Millions of Migraine Attacks, Many Answers, More Questions

In the landscape of migraine treatment, many unanswered questions remain-particularly, which medications are most effective as acute agents and for which patients? Given the heterogeneity of patients, clinicians' practice, and the integration of new agents into migraine care, this is an ambitious question to address.1 At the same time, this question is crucial both because proper acute treatment is an important metric of quality of care and such treatments are woefully underused in the general population.2,3.

A cohort-based nutrition ECHO for community health workers

Project Extension for Community Healthcare Outcomes (ECHO) Nevada applied the ECHO virtual hub-and-spoke telementoring model over nine 6-week cohorts (between November 2019 and November 2021) supporting community health workers (CHWs) who advise clients with diabetes or pre-diabetes. This study describes the program implementation, including evaluation data collection efforts. Didactic topics included 'Intro to Healthy Eating and Easy Wins' to 'Grocery Shopping, Cooking Tips, Reading Labels, Meal Plans' and 'Reducing Bias and Being a Good Role Model'. Spoke participants signed up to review cases. Seventy-three of the enrolled participants (n = 100) attended three or more of the six sessions. Spoke participants completed 42 case presentations. The average self-efficacy increased from 2.7 [standard deviation (SD): 1.1] before completing the program to 4.1 (SD: 0.8) after completing the program. Average knowledge scores increased from 71 (SD: 16) before completing the program to 83 (SD: 14) after completing the program. Five group interviews drew actionable feedback that was incorporated into the program. Key elements of the ECHO model were successfully incorporated to support educational goals of a cohort of CHWs in nutritional coaching. Our program evaluation data tracking system shows non-significant but encouraging results regarding self-efficacy improvement and knowledge retention.

Secondary Headache Disorders: Approach, Workup, and Special Considerations for Select Populations

Headache is one of the most common diagnoses in neurology. A thorough understanding of the clinical presentation of secondary headache, which can be life-threatening, is critical. This review provides an overview of the diagnostic approach to a patient with headache, including discussion of "red," "orange," and "green" flags. We emphasize particular scenarios to help tailor the clinical workup to individual circumstances such as in pregnant women, when particular attention must be paid to the effects of blood pressure and hypercoagulability, as well as in older adults, where there is a need for higher suspicion for an intracranial mass lesion or giant cell arteritis. Patients with risk factors for headache secondary to alterations in intracranial pressure, whether elevated (e.g., idiopathic intracranial hypertension) or decreased (e.g., cerebrospinal fluid leak), may require more specific diagnostic testing and treatment. Finally, headache in patients with COVID-19 or long COVID-19 is increasingly recognized and may have multiple etiologies.

Quantifying Balance Billing for Out-of-Network Behavioral Health Care in Employer-Sponsored Insurance

OBJECTIVE

The study estimated balance billing for out-of-network behavioral health claims and described subscriber characteristics associated with higher billing.

METHODS

Claims data (2011-2014) from a national managed behavioral health organization's employer-sponsored insurance (N=196,034 family-years with out-of-network behavioral health claims) were used to calculate inflation-adjusted annual balance billing-the submitted amount (charged by provider) minus the allowed amount (insurer agreed to pay plus patient cost-sharing) and any discounts offered by the provider. Among family-years with complete sociodemographic data (N=68,659), regressions modeled balance billing as a function of plan and provider supply, subscriber and family-year, and employer characteristics. A two-part model accounted for family-years without balance billing.

RESULTS

Among the 50% of family-years with balance billing, mean±SD balance billing was $861±$3,500 (median, $175; 90th percentile, $1,684). Adjusted analysis found balance billing was higher ($523 higher, 95% confidence interval [CI]=$340, $705) for carve-out versus carve-in plans and for health maintenance organization (HMO) enrollees versus non-HMO enrollees ($156, 95% CI=$75, $237); for subscribers with a bachelor's degree, compared with an associate's degree or with a high school diploma or lower (between $172 [95% CI=$228, $116] and $224 [95% CI=$284, $163] higher, respectively); and for subscribers ages 45-54, compared with those ages 35-44 and 18-24 (between $57 [95% CI=$103, $10] and $290 [95% CI=$398, $183] higher, respectively). Balance billing was lower in states with more in-network providers per capita (-$8, 95% CI=-$10, -$5).

CONCLUSIONS

Balance billing for out-of-network behavioral health claims may be burdensome. Expanded behavioral health networks may improve access.

Skeletal Muscle Manifestations and Creatine Kinase in COVID-19

Background and Purpose

Skeletal muscle symptoms and elevated creatine kinase (CK) levels have been consistently reported as part of the COVID-19 disease process. Previous studies have yet to show a consistent relationship between CK levels and skeletal muscle symptoms, disease severity, and death from COVID-19. The purpose of this study is to determine whether elevated CK is associated with a COVID-19 course requiring intubation, intensive care, and/or causing death. Secondary objectives: To determine if there is a relationship between elevated CK and (1) skeletal muscle symptoms/signs (2) complications of COVID-19 and (3) other diagnostic laboratory values.

Methods

This is a retrospective, single center cohort study. Data were collected from March 13, 2020, to May 13, 2020. This study included 289 hospitalized patients with laboratory-confirmed SARS-CoV-2 and measured CK levels during admission.

Results

Of 289 patients (mean age 68.5 [SD 13.8] years, 145 [50.2%] were men, 262 [90.7%] were African American) with COVID-19, 52 (18.0%) reported myalgia, 92 (31.8%) reported subjective weakness, and 132 (45.7%) had elevated CK levels (defined as greater than 220 U/L). Elevated CK was found to be associated with severity of disease, even when adjusting for inflammatory marker C-reactive protein (initial CK: OR 1.006 [95% CI: 1.002-1.011]; peak CK: OR 1.006 [95% CI: 1.002-1.01]; last CK: 1.009 [95% CI: 1.002-1.016]; q = .04). Creatine kinase was not found to be associated with skeletal muscle symptoms/signs or with other laboratory markers.

Conclusions

Creatine kinase is of possible clinical significance and may be used as an additional data point in predicting the trajectory of the COVID-19 disease process.

Comparing Gold-standard Copayment and Coinsurance Values From Claims Processing Engines to Values Derived From Behavioral Health Claims Databases

BACKGROUND

While researchers use patient expenditures in claims data to estimate insurance benefit features, little evidence exists to indicate whether the resulting measures are accurate.

OBJECTIVE

To develop and test an algorithm for deriving copayment and coinsurance values from behavioral health claims data.

SUBJECTS

Employer-sponsored insurance plans from 2011 to 2013 for a national managed behavioral health organization (MBHO).

MEASURES

Twelve benefit features, distinguishing between carve-in and carve-out, in-network and out-of-network, inpatient and outpatient, and copayment and coinsurance, were created. Measures drew from claims (claims-derived measures), and benefit feature data from a claims processing engine database (true measures).

STUDY DESIGN

We calculate sensitivity and specificity of the claims-derived measures' ability to accurately determine if a benefit feature was required and for plan-years requiring the benefit feature, the accuracy of the claims-derived measures. Accuracy rates using the minimum, 25th, 50th, 75th, and maximum claims value for a plan-year were compared.

PRINCIPAL FINDINGS

Sensitivity (82% or higher for all but 3 benefit features) and specificity (95% or higher for all but 2 benefit features) were relatively high. Accuracy rates were highest using the 75th or maximum claims value, depending on the benefit feature, and ranged from 69% to 99% for all benefit features except for out-of-network inpatient coinsurance.

CONCLUSIONS

For most plan-years, claims-derived measures correctly identify required specialty mental health copayments and coinsurance, although the claims-derived measures' accuracy varies across benefit design features. This information should be considered when creating claims-derived benefit features to use for policy analysis.

The Effects of Three Kinds of Insurance Benefit Design Features on Specialty Mental Health Care Use in Managed Care

BACKGROUND

Insurance benefit features play a role in determining access to specialty mental health care. Previous research, primarily examining the effects of copayments, coinsurance, and deductibles in a fee-for-service setting, has concluded that specialty mental health use is highly sensitive to changes in financial requirements. Less is known about the effects of other benefit features and the effects of all of these features in a managed care environment.

AIMS OF THE STUDY

Determine whether increased generosity of three types of benefit features was associated with increases in specialty mental health use and expenditures in a managed care setting. Secondary analyses investigated whether these associations varied by income level.

