D.T.G. Hobson

Delayed postpartum preeclampsia and eclampsia: Demographics, clinical course, and complications

OBJECTIVE: To estimate and evaluate the demographics, clinical course, and complications of delayed postpartum preeclampsia in patients with and without eclampsia. METHODS: We conducted a retrospective cohort study of patients who were discharged and later readmitted with the diagnosis of delayed postpartum preeclampsia more than 2 days to 6 weeks or less after delivery between January 2003 and August 2009. RESULTS: One hundred fifty-two patients met criteria for the diagnosis of delayed postpartum preeclampsia. Of these, 96 (63.2%) patients had no antecedent diagnosis of hypertensive disease in the current pregnancy, whereas seven (4.6%), 14 (9.2%), 28 (18.4%), and seven (4.6%) patients had gestational hypertension, chronic hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension, respectively, during the peripartum period. Twenty-two patients (14.5%) developed postpartum eclampsia, and more than 90% of these patients presented within 7 days after discharge from the hospital. The most common presenting symptom was headache in 105 (69.1%) patients. Patients who developed eclampsia were significantly younger than those who did not (mean±standard deviation, 23.2±6.2 compared with 28.3±6.7 years; adjusted odds ratio [OR] 1.13, 95% confidence interval [CI] 1.02–1.26, P=.03), and other demographic variables were no different. A lower readmission hemoglobin was associated with a lower odds of progression to eclampsia (10.7±1.7 compared with 11.6±2.2 g/dL, adjusted OR 0.75, 95% CI 0.57–0.98, P=.04). CONCLUSION: One week after discharge appears to be a critical period for the development of postpartum eclampsia. Education about the possibility of delayed postpartum preeclampsia and eclampsia should occur after delivery, whether or not patients develop hypertensive disease before discharge from the hospital. LEVEL OF EVIDENCE: III

Comparative analysis of different laparoscopic hysterectomy procedures.

PurposeTo compare the antecedent gynecological characteristics, indications for, and complications associated with, the different laparoscopic approaches to hysterectomy, in women with benign gynecological conditions.MethodsA retrospective cohort study of 957 patients who underwent laparoscopic supracervical (LSH), total (TLH), and assisted vaginal (LAVH) hysterectomies between January 2003 and December 2009.ResultsAmong 957 LH, 799 (83.5%) were LSH, 62 (6.4%) TLH, and 96 (10.1%) LAVH. Demographic characteristics were not different among the groups. Antecedent gynecologic conditions that were associated with the type of laparoscopic hysterectomy (LH) performed were: postmenopausal bleeding [LAVH vs. LSH, odds ratio (OR) 2.20; 95% confidence interval (CI) 1.04–4.65], previous pelvic surgery (TLH vs. LSH, OR 1.92; CI 1.05–3.52), previous cesarean delivery (LAVH vs. LSH, OR 0.39; CI 0.21–0.76), and prior hysteroscopy (LAVH vs. LSH, OR 0.29; CI 0.16–0.50). Preoperative diagnoses that were associated with the choice of LH were: menometrorrhagia (LAVH vs. LSH, OR 0.23; CI 0.14–0.38; TLH vs. LSH, OR 0.50; CI 0.26–0.98), uterine fibroids (LAVH vs. LSH, OR 0.25; CI 0.15–0.41), endometrial hyperplasia (TLH vs. LSH, OR 5.5; CI 2.04–14.84), and cervical dysplasia (TLH vs. LSH, OR 17.1; CI 6.83–42.79; LAVH vs. LSH, OR 8.05; CI 3.05–22.06). Estimated blood loss, operating time, and length of hospital stay were significantly reduced with LSH.ConclusionAntecedent gynecological history and the indications for surgery were associated with the type of LH performed in our institution. LSH was the most common approach and was associated with significantly less morbidity.

New onset delayed postpartum preeclampsia: different disorders?

