Angelica Garrett

Persistent Urinary Podocyte Loss following Preeclampsia May Reflect Subclinical Renal Injury

Objective Studies have shown that podocyturia, i.e., urinary loss of viable podocytes (glomerular epithelial cells), is associated with proteinuria in preeclampsia. We postulated that urinary podocyte loss may persist after preeclamptic pregnancies, thus resulting in renal injury. This may lead to future chronic renal injury. In addition, we compared the postpartum levels of the angiogenic factors, which previously have been associated with preeclampsia, between normotensive versus preeclamptic pregnancies. Study Design The diagnosis of preeclampsia was confirmed using standard clinical criteria. Random blood and urine samples were obtained within 24 hours prior to delivery and 5 to 8 weeks postpartum. Urine sediments were cultured for 24 hours to select for viable cells and staining for podocin was used to identify podocytes. Serum samples were analyzed for the levels of angiogenic markers using ELISA (enzyme-linked immunosorbent assay) methodology. Results At delivery, preeclamptic patients (n = 10) had significantly higher proteinuria (p = 0.006) and podocyturia (p<0.001) than normotensive pregnant patients (n = 18). Postpartum proteinuria was similar between these two groups (p = 0.37), while podocyturia was present in 3 of 10 women with preeclampsia and in none of the normotensive controls (p = 0.037). Angiogenic marker levels, including placental growth factor, soluble vascular endothelial growth factor receptor fms-like tyrosine kinase receptor-1 and endoglin, were not significantly different between women with preeclampsia and women with a normotensive pregnancy, either at delivery or postpartum. Conclusion Persistent urinary podocyte loss after preeclamptic pregnancies may constitute a marker of ongoing, subclinical renal injury.

Use of computed tomography in the diagnosis of bowel complications after gynecologic surgery.

OBJECTIVE: To determine factors predictive of bowel complications after gynecologic surgery and establish the added utility of computed tomography (CT) in the diagnostic process. METHODS: Patients who underwent gynecologic surgery between January 2, 2008, and December 30, 2010, who had CT scans of the abdomen, pelvis, or abdomen and pelvis within 42 days for a suspected bowel complication were identified. Logistic regression analysis was used to identify factors predictive of bowel-related complications. The diagnostic accuracy of CT was compared among patient risk groups based on clinical suspicion (pretest probability) of bowel complications. RESULTS: Among 205 eligible patients, 38 (18.5%) patients had a bowel-related complication. Mean time from surgery to CT was 12.4 (10.1) days. Clinical characteristics were used to develop a clinical model that included unexpected drainage from the drain, wound, or stoma (adjusted odds ratio [OR] 26.3, 95% confidence interval [CI] 3.1–224.4, P=.003), coronary artery disease (OR 10.7, CI 1.4–80.9, P=.022), laparotomy (compared with minimally invasive surgery) (OR 4.4, CI 1.1–17.2, P=.032), and age older than 45 years (OR 2.4, CI 0.7–8.8, P=.18). Addition of CT to clinical evaluation increased the predictive ability of the model (area under the curve) from 0.73 to 0.99. Among 57 low-risk patients, three with confirmed bowel-related complications would have been missed if CT was not performed. Among 13 high-risk patients, CT sensitivity was 70%, and it was negative for bowel complications in three patients subsequently confirmed to have serious complications (one anastomotic leak, two bowel perforations). CONCLUSIONS: In patients who have undergone gynecologic surgery and have a high clinical probability of a postoperative bowel-related complication, CT alone may fail to accurately identify patients with serious complications. LEVEL OF EVIDENCE: II

Predictors of Third- and Fourth-Degree Lacerations in Forceps-Assisted Delivery: A Case–Control Study

INTRODUCTION: The objective of this study was to develop a model for predicting perineal lacerations in women attempting forceps-assisted delivery. METHODS: We identified all forceps-assisted deliveries at our institution from January 1, 2002 to June 30, 2012. Multiple gestations were excluded. The laceration group included third and fourth degree was compared with a control group including a random sample of women who had a forceps-assisted delivery without lacerations. Regression models were used to develop the best model for predicting perineal lacerations associated with forceps-assisted delivery. RESULTS: Out of a total of 17,111 vaginal deliveries, 794 (4.6%) had a forceps-assisted delivery. After exclusions, 769 women were included. Of those, 146 (19.0%) had lacerations. The laceration group was significantly older, had more primiparas, more pregnancy greater than 40 weeks of gestation, more forceps-assisted delivery for arrest, longer second stage, more occipitoposterior position, and less use of episiotomy (Table 1). The following were independent predictors in the final model: age younger than 30 years, pregnancy greater than 40 weeks of gestation, primiparous, occipitoposterior position, and absence of episiotomy with adjusted odds ratio of 2.4 (95% confidence interval [CI] 1.4–4.2), 1.9 (95% CI 1.2–3.1), 3.6 (95% CI 1.9–7.3), 2.0 (95% CI 1.0–3.9), and 2.2 (95% CI 1.3–3.7), respectively. The final model had a range of predicted probabilities (11–90%) (Fig. 1). Table 1 Baseline Characteristics (Gill, p. 145–6S) Fig. 1. Receiver operator characteristic curve for final model for predicting risk of perineal laceration during forceps-assisted delivery. (Gill, p. 145–6S) CONCLUSION: We present a model that can accurately stratify patient risk for laceration during forceps-assisted delivery.