METHODS

A first-differences design used linked claims, enrollment, and benefit data for 1,242,949 non-elderly adults (aged 18-64) with employer-sponsored insurance, before (2009) and after (2011) national behavioral health parity implementation. The data were provided by a large national managed behavioral health organization. Benefit design features included combined cost sharing from copayment and coinsurance, deductibles, the presence of annual use limits, cost sharing penalties associated with services used without getting required prior-authorization, and provider network. Outcomes included visits/days, total expenditures and patient out-of-pocket expenditures for individual psychotherapy and inpatient use, with separate values for in-network and out-of-network (OON) service use. Ordinary least squares regression was performed on change scores (2011 minus 2009 values) of all outcomes to implement the first-differences study design and normalize distributions of otherwise heavily skewed (towards zero) variables. Regressions stratified by higher income (>=USD75,000) and net worth (>=USD100,000) and lower income/net worth were also conducted.

RESULTS

For in-network individual psychotherapy, larger increases in cost sharing from copayment and coinsurance were modestly associated with larger decreases in use and total expenditures (beta_visits=--0.00008, p-value=0.030; beta_total expenditures=USD--0.00629, p-value=0.011), and elimination of treatment limits was associated with larger increases in use (beta=0.09637, p-value=0.002) and total expenditures (beta=USD6.57506, p-value=0.001). These results were observed among all enrollees of plans that covered in-network and out-of-network plans and among a sub-set of these enrollees who did not change plans between 2009 and 2011. Benefit features had fewer associations with inpatient care and OON services.

DISCUSSION

Elimination of limits was associated with small average increases in in-network individual psychotherapy utilization and expenditures. Cost sharing sensitivities of individual psychotherapy visits to financial requirements reported here were small, and resembled previous findings based in a managed care setting, which were smaller than findings based on the fee-for-service settings. Cost sharing may not pose a practical barrier to specialty behavioral health for non-elderly adults with employer-sponsored managed care plans. However, the influence of cost sharing may vary by specific healthcare needs, something that should be explored in further research.

The Mental Health Parity and Addiction Equity Act (MHPAEA) evaluation study: Did parity differentially affect substance use disorder and mental health benefits offered by behavioral healthcare carve-out and carve-in plans?

BACKGROUND

To assess whether implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA) was associated with: 1. Reduced differences in financial requirements (i.e., copayments and coinsurance) for substance use disorder (SUD) versus specialty mental health (MH) care and 2. Reductions in the level of cost-sharing for SUD-specific services.

METHODS

MH and SUD copayments and coinsurance, 2008-2013, were obtained from benefits databases for carve-in and carve-out plans from Optum®. Linear regression was used to estimate the association of MHPAEA with differences between MH and SUD care financial requirements among carve-in and carve-out plans. A two-part regression model investigated whether MHPAEA was associated with changes in the use or level of financial requirements for SUD-specific services among carve-out plans.

RESULTS

MHPAEA was not associated with significant changes in the difference between SUD and MH copayments or coinsurance levels among either carve-in or carve-out plans. MHPAEA was associated with decreases in the levels of inpatient (in-network: -$51.17; out-of-network: -$34.39) and outpatient (in-network: -$10.26) detox copayments, but increases in the levels of in-network outpatient detox coinsurance (6 percentage points) among all carve-out plans.

CONCLUSION

Even if SUD benefits had been historically less generous than MH benefits, SUD financial requirements were already at parity with MH financial requirements by the time MHPAEA was passed, among Optum® plans. MHPAEA's SUD parity mandate reduced cost-sharing for detox services via copayments, but, for outpatient detox, the law simultaneously increased cost-sharing via coinsurance.

The Mental Health Parity and Addiction Equity Act Evaluation Study: Impact on Mental Health Financial Requirements among Commercial "Carve-In" Plans

OBJECTIVE

Did mental health cost-sharing decrease following implementation of the Mental Health Parity and Addiction Equity Act (MHPAEA)?

DATA SOURCE

Specialty mental health copayments, coinsurance, and deductibles, 2008-2013, were obtained from benefits databases for "carve-in" plans from a national commercial managed behavioral health organization.

STUDY DESIGN

Bivariate and regression-adjusted analyses compare the probability of use and (conditional) level of cost-sharing pre- and postparity. An interaction term is added to compare differential levels of pre- and postparity cost-sharing changes for plans that were and were not already at parity pre-MHPAEA.

FINDINGS

Controlling for employer/plan characteristics, MHPAEA is associated with higher intermediate care copayments ($15.9) but lower outpatient ($2.6) copayments among in-network-only plans. Among plans with in- and out-of-network benefits, MHPAEA is associated with lower inpatient ($23.2) and outpatient ($2.5) copayments, but increases in inpatient and intermediate in-network and out-of-network coinsurance (about 1 percentage point). Among the few plans not at parity pre-MHPAEA, changes in use and level of cost-sharing associated with MHPAEA were more dramatic.

CONCLUSION

Mixed evidence that MHPAEA led to more generous mental health benefits may stem from the finding that many plans were already at parity pre-MHPAEA. Future policy focus in mental health may shift to slowing growth in cost-sharing for all health services.

The Mental Health Parity and Addiction Equity Act (MHPAEA) Evaluation Study: Impact on Quantitative Treatment Limits

OBJECTIVE

The Mental Health Parity and Addiction Equity Act (MHPAEA) significantly changed regulations governing behavioral health benefits for large, commercially insured employers. Pre-MHPAEA, many plans covered only a specific number of behavioral health treatment days or visits; post-MHPAEA, such quantitative treatment limits (QTLs) were allowed only if they were "at parity" with medical-surgical limits. This study assessed MHPAEA's effect on the prevalence of behavioral health QTLs.

METHODS

Analyses used 2008-2013 specialty behavioral health benefit design data for Optum large-group plans, both carve-outs (N=2,257 plan-years, corresponding to 1,527 plans and 40 employers) and carve-ins (N=11,644 plan-years, 3,569 plans, and 340 employers). Descriptive statistics were calculated for limits existing at parity implementation, distinguished by accumulation period (annual or lifetime), level of care (inpatient, intermediate, or outpatient), unit (days, visits, or courses), condition, and network level. Proportions of plans using specific limits during the preparity (2008-2009), transition (2010), and postparity (2011-2013) periods were compared with Fisher's exact tests.

RESULTS

Preparity, the most common QTLs were annual visit or day limits. Accounting for overlap in limit types, 89% of regular carve-out plans, 90% of in-network-only carve-outs, and 77% of carve-in plans limited outpatient visits; 66% of regular carve-out plans, 74% of in-network-only carve-outs, and 73% of carve-ins limited inpatient or intermediate days. Postparity, QTLs almost entirely disappeared (p<.001).

CONCLUSIONS

Before MHPAEA, QTLs were common. Postimplementation, virtually all plans dropped such limits, suggesting that MHPAEA was effective at eliminating QTLs. However, increasing access to behavioral health care will mean going beyond such QTL changes and looking at other areas of benefit management.

Anticoagulation in atrial fibrillation: impact of mental illness

OBJECTIVES

To characterize warfarin eligibility and receipt among Veterans Health Administration (VHA) patients with and without mental health conditions (MHCs).

STUDY DESIGN

Retrospective cohort study.

METHODS

This observational study identified VHA atrial fibrillation (AF) patients with and without MHCs in 2004. We examined unadjusted MHC-related differences in warfarin eligibility and warfarin receipt among warfarin-eligible patients, using logistic regression for any MHC and for specific MHCs (adjusting for sociodemographic and clinical characteristics).

RESULTS

Of 125,670 patients with AF, most (96.8%) were warfarin-eligible based on a CHADS2 stroke risk score. High stroke risk and contraindications to anticoagulation were both more common in patients with MHC. Warfarin-eligible patients with MHC were less likely to receive warfarin than those without MHC (adjusted odds ratio [AOR], 0.90; 95% CI, 0.87-0.94). The association between MHC and warfarin receipt among warfarin-eligible patients varied by specific MHC. Patients with anxiety disorders (AOR, 0.86; 95% CI, 0.80-0.93), psychotic disorders (AOR, 0.77; 95% CI, 0.65-0.90), and alcohol use disorders (AOR 0.62, 95% CI 0.54-0.72) were less likely to receive warfarin than patients without these conditions, whereas patients with depressive disorders and posttraumatic stress disorder were no less likely to receive warfarin than patients without these conditions.

CONCLUSIONS

Compared with patients with AF without MHCs, those with MHCs are less likely to be eligible for warfarin receipt and, among those eligible, are less likely to receive such treatment. Although patients with AF with MHC need careful assessment of bleeding risk, this finding suggests potential missed opportunities for more intensive therapy among some individuals with MHCs.

