Outcomes of trial of labor following previous cesarean delivery among women with fetuses weighing >4000 g

OBJECTIVE

To compare outcomes at term of a trial of labor in women with previous cesarean delivery who delivered neonates weighing > 4000 g versus women with those weighing < or = 4000 g.

STUDY DESIGN

We reviewed medical records for all women undergoing a trial of labor after prior cesarean delivery during a 12-year period. The current analysis was limited to women at term with one prior cesarean and no other deliveries. The rates of cesarean delivery and symptomatic uterine rupture for women with infants weighing > 4000 g were compared to the rates for women with infants weighing < or = 4000 g. Logistic regression was used to control for the potential confounding by use of epidural, maternal age, labor induction, labor augmentation, indication for previous cesarean, type of uterine hysterotomy, year of delivery, receiving public assistance, and maternal race. Adjusted odds ratios and 95% confidence intervals were calculated.

RESULTS

Of 2749 women, 13% (365) had infants with birth weights > 4000 g. Cesarean delivery rate associated with birth weights < or = 4000 g was 29% versus 40% for those with birth weights > 4000 g (P = .001). With use of logistic regression, we found that birth weight > 4000 g was associated with a 1.7-fold increase in risk of cesarean delivery (95% CI, 1.3-2.2). The rate of uterine rupture for women with infants weighing < or = 4000 g was 1.0% versus a 1.6% rate for those with infants weighing > 4000 g (P = .24). Although the logistic regression analysis revealed a somewhat higher rate of uterine rupture associated with birth weights of > 4000 g (adjusted OR, 1.6; 95% CI, 0.7-4.1), this difference was not statistically significant. The rate of uterine rupture was 2.4% for women with infants weighing > 4250 g, but this rate did not differ significantly from the rate of uterine rupture associated with birth weights < or = 4250 g (P = .1).

CONCLUSION

A trial of labor after previous cesarean delivery may be a reasonable clinical option for pregnant women with suspected birth weights of > 4000 g, given that the rate of uterine rupture associated with these weights does not appear to be substantially increased when compared to lower birth weights. However, some caution may apply when considering a trial of labor in women with infants weighing > 4250 g. In these women with infants weighing > 4000 g, the likelihood of successful vaginal delivery, although lower than for neonates weighing < or = 4000 g, is still 60%.

Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women

OBJECTIVE

Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning.

STUDY DESIGN

Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm.

RESULTS

At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2--2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7--7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3--4.8), and women who breast-fed were > or = 4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7--7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations.

CONCLUSIONS

Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth.

Trial of labor after 40 weeks' gestation in women with prior cesarean

OBJECTIVE

To compare outcomes in women with prior cesareans delivering at or before 40 weeks' gestation with those delivering after 40 weeks.

METHODS

We reviewed labor outcomes over 12 years at one institution for women with one prior cesarean and no other deliveries who had a trial of labor at term. We analyzed the rates of symptomatic uterine rupture and cesarean for term deliveries before or after 40 weeks and stratified for spontaneous and induced labor. Potential confounding by birth weight was controlled using logistic regression. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

Of 2775 women with one prior scar and no other deliveries, 1504 delivered at or before 40 weeks and 1271 delivered after 40 weeks. For spontaneous labor, rupture rate at or before 40 weeks was 0.5% compared with 1.0% after 40 weeks (P =.2, adjusted OR 2.1, CI 0.7, 5.7). For induced labor, uterine rupture rates were 2.1% at or before 40 weeks and 2.6% after 40 weeks (P =.7, adjusted OR 1.1, CI 0.4, 3.4). For spontaneous labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 25% compared with 33.5% after 40 weeks (P =.001, adjusted OR 1.5, CI 1.2, 1.8). For induced labor, rate of cesareans during subsequent trials of labor at or before 40 weeks was 33.8% compared with 43% after 40 weeks (P =.03, adjusted OR 1.5, CI 1.1, 2.2).

CONCLUSION

The risk of uterine rupture does not increase substantially after 40 weeks but is increased with induction of labor regardless of gestational age. Because spontaneous labor after 40 weeks is associated with a cesarean rate similar to that following induced labor before 40 weeks, awaiting spontaneous labor after 40 weeks does not decrease the likelihood of successful vaginal delivery.

Oxytocin dose and the risk of uterine rupture in trial of labor after cesarean

OBJECTIVE

To examine the association between uterine rupture and oxytocin use in trial of labor after cesarean.

METHODS

A case-control study was performed. Cases were all women with uterine ruptures who received oxytocin during a trial of labor after a single cesarean delivery within a 12-year period (n = 24). Four controls undergoing trial of labor after a single cesarean delivery were matched to each case by 500 g birth weight category, year of birth, and by induction or augmentation (n = 96). The study had an 80% power to detect a 40% increase in oxytocin duration or a 65% increase in total oxytocin dose.

RESULTS

No significant differences were seen in initial oxytocin dose, maximum dose, or time to maximum dose. Although women with uterine ruptures had higher exposure to oxytocin as measured by mean total oxytocin dose (544 mU higher) and oxytocin duration (54 minutes longer), these differences were not statistically significant. Women with uterine rupture who received oxytocin were more likely to have experienced an episode of uterine hyperstimulation (37.5% compared with 20.8%, P =.05). However, the positive predictive value of hyperstimulation for uterine rupture was only 2.8%.

CONCLUSION

Although no significant differences in exposure to oxytocin were detected between cases of uterine rupture and controls, the rarity of uterine rupture limited our power to detect small differences in exposure. In women receiving oxytocin, uterine rupture is associated with an increase in uterine hyperstimulation, but the clinical value of hyperstimulation for predicting uterine rupture is limited.

Interdelivery interval and risk of symptomatic uterine rupture

OBJECTIVE

To relate interdelivery interval to risk of uterine rupture during a trial of labor after prior cesarean delivery.

METHODS

We reviewed the medical records of all women who had a trial of labor after cesarean delivery over 12 years (July 1984 to June 1996). Analysis was limited to women with only one prior cesarean delivery and no prior vaginal deliveries who delivered term singletons and whose medical records included the month and year of the prior delivery. The time in months between the prior cesarean delivery and the index trial of labor was calculated, and the women were divided accordingly to permit comparison with respect to symptomatic uterine rupture.

