IM morphine sulfate, and (4). PCA morphine sulfate. A combination of methods were used to compare these different pain management strategies. A survey questionnaire, using Likert scale responses, was administered to evaluate maternal satisfaction with pain control. Visual Analog Scale (VAS) scores and information regarding breastfeeding and rooming-in were also collected. RESULTS: A total of 1256 women were allocated to the 4 analgesia study groups. The median meperidine dosages for the IM and PCA groups were 350 mg and 600 mg, respectively (P

Second-trimester cervical sonography: features other than cervical length to predict spontaneous preterm birth.

OBJECTIVE: To estimate whether cervical and lower uterine segment characteristics other than cervical length and funneling predict recurrent preterm birth. METHODS: We conducted a secondary analysis of a multicenter, blinded observational study of 181 women with singletons and prior spontaneous preterm births. Endovaginal ultrasonic examinations were performed at 2-week intervals between 16 0/7 weeks and 23 6/7 weeks of gestation. Cervical canal contour (straight/curved), cervical position (horizontal/vertical), posterior cervical width, lower uterine segment thickness, vascularity, endocervical canal dilation, with or without associated membrane prolapse and chorioamnion visible at the internal os, were systematically assessed. RESULTS: At the initial sonogram (16 0/7-18 6/7 weeks), membranes visible overlying the internal os (relative risk 1.9, confidence interval [CI] 1.2, 3.1) and canal dilation of 2-4 mm (relative risk 2.6, CI 1.4, 4.7) were significant predictors of spontaneous preterm birth of less than 35 weeks in univariate analyses. Only canal dilation remained statistically significant after controlling for cervical length (odds ratio 5.5, CI 1.1, 28.6). CONCLUSION: Endocervical canal dilation of 2-4 mm during second-trimester endovaginal sonography was associated with an increased risk of recurrent preterm delivery independent of cervical length. LEVEL OF EVIDENCE: II-2

A randomized, placebo-controlled trial of corticosteroids for hyperemesis due to pregnancy.

OBJECTIVE: Hyperemesis gravidarum, a severe form of nausea and vomiting due to pregnancy for which there is no proven pharmacological treatment, is the third leading cause for hospitalization during pregnancy. Corticosteroids are commonly used for the treatment of nausea and vomiting due to cancer chemotherapy-induced emesis and might prove useful in hyperemesis gravidarum. METHODS: A randomized, double-blind, placebo-controlled trial was conducted in 126 women who previously had not responded to outpatient therapy for hyperemesis gravidarum during the first half of pregnancy. Intravenous methylprednisolone (125 mg) was followed by an oral prednisone taper (40 mg for 1 day, 20 mg for 3 days, 10 mg for 3 days, 5 mg for 7 days) versus an identical-appearing placebo regimen. All women also received promethazine 25 mg and metoclopramide 10 mg intravenously every 6 hours for 24 hours, followed by the same regimen administered orally as needed until discharge. The primary study outcome was the number of women requiring rehospitalization for hyperemesis gravidarum. RESULTS: A total of 110 women delivered at our hospital and had pregnancy outcomes available for analysis; 56 were randomized to corticosteroids and 54 were administered placebo. Nineteen women in each study group required rehospitalization (34% versus 35%, P =.89, for corticosteroids versus placebo, respectively). CONCLUSION: The addition of parenteral and oral corticosteroids to the treatment of women with hyperemesis gravidarum did not reduce the need for rehospitalization later in pregnancy.

Critical care infectious disease.

Septic shock, toxic shock syndrome, acute respiratory distress syndrome, and catheter-related infections are conditions in which intensive care management of the patient may be necessary. Toxic shock syndrome is a toxin-mediated illness that is not limited to young menstruating women and should be considered in women and men who present with fever, hypotension, rash, and multiorgan dysfunction. Sepsis is the leading cause of death in critically ill patients in the United States and is the most common predisposing factor for acute lung injury or acute respiratory distress syndrome. Central venous catheters are often a necessity for optimal patient care in these critically ill patients.

Acute renal failure in association with severe hyperemesis gravidarum.

BACKGROUND: Severe hyperemesis gravidarum is a rare but potentially devastating complication of pregnancy. Among its many potential complications are dehydration, electrolyte imbalance, malnutrition, Wernicke encephalopathy, and compromised renal function. CASE: We report the case of a 21-year-old woman at 15 weeks' gestation presenting to the emergency department with severe hyperemesis gravidarum associated with acute renal failure. Her initial serum creatinine and blood urea nitrogen were 10.7 mg/dL and 171 mg/dL, respectively. The patient underwent daily hemodialysis for 5 days with subsequent return of renal function to normal. CONCLUSION: Women with severe hyperemesis gravidarum may be at risk for acute renal failure caused by severe intravascular volume depletion.