Evaluation of risk-factor-based screening for thyroid peroxidase antibody positivity in pregnancy

OBJECTIVE

To determine whether risk-factor-based screening for thyroid dysfunction in pregnancy performs well for detecting thyroid peroxidase antibodies (TPOAb), a marker for autoimmune thyroid disease.

STUDY DESIGN

We prospectively evaluated pregnant women for thyroid dysfunction using The Endocrine Society's eleven screening questions. Serum was analysed for TPOAb.

RESULT

We enrolled 546 women. TPOAb positivity was higher in women with a personal (odds ratio (OR) = 8·0; 95% confidence interval (CI) = 1·7-37·4; P = 0·02) or family history of thyroid disease (OR = 2·7; 95% CI = 1·3-5·7; P = 0·02). There was no association between the number of positive responses and TPOAb positivity (P = 0·41). Risk-factor-based screening missed 18 women (33%) with TPOAb.

CONCLUSION

One-third of women with TPOAb were missed by the case-finding method. A personal or family history of thyroid disease was most strongly associated with TPOAb positivity.

Bile acid concentration reference ranges in a pregnant Latina population

OBJECTIVE

The total bile acid (TBA) concentration criterion for diagnosing intrahepatic cholestasis of pregnancy varies in the published literature. The purpose of this study was to establish pregnancy-specific reference ranges for the TBA concentration among Latina women.

STUDY DESIGN

Self-identified Latina women (n = 211) over 18 years of age with a singleton pregnancy were recruited and had random serum samples drawn during the second and third trimesters. The total and fractionated bile acid concentrations were analyzed by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and reference ranges were calculated. Laboratory-provided general reference ranges from a general population of adult men and nonpregnant women were used for comparison.

RESULTS

The TBA reference range for our Latina pregnant population (<8.5 µmol/L) was markedly lower than the laboratory-provided reference range (4.5 to 19.2 µmol/L).

CONCLUSION

These data suggest that the upper TBA concentration reference range in our Latina pregnant population is 8.5 µmol/L, based on LC-MS/MS measurements.

Posttraumatic stress symptoms following pregnancy complicated by hyperemesis gravidarum

OBJECTIVE

Hyperemesis gravidarum (HG) can be accompanied by severe physical and emotional distress. Most studies have focused on the physical and psychological stress associated with this condition during the affected pregnancy. This study explores posttraumatic stress symptoms (PTSS) and negative life outcomes following HG pregnancies.

METHODS

A total of 610 women (HG = 377 and control = 233) were recruited and completed an online survey. χ-square analyses were used to compare the HG and control groups on various life outcome variables.

RESULTS

Eighteen percent of women with HG reported full criteria PTSS (n = 68). Negative life outcomes regarding financial and marital status, career, as well as psychological and physical well-being differed significantly for the HG groups compared to the control group (0.001 < p < 0.05).

CONCLUSIONS

PTSS is common following HG pregnancies and is associated with negative life outcomes including inability to breastfeed, marital problems, financial problems, and inability of self care.

Familial aggregation of hyperemesis gravidarum

OBJECTIVE

This study was undertaken to determine whether there is familial aggregation of hyperemesis gravidarum (HG), making it a disease amenable to genetic study.

STUDY DESIGN

Cases with severe nausea and vomiting in a singleton pregnancy treated with intravenous hydration and unaffected friend controls completed a survey regarding family history.

RESULTS

Sisters of women with HG have a significantly increased risk of having HG themselves (odds ratio, 17.3; P = .005). Cases have a significantly increased risk of having a mother with severe nausea and vomiting; 33% of cases reported an affected mother compared to 7.7% of controls (P < .0001). Cases reported a similar frequency of affected second-degree maternal and paternal relatives (18% maternal lineage, 23% paternal lineage).

CONCLUSION

There is familial aggregation of HG. This study provides strong evidence for a genetic component to HG. Identification of the predisposing gene(s) may determine the cause of this poorly understood disease of pregnancy.

Evidence against a link between hyperemesis gravidarum and personality characteristics from an ethnically diverse sample of pregnant women: a pilot study

BACKGROUND

Hyperemesis gravidarum (HG), a pregnancy-related condition marked by extreme nausea and vomiting, has been considered a psychosomatic illness associated with long-standing personality characteristics (e.g., hysteria). In this pilot study, we examined personality, somatic, and psychological variables with ethnically diverse samples of women with HG and women with typical levels of nausea and vomiting of pregnancy (NVP).

METHODS

Personality (Minnesota Multiphasic Personality Index-2 [MMPI-2] and MMPI-2RF), somatic (MMPI-2RF), and psychological (Beck Depression Inventory-II [BDI-II] and NVP-related quality of life) variables collected during the first trimester of pregnancy were compared between 15 women with HG and 15 women with normal levels of NVP matched for age, education, marital status, insurance source, and race/ethnicity. A secondary analysis was performed comparing these variables among a group of 9 asymptomatic pregnant women to the HG and NVP groups.

RESULTS

No significant differences were found between the HG and NVP groups on any personality, somatic, or psychological variables. Both groups had clinically significant elevations on the MMPI-2 hypochondriasis scale, which incorporates somatic symptoms. The NVP group had a clinically significant elevation on the MMPI-2RF gastrointestinal complaints scale. Both groups had significantly higher means on the MMPI-2 and MMPI-2RF scales than the asymptomatic group. Predominantly Spanish speakers appeared particularly vulnerable to psychological distress associated with somatic complaints.

CONCLUSIONS

The results of this pilot study suggest that research with HG patients is feasible and that psychological distress expressed by women with HG and NVP may reflect reactions to somatic symptoms. No evidence was found to support an association between HG and personality characteristics. Recommendations for future research are provided, such as examining the potential benefits of translation services for Spanish-speaking HG patients.

Late pregnancy complications can affect risk estimates of elective induction of labor

OBJECTIVE

Multiple observational studies have emphasized the increased risk of elective induction versus spontaneous labor. We estimated the risks of elective induction before 39 weeks compared to expectant management.

METHODS

Using a single institution's delivery data (1996-2004), we identified women with uncomplicated term gestations who underwent elective induction before 39 weeks (Early Induction Group). A comparison group of women eligible for elective induction before 39 weeks but who were managed expectantly was created by identifying the remaining deliveries ≥ 39 weeks and excluding women with "established" pregnancy complications such as diabetes or heart disease (Expectant Management Group), but retaining women with complications that may have developed while waiting, e.g. gestational hypertension or abruption.

RESULTS

Pregnancies in the Early Induction Group were generally not at increased risk for morbidity when compared to the entire Expectant Management Group, in whom 49% developed pregnancy complications or went postdates. These pregnancies had poorer maternal and neonatal outcomes when compared to patients who remained uncomplicated with spontaneous labor onset, thus reducing the overall benefit of expectant management.