The financial performance of rural hospitals and implications for elimination of the Critical Access Hospital program

PURPOSE

To compare the financial performance of rural hospitals with Medicare payment provisions to those paid under prospective payment and to estimate the financial consequences of elimination of the Critical Access Hospital (CAH) program.

METHODS

Financial data for 2004-2010 were collected from the Healthcare Cost Reporting Information System (HCRIS) for rural hospitals. HCRIS data were used to calculate measures of the profitability, liquidity, capital structure, and financial strength of rural hospitals. Linear mixed models accounted for the method of Medicare reimbursement, time trends, hospital, and market characteristics. Simulations were used to estimate profitability of CAHs if they reverted to prospective payment.

FINDINGS

CAHs generally had lower unadjusted financial performance than other types of rural hospitals, but after adjustment for hospital characteristics, CAHs had generally higher financial performance.

CONCLUSIONS

Special payment provisions by Medicare to rural hospitals are important determinants of financial performance. In particular, the financial condition of CAHs would be worse if they were paid under prospective payment.

Recognition of rapid speech by blind and sighted older adults

PURPOSE

To determine whether older blind participants recognize time-compressed speech better than older sighted participants.

METHOD

Three groups of adults with normal hearing participated (n = 10/group): (a) older sighted, (b) older blind, and (c) younger sighted listeners. Low-predictability sentences that were uncompressed (0% time compression ratio [TCR]) and compressed at 3 rates (40%, 50%, and 60% TCR) were presented to listeners in quiet and noise.

RESULTS

Older blind listeners recognized all time-compressed speech stimuli significantly better than did older sighted listeners in quiet. In noise, the older blind adults recognized the uncompressed and 40% TCR speech stimuli better than did the older sighted adults. Performance differences between the younger sighted adults and older blind adults were not observed.

CONCLUSIONS

The findings support the notion that older blind adults recognize time-compressed speech considerably better than older sighted adults in quiet and noise. Their performance levels are similar to those of younger adults, suggesting that age-related difficulty in understanding time-compressed speech is not an inevitable consequence of aging. Instead, frequent listening to speech at rapid rates, which was highly correlated with performance of the older blind adults, may be a useful technique to minimize age-related slowing in speech understanding.

Recognition of time-compressed and natural speech with selective temporal enhancements by young and elderly listeners

PURPOSE

The goal of this experiment was to determine whether selective slowing of speech segments improves recognition performance by young and elderly listeners. The hypotheses were (a) the benefits of time expansion occur for rapid speech but not for natural-rate speech, (b) selective time expansion of consonants produces greater score increments than other forms of selective time expansion, and (c) older listeners benefit from time expansion of speech

METHOD

Participants (n=10-16 per group) were younger and older adults with normal hearing or with hearing loss. A repeated-measures design was used to assess recognition of sentence-length stimuli presented in 2 baseline speech rates: natural and 50% time compression. Selective time expansion of consonants, vowels, or pauses was applied to the natural-rate and time-compressed sentence-length stimuli.

RESULTS

Listeners showed excellent performance for natural-rate speech, regardless of time-expansion method. Recognition was significantly poorer for the time-compressed sentences, but performance by elderly listeners and listeners with hearing loss improved with selective time expansion, particularly when applied to consonant segments.

CONCLUSION

The findings support the hypothesis that older listeners and listeners with hearing impairment benefit from selective time expansion of consonants applied to rapid speech, without a corresponding decrement when applied to normal-rate speech.

Effects of age and sequence presentation rate on temporal order recognition

The experiments examined the ability of younger and older listeners to identify the temporal order of sounds presented in tonal sequences. The stimuli were three-tone sequences that spanned two-octave frequency range, and listeners identified random permutations of tone order using labels of relative pitch. Some of the sequences featured uniform timing characteristics, and the sequence duty cycle was varied across conditions to examine the relative influence of tonal durations and intertone interval on recognition performance across a range of sequence presentation rates. Other stimulus sequences featured nonuniform timing with unequal tone durations and intertone intervals. The listeners were groups of younger and older persons with or without hearing loss. Results indicated that temporal order recognition was influenced primarily by sequence presentation rate, independent of tonal duration, tonal interval spacing, or sequence timing characteristics. The performance of older listeners was poorer than younger listeners, but the age-related recognition differences were independent of sequence presentation rate. There were no consistent effects of hearing loss on temporal ordering performance.

A matched controlled study of Kielland's forceps for transverse arrest of the fetal vertex

This study attempted to determine whether delivery with Kielland's forceps for deep transverse arrest is less favourable than other instruments. One hundred and forty-six women who underwent rotation and delivery with Kielland's forceps between 1994 and 1997 were matched by parity and birth weight to one of two control groups: delivery by non-rotational forceps or the vacuum extractor. No significant differences were found in maternal or neonatal outcome (vaginal lacerations, 3rd- or 4th-degree perineal tears, postpartum haemorrhage, fever, blood transfusion, duration of hospitalisation, Apgar score, asphyxia, scalp trauma, admission to the intensive care unit or neonatal hospitalisation). The incidence of heart rate abnormalities prior to instrumental delivery was similar. The 'failure to deliver' rate (8.9% after Kielland's forceps) was not different to the 7.5% and 6.8% found in each control group. These data indicate that the outcome after Kielland's forceps delivery is similar to other instrumental deliveries if performed by experienced obstetricians.

Expectant management of severe preeclampsia remote from term

Traditionally, preeclamptic women who meet accepted criteria for severe disease are delivered expeditiously, regardless of gestational age. Although delivery is always appropriate therapy for the mother, it may not be optimal for the fetus remote from term. Several recent randomized clinical trials support expectant management of severe preeclampsia remote from term in well-selected patients. We have described our rationale and guidelines for management, which we believe should be performed only at tertiary perinatal centers.

Neonatal outcome in severe preeclampsia at 24 to 36 weeks' gestation: does the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome matter?

OBJECTIVE

Our purpose was to compare neonatal outcome after preterm delivery of infants whose gestation was complicated by the HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, partial HELLP syndrome, or severe preeclampsia.

STUDY DESIGN

We reviewed the maternal and neonatal charts from 269 consecutive pregnancies complicated by the HELLP syndrome or severe preeclampsia managed at our perinatal center. The HELLP syndrome was defined by previously published laboratory criteria. Viable pregnancies were divided into 3 groups: HELLP syndrome, partial HELLP syndrome (at least 1, but not all 3, features of the HELLP syndrome), and severe preeclampsia (no features of the HELLP syndrome). Results were compared by means of chi2 analysis and Student t test where appropriate. Logistic regression was used to evaluate outcome variables at different gestational ages.

RESULTS

There were no significant differences in complications among the 3 groups at each gestational age. There was, as expected, a significant decrease in morbidity and mortality rates with advanced gestational age.

CONCLUSIONS

In severe preeclampsia, neonatal morbidity and death are related to gestational age rather than to the presence or absence of the HELLP syndrome. Whether expectant management is safe for women with the HELLP syndrome requires further study.

Progression of labor in twin versus singleton gestations

OBJECTIVE

The aim of this study was to investigate whether labor curves of twin gestations differ from those of singleton gestations.

STUDY DESIGN

Among 1821 twin deliveries at our institution (1984-1996), we found 69 nulliparous and 94 multiparous women who were delivered at term (>/=37 weeks) of a vertex twin A with a birth weight of >/=2500 g. We excluded women who had any of the following: induction of labor, oxytocin augmentation, cervical dilatation >6 cm on admission, tocolysis during the previous 14 days, height <150 cm, hypertension, and diabetes. Women with singleton gestations (n = 163) who met the same exclusion criteria were matched for parity and maternal age (+/-3 years). Stage 1 of labor was defined as the interval between 4 and 10 cm cervical dilatation. Kaplan-Meier survival analysis was used for comparison between the groups.

RESULTS

The study and control groups were similar in mean maternal height; however, women with twins were significantly heavier than were those with singletons (79.3 +/- 11.2 kg vs 73.2 +/- 10.8 kg, P <.001), had a higher frequency of epidural anesthesia (82% vs 62%), and had a significantly lower birth weight of the presenting fetus (2779.1 +/- 242.5 g vs 3301.4 +/- 429.2 g, P <.001). The cervical effacements and vertex stations on admission were similar in the 2 groups. On admission the cervical dilatation of women delivered of twins was smaller than that of the control group. Twin gestations had a significantly shorter first stage of labor than did their matched singleton control gestations (3.0 +/- 1.5 hours vs 4.0 +/- 2. 6 hours, P <.0001). This difference was apparent only in nulliparous women. No statistical difference was noted in the mean length of the second stage of labor (0.8 +/- 0.5 hour for twins and 0.7 +/- 0.6 hour for singletons).

