Martin L. Schwartz

Uterine rupture associated with the use of misoprostol in the gravid patient with a previous cesarean section

OBJECTIVE Our purpose is to report our experience with uterine rupture in patients undergoing a trial of labor after previous cesarean delivery in which labor was induced with misoprostol. The literature on the use of misoprostol in the setting of previous cesarean section is reviewed. STUDY DESIGN This report was based on case reports, a computerized search of medical records, and literature review. RESULTS Uterine rupture occurred in 5 of 89 patients with previous cesarean delivery who had labor induced with misoprostol. The uterine rupture rate for patients attempting vaginal birth after cesarean section was significantly higher in those who received misoprostol, 5.6%, than in those who did not, 0.2% (1/423, P =.0001). Review of the literature reveals insufficient data to support the use of misoprostol in the patient with a previous cesarean delivery. CONCLUSION Misoprostol may increase the risk of uterine rupture in the patient with a scarred uterus. Carefully controlled studies of the risks and benefits of misoprostol are necessary before its widespread use in this setting.

Spontaneous liver hematoma in pregnancy not clearly associated with preeclampsia: A case presentation and literature review

Spontaneous liver hemorrhage with formation of subcapsular hematomas and rupture of Glissans capsule is a rare but often lethal complication of pregnancy. This entity has usually been associated with severe preeclampsia or the HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome. A case of spontaneous subcapsular hematoma of the liver occurring in the third trimester is presented in which the patient probably had neither preeclampsia nor the HELLP syndrome. The literature on liver hematomas in pregnancy published since 1982 when the term HELLP syndrome was coined is reviewed with a focus on the association of liver hematomas with preeclampsia and the HELLP syndrome. Therapy and maternal and neonatal outcomes for this entity are reassessed.

The diagnosis and classification of gestational diabetes mellitus: Is it time to change our tune?

OBJECTIVE This study was designed to determine the impact on our population of adopting the Carpenter and Coustan criteria for gestational diabetes mellitus in place of the currently used National Diabetes Data Group criteria, to review the evidence supporting replacement of the National Diabetes Data Group criteria with the Carpenter and Coustan criteria, and to propose analogous diagnostic criteria for diabetes in pregnant and nonpregnant women. STUDY DESIGN The National Diabetes Data Group criteria and the proposed Carpenter and Coustan criteria were both used to retrospectively review medical records of patients screened for gestational diabetes mellitus during 1995 and 1996 in the Kaiser Permanente Northwest Division. Computerized search was performed on automated data systems and software was used for statistical analyses. A MEDLINE review of relevant literature was conducted. RESULTS Of 8857 pregnant women screened for gestational diabetes in 1995 and 1996, 284 (3.21%) met the National Diabetes Data Group criteria, whereas 438 (4.95%) met the Carpenter and Coustan criteria. We estimate that in our population use of the Carpenter and Coustan criteria in 1996 could at best have reduced the prevalence of infants weighing >/=4000 g from 17.1% to 16.9% and the prevalence of infants weighing >/=4500 g from 2.95% to 2.91%. CONCLUSIONS Replacing the National Diabetes Data Group criteria with the Carpenter and Coustan criteria would increase by 54% the number of pregnant women with a diagnosis of gestational diabetes mellitus and would also increase costs, while only minimally affecting prevalence of infant macrosomia. The medical literature does not provide compelling evidence for adopting the Carpenter and Coustan criteria. Standardization of both measurement of venous plasma glucose level and diagnostic criteria for gestational diabetes mellitus is an important goal. Parallel criteria for diagnosis and classification of diabetes mellitus in pregnant and nonpregnant women should be developed.