CONCLUSIONS

Failure to account for the large proportion of women who develop late pregnancy complications can falsely elevate the estimated risk of elective induction prior to 39 weeks.

The mechanical PR interval in fetuses of women with intrahepatic cholestasis of pregnancy

OBJECTIVE

The purpose of this study was to evaluate the fetal mechanical PR interval in intrahepatic cholestasis of pregnancy (ICP).

STUDY DESIGN

Fetal echocardiography was performed for women with ICP and control subjects. Clinical characteristics, total bile acids, and liver profile tests were compared between groups.

RESULTS

Fourteen women with ICP and 7 control subjects were enrolled. Total bile acids (28.3 vs 6.2 μmol/L; P < .001), aspartate aminotransferase (53 vs 23 IU/L; P = .002), alanine aminotransferase (63 vs 19 IU/L; P = .002), and the PR interval (124 vs 110 msec; P = .006) were significantly higher in fetuses with ICP than in control fetuses. On multivariable linear regression analysis, only the presence of ICP was associated significantly with an increase in the PR interval (95% confidence interval, 4-24 msec; P = .01).

CONCLUSION

The fetal cardiac conduction system is altered in ICP. Further investigation is needed to determine whether fetal echocardiography can help to predict which fetuses are at risk for death that is associated with ICP.

The effect of barusiban, a selective oxytocin antagonist, in threatened preterm labor at late gestational age: a randomized, double-blind, placebo-controlled trial

OBJECTIVE

The objective of the study was to compare barusiban with placebo in threatened preterm labor.

STUDY DESIGN

This was a randomized, double-blind, placebo-controlled, multicenter study. One hundred sixty-three women at 34-35 weeks plus 6 days, and with 6 or more contractions of 30 seconds duration during 30 minutes, cervical length 15 mm or less, and cervical dilatation > 1 and < 4 cm were randomized to a single intravenous bolus of barusiban (0.3, 1, 3, or 10 mg) or placebo. The primary endpoint was percentage of women who did not deliver within 48 hours.

RESULTS

None of the barusiban doses reduced the number of uterine contractions compared with placebo. There was no significant difference in the percentage of women who did not deliver within 48 hours (72% placebo and 65-88% barusiban groups; P = .21-.84). Barusiban was not associated with an adverse safety profile in the woman, fetus, neonate, or infant.

CONCLUSION

An intravenous bolus of barusiban was no more effective than placebo in stopping preterm labor in pregnant women at late gestational age.

Are patients with twin-twin transfusion syndrome and a very short cervix candidates for laser surgery?

OBJECTIVES

The purpose of this study was to determine the relationship between cervical length (CL) and perinatal outcomes in cases of twin-twin transfusion syndrome (TTTS) treated with laser surgery and to assess whether patients with a very short cervix (0.5-1.9 cm) are appropriate candidates for laser surgery.

METHODS

All women who underwent laser surgery for TTTS from March 2006 to April 2008 at the study institution were evaluated consecutively. Patients were grouped according to pre-operative CL: greater than 2.5, 2 to 2.5, and 0.5 to 1.9 cm. The gestational age at delivery, latency from laser surgery to delivery, and 30-day neonatal survival were documented prospectively and compared among these groups.

RESULTS

The 99 women in the study population were grouped by CL: greater than 2.5 cm (n = 76), 2 to 2.5 cm (n = 13), and 0.5 to 1.9 cm (n = 10). For these groups, the median gestational ages at delivery were 34, 32.29, and 31.86 weeks, respectively (P = .411). The median latencies from laser surgery to delivery were 12.79, 11, and 11.07 weeks (P = .424). The frequency rates of at least 1 surviving twin were 69 of 76 (91%), 13 of 13 (100%), and 8 of 10 (80%) (P = .254). Finally, dual survivors were observed in 54 of 76 (71%), 12 of 13 (92%), and 5 of 10 (50%) (P = .08).

CONCLUSIONS

In cases of TTTS complicated by a very short cervix (0.5-1.9 cm), treatment with laser surgery resulted in perinatal outcomes that were sufficiently favorable to justify the surgery, suggesting that these patients should not be excluded from undergoing laser surgery for TTTS.

Alteration of secretory leukocyte protease inhibitor in human myometrium during labor

OBJECTIVE

Secretory leukocyte protease inhibitor (SLPI) has been shown to have antimicrobial and antiinflammatory properties. The aim of this study was to verify its expression in human myometrium.

STUDY DESIGN

Myometrium was obtained at time of cesarean delivery with (n = 9) or without (n = 11) labor. Expression of SLPI was detected using real-time polymerase chain reaction, enzyme-linked immunosorbent assay, and immunohistochemistry. SLPI expression relative to nuclear factor-kappaB p65 subunit was compared between subjects. SLPI response to inflammatory mediators was studied in myometrial explants.

RESULTS

SLPI was predominantly localized in the nuclei of myocytes and colocalized with CD68(+) macrophages. The nuclear immunoreactivity of SLPI was increased after the onset of labor and was associated with increased nuclear translocation of nuclear factor-kappaB p65 subunit. Treatment with lipopolysaccharide, interleukin-1beta, or tumor necrosis factor-alpha increased SLPI messenger RNA and protein concentrations slightly in myometrium explants.

CONCLUSION

SLPI was expressed in human myometrium and increased after the onset of labor.

High prevalence of severe nausea and vomiting of pregnancy and hyperemesis gravidarum among relatives of affected individuals

OBJECTIVE

The goal of this study was to determine the prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of affected individuals.

STUDY DESIGN

Family history data were obtained on 1224 self-reported cases of hyperemesis gravidarum. Cases completed an online survey administered by the Hyperemesis Education and Research Foundation between 2003 and 2006.

RESULTS

Approximately 28% of cases reported their mother had severe nausea and vomiting or hyperemesis gravidarum while pregnant with them. Of the 721 sisters with a pregnancy history, 137 (19%) had hyperemesis gravidarum. Among the most severe cases, those requiring total parenteral nutrition or nasogastric feeding tube, the proportion of affected sisters was even higher, 49/198 (25%). Nine percent of cases reported having at least two affected relatives including sister(s), mother, grandmother, daughters, aunt(s), and cousin(s).

CONCLUSION

There is a high prevalence of severe nausea and vomiting of pregnancy/hyperemesis gravidarum among relatives of hyperemesis gravidarum cases in this study population. Because the incidence of hyperemesis gravidarum is most commonly reported to be 0.5%, this study provides strong but preliminary evidence for a genetic component to extreme nausea and vomiting of pregnancy.