RESULTS

Two thousand four hundred nine women had trials of labor after one prior cesarean delivery and had complete data from the medical records. There were 29 uterine ruptures (1.2%) in the population. For interdelivery intervals up to 18 months, the uterine rupture rate was 2.25% (seven of 311) compared with 1.05% (22 of 2098) with intervals of 19 months or longer (P =.07). Multiple logistic regression was used to assess the risk of uterine rupture according to interdelivery interval while controlling for maternal age, public assistance, length of labor, gestational age at least 41 weeks, and oxytocin use. Women with interdelivery intervals of up to 18 months were three times as likely (95% confidence interval, 1.2, 7.2) to have symptomatic uterine rupture.

CONCLUSION

Interdelivery intervals of up to 18 months were associated with increased risk of symptomatic uterine rupture during a trial of labor after cesarean delivery compared with that for longer interdelivery intervals.

Effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor

OBJECTIVE

We examined the effect of prior vaginal delivery on the risk of uterine rupture in pregnant women undergoing a trial of labor after prior cesarean delivery.

STUDY DESIGN

The medical records of all pregnant women with a history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. For the current analysis, the study population was limited to term pregnancies. The effect of previous vaginal delivery on the risk of uterine rupture during a subsequent trial of labor was evaluated. Separate analyses were performed for women with a single previous cesarean delivery and for those with >1 prior cesarean delivery. For each of these subgroups, the rate of uterine rupture among women who had > or =1 prior vaginal delivery was compared with the rate among women with no prior vaginal delivery. Logistic regression analysis was used to examine the associations with control for confounding factors.

RESULTS

Of 3783 women with 1 prior scar, 1021 (27.0%) also had > or =1 prior vaginal delivery. During a subsequent trial of labor, the rate of uterine rupture was 1.1% among pregnant women without prior vaginal delivery and 0.2% among pregnant women with prior vaginal delivery (P =.01). Logistic regression analysis controlling for duration of labor, induction, birth weight, maternal age, year of birth, epidural analgesia, and oxytocin augmentation indicated that, among women with a single scar, those with a prior vaginal delivery had a risk of uterine rupture that was one fifth that of women without a previous vaginal delivery (odds ratio, 0.2; 95% confidence interval, 0.04-0.8). In the group of 143 pregnant women with >1 previous cesarean delivery, women with a prior vaginal delivery had a somewhat lower risk of uterine rupture (3.9% vs 2.5%; adjusted odds ratio, 0.6; 95% confidence interval, 0.01-6.7). This difference was not statistically significant.

CONCLUSION

Among women with 1 prior cesarean delivery undergoing a subsequent trial of labor, those with a prior vaginal delivery were at substantially lower risk of uterine rupture than women without a previous vaginal delivery.

Preeclampsia-eclampsia: clinical and neuroradiographic correlates and insights into the pathogenesis of hypertensive encephalopathy

PURPOSE

To investigate the clinical parameters that are associated with the development of brain edema of hypertensive encephalopathy in patients with preeclampsia-eclampsia.

MATERIALS AND METHODS

Twenty-eight patients with preeclampsia-eclampsia and neurologic symptoms underwent magnetic resonance (MR) imaging. Clinical parameters recorded at the time of MR imaging included serum electrolytes and various indices of hematologic, renal, and hepatic function. Several data were available 1 week prior to the development of neurologic symptoms in 11 patients. Univariate analysis and multivariate logistic regression analyses were performed to study possible associations between these parameters and brain edema at MR imaging.

RESULTS

The 20 patients with brain edema at MR imaging had a significantly greater incidence of abnormal red blood cell morphology (14 [82%] of 17 patients vs two [25%] of eight, P: <.005) and higher levels of lactic dehydrogenase (LDH) (339 U/L +/- 65 [SD] vs 258 U/L +/- 65, P: =.007) than the eight with normal MR imaging findings; multivariate logistic regression analysis showed a strong association with red blood cell morphology only. Moreover, LDH levels were elevated before the development of neurologic abnormalities (P: <.05). Blood pressures were not significantly different between groups at any time.

CONCLUSION

Brain edema at MR imaging in patients with preeclampsia-eclampsia was associated with abnormalities in endothelial damage markers and not with hypertension level.

Labor after previous cesarean: influence of prior indication and parity

OBJECTIVE

To determine whether the risk of cesarean for women who had trials of labor after one prior cesarean differs from that of nulliparas overall and by indications for those cesareans.

METHODS

We reviewed medical records of women who had trials of labor after cesareans between July 1984 and June 1996, and of nulliparas who delivered between December 1994 and August 1995. Cesarean rates for women with prior cesareans were compared with the rates for nulliparas overall and by prior cesarean indication (breech, failure to progress, nonreassuring fetal testing, or other). Lengths of labor for women who had repeat cesareans for failure to progress in index pregnancies were compared by prior cesarean indication.

RESULTS

The cesarean rate was 28.7% (634 of 2207) for the prior cesarean group and 13.5% (219 of 1617) for nulliparas (P =.001), and varied according to the prior cesarean indication (13.9%, 37.3%, 25. 4%, and 24.8% for breech, failure to progress, nonreassuring fetal testing, and other, respectively). Mean durations of labor in the index pregnancies for women who had cesareans for failure to progress were 13.9, 11.5, 13.4, and 15.1 hours for breech, failure to progress, nonreassuring fetal testing, and other, respectively.

CONCLUSION

Overall rates of cesareans were higher for women with one prior cesarean than for nulliparas. Rates of cesareans after trials of labor were related to the prior cesarean indications. Rates were highest for women whose prior cesareans were for failure to progress and lowest for women whose prior cesareans were for breech. The latter group had a rate that was essentially identical to that of nulliparas. Among women with cesareans for failure to progress in index pregnancies, lengths of labor were shorter for those whose prior cesareans were for failure to progress than for those whose prior cesareans were for other indications, suggesting that physicians may intervene earlier in these cases.

Midline episiotomy and anal incontinence: retrospective cohort study

OBJECTIVE

To evaluate the relation between midline episiotomy and postpartum anal incontinence.

DESIGN

Retrospective cohort study with three study arms and six months of follow up.

SETTING

University teaching hospital.

