Corticosteroids for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP): what evidence?

The fundamental premise that has governed the proposal relative to the use of corticosteroids for the purpose of disease modification in Hemolysis, Elevated Liver Enzymes, and Low Platelets (HELLP) syndrome was that pre-eclampsia is a condition characterized by an inappropriate maternal systemic inflammatory response and possibly immune-mediated impairment in maternal-fetal communication, while corticosteroids have the capacity to exercise anti-inflammatory and immunosuppressive effects. The present article reviews the evidence behind this proposal, concluding that corticosteroids administration, either antepartum or postpartum, does not improve the outcome of pregnancies affected by HELLP syndrome. The risks associated with such an approach, especially in fetuses manifesting growth restriction and absent end-diastolic flow, are also discussed. The literature published in English between 1990 and 2006 was searched for papers dealing with corticosteroids treatment for disease modification in pre-eclampsia and HELLP syndrome, using a combination of keywords including ''HELLP syndrome '', ''pre-eclampsia'', ''corticosteroids'', and ''maternal and fetal outcomes''. The MEDLINE bibliographic database yielded 9 studies relevant to this topic, including one retrospective analysis, 7 randomized trials, and one meta-analysis. Until more convincing data become available, corticosteroids for disease modification in women with HELLP syndrome should not be used outside the setting of an approved investigational protocol.

Teaching the Laufe-Piper forceps technique at cesarean delivery.

OBJECTIVE: To present a method of teaching forceps technique during cesarean delivery of breech-presenting infants using Laufe-Piper forceps and to evaluate its usefulness. STUDY DESIGN: For several years, residents at the University of Texas Medical Branch, Galveston, have learned and practiced Piper forceps technique during cesarean delivery. To assess their experience with this method, we mailed questionnaires to third- and fourth-year residents and recent graduates of the Galveston program. The same surveys were mailed to a control group of residents and recent graduates of two other programs where this teaching exercise is not practiced routinely. RESULTS: Responses were received from 32 (74%) study subjects and 63 (71%) controls. Demographic characteristics and experience with vaginal breech delivery were similar between the two groups. Respondents from the Galveston program noted greater annual use of forceps for vaginal delivery of cephalic-presenting infants (P = .012). They also rated themselves as more comfortable (P = .023) and more skilled (P = .006) with Piper forceps than controls. Of 53 respondents who had had previous experience with this teaching method, 47 noted that it provided a great or moderate educational benefit, and 36 strongly or moderately believed it gave them more confidence in using Piper forceps during vaginal breech delivery. Using multiple regression analysis, sex, overall level of experience, Piper forceps experience during vaginal delivery and overall forceps use were stronger determinants of self-rated comfort and skill than was experience with Laufe-Piper forceps during cesarean. CONCLUSION: Laufe-Piper forceps can be used for cesarean delivery of breech-presenting infants. This practice promotes confidence and skill for their use at vaginal delivery.

Does asphyxia cause cerebral palsy?

The incidence of cerebral palsy is 1 per 1,000, whereas the proportion caused by perinatal asphyxia is only 8% to 10%. The purpose of this article is to review the relationship between asphyxia and cerebral palsy. Only a minority of cases, those involving severe pathological fetal academia, are consistently associated with neonatal encephalopathy and an increased risk of cerebral palsy.

Umbilical cord blood gas analysis at delivery.

Fetal acid-base status is the end point that all antepartum and intrapartum surveillance tools are designed to assess, either directly or indirectly. Umbilical arterial blood pH is normal in 80% of depressed newborns, thereby proving the absence of birth asphyxia both in the delivery room and in the courtroom. The technique, normal ranges, and risks, benefits and cost analysis of routine versus selected umbilical blood sampling are considered. The American College of Obstetricians and Gynecologists recommends performing umbilical blood sampling for acid-base analysis in selected deliveries. However, in our opinion routine umbilical blood sampling at all deliveries has merit.

Vulvovaginal hematomas complicating delivery. Rationale for drainage of the hematoma cavity.

OBJECTIVE: To review the management of puerperal vulvovaginal hematomas and report on the use of closed system drainage in cases in which operative intervention was used. STUDY DESIGN: A retrospective review of medical records for a five-year period was conducted. The charts of all patients in whom puerperal vulvovaginal hematomas occurred were reviewed and data extracted regarding possible etiologic factors, details of delivery, characterization of the hematoma, surgical intervention and type of drain used. Also recorded was length of stay and postoperative complications. RESULTS: Eleven patients with hematomas were identified, for an incidence of 1/526. All patients received antibiotics; transfusion was required in eight patients. Drains were used in nine patients: Penrose in four and closed system drainage in five. All drains were brought through a separate site distant from the repair. There was one postoperative abscess, which resolved with wound care, resulting in no long-term morbidity. CONCLUSION: Puerperal vulvovaginal hematomas may be a life-threatening event. Review of the literature and our experience suggests that aggressive operative management and the use of drains are beneficial in the management of these patients. Closed system drainage may be an effective adjunct in the management of vulvovaginal hematomas.

