Postpartum medical management of hypertension and risk of readmission for hypertensive complications.

OBJECTIVE: To compare the risk of readmission in those receiving no treatment, labetalol, nifedipine or both at hospital discharge following delivery complicated by presence of hypertension. STUDY DESIGN: Retrospective study at a single tertiary care center over a 4-year period (2017-2020). Those with peripartum hypertension (pHTN), defined as any SBP greater than 140 mmHg or DBP greater than 90 mmHg on two occasions 4 h apart during their admission for delivery were included. The primary outcome was postpartum readmission because of hypertensive complications. Analysis was stratified by medication prescribed at discharge (no treatment prescribed, labetalol, nifedipine, or both). The risks of readmission for the management of pHTN were estimated using logistic regression and adjusted for confounding variables. RESULTS: Nineteen thousand, four hundred and twenty-five women gave birth during the study period and 4660 (24.0%) met the described definition of pHTN. Of those, 1232 (26.4%) were discharged on antihypertensive medication (s). There were 217 (4.7%) readmissions for hypertensive complications following discharge. Compared with patients who did not receive antihypertensive medication at discharge, any nifedipine prescription was found to significantly decrease the risk of readmission: monotherapy [aOR 0.27 (0.15-0.48)], nifedipine with labetalol [aOR 0.35 (0.16-0.77)]. Labetalol monotherapy was associated with increased risk of readmission [aOR 1.66 (1.06-2.61)]. CONCLUSION: The risk of postpartum readmission for hypertensive complication was reduced by 65% when patients were discharged on nifedipine monotherapy and 56% with combined nifedipine and labetalol treatment when compared with no treatment. Patients discharged on labetalol monotherapy were nearly six times as likely to be readmitted for hypertensive complications when compared with patients on nifedipine monotherapy.

Postpartum management of hypertension and effect on readmission rates.

BACKGROUND: Postpartum hypertension is a source of significant morbidity and mortality in the United States. While advances have been made in the peripartum management of hypertension, there is little data to guide ongoing management postpartum. OBJECTIVE: To determine whether an association exists between (1) hospital readmission and (2) hypertension in the 12 hours before discharge and the prescription of antihypertensive medications at the time of discharge. The secondary objective included evaluating the median time to readmission for hypertensive complications. STUDY DESIGN: This was a retrospective cohort study of all women with peripartum hypertension at a single tertiary care center over a 3-year period (2017-2019). Peripartum hypertension was defined as any systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg on 2 occasions, 4 hours apart, in the electronic medical record during the patients' admission for delivery. As potential risk factors for readmission, we also identified if the patients were discharged with a prescription for antihypertensive medication and assessed the blood pressure measurements during the 12 hours before discharge. The primary outcome of interest was postpartum readmission because of hypertensive complications. Readmission was defined as emergency room evaluation or hospital readmission because of hypertensive complications. Analysis was stratified into 4 comparison groups on the basis of the blood pressure and antihypertensive medications on discharge. The rate of postpartum readmissions was calculated. The risks of readmission were estimated using logistic regression and were adjusted for appropriate confounding variables. RESULTS: Of 14,577 women who gave birth during the study period, 3480 (24%) met the definition of peripartum hypertension. Of those, 176 (5.1%) were readmitted within a median of 3 days from discharge. Sixty percent of patients readmitted had an International Classification of Diseases, Tenth Revision code for peripartum hypertension assigned by providers during their admission. Women with systolic blood pressure ≥140 mm Hg or diastolic blood pressure ≥90 mm Hg before discharge were at a higher risk of readmission irrespective of being discharged with antihypertensive medication. Compared with those who were discharged normotensive, women who had hypertension in the 12 hours before discharge and were discharged with an antihypertensive prescription were at a significantly increased risk of readmission, adjusted odds ratio, 2.90; 95% confidence interval, 1.11-7.57. CONCLUSION: Untreated hypertension within 12 hours before discharge was associated with a 32% higher risk of readmission in those who were not prescribed antihypertensive medications at discharge and a 3-fold increased risk of readmission in patients discharged on antihypertensive medication. These findings highlight the importance of treatment to normalize the blood pressure for at least 12 hours before discharge.

