Kristin Coppage

Treatment of hypertensive complications in pregnancy.

Hypertension is the most common medical disorder during pregnancy. Approximately 70 percent of women diagnosed with hypertension during pregnancy will have gestational hypertension-preeclampsia. The term gestational hypertension-preeclampsia is used to describe a wide spectrum of patients who may have only mild elevation in blood pressure to those with severe hypertension with various organ dysfunctions (acute gestational hypertension, preeclampsia, eclampsia, and the syndrome of hemolysis, elevated liver enzymes, and low platelets (HELLP syndrome). The exact incidence of gestational hypertension-preeclampsia in the United States is unknown. Estimates range from 6% to 8% of all pregnancies. The treatment of hypertensive disorders in pregnancy requires careful assessment of the maternal and fetal conditions. Therapeutic decisions must take into account fetal age, maternal symptoms, tests of fetal well-being, as well as maternal status, in order to ensure the best overall outcome. Treatment of mild gestational hypertension with antihypertensive medications has not been shown to improve outcome, however, in cases of severe disease treatment has been shown to be beneficial. The purpose of this review is to discuss the different treatment modalities used in the hypertensive disorders of pregnancy. Management strategies will not be discussed.

The diagnostic dilemma of thrombotic thrombocytopenic purpura/hemolytic uremic syndrome in the obstetric triage and emergency department : lessons from 4 tertiary hospitals

OBJECTIVE We report a series of occurrences of thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome (HUS) in pregnancy that emphasizes early diagnosis. STUDY DESIGN Fourteen pregnancies with TTP (n = 12) or HUS (n = 2) were studied. Analysis focused on clinical and laboratory findings on examination, initial diagnosis, and treatment. RESULTS There were 14 pregnancies in 12 patients; 2 cases of TTP were diagnosed as recurrent. Five women were admitted to the emergency department (ED), and 7 patients were admitted to an obstetrics triage. Patients who were evaluated by an obstetrician were treated initially for hemolysis, elevated liver enzymes and low platelets syndrome/preeclampsia, whereas patients who were seen in the ED had a diagnosis that is commonplace in the ED (panic attack, domestic violence, gastroenteritis). Latency from the onset of symptoms to diagnosis ranged from 1-7 days. Plasmapheresis treatments in early gestation resulted in favorable maternal-neonatal outcome. Maternal and perinatal mortality rates were 25% each. CONCLUSION TTP/HUS is a challenging diagnosis in obstetric triage and ED areas. We propose a management scheme that suggests how to triage patients for early diagnosis in pregnancy.

Maternal and perinatal outcome in women with a history of stroke

OBJECTIVE The purpose of this study was to determine recurrence risk and pregnancy outcome in 23 women with a history of stroke. STUDY DESIGN We conducted a descriptive study of 23 women (35 pregnancies) with a history of stroke. Charts were reviewed from 1990 through 2002. The data were analyzed for the antenatal treatment strategies, recurrence risk for stroke, and pregnancy outcome. RESULTS There were 23 study patients with 35 subsequent pregnancies. Associated risk factors of the stroke were thrombophilia (5 women), sickle cell disease (3 women), maternal cardiac malformations (3 women), hypertension (3 women), oral contraceptive use (2 women), cerebral arteriovenous malformations (2 women), head trauma (1 woman), meningitis (1 woman), endocarditis (1 woman), and idiopathic reason (2 women). Four women with 9 subsequent pregnancies had a stroke that was associated with a previous pregnancy or postpartum incident. Two of these 9 pregnancies received anticoagulation (heparin, 1 pregnancy; heparin plus aspirin, 1 pregnancy). Nineteen women with 26 subsequent pregnancies had a stroke before pregnancy. Nine of these 26 pregnancies received anticoagulation (heparin, 5 pregnancies; aspirin, 3 pregnancies; heparin plus aspirin, 1 pregnancy). The remaining pregnancies did not receive prophylactic anticoagulation. Overall, there were 21 term deliveries, 8 preterm deliveries, 5 miscarriages, and 1 fetal death. Three of 34 pregnancies (9%) were small for gestational age infants. There were no recurrent thrombotic episodes during pregnancy or after delivery. Maternal complications included admission to the intensive care unit for uncontrolled hypertension in 1 patient. CONCLUSION Women with a history of stroke have a low risk of recurrent stroke (0%). This information is useful for the prepregnancy counseling of such individuals. The need for prophylactic anticoagulation in patients with a previous stroke cannot be answered by this study.