William E. Roberts

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.

Operative vaginal delivery : A survey of fellows of ACOG

Objective To document operative vaginal delivery rates of ACOG Fellows and to stratify practice patterns with regard to mid-pelvic delivery and deep transverse arrest by the time elapsed since residency. Methods A survey was mailed to a random sample of 1600 ACOG Fellows. Of the 597 respondents (37%), 558 who still practice obstetrics formed the study group. Selection bias regarding recipients of the survey was reduced by random-ization by an uninvolved third party. The length of time since residency was categorized as 10 years or fewer (“recent,” 31%), 11–20 years (“intermediate,” 43%), and more than 20 years (“remote,” 26%). Results The majority of respondents (338 of 558, 61%) reported an operative vaginal delivery rate of 15% or less. One hundred forty-two (25%) use only forceps, whereas 78 (14%) use vacuum extraction exclusively. More than half have abandoned mid-pelvic operative vaginal deliveries, and of the 41% who still perform these operations, about half use forceps. In cases of deep transverse arrest, about 25% perform cesarean delivery, whereas 26% and 42% use forceps or vacuum, respectively. Resident training and practice in vacuum delivery were more common in the recently trained groups (recent > intermediate > remote; P < .001). There were no differences among the groups with respect to attempting mid-pelvic operative vaginal delivery (P = .29), but the remote group was more likely to use forceps, whereas the recent group was more likely to use vacuum (P = .039). A large disparity existed among the groups regarding the management of deep transverse arrest, with vacuum use associated with group assignment (P < .001). Conclusions The majority of respondents have an operative vaginal delivery rate of no more than 15%. Most respondents have abandoned mid-pelvic operative vaginal delivery. Practice patterns reflect differences in residency training; the more recently trained Fellows more often were taught and use vacuum for delivery.

Delivery of the nonvortex second twin: Breech extraction versus external cephalic version

Abstract OBJECTIVE: Our purpose was to compare the maternal and perinatal outcomes of twin gestations in which the nonvortex second twin was delivered by total breech extraction versus those delivered by external cephalic version. STUDY DESIGN: The intrapartum courses of 284 consecutive twin gestations were analyzed retrospectively. Once those with actual birth weight RESULTS: The two groups were similar for mean (±SD) maternal age, gravidity, parity, gestational age at delivery, ultrasonographic estimate of birth weight for twin B, incidence of breech or transverse presentation for the second fetus, and actual birth weight of the first or second newborn. Suspected fetal distress that led to cesarean delivery occurred significantly more often in parturients who underwent attempted external version (421) than total breech extraction (023, p=0.04). The incidence of eventual abdominal delivery was also significantly higher in patients who underwent attempted external cephalic version (1021) rather than breech extraction (123, p=0.001). For twin B the occurrence of low Apgar scores at 1 minute was significantly higher for infants after attempted external version (721) rather than breech extraction (123, p=0.02), but the mean pH, number with Apgar scores CONCLUSION: On the basis of our experience, total breech extraction of the nonvertex second twin is preferable to external cephalic version because it appears to be associated with a significantly lower incidence of fetal distress and abdominal delivery with comparable neonatal outcome.

Shoulder Dystocia and Operative Vaginal Delivery

Our objective was to determine the factors involved in the development of shoulder dystocia in association with operative vaginal delivery. In this prospective study, patients who were candidates for operative vaginal delivery were randomized either to forceps (N = 315) or vacuum with M-cup (N = 322) and timed from initial placement of instrument to final delivery. Data were gathered prior to and after instrumental delivery. Statistics used were Pearson chi square, Fishers exact, analysis of variance, and multiple logistic regression. There were a total of 21 patients with shoulder dystocia in both groups (3.3% incidence). Discriminant factors that did nor meet significance included use of epidural analgesia (P = .12), station (P = .99), previous vaginal delivery (P = .99), fetal gender (P = .54), indication for operative vaginal delivery (P = .63), > 45 degrees rotation (P = .68), use of episiotomy (P = .62), maternal weight (P = .26), and maternal diabetes (P = .08). Nearly attaining significance in univariate analysis was randomization to vacuum (P = .052). Significant factors included gestational age (P = .03), time required to effect delivery (P = .007), and birthweight (P = .0001). When these factors were subjected to stepwise multiple logistic regression, three factors remained as significant associations with shoulder dystocia: randomization to vacuum (P = .04), time for delivery (P = .03), and birthweight (P = .0001). In this operative vaginal delivery trial, shoulder dystocia was strongly associated with large fetal size, longer time to delivery, and the use of vacuum for delivery.

