Michael J. Fassett

Reversible peripartum liver failure: a new perspective on the diagnosis, treatment, and cause of acute fatty liver of pregnancy, based on 28 consecutive cases.

OBJECTIVE We sought to describe our experience with the clinical diagnosis, management, and course of patients with acute fatty liver of pregnancy. STUDY DESIGN Twenty-eight cases of acute fatty liver of pregnancy at the Los Angeles County and University of Southern California Medical Center from 1982 to June 1997 were identified, and presenting symptoms, clinical course, laboratory values, maternal complications, and neonatal outcomes were studied. RESULTS The incidence of acute fatty liver of pregnancy was 1 in 6659 births. There were no maternal deaths. Initial presentation was at an average of 37 weeks of gestation with a characteristic prodrome of malaise, nausea, vomiting, and abdominal pain. No patient was admitted with the diagnosis of acute fatty liver of pregnancy. The condition was diagnosed most commonly on the second hospital day after laboratory results indicated coagulopathy, renal insufficiency, and liver function abnormalities. One patient underwent liver biopsy at cesarean delivery. Radiologic studies did not aid with the diagnosis. Twenty-one patients were admitted in spontaneous labor, and 16 labors were complicated by abnormal fetal heart rate patterns or meconium. There was 1 stillbirth and 1 neonatal death as a result of perinatal asphyxia. Maternal morbidity consisted of hypoglycemia, infection, renal insufficiency, coagulopathy, encephalopathy, and wound complications. All patients had evidence of disseminated intravascular coagulopathy with profoundly decreased antithrombin levels. All patients recovered normal liver function post partum. CONCLUSIONS Reversible peripartum liver failure may be diagnosed and managed on the basis of clinical and laboratory criteria. With adequate support, these patients may have full recovery of hepatic function.

Mifepristone for preinduction cervical ripening beyond 41 weeks’ gestation: a randomized controlled trial ☆

Objective To compare the effect of mifepristone with placebo on cervical ripening before labor induction in prolonged pregnancies. Methods One hundred eighty women with pregnancies beyond 41 weeks and undilated, uneffaced cervices were assigned randomly to receive mifepristone 200 mg or placebo and observed for 24 hours. We then gave intravaginal misoprostol 25 μg every 4 hours or intravenous oxytocin. We expected 60% of placebo-treated and 80% of mifepristone-treated women to deliver vaginally within 48 hours. Results Among 180 subjects, 97 received mifepristone and 83 received placebo. The mean interval (± standard deviation [SD]) from start of induction to delivery was 2209 ± 698 minutes for mifepristone-treated subjects and 2671 ± 884 minutes for placebo-treated subjects (P < .001, log-transformed data). Twelve (13.6%) mifepristone-treated women and seven (10.8%) placebo-treated women delivered vaginally on day 1 (P = .60). After 24 hours, the median Bishop score for both groups was 3 (0–11) (P = .51). One hundred thirty-one subjects required misoprostol, 65 (67.0%) were mifepristone-treated women, and 66 (79.5%) placebo-treated women (P = .06). The median (range) oxytocin dose was 871.5 (0–22,174) mU for mifepristone-treated women and 2021.0 (0–24,750) mU for placebo-treated women (P = .02). Seventy-seven (87.5%) mifepristone-treated women and 46 (70.8%) placebo-treated women delivered vaginally 48 hours after the start of treatment (P = .01). There were nine cesareans in the mifepristone group and 18 in the placebo group (P = .02). More nonreassuring fetal heart rate patterns and uterine contractile abnormalities occurred in mifepristone-treated subjects. There were no statistically significant differences in neonatal outcomes between groups. Conclusion Mifepristone had a modest effect on cervical ripening when given 24 hours before labor induction, appearing to reduce the need for misoprostol and oxytocin compared with placebo.