Regulatory and methodologic challenges to tocolytic development

The development of tocolytic medications faces challenges common to all drug development programmes, principally related to evolving understanding of the pathophysiology. There are unique impediments to drug development for pregnancy-related conditions in general and for tocolysis in particular. The purpose of this brief overview is to familiarize the obstetrician with the current challenges to drug development, focusing in particular on the problems of tocolytic development. A strategy for encouraging drug development for preterm labour and for pregnancy-related problems in general is presented.

The prevalence of intrahepatic cholestasis of pregnancy in a primarily Latina Los Angeles population

OBJECTIVE

To establish the prevalence of intrahepatic cholestasis of pregnancy (ICP) in a primarily Latina population in the United States.

STUDY DESIGN

Over a period of 16 months, a convenience sample of subjects admitted to labor and delivery in the third trimester was enrolled. Each subject completed a questionnaire rating their severity of pruritus on a numeric scale of 1 to 10. Serum was analyzed via radioimmunoassay for total bile acid concentration. ICP was defined as pruritus score >4 and a total serum bile acid concentration of >or=20 micromol/l. Ethnicity was determined from hospital record demographic data.

RESULTS

All invited participants enrolled in the study. Three hundred and forty subjects were enrolled. Three hundred and sixteen subjects (93%) were identified as Latina. The serum bile acid concentration range for the entire study population was 1 to 580 micromol/l with a mean of 10.4+/-34.9 micromol/l. Twenty-four (7.1%) subjects had a serum bile acid concentration >or=20 micromol/l. A pruritus score >4 was found in 19.7% (67/340). Of the 24 subjects with a bile acid concentration >or=20 micromol/l, 19 also had a pruritus score >4. Thus, the prevalence of ICP in this population was 5.6% (19/340). In subjects with ICP, the mean serum bile acid concentration was 89.5+/-124.0 micromol/l. When controlling for confounders, women with ICP were associated with higher rates of chorioamnionitis (P=0.043) and their fetuses had higher rates of thick meconium (P=0.053).

CONCLUSIONS

The overall prevalence of ICP in this population was 5.6%, 10 to 100 times higher than previously reported data from the United States. Larger studies of perinatal morbidity examining the diagnostic criteria of cholestasis need to be conducted.

Pregnancy outcomes during treatment with interferon beta-1a in patients with multiple sclerosis

BACKGROUND

Although patients with multiple sclerosis (MS) are advised to stop interferon (IFN) beta-1a therapy before becoming pregnant, some patients become pregnant while on treatment.

METHODS

We examined individual patient data from eight clinical trials with IFNbeta-1a.

RESULTS

Of 3,361 women in the studies, 69 pregnancies were reported, of which 41 were patients receiving (or who had stopped receiving within 2 weeks prior to conception) IFNbeta-1a (in utero exposure group), 22 were patients who discontinued IFNbeta-1a treatment more than 2 weeks before conception (previous exposure group), and six were patients receiving placebo. The 41 in utero exposure pregnancies resulted in 20 healthy full-term infants, one healthy premature infant, nine induced abortions, eight spontaneous abortions, one fetal death, and one congenital anomaly (hydrocephalus). One patient was lost to follow-up. The 22 previous exposure pregnancies resulted in 20 full-term healthy infants, one healthy premature infant, and one birth-related congenital anomaly (Erb palsy).

CONCLUSIONS

The majority (21/31) of pregnancies that had the potential to go to full term produced healthy infants. The rate of spontaneous abortion was higher, but not significantly so, in the in utero exposure group compared to general population estimates. Until more exposure data become available, patients remain advised to stop IFNbeta therapy before becoming pregnant.

Left atrial thrombosis in pregnant women with mitral stenosis and sinus rhythm

OBJECTIVE

The purpose of this study was to describe pregnant patients with mitral stenosis who had intracardiac thrombosis in the absence of atrial fibrillation.

STUDY DESIGN

We reviewed the clinical course of 3 pregnant women with severe mitral stenosis and normal sinus rhythm who had clinically significant intracardiac thrombosis.

RESULTS

The first patient was examined at 21 weeks of gestation with embolic stroke that was the result of left atrial thrombus. A second patient was found to have a large left atrial thrombus that prevented the performance of balloon valvuloplasty. The third patient had left atrial clot that partially occluded the mitral valve orifice and led to the development of pulmonary edema that resulted in an emergent cesarean delivery and anoxic brain injury in the newborn infant.

CONCLUSION

Pregnant patients with mitral stenosis in normal sinus rhythm can experience thromboembolic events that can be detrimental to both the mother and the fetus. Anticoagulation therefore should be strongly considered in this group.

Oral misoprostol vs. intravaginal prostaglandin E2 for preinduction cervical ripening. A randomized trial

OBJECTIVE

To compare orally administered misoprostol with intravaginal prostaglandin E2 for cervical ripening and labor induction.

STUDY DESIGN

Patients presenting with medical or obstetric indications for labor induction whose Bishop's score was < or = 6 were randomly allocated to receive either 50 micrograms of oral misoprostol or 4 mg of intravaginal prostaglandin E2. If adequate cervical ripening (Bishop score of 9 or cervical dilatation of 3) or active labor did not ensue, repeat doses of each medication were administered every four hours. A maximum of six doses of either oral misoprostol or intravaginal prostaglandin E2 was permitted. Intravenous oxytocin was subsequently administered according to a standardized infusion protocol.

RESULTS

Sixty patients were enrolled, with 29 randomized to the oral misoprostol arm and 31 to the prostaglandin E2 group. The data on 58 patients were eligible for analysis. Delivery occurred within 48 hours in 96.4% (27/28) of those administered oral misoprostol as compared to 76.7% (23/30) of those who received intravaginal prostaglandin E2 (P = .03). The mean time intervals from the start of induction to delivery were similar between the two groups (1,496 +/- 120 vs. 1,723 +/- 230 minutes, P = .40). No statistically significant differences existed between the two groups with respect to intrapartum complications, tachysystole, uterine hyperstimulation or adverse neonatal outcomes.

CONCLUSION

Oral administration of misoprostol is an effective alternative to intravaginal prostaglandin E2 for preinduction cervical ripening.

