Christy M. Isler

Gestational diabetes is associated with depressed adiponectin levels.

Objective: Adiponectin is a 29-kd adipocyte-secreted protein that has been linked to insulin resistance in obesity and diabetes. The aim of the present study was to evaluate adiponectin levels in the insulinresistant state of diabetes in gestation. Methods: Term, gravid subjects with diabetes (n = 31; age, 30.0±0.9 years; weight, 98.8±4.6 kg) and healthy, term, gravid subjects (n = 27; age, 26.1±1.1 years; weight, 91.2±3.78 kg) were examined. The diabetes group consisted of 11 class A1, 11 class A2, and nine class B subjects. Plasma insulin, glucose, adiponectin, and leptin were measured on samples obtained immediately before Cesarean or vaginal delivery. Data were presented as means ± SE, and signficance is set at P ≤ .05. Results: We observed decreased adiponectin levels in class A2 (4.93 ± 0.58,μg/mL; P = .013) and class B diabetics (3.33 ± 0.56,μg/mL; P = .001) as compared to controls (8.17 ± 0.82,μg/mL), while a nonsignficant decrease was also observed in class A 1 (6.58 ± 1. 13,μg/mL; P = .213). When grouping all gravid subjects, we observed that non-Caucasian subjects (n = 42) (5.51 ± 0.51,μg/mL; P - .003) had lower adiponectin levels than Caucasian subjects (n = 16) (8.88 ± 1. 11 ug/mL). Within tIe non-Caucasian group, wefound significantly lower adiponectin levels in diabetic gravid subjects (class A2: 4.24 ± 0.75,μg/mL; P = .044; and class B: 3.33 ± 0.56 μg/mL; P = .005) compared tvith nondiabetic gravid subjects (7.05 ± 0.80 μg/mL). Conclusion: Class A2 and B gestational diabetes are associated with suppressed levels of adiponectin, similar to thatfound in other insulin-resistant states (type II diabetes and obesity).

Dexamethasone compared with betamethasone for glucocorticoid treatment of postpartum HELLP syndrome

Objectives: To compare the efficacy of dexamethasone and betamethasone to ameliorate the course of postpartum hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Methods: A prospective, mixed randomized/non‐randomized clinical investigation of patients with postpartum HELLP syndrome. Treatment with either dexamethasone or betamethasone was continued until there was evidence of disease recovery. Results: Baseline characteristics of both the dexamethasone (n=18) and betamethasone (n=18) groups were similar. Although the time to discharge from the obstetrical recovery room was not statistically significant between groups, reduction in mean arterial blood pressure was more pronounced in the dexamethasone group as compared with the betamethasone group (−15.3±1.4 mmHg vs. −7.5±1.4 mmHg, respectively, P<0.01). Patients in the dexamethasone group required less antihypertensive treatment than the betamethasone group (6% vs. 50%, P=0.01) and also had a decreased need for readmission to the obstetrical recovery room (0% vs. 22%, P=0.03). Conclusion: This investigation supports the use of dexamethasone as the superior glucocorticoid to use for patients with postpartum HELLP syndrome.

Postpartum seizure prophylaxis: using maternal clinical parameters to guide therapy

OBJECTIVE: To use individual patient clinical parameters to signal cessation of postpartum magnesium sulfate seizure prophylaxis for the spectrum of pregnancy‐related hypertensive disorders. METHODS: This was a prospective study using clinical symptoms (absence of headache, visual changes, epigastric pain) and signs (sustained blood pressure less than 150/100 without need for acute antihypertensive therapy, spontaneous diuresis more than 100 mL per hour for no less than 2 hours) to signal cessation of intravenous magnesium sulfate postpartum in gravidas diagnosed with preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome. Laboratory assessments (including proteinuria) were not used as criteria for drug discontinuation. RESULTS: Five hundred three patients were enrolled and classified according to American College of Obstetricians and Gynecologists criteria (mild preeclampsia, severe preeclampsia, chronic hypertension with superimposed preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, low platelets syndrome). Maternal age, gestational age, and hours of magnesium therapy before delivery were not statistically different among groups. There was no significant difference in the duration of postpartum magnesium sulfate therapy among groups with the median duration of therapy 4 hours (range 2‐77 hours). No eclamptic seizures occurred after magnesium discontinuation. Thirty‐eight patients (7.6%) required reinstitution of magnesium therapy for 24 hours because of exacerbation of blood pressure (sustained blood pressure more than 160/110) associated with headache or visual changes. CONCLUSION: Clinical criteria, when compared with arbitrary protocols, can be used successfully to shorten the duration of postpartum magnesium sulfate administration for seizure prophylaxis in patients with pregnancy‐related hypertensive disorders. (Obstet Gynecol 2003;101:66‐9.

