Hypertension in pregnancy.
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Blood Pressure↗
Biomedical subjects
B M Sibai
Publications and source records attributed to B M Sibai.
Erythromycin therapy in preterm premature rupture of the membranes: a prospective, randomized trial of 220 patients.
OBJECTIVES: The use of prophylactic antibiotics in the management of preterm premature rupture of the membranes has not been adequately studied. The purpose of this study was to evaluate the efficacy of oral erythromycin therapy in the prolongation of latency and reduction of infectious morbidity after preterm premature rupture of membranes. STUDY DESIGN: In this randomized, prospective, double-blind, placebo-controlled study, 220 women at 20 to 35 weeks' gestation were evaluated. Subjects received oral erythromycin 333 mg (n = 106) or indistinguishable placebo (n = 114) every 8 hours from randomization to delivery. RESULTS: Prolongation of latency was identified with erythromycin therapy (p = 0.02), particularly for those destined to have chorioamnionitis (p = 0.003) and those with oligohydramnios (p = 0.01). No decrease in the incidence of maternal or neonatal infectious morbidity was seen. CONCLUSIONS: Oral erythromycin delays, but does not prevent, the onset of clinical infection when administered to women with preterm premature rupture of membranes. This regimen does not decrease neonatal morbidity and mortality.
Delivery, Obstetric↗
Eclampsia. VII. Pregnancy outcome after eclampsia and long-term prognosis.
OBJECTIVES: Our goal was to report pregnancy outcome and long-term prognosis after eclampsia. STUDY DESIGN: Women whose pregnancies were managed at the E.H. Crump Women's Hospital between August 1977 and April 1989 were studied. A total of 223 women with eclampsia underwent follow-up for an average of 7.2 years. Thirteen had preexisting hypertension and 210 were normotensive (31 were multiparous and 179 were nulliparous). RESULTS: Among these women 23 who were multiparous and 159 who were nulliparous had 366 subsequent pregnancies: 22% of pregnancies were complicated by preeclampsia, 1.9% by eclampsia, and 2.5% by abruptio placentae; 2.7% resulted in perinatal death. Within the nulliparous group, women who had eclampsia before 37 weeks' gestation in the index pregnancy had significantly higher incidences of preeclampsia and poor perinatal outcome in subsequent pregnancies as compared with those who had eclampsia at greater than or equal to 37 weeks' gestation; the highest incidence of obstetric complications occurred in those having eclampsia at less than or equal to 30 weeks. Twenty of the 210 normotensive women (9.5%) had chronic hypertension on follow-up; the highest incidence (17.9%) being in those with eclampsia at less than or equal to 30 weeks and the lowest incidence (4.8%) in those having eclampsia at greater than or equal to 37 weeks. Women with eclampsia who had preeclampsia in subsequent pregnancies had a higher incidence of chronic hypertension as compared with those who were normotensive in subsequent pregnancies (25% vs 2%, p less than 0.0001). Long-term maternal complications included dialysis required in one patient and one case of cardiomyopathy in women with chronic hypertension; there was one maternal death in a women with chronic hypertension. None of the women had evidence of neurologic deficit or seizures during follow-up. CONCLUSIONS: These findings should be used in counseling women who have had eclampsia and are considering future pregnancies.
Adult↗
Nematode infections: is it wise to withhold medical treatment during pregnancy? I. Biliary complications.
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Adult↗
Successive pregnancies complicated by idiopathic sideroblastic anemia.
Sideroblastic anemias are a diverse group of hypoproliferative anemias characterized by defective iron use within erythropoietic cells and a defect in heme biosynthesis. This report describes the first case of successive pregnancies in a patient with idiopathic sideroblastic anemia. Periodic transfusions with washed erythrocytes and oral pyridoxine resulted in normal maternal and perinatal outcome.
Adult↗
Hepatic histopathologic condition does not correlate with laboratory abnormalities in HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count)
OBJECTIVE: Our objective was to categorize the histologic findings in the liver in patients with HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count) and to correlate these findings with the severity of clinical laboratory abnormalities. STUDY DESIGN: Eleven patients with laboratory criteria for HELLP syndrome who required cesarean delivery underwent needle biopsy of the liver under direct visualization. RESULTS: Eight patients had periportal hemorrhage, and six had fibrin deposition. Fatty infiltration was seen in four, one with large-droplet fat, three with microvesicular fat. There was no statistically significant correlation between the severity of the histologic findings of periportal hemorrhage and fibrin deposition and the clinical laboratory findings. Fatty infiltration did not correlate with the severity of the HELLP syndrome's histologic condition, but, in contrast, did correlate with thrombocytopenia and aminotransferase elevations. CONCLUSIONS: Laboratory abnormalities do not accurately reflect the severity of the underlying histopathologic condition in HELLP syndrome. We propose that all patients with HELLP syndrome, regardless of the degree of their laboratory abnormalities, be treated aggressively, primarily with delivery.