Psychological factors and hyperemesis gravidarum

Hyperemesis gravidarum (HG) is a condition of severe, intractable nausea and vomiting during pregnancy. It has long been held that HG is a psychosomatic illness reflective of a long-term psychological trait, that is, conversion disorder. We investigated this possibility by conducting a two-phase study: (1) a comparison of women with (n = 9) and without (n = 10) HG during pregnancy and (2) a comparison of nonpregnant women who did (n = 10) and did not (n = 12) have HG during their most recent pregnancies. The pattern of findings differed between experiments 1 and 2. During pregnancy, women with HG scored significantly higher on three scales associated with conversion disorder (all p values <0.01) than did women without HG. There were no significant differences between HG subjects and controls after pregnancy. We find no support for the theory that HG is a psychosomatic condition. Rather, it appears to be a complex interaction of biological, psychological, and sociocultural factors.

Serial salivary estriol to detect an increased risk of preterm birth

OBJECTIVE

To evaluate serial measurements of salivary estriol (E3) to detect increased risk of spontaneous preterm labor and preterm birth.

METHODS

A masked, prospective, multicenter trial of 956 women with singleton pregnancies was completed at eight United States medical centers. Saliva was collected weekly, beginning at the 22nd week of gestation until birth, and tested for unconjugated E3 by enzyme-linked immunosorbent assay. Women were separated into high-risk and low-risk groups using the Creasy scoring system.

RESULTS

A single, positive (at or above 2.1 ng/mL) salivary E3 test predicted an increased risk of spontaneous preterm labor and delivery in the total population (relative risk [RR] 4.0, P <.005), in the low-risk population (RR 4.0, P < or =.05), and in the high-risk population (RR 3.4, P =.05). Two consecutive positive tests significantly increased the RR in all study groups, with a dramatic improvement in test specificity and positive predictive value but only a modest decrease in sensitivity. In women who presented with symptomatic preterm labor, salivary E3 identified 61% of those who delivered within 2 weeks, using a threshold of 1.4 ng/mL.

CONCLUSION

Elevated salivary E3 is associated with increased risk of preterm birth in asymptomatic women and symptomatic women who present for evaluation of preterm labor.

An oxytocin receptor antagonist (atosiban) in the treatment of preterm labor: a randomized, double-blind, placebo-controlled trial with tocolytic rescue

OBJECTIVES

This study was designed to evaluate the efficacy and safety of the oxytocin receptor antagonist atosiban in the treatment of preterm labor.

STUDY DESIGN

A multicenter, double-blind, placebo-controlled trial with tocolytic rescue was designed. Five hundred thirty-one patients were randomized to receive, and 501 received, either intravenous atosiban (n = 246) or placebo (n = 255), followed by subcutaneous maintenance with the assigned agent. Standard tocolytics as rescue tocolysis were permitted after 1 hour of either placebo or atosiban if preterm labor continued. The primary end point was the time from the start of study drug to delivery or therapeutic failure. Secondary end points were the proportion of patients who remained undelivered and did not receive an alternate tocolytic at 24 hours, 48 hours, and 7 days.

RESULTS

No significant difference was found in the time from start of treatment to delivery or therapeutic failure between atosiban and placebo (median, 25.6 days vs 21.0 days, respectively; P =.6). The percentages of patients remaining undelivered and not requiring an alternate tocolytic at 24 hours, 48 hours, and 7 days were significantly higher in the atosiban group than in the control group (all P < or =.008). A significant treatment-by-gestational age interaction existed for the 48-hour and 7-day end points. Atosiban was consistently superior to placebo at a gestational age of > or =28 weeks. Fourteen atosiban-treated patients and 5 placebo-treated patients were randomized at <24 weeks; the incidence of fetal-infant deaths was higher for the atosiban group at <24 weeks. Maternal-fetal adverse events were similar except for injection-site reactions, which occurred more often with atosiban.

CONCLUSIONS

In this trial the treatment of patients in preterm labor with atosiban resulted in prolongation of pregnancy for up to 7 days for those at a gestational age > or =28 weeks, and this occurred with a low rate of maternal-fetal adverse effects. In addition, at a gestational age > or =28 weeks, the infant morbidity and mortality of atosiban-initiated standard care were similar to those with placebo-initiated standard care. Given that all patients in this study were eligible for tocolysis and that, in practice, nearly all patients who are eligible for a tocolytic receive one, the benefit of using atosiban is the placebo-like maternal-fetal side effect profile. These observations support the use of this oxytocin receptor antagonist in the treatment of patients in preterm labor with intact membranes. Efficacy and infant outcome data at <28 weeks are inconclusive.

Unstable angina during pregnancy in two patients with premature coronary atherosclerosis and aortic stenosis in association with familial hypercholesterolemia

Obstructive atherosclerotic coronary artery disease is uncommon in women during childbearing age, and the occurrence of myocardial ischemia during pregnancy has therefore been anecdotal. Two young patients with premature coronary artery disease in association with familial hypercholestrolemia had unstable angina in the second trimester of pregnancy. Workup revealed coronary artery disease and aortic stenosis. One patient opted for abortion at the twentieth week of gestation, and the other decided to continue pregnancy and was delivered by cesarean at 28 weeks' gestation. Coronary artery bypass grafting was performed after pregnancy in both patients. In addition, one of the patients underwent aortic valve replacement, and other had replacement of the narrowed ascending aorta with uneventful recovery. Our report describes an uncommon presentation of unstable angina during pregnancy in 2 young women with premature coronary artery disease and aortic valvular and supravalvular stenosis as a result of familial hypercholesterolemia. The management of these conditions during pregnancy is influenced by the effects of available therapeutic modalities on both maternal and fetal outcome.

Obstetric implications of activated protein C resistance and factor V Leiden mutation

An increasing number of reports have focused on activated protein C resistance (APCR) as it has been shown not only to be the most common genetic factor predisposing patients to thromboembolic disease but the most common identifiable cause overall. More than 90 percent of the cases of APCR are caused by the factor V Leiden mutation, in which a guanine to adenine substitution in the factor V gene at nucleotide position 1691 results in a glutamine to arginine switch at position 506. Recent studies have also pointed to evidence of an association between APCR/factor V Leiden mutation and hypertensive disorders of pregnancy, first and second trimester miscarriage, placental infarction, and placental abruption.

Analysis of McRoberts' maneuver by x-ray pelvimetry

OBJECTIVE

To document radiographically the changes in pelvic dimensions created by McRoberts' maneuver.

METHODS

Women at least 37 weeks' pregnant who presented to labor and delivery were eligible for study entry. Anterior-posterior and lateral x-rays were taken with women in the dorsal lithotomy position and after application of McRoberts' maneuver, in which the maternal legs were hyperflexed 45 degrees onto the maternal abdomen. A two-tailed paired t test was used to assess the changes in the pelvic diameters, with P < .05 considered statistically significant.