CONCLUSION

Twin gestations have a significantly shorter first stage of labor than do singleton gestations. This difference may be the result of the birth weight of the presenting twin being lower than that of its singleton counterpart or to differences in uterine contractility in twin and singleton gestations. Different labor curves should be considered for managing twin deliveries.

Adjustment of magnesium sulfate infusion rate in patients with preterm labor

OBJECTIVE

Our purpose was to investigate factors that might influence serum magnesium levels during intravenous magnesium sulfate tocolytic therapy.

STUDY DESIGN

Thirty-three women receiving magnesium sulfate for preterm labor participated in this prospective, observational study. Gestational ages were 24 to 34 weeks. Four groups of women were identified according to the maintenance magnesium infusion rate required for arresting preterm labor after 5 g of therapy induction: 1.5, 2, 2.5, and 3 g/h. Serum magnesium samples were drawn after a predefined period of at least 18 hours of arrested preterm labor, at a minimum of every 6 hours. Variables examined included serum albumin; serum protein; serum ionized calcium; serum creatinine; creatinine clearance; 24-hour urine output; maternal height, weight, body surface area; and body mass index.

RESULTS

By use of a multivariate stepwise regression model we identified four variables that independently and significantly contributed to the model: magnesium infusion rate (P < .001); total serum protein level (P < .001); serum creatinine level (P = .009); and maternal weight squared (P = .026). Seventy-two percent of the variance was accounted for by use of these parameters. A predictive linear model, developed to relate these factors, produced the following formula: Suggested magnesium infusion rate = 0.89 x Serum magnesium concentration (mg/dL) - 3.16 x Serum creatinine (mg/dL) - 0.66 x Serum total proteins (g/dL) + 0.0001 x (maternal weight)2 (kg) + 2.30.

CONCLUSIONS

Serum creatinine, serum protein, and maternal weight can be used to adjust the dose of magnesium sulfate in patients with premature labor to achieve therapeutic serum levels of magnesium more rapidly and safely.

The clinical utility of serum uric acid measurements in hypertensive diseases of pregnancy

OBJECTIVE

Our purpose was to evaluate the clinical utility of serum uric acid measurements in the hypertensive diseases of pregnancy.

STUDY DESIGN

We performed a nested case-control study to assess the clinical utility of serum uric acid measurements in women with hypertensive diseases of pregnancy. We identified 344 women who had serum uric acid measurements at term and categorized them into five diagnostic groups according to definitions of hypertensive diseases in pregnancy published by the National Working Group on Hypertension in Pregnancy: transient hypertension of pregnancy (n = 69), preeclampsia (n = 130), chronic hypertension (n = 23), chronic hypertension with superimposed preeclampsia (n = 29), and normal (n = 93). We compared the mean uric acid concentration for each group with use of a one-way analysis of variance and Scheffe's post hoc test and calculated the sensitivities and specificities in diagnosing preeclampsia as well as the likelihood ratios for serum uric acid values of 5.5, 6.0, and 6.5 mg/dl. We also examined the correlation between serum uric acid levels and several clinical outcome measures in women with hypertensive diseases of pregnancy.

RESULTS

The mean serum uric acid values for women with preeclampsia (6.2 +/- 1.4 mg/dl) and transient hypertension (5.6 +/- 1.7 mg/dl) were significantly higher than those of controls (4.3 +/- 0.8 mg/dl, p < 0.05). The difference in mean serum uric acid values between women with chronic hypertension (4.9 +/- 1.0 mg/dl) and superimposed preeclampsia (5.8 +/- 1.4 mg/dl) were not statistically significant. The likelihood ratio of having preeclampsia with a serum uric acid value of 5.5 mg/dl was 1.41 in gestational hypertension of pregnancy and 2.5 in chronic hypertension. With use of a receiver-operator characteristic curve, we were unable to identify a serum uric acid value that could be used to differentiate various hypertensive diseases of pregnancy. There was a weak correlation between serum uric acid values and several clinical outcome measures of preeclampsia (r = 0.06 to 0.26).

CONCLUSION

Although mean serum uric acid values are elevated in women with preeclampsia, the clinical utility of serum uric acid values in differentiating various hypertensive diseases of pregnancy appears to be limited. In the setting of chronic hypertension, however, a serum uric acid level of > or = 5.5 mg/dl could identify women with an increased likelihood of having superimposed preeclampsia.

Renal hemodialysis and maternal serum triple analyte screening

The obstetrical management of women with renal disease is complicated and associated with increased fetal and maternal morbidity. However, maternal serum screening is an integral part of obstetrical care and should be offered to all women. We found that maternal serum levels of a-fetoprotein and human chorionic gonadotropin did not significantly change as a result of hemodialysis, whereas levels of unconjugated estriol were markedly decreased following hemodialysis. Maternal serum screening should be limited to alpha-fetoprotein analysis in women undergoing hemodialysis until the effects of hemodialysis on all serum analytes are better delineated.

Effect of indomethacin and N omega-nitro-L-arginine methyl ester on the pressure/flow relation in isolated perfused hindlimbs from pregnant and nonpregnant rats

OBJECTIVE

To compare the pressure/flow relationship and to assess the roles of prostaglandins and nitric oxide in flow-induced vasodilation in the nonpregnant and late-pregnant rat hindlimb vasculature.

METHODS

Pressure/flow and conductance/flow relationships were determined in isolated, Krebs buffer-perfused, norepinephrine (0.5 mumol/L) preconstricted hindlimbs from nonpregnant and late-pregnant Wistar-Kyoto rats before and after inhibition of cyclo-oxygenase with indomethacin (20 mumol/L), or nitric oxide synthase with N omega-nitro-L-arginine methyl ester (300 mumol/L).

RESULTS

There were no significant differences in baseline perfusion pressure between nonpregnant and pregnant rat hindlimbs perfused at 2 mL/min (20.6 +/- 0.8 and 19.7 +/- 1.1 mmHg, respectively) and norepinephrine increased perfusion pressure about twofold (40.8 +/- 2.0 and 34.8 +/- 1.8 mmHg, respectively). After constriction, perfusion pressure increased linearly as flow was increased in a stepwise manner to a maximum of 4 mL/min. The slope of the pressure/flow regression line for the pregnant rat hindlimbs (6.00) was significantly lower (P < or = .001) than that for the nonpregnant rat hindlimbs (8.44). Vascular conductance also increased as flow was increased, and was significantly greater at all flow rates in the pregnant compared to the nonpregnant rat hindlimbs. Indomethacin slightly decreased the constrictor response to norepinephrine and increased the pressure/flow regression line slope in nonpregnant, but not in pregnant rat hindlimbs. N omega-nitro-L-arginine methyl ester abolished flow-mediated vasodilation in nonpregnant and pregnant rat hindlimbs, and there was no longer any significant difference between the pressure/flow regression line slopes.

CONCLUSION

These results suggest that flow-induced vasodilation, mediated by endothelium-derived nitric oxide, is enhanced during pregnancy allowing the maternal vasculature to accommodate increased blood flow without increased blood pressure.

Hemostatic efficacy of a fibrin sealant-based topical agent in a femoral artery injury model: a randomized, blinded, placebo-controlled study

PURPOSE

The efficacy of currently available topical hemostatic agents requires the formation of fibrin generated from circulating blood. Fibrin sealant, which is prepared from high concentrations of thrombin and fibrinogen, has been used in liquid form to promote hemostasis during vascular surgery. In a blinded, randomized, placebo-controlled fashion, we evaluated a dry dressing of purified, viral-inactivated human fibrinogen and human thrombin in a large animal model of arterial injury.

METHODS

Dressings were prepared by application of a layer of lyophilized human fibrin sealant or immunoglobulin G (IgG, control) to a silicone backing material. Six anesthetized female Yorkshire pigs (16 to 27 kg) received bilateral, 4 mm longitudinal femoral arteriotomies after surgical exposure of the arteries. The arteriotomies were not closed. In each animal a fibrin sealant dressing was applied to one artery and a control dressing to the other. Each dressing was secured on the arteriotomy by a mechanical device. After application of the dressings, blood flow was restored to each limb for 1 hour. The compressive device was released for 5 seconds at intervals of 15 minutes to assess hemostasis. Blood flow was measured distal to each arteriotomy with a dual-channel flowmeter to adjust equal bilateral compression.