Adolescent↗
Nonimmune hydrops fetalis associated with maternal infection with syphilis.
Intrauterine infection with syphilis was diagnosed by reactive maternal serologic studies, ultrasonographic findings, and exclusion of other causes in three hydropic fetuses at 31, 34, and 35 weeks' gestation. With penicillin therapy and preterm delivery all infants survived through the perinatal period. Intrauterine infection that follows syphilis is a potentially treatable cause of nonimmune hydrops.
Adolescent↗
Baking powder pica mimicking preeclampsia.
We report a case of baking powder pica during pregnancy that was associated with maternal hypertension, hypokalemia, and elevated liver function tests. After discontinuation of baking powder ingestion and correction of electrolyte abnormalities, the blood pressure and the liver function tests normalized.
Adult↗
A randomized prospective comparison of nifedipine and bed rest versus bed rest alone in the management of preeclampsia remote from term.
OBJECTIVE: The objective of our study was to test the hypothesis that treatment with nifedipine for mild preeclampsia remote from term reduces the number of days of maternal hospitalization and improves pregnancy outcome. STUDY DESIGN: A total of 200 patients at 26 to 36 weeks' gestation were randomly allocated to treatment with either bed rest alone (n = 100) or bed rest in combination with nifedipine (n = 100). RESULTS: Patients receiving nifedipine had significantly lower systolic (p < 0.0001) and diastolic (p < 0.0001) blood pressures during therapy. Severe hypertension as an indication for delivery was significantly (p < 0.05) more frequent in the bed-rest-alone group. The two study groups had similar average days of maternal hospitalization (12.6 +/- 7.9 vs 12.3 +/- 10.3) and pregnancy prolongation (22.3 +/- 13.5 vs 22.5 +/- 15.7). There were no differences between groups with respect to birth weight, incidences of small-for-gestational-age infants and preterm birth, number of days spent in special care unit, or cord blood gas measurement. CONCLUSION: Nifedipine therapy for preeclampsia reduces maternal blood pressure but does not reduce number of days of maternal hospitalization or improve perinatal outcome.
Bed Rest↗
Magnesium sulfate therapy in preeclampsia is associated with increased urinary cyclic guanosine monophosphate excretion.
OBJECTIVE: Our objective was to determine if maternal urinary cyclic guanosine monophosphate levels are altered in preeclampsia. STUDY DESIGN: Aliquots from 24-hour urine samples collected from 57 women with preeclampsia and 14 normotensive pregnant women in the third trimester of pregnancy were assayed for urinary cyclic guanosine monophosphate. Urinary cyclic guanosine monophosphate values were expressed per milligram of urinary creatinine to standardize for renal function. RESULTS: There was no difference in gestational age at time of urine collection between the two groups. Urinary cyclic guanosine monophosphate levels (mean +/- SD) were similar between normotensive and preeclamptic pregnant women (751 +/- 498 vs 632 +/- 363 pmol/mg urinary creatinine, respectively, p = 0.12). Preeclamptic women receiving magnesium sulfate had significantly higher levels of urinary cyclic guanosine monophosphate than those not receiving magnesium sulfate (786 +/- 360 vs 555 +/- 344 pmol/mg urinary creatinine, respectively, p = 0.02). CONCLUSIONS: These preliminary results indicated that cyclic guanosine monophosphate excretion increases in patients with preeclampsia during magnesium sulfate infusion. The vascular smooth muscle relaxation effects of magnesium sulfate may be mediated by directly increasing cyclic guanosine monophosphate production or indirectly through endothelium-derived relaxing factor.
Cyclic GMP↗
Cerebral imaging in eclampsia: magnetic resonance imaging versus computed tomography.