RESULTS

Thirty-six subjects were enrolled in the study and 34 x-rays were suitable for analysis. McRoberts' maneuver was associated with an increase in the mean angle of inclination between the symphysis pubis and the sacral promontory (51.53 +/- 2.03 versus 38.07 +/- 1.96 degrees, P < .001). There was a 24% decrease in the angle created by drawing a line bisecting the symphysis pubis relative to the horizontal (P < .001). With McRoberts' maneuver the angle created by a line bisecting the longitudinal axis of the fifth lumbar vertebra and the longitudinal axis of the upper sacrum also increased (133.75 +/- 2.25 to 140.14 +/- 2.12 degrees, P = .04).

CONCLUSION

Ours are the first systematic observations of pelvic changes associated with McRoberts' maneuver, confirming the traditional thinking that the maneuver causes a significant cephalad rotation of the symphysis pubis and subsequent flattening of the sacrum.

Clinical Implications of Perinatal Depression

The evaluation of the depressed newborn as a possible role in intrapartum asphyxia must be based on the objective findings of the fetal heart rate tracing, umbilical cord blood gas, and newborn neurologic function. Using these points as a basis for long-term followup, the following principles have been elucidated: Intrapartum asphyxia is an uncommon cause of childhood neurologic disfunction, the intrapartum insult necessary to cause long-term neurologic dysfunction is profound, and the child who does not manifest encephalopathy in the newborn period will not suffer long-term neurologic dysfunction that can be attributed to intrapartum asphyxia.

Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy

OBJECTIVE

To estimate the incidence, timing, and associated clinical characteristics of objectively diagnosed pregnancy-associated venous thromboembolism.

METHODS

We retrospectively reviewed venous thromboembolism cases (deep venous thrombosis and pulmonary embolism) that occurred between 1978 and 1996. Study inclusion criteria required the objective diagnosis with either Doppler ultrasound, venography, impedance plethysmography, pulmonary angiography, ventilation-perfusion scanning, or computed tomography or magnetic resonance imaging.

RESULTS

Among 268,525 deliveries there were 165 (0.06%) episodes of venous thromboembolism (one per 1627 births). There were 127 cases of deep venous thrombosis and 38 cases of pulmonary embolism. Only 14% (23 of 165 patients) had a history of venous thromboembolism. Most cases of deep venous thrombosis were in the left leg (104 of 127, 81.9%), with nearly three quarters of them (94 of 127, 74.8%) occurring during the antepartum period. Among cases of antepartum deep venous thrombosis, half were detected before 15 weeks' gestation (47 of 95, 49.5%), and only 28 cases occurred after 20 weeks (P < .001). Most of the pulmonary embolisms occurred in the postpartum period (23 of 38, 60.5%) and were strongly associated with cesarean delivery (19 of 36,470 compared with four of 232,032, P < .001).

CONCLUSION

The incidence of venous thromboembolism during pregnancy is lower than has been previously described. Most cases occurred in the antepartum period, with the risk of deep venous thrombosis appearing to begin even before the second trimester.

Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases

OBJECTIVE

We sought to describe our experience with the clinical diagnosis, management, and course of patients with acute fatty liver of pregnancy.

STUDY DESIGN

Twenty-eight cases of acute fatty liver of pregnancy at the Los Angeles County and University of Southern California Medical Center from 1982 to June 1997 were identified, and presenting symptoms, clinical course, laboratory values, maternal complications, and neonatal outcomes were studied.

RESULTS

The incidence of acute fatty liver of pregnancy was 1 in 6659 births. There were no maternal deaths. Initial presentation was at an average of 37 weeks of gestation with a characteristic prodrome of malaise, nausea, vomiting, and abdominal pain. No patient was admitted with the diagnosis of acute fatty liver of pregnancy. The condition was diagnosed most commonly on the second hospital day after laboratory results indicated coagulopathy, renal insufficiency, and liver function abnormalities. One patient underwent liver biopsy at cesarean delivery. Radiologic studies did not aid with the diagnosis. Twenty-one patients were admitted in spontaneous labor, and 16 labors were complicated by abnormal fetal heart rate patterns or meconium. There was 1 stillbirth and 1 neonatal death as a result of perinatal asphyxia. Maternal morbidity consisted of hypoglycemia, infection, renal insufficiency, coagulopathy, encephalopathy, and wound complications. All patients had evidence of disseminated intravascular coagulopathy with profoundly decreased antithrombin levels. All patients recovered normal liver function post partum.

CONCLUSIONS

Reversible peripartum liver failure may be diagnosed and managed on the basis of clinical and laboratory criteria. With adequate support, these patients may have full recovery of hepatic function.

Brachial plexus palsy: an in utero injury?

Acquired brachial plexus injury historically has been linked with excessive lateral traction applied to the fetal head, usually in association with shoulder dystocia. Recent reports in the obstetric literature, however, have suggested that in utero forces may underlie a significant portion of these injuries. Brachial plexus palsies may therefore precede the delivery itself and may occur independent of the actions of the accoucheur. Thus we propose that the long-held notions of a traction-mediated pathophysiologic mechanism for all brachial plexus injuries warrant critical reappraisal.

Massive fetomaternal hemorrhage and fetal death: are they predictable?

OBJECTIVE

To report the incidence of massive fetomaternal hemorrhage (FMH) associated with fetal death and to test the hypothesis that FMH is more likely to occur in those with risk factors for FMH.

STUDY DESIGN

All cases of fetal death of infants weighing > 500 gm between January 1, 1990 and December 31, 1994 were reviewed for evidence of massive FMH (> or = 2% fetal cells in the maternal circulation as measured by the Betke-Kleihauer test). Women with risk factors were compared with those without risk factors with respect to the occurrence of massive FMH.

RESULTS

The prevalence of massive FMH was 14 of 319 (4.4%) cases, occurring in 4 of 102 (3.9%) of those with risk factors and 10 of 217 (4.6%) of patients without risk factors (p = 0.78). Otherwise unexplained fetal death was associated with massive FMH in 5 of 141 (3.5%). Major fetal anomalies were present in 5 of 14 (35.7%) cases of massive FMH.

CONCLUSION

Clinical risk factors do not predict an increased likelihood of massive FMH. Massive FMH is associated with fetal anomalies. Betke-Kleihauer testing should be performed in all cases of fetal death, including those with anomalies regardless of the presence or absence of risk factors for FMH.

