Ihab M. Usta

Maternal morbidity and mortality in 442 pregnancies with hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome)

OBJECTIVE Our purpose was to describe the incidence and effects of serious obstetric complications on maternal outcome in pregnancies complicated by HELLP syndrome. STUDY DESIGN A prospective cohort study was performed on 442 pregnancies with HELLP syndrome managed at this center from August 1977 through July 1992. RESULTS Of 437 women who had 442 pregnancies with HELLP syndrome; 309 (70%) of the cases occurred ante partum and 133 (30%) post partum; 149 (11%) developed at < 27 weeks and 80 (18%) at term. Maternal mortality was 1.1% (five patients). Serious maternal morbidity included disseminated intravascular coagulation (21%), abruptio placentae (16%), acute renal failure (7.7%), pulmonary edema (6%), subcapsular liver hematoma (0.9%), and retinal detachment (0.9%). Fifty-five percent of patients required transfusions with blood or blood products, and 2% required laparotomies for major intraabdominal bleeding. Abruptio placentae was strongly correlated with the development of disseminated intravascular coagulation (p < 0.0001), acute renal failure (p < 0.001), and pulmonary edema (p < 0.01). Moreover, there was a strong association between pulmonary edema and acute renal failure (p < 0.0001). There were no differences in laboratory findings between HELLP syndrome before and after delivery; however, women with postpartum HELLP syndrome had significantly higher incidences of pulmonary edema and renal failure. CONCLUSION HELLP syndrome is associated with serious maternal morbidity, especially when it arises in the postpartum period.

Acute fatty liver of pregnancy: An experience in the diagnosis and management of fourteen cases

OBJECTIVE Our purpose was to investigate the diagnostic problems and maternal-perinatal outcome in cases of acute fatty liver of pregnancy. STUDY DESIGN Fourteen cases with acute fatty liver of pregnancy managed during the past 8-years were studied with emphasis on presenting symptoms, admitting diagnosis, laboratory findings, clinical course, maternal complications, and neonatal outcome. RESULTS The mean gestational age at onset was 34.5 weeks (range 28 to 39). Only seven patients had acute fatty liver of pregnancy as a definite or suspected diagnosis on admission. Computed tomography of the liver was performed on 10 patients, with only two positive results. There were no maternal deaths; however, maternal morbidity was frequent: four patients had hepatic encephalopathy, three pulmonary edema, three ascites, four respiratory arrest, two diabetes insipidus, and 10 had transfusion of blood or blood products to correct either disseminated intravascular coagulation or excessive bleeding. Coagulation abnormalities were common: hypofibrinogenemia (< 300 mg/dl) in 13 patients (93%), prolonged prothrombin time in 12 (86%), and prolonged partial thromboplastin time in 11 (79%). The corrected perinatal mortality was 6.6%. CONCLUSION Acute fatty liver of pregnancy should be suspected in all patients with symptoms of preeclampsia in the presence of hypoglycemia, low fibrinogen, and prolonged prothrombin time, particularly in the absence of severe abruptio placentae. Computed tomography of the liver has a high false-negative rate in patients with acute fatty liver of pregnancy. In spite of the literatures dismal prognosis, our findings indicate that maternal and perinatal outcomes appear favorable in well-managed patients.

Pregnancy outcome in spontaneous twins versus twins who were conceived through in vitro fertilization

OBJECTIVE The purpose of this study was to compare maternal and neonatal complications in spontaneous versus in vitro fertilization twins. STUDY DESIGN Twin gestations that were delivered from 1995 to 2000 were reviewed. Cases consisted of 56 in vitro fertilization twins, each of which was matched to two control mothers by age and parity. They were compared regarding various maternal and neonatal complications. RESULTS In vitro fertilization twins were more likely to have preterm labor compared with control twins, with no difference in the incidences of pregnancy-induced hypertension, gestational diabetes mellitus, placenta previa, or preterm premature rupture of membranes between the two groups. The cesarean delivery rate was significantly higher in cases of twins who were conceived by in vitro fertilization (76.8% vs 58.0%, P=.026), despite a similar rate of elective cesarean delivery and the incidence of nonvertex twin A in both groups. The preterm delivery rate was significantly higher (67.9% vs 41.1%, P=.002) and the gestational age was significantly lower (35+/-3 weeks vs 36+/-3 weeks, P=.043) in cases compared with control subjects. Both twins were, on the average, 230 g lighter in the in vitro fertilization group compared with the control group. However, intrauterine growth restriction was more frequent in the control group (36.6% vs 25%, P=.044). There was a significantly higher incidence of admission to the neonatal intensive care unit, respiratory distress syndrome, a need for mechanical ventilation, and pneumothorax in cases compared with control subjects. CONCLUSION When compared with spontaneous twins, in vitro fertilization twins are more likely to be delivered by cesarean delivery and to have a higher incidence of preterm birth and prematurity-related respiratory complications with a longer nursery stay.

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).

Advanced maternal age. Part I: obstetric complications.

More women are postponing pregnancy into the fourth and fifth decades of life for a variety of reasons. Advanced maternal age, traditionally defined as age more than 35 years, has been associated with increased obstetric morbidity and interventions. In addition, perinatal complications are reported to be higher in this patient population, although recent data point to a more favorable outcome. This article reviews the available literature with special emphasis on antepartum, intrapartum, and postpartum complications and perinatal outcome.