PARTICIPANTS

Primiparous women who vaginally delivered a live full term, singleton baby between 1 August 1996 and 8 February 1997: 209 who received an episiotomy; 206 who did not receive an episiotomy but experienced a second, third, or fourth degree spontaneous perineal laceration; and 211 who experienced either no laceration or a first degree perineal laceration.

MAIN OUTCOME MEASURES

Self reported faecal and flatus incontinence at three and six months postpartum.

RESULTS

Women who had episiotomies had a higher risk of faecal incontinence at three (odds ratio 5.5, 95% confidence interval 1.8 to 16.2) and six (3.7, 0.9 to 15.6) months postpartum compared with women with an intact perineum. Compared with women with a spontaneous laceration, episiotomy tripled the risk of faecal incontinence at three months (95% confidence interval 1.3 to 7.9) and six months (0.7 to 11.2) postpartum, and doubled the risk of flatus incontinence at three months (1.3 to 3.4) and six months (1.2 to 3.7) postpartum. A non-extending episiotomy (that is, second degree surgical incision) tripled the risk of faecal incontinence (1.1 to 9.0) and nearly doubled the risk of flatus incontinence (1.0 to 3.0) at three months postpartum compared with women who had a second degree spontaneous tear. The effect of episiotomy was independent of maternal age, infant birth weight, duration of second stage of labour, use of obstetric instrumentation during delivery, and complications of labour.

CONCLUSIONS

Midline episiotomy is not effective in protecting the perineum and sphincters during childbirth and may impair anal continence.

Preeclampsia prevention and management

Preeclampsia is a multisystem disorder specific to pregnancy with a high maternal and perinatal morbidity and mortality. The cause of this disorder is unknown. Preeclampsia likely represents the clinical end point of multiple contributory factors, and it is unlikely that any single cause will be found. The blueprint for the development of preeclampsia is laid down early in pregnancy, and delivery of the fetus and placenta remains the only effective treatment. Efforts to prevent preeclampsia in women at high risk have been largely unsuccessful. Until the pathogenesis of preeclampsia is well defined, it is unlikely that effective preventive strategies will be developed.

The role of calcium in health and disease

Skeletal fragility at the end of the life span (osteoporosis) is a major source of morbidity and mortality. Adequate calcium intake from childhood to the end of the life span is critical for the formation and retention of a healthy skeleton. High intakes of calcium and vitamin D potentiate the bone loss prevention effects of hormone replacement therapy in postmenopausal women. Pregnancy and lactation are not risk factors for skeletal fragility, although lactation is associated with a transient loss of bone that cannot be prevented by calcium supplementation. Low calcium intake has been implicated in the development of hypertension, colon cancer, and premenstrual syndrome, and it is associated with low intakes of many other nutrients. Encouragement of increased consumption of calcium-rich foods has the potential to be a cost-effective strategy for reducing fracture incidence later in life and for increasing patients' dietary quality and overall health.

Intrapartum uterine rupture and dehiscence in patients with prior lower uterine segment vertical and transverse incisions

OBJECTIVE

To determine whether gravidas with prior low vertical uterine incision(s) are at a higher risk for uterine rupture during a trial of labor after cesarean delivery than women with prior low transverse uterine incision(s).

METHODS

The medical records of women undergoing a trial of labor after prior cesarean delivery over a 12-year period (July 1984-June 1996) at a tertiary-care hospital were reviewed. Maternal and perinatal outcomes for women with prior low transverse and low vertical incision were compared. Women whose low vertical incision was noted to extend into the corpus of the uterus were excluded. All uterine scar disruptions, which included both symptomatic ruptures and detected asymptomatic dehiscences, were analyzed together, and ruptures were examined separately.

RESULTS

The outcomes of 2912 patients undergoing trial of labor for the low transverse group and 377 patients undergoing trial of labor for the low vertical group were compared. Overall, there were 38 (1.3%) scar disruptions in the low transverse group and six (1.6%) in the low vertical group, P = .6. There were 28 (1.0%) symptomatic ruptures in the low transverse group and 3 (0.8%) in the low vertical group, P > .999. The study had a power of 80% to detect an increase in the low vertical rupture rate from 1% (as noted for low transverse incisions) to 3%.

CONCLUSION

Gravidas with a prior low vertical uterine incision are not at increased risk for uterine rupture during a trial of labor compared with women with a prior low transverse uterine incision.

Uterine rupture during induced or augmented labor in gravid women with one prior cesarean delivery

OBJECTIVE

Our purpose was to examine the risk of uterine rupture during induction or augmentation of labor in gravid women with 1 prior cesarean delivery.

STUDY DESIGN

The medical records of all gravid women with history of cesarean delivery who attempted a trial of labor during a 12-year period at a single center were reviewed. The current analysis was limited to women at term with 1 prior cesarean delivery and no other deliveries. The rate of uterine rupture in gravid women within that group undergoing induction was compared with that in spontaneously laboring women. The association of oxytocin induction, oxytocin augmentation, and use of prostaglandin E(2) gel with uterine rupture was determined. Logistic regression analysis was used to examine these associations, with control for confounding factors.

RESULTS

Of 2774 women in the analysis, 2214 had spontaneous onset of labor and 560 women had labor induced with oxytocin or prostaglandin E(2) gel. The overall rate of rupture among all patients with induction of labor was 2.3%, in comparison with 0.7% among women with spontaneous labor (P =.001). Among 1072 patients receiving oxytocin augmentation, the rate of uterine rupture was 1.0%, in comparison with 0.4% in nonaugmented, spontaneously laboring patients (P =.1). In a logistic regression model with control for birth weight, use of epidural, duration of labor, maternal age, year of delivery, and years since last birth, induction with oxytocin was associated with a 4.6-fold increased risk of uterine rupture compared with no oxytocin use (95% confidence interval, 1.5-14.1). In that model, augmentation with oxytocin was associated with an odds ratio of 2.3 (95% confidence interval, 0.8-7.0), and use of prostaglandin E(2) gel was associated with an odds ratio of 3.2 (95% confidence interval, 0.9-10.9). These differences were not statistically significant.

CONCLUSION

Induction of labor with oxytocin is associated with an increased rate of uterine rupture in gravid women with 1 prior uterine scar in comparison with the rate in spontaneously laboring women. Although the rate of uterine rupture was not statistically increased during oxytocin augmentation, use of oxytocin in such cases should proceed with caution.

Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries

OBJECTIVE

We sought to determine whether there is a difference in the rate of symptomatic uterine rupture after a trial of labor in women who have had 1 versus 2 prior cesarean deliveries.

STUDY DESIGN

The medical records of all women with a history of either 1 or 2 prior cesarean deliveries who elected to undergo a trial of labor during a 12-year period (July 1984-June 1996) at the Brigham and Women's Hospital were reviewed. Rates of uterine rupture were compared for these 2 groups. Potential confounding variables were controlled by using logistic regression analyses.

RESULTS

Women with 1 prior cesarean delivery (n = 3757) had a rate of uterine rupture of 0.8%, whereas women with 2 prior cesarean deliveries (n = 134) had a rate of uterine rupture of 3.7% (P =.001). In a logistic regression analysis that was controlled for maternal age, use of epidural analgesia, oxytocin induction, oxytocin augmentation, the use of prostaglandin E(2) gel, birth weight, gestational age, type of prior hysterotomy, year of trial of labor, and prior vaginal delivery, the odds ratio for uterine rupture in those patients with 2 prior cesarean deliveries was 4.8 (95% confidence interval, 1.8-13. 2)

CONCLUSIONS

Women with a history of 2 prior cesarean deliveries have an almost 5-fold greater risk of uterine rupture than those with only 1 prior cesarean delivery.

Eclampsia: a 13-year experience at a United States tertiary care center

Eclampsia, the occurrence of a grand mal seizure in the setting of hypertension in pregnancy, remains a major women's health issue and an important cause of maternal and fetal morbidity in the United States. We reviewed the incidence, management, and outcome of cases of eclampsia during a 13-year period at a major maternity hospital. We confirmed 33 cases of eclampsia seen during that period and have evaluated risk factors in this population. Medical records were reviewed to obtain demographic and clinical data. Characteristics of the eclamptic women were compared with those of the general obstetric population during the same time period. The overall incidence of eclampsia at this tertiary care center was 0.028%. The majority of eclamptic women (75%) had four or more prenatal visits. Young age (< or = 20 years) and first pregnancy remained important risk factors for eclampsia. Although many women with eclampsia had preceding hypertension or elevated urine protein levels or both, some experienced eclampsia as their first disease manifestation. Although the occurrence of eclampsia was low, eclampsia continues to complicate pregnancy in this large U.S. obstetric population.

Trial of labor after cesarean delivery: the effect of previous vaginal delivery

OBJECTIVE

This study examined the effects of order of previous modes of delivery on the rate of cesarean delivery and duration of a trial of labor among women with a history of 1 previous cesarean delivery and 1 previous vaginal delivery.

STUDY DESIGN

The medical records of 4393 women at our institution who were seen June 1984-July 1996 for a trial of labor after a previous cesarean delivery were abstracted. The 800 women with a history of 1 previous cesarean and 1 previous vaginal delivery were included in this analysis. They were split into 2 groups by obstetric history: (1) 1 cesarean delivery followed by 1 vaginal delivery (vaginal last) and (2) 1 vaginal delivery followed by 1 cesarean delivery (cesarean last). Patient characteristics, durations of labor, and rates of cesarean delivery were compared with chi2 analysis, the Student t test, and the Wilcoxon rank sum test. Possible confounding variables were controlled for with multivariate logistic regression.

RESULTS

The rates of cesarean delivery for the vaginal last and cesarean last groups were 7.2% and 14.7%, respectively (P = .002). The median durations of labor for the vaginal last and cesarean last groups were 5.6 and 7.0 hours, respectively (P = .01). The differences in cesarean rates and durations of labor were seen regardless of the indication for the previous cesarean delivery.

CONCLUSIONS

Among women with 1 previous cesarean and 1 previous vaginal delivery, those whose most recent delivery was vaginal had a lower rate of cesarean delivery and shorter duration of labor than did those whose most recent delivery was cesarean.

May-Hegglin anomaly: a case of vaginal delivery when both mother and fetus are affected

May-Hegglin anomaly is a rare, autosomal dominant disorder characterized by thrombocytopenia and a variable bleeding tendency. In almost all the case reports in the recent literature, platelet transfusion and cesarean section were performed to avoid maternal and neonatal bleeding. We present a case of a woman with May-Hegglin anomaly who had no history of a bleeding tendency. She had a vaginal delivery and a platelet count of 16,000/mm3; the neonate's platelet count was 35,000/mm3. There were no complications. We advocate a reappraisal of basing platelet transfusion and mode of delivery on the platelet count in patients with May-Hegglin anomaly.

The prevention and management of pre-eclampsia and eclampsia

Pre-eclampsia and eclampsia remain one of the leading causes of maternal morbidity and mortality worldwide. They also contribute to perinatal morbidity and mortality as well. Multiple strategies have been proposed for the prevention of pre-eclampsia, with mixed results. Likewise, different strategies for the management of pre-eclampsia have been proposed, also with mixed results. While the prevention of pre-eclampsia remains unachievable, meticulous medical management of mother and fetus will contribute to an overall lowering of pre-eclampsia and eclampsia's contribution to perinatal and maternal morbidity and mortality.

Regulation of the sodium pump in pregnancy-related tissues in preeclampsia

OBJECTIVE

This study examined the expression of the three alpha-isoforms of the sodium pump in preeclampsia. Reductions in sodium pump number and activity in smooth muscle may underlie hypertension in preeclampsia.

STUDY DESIGN

Northern and Western analyses were used to determine whether sodium pump alpha-isoform regulation in myometrium, placenta, and umbilical artery of women with preeclampsia differed from those with normotensive pregnancies.

RESULTS

Levels of alpha1 and alpha3 messenger ribonucleic acid were reduced in myometrium of women with preeclampsia compared with normotensive pregnancies, as was alpha2 messenger ribonucleic acid in preeclamptic placenta. Protein expression of the alpha-isoforms was unaltered in placenta and umbilical artery from women with preeclampsia versus those with normotensive pregnancies, but myometrial alpha2 protein levels were reduced significantly in women with preeclampsia. Moreover, myometrial alpha1 protein expression was undetectable.

CONCLUSIONS

Reduced smooth muscle sodium pump expression in preeclampsia may raise cell sodium, increase pressor sensitivity, or increase tone directly, which may contribute to hypertension in preeclampsia.