Modern obstetric management and outcome of infants with gastroschisis

OBJECTIVE To determine whether outcomes of infants with gastroschisis differed by mode or site of delivery, diagnostic method, or when maternal-fetal medicine consultation was given. METHODS Charts of 32 infants born at the University of Mississippi Medical Center or admitted to the neonatal intensive care unit between September 1992 and June 1998 were reviewed for maternal demographic characteristics and neonatal outcomes. Statistical analysis was done using Student t test, analysis of variance, chi2, and Kruskal-Wallis test with P<.05 considered statistically significant. RESULTS There were no statistically significant differences in neonatal outcomes by method or site of delivery, diagnostic method, or maternal-fetal medicine consultation before delivery. Infants delivered vaginally had higher Apgar scores at 1 and 5 minutes (9 versus 7 and 9 versus 8, respectively, P<.05). Vaginally delivered infants required more days of antibiotic therapy than those delivered abdominally (10 versus 3 days, P<.05) but had a shorter interval to enteral feedings (15 versus 30 days, P<.05). CONCLUSION Outcomes of infants with isolated gastroschisis were not significantly affected by method or site of delivery, diagnostic method, or maternal-fetal surveillance. Although the findings of this investigation were largely negative and the statistical power limited due to the rarity of this fetal disruption, small series of cases of gastroschisis need to be analyzed to resolve current controversies surrounding optimal treatment of gastroschisis.

Amniotic fluid volume estimation and the biophysical profile: A confusion of criteria

The biophysical profile (BPP) can be used as an initial test of fetal health and as a secondary back-up assessment of fetuses at risk of adverse outcomes when preliminary evaluations are not reassuring. The BPP evaluates five characteristics: fetal movement, tone, breathing, heart reactivity, and amniotic fluid (AF) volume estimation. Three of the most frequently used obstetric textbooks define adequate AF volume differently. In two of the three, the stated method of evaluating AF volume differs from that actually used by the referenced authors. We reviewed articles by Manning and found that his methodology changed from a 1-cm pocket in one plane to a 1-cm pocket in two perpendicular planes, and finally to a 2-cm vertical pocket with a 1-cm horizontal measurement. The 2 x 2-cm pocket is a fourth methodology that has been introduced recently. It is not known how often and in which groups each of the four methods has been used to evaluate abnormal AF volumes. The relevance and importance of determining precisely the ultrasound measurement actually used for investigations are emphasized by looking at women with AF indices < or = 5. Fifty-three percent of those women had a 2 x 2 pocket, 72% had a 2 x 1 pocket, and 95% had a 1 x 1 pocket. The diagnosis of low fluid can lead to additional testing, hydration, and intervention, so the importance of a universal definition linked with pregnancy outcomes cannot be overemphasized.

Cardiopulmonary morbidity as a complication of severe preeclampsia HELLP syndrome.

OBJECTIVE:To profile the types and frequencies of cardiopulmonary morbidity encountered in patients with severe preeclampsia with or without hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome).STUDY DESIGN:We initiated a retrospective study of 979 patients with severe preeclampsia with and without HELLP syndrome. Types of cardiopulmonary morbidity were analyzed among the three classes of HELLP syndrome and severe preeclampsia without HELLP syndrome.RESULTS:Cardiopulmonary morbidity occurred in 7.6% of study patients. As a group, patients with cardiopulmonary complications were more likely to have cesareans (11% vs 6%, p = 0.019) earlier in gestation (1366 ± 700 gm birth weight versus 1734 ± 892 gm birth weight, p = 0.021), with higher peak postpartum blood pressures (<0.001) and with more abnormal laboratory values indicative of multisystem disease, compared with patients without this complication. Patients with cardiopulmonary complications required almost twice as long to achieve diuresis as comparison patients (22 ± 23 hours versus 12 ± 11 hours, p < 0.001).CONCLUSION: The probability of cardiopulmonary complications increases significantly when patients develop class 1 HELLP syndrome. Of all cardiopulmonary complications, acute lung injury/acute respiratory distress syndrome is most specific to class 1 HELLP syndrome. Transient renal dysfunction is closely related to cardiopulmonary morbidity.

Randomized trial of intermittent or continuous amnioinfusion for variable decelerations.

