Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence.

In view of the important protective role of the fetal membranes, wound sealing, tissue regeneration, or wound healing could be life saving in cases of preterm premature rupture of the membranes. Although many investigators are studying the causes of preterm premature rupture of membranes, the emphasis has not been on the wound healing capacity of the fetal membranes. In this review, the relevant literature on the pathophysiologic condition that leads to preterm premature rupture of membranes will be summarized to emphasize a continuum of events between rupture and repair. We will present the current knowledge on fetal membrane wound healing and discuss the clinical implications of these findings. We will critically discuss recent experimental interventions in women to seal or heal the fetal membranes after preterm premature rupture of membranes.

Human fetal membranes: their preterm premature rupture.

At the 1999 annual meeting of the Society for the Study of Reproduction there were three speakers in the minisymposium entitled "I've got to get out of here: fetal-maternal interactions involved in parturition". The primary focus was on research progress in understanding the mechanisms involved in human parturition. Although the title of the symposium emphasized the need to "get out", there was considerable emphasis on understanding the problem of "getting out too early" or preterm birth. While preterm birth is unusual in most species, it is of major clinical importance in the human. The data presented by one of the speakers is reviewed here with a focus on preterm labor and preterm premature rupture of the fetal membranes as mechanisms involved in the diverse pathology of preterm birth.

Limited clinical utility of blood and urine cultures in the treatment of acute pyelonephritis during pregnancy.

OBJECTIVE: The purpose of this study was to determine the utility of urine and blood cultures in the clinical management of pregnant women with acute pyelonephritis. STUDY DESIGN: Data were pooled from three randomized controlled trials that were conducted at two university-based tertiary care centers and included 391 pregnant women with pyelonephritis. The results of urine and blood cultures were correlated with clinical management decisions, outcome, length of hospital stay, and cost. RESULTS: Results of 98% of urine cultures (382/391) and 99% of blood cultures (388/391) were available for analysis. The most common pathogen isolated was Escherichia coli, which was found in 79% of the urine cultures (300/382) and in 77% of the blood cultures (27/35). Susceptibility testing revealed 46% resistance to ampicillin; 7%, 2%, and 0% resistances to first-, second-, and third-generation cephalosporins, respectively; and 1% resistance to gentamicin. Six percent of the participants (25/391) required changes in antibiotic therapy, most commonly for persistent fever (6/25, 25%). Positive blood culture results directly influenced management by prolonging the duration of hospitalization, with means of 4.6 +/- 2.6 hospital days for women with bacteremia and 2.6 +/- 1.5 hospital days for women without bacteremia (P <.001) despite similar durations of symptoms. CONCLUSION: Urine and blood cultures with sensitivity testing had limited utility in the clinical management of pregnant women with pyelonephritis. Decisions to change antibiotic treatment were affected more by clinical course than by culture results. We suggest that elimination of blood and urine cultures might simplify management and result in significant cost savings without compromising patient care.

Fetal membrane distention: II. Differentially expressed genes regulated by acute distention in vitro.

OBJECTIVE: This study was undertaken to identify genes with expression up-regulated by acute distention in the human fetal membranes. STUDY DESIGN: Fetal membrane explants were distended reproducibly in a novel device in vitro for 4 hours, and suppression subtractive hybridization was used to identify the candidate genes for up-regulation of expression in response to this stimulus. The up-regulation in response to distention was confirmed by quantitative Northern blot analysis both after a 4-hour in vitro distention and after labor in vivo. RESULTS: Suppression subtractive hybridization identified 3 genes with expression up-regulated by acute distention: an interferon-stimulated gene encoding a 54-kd protein, the gene for huntingtin-interacting protein 2 (a ubiquitin-conjugating enzyme), and a novel transcript. Expression of each of the distention-responsive genes found to be up-regulated in vitro was also up-regulated in fetal membranes in association with labor. CONCLUSIONS: Suppression subtractive hybridization was successfully applied to a complex tissue, the human fetal membranes, and 3 novel distention-responsive genes were identified. Both acute in vitro distention and labor in vivo up-regulate expression of at least 3 genes in the human fetal membranes.

Fetal membrane distention: determination of the intrauterine surface area and distention of the fetal membranes preterm and at term.

