Chronic hypertension in pregnancy.

Hypertension is the most common medical disorder during pregnancy. Chronic hypertension is a serious medical complication in pregnancy with increased maternal and perinatal morbidity and mortality. Those who develop uncontrolled severe hypertension, those with target organ damage, and those who are poorly compliant with prenatal visits are at high risk for poor perinatal outcome. Maternal complications include abruptio placenta, stroke, and superimposed pre-eclampsia. Fetal complications include prematurity, low birth weight, and perinatal death. Careful antepartum, intrapartum and postpartum management of women with high-risk chronic hypertension in pregnancies may reduce morbidity and mortality.

Serum levels of adhesion molecules in women with pregnancy-induced hypertension.

In a matched pair study, we investigated the serum levels of intercellular adhesion molecule-1 (ICAM-1), vascular cell adhesion molecule-1 (VCAM-1), platelet endothelial cell adhesion moleculae-1 (PECAM-1) and P-selectin in 40 nulliparous patients with pregnancy-induced hypertension (PIH) and in 40 normotensive pregnant controls by using an enzyme-linked immunosorbent assay (ELISA). Multivariate logistic regression models were used to analyze the influence of elevated serum levels of adhesion molecules on the occurrence of PIH and on the association with the severe form of the disease. The median serum levels of ICAM-1, VCAM-1 and PECAM-1 were significantly elevated in women with PIH compared to controls (296 and 222 ng/ml, p = 0.003, 633 and 505 ng/ml, p = 0.02 and 7.7 and 6.6 ng/ml, p < 0.0001, respectively), whereas the differences of the median serum levels of P-selectin were not significantly between groups. In a multivariate logistic regression model, the serum levels of ICAM-1 and PECAM-1 revealed a significant influence on the occurrence of PIH versus healthy pregnant women (p = 0.04 and p = 0.006, respectively), whereas VCAM-1 and P-selectin serum levels were not associated with the occurrence of pregnancy-induced hypertension (p = 0.3 and p = 0.2, respectively). In a multivariate logistic regression model, the serum levels of PECAM-1 were associated with severe disease (p = 0.002). Our data indicate that the expression of ICAM-1 and PECAM-1 is upregulated in patients with pregnancy-induced hypertension. Elevated serum levels of PECAM-1 were associated with the development of severe disease.

Maternal and fetal inherited thrombophilias are not related to the development of severe preeclampsia.

OBJECTIVE: Thrombotic vascular disease may predispose patients to the development of preeclampsia. The purpose of this study was to determine whether maternal or fetal genotype frequencies of the inherited thrombophilic gene mutations (factor V Leiden, methylenetetrahydrofolate, and prothrombin) are altered in severe preeclampsia. STUDY DESIGN: We performed a prospective cross-sectional study to compare the maternal and fetal genotype frequencies of factor V Leiden, methylenetetrahydrofolate, and prothrombin. One hundred ten patients with severe preeclampsia were matched for gestational age to 97 normotensive pregnancies. Umbilical cord blood was obtained from 92 control patients and 75 patients with preeclampsia. Deoxyribonucleic acid was extracted from leukocytes and polymerase chain reaction was performed. Polymerase chain reaction products were digested with the appropriate restriction enzyme and fractionated by gel electrophoresis. Genotype frequencies were calculated. Statistical significance was determined by the chi(2) test. RESULTS: There were no significant differences between patients with severe preeclampsia and control patients regarding frequency of maternal factor V Leiden G/506/A mutation (4.4% vs 4.3%; P =.96), methylenetetrahydrofolate CC/667/TT mutation (9.6% vs 6.3%; P =.54), or prothrombin G/20210/A mutation (0% vs 1.1%; P =.92). In addition, no statistical difference could be found between fetal thrombophilias and the development of preeclampsia. Findings were similar in both white (n = 47) and African American (n = 63) preeclamptic subsets. Moreover, there was no association between any of the maternal or fetal genetic polymorphisms and the incidence of hemolysis, elevated liver enzymes, and low platelet count syndrome (n = 21); eclampsia (n = 12); or intrauterine growth restriction (n = 9). CONCLUSION: Inherited thrombophilias are not associated with severe preeclampsia.

Chronic hypertension in pregnancy.