Peripartum Morbidity after Cesarean Delivery for Arrest of Dilation at 4 to 5 cm Compared with 6 to 10 cm.

OBJECTIVE: Given that recent consensus guidelines established to decrease cesarean delivery (CD) rates use 6 cm to define the onset of the active phase of labor, our objective was to evaluate maternal and neonatal outcomes after CD for the indication of arrest of dilation at 4 to 5 cm compared with ≥ 6 cm. STUDY DESIGN: We performed a secondary analysis using data from the Maternal Fetal-Medicine Units Network Cesarean Registry. We included nulliparous women with term, singleton, vertex gestations who underwent primary CD for arrest of dilation. We compared those who reached a maximum cervical dilation of 4 to 5 cm with those of ≥6 cm. Our primary outcome was composite maternal morbidity that included chorioamnionitis, endometritis, transfusion, wound complication, operative injury, intensive care unit admission, or death. RESULTS: Of the 73,257 women in the dataset, 5,681 met the inclusion criteria. After adjusting for confounders, there was no difference in composite maternal (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 0.94-1.52) or neonatal morbidity (aOR: 0.94; 95% CI: 0.79-1.10) between the groups. CONCLUSION: In this historical cohort, maternal and neonatal outcomes after CD for arrest of dilation ≥ 6 cm were comparable to those performed at 4 to 5 cm and support recent labor management guidelines.

Uterine artery Doppler and prediction of preeclampsia.

Identifying patients at risk for preeclampsia would allow an increase in perinatal surveillance and possibly decrease the inherent maternal and fetal morbidity and mortality associated with severe preeclampsia and eclampsia. First and second trimester uterine artery Doppler velocimetry is a sensitive screening tool for the detection of preeclampsia and intrauterine growth retardation (IUGR) requiring delivery before 34 weeks. The performance of uterine artery Doppler velocimetry as a screening test depends on the prevalence of the adverse outcome in the studied population and whether the adverse outcomes are assessed individually or collectively as a group. Future research in this area should focus on identification of additional markers that may be incorporated into a prediction model for early identification of patients at risk for adverse outcomes.

Spontaneous methicillin-resistant Staphylococcus aureus epidural abscess in pregnancy.

BACKGROUND: Epidural abscess is a rare complication of regional anesthesia, and spontaneous formation is even more uncommon. Diabetes mellitus, concomitant infection, intravenous drug use, and immune suppression are risk factors for spontaneous epidural abscess. CASE: A 29-year-old white woman presented at 28 weeks of estimated gestational age reporting an intermittent headache. She had Horner syndrome and was hospitalized. A cervicothoracic epidural abscess was diagnosed. Surgical decompression and parenteral antibiotics resulted in complete resolution of neurologic symptoms. Cultures were positive for methicillin-resistant Staphylococcus aureous. CONCLUSION: Spontaneous epidural abscess is a rare condition and diagnosis is often delayed. The finding of Horner syndrome led to imaging of the cervical spine and diagnosis of epidural abscess. Early intervention resulted in resolution of neurologic symptoms and a successful pregnancy outcome.

Spontaneous severe ovarian hyperstimulation syndrome in successive pregnancies with successful outcomes.

BACKGROUND: Ovarian hyperstimulation syndrome is a known complication of ovarian stimulation, particularly with injectable gonadotropins. Spontaneous ovarian hyperstimulation is rare and often involves a conformational change in the follicle-stimulating hormone receptor, increasing its binding with human chorionic gonadotropin or thyroid-stimulating hormone. Few data are available regarding the management or outcomes of spontaneous ovarian hyperstimulation syndrome. CASE: A 23-year-old white female without history of infertility treatment presented with ovarian hyperstimulation syndrome in two pregnancies. The patient was treated by paracentesis catheter placement and albumin replacement. She had regression of symptoms between 11 weeks and 12 weeks of gestation in both pregnancies and delivered healthy term infants. CONCLUSION: The case presented involves a patient with spontaneous severe ovarian hyperstimulation syndrome in two successive pregnancies. The patient was managed aggressively with paracentesis and albumin replacement resulting in two successful pregnancies.