OBJECTIVE: This study was undertaken to obtain an accurate measurement of the intrauterine surface area and the degree of distention of the apposed fetal membranes preterm and at term. STUDY DESIGN: Serial longitudinal images of the uterus in 23 women between 25 and 41 weeks' gestation were obtained by ultrasonography. A Mathematica (Wolfram Research, Inc, Champaign, Ill) program assembled a 3-dimensional image and calculated the intrauterine surface area for each patient. The surface areas of the placental amnion and membranes were measured in vitro after delivery. From these measurements the degree of distention of each fetal membrane in vivo was calculated. RESULTS: The mean calculated intrauterine surface areas were as follows: 1037 +/- 70 cm(2) (25-29 weeks' gestation, n = 4), 1376 +/- 121 cm(2) (30-34 weeks' gestation, n = 4), and 1876 +/- 307 cm(2) (37-41 weeks' gestation, n = 15, P =.0021 by Wilcoxon rank sum test). The surface areas of the expelled membranes at 25 to 29, 30 to 34, and 37 to 41 weeks' gestation were 737 +/- 61 cm(2), 855 +/- 77 cm(2), and 1115 +/- 149 cm(2), respectively. The ratios of intrauterine surface area to the area of the expelled membrane and hence a measure of the degree of distention in vivo were 1.4 +/- 0.05 at 25 to 29 weeks' gestation (n = 4), 1.6 +/- 0.2 at 30 to 34 weeks' gestation (n = 4), and 1.7 +/- 0.3 at term (n = 15). CONCLUSION: The intrauterine surface area in vivo increases during gestation. The surface area of the fetal membranes as measured in vitro increases to a lesser extent. The fetal membranes are therefore distended in vivo.

Outpatient treatment of acute pyelonephritis in pregnancy after 24 weeks.

OBJECTIVE: To compare outpatient to inpatient management of acute pyelonephritis in pregnancy beyond 24 weeks' gestation. METHODS: Ninety-two gravidas past 24 weeks' gestation, randomized to outpatient or inpatient therapy, received two 1-g doses of intramuscular ceftriaxone at 24-hour intervals while hospitalized, then were discharged and reevaluated within 48-72 hours or remained hospitalized until afebrile for 48 hours. Subjects received oral cephalexin after initial treatment. Urine cultures were done on admission and 5-14 days after therapy. Surveillance continued until delivery. We anticipated that 15% of outpatients and 0.01% of inpatients would require changes in antibiotic therapy. RESULTS: Twenty-one percent of women evaluated were excluded. Thirteen of 46 (28%) outpatients' hospitalization exceeded 24 hours. Six outpatients (13.0%) and one inpatient did not respond to initial therapy and were treatment failures (relative risk [RR] 1.82, 95% confidence interval [CI] 1.00, 3.31). Within 2 weeks of initial therapy, seven of 81 (8.6%) subjects had positive urine cultures, four outpatients versus three inpatients (P > .999). Eleven of 84 (13.1%) deliveries for which birth data were available occurred preterm (six of 41 outpatients versus five of 43 inpatients) (RR 1.14, 95% CI 0.61, 2.11). CONCLUSION: There were no significant differences in clinical responses or birth outcomes of inpatients or outpatients treated for acute pyelonephritis after 24 weeks' gestation if they completed their assigned protocols. Thirty percent of outpatients were unable to, and most women with acute pyelonephritis in the third trimester were not candidates for outpatient therapy.

Genes upregulated in human fetal membranes by infection or labor.

OBJECTIVE: To determine whether suppression subtractive hybridization can detect genes in fetal membranes that are upregulated by infection, preterm premature rupture of membranes (PROM), or labor. METHODS: Using suppression subtractive hybridization, messenger RNAs from a preterm fetal membrane obtained at cesarean delivery without labor (control) were subtracted from a pool of messenger RNAs of three patients with preterm PROM and vaginal delivery. Eight candidate genes identified as upregulated were quantitated by Northern analysis in each of the tissues and in additional patient subgroups. RESULTS: Eight differentially upregulated genes were identified in preterm labor with PROM. Four of the genes are known to be involved in the response to inflammation or infection, and subsequent histologic examination showed one of the preterm PROM tissues to be infected. F-actin capping protein and chitinase precursor, not previously known to be involved in infection, were also upregulated in the infected tissue from preterm PROM. Northern blots using additional subgroups of patients showed that a regulatory G-protein signaling protein gene was significantly upregulated at term by labor in addition to significant upregulation of interleukin-8. There was a strong correlation between the gene expression for complement factor-B and duration of membrane rupture in the patients with preterm PROM. CONCLUSION: Two novel genes potentially involved in the response to inflammation or infection have been identified. A regulatory G-protein signaling protein and interleukin-8 gene expression were upregulated by labor. Complement factor-B gene expression was directly related to the duration of membrane rupture.