Pregnant women with chronic hypertension are at risk for maternal and perinatal morbidity. Careful assessment and management of these patients during pregnancy are the keys to reducing maternal and fetal complications. Antihypertensive treatment should be used in women with high-risk chronic hypertension, whereas drug therapy does not improve pregnancy outcome in women at low risk. Prophylactic low-dose aspirin started early in pregnancy in women with chronic hypertension is not effective in reducing the frequency of superimposed preeclampsia and should be avoided.

Obstetric antecedents to apparent stillbirth (Apgar score zero at 1 minute only).

OBJECTIVE: To identify antecedent risk factors for the delivery of an infant with an Apgar score of 0 at 1 minute who is subsequently successfully resuscitated. METHODS: Infants born between January 1986 and February 1999 with 1-minute Apgar score of 0 followed by 5-minute Apgar score above 0 were studied. Each eligible infant was randomly matched with two control infants, born in the same year, with 1-minute Apgar score greater than 0. Hospital records of their mothers were reviewed. The variables were compared between the groups by univariate analysis. Those factors demonstrating significant differences were then analyzed by logistic regression. P <.05 was considered statistically significant. RESULTS: Seventy-four of 81,603 infants (0.9:1000 births) born with an Apgar score of 0 at 1 minute only were compared with 148 control babies. Univariate analysis revealed significant differences between study and control group regarding: gestational age, abruptio placentae, preterm premature rupture of membranes, chorioamnionitis, preeclampsia, small-for-gestational age, male gender, bradycardia, and abnormal fetal heart rate (FHR) other than bradycardia, respectively. Logistic regression of these factors found gestational age, bradycardia, and abnormal FHR to be independent risk factors for the delivery of an apparent stillborn infant. After exclusion of FHR criteria, logistic regression found gestational age (odds ratio [OR] 0.8 per week), male gender (OR 2.5), preeclampsia (OR 3.9), and abruptio placentae (OR 13.6) to be independent risk factors for the delivery of an apparent stillborn infant. CONCLUSION: Preterm birth, male gender, preeclampsia, and abruptio placentae are independently associated with an increased risk of apparent stillbirth.

Placenta growth factor is not an early marker for the development of severe preeclampsia.

OBJECTIVE: Our purpose was to determine whether plasma concentrations of placenta growth factor may be used as a marker for women who ultimately have severe preeclampsia. STUDY DESIGN: We performed a nested case-control study to compare plasma concentrations of placenta growth factor in women with severe preeclampsia with the concentrations in normotensive pregnant control subjects. Plasma samples were collected at <20 weeks' gestation and again in the third trimester. Twenty-two women who ultimately had severe preeclampsia were matched for gestational age at delivery with 22 normotensive control subjects. Placenta growth factor concentrations were measured by a specific antigen capture enzyme-linked immunosorbent assay. Comparisons were made by using the Mann-Whitney U test for nonparametric data such as placenta growth factor concentrations. The Student t test was used for parametric data. RESULTS: A total of 880 pregnant women were screened. Severe preeclampsia developed in 22, for an incidence of 2.5%. As expected, women with severe preeclampsia had significantly higher systolic and diastolic blood pressures, and their infants had lower birth weights. Placental weights at delivery were similar between those with severe preeclampsia and control subjects (659 vs 699 g; P =.51). During the third trimester, the median placenta growth factor concentrations were significantly lower in women with severe preeclampsia than in normotensive control subjects (125 vs 449 pg/mL; P =.003). When samples drawn at <20 weeks' gestation were compared, there was no difference between the group with severe preeclampsia and those who remained normotensive (98.8 vs 56.34 pg/mL; P =.15). CONCLUSION: During the third trimester, patients with severe preeclampsia have decreased maternal concentrations of placenta growth factor. This difference is not seen earlier in pregnancy. Lower concentrations of placenta growth factor may be a result of severe preeclampsia rather than a causal factor. Placenta growth factor is not a good marker for the subsequent development of severe preeclampsia.

Lack of association of severe preeclampsia with maternal and fetal mutant alleles for tumor necrosis factor alpha and lymphotoxin alpha genes and plasma tumor necrosis factor alpha levels.