Hypertensive disorders of pregnancy. Differentiating preeclampsia from active systemic lupus erythematosus

The diagnosis of preeclampsia is made on the basis of hypertension, proteinuria and edema. Unfortunately, all three of these findings can be seen in the patient who is experiencing a flare of systemic lupus erythematosus. The management of these conditions is entirely different. Preeclampsia frequently results in the need for delivery and occasionally, especially when remote from term, can result in significant neonatal morbidity and mortality. Systemic lupus may be treatable with a variety of pharmacologic agents. It is not always possible to make the distinction between active lupus and preeclampsia, and occasionally the two occur concurrently. Nevertheless, the goal of the rheumatologist and perinatologist is to try to make that distinction. Physical findings and serologic markers can be useful in helping to distinguish between these two diagnoses. Under certain circumstances, delivery is indicated despite the presence of continued uncertainty as to the actual diagnosis.

Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management

Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.

Birth weight as a predictor of brachial plexus injury

OBJECTIVE

To examine the relationship between birth weight and brachial plexus injury and estimate the number of cesareans needed to reduce such injuries.

METHODS

All 80 neonatal records coded for brachial plexus injury from October 1985 to September 1993 at the Brigham and Women's Hospital in Boston, Massachusetts, were studied along with linked maternal files. Birth weight, method of delivery, presence or absence of shoulder dystocia, and any diagnosis of maternal gestational or nongestational diabetes were abstracted. Data for the group with brachial plexus injury were compared with data for live-born infants without this injury during the same period. The sensitivity and specificity of birth weight as a predictor of brachial plexus injury were calculated. Further, the number of cesarean deliveries necessary to prevent a single brachial plexus injury was estimated using various weight cutoffs (4000, 4500, and 5000 g) for elective cesarean delivery.

RESULTS

Among 77,616 consecutive deliveries, there were 80 brachial plexus injuries identified, for an incidence of 1.03 per 1000 live births. The incidence of brachial plexus injury increased with increasing birth weight, operative vaginal delivery, and the presence of glucose intolerance. In the group of women without diabetes, between 19 and 162 cesarean deliveries would have been necessary to prevent a single immediate brachial plexus injury. Among women with diabetes, between five and 48 additional cesareans would have been required.

CONCLUSION

Although birth weight is a predictor of brachial plexus injury, the number of cesarean deliveries necessary to prevent a single injury is high at most birth weights. Because of the large number of cesarean deliveries needed to prevent a single brachial plexus injury in infants born to women without diabetes, it is difficult to recommend routine cesarean delivery for suspected macrosomia in these women.

The value of elevated second-trimester beta-human chorionic gonadotropin in predicting development of preeclampsia

OBJECTIVE

Our purpose was to investigate the association of an elevated second-trimester serum beta-human chorionic gonadotropin concentration with the subsequent development of hypertension in pregnancy and to evaluate its utility as a screening test for preeclampsia.

STUDY DESIGN

We examined 6286 nondiabetic women with singleton pregnancies who, as part of triple-screen testing, had a serum beta human chorionic gonadotropin level drawn between 15 and 22 weeks' gestation between November 1, 1991, and November 30, 1994. Medical records of women with hypertension (n = 675) were reviewed, patients with chronic hypertension were excluded, and the remainder were classified as having gestational hypertension (n = 333), mild preeclampsia (n = 110), or severe preeclampsia (n = 84). The beta-human chorionic gonadotropin level expressed as multiples of the median adjusted for maternal weight and gestational age was compared between normotensive and hypertensive complicated pregnancies.

RESULTS

In the overall population beta-human chorionic gonadotropin levels > or = 2.0 multiples of the median during the second trimester were significantly associated with development of hypertension in pregnancy. The rate ratio for development of overall hypertension was 1.6 (95% confidence interval 1.3 to 2.0) and for preeclampsia 1.8 (95% confidence interval 1.3 to 2.6). When stratified by parity, a statistically significant association remained only among multiparous women, for overall hypertension (rate ratio 2.2, 95% confidence interval 1.6 to 3.2) and for preeclampsia (rate ratio 3.4, 95% confidence interval 2.1 to 5.6). Adjusting for confounding factors did not alter the results. In the overall population, with the use of 2.0 multiples of the median of beta-human chorionic gonadotropin as a cutoff value, the sensitivity of beta-human chorionic gonadotropin as a screen for development of hypertension was 15.6%, the specificity was 90.0%, and the positive predictive value was 12.8%.

CONCLUSION

Overall, second-trimester serum beta-human chorionic gonadotropin levels were elevated among women who had hypertension during pregnancy. In our population this association was statistically significant only among multiparous women. The utility of an elevated second-trimester beta-human chorionic gonadotropin level as a screening test for preeclampsia is limited.

Obstetric management of the high-risk lupus pregnancy

With improvements in diagnosis and treatment, the prognosis of patients with systemic lupus erythematosus has generally improved in recent years, and similarly the outlook for women who become pregnant in the setting of this disorder is far more optimistic than it once was. The risk of significant morbidity to both the mother and fetus exists, however. Beginning with preconception counseling, a careful and thorough approach to the care of the patient and cooperation among her various health care providers optimizes the chance of a successful pregnancy.

A randomized controlled trial of prenatal pediatric visits for urban, low-income families

BACKGROUND

Prenatal pediatric visits have been recommended by the American Academy of Pediatrics to allow the pediatrician to counsel parents on infant care issues, establish a supportive relationship, and provide pediatric practice information to parents. We hypothesized that prenatal pediatric visits would have an impact on breastfeeding decisions, health care behaviors, health care utilization, and the doctor-patient relationship.

METHODS

We conducted a randomized controlled trial of prenatal pediatric visits for urban, low-income families to measure the impact on breastfeeding decisions, infant car safety seat use, circumcision, health maintenance, and emergency room visits and the pediatrician's perception that he/she would know the mother better. Pregnant women were recruited prenatally from the obstetrics clinic. Outcomes were measured by maternal interview prenatally and when the infant was 2 months old, in addition to review of the nursery record. Physicians were interviewed after the 2-month visit. Health care utilization was measured by chart review at 7 months.