RESULTS

Blood loss (mean +/- SEM) was significantly less from the arteriotomy treated with the fibrin-based dressing compared with the control dressing (4.9 +/- 4.0 ml versus 82.3 +/- 11.1 ml; p = 0.0005). Complete hemostasis was achieved at the first 15-minute interval in five of six arteriotomies treated with fibrin sealant and in none of the six control arteriotomies during 1 hour of assessment (p = 0.03). Blood flow through each femoral artery at baseline was the same in both treatment and control arteries (fibrin sealant, 114.2 +/- 17.4 ml/min; control, 106.7 +/- 16.5 ml/min; p = 0.24) and was not significantly different throughout the experiment.

CONCLUSIONS

Fibrin-based dressings provide effective hemostasis in a large animal model of arterial injury. Further development of these dressings will address optimal formulation and configuration for clinical use. Our results suggest that fibrin-based dressings will be effective in promotion of hemostasis in arterial bleeding, without compromising blood flow.

Cerebrovascular disorders complicating pregnancy--beyond eclampsia

OBJECTIVE

Our purpose was to investigate the problems encountered in the diagnosis and management of cerebrovascular disorders associated with pregnancy and the puerperium.

STUDY DESIGN

Pregnancies complicated by cerebrovascular disorders were identified by retrospective chart review (1985 to 1995). Events associated with trauma, neoplasm, drug ingestion, and infection were excluded.

RESULTS

The study population comprised 24 women with a variety of cerebrovascular disorders: 14 with infarction (5 arterial, 9 venous), 6 with intracranial hemorrhage (3 anatomic malformation, 3 unknown etiology), 3 with hypertensive encephalopathy, and 1 with an unruptured aneurysm. Blood pressure reflected physical condition at presentation and did not predict diagnosis or outcome except in the 3 women with hypertensive encephalopathy. Only 4 of 14 women with infarction and 1 of 6 with intracranial hemorrhage had a diastolic blood pressure > or = 110 mm Hg. Presumption of eclampsia delayed the diagnosis in 10 women (41.7%). In addition, patient delay in seeking medical attention complicated 10 cases. After review, none of the adverse maternal outcomes were deemed preventable by earlier physician intervention. Seven maternal deaths occurred (29.2%). Neonatal outcome was related to the gestational age and the maternal condition at presentation.

CONCLUSION

Cerebrovascular disorders are an uncommon and unpredictable complication of pregnancy that are associated with substantial maternal and fetal mortality. Suspected eclampsia unresponsive to magnesium sulfate therapy warrants an immediate neuroimaging study. Interestingly, in women with intracranial hemorrhage, severe hypertension was not an associated predictive factor.

Do twins mature earlier than singletons? Results from a matched cohort study

OBJECTIVE

Our purpose was to determine whether, as a consequence of advanced maturity, preterm twin infants have a more favorable neonatal outcome than matched singleton infants.

STUDY DESIGN

A matched cohort study design was used. Two hundred twenty-four twin infants (112 sets) were matched for gestational age, race, gender, and mode of delivery with singleton infants who were delivered because of refractory preterm labor. Pregnancies with maternal medical disease including preeclampsia, premature rupture of membranes, twin-twin transfusion syndrome, and known fetal anomalies were excluded. Information was obtained by review of maternal and neonatal charts.

RESULTS

There was no difference in the incidence of neonatal death (5% vs 7%, p = 0.66), respiratory distress syndrome (38% vs 35%, p = 0.54), grades 3 and 4 intraventricular hemorrhage (5% vs 4%, p = 0.63), grades 2 and 3 necrotizing enterocolitis (4% vs 6%, p = 0.52), and 5-minute Apgar score < or = 6 (21% vs 21%, p = 1.00). Twins had a higher incidence of admission to the Special Care Unit (88% vs 72%, p < 0.001). Results were similar when analysis was limited to presenting twins, nonpresenting twins, and twins concordant with controls for antenatal glucocorticoid exposure.

CONCLUSION

Twin infants do not have accelerated maturation and improved neonatal outcome compared with matched singleton infants born at the same gestational age because of preterm labor.

The effect of chronic nitric oxide synthesis inhibition on blood pressure and angiotensin II responsiveness in the pregnant rat

OBJECTIVES

Our purpose was to determine whether blockade of inducible or endothelial nitric oxide synthesis prevents maternal vasodilation and blunting of angiotensin II responsiveness in the pregnant rat.

STUDY DESIGN

Pregnant and nonpregnant rats were given (1) drinking water alone (untreated), (2) drinking water containing the inducible nitric oxide synthase inhibitor aminoguanidine (0.5 gm/L), or (3) drinking water containing the nonselective nitric oxide synthase inhibitor N omega-nitro-L-arginine methyl ester (0.5 gm/L) from postmating days 5 to 21. On days 7, 14, and 20, 24-hour urinary nitrate-nitrite excretion, urine protein concentration, hematocrit, mean arterial blood pressure, and pressor responses to angiotensin II (12.5 to 200 ng/kg) were measured. On day 21 litter size, fetal weight, and fetal mortality were determined.

RESULTS

Urinary nitrate-nitrite excretion was increased, and hematocrit and blood pressure were decreased by day 20 of pregnancy. Angiotensin II pressor responses were decreased on days 14 and 20 of pregnancy. Aminoguanidine slightly decreased nitrate-nitrite excretion in pregnant, but not nonpregnant rats, and abolished the late pregnancy increase. Aminoguanidine did not affect hematocrit, blood pressure, or angiotensin II responsiveness in either pregnant or nonpregnant rats. N omega-nitro-L-arginine methyl ester greatly reduced nitrate-nitrite excretion and induced hypertension in both nonpregnant and pregnant rats, but on day 20 blood pressure of the pregnant rats was significantly lower than that of the nonpregnant rats. N omega-nitro-L-arginine methyl ester increased angiotensin II responsiveness on days 14 and 20 only in the pregnant rats. N omega-nitro-L-arginine methyl ester, but not aminoguanidine, increased fetal mortality and decreased fetal weight.

CONCLUSIONS

Inducible nitric oxide synthesis accounts for increased nitrate-nitrite excretion during pregnancy. Endothelium-derived nitric oxide may attenuate angiotensin II responsiveness but does not cause vasodilation and the fall in blood pressure during the last week of gestation.

The effect of magnesium sulfate therapy on the duration of labor in women with mild preeclampsia at term: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

The primary outcome was to determine whether magnesium sulfate therapy prolongs the duration of labor in women with mild preeclampsia. Secondary outcomes were to assess the side effects associated with magnesium sulfate therapy: hours and maximum dose of oxytocin, incidence of progression to severe preeclampsia, incidence of cesarean delivery, change in maternal hematocrit, incidence of postpartum hemorrhage, incidence of maternal infection, and Apgar scores.

STUDY DESIGN

Women with a diagnosis of mild preeclampsia at term were randomized to receive standard therapy during labor and for 12 hours post partum with either magnesium sulfate (n = 67) or a matching placebo solution (n = 68).

RESULTS

There was no difference between magnesium sulfate and placebo with respect to the primary outcome variables: total length of labor (median 17.8 hours vs 16.5 hours, p = 0.7) and length of the active phase of labor (median 5.4 hours vs 6.0 hours, p = 0.5). In addition, no difference was observed in the secondary outcome variables: hours of oxytocin use, change in hematocrit, frequency of maternal infection, progression to severe preeclampsia, incidence of cesarean delivery, and Apgar scores. Although not statistically significant, the incidence of postpartum hemorrhage was approximately fourfold greater in the magnesium sulfate group (relative risk 4.1, 95% confidence interval 0.5 to 35.4). There was a significant difference in the maximum dose of oxytocin used (13.9 +/- 8.6 mU/min with magnesium sulfate vs 11.0 +/- 7.6 mU/min with placebo, p = 0.036).

CONCLUSION

The use of magnesium sulfate during labor in women with mild preeclampsia at term does not affect any component of labor but did necessitate a higher dose of oxytocin.

Fetal plasma levels of cellular fibronectin as a measure of fetal endothelial involvement in preeclampsia

OBJECTIVE

To determine the degree of fetal endothelial involvement in preeclampsia by measuring fetal plasma concentrations of cellular fibronectin.

METHODS

In a prospective cohort study, fetal plasma was collected at delivery from the chorionic plate arteries and veins in a convenience sample of 28 pregnancies complicated by preeclampsia and in 28 normal pregnancies. Stored plasma was assayed for cellular fibronectin using a sensitive and specific enzyme immunoassay. On the basis of a desired power of 0.8, alpha of .05, and expected fetal plasma cellular fibronectin values of 4 +/- 2 micrograms/mL, 26 women were required in each group to detect a 40% difference between the groups. Results were compared using the unpaired Student t test, chi 2 analysis with Yates correction, and linear regression.