OBJECTIVE: The purpose of this study was to determine whether the increased frequency of mutant alleles of the gene for tumor necrosis factor alpha and elevated maternal and fetal plasma levels of tumor necrosis factor alpha were associated with severe preeclampsia. STUDY DESIGN: We performed a prospective cross-sectional study involving 112 patients with severe preeclampsia matched for gestational age with 106 normotensive pregnant women. Deoxyribonucleic acid for restriction fragment length polymorphism analysis was extracted from maternal and fetal blood. Two mutations associated with the gene for tumor necrosis factor alpha were assayed by polymerase chain reaction. Polymerase chain reaction products were digested with the restriction enzyme Ncol and then fractionated by gel electrophoresis. Genotypic frequencies were calculated. Maternal and fetal plasma tumor necrosis factor alpha levels were assayed by the dual monoclonal antibody sandwich enzyme-linked immunosorbent assay technique. The chi2 test, the Fisher exact test, the Student t test, and the Mann-Whitney test were performed to calculate statistical significance. RESULTS: The differences in the genotypic frequencies of the two loci were not significant in either maternal or fetal samples between control women and women with pregnancies complicated by severe preeclampsia. There was no statistical difference in median maternal plasma levels of tumor necrosis factor alpha between control subjects (0.0 pg/mL) and patients with severe preeclampsia (2.5 pg/mL; P =.36). Unexpectedly, fetal plasma tumor necrosis factor alpha levels were found to be significantly elevated in control women (18.4 pg/mL) relative to women with severe preeclampsia (9.1 pg/mL; P <.0001). CONCLUSION: Neither the genotypic frequencies for tumor necrosis factor alpha mutant alleles nor maternal tumor necrosis factor alpha plasma levels were increased in patients with severe preeclampsia.

Elevation of both maternal and fetal extracellular circulating deoxyribonucleic acid concentrations in the plasma of pregnant women with preeclampsia.

OBJECTIVE: Elevated amounts of circulating fetal deoxyribonucleic acid in maternal plasma have recently been detected in pregnancies complicated by preeclampsia. We attempted to confirm this finding and simultaneously examined the quantity of maternal circulating deoxyribonucleic acid. STUDY DESIGN: Circulating deoxyribonucleic acid was measured by realtime quantitative polymerase chain reaction in plasma samples obtained from 44 women with preeclampsia and a matched cohort of 53 normotensive pregnant women. RESULTS: We confirmed that circulating fetal deoxyribonucleic acid levels were significantly elevated in pregnancies complicated by preeclampsia (3194.6 vs 332.8 copies/mL; P < .001). We also showed for the first time that circulating maternal deoxyribonucleic acid levels are also elevated (219,023.9 vs 20,235.8 copies/mL; P < .001). The increases in these deoxyribonucleic acid levels corresponded to the severity of the disorder, and values were correlated with each other in pregnancies complicated by preeclampsia (r = 0.556; P < .001) but not normotensive pregnancies (r = 0.046; P = .747). CONCLUSION: The releases of both free fetal and maternal deoxyribonucleic acid were found to be affected in preeclampsia.

HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome versus severe preeclampsia: onset at < or =28.0 weeks' gestation.

OBJECTIVE: Our purpose was to determine whether the onset of the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome in women at < or =28.0 weeks' gestation is associated with an increased risk of adverse maternal and perinatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age. STUDY DESIGN: Sixty-four patients with either the HELLP syndrome (n = 32) or severe preeclampsia but absent HELLP syndrome laboratory test results (n = 32), admitted at < or =28.0 weeks' gestation between July 1, 1992, and April 30, 1999, were studied. Maternal and perinatal outcomes were compared between the 2 groups. Statistical analysis was performed by the Student t test and the Fisher exact test. RESULTS: There were no significant differences between the 2 groups regarding African-American race (59% vs 75%), nulliparity (50% vs 56%), or the use of corticosteroids (59% vs 78%). There were no maternal deaths. One woman with the HELLP syndrome had a liver hematoma. The rate at which transfusion of blood products was required was significantly greater in women with the HELLP syndrome than in those with severe preeclampsia only (25% vs 3%; P <.05). There were no significant differences between the 2 groups with respect to eclampsia (16% vs 13%), abruptio placentae (6% vs 9%), disseminated intravascular coagulopathy (13% vs 0%), pulmonary edema (13% vs 6%), acute renal failure (3% vs 0%), pleural effusion (3% vs 3%), or ascites (6% vs 16%). No significant differences were found between the 2 groups with respect to neonatal death (11% vs 17%), respiratory distress syndrome (78% vs 86%), or composite neonatal morbidity. CONCLUSIONS: Except for the need for transfusion of blood products in women with the HELLP syndrome, onset at < or =28.0 weeks' gestation is not associated with an increased risk of adverse maternal or neonatal outcomes in comparison with the risk for women with severe preeclampsia but without the HELLP syndrome at a similar gestational age.