RESULTS

A total of 156 pregnant women were enrolled and randomized, 81 to the intervention group and 75 to the control group. Of mothers who breastfed, 45% in the intervention group changed their mind in favor of breastfeeding after enrollment compared with 14% in the control group. Mothers in the intervention group compared with the control group were more likely to make fewer emergency room visits, 0.58 compared with 1.0. Pediatricians were more likely to think that they knew mothers in the intervention group well, 54% versus 29% in the control group, yet 67% of mothers in both groups agreed their pediatrician knew them well. There were no differences between groups in initiation or duration of breastfeeding at 30 or 60 days, infant car safety seat use, circumcision, or health maintenance visits.

CONCLUSIONS

Prenatal pediatric visits have potential impact on a variety of health care outcomes. Among urban, low-income mothers, we found beneficial effects on breastfeeding decisions, a decrease in emergency department visits, and an initial impact on the doctor-patient relationship. We suggest urban practices actively promote prenatal pediatric visits.

Depressive symptoms, stress, and social support in pregnant and postpartum adolescents

OBJECTIVE

To assess prospectively the incidence and course of depressive symptoms among pregnant and postpartum adolescents and explore the roles of stress and social support as influencing factors.

METHODS

Pregnant teenagers attending a comprehensive adolescent pregnancy and parenting program were enrolled during their third trimester of pregnancy and followed up through 4 months post partum. Depressive symptoms and social support were measured with validated, self-administered instruments during the third trimester and at 2 and 4 months post partum. Stress was measured during the prenatal and postpartum periods.

RESULTS

Study participants (N=125) were predominantly black (93%), and wee aged 12 to 18 years. Completed assessments were obtained from 114 subjects at 2 months post partum and 108 at 4 months. Forty-two percent had significant depressive symptoms in the third trimester, with 36% and 32% having scores that indicated depression at 2 and 4 months post partum. Stress levels increased significantly from the third trimester to the postpartum period (P < .01) and were positively associated with depressive symptoms. Receiving social support from the adolescent's mother or the infant's father, especially in the postpartum period, was significantly associated with lower rates of depression. Reporting conflict with the infant's father was strongly associated with increased rates of depressive symptoms.

CONCLUSIONS

Results indicate that depressive symptoms are common among pregnant teenagers and postpartum adolescents. Stress and social support appear to be important mediators. Identifying those teenagers with high stress and conflict and low levels of support will help identify those who are at particular risk for depressive symptoms.

A prospective longitudinal evaluation of pregnancy in the Marfan syndrome

OBJECTIVE

We undertook a prospective evaluation of the outcomes of pregnancy, both maternal and fetal, and the long-term impact of pregnancy on Marfan syndrome in a series of consecutive, unselected patients.

STUDY DESIGN

Forty-five pregnancies in 21 Marfan syndrome patients were prospectively observed in one institution between 1983 and 1992. During pregnancy, patients were monitored with serial echocardiograms and close attention to symptoms. Maternal and fetal outcomes were monitored with serial echocardiographic data were analyzed by least-squares regression. Eighteen of the patients were followed up for 15 months to 13 years after the completion of their last pregnancy for investigation of the long-term impact of pregnancy on the cardiovascular manifestations of Marfan syndrome.

RESULTS

Aortic dissection occurred in two patients, both with increased risk for dissection established before pregnancy. The incidence of obstetric complications otherwise did not exceed that in the general population. Echocardiographic data demonstrated little to no change in aortic root diameter throughout pregnancy in most patients. Long-term follow-up showed no apparent worsening of cardiovascular status attributable to pregnancy in comparison with a group of 18 women with Marfan syndrome who were of similar age, had a similar degree of disease severity, and underwent no pregnancies.

CONCLUSIONS

Patients with Marfan syndrome in whom cardiovascular involvement is minor and aortic root diameter is < 40 mm usually tolerate pregnancy well, with favorable maternal and fetal outcomes, and without subsequent evidence of aggravated aortic root dilatation over time.

Evaluation of preterm delivery in a systemic lupus erythematosus pregnancy clinic

OBJECTIVE

To identify the primary etiology of preterm birth in women with systemic lupus erythematosus, analyzing prospective data collected on 66 pregnancies in 58 women followed-up at a lupus pregnancy center.

METHODS

Hospital records were reviewed and subjects were interviewed for pregnancies delivered after 23 completed weeks' gestation in women cared for at the Hopkins Lupus Pregnancy Center. A control group consisted of all women delivered at the same hospital during 2 years of the study period.

RESULTS

Preterm premature rupture of membranes (PROM) occurred in 13 of 33 (39%) pregnancies delivered at 24-36 weeks' gestation. In addition, term PROM also occurred with high incidence in ten of 33 (30.3%) pregnancies delivered after 36 weeks' gestation. The rate of PROM in study subjects differed from that in controls at 34-36 weeks' gestation and after 36 weeks.

CONCLUSION

Premature rupture of membranes is more common in pregnancies occurring in women with systemic lupus erythematosus than in control pregnancies. Disease activity, prednisone use, and serologic studies are not predictive. Premature rupture of membranes is the major etiology of preterm birth in this cohort.

Eclampsia

This article defines and then delineates pre-eclampsia and eclampsia, reviewing the clinical features, neurologic manifestations, and underlying causes. There is a review of the pathophysiology including hypertension, coagulopathy, and cerebral pathology including newer findings involving immune system abnormalities. The diagnosis including laboratory studies, imaging, and electroencephalography.

[Ca2+]i signaling in pregnant human myometrium

The purpose of the present study was to determine the changes in intracellular ionized calcium concentration ([Ca2+]i) or [Ca2+]i sensitivity accompanying spontaneous and agonist-induced contraction of human myometrium at term pregnancy, as well as to quantify the response to three prototypical agonists: 1) oxytocin, 2) vasopressin, and 3) phenylephrine. Uterine biopsies were obtained at the time of cesarean section from patients who delivered at or near full-term gestation. These preparations were used to measure isometric force development and [Ca2+]i levels with the luminescent calcium indicator aequorin. Concentration-response relationships were determined with respect to isometric force development in the presence of the agonist. [Ca2+]i-force relationships were determined with respect to spontaneous phasic contractions, as well as agonist-induced phasic and tonic contractions. The results provide evidence that the phasic nature of term human myometrium is due to 1) the resting [Ca2+]i level being less than the calcium threshold for contractions and 2) the inability of the tissue to maintain high [Ca2+]i levels for prolonged periods of time. In addition, calcium-independent mechanisms of regulation were suggested by the relatively minor calcium sensitizing action of oxytocin and the observation that relaxation of tonic contractions preceded the fall in [Ca2+]i levels.