A relaxin-mediated pathway to preterm premature rupture of the fetal membranes that is independent of infection.

OBJECTIVE: This study was designed to show whether the overexpression of relaxin in the decidua of patients with preterm premature rupture of the membranes is independent of or a consequence of chorioamnionitis. STUDY DESIGN: Two experiments were conducted. In the first experiment fetal membranes and decidua were collected from patients with preterm premature rupture of the membranes (n = 17) or preterm labor (n = 17) and were divided according to their degree of histologic infection. Messenger ribonucleic acid was isolated from the tissues and quantitative, sequential Northern analyses were carried out for the expression of human relaxin, interleukin-1beta, interleukin-6, and interleukin-8. The second experiment was aimed at increasing the numbers of messenger ribonucleic acid preparations in the two extreme categories, uninfected and severely infected tissues, with preterm premature rupture of the membranes and preterm labor. Some samples of messenger ribonucleic acid from the first experiment were rerun with the Northern analyses in the second experiment. These repeat samples showed no statistical differences in the results run at different times. Therefore the data from the respective groups of patients in both experiments were pooled for statistical analysis. RESULTS: In both the first experiment and in the pooled data of the two experiments the expression of the relaxin genes was significantly greater (P < .005) in the tissues from patients with preterm premature rupture of the membranes compared with those with preterm labor, in the absence of infection. No effect of the level of infection on the expression of relaxin was noted. In contrast, interleukin-6 gene expression was significantly increased (P < .05) in severely infected tissues, which was independent of whether the delivery was from preterm premature rupture of the membranes or preterm labor. The expression of the interleukin-1beta and interleukin-8 genes were only marginally increased even in severe infection. Marked patient variability in expression of the interleukin genes, especially in severe infection, was noted. CONCLUSION: A relaxin-mediated pathway that leads to preterm premature rupture of the membranes may exist independent of infection.

A randomized trial of three antibiotic regimens for the treatment of pyelonephritis in pregnancy.

OBJECTIVE: To compare the effectiveness of three antibiotic regimens for the treatment of acute pyelonephritis in pregnancy. METHODS: One hundred seventy-nine pregnant women earlier than 24 weeks' gestation who had acute pyelonephritis were randomized to 1) intravenous (i.v.) ampicillin and gentamicin, 2) i.v. cefazolin, or 3) intramuscular ceftriaxone. All participants then completed 10-day courses of oral cephalexin after primary treatment. A urine culture was performed on admission and 5-14 days after completion of therapy. Surveillance for persistent or recurrent infection and obstetric complications continued until delivery. On the basis of a two-sided hypothesis test and with alpha = .025, 60 subjects were needed in each group for statistical power greater than 80% to detect a difference between ceftriaxone and other antibiotics if hospital length of stay differed by 1 or more days. RESULTS: The treatment groups were similar in age, parity, temperature, gestational age, and initial white blood cell count. There were no statistically significant differences in length of hospitalization, hours until becoming afebrile, days until resolution of costovertebral angle tenderness, or infecting organism. There were no statistically significant differences in birth outcomes between the three groups. The average (standard deviation) age at delivery was 38.8 +/- 3.6 weeks. The average birth weight was 3274 +/- 523 g. Eleven (6.9%) of 159 subjects delivered prematurely. Escherichia coli was the most common uropathogen isolated (137 of 179, 76.5%). Blood cultures were positive for organisms in 15 cases (8.4%). At follow-up examination within 2 weeks of initial therapy, eight (5.0%) of 159 subjects had urine cultures positive for organisms. Ten women (6.3%) had cultures positive for organisms later in their antepartum course, and 10 other participants (6.3%) developed recurrent pyelonephritis. CONCLUSION: There are no significant differences in clinical response to antimicrobial therapy or birth outcomes among subjects treated with ampicillin and gentamicin, cefazolin, or ceftriaxone for acute pyelonephritis in pregnancy before 24 weeks' gestation.