Risk factors for meconium aspiration syndrome

Objective To identify potential predictors of meconium aspiration syndrome (MAS) in pregnancies complicated by moderate or thick meconium-stained amniotic fluid (AF). Methods In the period 1990–1993, 937 vertex singleton pregnancies with moderate or thick meconium-stained AF were delivered; of these, 39 neonates developed MAS and 898 did not. The two groups were compared retrospectively according to maternal findings, pregnancy outcome, and neonatal complications, using univariate analysis (P < .05 considered significant) and stepwise multiple logistic regression analysis to identify independent significant factors for prediction of MAS and to calculate odds ratios (OR) and 95% confidence intervals. Results The two groups had a similar mean gestational age at delivery and birth weight. They also had similar incidences of post-dates pregnancies, small and large for gestational age infants, and amnioinfusion use. Univariate analysis identified significant differences between the two groups in 13 variables, two of which were excluded from logistic analysis because of inadequate data. Logistic regression analysis identified only six variables with independent, statistically significant effects on MAS: admission for induction with nonreassuring fetal heart tracing (OR 6.9), need for endotracheal intubation and suctioning below the vocal cords (OR 4.9), 1-minute Apgar score of 4 or less (OR 3.1), present cesarean delivery (OR 3.0), and previous cesarean delivery (OR 2.5). Cigarette smoking was associated with a lower risk for MAS (OR 0.07). The presence of at least one of the five risk factors had a sensitivity of 92%, a specificity of 56%, a positive predictive value of 8%, and a negative predictive value of 99% for MAS. Conclusion Considering the high negative predictive value of the test, infants without any risk factors will not develop MAS and thus can be safely allowed to room with their mothers. Furthermore, this model helps to identify infants who may benefit from 24-hour observation and in counseling women about the neonatal risk for developing MAS.

Imperforate hymen : report of an unusual familial occurrence

Background: Although imperforate hymen occurs in approximately 0.1¶ of female newborns, familial occurrence of imperforate hymen has been reported only once. Cases: We report two families in which imperforate hymen was diagnosed in three siblings of each family. One family is described in detail; the patients were two postmenarchal young women and one premenarchal girl. Conclusion: Imperforate hymen usually occurs sporadically but can be familial. We advise screening all female newborns and children for vaginal patency, especially family members of an affected child. Identification of other families with a similar problem might point to a specific mode of inheritance.(Obstet Gynecol 1993;82:655-6)

Obstetric outcome of teenage pregnancies compared with adult pregnancies

Background. To compare the obstetric outcome of teenage pregnancies with that of older women. Methods. Retrospective chart review of singleton births ≥24 weeks’ gestational age at the American University of Beirut from 1994 to 2003. Adolescents (<20 years) were compared to subsequently delivered women aged 25–30 years (controls), n = 486 each. Results. Only 131 (27.0%) adolescents were <18 years. More adolescents were nulliparous (79.8 versus 17.9%; p<0.0001). Preterm delivery <37 but not <34 weeks occurred more frequently in cases (11.1 versus 5.8%, p = 0.004). Pre‐eclampsia was more commonly encountered (2.9 versus 0.6%; p = 0.012) and mean predelivery haematocrit was lower in cases (30.6±3.3 versus 33.8±4.3%, p<0.001), but the incidence of gestational diabetes, placenta previa, abruptio placentae, breech presentation, or meconium‐stained amniotic fluid were similar. Caesarean delivery was performed less frequently in cases (9.2 versus 14.0%; p = 0.028), but primary caesarean and operative vaginal delivery rates were similar though vacuum was used more frequently in multiparous controls (0.2 versus 2.7%, p = 0.011). Nulliparous cases had shorter first and second stages of labour (384±304 versus 524±339 min, p<0.0001 and 47±36 versus 63±50 min, p = 0.002), respectively. Mean birth weight was higher in controls (3177±567 versus 3284±511 g, p<0.001), but intrauterine growth restriction, birth weight <2500 g, low Apgar scores, intrauterine fetal death, and stillbirths were similar in both groups. Conclusions. Adolescents are more likely to deliver preterm than older women, and are more likely to suffer from anaemia and pre‐eclampsia. Nulliparous adolescents have a quicker progress of labour while multiparous adolescents require vacuum less frequently compared to their older counterparts. In most other respects, they have comparable maternal and perinatal morbidity.

Cocoa butter lotion for prevention of striae gravidarum: a double‐blind, randomised and placebo‐controlled trial*

Objective  To assess whether application of cocoa butter lotion reduces the development of striae gravidarum (SG).

Fetal Macrosomia (≥4500 g): Perinatal Outcome of 231 Cases According to the Mode of Delivery

OBJECTIVE: To determine perinatal complications in infants ≥4500 g according to delivery mode.STUDY DESIGN: Records of 231 mothers and live cephalic infants weighing ≥4500 g over a 13-year period were retrospectively reviewed. Maternal and perinatal complications were compared in relation to delivery mode.RESULTS: Vaginal delivery (NVD) was achievable in 168/189 (88.9%) of women allowed to labor, of which 36.9% were operative. The cesarean delivery (CS) rate was 27.3%. The NVD group had a lower incidence of diabetes; however, hypoglycemia and transient tachypnea were more common in the CS group. The frequency of low Apgar scores at 1 and 5 minutes was similar in both groups. A total of 13 (7.7%) major fetal injuries were documented in the NVD group (arm weakness 3, hematoma 3, clavicular fracture 2, and brachial plexus injury 5). Shoulder dystocia was documented in only 7/13 (53.8%).CONCLUSION: Vaginal delivery is achievable in 88.9% of pregnancies with infants ≥4500 g allowed to labor, at the expense of a 7.7% risk of perinatal trauma.