Randomized comparative study of cefepime and cefotaxime in the treatment of acute obstetric and gynaecological infections.

Patients with presumed acute gynaecological infections were randomized (2:1) to receive cefepime 2 g every 12 h (n = 159) or cefotaxime 2 g every 8 h (n = 72), both im or by a 30-min i.v. infusion. For evaluation of efficacy, patients were required to have a bacteriologically documented infection, with at least one pathogen isolated susceptible to both drugs. Duration of treatment was 2-8 days in the 95 cefepime-treated patients and 3-10 days in the 36 cefotaxime-treated patients with evaluable infections; approximately three-quarters of the patients in each group were treated for 4-5 days. Clinical response was satisfactory in 81/95 (85%) of the evaluable cefepime recipients and 30/36 (83%) of the evaluable cefotaxime recipients (P = 0.802). In total, 211 (85%) of the 247 pathogens isolated from evaluable cefepime recipients were eradicated, compared with 98 (90%) of 109 pathogens isolated from evaluable cefotaxime recipients. All pathogens were eradicated in 77 (81%) cefepime-treated patients and in 31 (86%) cefotaxime-treated patients (P = 0.379). Overall response to treatment, calculated by combining clinical response and individual patient bacteriological response, was considered effective, partially effective or ineffective in 77%, 13% and 11% of cefepime-treated patients respectively and in 75%, 19% and 6% of cefotaxime-treated patients respectively (P = 0.932 for effective response). Adverse clinical events were reported by 68 (43%) of 159 cefepime recipients and by 26 (36%) of 72 cefotaxime recipients (P = 0.342); adverse events were deemed drug-related in 6% of cefepime recipients (diarrhoea, rash and headache) and in 1% of cefotaxime recipients (diarrhoea, pruritus and rash). Treatment was discontinued prematurely due to adverse events in five cefepime-treated patients and in one cefotaxime-treated patient (P = 0.476). Local intolerance was reported by 33 (21%) of the 159 cefepime-treated patients and by 14 (19%) of the 72 cefotaxime-treated patients receiving drug via the iv route alone; none of the patients discontinued treatment because of local intolerance. Laboratory test abnormalities were observed in a small number of patients in each group (1-8%), but none warranted discontinuation of treatment. Cefepime 2 g bd appears to have efficacy and safety comparable to that of cefotaxime 2 g tid in the treatment of acute obstetric and gynaecological infections.

Karyotypic abnormalities and hydramnios. Role of amniocentesis.

Hydramnios complicates up to 1.6% of pregnancies, with major fetal malformations found in an average of 20% of patients with hydramnios. Chromosomal abnormalities, although associated with some conditions in which hydramnios is present, have not been reported to complicate a significant percentage of hydramnios cases. Data from 45 patients admitted during the period January 1, 1985-May 31, 1990, were analyzed. All patients had hydramnios sufficiently severe to merit hospitalization for diagnosis and/or treatment. Amniocentesis was performed at the discretion of the attending physician and not under a specific protocol. The incidence of major fetal structural malformations was 36%. Of patients in whom amniocentesis was performed, 22% were found to have karyotypic abnormalities, none of which was specifically suspected prior to the amniocenteses. Neither the estimated gestational age nor the assessment of the amount of amniotic fluid differed between those with karyotypic abnormalities and those with normal chromosome complements. This information suggests that both advanced ultrasound studies and amniocentesis are beneficial in the evaluation of hydramnios.

Prenatal corticosteroid therapy to prevent respiratory distress syndrome.

Recently, an editor observed that the number of clinical trials has multiplied and that several trials of the same treatment may be published serially over a span of 10 years or more. He was not discussing antenatal CS therapy, was he? He added that meta-analysis should decide whether characteristics of patients, their therapies, and outcomes in each trial are comparable. Were they? Neither controlled trials in large numbers nor meta-analysis of these trials have swayed obstetricians toward routine use of antenatal CS as a single intervention. Perhaps the data from studies of combined hormonal therapy or of prenatal-postnatal therapy, or of a combination of both of these approaches will increase the use of antenatal CS. Ironically, maybe a retrospective study will provide the stimulus. Time will tell.

A prospective study of two dosing regimens of oxytocin for the induction of labor in patients with unfavorable cervices.

The ideal regimen for induction of labor with oxytocin with respect to the magnitude and frequency of dosage changes has not been defined. In spite of few data regarding labor induction with an unfavorable cervix, the initial dose recommended by the American College of Obstetricians and Gynecologists is lower than that of other commonly used protocols. Eighty patients with unfavorable cervices and unruptured membranes, without evidence of labor, were randomized to one of two protocols and met criteria for data analysis. Patients in both protocols were given an initial dose of oxytocin of 2 mU/min. Patients in protocol A (n = 32) then received incremental increases of oxytocin of 1 mU/min at 30-minute intervals, while those in protocol B (n = 48) received incremental increases of 2 mU/min at 15-minute intervals. Induction failures were higher among patients on protocol A (31% vs 8%, p less than 0.05). Patients on protocol B had shorter times to delivery (mean = 10 hours 57 minutes vs 8 hours 3 minutes; p less than 0.05). The number of operative deliveries were similar regardless of protocol. There were no significant differences (p = NS) among groups and protocols in maternal and fetal complications, cesarean section rate, and uterine hyperstimulation. In this population a more aggressive protocol may lead to fewer induction failures and shorter induction-to-delivery intervals.