RESULTS

There was no statistically significant difference in fetal plasma concentrations of cellular fibronectin in women with preeclampsia compared with normal pregnant women, either in arteries (3.2 +/- 1.1 and 2.9 +/- 1.5 micrograms/mL; P = .33) or veins (3.3 +/- 1.5 and 2.8 +/- 1.6 micrograms/mL; P = .18). Plasma cellular fibronectin concentrations in fetal arteries correlated significantly with those in fetal veins (r = 0.45, P < .001), but not with those in maternal veins (r = 0.15, P = .27).

CONCLUSION

Fetal plasma cellular fibronectin concentrations are similar in preeclamptic and normal pregnancies. We found no evidence that factors responsible for maternal endothelial involvement in preeclampsia are operative in the fetal circulation.

The importance of urinary protein excretion during conservative management of severe preeclampsia

OBJECTIVES

We determined the natural course of urinary protein excretion during conservative management of severe preeclampsia and investigated whether changes in urinary protein excretion can predict maternal or perinatal outcome.

STUDY DESIGN

We reviewed the medical charts of 66 women with severe preeclampsia which was managed conservatively before 32 weeks of gestation and who had at least two 24-hour urinary protein determinations 4 or more days apart after admission.

RESULTS

Fifty-nine (89%) of 66 women had an increase in proteinuria during conservative management of severe preeclampsia. The median increase in protein excretion after admission was 660 mg/24 hours (range-4580 to 18,960 mg/24 hours). Patients were divided into two groups. The first group (n = 24) had an increase in 24-hour urinary protein excretion of > or = 2 gm; the second group (n = 42) had a 24-hour urinary protein excretion that decreased (n = 7) or increased by < 2 gm (n = 35). There were no cases of eclampsia or stillbirth in either group. The rate of HELLP (hemolysis, elevated liver enzyme levels, low platelet counts) syndrome, abruptio placentae, cesarean delivery because of fetal distress, 5-minute Apgar scores < or = 6, and the admission-to-delivery intervals were all similar in the two groups.

CONCLUSIONS

Proteinuria increases in most women with severe preeclampsia managed conservatively. No differences in maternal or fetal outcomes were found between pregnancies with marked increases in proteinuria and those with modest or no increases.

Dietary consumption and plasma concentrations of vitamin E in pregnancies complicated by preeclampsia

OBJECTIVE

Vitamin E, a potent antioxidant, has been suggested to play a role in preventing preeclampsia. Our aim was to determine whether consumption and plasma levels of vitamin E are lower in the preeclamptic than in normal women.

STUDY DESIGN

A case-control study design was used. We identified 48 women with preeclampsia (late-pregnancy hypertension, proteinuria, and hyperuricemia). Ninety normal women served as the control group. Vitamin E consumption was estimated by use of a previously validated dietary recall questionnaire administered by a single trained research nurse to 42 of the preeclamptic women and all 90 of the control women. Blood was drawn from all women and stored until assayed at -70 degrees C. Plasma vitamin E concentrations were determined by use of high-pressure liquid chromatography.

RESULTS

The mean dietary vitamin E consumption was similar for both the preeclamptic and control group (11.74 +/- 9.39 vs 11.34 +/- 7.51 mg/24 hr, p = 0.73). When the analysis also included estimations of vitamin E supplements, the total consumption was found to be higher in those who had preeclampsia than in controls (37.20 +/- 20.54 vs 22.3 +/- 27.24 mg/24 hr, p = 0.003). The mean plasma vitamin E concentration was significantly higher in preeclamptic than in control patients (1.41 +/- 0.39 vs 1.15 +/- 0.32 mg/dl, p < 0.001). Among the preeclamptic patients, those with severe disease associated with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (n = 11) had the highest plasma vitamin E concentrations.

CONCLUSIONS

We found no evidence that low vitamin E consumption is related to the development of preeclampsia. Higher plasma vitamin E concentrations in preeclamptic patients are speculated to represent a response to oxidative stress.

Serial amniotic fluid index in severe preeclampsia: a poor predictor of adverse outcome

OBJECTIVE

The purpose of the study was to determine the relationship between low amniotic fluid index and intrauterine growth restriction and nonreassuring fetal testing in patients with severe preeclampsia.

STUDY DESIGN

We reviewed the medical records of 136 women with severe preeclampsia managed conservatively for at least 48 hours. Patients were followed up with a daily nonstress test and amniotic fluid index. We evaluated amniotic fluid index < or = 5 cm and < or = 7 cm, measured on admission or just before delivery (i.e., final), and attempted to correlate these findings with the incidence of nonreassuring fetal testing necessitating cesarean section or the incidence of intrauterine growth restriction (birth weight < or = 10th percentile).

RESULTS

One hundred seven patients had a cesarean section, but only 42 (39%) of these were for a nonreassuring fetal heart rate tracing or a persistent biophysical profile of < or = 4, and 38 (36%) of the pregnancies resulted in infants with intrauterine growth restriction. During expectant management, the amniotic fluid index worsened for 61 (45%) patients and improved or remained the same for 75 (55%). For those with an amniotic fluid index of < or = 5 cm both on admission and at delivery, there was a significantly higher incidence of intrauterine growth restriction compared with those with an amniotic fluid index > 5 cm (p = 0.007 and p = 0.029, respectively). However, there was no association between intrauterine growth restriction and an amniotic fluid index < or = 7 cm. Moreover, there was no difference in the frequency of nonreassuring fetal heart rate testing on the basis of amniotic fluid volume (p = 0.59) or intrauterine growth restriction (p = 0.4).

CONCLUSIONS

For women with severe preeclampsia remote from term, an amniotic fluid index < or = 5 cm is predictive of intrauterine growth restriction but lacks sensitivity. There is no association between the amniotic fluid index status and frequency of cesarean section for fetal distress or nonreassuring fetal testing.

Trial of Calcium for Preeclampsia Prevention (CPEP): rationale, design, and methods

The results of ten clinical trials suggest that supplemental calcium may prevent preeclampsia. However, methodologic problems and differences in study design limit the acceptance of the results and their relevance to other patient populations. Many of the trials were conducted in countries where, unlike the United States, the usual daily diet contained little calcium. Moreover, none of the trials has reported the outcome of systematic surveillance for urolithiasis, a potential complication of calcium supplementation. In response to the need for a thorough evaluation of the effects of calcium supplementation for the prevention of preeclampsia in the United States, the trial of Calcium for Preeclampsia Prevention (CPEP) was undertaken at five university medical centers. Healthy nulliparous patients were randomly assigned to receive either 2 g supplemental calcium daily (n = 2295) or placebo (n = 2294) in a double-blind study. Study tablets were administered beginning from 13 to 21 completed weeks of gestation and continued until the termination of pregnancy. CPEP employed detailed diagnostic criteria, standardized techniques of measurement, and systematic surveillance for the major study endpoints and for urolithiasis. The nutrient intake of each patient was assessed at randomization and at 32-33 weeks gestation. This report describes the study rationale, design, and methods.

Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in pregnancy: review of 11 cases

OBJECTIVE

Little information exists regarding thrombotic thrombocytopenic purpura and hemolytic uremic syndrome during pregnancy. We report a series of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome complicating pregnancy, with emphasis on diagnosis and management of this rare disorder.

STUDY DESIGN

Between January 1988 and February 1996, 11 women with either thrombotic thrombocytopenic purpura (n = 8) or hemolytic uremic syndrome (n = 3) were evaluated. Clinical and laboratory findings and maternal and neonatal outcomes were recorded from the medical records.

RESULTS

Eight of the 11 women were in the third trimester or peripartum period, and three were seen before fetal viability. Treatment included fresh-frozen plasma in all women, plasmapheresis (n = 8), packed red blood cells (n = 9), and platelet transfusions (n = 5); 1 patient required splenectomy. There were two maternal deaths. Of the 9 surviving women, 4 had chronic renal disease, 1 of whom also had residual neurologic deficit. Preterm delivery occurred in 5 of 8 pregnancies continuing beyond 20 weeks. Indications for delivery in these 5 women included worsening maternal medical disease, nonreassuring fetal testing, and spontaneous preterm labor. Six of 8 women with viable fetuses underwent cesarean delivery. These 6 infants were born in good condition without thrombocytopenia. Of the remaining 2 infants delivered vaginally, one was healthy at 35 weeks and the other was stillborn.

CONCLUSION

Thrombotic thrombocytopenic purpura and hemolytic uremic syndrome complicating pregnancy is associated with high maternal mortality and long-term morbidity. Preterm delivery and intrauterine fetal death are frequent complications of these pregnancies. Improved survival after this disorder has been attributed to aggressive treatment with plasma transfusion or plasmapheresis.