Elevated serum human chorionic gonadotropin as evidence of secretory response in severe preeclampsia

OBJECTIVE

Because preeclampsia is a trophoblastic disorder and human chorionic gonadotropin is secreted from trophoblast, we sought to determine whether measurement of serum human chorionic gonadotropin might reflect a different trophoblastic secretory response of preeclampsia.

STUDY DESIGN

Twenty patients with mild preeclampsia and 12 with severe preeclampsia were matched with 32 healthy, normotensive women in the third trimester with singleton pregnancies. Serum total human chorionic gonadotropin and total human chorionic gonadotropin-beta were measured by a two-site immunoenzymometric assay, and total hCG-alpha was determined by a double-antibody radioimmunoassay. Wilcoxon signed-rank and Mann-Whitney rank-sum tests were used for statistical analysis.

RESULTS

Serum total human chorionic gonadotropin, total human chorionic gonadotropin-alpha, and total human chorionic gonadotropin-beta levels were significantly higher in severely preeclamptic women (p < 0.05), but not in those with mild preeclampsia, compared with those in their matched controls.

CONCLUSION

Elevated serum human chorionic gonadotropin levels in severely preeclamptic women might reflect a significantly pathologic change and secretory reaction of the placenta.

Phenytoin versus magnesium sulfate in preeclampsia: a pilot study

A randomized clinical trial was designed to determine whether there are clinically demonstrable advantages of phenytoin over magnesium sulfate in preeclamptic patients because of the latter drug's uterine relaxant properties. An intravenous infusion, immediately after randomization, of either phenytoin or magnesium sulfate, with subsequent measurement of serum concentrations and maintenance of therapeutic levels was given to 103 preeclamptic and two eclamptic women. Observed were the rate of cervical dilation during active labor and change in hematocrit between predelivery and 24-hour postdelivery values and the incidence of side effects ascertained by interview. Compared with those receiving magnesium sulfate, patients receiving phenytoin had more rapid cervical dilation (3.3 cm/hr versus 1.5 cm/hr, p = 0.016) and a smaller fall in hematocrit after delivery (-4.7% versus -7.6%, p = 0.034). A significantly lower incidence of hot flushes (15% versus 46%, p < 0.005) and a trend toward less dyspnea and weakness were reported by phenytoin-treated patients. Our phenytoin regimen produced acceptable serum phenytoin levels (10 to 25 micrograms/ml) in 96% of patients.

Drug supplementation in pregnancy

Since antiquity, there have been references in medicine to the role of nutrition in pregnancy outcome. Reviewing articles on nutrition and drug supplementation in pregnancy, one is struck by the variety of remedies that have been tried and the variety of effects that have been attributed to them. The number of herbal remedies that have been touted is astounding, and the entire science of Geophagia evolved in the hope identifying of those population-specific customs that may have had a positive effect on birth outcome as an adaptive mechanism. Most recently, there has been renewed interest in the role of nutritional and drug supplementation in pregnancy, specifically in the areas of pregnancy-induced hypertension and teratogenesis. In this article, I briefly review the role of drug supplementation in pregnancy, ranging from established needs such as iron to prevent iron-deficiency anemia to the controversies of low-dose aspirin supplementation for the prevention of preeclampsia and preconceptional folic acid supplementation for the prevention of neural tube defects.

Effect of fat and fat-free mass deposition during pregnancy on birth weight

OBJECTIVES

The purposes of our study were to describe the patterns and location of fat and fat-free mass deposition during pregnancy and to evaluate their effects on fetal growth.

STUDY DESIGN

Our study is a prospective follow-up of 105 healthy pregnant women who were delivered of term infants. Body composition was evaluated eight times during gestation with anthropometric measures and bioimpedance techniques. Body fat and fat-free mass were calculated with equations specifically developed for this population.

RESULTS

Total weight gain was 10.0 +/- 3.5 kg; net weight gain was 3.7 +/- 0.31 kg; birth weight was 3211 +/- 467 gm (values are mean +/- SEM). In these women fat was deposited mostly in the thigh and subscapular region for a total of 6.23 +/- 0.19 kg at term. The period of pregnancy of the largest maternal fat deposition per week is between the twentieth and thirtieth weeks. After adjusting by prepregnancy weight, birth weight is associated with maternal changes in thigh skin folds and fat gain before the thirtieth week of gestation. Infants born to mothers with low fat gain before the thirtieth week were 204 gm lighter than infants born to mothers with fat gain > or = 25th percentile of this population.

CONCLUSION

Maternal nutritional status at the beginning of gestation and the rate of fat gain early in pregnancy are the two nutritional indicators most strongly associated with fetal growth in this population.

Seroprevalence of human immunodeficiency virus type 1 among pregnant women

Five (0.74%) of 678 women delivering in 1985 at a tertiary referral hospital for high-risk pregnancies and 16 (1.34%) of 1198 women visiting an urban prenatal obstetrics clinic in 1986-1987 had serologic evidence of human immunodeficiency virus type 1 (HIV-1) infection. Unlinked testing (removal of personal identifiers from the blood specimen and the epidemiologic data sheet) of residual serum from hepatitis B virus serologic testing was used. Neither age, marital status, payor status, nor serologic markers of hepatitis B virus infection was useful in identifying women at risk for HIV-1 infection. As a result of these data, we have initiated a program in which counseling is offered to all women and testing for those who consent. Unlinked testing of women who refuse consent is performed for epidemiologic purposes. This will allow us to continue to plan for health care resource needs and to track the course of the epidemic in various subgroups of pregnant women.