Association between maternal inflammatory bowel disease and adverse perinatal outcomes

Objective:To examine whether inflammatory bowel disease (IBD) is associated with ischemic/inflammatory conditions during pregnancy.Study Design:A retrospective cohort study using the 2000 to 2012 Kaiser Permanente Southern California maternally-linked medical records (n=395 781). The two major subtypes of IBD, ulcerative colitis and Crohn’s diseases were studied. Adjusted odds ratios (ORs) were used to quantify the associations.Result:A pregnancy complicated by IBD was associated with increased incidence of small-for-gestational age birth (OR=1.46, 95% confidence interval (CI)=1.14 to 1.88), spontaneous preterm birth (OR=1.32, 95% CI=1.00 to 1.76) and preterm premature rupture of membranes (OR=1.95, 95% CI=1.26 to 3.02). Further stratifying by IBD subtypes, only ulcerative colitis was significantly associated with increased incidence of ischemic placental disease, spontaneous preterm birth and preterm premature rupture of membranes.Conclusion:The findings underscore the potential impact of maternal IBD on adverse perinatal outcomes. Clinicians should be aware that the association between IBD and adverse perinatal outcome varies by IBD subtypes.

Mifepristone: Effect on Plasma Corticotropin-Releasing Hormone, Adrenocorticotropic Hormone, and Cortisol in Term Pregnancy

OBJECTIVE: To compare the effects of in vivo mifepristone with placebo on plasma corticotropin-releasing hormone (CRH), adrenocorticotropic hormone (ACTH), and cortisol levels concentrations in term human pregnancies.STUDY DESIGN: In all, 24 women participating in a randomized controlled trial of mifepristone for preinduction cervical ripening were enrolled in this ancillary study. Participants with uncomplicated singleton pregnancies beyond 41 weeks gestation and undilated, uneffaced cervices were randomized to either placebo or mifepristone 200 mg orally and observed for 24 hours prior to receiving either intravaginal misoprostol and/or intravenous oxytocin. Blood samples were obtained before medication administration, 3 and 6 hours later, and then every 6 hours until delivery. Plasma hormone levels were measured by radioimmunoassay.RESULTS: Basal levels of CRH, ACTH, and cortisol were similar in the placebo (n=13) and mifepristone groups (n=11). Compared to placebo treatment, exposure to mifepristone resulted in significant elevation of plasma cortisol within 18 hours. Plasma CRH and ACTH were unaffected. Progression of labor was associated with significant increases in cortisol in both groups, while CRH and ACTH levels were not altered. Compared to basal levels within each group, plasma cortisol at delivery was significantly elevated within both the mifepristone (156.8±17.7 vs 332.6±48.5 ng/ml, p=0.008) and the placebo (166.6±34.3 vs 342.4±46.4 ng/ml, p=0.003) groups. However, plasma CRH, ACTH, and cortisol levels at delivery did not differ between the groups.CONCLUSION: Mifepristone exposure and induced labor were associated with significant increases in plasma cortisol without alterations of systemic CRH or ACTH levels.

Uterine Activity after Oral Mifepristone Administration in Human Pregnancies beyond 41 Weeks’ Gestation

Background/Aim: To examine the effect of oral mifepristone on uterine activity in postterm human pregnancies. Methods: As part of a randomized, placebo-controlled trial comparing 200 mg oral mifepristone to placebo for preinduction cervical ripening in women with well-dated pregnancies beyond 41 weeks’ gestation with unfavorable cervices, uterine activity was continuously recorded with external tocodynamometry and contraction frequency tabulated. Results: Ninety-seven women received mifepristone and 83 women received placebo. Uterine activity (uterine contractions/hour) was greater in the mifepristone than in the placebo group between 7 h (8.03 ± 0.48 vs. 5.90 ± 0.39, p = 0.001) and 24 h (8.53 ± 0.68 vs. 6.61 ± 0.46, p = 0.02) after dosing. Conclusion: Oral mifepristone administration to women with pregnancies beyond 41 weeks increases uterine activity in the absence of externally administered uterotonic agents.

Accuracy of reporting maternal and infant perinatal service system coding and clinical utilization coding

Abstract Background: To determine the extent to which the accuracy of reporting maternal and fetal clinical diagnoses and procedural coding varies between clinical utilization and perinatal services