Clinical utility of strict diagnostic criteria for the HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome

OBJECTIVE

Our purpose was to compare the maternal outcome of pregnancies complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome, partial HELLP syndrome, or severe preeclampsia.

STUDY DESIGN

In a retrospective cohort study we reviewed the maternal charts of 316 women with HELLP syndrome or severe preeclampsia managed at our perinatal center between July 1, 1992, and June 30, 1995. HELLP syndrome was strictly defined by previously published laboratory criteria. Women were divided into three groups: HELLP syndrome (n = 67), partial HELLP syndrome (one or two but not all three features of HELLP syndrome, n = 71), and severe preeclampsia (no features of HELLP syndrome, n = 178). Results were compared by chi 2 analysis and one-way analysis of variance.

RESULTS

Mean gestational ages at delivery in the HELLP, partial HELLP, and severe preeclampsia groups were, respectively, 31.7, 32.7, and 34.5 weeks (p < 0.001 between HELLP and severe preeclampsia). There was one maternal death from intracerebral hemorrhage in the HELLP group. In women with HELLP syndrome there was a higher incidence of cesarean section (p < 0.05), disseminated intravascular coagulation (p < 0.001), and need for transfusion (p < 0.001) than in the other two groups.

CONCLUSIONS

Higher incidences of maternal complications in women with HELLP syndrome stress the importance of strict criteria for the definition of HELLP syndrome. Women with partial HELLP syndrome should be studied and managed separately from women with complete HELLP syndrome.

Maternal and neonatal outcome of 846 term singleton breech deliveries: seven-year experience at a single center

OBJECTIVE

Our purpose was to evaluate the maternal and neonatal outcome of 846 consecutive term singleton breech deliveries at a single center.

STUDY DESIGN

We reviewed the maternal and neonatal charts of all women who delivered singleton breech fetuses between 1984 and 1990 and divided them into two groups: women who fulfilled the criteria for trial of labor (group 1, n = 613) and those who did not meet these criteria and underwent scheduled cesarean section (group 2, n = 233).

RESULTS

In group I, 326 women (53.2%) were delivered vaginally. There were no maternal deaths. Febrile morbidity and length of hospitalization were significantly higher in the women who required cesarean section in labor compared with those delivered vaginally. In the total study population there were no stillbirths and eight neonatal deaths, 6 of which had major malformations incompatible with life. The remaining two deaths occurred in group I (0.33% corrected neonatal mortality in group 1). Newborns in Group 1 exhibited a higher rate of trauma with borderline statistical significance (3.0% vs 0.5%, p = 0.052). No significant differences were found in the rates of low Apgar scores, intubation, and intensive care unit admission.

CONCLUSION

Although certain short-term outcome variables may appear less favorable in term singleton breech infants delivered vaginally, large randomized studies of short- and long-term outcome should be undertaken because current data are not sufficiently conclusive to warrant routine cesarean section for term breech presentation.

Is fetal neurologic and physical development accelerated in preeclampsia?

OBJECTIVE

Our objective was to determine whether the Ballard score, a maturity score for neonatal neuromuscular and physical development, is more advanced in preterm infants of preeclamptic women than in controls.

STUDY DESIGN

A matched cohort study design was used. One hundred women with strictly defined preeclampsia (new-onset hypertension, proteinuria, and hyperuricemia) were matched for gestational age, race, and gender to 100 normotensive women with preterm delivery. All patients had an assigned antenatal gestational age based on ultrasonography before 24 weeks. The gestational age, based on antenatal ultrasonography and last menstrual period, was compared with the Ballard score given at the time of neonatal physical examination within the first 12 hours after delivery. The difference in gestational age between the Ballard score and antenatal ultrasonography (Ballard score - ultrasonography) was calculated for each patient. Results are expressed as median and range and are compared with a Student t test.

RESULTS

The mean gestational age at delivery by antenatal ultrasonography in patients with severe preeclampsia was 32.06 +/- 2.74 and 32.03 +/- 2.70 weeks, respectively. The median difference between scores in patients with severe preeclampsia and normal patient were 1.3 +/- 1.8 and 1.5 +/- 1.6 weeks, respectively (p = 0.41).

CONCLUSION

On the basis of criteria defined by the Ballard score, preeclampsia was not associated with accelerated fetal neurologic and physical development.

Plasma and placental calcitonin gene-related peptide in pregnancies complicated by severe preeclampsia

OBJECTIVE

Our purpose was to determine the concentration of calcitonin gene-related peptide, a potent vasodilator, in maternal plasma, fetal plasma, and placental tissue from pregnancies complicated by severe preeclampsia.

STUDY DESIGN

The following groups were studied: severe preeclampsia (group 1, n = 21), normal pregnancies matched for mode of delivery (group 2, n = 21), and nonpregnant women (group 3, n = 17). Maternal venous blood samples were drawn before labor, and fetal venous samples were drawn from the chorionic plate immediately after delivery. Calcitonin gene-related peptide was also quantified in placental tissue samples from 15 patients in group 1 and 15 patients in group 2. Calcitonin gene-related peptide was measured with a sensitive and specific radioimmunoassay.

RESULTS

No differences were found between maternal plasma calcitonin gene-related peptide concentrations in groups 1 and 2 (29.8 +/- 4.2 and 30.4 +/- 4.3 pmol/L, respectively). Both had levels similar to those in group 3 (28.5 +/- 5.4 pmol/L). Maternal plasma concentrations in the preeclamptic group were unchanged 3 days post partum (29.1 +/- 3.6 pmol/L). Fetal plasma calcitonin gene-related peptide concentrations were similar in groups 1 and 2 (30.2 +/- 3.9 and 32.2 +/- 8.8 pmol/L, respectively). A significant correlation was found between maternal and fetal calcitonin gene-related peptide concentrations (r = 0.43, p < 0.01). Like plasma levels, calcitonin gene-related peptide levels in the supernatants of placental extracts were not different in preeclamptic and normal pregnancies (108.0 +/- 70.4 and 100.9 +/- 56.1 fmol/gm, respectively).

CONCLUSION

On the basis of plasma and placental concentrations, calcitonin gene-related peptide does not seem to play an important role in the pathophysiologic mechanisms of preeclampsia.

Daily antenatal testing in women with severe preeclampsia

OBJECTIVE

Our purpose was to determine whether daily antenatal testing in the expectant management of severe preeclampsia remote from term prevents stillbirth or neonatal compromise at birth.

STUDY DESIGN

We reviewed the medical records of 68 women with severe preeclampsia remote from term who underwent expectant management with daily fetal testing until delivery. On admission each patient had reassuring nonstress testing (absence of persistent severe variable or late decelerations), biophysical profile (> or = 6), and amniotic fluid volume (> or = 2 cm maximal vertical pocket before 32 weeks or amniotic fluid index > or = 5 after 32 weeks).

RESULTS

There were no stillbirths. Twenty-one patients (31%) had nonreassuring testing necessitating delivery. Two neonatal deaths occurred as a result of complications of prematurity. There were no statistical differences in the cord arterial pH (p = 0.93) or in the 1- and 5-minute Apgar scores (p = 0.18 and p = 0.88, respectively) between those with normal and abnormal antenatal testing.

CONCLUSIONS

Because optimizing neonatal outcome is the only reason to prolong pregnancy in women with severe preeclampsia, confirmation of fetal well-being is mandatory. Because neither stillbirths nor fetal compromise at birth occurred in patients undergoing daily antenatal testing, we recommend daily testing in patients with severe preeclampsia managed expectantly.

Preeclampsia and related disorders. Clinical aspects and relevance of endothelin and nitric oxide

Preeclampsia is a pregnancy-specific disorder believed to result from widespread endothelial dysfunction. Endothelin and NO are two potent vasoactive agents of endothelial origin and, as such, are postulated to play an important role in the pathogenesis of preeclampsia. If these agents are found to be important in preeclampsia, they will most likely exert their effects locally, rather than systemically. Future research on the autocrine and paracrine effects of endothelin and NO may yield important insights into the cause and pathogenesis of this enigmatic disease.

Neonatal outcome after preterm delivery for preeclampsia

OBJECTIVE

Our purpose was to determine whether maternal preeclampsia per se has a beneficial effect on neonatal outcome after delivery before 35 weeks.