Pregnancy, the postpartum, and steroid hormones: effects on cognition and mood

The effects of pregnancy on cognition and mood were examined using a repeated-measures design. Nineteen women, average age 33, were tested with a comprehensive neuropsychological battery during their last 2 months of pregnancy and again within 2 months of delivery. Blood samples were obtained from all subjects and assayed for a variety of steroid hormones implicated in cognitive and mood functioning. Most participants also completed several self-report measures of mood. In comparison with performance after delivery, women showed significantly more impairment in aspects of verbal memory during pregnancy and also tended to report more negative mood states. Memory deficits were not explained by mood disturbances. No hormone assayed consistently related to cognitive performance during pregnancy. During pregnancy, higher levels of progesterone (P) were associated with greater mood disturbances and higher levels of dehydroepiandrosterone (DHEA) with better mood. After delivery, testosterone (T) was strongly and consistently associated with greater reported mood disturbances. Our results confirm a peripartal memory deficit, which cannot be explained by the dramatic rise in circulating steroid hormones, or by mood status during pregnancy. Steroidal hormones, namely P, DHEA and T, appear to play a role in mood disturbances during, and after, pregnancy. Studies beginning earlier in pregnancy and continuing for an extended period of time after delivery are needed to confirm and expand these observations.

A role for estriol in human labor, term and preterm

Although estriol has been studied as an indicator of fetal well-being in the past, its broader biologic role has not been elucidated. Estriol in the maternal compartment closely reflects fetal adrenal activity, and increased fetal adrenal activity prior to the onset of labor is a common link in mammalian parturition. In humans, estriol increases before spontaneous labor and may be a clinically useful marker for some cases of preterm labor.

Serial betamethasone administration: effect on maternal salivary estriol levels

OBJECTIVE

Maternal salivary estriol levels are an indirect measure of fetal adrenal activity, which may be affected by administration of betamethasone. The objective was to compare sequential salivary estriol levels in patients receiving serial betamethasone therapy with those of healthy pregnant patients.

STUDY DESIGN

Ten patients at high risk for preterm delivery were asked to obtain salivary specimens before and 1 to 2 days after each administration of weekly betamethasone treatments between 24 and 32 weeks' gestation. These values were compared with those of specimens obtained throughout gestation in healthy women who were not delivered preterm. Unconjugated salivary estriol was measured with a sensitive and specific enzyme-linked immunoassay (Biex, Inc, Dublin, Calif).

RESULTS

The effect of betamethasone on salivary estriol levels did not change with time, showing an average of 23.1% drop from pretreatment to posttreatment levels but rebounding to the same starting level before the next dose. When weekly pretreatment values were looked at across time, the geometric mean of the individual patients' slopes did not differ significantly from no change. The same was true of the posttreatment values. The rate of change with advancing gestation was compared between 182 control subjects and the 10 study subjects. The average change was +8.8% per week in the control subjects and -1.3% per week in the study patients (P =.003).

CONCLUSIONS

Maternal administration of betamethasone significantly suppressed salivary estriol levels. These levels returned to pretreatment values each week before the next dose; however, the rise normally associated with advancing gestational age was not observed.

Efficacy of azithromycin in reducing lower genital Ureaplasma urealyticum colonization in women at risk for preterm delivery

OBJECTIVE

The purpose of this study was to determine if azithromycin is effective in reducing lower genital colonization of Ureaplasma urealyticum in women with preterm labor or preterm premature rupture of membranes (PROM).

METHODS

A randomized, double-blinded, placebo-controlled prospective study of 60 pregnancies was carried out between 22 and 34 weeks. Genital mycoplasma cultures were performed at the time of admission. Patients were randomized to receive either a single dose of azithromycin (four 250 mg capsules) or a placebo in addition to prophylactic intravenous ampicillin. Repeat cultures were done on undelivered patients 7 days after enrollment. The study had power to detect a 50% decrease in colonization.

RESULTS

Overall, lower genital colonization was 47/59 (79.7%) for U. urealyticum. Seven days after enrollment, U. urealyticum was isolated in 14/15 (93.3%) of the azithromycin-treated cases and in 11/14 (78.6%) of the controls (RR = 1.19, 95% CI = 0.88-1.61). Vertical transmission of U. urealyticum was 3/15 (20%) in the azithromycin-treated cases and 5/10 (50%) for the controls (RR = 0.40, 95%, CI = 0.12-1.31).

CONCLUSION

These data suggests that a single 1 g dose of azithromycin is ineffective in reducing lower genital colonization with U. urealyticum.

Favorable response of Eisenmenger syndrome to inhaled nitric oxide during pregnancy

OBJECTIVE

Our goal was to evaluate the effectiveness of therapy with a specific pulmonary vasodilator, nitric oxide, in a woman with Eisenmenger syndrome during pregnancy.

STUDY DESIGN

Eisenmenger syndrome consists of a congenital communication between the systemic and pulmonary circulation with secondary pulmonary hypertension causing reversal of flow through the shunt. Maternal morbidity is approximately 50% with the greatest risk of death being in the peripartum period. Pharmacologic therapy to relieve worsening pulmonary hypertension is confounded by the undesired effects of vasodilators on the systemic circulation. Therapy with a specific pulmonary vasodilator, nitric oxide, was attempted.

RESULTS

A 27-year-old woman with Eisenmenger syndrome at 36 weeks' gestation was treated with inhaled nitric oxide during the second stage of labor and the postpartum period when she experienced progressive refractory hypoxemia. Administration of nitric oxide was followed by improved oxygenation and lowering of pulmonary artery pressures. A brief episode of methemoglobinemia responded to lowering of the nitric oxide concentration and administration of intravenous methylene blue. Nitric oxide was discontinued after 48 hours. The patient died 2 days later despite continued vasodilator therapy including intra-pulmonary artery prostacyclin.

CONCLUSION

Inhaled nitric oxide can be used to correct the hypoxemia of Eisenmenger syndrome. Nitric oxide inhalation is easily performed, and pulmonary vasodilatory effects commence within minutes after administration.

Shoulder dystocia

Shoulder dystocia continues to represent a largely unpredictable and potentially disastrous obstetric emergency. Recent attention has been focused on the effectiveness of obstetric maneuvers employed to alleviate shoulder dystocia. Reports have also questioned the traditional thinking that brachial plexus injury is caused by application of excessive lateral traction to the fetal head. Rather, in-utero forces may underlie a significant portion of these injuries.

Oxytocin receptor antagonists. Update

For over three decades, scientists in a number of different laboratories have worked to design peptide analogues of oxytocin (OT) selective for the oxytocin receptor. Although there has been some interest in their use for treatment of dysmenorrhea, the principal clinical venue for such agents has been thought to lie in treatment of preterm labor. A major difficulty in identifying the clinical role for an OT antagonist had been our incomplete understanding of the role of OT in both term and preterm labor. This article begins with a review of the current understanding of the role of OT in the initiation and maintenance of labor in the human.

The efficacy of methylprednisolone in the treatment of hyperemesis gravidarum: a randomized, double-blind, controlled study

OBJECTIVE

The study compared the efficacy of methylprednisolone with that of promethazine for the treatment of hyperemesis gravidarum.