Objective: Delayed postpartum preeclampsia is a poorly studied disorder. We compared new onset delayed postpartum preeclampsia (NOPP) to recurrent/persistent, delayed onset postpartum preeclampsia (RPP) to see whether these were different disorders. Methods: Delayed onset preeclampsia was defined as readmission >2 days to ≤6 weeks postpartum for preeclampsia. The NOPP group had no antecedent diagnosis of hypertensive disorders in the current pregnancy, and was compared to the RPP defined as a prior hypertensive disorder in the current pregnancy in terms of maternal demographics, obstetric and medical history, intrapartum and early postpartum course and clinical signs and symptoms and outcomes on postpartum readmission. Results: There were a total of 56 (36.8%) patients in the RPP and 96 (63.2%) patients in the NOPP groups. NOPP cases delivered significantly later 39.0 ± 2 weeks vs. 37 ± 3.0 weeks p < 0.001, and had significantly lower blood pressure during the antepartum, early postpartum and readmission periods. In addition the NOPP group had significantly higher average number of symptoms 2 vs. 1.5 p = 0.013 on postpartum readmission. There were no statistically significant differences in the rates of major complications. Conclusions: In this comprehensive study of delayed postpartum preeclampsia, there were few significant differences in the clinical course and no differences in complications in the NOPP subgroup compared to cases with preeclampsia recurring in the late postpartum period.

Determinants and complications of emergent cesarean hysterectomy: supracervical vs total hysterectomy

OBJECTIVE We sought to determine whether emergent cesarean supracervical hysterectomy is associated with reduced risk of complications compared to total hysterectomy. STUDY DESIGN We conducted a cohort study of 150 women who underwent emergent cesarean hysterectomy at our medical center from 1991 through 2008. We compared the risk factors and indications, and intraoperative and postoperative complications associated with the 2 surgical procedures. RESULTS During the study period, a total of 164 cesarean hysterectomies were performed; 91% (n = 150) of these cases were performed emergently of which 53.3% were total and 46.7% were supracervical. There was a significant decline in the relative frequency of total hysterectomy: 71%, 56%, and 24% during 1991-1996, 1997-2002, and 2003-2008, respectively (P < .001). Risk factors, indications for surgery, operative variables, and postoperative complication rates were independent of the type of hysterectomy. CONCLUSION Using a cohort of 150 cases from our institution, we found no evidence of increased surgical time or complications associated with total hysterectomy.

Pregnancy complicated by recurrent brain abscess after extraction of an infected tooth.

BACKGROUND: Odontogenic infections are quite common and, in unusual cases, can extend beyond the oral cavity with potentially life-threatening complications. CASE: A 35-year-old woman, G3P0020, underwent extraction of an infected left maxillary third molar tooth at 19 3/7 weeks of gestation and later presented with mental status changes. Computed tomography revealed left pterygoid muscle abscess, which progressed to brain abscess. She underwent multiple partial lobectomies to drain her recurrent brain abscess. The pregnancy continued until term, and she underwent a cesarean delivery. CONCLUSION: Brain abscess is a rare but life-threatening complication of pregnancy. This case illustrates the potential complications after extraction of an infected tooth in pregnancy.

Outcomes following intra-amniotic instillation with indigo carmine to diagnose prelabor rupture of membranes in singleton pregnancies: A single center experience

Abstract Objective: To evaluate clinical outcomes of women with singleton pregnancies that underwent intra-amniotic dye instillation (amniodye test) following equivocal diagnosis of prelabor rupture of membranes (PROM). Method: Records of 34 pregnant women who underwent amniodye test for equivocal PROM were reviewed. Comparisons of characteristics, amniotic fluid (AF) cultures, AF interleukin (IL)-6 concentrations, and placenta pathology results between women who tested positive and those who tested negative were performed. A sub-analysis of women who were amniodye test-negative was also performed. Results: (1) Commonest indication for amniodye test was a typical history of PROM with positive conventional tests and persistently normal AF volume, (2) amniodye test-positive women had a shorter procedure-to-delivery interval (p = 0.008), and a greater proportion of histologic acute chorioamnionitis (p = 0.04) and funisitis (p = 0.01) than amniodye-negative women, and (3) in addition to similarities to women with amniodye-positive test, amniodye test-negative women who delivered <34 weeks, had a greater proportion of women with risk for preterm birth (p = 0.04), than their counterparts who delivered between 34 0/7 and 36 6/7 weeks. Conclusion: Equivocal diagnosis of PPROM should warrant an amniodye test to avoid iatrogenic intervention in women with intact amniotic membranes. AF analysis should be performed in amniodye test-negative women.