Everett F. Magann

Pre-pregnancy body mass index and pregnancy outcomes.

Objective: To determine the effect of maternal pre‐pregnancy BMI on pregnancy outcomes.

The spectrum of severe preeclampsia: Comparative analysis by HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome classification☆☆☆★

OBJECTIVE This study was undertaken to explore the spectrum of maternal disease with a triple classification system of HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome and compare these classes with severe preeclampsia without HELLP syndrome. STUDY DESIGN In this retrospective analytic study the pregnancies of 777 patients with class 1, 2, or 3 HELLP syndrome were compared and contrasted with those of 193 women with severe preeclampsia but without HELLP syndrome. RESULTS Eclampsia, epigastric pain, nausea and vomiting, significant proteinuria, major maternal morbidity, and stillbirth increased as HELLP syndrome worsened from class 3 to class 1. In contrast, headache and diastolic hypertension were more common among the significantly heavier patients with severe preeclampsia without HELLP syndrome. Approximately half of pregnancies complicated by class 1 HELLP syndrome exhibited significant maternal morbidity, compared with only 11% of those complicated by severe preeclampsia without HELLP syndrome. Although a significant trend was apparent in increasing levels of lactate dehydrogenase, aspartate aminotransferase, and uric acid as HELLP syndrome worsened, there was considerable variation within groups. CONCLUSION Laboratory and clinical indices of disease severity in patients with severe preeclampsia or eclampsia generally were highest with class 1 HELLP syndrome and were lowest when HELLP syndrome was absent. Class 3 HELLP syndrome is considered a clinically significant transitional group.

Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis

OBJECTIVE Our purpose was to perform a meta-analysis of studies on the risks of cesarean delivery for fetal distress, 5-minute Apgar score <7, and umbilical arterial pH <7.00 in patients with antepartum or intrapartum amniotic fluid index >5.0 or <5.0 cm. STUDY DESIGN Using a MEDLINE search, we reviewed all studies published between 1987 and 1997 that correlated antepartum or intrapartum amniotic fluid index with adverse peripartum outcomes. The inclusion criteria were studies in English that associated at least one of the selected adverse outcomes with an amniotic fluid index of </=5.0 cm versus >5.0 cm. Contingency tables were constructed for each study, and relative risks and standard errors of their logs were calculated. Fixed-effects pooled relative risks were calculated for groups of studies that were homogeneous, whereas random-effects pooled relative risks were calculated for significantly heterogeneous groups of studies. RESULTS Eighteen reports describing 10,551 patients met our inclusion criteria. An antepartum amniotic fluid index of </=5.0 cm, in comparison with >5.0 cm, is associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 2.2; 95% confidence interval, 1.5-3.4) and an Apgar score of <7 at 5 minutes (pooled relative risk, 5.2; 95% confidence interval, 2.4-11.3). An intrapartum amniotic fluid index of </=5.0 cm is also associated with an increased risk of cesarean delivery for fetal distress (pooled relative risk, 1.7; 95% confidence interval, 1.1-2.6) and an Apgar score <7 at 5 minutes (pooled relative risk, 1.8; 95% confidence interval, 1.2-2.7). A poor correlation between the amniotic fluid index and neonatal acidosis was noted in the only study that examined this end point. More than 23,000 patients are necessary to demonstrate that the incidence of umbilical arterial pH <7.00 is 1.5 times higher among those with oligohydramnios in labor than among those with adequate amniotic fluid index (alpha = 0.05; beta = 0.2) CONCLUSIONS An antepartum or intrapartum amniotic fluid index of </=5.0 cm is associated with a significantly increased risk of cesarean delivery for fetal distress and a low Apgar score at 5 minutes. There are few reports linking amniotic fluid index and neonatal acidosis, the only objective assessment of fetal well-being. A multicenter study with sufficient power should be undertaken to demonstrate that a low amniotic fluid index is associated with an umbilical arterial pH <7.00.