Amniotic cavity accumulation of magnesium with prolonged magnesium sulfate tocolysis.

In seven women, continuous intravenous tocolysis with magnesium sulfate for 4-28 days resulted in high amniotic fluid magnesium levels (10.54 mg% +/- 1.83 SD). In all cases the amniotic fluid magnesium level greatly exceeded the maternal serum level in a sample collected simultaneously. Additionally, when amniorrhexis and delivery occurred within one hour of each other, the fetal magnesium levels uniformly exceeded the maternal levels in paired maternal and cord blood samples.

Umbilical arterial and venous acid-base and blood gas values and the effect of chorioamnionitis on those values in a cohort of preterm infants.

Umbilical arterial and venous acid-base and blood gas values in uncomplicated premature births are similar to values that are reported in term infants and are unaffected by birth weight or gestational age. In this group of patients chorioamnionitis had no significant effects on umbilical arterial acid-base or blood gas values or on the percentage of patients that were born with acidemia. Apgar scores were significantly lower in the group with chorioamnionitis in spite of a virtual absence of acidemia, which again suggests that low Apgar scores alone do not confirm a diagnosis of birth asphyxia.

Validation of the 1988 ACOG forceps classification system.

In February 1988, an ACOG Committee Opinion substantially revised the classification of forceps operations. The revision addressed two significant shortcomings of the old system: Outlet forceps had been defined too narrowly and midforceps too imprecisely. We now report the results of a prospective study of 357 forceps deliveries classified using each system. Allowing up to 45 degrees of rotation in an outlet forceps delivery did not increase morbidity measured by any criterion. Dividing the old midforceps group by precisely identifying station and rotation permitted greater stratification of the risks of short-term neonatal and maternal morbidity. We conclude that our results validate the 1988 classification scheme.

Guidelines for establishing a maternal serum alpha-fetoprotein screening program.

Maternal serum alpha-fetoprotein (MSAFP) screening of all pregnant women between 15 and 20 weeks gestational age is generally recognized as a standard of care in current obstetric practice. There are many factors to consider when deciding to establish MSAFP testing as an in-house procedure versus ship-out testing by a reference laboratory at fee-for-service cost. In this report, we review clinical and analytical aspects of MSAFP testing, along with appropriate guidelines for establishing an on-site MSAFP screening program.

Postpartum hemorrhage: placenta accreta, uterine inversion, and puerperal hematomas.

Puerperal hematomas, although rare, can be potentially morbid or life-threatening events. Early surgical management, including clot evacuation, layered closure, drainage, antibiotics, and fluid replacement (including blood), usually result in satisfactory outcome. Prevention is clearly preferable and often achievable with careful initial repair of episiotomies and lacerations.

Cost-effectiveness of intrapartum screening and treatment for maternal group B streptococci colonization.

Early-onset neonatal group B streptococci infection occurs in two cases per 1000 live births in the United States and is associated with a mortality rate greater than 20%. Nearly 30% of infected infants have concomitant meningitis and half suffer permanent neurologic damage. Group B streptococci also account for at least 20% of postpartum metritis. The annual cost of group B streptococci infection in the United States is conservatively estimated at nearly 2000 neonatal deaths and greater than $500 million, excluding the costs of long-term neurologic handicaps. Intrapartum chemoprophylaxis with ampicillin is effective in curtailing transmission of group B streptococci from mother to infant. Methods have been developed to identify maternal colonization before delivery. We applied principles of decision analysis to evaluate cost-effectiveness of intrapartum screening for maternal group B streptococci colonization with various reported methods in cohorts of low- and high-risk women. In the United States intrapartum screening for group B streptococci is cost-effective and offers the potential to avert a significant number of neonatal deaths and postpartum infections.

Group A beta-hemolytic Streptococcus as a cause of toxic shock syndrome. A case report.

Group A beta-hemolytic Streptococcus (pyogenes) has been associated recently with toxic-shock-like syndrome similar to staphylococcal toxic shock as described originally in 1978. A group A beta-hemolytic streptococcal infection occurred in a recent postpartum patient and clinically resembled staphylococcal toxic shock.

Emergent cerclage.

Emergent cerclage may be defined as that performed in the setting of advanced cervical dilation with bulging or "hourglass" membranes. During a five year period, 15 patients with bulging or hourglass membranes and marked cervical dilation in the second trimester were treated with emergent cerclage. Included were two triplet gestations. Complications were limited to intraoperative rupture of fetal membranes in two patients and chorioamnionitis either in the early postoperative period (two) or later in pregnancy (three). Pregnancy was prolonged for a sufficient time to deliver viable fetuses in 11 of 15 patients. Eleven of 13 neonates of a gestational age of 24 weeks or more survived. The lack of significant maternal morbidity combined with the results for the fetus-infant supports further efforts in this area.