Developmental regulation of the human relaxin genes in the decidua and placenta: overexpression in the preterm premature rupture of the fetal membranes.

The decidua and placenta synthesize the human relaxins, termed H1 and H2, believed to be involved in collagen remodeling in the amnion and chorion in an autocrine/paracrine manner. The developmental regulation of the relaxin genes was quantitated in normal pregnancy by in situ hybridization histochemistry with six 48-mer oligonucleotide probes that detect both relaxin genes. A significant increase in relaxin expression occurred in both decidua (p < 0.01) and placenta (p < 0.05) at 12.5-14.4 wk gestation, with the mean peak value in the placenta more than double that of the decidua, suggesting a coordinate regulation of the relaxin genes. At term after spontaneous labor and delivery, a marginal increase in both decidual and placental relaxin gene expression occurred. Given these normal data, three abnormal preterm situations were investigated: 1) premature uterine contractions without prior rupture of the membranes, 2) premature rupture of the fetal membranes (PPROM), 3) cesarean section for medical reasons with intact membranes and no uterine contractions. Tissues showing intrauterine infection were eliminated. Significantly more relaxin was expressed in the preterm decidua from patients with PPROM when compared to patients in group 1 (p < 0.02) or group 3 (p < 0.008). These data were confirmed by Northern analysis with a relaxin cRNA probe. The placental tissues after PPROM also had a significantly higher and a uniform overexpression of relaxin in the placental syncytiotrophoblast. Tissues collected at term, in comparison, showed no such increases in decidua or placenta.

Catastrophic shoulder dystocia and emergency symphysiotomy.

We present three cases of shoulder dystocia unrelieved by standard maneuvers, including cephalic replacement. Symphysiotomy was performed in an effort to preserve fetal life. All three infants sustained severe neurologic injury and later died. Maternal morbidity including urinary incontinence was significant but responded to treatment. Symphysiotomy may be the only method of relieving some cases of shoulder dystocia, but its role remains unclear because of operator inexperience and maternal morbidity.

Urinary tract infections complicating pregnancy.

Urinary tract infections (asymptomatic bacteriuria, cystitis, and pyelonephritis) are frequently encountered medical complications of pregnancy. The majority of infections in pregnancy are asymptomatic; however, even covert bacteriuria places the mother at risk for low birth weight and preterm birth. Pyelonephritis can result in significant maternal and fetal morbidity and mortality. Therefore, all pregnant women should be screened for asymptomatic bacteriuria, and urinary tract infections should be promptly treated to prevent adverse pregnancy outcome. This article reviews the diagnosis, etiology, treatment, and complications associated with urinary tract infections in pregnancy.

Usefulness of coagulation studies and blood banking in patients with symptomatic placenta previa.

We conducted this study to ascertain the usefulness of coagulation studies and blood bank utilization in the patient with symptomatic placenta previa. During a 2-year interval, 97 patients with uterine bleeding due to placenta previa diagnosed > or = 24 weeks' gestation were evaluated. The following studies were routinely obtained: complete blood count including platelet count, fibrinogen, prothrombin time, and a Kleihauer-Betke test. A type and cross-match was sent to the blood bank, and blood availability was maintained for all patients throughout the course of hospitalization. For 92 of 97 patients the laboratory values and need for immediate blood availability were analyzed. No abnormal prothrombin times or Kleihauer-Betke tests were found. There was one low fibrinogen value in a patient with a normal complete blood count. The initial hematocrits ranged from 16.5 to 40.0%, and the initial hemoglobins ranged from 5.5 to 14.1 mg/dL. Five patients had platelet counts of < or = 150 k/mm3 (range 75 to 149 k/mm3). Fourteen patients (14.6%) required transfusion, two received their transfusion antepartum and 12 received perioperative transfusion with a cesarean delivery. During this time period, only two patients required emergent delivery within 1 hr of presentation to the hospital. One patient had delayed seeking medical attention for more than 3 hr prior to admission despite significant hemorrhage. Coagulation studies and Kleihauer-Betke tests have limited utility in the symptomatic patient with uterine bleeding from placenta previa. Continuous availability of cross-matched blood in the antepartum period appears unnecessary as no patients in this investigation were transfused emergently.