STUDY DESIGN

A matched cohort study design was used. Two hundred twenty-three infants of strictly defined preeclamptic women were matched for gestational age, race, gender, and mode of delivery with infants of normotensive women with preterm labor and delivery. Pregnancies with multiple gestation, premature rupture of membranes, known fetal anomalies, diabetes, or maternal medical disease were excluded. Information was obtained by review of maternal and neonatal charts. Paired categoric and continuous data were compared by McNemar's test and the Wilcoxon signed-rank test, respectively.

RESULTS

There was no difference in the incidence of neonatal death (4.5% vs 4.5%, p = 0.82), respiratory distress syndrome (22.0% vs 22.0%, p = 0.88), grades 3 and 4 intraventricular hemorrhage (2.2% vs 2.2%, p = 0.72), grades 2 and 3 necrotizing enterocolitis (5.8% vs 4.0%, p = 0.48), and culture-proved sepsis (9.0% vs 9.0%, p = 0.85). Results were similar when analysis was limited to infants born at < or = 32 weeks, infants born to mothers with severe preeclampsia, and infants with intrauterine growth restriction.

CONCLUSION

Maternal preeclampsia per se does not have a beneficial effect on the postnatal course of infants born at 24 to 35 weeks' gestation.

Identification of the domain within fibroblast growth factor-1 responsible for heparin-dependence

While the prototype members of the fibroblast growth factor (FGF) family, FGF-1 and FGF-2 are structurally related, the structural differences between these polypeptides predict that they will ultimately exhibit different biological roles. Indeed, a significant difference between these proteins is the dependence of FGF-1 on heparin for the generation of maximal mitogenic activity. In order to gain structural insight into the issue of FGF-1 heparin-dependence, a synthetic gene encoding FGF-2 was constructed with oligonucleotides in a four-cassette format similar to a synthetic gene previously constructed for FGF-1 (Forough et al. 1992, Biochem. Biophys. Acta 1090 293-298). This strategy permitted the molecular shuffling of corresponding cassette(s) between FGF-1 and FGF-2 to yield FGF-1:FGF-2 chimeras. Three amino acid changes (Lys86-->Glu, Tyr120-->His, and Thr121-->Ala) were introduced into the synthetic FGF-2 gene by the cassette format to generate convenient FGF-1 restriction sites, but these alterations did not significantly affect the mitogenic activity or the heparin-binding affinity of the recombinant FGF-2 protein when compared with native FGF-2. Among the various FGF-1:FGF-2 chimeric constructs, one designated FGF-C(1(1/2)1 1), which represents FGF-1 containing FGF-2 amino acid residues 65 to 81, displayed FGF-1-like heparin-binding affinity but it did not require the addition of exogenous heparin to manifest its mitogenic activity. These data suggest that the sequence within residues 65 and 81 from FGF-2 significantly contributes to the heparin-dependent character of FGF-1.

Plasma from preeclamptic women increases human endothelial cell prostacyclin production without changes in cellular enzyme activity or mass

OBJECTIVE

We investigated differences in prostacyclin production by endothelial cells exposed to plasma from either preeclamptic women or normal pregnant women.

STUDY DESIGN

A case-control study of matched preeclamptic and normal pregnancies was used to compare prostacyclin synthesis by human umbilical vein endothelial cells incubated with pregnancy plasma for 24 hours. Prostacyclin concentrations in conditioned media were measured by radioimmunoassay of its stable metabolite (6-keto-prostaglandin F1 alpha). Human umbilical vein endothelial cell lysates were used to determine concentrations of the enzymes cyclooxygenase and prostacyclin synthase.

RESULTS

Prostacyclin production by human umbilical vein endothelial cells incubated with plasma from preeclamptic women was significantly greater than that by cells exposed to normal pregnancy plasma. Differences in prostacyclin production under the two experimental conditions could be explained neither by differences in enzyme mass nor activities of cyclooxygenase and prostacyclin synthase.

CONCLUSION

The stimulatory effect of preeclampsia plasma on prostacyclin biosynthesis in human umbilical vein endothelial cells appears to be manifested at a step(s) proximal to the activation of cyclooxygenase. Possible mechanisms are increased phospholipase A2, lipoprotein, or lipid peroxide activities in preeclampsia.

Pregnancies complicated by HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets): subsequent pregnancy outcome and long-term prognosis

OBJECTIVE

Our purpose was to describe subsequent pregnancy outcome and long-term maternal prognosis in women with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) during the index pregnancy.

STUDY DESIGN

This is a descriptive and analytic study of women with HELLP syndrome admitted to E.H. Crump Women's Hospital between August 1977 and July 1992. HELLP syndrome was defined by previously published laboratory criteria. Only patients who were delivered > 2 years ago were included (median 4 years, range 2 to 14 years). Data on these patients were obtained from our obstetric clinics, local physicians, local health departments, and hospital records.

RESULTS

Adequate follow-up data were available on 341 patients. One hundred fifty-two women subsequently became pregnant. One hundred thirty-nine normotensive women had 192 subsequent pregnancies. Complications included preeclampsia (19%), preterm delivery (21%), intrauterine growth restriction (12%), abruptio placentae (2%), perinatal death (4%), and HELLP syndrome (3%). Seven of the 113 women with at least 5 years' follow-up (6.2%) had chronic hypertension, and 98 received oral contraceptive pills without complications. Thirteen women with preexisting chronic hypertension had 20 subsequent pregnancies. These women had a higher rate of preeclampsia (75%), preterm delivery (80%), intrauterine growth restriction (45%), abruptio placentae (20%), and perinatal death (40%) but a low rate of recurrent HELLP syndrome (5%).

CONCLUSIONS

Women with HELLP syndrome have an increased risk of obstetric complications in future pregnancies but a low risk for recurrent HELLP syndrome. Oral contraceptive pills should not be contraindicated in normotensive women.

Biochemical corroboration of endothelial involvement in severe preeclampsia

This prospective, nested, case-control study investigated whether elevated plasma cellular fibronectin concentrations previously reported in preeclamptic women likely reflect endothelial dysfunction. In addition to higher maternal plasma concentrations of cellular fibronectin, we found higher levels of von Willebrand factor, tissue plasminogen activator, and plasminogen activator inhibitor-1 in maternal plasma, providing biochemical corroboration of endothelial dysfunction in severe preeclampsia.

Conservative management of severe preeclampsia remote from term

Traditionally, preeclamptic women who meet established criteria for severe disease are delivered expeditiously. Although delivery is always appropriate therapy for the mother, it may not be for the fetus remote from term. Two recent randomized clinical trials have demonstrated favorable neonatal outcomes after conservative management of severe preeclampsia remote from term. Nevertheless, because such management entails risk for both the mother and fetus, patients must be selected carefully. We consider women who have severe disease--by ACOG criteria for blood pressure (systolic persistently at least 160 mmHg or diastolic persistently at least 110 mmHg) or proteinuria (5 g/day or greater)--to be candidates for conservative management with close maternal and fetal surveillance. As long as maternal blood pressure can be controlled pharmacologically, maternal laboratory values are stable, and fetal biophysical profiles are normal, we manage these patients conservatively up to 34 weeks' gestation. Using these guidelines at our institution, we found that approximately two-thirds of patients with severe preeclampsia before 34 weeks were eligible for conservative management. We recommend that such management be performed only at tertiary perinatal centers.

Obstetric characteristics among nulliparas under age 15

OBJECTIVE

To describe and analyze the obstetric characteristics of adolescent women under 15 years of age.

METHODS

A matched cohort design was used. The pregnancies of 261 nulliparous women under age 15 delivered at our institution between January 1990 and December 1992 were compared to 261 nulliparous controls aged 20-29, matched for race, infant gender, and year of delivery. Multiple gestation and delivery immediately after hospital admission were exclusion criteria.

RESULTS

The number of antepartum admissions was identical (n = 35 in each group). There were no significant differences between the study and control groups in cervical dilatation at admission, frequency of labor induction (12.6% for each), epidural anesthesia (44.4 versus 49.4%), mean birth weight (2918 +/- 661 versus 2979 +/- 753 g), or preterm birth (24.1 versus 20.3%). Use of oxytocin was less common and magnesium sulfate more common in the adolescent group. Nevertheless, the duration of the active phase of labor and the rate of cesarean delivery were significantly lower in the adolescent group (4.5 +/- 2.7 versus 5.2 +/- 2.4 hours, P = .02; and 13.8 versus 25.3%, P = .001, respectively). The incidence of operative vaginal delivery was not different between the groups. Analysis of the data after controlling for fetal presentation, marital status, and insurance status did not alter these findings. Postpartum complications were similar.

CONCLUSION

Pregnancy at the lower limit of reproductive age in an urban American population is not associated with an abnormal labor course, as is commonly believed.