The recurrence risk of the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) in subsequent gestations

OBJECTIVE Although it is an important clinical issue, accurate prediction of recurrence risk for the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP) has been problematic because of limited patient experience. This study was undertaken to determine the likelihood that this form of severe preeclampsia-eclampsia or any other hypertensive disorder would occur in a subsequent pregnancy. STUDY DESIGN An extensive retrospective analysis of medical records and patient follow-up regarding subsequent pregnancy outcome were undertaken for the 481 patients with HELLP syndrome managed at this tertiary medical center between Jan. 1, 1980, and Oct. 30, 1991. The Mississippi three-class system was used to define severity of disease on the basis of the lowest observed perinatal platelet count (class 1 < or = 50,000/microliters, class 2 > 50,000/microliters to < or = 100,000/microliters, and class 3 > 100,000/microliters to < or = 150,000/microliters). RESULTS Subsequent gestations (n = 195) occurred in 122 of 481 patients. Evaluable data were available for analysis in 161 of 195 possible pregnancies. Seventy-eight (48%) pregnancies were complicated by some type of hypertensive disorder, 44 (27%) of which had class 1, 2, or 3 HELLP syndrome. Non-HELLP preeclampsia-eclampsia was detected in 25 subsequent gestations (15%). Thus the total frequency of preeclampsia was 69 in 161 (43%). If the data for class 3 HELLP are completely excluded from the analysis, 81 subsequent evaluable and viable gestations were identified, 19 pregnancies with preeclampsia-eclampsia (23%) and 15 patients with HELLP syndrome (19%), for a total recurrence rate of 42%. Subsequent HELLP gestations were frequently delivered abdominally (64%) on average 2 weeks later than the index pregnancy (32.6 +/- 5.0 weeks versus 34.7 +/- 5.3 weeks). Delivery at < 32 weeks conferred a high risk (61%) for a similar preterm delivery in a subsequent gestation. CONCLUSION The risk of recurrence of the HELLP syndrome in our population is 19% to 27%. When data from all pregnancies with all forms of preeclampsia are considered, the risk of recurrence for any type of preeclampsia-eclampsia is 42% to 43%. A previous preterm delivery is a very high risk factor for recurrence of prematurity with preeclampsia-eclampsia.

Postpartum corticosteroids: accelerated recovery from the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP).

OBJECTIVE Because most morbidity and mortality associated with atypical preeclampsia and the syndrome of hemolysis, elevated liver enzymes, and low platelets is a postpartum phenomenon, we undertook this investigation to evaluate the use of high-dose corticosteroids to minimize maternal morbidity and accelerate postpartum recovery in patients with this form of severe preeclampsia. STUDY DESIGN Into this prospective, randomized study 40 parturients with the syndrome were recruited. The syndrome was defined by a clinical presentation consistent with a diagnosis of severe preeclampsia or eclampsia in addition to laboratory evidence of hemolysis, hepatic dysfunction, and thrombocytopenia. Immediately post partum 20 parturients assigned to the treatment group received four doses of intravenous dexamethasone at 12-hour intervals (10 mg, 10 mg, 5 mg, 5 mg) over 36 hours. Patients assigned to the control group received no corticosteroids. All study subjects were intensively monitored by mean arterial pressure and urinary output every 2 hours, hematocrit and platelet count every 6 hours and lactic dehydrogenase, aspartate aminotransferase, and alanine aminotransferase every 12 hours for the first 48 hours post partum. RESULTS The steroid-treated group with the syndrome of hemolysis, elevated liver enzymes, and low platelets had significant changes over time in mean arterial pressure, urinary output, platelet count, lactic dehydrogenase and aspartate aminotransferase versus the control group with the syndrome. Relative to the control group, the mean arterial pressure became significantly decreased at 22 hours in the steroid-treated group (p < 0.03), urinary output increased significantly by 16 hours (p < 0.02), the platelet count increased significantly by 24 hours (p < 0.05), and both lactic dehydrogenase and aspartate aminotransferase decreased significantly by 36 hours (p < 0.04 and p < 0.05, respectively). CONCLUSIONS In association with high-dose corticosteroid administration, parturients with the syndrome of hemolysis, elevated liver enzymes, and low platelets recovered from the disease process more rapidly than did control subjects, as measured by urinary output, mean arterial pressure, platelet count, lactic dehydrogenase, and aspartate aminotransferase. In this disease process, which has significant associated morbidity and mortality, especially in patients with advanced cases, high-dose corticosteroid therapy appears to significantly hasten recovery and lessen the severity of the disease post partum. We postulate that use of this therapeutic approach in properly selected patients could result in lessened overall maternal morbidity and mortality, shorter patient stays in recovery and intensive-care areas, and shorter overall hospitalization with reduced medical care costs.

Twelve steps to optimal management of HELLP syndrome.