Management of the symptomatic placenta previa: a randomized, controlled trial of inpatient versus outpatient expectant management.

OBJECTIVE: Our purpose was to determine the safety, efficacy, and costs of inpatient and outpatient management of symptomatic placenta previa. STUDY DESIGN: Fifty-three women with the initial diagnosis of placenta previa at 24 to 36 weeks' gestation who required hospitalization for vaginal bleeding were stabilized and then randomized to receive either inpatient or outpatient expectant management. Twenty-seven inpatients were placed at bed rest with minimal ambulation, received weekly corticosteroids until 32 weeks of gestation, and underwent ultrasonographic examination at 2-week intervals to assess fetal growth and placental location. Twenty-six outpatients were discharged home after > or = 72 hours of hospitalization. Each week they also received corticosteroids, until 32 weeks' gestation, and ultrasonographic evaluations. Outpatients with recurrent bleeding were readmitted for evaluation. All subjects who reached 36 weeks' gestation with persistent placenta previa underwent amniocentesis. When fetal lung maturity was present, cesarean delivery was electively performed. RESULTS: There were insignificant differences between inpatients and outpatients for mean age, parity, race, type of previa (complete or partial), number of prior vaginal bleeding episodes, and initial hemoglobin value. The mean estimated gestational age at enrollment was 29.1 +/- 3.1 (SD) weeks for inpatients and 29.9 +/- 3.1 weeks for outpatients. In eight patients the placenta was found to no longer cover the internal os by 36 weeks' gestation. There were seven patients in each group who did not complete the protocol for initial treatment assignment. The average estimated gestational age at delivery for the inpatients was 34.5 +/- 2.4 weeks and 34.6 +/- 2.3 weeks for the outpatients (p = 0.90), whereas the mean birth weights were 2413.7 +/- 642.7 gm and 2607.8 +/- 587.1 gm, respectively (p = 0.28). Thirty-three patients (62.3%) had recurrent episodes of bleeding, with 26 requiring expeditious cesarean delivery. Four (14.8%) inpatients and one (3.7%) outpatient required blood transfusion (p = 0.67). There was no difference in neonatal morbidity (defined as the presence of respiratory distress syndrome, intracranial hemorrhage, or culture-proved sepsis) between the two groups (relative risk 1.16, 95% confidence interval 0.66 to 2.02). There were no neonatal deaths. The mean number of maternal hospital days differed significantly between the two groups: inpatients required an average of 28.6 +/- 20.3 days and outpatients remained hospitalized for an average of 10.1 +/- 8.5 days (p < 0.0001). Cost analysis based on maternal hospital days reveals a net savings of +15,080 per patient if women with symptomatic placenta previa initially diagnosed before 37 weeks' gestation are treated as outpatients. CONCLUSIONS: For selected patients, outpatient management of symptomatic placenta previa appears to be an acceptable alternative to traditional conservative expectant inpatient management.

Outpatient treatment of pyelonephritis in pregnancy: a randomized controlled trial.

OBJECTIVE: To compare the safety and efficacy of outpatient and inpatient treatment of pyelonephritis in pregnancy. METHODS: We performed a randomized controlled trial of pregnant women with pyelonephritis before 24 weeks' estimated gestational age, comparing inpatient and outpatient treatment. Sixty inpatients received cefazolin intravenously until afebrile for 48 hours, and 60 outpatients received two injections of ceftriaxone intramuscularly. All patients completed a 10-day course of oral cephalexin. We performed a urine culture 5-14 days after completion of therapy. RESULTS: The two groups were similar with respect to age, parity, temperature, estimated gestational age, initial white blood cell count, and incidence of bacteremia. Escherichia coli was the major uropathogen isolated (86% of cultures, 95 of 111). Twelve percent (13 of 111) of bacteria were resistant to cefazolin. Eleven outpatients and 12 inpatients had positive urine cultures after therapy (relative risk 0.9, 95% confidence interval 0.4-1.9). Three patients in each group had recurrent pyelonephritis. We switched six inpatients to gentamicin because of a worsening clinical picture (two) or a prolonged febrile course (four); no outpatients required a change in antibiotic (Fisher exact test, P = .03). One preterm delivery occurred in an inpatient with recurrent pyelonephritis. CONCLUSION: Outpatient antibiotic therapy is effective and safe in selected pregnant women with pyelonephritis.