Reductions of vascular endothelial growth factor and placental growth factor concentrations in severe preeclampsia.

OBJECTIVE: The aim of this study was to determine whether plasma concentrations of vascular endothelial growth factor and placental growth factor are altered in women with severe preeclampsia. STUDY DESIGN: We performed a case-control study to compare plasma concentrations of vascular endothelial growth factor and placental growth factor between women with severe preeclampsia and normotensive women admitted for delivery. Twenty-one women with severe preeclampsia were matched for gestational age and ethnicity with 21 normotensive women. Vascular endothelial growth factor and placental growth factor concentrations were measured with a specific antigen-capture enzyme-linked immunosorbent assay. RESULTS: Women with severe preeclampsia demonstrated significantly lower plasma concentrations of both vascular endothelial growth factor (6.36 +/- 3.96 pg/mL vs 18.65 +/- 5.98 pg/mL; P <.0001) and placental growth factor (138 +/- 119 pg/mL vs 531 +/- 340 pg/mL; P <.0001) than did women with normotensive pregnancy. Logistic regression analysis showed an independent association between plasma vascular endothelial growth factor concentration and plasma placental growth factor concentration and preeclampsia. CONCLUSION: Patients with severe preeclampsia had decreased maternal serum concentrations of both vascular endothelial growth factor and placental growth factor.

Crack cocaine, myocardial infarction, and troponin I levels at the time of cesarean delivery.

IMPLICATIONS: During the peripartum period, cocaine-abusing women are highly susceptible to myocardial infarction. This report describes a case of myocardial infarction diagnosed by increased troponin I levels in a pregnant patient with a history of recent crack cocaine use and severe preeclampsia.

Risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome.

OBJECTIVE: This study was undertake to determine risk factors for adverse maternal outcomes among women with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome. STUDY DESIGN: Maternal medical records of pregnancies complicated by HELLP syndrome managed between July 1, 1992, and April 30, 1999, were reviewed. Risk factors evaluated included maternal age, parity, race, previous preeclampsia, chronic hypertension, gestational age at diagnosis, mean arterial blood pressure, nadir blood platelet count (<50,000 cells/microL vs > or =50,000 cells/microL), and peak serum levels of aspartate aminotransferase and lactate dehydrogenase. Maternal outcome variables analyzed included eclampsia, abruptio placentae, disseminated intravascular coagulopathy, pulmonary edema, pleural effusion, ascites, acute renal failure, liver hematoma, need for transfusion of blood products, cesarean delivery, and death. Statistical analysis was performed with the Student t test, the chi(2) test, and logistic regression analysis. RESULTS: A total of 183 women with HELLP syndrome were studied. Eclampsia was present in 6%, abruptio placentae was present in 10%, and disseminated intravascular coagulopathy was present in 8%. Forty-one women (22%) required transfusion of blood products. Incidence of eclampsia significantly decreased with increasing gestational age, from 16% at < or =28 weeks' gestation to 3% at >32 weeks' gestation (P <.05) and was higher among African American patients than among white patients (12% vs 3%; P <.05). Logistic regression analysis showed an independent relationship between eclampsia and race (P <.05). Incidence of abruptio placentae was higher among women with previous preeclampsia than among women without this clinical history (26% vs 5%; P <.05). Disseminated intravascular coagulopathy was significantly associated with abruptio placentae (P <.0001) and acute renal failure (P <.0001). A nadir platelet count of <50, 000/microL, a peak serum aspartate aminotransferase level of >150 U/L, and a peak serum lactate dehydrogenase level of >1400 U/L were not independent risk factors for adverse outcome. CONCLUSIONS: Among women with HELLP syndrome, African American race is a risk factor for eclampsia. Both acute renal failure and abruptio placentae are associated with disseminated intravascular coagulopathy. Laboratory parameters of HELLP syndrome are not independent risk factors for adverse maternal outcome.