Objective To determine whether continuous or intermittent bolus amnioinfusion is more effective in relieving variable decelerations. Methods Patients with repetitive variable decelerations were randomized to an intermittent bolus or continuous amnioinfusion. The intermittent bolus infusion group received boluses of 500 mL of normal saline, each over 30 minutes, with boluses repeated if variable decelerations recurred. The continuous infusion group received a bolus infusion of 500 mL of normal saline over 30 minutes and then 3 mL per minute until delivery occurred. The ability of the amnioinfusion to abolish variable decelerations was analyzed, as were maternal demographic and pregnancy outcome variables. Power analysis indicated that 64 patients would be required. Results Thirty-five patients were randomized to intermittent infusion and 30 to continuous infusion. There were no differences between groups in terms of maternal demographics, gestational age, delivery mode, neonatal outcome, median time to resolution of variable decelerations, or the number of times variable decelerations recurred. The median volume infused in the intermittent infusion group (500 mL) was significantly less than that in the continuous infusion group (905 mL, P = .003). Conclusion Intermittent bolus amnioinfusion is as effective as continuous infusion in relieving variable decelerations in labor. Further investigation is necessary to determine whether either of these techniques is associated with increased occurrence of rare complications such as cord prolapse or uterine rupture.

Takotsubo cardiomyopathy in pregnancy.

BACKGROUND: Takotsubo cardiomyopathy is a cardiac condition associated with the acute onset of chest pain, abnormalities in cardiac enzymes and electrocardiogram, and a distinct pattern of left ventricular dysfunction on echocardiography. This case evaluates an obstetric patient diagnosed with Takotsubo cardiomyopathy during her 23rd week of pregnancy. CASE: A woman (G3P2002) at 23 weeks in an intrauterine pregnancy was admitted with chest pain. ST-segment elevation was noted on electrocardiogram with elevated cardiac enzymes. Subsequent tracings showed resolution of ST elevation with conservative management. Echocardiography was consistent with Takotsubo cardiomyopathy. She delivered through spontaneous vaginal delivery at term after a complete resolution of her cardiomyopathy. CONCLUSION: Although uncommon, physicians who manage cardiac complications should be familiar with the diagnosis and management of Takotsubo cardiomyopathy.

The importance of parity to major maternal morbidity in the eclamptic mother with HELLP syndrome

Objective: To determine if the rate of major morbidity from severe preeclampsia with/without hemolypis, elevated liver enzymes and low platelets (HELLP) syndrome differs by parity. Methods: Retrospective investigation of 970 gravidas with severe preeclampsia with and without HELLP syndrome analyzed according to parity. Results: Altogether 609 (63%) patients were nulliparous and 361 (37%) parous. Between groups there was no significant difference in the incidence of overall major morbidity (21% vs 19%, p = 0.467), or specific morbidities including hematologic/coagulopathic (13.6% vs 11.9%, p = 0.442), cardiopulmonary (8.9% vs 7.2%, p = 0.362), CNS/visual (1.8% vs 2.8%, p = 0.319), or hepatorenal (0.8% vs 2.2%, p = 0.068). Although eclampsia was significantly more common in nulliparas (10.2%) than in parous patients (5.5%, p = 0.012), the latter significantly more often demonstrated major maternal morbidity associated with eclampsia (50%) than did nulliparous patients (25%, p = 0.043). Conclusions: Unless parous patients with severe preeclampsia with or without HELLP syndrome develop eclampsia, their disease acuity does not differ significantly from their nulliparous counterparts.

Septic pelvic thrombophlebitis and preeclampsia are related disorders.

Objective: To elicit factors associated with the postpartum development of septic pelvic thrombophlebitis in a single large referral tertiary patient population. Methods: A nine‐year single institution retrospective case review of all patients with enigmatic fever and septic pelvic thrombophlebitis was analyzed. Results: A total of 55 patients with septic pelvic thrombophlebitis were provided care during the study interval. The average gestational age at delivery was 36.8 ± 4.3 weeks. The most prevalent concurrent medical complication of pregnancy was preeclampsia (45%) while chorioamnionitis affected only 13%. The average length of ruptured membranes was 22.8 ± 56.8 hours (median 10.5, 95% confidence interval [CI] 7.0–38.7 hours), with 22% of patients undergoing amnion rupture at the time of cesarean delivery. Prolonged (> 24 hours) amnion rupture occurred in only 9% of patients. Most affected patients were delivered abdominally (91%) but a minority delivered vaginally (9%). Antibiotic therapy for presumed infection was initiated at 27.4 ± 24.6 hours postpartum. Subsequently intravenous heparin therapy was initiated 128.9 ± 54.2 hours thereafter enigmatic fever defervesed 37.2 ± 36.8 hours later (median 34.0, 95% CI 27.2–47.3 hours). Patients received 6.3 ± 1.8 days of heparin therapy. Conclusion: In this series, septic pelvic thrombophlebitis was frequently preceded by cesarean delivery and commonly associated with preeclampsia. Unexpectedly, a small number of patients suffered prolonged rupture of membranes or chorioamnionitis. We speculate that the cesarean delivery of a population of at‐risk patients with preeclampsia may predispose them to develop septic pelvic thrombophlebitis.