Enhanced in vitro and in vivo cytotoxicity of umbilical cord blood cells against human breast cancer following activation with IL-15 and colony stimulating factors.

BACKGROUND: Cord blood mononuclear cells (MNC) are a rich source of precursor cytotoxic effector cells. Earlier we have shown that interleukin-2 (IL-2)-activated MNC from cord blood have significant cytotoxic activity against human leukemia and breast cancer cells in vitro and in vivo, compared to MNC from peripheral blood. MATERIALS AND METHODS: In order to further improve the antitumor cytotoxic ability of cord blood MNC, IL-2 was combined with IL-15 and colony stimulating factors GMCSF, G-CSF and M-CSF for the activation. The activated cells were examined for their cytotoxic effects in vitro against human breast cancer cell lines MDA-231, MDA453 and SKB43 and in vivo against MDA-231 grown in SCID mice. Phenotypes of these activated cells were determined using flow cytometry. The expression of immune response related genes in activated cells was measured using RT-PCR techniques. RESULTS: There was a significant increase in cytotoxicity of the effector cells activated with IL-2, IL-15 and some colony stimulating factors compared to cells activated with each of these cytokines alone or other combinations. Our results demonstrated the increase in cytotoxicity appears to be due to: 1) increase in CD56-positive cytotoxic cells; 2) cytokine/cytotoxic factors produced by the effector cells, such as Interferon-7 and Perforin; 3) stimulation by accessory cells, such as dendritic cells. In vivo administration of in vitro-activated cord blood cells into SCID mice bearing MDA-231 tumors reduced the number of metastases and increased survival compared to untreated tumor bearing controls. CONCLUSION: The combination of IL-2 with IL-15 and CSF is better for the activation of cord blood effector cells than to IL-2 alone.

Comparison of phenotypic and functional dendritic cells derived from human umbilical cord blood and peripheral blood mononuclear cells.

Dendritic cells (DC) are important accessory cells that are capable of initiating an immune response. Generation of functional DC has potential clinical use in treating diseases such as cancer. In this report, we have demonstrated the generation of functional DC from mononuclear cells isolated from human umbilical cord blood cells (UCBC) and peripheral blood cells (PBC) using a defined medium Prime Complete Growth Medium (PCGM) (GenePrime LLC, Gaithersburg, MD). DC generated using PCGM showed the typical phenotype of DC as determined by flow cytometry and electron microscopy. Further analysis of the DC using confocal microscopy showed localization of the antigen and major histocompatibility complex (MHC) molecules in the cytoplasm 3-5 days following tumor antigen loading into DC. Subsequently, the tumor antigen-MHC complex was localized on the surface of DC. DC generated from UCBC or PBC also increased (p < 0.001) the allogeneic mixed lymphocyte reaction, confirming their immune accessory functions compared to a control mixed lymphocyte reaction (MLR) without DC added. Interestingly, DC generated using PCGM medium also significantly enhanced the hematopoietic colony (CFU-C)-forming ability. Furthermore, addition of 5% DC derived from cord blood loaded with tumor antigen also significantly (p < 0.001) increased peripheral and cord blood-derived antigen-specific cytotoxic T lymphocyte (CTL)-mediated killing of human leukemic cells (K562) and breast cancer cells (MDA-231). Thus, these results show that functional DC generated from cord blood using a defined medium are a useful source of accessory cells for augmenting CTL-mediated cytotoxicity and have potential use in cellular therapy for human leukemia and breast cancer.