The early diagnosis and treatment of HELLP syndrome remains problematic for the obstetric health care provider. The nonspecific signs and symptoms of this disorder early in the disease process make the accurate diagnosis difficult and delays early treatment, which has the best prognosis for both maternal and perinatal outcome. The introduction of high-dose nonmineralocorticosteriods to assist in the treatment of these patients is an exciting new development. Use of the 12-step approach to the diagnosis and management of pregnancies complicated by HELLP syndrome has proven to be a successful tool to help us achieve the best possible maternal and perinatal outcome.

Postpartum Hemorrhage After Vaginal Birth: An Analysis of Risk Factors

Objective: To determine, in a single tertiary obstetric hospital, the incidence of and risk factors for postpartum hemorrhage (PPH) after a vaginal birth. Methods: PPH was defined as measured blood loss greater than 1,000 mL and/or need for a transfusion. Results: Over a 4-year period, 13,868 of 19,476 women delivered vaginally, with a PPH rate of 5.15%. Identified risk factors for PPH were Asian race, maternal blood disorders, prior PPH, history of retained placenta, multiple pregnancy, antepartum hemorrhage, genital tract lacerations, macrosomia (>4 kg), and induction of labor, as well as chorioamnionitis, intrapartum hemorrhage, still birth, compound fetal presentation, epidural anesthesia, prolonged first/second stage of labor, and forceps delivery after a failed vacuum. Conclusions: Identification of risk factors for PPH after a vaginal delivery may afford prophylactic treatment of such women with reduction of morbidity.

Measurement of amniotic fluid volume: Accuracy of ultrasonography techniques

OBJECTIVE Our purpose was to determine amniotic fluid volume by the dye-dilution technique and compare it with the amniotic fluid index, largest vertical pocket, and two-diameter pocket (defined as vertical x horizontal of the largest vertical pocket). STUDY DESIGN This prospective study involved 40 women undergoing amniocentesis in late pregnancy to detect fetal lung maturity or evidence of chorioamnionitis. The amniotic fluid volume was quantified ultrasonographically by means of the amniotic fluid index, largest vertical pocket, and two-diameter pocket. During amniocentesis the fluid volume was calculated by the dye-dilution technique of Charles and Jacoby. RESULTS Ultrasonographic measurements by amniotic fluid index, largest vertical pocket, and two-diameter pocket correctly predicted normal amniotic fluid and hydramnios (74%). A new measurement, two-diameter pocket, gave a significantly more accurate estimate of oligohydramnios than did amniotic fluid index (p < 0.002) or largest vertical pocket (p < 0.0003). CONCLUSION All three indices are moderately accurate in identifying normal amniotic fluid volume and hydramnios. Two-diameter pocket is the most accurate test to predict oligohydramnios.

Early risk assessment of severe preeclampsia: Admission battery of symptoms and laboratory tests to predict likelihood of subsequent significant maternal morbidity

OBJECTIVE This study was undertaken to investigate the utility of an admission battery of findings and laboratory data in the discrimination of patients with severe preeclampsia with or without HELLP (hemolysis, elevated liver enzyme levels, and low platelet count) syndrome at high risk for development of significant maternal morbidity. STUDY DESIGN The clinical and laboratory findings at hospital admission for 970 patients with severe preeclampsia with or without HELLP syndrome were studied retrospectively to develop parameters associated with low, moderate, and high risks for the subsequent development of significant maternal morbidity involving the hematologic and coagulation, cardiopulmonary, and hepatorenal systems. RESULTS Nausea and vomiting and epigastric pain are independent risk factors for complicated severe preeclampsia. Results of a panel of tests with values including lactate dehydrogenase level >1400 IU/L, aspartate aminotransferase level >150 IU/L, alanine aminotransferase level >100 IU/L, uric acid level >7.8 mg/dL, serum creatinine level >1.0 mg/dL, and 4+ urinary protein by dipstick can be used to discriminate the patient at high risk for significant maternal morbidity. Concentrations of lactate dehydrogenase, aspartate aminotransferase, and uric acid above these cut points have the strongest predictive value and are risk additive with worsening thrombocytopenia. CONCLUSION The presence of nausea and vomiting, epigastric pain, or both in association with admission laboratory values that are in excess of the cutoffs for lactate dehydrogenase, aspartate aminotransferase, and uric acid concentrations or for all 6 tests is predictive of high risk of morbidity for the patient with severe preeclampsia. These factors are independent of and additive with the rising maternal risk associated with decreasing platelet count.

Effectiveness of progestogens to improve perinatal outcome in twin pregnancies: an individual participant data meta-analysis

In twin pregnancies, the rates of adverse perinatal outcome and subsequent long‐term morbidity are substantial, and mainly result from preterm birth (PTB).