Prophylaxis of eclamptic seizures: current controversies

Treatment of this pathophysiologically poorly understood disease is controversial. Despite this uncertainty, the goals of management of the patient with preeclampsia and eclampsia are diagnosis, stabilization, and delivery of the baby. Stabilization refers to both mother and fetus and should include the prevention of eclampsia or the recurrence of eclamptic seizures. There are empiric data supporting the use of magnesium sulfate for the management of preeclampsia and eclampsia in North America, but there are few data to support its efficacy as a classic anticonvulsant. Until controlled trials are completed, we suggest that magnesium sulfate continue to be used in preeclampsia, with the addition of established anticonvulsant medications when eclampsia occurs. Data on established antiepileptic drugs such as diazepam and phenytoin support their use in treating patients with eclamptic seizures. As stated in an earlier review, "in treating preeclampsia, magnesium sulfate therapy may have a role and may moderate factors leading to eclampsia. Whether magnesium sulfate therapy may have some as yet unproved effect on epileptogenic foci or seizure propagation is not the important issue for the physician caring for the eclamptic patient. Until adequately designed therapeutic trials are available, it is our opinion that treatment should be based on the use of anticonvulsant drugs of established efficacy in seizure control and prophylaxis (p. 1363)."

Prevention of preeclampsia

Preeclampsia is a disease unique to pregnancy. Treatment for the disease has remained suboptimal because of the unknown etiology of the disease. Preventive strategies have been suggested and have provided new ways to approach the patient at risk for developing preeclampsia.

Management of the pregnant lupus patient

Increased understanding of SLE as it relates to pregnancy has allowed for many women with lupus today to have a successful pregnancy. However, pregnancies are high risk with up to 25 percent ending in miscarriage and with a high frequency of preterm delivery.

Pregnancy-induced hypertension and low birth weight: the role of calcium

Considerable interest has developed regarding the role of calcium in the regulation of blood pressure. Epidemiologic investigations, laboratory evaluations, and clinical trials all confirm that the relationship between calcium and blood pressure extends to include the pregnant state. On the basis of current information it is clear that calcium supplementation during pregnancy lowers blood pressure. Additionally, the effect of calcium on blood pressure may influence the incidence and/or gestational age of development of preeclampsia. Additionally, the effect on smooth-muscle relaxation detected in calcium-supplemented patients may affect the incidence of prematurity. Although the mechanism for these effects has not been entirely elucidated, calcium supplementation appears to affect circulating concentrations of parathyroid hormone and renin, which may modulate intracellular ionized calcium, resulting in the observed effect on smooth-muscle relaxation. This effect may also be responsible for reduced uterine activity and for a lowering of the incidence of prematurity.

Calcium, magnesium, and zinc supplementation and perinatal outcome

The overall importance of nutrition to favorable perinatal outcome is only beginning to be fully appreciated. Although nutritional status can be linked to such things as socioeconomic class and education, it is nutrition directly that exerts a biologic effect. This review has attempted to look at three elements and their relationship to maternal and fetal outcome. At the present time, there does not seem to be a role for routine magnesium supplementation during pregnancy. Magnesium deficiency, as an isolated nutritional deficiency, is rare, and the evidence is, at best, weak that magnesium supplementation reduces the risk of poor perinatal outcome. Zinc deficiency is also a very rare isolated nutritional finding. Our ability to measure zinc accurately, be it in leukocytes or serum, is improving, but the routine use of zinc supplements during pregnancy cannot be recommended at this time. It may be that zinc will be a useful diagnostic marker, rather than a therapeutic intervention. There is substantial evidence that the average American diet does not contain sufficient calcium. An expansive literature continues to grow in the areas of calcium and colon cancer, calcium and breast cancer, calcium and hypertension, and calcium and osteoporosis. Is it possible that our susceptibilities to these problems begin in utero? Obviously, the answer is unknown. What is known is that supplemental calcium to some degree is needed in the diets of most Americans and in about two thirds of pregnant women. Calcium supplementation seems to affect blood pressure favorably and, pending confirmation with larger trials, may significantly reduce prematurity and preeclampsia risk, thus improving perinatal outcome for a large number of our high-risk patients.

Assessment of fibrin(ogen) degradation products in preeclampsia using immunoblot, enzyme-linked immunosorbent assay, and latex-based agglutination

Plasma and serum from pregnant women with preeclampsia (N = 35) and normotensive pregnant (N = 71) and nonpregnant (N = 10) controls were screened for fibrin(ogen) degradation products (fibrinogen and cross-linked fibrin degradation products, and fibrin polymers) using three different assay systems (immunoblot, enzyme-linked immunosorbent assay [ELISA], and latex-bead agglutination assay). All tests showed statistically significant differences (P less than .05) between the preeclamptic patients and the other two groups (pregnant and nonpregnant women). The ELISA assay for total fibrin(ogen) degradation products was the most sensitive test, but was less specific than D-dimer latex. Eleven of the 35 preeclamptic women developed HELLP syndrome (hemolysis, elevated liver enzyme, and low platelet counts). Positive tests were as common in the 11 preeclamptic women who developed the syndrome as in the 24 who did not. These results suggest that fibrinolytic disorders are secondary pathophysiologic events in the course of preeclampsia, but further studies with a larger number of patients are needed.

Routine prenatal screening for HIV infection

Guidelines in most developed countries for testing pregnant women for HIV infection recommend that screening should be directed to groups with acknowledged risk factors for infection. Our prospective study of HIV seroprevalence among 2724 pregnant women in an inner-city area of Baltimore, USA, showed that if these guidelines had been applied only 57% of HIV-seropositive women would have been detected. By offering counselling and HIV testing to all pregnant women, the detection rate was raised to 87%. We conclude that screening directed at women who admit risk factors is not effective in identifying HIV-infected women and that routine HIV screening should be offered to all pregnant women.

The incidence of human immunodeficiency virus (HIV) in fetal cord samples utilized as serum supplements for in vitro fertilization

Prior to initiating routine fetal cord serum (FCS) supplementation in our in vitro laboratory, the incidence of HIV in 306 random fetal cord samples obtained at the Labor and Delivery Unit of the Johns Hopkins Hospital from July 1985 to January 1988 was determined from a cross-sectional patient sample. Of 306 samples, 3 (0.98%) were positive for HIV, and confirmed by Western blot analysis, enzyme immunoassay (ELISA), a prevalence significantly higher than a national sample (0.012%). The use of FCS in this setting was determined to be an unacceptable risk to patients undergoing in vitro fertilization. The 90-day quarantine period for verification of HIV seronegativity applied to semen donors may not be applicable to FCS sampling. Patient risk may also increase with pooling of FCS samples prior to HIV testing.