STUDY DESIGN

Patients with a normal-appearing intrauterine pregnancy of < or = 16 weeks' gestation with hyperemesis gravidarum (persistent vomiting and large ketonuria despite outpatient therapy) were admitted to the hospital for continuous intravenous hydration and offered participation in the study. Patients meeting study criteria were randomly assigned to receive (from identical-appearing dispensers packaged in advance with a 2-week supply) oral methylprednisolone, 16 mg 3 times daily, or oral promethazine, 25 mg 3 times daily. After 3 days the methylprednisolone was tapered completely during the course of 2 weeks whereas the promethazine was continued without change for 2 weeks. For patients who continued to vomit after 2 days the study medication was discontinued. Patients receiving study medication at discharge continued to take the remainder of the assigned medication from the packaged pill dispensers. Patients were followed up weekly. The study outcomes, as established in advance, were (1) improvement of symptoms within 2 days of starting therapy and (2) readmission for hyperemesis within 2 weeks of starting the study.

RESULTS

Forty patients were enrolled in the course of 11 months (20 per group). There were no significant differences between the groups with respect to maternal age, gravidity, parity, gestational age at entry, number of previous admissions, or > 5% body weight loss. Three patients in the methylprednisolone group and 2 in the promethazine group failed to stop vomiting within 2 days. One patient from the promethazine group was unavailable for follow-up. No patient from the methylprednisolone group but 5 of the 17 patients receiving promethazine were readmitted for hyperemesis within 2 weeks of discharge (P = .0001). There were no adverse effects noted for either drug.

CONCLUSION

A short course of methylprednisolone is more effective than promethazine for the treatment of hyperemesis.

Ballantyne syndrome: is placental ischemia the etiology?

Ballantyne syndrome is a condition in which the gravid patient essentially "mirrors" the in utero state of the hydropic fetus. The exact pathophysiological mechanism, however, is unclear. At 25 weeks gestation, a 28-year-old G3P2 presented with acute onset lower extremity edema, hyperuricemia, polyhydramnios, generalized pruritus, hemodilutional anemia, and pre-term labor. The human chorionic gonadotrophin (hCG) level was markedly elevated, at 570,020 mIU/ml. Postpartum, she developed a pre-eclampsia-like syndrome with oliguria and pulmonary effusions. Associated placental findings included a 8 x 7 x 7 cm chorangioma. Underlying placental ischemia, reflected by a hyperproliferative trophoblast, increased hCG secretion, and increased placental resistance may account for the maternal findings of Ballantyne syndrome.

Incidence, clinical characteristics, and timing of objectively diagnosed venous thromboembolism during pregnancy

Objective: To determine the incidence, timing, and associated clinical characteristics of objectively diagnosed pregnancy-associated venous thromboembolism (VTE).Methods: A retrospective review of VTE cases occurring between 1978 and 1996 was performed. Cases of deep venous thrombosis (DVT) and pulmonary embolism (PE) were identified by ICD-9 discharge diagnosis code and review of antepartum and coagulation laboratory databases. Study inclusion criteria required the objective diagnosis of VTE with either Doppler ultrasound, impedance plethysmography, pulmonary angiography, ventilation-perfusion scanning, or CT/MRI.Results: Among 268,525 deliveries there were 165 (0.06%) episodes of VTE (1/1627 births). There were 127 cases of DVT and 38 cases of PE. Only 14% (23/165) had a prior history of DVT or PE. Most DVTs occurred in the left leg (104/127, 81.9%). Nearly three quarters of the DVTs (95/127, 74.8%) occurred in the antepartum period. Among the antepartum DVT cases, half were detected prior to 15 weeks of gestation (47/95, 49.5%), with only 28 cases occurring after 20 weeks (P <.0001). The majority of the PEs occurred in the postpartum period (23/38, 60.5%). There were only 3 maternal deaths due to PE, all associated with cesarean section. Only 1 patient developed PE while on heparin therapy for DVT while 11 others had complications attributable to heparin use.Conclusion: Most pregnancy-related VTE occurs in the antepartum period. The risk of deep venous thrombosis appears to begin early in pregnancy, even before the second trimester. The highest risk period for pulmonary embolism is after cesarean delivery. Maternal complications of heparin anticoagulation during pregnancy are rare.

Pharmacokinetic and pharmacodynamic evaluation of atenolol during and after pregnancy

STUDY OBJECTIVE

To evaluate changes due to pregnancy on atenolol's pharmacokinetics, response of maternal heart rate to atenolol, and the drug's effect on fetal heart rate.

DESIGN

Prospective study.

SETTING

Large university teaching hospital.

PATIENTS

Fourteen pregnant women who were receiving oral atenolol for cardiac disease were enrolled and 10 completed the study.

INTERVENTIONS

Patients were studied for 12 hours during the third trimester (TT) and again 6 weeks postpartum (PP).

MEASUREMENTS AND MAIN RESULTS

Fetal heart rates, and maternal heart rates at rest and during exercise were recorded. Maternal plasma and urine atenolol concentrations were measured. Average resting heart rates (TT 68+/-10, PP 62+/-9 beats/min) and maximum heart rate during exercise (TT 100+/-6, PP 87+/-7 beats/min) were significantly higher in the third trimester than postpartum (p<0.05). The 12-hour atenolol area under the curve (TT 0.208+/-0.061, PP 0.215+/-0.089 ng/ml/day) and maximum plasma concentrations during the time of exercise tests (TT 1.07+/-0.39, PP 1.14+/-0.53 mmol/L) were not significantly different. Individual and population pharmacokinetics did not differ significantly between study periods. The fetal heart rate did not correlate with maternal atenolol concentration.

CONCLUSION

Constant dosages of atenolol result in higher heart rates during pregnancy compared with the postpartum period. This lack of heart rate control is not due to significant changes in atenolol's pharmacokinetics or plasma concentrations.

Attempted vaginal birth after cesarean section: a multicenter comparison of outpatient prostaglandin E(2) gel with expectant management

Objective: To compare the clinical effectiveness and safety of outpatient administration of an intracervical prostaglandin (PG) E(2) gel with expectant management for women with an unfavorable cervix who wish to attempt a vaginal birth after cesarean section.Study Design: This outpatient study was a randomized, multicenter investigation involving pregnant women at term with one previous low transverse cesarean section. Each had an unfavorable cervix (Bishop score </=4) and was a candidate for vaginal delivery. Those randomly assigned to receive the gel, rather than expectant management, were given a 0.5 mg dose of PGE(2) (Prepidil) intracervically at 39 weeks gestation. This cervical ripening treatment was repeated at weekly office visits for up to 3 doses.Results: Of the 294 cases, 143 received the gel while 151 underwent expectant management. No differences between the two groups were found for maternal demographics, race, parity, or predose Bishop score. The rates of repeat cesarean section did not differ (P =.68) with use of the gel (61, 42%) or with expectant therapy (48, 45%). The onset of active labor, the duration of labor among those delivering vaginally, and the 1-minute and 5-minute Apgar scores were not different between the two groups. No uterine rupture was apparent, and adverse effects during labor were as likely to occur in the two groups.Conclusions: Although its safety was confirmed for outpatient use and for persons with a prior cesarean delivery, intracervical prostaglandin E(2) gel did not improve the chance of a vaginal birth after a cesarean delivery.