Low birth weight and preeclampsia in pregnancies complicated by hyperthyroidism.

OBJECTIVE: To determine whether control of hyperthyroidism during pregnancy reduces the risk of low birth weight infants and severe preeclampsia. METHODS: Labor, delivery, and postpartum records of 181 hyperthyroid women were reviewed for maternal and fetal outcomes. Subjects were separated into three groups based on their thyroid status: controlled (n = 34), including women who were euthyroid at presentation and delivery; controlled during pregnancy (n = 90), including women who were hyperthyroid at presentation and euthyroid at delivery; and uncontrolled (n = 57), including women who were hyperthyroid at presentation and delivery. RESULTS: The risk of low birth weight infants was 0.74 (95% confidence interval [CI] 0.18-3.08) among controlled women, 2.36 (95% CI 1.36-4.12) among women who were controlled during pregnancy, and 9.24 (95% CI 5.47-15.6) among women who were uncontrolled during pregnancy compared to the incidence among nonhyperthyroid mothers. The risk of severe preeclampsia was significantly higher (odds ratio 4.74, 95% CI 1.14-19.7) among uncontrolled women compared with those who were controlled during their pregnancies. Elevated TSH-receptor antibody levels were not related to preeclampsia. Maternal thioamide therapy did not adversely affect neonatal outcomes. CONCLUSION: Lack of control of hyperthyroidism significantly increases the risk of low birth weight infants and severe preeclampsia.

A comparison of propylthiouracil versus methimazole in the treatment of hyperthyroidism in pregnancy.

OBJECTIVE: Our purpose was to demonstrate that propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism during pregnancy. STUDY DESIGN: Between 1974 and 1990 records were available on 185 pregnant patients with a history or diagnosis of hyperthyroidism. Ninety-nine patients were treated with propylthiouracil and 36 with methimazole. The response to therapy was compared with respect to the time to normalization of the free thyroxine index and the incidences of congenital anomalies and hypothyroidism. RESULTS: The time to normalization of the free thyroxine index was compared in the two groups by means of survival analysis. The median time to normalization of the free thyroxine index on propylthiouracil and methimazole was 7 and 8 weeks, respectively (p = 0.34, log-rank test). The incidence of major congenital malformations in mothers treated with propylthiouracil and methimazole was 3.0% and 2.7%, respectively. No neonatal scalp defects were seen. One infant was overtly hypothyroid at delivery. CONCLUSION: Propylthiouracil and methimazole are equally effective and safe in the treatment of hyperthyroidism in pregnancy.

Outpatient parenteral antibiotic therapy. Management of serious infections. Part II: Amenable infections and models for delivery. Pyelonephritis.

Outpatient therapy is currently recommended for women with uncomplicated pyelonephritis, not those with sepsis, renal insufficiency or pathology, or significant underlying disease. Parenteral therapy is usually initiated in the emergency department, followed by oral therapy at home. Pregnant patients are hospitalized, though studies suggest that outpatient therapy may be appropriate.

Perinatal outcome in hypothyroid pregnancies.

OBJECTIVE: To relate hypothyroidism to perinatal outcome. METHODS: A cohort of 68 hypothyroid patients with no other medical illnesses was divided into two groups according to the initial thyroid function tests. The first group had 23 women with overt hypothyroidism, and the second had 45 subjects with subclinical hypothyroidism. We sought to identify the pregnancy outcomes of gestational hypertension, low birth weight, fetal death, congenital anomalies, maternal anemia, and postpartum hemorrhage. RESULTS: Gestational hypertension--namely, eclampsia, preeclampsia, and pregnancy-induced hypertension--was significantly more common in the overt and subclinical hypothyroid patients than in the general population, with rates of 22, 15, and 7.6%, respectively. In addition, 36% of the overt and 25% of the subclinical hypothyroid subjects who remained hypothyroid at delivery developed gestational hypertension. Low birth weight in both overt and subclinical hypothyroid patients was secondary to premature delivery for gestational hypertension. Except for one stillbirth and one case of clubfeet, hypothyroidism was not associated with adverse fetal and neonatal outcomes. CONCLUSION: Normalization of thyroid function tests may prevent gestational hypertension and its attendant complications in hypothyroid patients.