Outcome after successful resuscitation of babies born with apgar scores of 0 at both 1 and 5 minutes.

OBJECTIVE: Our purpose was to evaluate the outcome of infants who underwent successful resuscitation after initial Apgar scores of 0 at both 1 and 5 minutes. STUDY DESIGN: Eligible infants were identified through the perinatal database at the University of Tennessee, Memphis. Hospital records and long-term outcomes, where available, of babies who met the above criteria occurring between January 1986 and February 1999 were reviewed. RESULTS: Thirty-three of 81,603 infants (0.4/1000 births) met our study criteria. Twenty-two (67%) babies died during hospitalization. Mortality decreased significantly from 100% for babies with a birth weight of <750 g to 38% for those weighing > or =2500 g at birth (P =.03). All 6 babies delivered before 26 weeks' gestation died. The incidence of 10-minute Apgar scores >0 was significantly higher among survivors than among those who subsequently died (82% vs 33%, P <.05). Nine survivors had hypoxic-ischemic encephalopathy diagnosed before discharge. Of the 7 infants with available follow-up, 4 had significant persisting morbidity. Two infants had normal neurologic examinations at follow-up. CONCLUSION: Survival in babies born with 1- and 5-minute Apgar scores of 0 is predicted by birth weight, gestational age, and 10-minute Apgar score. Long-term sequelae are common but not ensured.

Failure of serum beta2-microglobulin levels as an early marker of preeclampsia.

OBJECTIVE: Our purpose was to determine whether second-trimester maternal serum beta(2)-microglobulin levels could be used to predict subsequent development of preeclampsia. STUDY DESIGN: We first did a cross-sectional study to compare serum concentrations of beta(2)-microglobulin between women with preeclampsia and normotensive women. Serum beta(2)-microglobulin concentrations of 11 consecutive patients hospitalized for preeclampsia were compared with those of 11 normotensive women hospitalized for threatened premature labor. The second part of the study consisted of a nested case-control study in which each woman in whom preeclampsia ultimately developed was matched with 2 women who remained normotensive throughout gestation. For that purpose a total of 450 consecutive healthy nulliparous women were studied prospectively. Blood samples were collected between 20 and 24.9 weeks' gestation and frozen at -20 degrees C until assay after groups had been selected. RESULTS: In the cross-sectional study serum beta(2)-microglobulin levels were significantly higher in women with preeclampsia than in control women (1.87 +/- 0.36 mg/L vs 1.01 +/- 0. 12 mg/L; t = 7.61; P <.0001). Among the 450 women who were followed up prospectively, preeclampsia developed in 7 (1.5 %). Fourteen of the women who remained normotensive were matched with the 7 women in whom preeclampsia ultimately developed. No difference was found in early serum beta(2)-microglobulin concentrations between women in whom preeclampsia subsequently developed and those who remained normotensive throughout gestation (1.02 +/- 0.12 vs 0.95 +/- 0.12 mg/L). CONCLUSIONS: Serum beta(2)-microglobulin levels do not predict subsequent preeclampsia.

Electroconvulsive therapy in a twin pregnancy: a case report.

We present a case of twin gestation complicated by severe depression and psychotic behavior; the mother was treated with electroconvulsive therapy (ECT). She had received multiple medications for treatment of her depression earlier during the first part of the pregnancy. However, frequent use of ECT later in the course of pregnancy did not result in adverse fetal outcome as is evident from normal fetal surveillance tests. We conclude that, when indicated, ECT during pregnancy improves maternal condition and does not adversely affect fetal well-being.

Music for the childbearing family.

The therapeutic values of music apply to many experiences in life. The author illustrates how exercise, relaxation, controlled breathing, and sensory stimulation are enhanced by the use of music in childbirth education classes, labor and delivery, nursery, postpartum, and in the home. Charts provide suggestions of musical selections that may be used as well as a guide to tempo and intensity. Adaptations to the clinical setting are also illustrated.