Prediction of hemorrhage at cesarean delivery

Objective: To identify and quantitate the risk factors that might be predictive of hemorrhage during abdominal delivery. Methods: Over a 2‐year period, 1610 women underwent cesarean delivery and 127 (7.9%) had hemorrhage, defined as a decrease in hematocrit of 10% or greater, estimated blood loss greater than 1500 mL, or packed red blood cell administration. These women were compared through a casecontrol study design with the next abdominal birth without hemorrhage that could be matched for age, parity, indication for cesarean delivery, type of anesthesia, type of skin incision, and antepartum hematocrit. Results: Preeclampsia (odds ratio 3.6, 95% confidence interval [CI] 1.8‐7.4), disorders of active labor (odds ratio 4.4, 95% CI 1.4‐13.7), Native American ethnicity (odds ratio 6.4, 95% CI 1.8‐22.4), previous postpartum hemorrhage (odds ratio 8.4, 95% CI 1.9‐37.4), and obesity of greater than 250 lb (odds ratio 13.1, 95% CI 1.7‐102.7) were all statistically associated with significant bleeding during abdominal delivery. Combinations of two or more of these factors were associated with a markedly increased risk for hemorrhage, with odds ratios of 18.4 or greater. Conclusions: Patients undergoing cesarean delivery who have factors exposing them to increased risk of hemorrhage can be identified prospectively. These women will benefit greatly from extended preoperative counseling when possible, effective utilization of blood bank technology through type and cross‐match requests, and preventive measures during abdominal delivery to minimize blood loss. (Obstet Gynecol 1994;83:923‐6)

Intrapartum Detection of a Maerosomie Fetus: Clinieal Versus 8 Sonographic Models

Summary: The purpose of this study was to determine whether clinical or sonographic models have 1) the highest accuracy in differentiating newborns with birth‐weights ≥ 4,000 g (macrosomia) versus ≤ 3,999 g, and 2) among macrosomics which method of predicting birth‐weight has the lowest percentage error. Prospectively, 602 consecutive parturients at term had a clinical estimate of birth‐weight followed by sonographic measurement of fetal parts. The sonographic prediction of birth‐weight was derived using 8 different models that utilize either 1 measurement or a combination of 2 to 4 parameters. The incidence of macrosomia was 11.1% (67 of 602). Analysis of ROC curves indicated that clinical predictions (w = 0.85) were significantly better than 4 of the 8 sonographic models. The mean standardized absolute error among maerosomie newborns is significantly lower when predictions are derived clinically (99 ± 70 g/kg) than using 1 or 2 fetal parts. Sonographic assessment of birth‐weight is not significantly more accurate in the detection of a maerosomie fetus than clinical predictions.

The interrelationship of eclampsia, HELLP syndrome, and prematurity: cofactors for significant maternal and perinatal risk

Objective To determine if there are differences between mothers and fetuses in eclamptic pregnancies with or without concurrent HELLP syndrome.

The intrapartum platelet count in patients with HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome: is it predictive of later hemorrhagic complications?

OBJECTIVE We wished to determine in patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelets) whether (1) there is an intrapartum threshold platelet count that is predictive of immediate or delayed hemorrhagic complications and (2) whether prophylactic platelet transfusion at delivery prevents these outcomes. STUDY DESIGN In this retrospective, descriptive study, the peripartal courses of 132 patients with class 1 (< or = 50,000/microliters platelet nadir) and 160 patients with class 2 (> 50,000 but < or = 100,000/microliters platelet nadir) HELLP syndrome were reviewed with special attention to laboratory data, evidence of hemorrhage, and details of platelet transfusion therapy. RESULTS A higher incidence of postpartum hemorrhagic complications (p < 0.001) occurred in class 1 versus class 2 HELLP pregnancies. The tendency to have postpartum incisional bleeding after abdominal or vaginal delivery was related to the degree of thrombocytopenia (p = 0.006). The antepartum threshold platelet count most predictive of subsequent postpartum hemorrhagic complications was < or = 40,000/microliters. The prophylactic administration of platelets does not appear to have either significantly decreased the incidence of postpartum hemorrhagic complications or significantly hastened normalization of the postpartum platelet count. CONCLUSIONS Although bleeding in the gravid patient is related to more factors than platelet count alone, patients with HELLP syndrome in whom an intrapartum platelet count above 40,000/microliters maintained are unlikely to have clinically significant postpartum bleeding. Patients with intrapartum platelet counts < or = 40,000/microliters, however, are at significant risk for postpartum bleeding, but prophylactic platelet transfusion at delivery does not ensure a significantly lower incidence of postpartum hemorrhagic complications.

Intrapartum fetal heart rate assessment: Monitoring by auscultation or electronic means

OBJECTIVE Our purpose was to assess the frequency with which auscultation could be used as the primary mode of fetal assessment during labor in a busy labor and delivery suite by means of published criteria. STUDY DESIGN During a 3-month period, 862 patients in labor with live fetuses between 24 and 43 weeks of gestation were available for auscultation in the prospective study. Auscultation was initiated during a contraction and extended for 30 seconds after uterine activity ceased. It was repeated every 15 minutes in the first stage and every 5 minutes in the second stage of labor. RESULTS In 420 patients this modality was not begun because of inability of the nurses to meet 1:1 staffing requirements. In 19 patients auscultation was not performed because of obesity (12) or patient refusal (7). Of the 423 assessed by auscultation 392 were unable to complete monitoring caused by the frequency requirement (n = 212) or the recording criteria (n = 163). Of the 31 patients where auscultation was successfully completed, there was a 1:1 nurse ratio during the entire labor. CONCLUSIONS Auscultation with stringent evaluation and recording frequency is not feasible under normal labor and delivery room conditions unless 1:1 nursing care is always available.

Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: a randomised clinical trial

Objective To determine whether the method used to expand the uterine incision for caesarean delivery affects the incidence of intra‐operative haemorrhage.