Stillbirth evaluation: what tests are needed?

OBJECTIVE

We sought to investigate what aspects of the stillbirth evaluation are considered to be essential and what tests can potentially be eliminated.

STUDY DESIGN

A retrospective analysis of 745 stillbirths occurring from January 1990 to December 1994 was conducted. A stillbirth was defined by an estimated gestational age >20 weeks' gestational age or fetal weight >500 gm. We attempted to arrive at an apparent cause for each stillbirth after evaluation of genetic or chromosomal abnormalities, obstetric history, maternal medical illnesses, laboratory tests, autopsy findings, and placental pathologic conditions.

RESULTS

We found that the most important aspects of stillbirth evaluation were placental pathologic conditions and autopsy. When the placenta was examined, a significant abnormality was detected in 30% (160 of 529) of the cases. When autopsy was performed, only 31% of fetal deaths (142 of 462) were unexplained; however, when no autopsy was performed, 44% (125 of 283) were unexplained (p = 0.0002). The following laboratory evaluations that were routinely performed were found to yield little definitive information: antinuclear antibody testing, Kleihauer-Betke test, and screening for congenital infections (toxoplasmosis, other viruses, rubella, cytomegalovirus, and herpes simplex virus). Overall, 36% (267 of 745) of stillbirths still remained unexplained despite a thorough evaluation in most cases.

CONCLUSION

The causes of stillbirth are many and varied, with a large proportion having no obvious cause. As this study demonstrates, certain laboratory tests can be eliminated in the workup of fetal death. In the evaluation of stillbirth a complete systematic method that incorporates placental pathologic conditions, as well as autopsy findings, should prove to be beneficial.

Obstetric maneuvers for shoulder dystocia and associated fetal morbidity

OBJECTIVE

We sought to determine the fetal injury rate associated with shoulder dystocia and to determine whether there is a higher rate of brachial plexus injury or bone fracture when fetal manipulation techniques are required for delivery.

STUDY DESIGN

A retrospective review of 285 cases of shoulder dystocia that occurred between January 1991 and December 1995 was performed. The type, sequence, and combination of obstetric maneuvers used to relieve the shoulder dystocia were noted. These cases were divided into two groups, as follows: (1) those resolved with McRoberts' maneuver, suprapubic pressure, or proctoepisiotomy or a combination of these and (2) those that required the addition of direct fetal manipulative maneuvers (Woods, posterior arm, or Zavanelli). Fetal injury was defined as the occurrence of brachial plexus palsy, clavicular fracture, humeral fracture, or fetal death caused by asphyxial complications.

RESULTS

The fetal injury rate was 24.9% (71/285), including 48 (16.8%) brachial plexus palsies, 27 (9.5%) clavicular fractures, and 12 (4.2%) humeral fractures. Sixteen infants had both nerve injury and bone fracture. Four (8.9%) brachial plexus palsies had documented persistence at 1 year of follow-up. One neonatal death occurred at age 3 months after an episode of hypoxic ischemic encephalopathy. The incidence of bone fracture was not higher when direct fetal manipulation was required: 21 of 127 (16.5%) versus 18 of 158 (11.4%), p = 0.21. The incidence of brachial plexus palsy was also similar in both groups (27/127 vs 21/158, p = 0.1).

CONCLUSIONS

Direct fetal manipulation techniques used to alleviate shoulder dystocia are not associated with an increased rate of bone fracture or brachial plexus injury.

Experience with oral methylprednisolone in the treatment of refractory hyperemesis gravidarum

OBJECTIVE

Our purpose was to describe the effect of oral methylprednisolone on the course of refractory hyperemesis gravidarum.

STUDY DESIGN

Patients with intractable hyperemesis gravidarum were candidates for oral methylprednisolone. Forty-eight milligrams per day was given for 3 days followed by a tapering dose over 2 weeks. If vomiting recurred after 2 weeks of therapy or during tapering, the medication was restarted or extended but not longer than 1 month total.

RESULTS

Seventeen of 18 patients (94%) were free of vomiting and were able to tolerate a regular diet within 3 days. Seven did not have further symptoms during their pregnancies. Nine vomited during or after tapering, but 7 of these responded to extension or reinstitution of therapy. Four of 6 patients on total parenteral nutrition at the start of therapy had a complete response within 3 days.

CONCLUSIONS

A short course of oral methylprednisolone appears to be a reasonable therapeutic alternative for intractable hyperemesis.

Spontaneous vaginal delivery: a risk factor for Erb's palsy?

OBJECTIVE

Our purpose was to determine whether Erb's palsies occurring in the absence of shoulder dystocia differ from those occurring after shoulder dystocia.

STUDY DESIGN

We compared the time course of resolution and incidence of persistent injury at 1 year of age in 17 cases of Erb's palsy without shoulder dystocia and 23 cases associated with shoulder dystocia.

RESULTS

The rate of persistence at 1 year was significantly higher in those Erb's cases without identified shoulder dystocia, 7 of 17 (41.2%) versus 2 of 23 (8.7%), p = 0.04. These cases of Erb's palsies also took longer to resolve (6.4 +/- 0.9 vs 2.6 +/- 0.7 months, p = 0.002), had a higher rate of associated clavicular fracture (12 of 17 vs 5 of 23, p = 0.006), and were more likely to occur in the posterior arm (10 of 15 vs 4 of 21, p = 0.009).

CONCLUSIONS

Erb's palsy occurring without shoulder dystocia may be a qualitatively different injury than that occurring with shoulder dystocia.

Symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver

Many authors have recommended the McRoberts' maneuver as the initial technique in the management of shoulder dystocia. There have been, however, no reported adverse maternal outcomes associated with this technique. We report a case of symphyseal separation and transient femoral neuropathy associated with the McRoberts' maneuver. An overly exaggerated lithotomy position and thigh abduction stretches the articular surfaces of the symphysis pubis and places increased pressure on the femoral nerve by the overlying inguinal ligament.