OBJECTIVES: Our objectives were to study the cerebral pathophysiology of eclampsia with the noninvasive technique of magnetic resonance imaging to compare the ability of magnetic resonance imaging to detect cerebral abnormalities in eclampsia with that of computed tomography. STUDY DESIGN: Twenty-four patients with eclampsia received both magnetic resonance imaging and computed tomographic scanning. RESULTS: Forty-six percent of the magnetic resonance imaging was abnormal and 33% of the computed tomography was abnormal. This higher incidence of abnormal magnetic resonance imaging scans was present in spite of the fact that they were obtained significantly longer after the patient's seizure activity. The most common abnormalities were cortisol, subcortical, and white matter edema. CONCLUSION: Magnetic resonance imaging and computed tomographic scan abnormalities in eclampsia are usually similar. Cerebral imaging is not necessary in patients with uncomplicated eclampsia.
Adolescent↗
Adult respiratory distress syndrome in pregnancy.
OBJECTIVE: Our objective was to determine the causes of adult respiratory distress syndrome in pregnancy, the treatment required, and maternal and perinatal outcomes. STUDY DESIGN: We examined a case series of 16 patients with adult respiratory distress syndrome initially treated in an obstetric intensive care unit. Criteria for the diagnosis were respiratory distress requiring mechanical ventilation and a lung injury score > 2.5. RESULTS: The incidence of adult respiratory distress syndrome in pregnancy was 1 per 2893 deliveries, occurring primarily in the third trimester. The causes were infection (n = 8), preeclampsia/eclampsia (n = 4), hemorrhage (n = 2), thrombotic thrombocytopenic purpura (n = 1), and smoke inhalation (n = 1). Most patients (69%) were delivered before or soon after admission to our hospital. Multiple organ failure developed in 12 patients (75%). Complications of mechanical ventilation occurred in 81% of cases. Other complications of intensive care unit support were endocarditis, superior vena cava thrombosis, line sepsis, and bacteremia. Maternal mortality was 44%; perinatal mortality was 20%. CONCLUSIONS: Adult respiratory distress syndrome in pregnancy is associated with a maternal mortality similar to that of studies in the nonpregnant patient. The main causes in pregnancy are hemorrhage, infection, and toxemia. All maternal deaths occurred in patients with multiorgan failure.
Critical Care↗
Endothelium-derived relaxing factor inhibition augments vascular angiotensin II reactivity in the pregnant rat hind limb.
OBJECTIVE: The purpose of our study was to determine whether endothelium-derived relaxing factor plays a role in the blunting of maternal vascular reactivity in pregnancy. STUDY DESIGN: We measured the concentration-pressor responses to norepinephrine (10(-8) to 10(-4) mol/L and angiotensin II (10(-10) to 10(-6) mol/L) in isolated, perfused hind limbs of nonpregnant and pregnant (postmating day 20 to 21) normotensive Wistar-Kyoto and spontaneously hypertensive rats. The hind limbs were perfused at 4 ml/min with Krebs-Ringer solution containing indomethacin (10(-5) mol/L to inhibit prostaglandin production and were either infused with N omega-monomethyl-L-arginine (10(-4) mol/L), a specific inhibitor of endothelium-derived relaxing factor synthesis, or 0.9% saline solution (untreated). RESULTS: Baseline perfusion pressure was similar in the nonpregnant and pregnant hind limbs of both strains, and N omega-monomethyl-L-arginine had no effect on perfusion pressure. Norepinephrine induced similar pressor responses in the nonpregnant and pregnant hind limbs of both strains, and N omega-monomethyl-L-arginine did not alter these responses. Angiotensin II pressor responses were significantly attenuated in the pregnant rat hind limbs compared with the nonpregnant rat hind limbs. N omega-monomethyl-L-arginine enhanced the angiotensin II responses in the pregnant, but not in the nonpregnant, rat hind limbs. CONCLUSION: The results suggest that rat pregnancy is not associated with generalized refractoriness to all vasoconstrictors and that endothelium-derived relaxing factor plays a role in attenuating vascular reactivity to angiotensin II.
Angiotensin II↗
How small is too small and how early is too early? A survey of American obstetricians specializing in high-risk pregnancies.
Four hundred and five Maternal-Fetal Medicine specialists were surveyed to determine their clinical opinions regarding intrapartum management of the severely preterm fetus requiring delivery. Intrapartum fetal heart rate monitoring was initiated at 23, 24, and 25 weeks' gestation by 10%, 43%, and 66% of respondents, respectively. Cesarean section was not performed at less than 24 weeks' gestation or less than 500 gm fetal weight. Ninety percent of respondents were willing to perform cesarean section for fetal distress or breech presentation at 26 weeks' gestation or 750 gm fetal weight. Delivery management prior to 26 weeks' gestation or for fetuses smaller than 750 gm was variable and appeared to be individualized. Due to inherent uncertainty regarding appropriate management and observed variability of response, we conclude that studies be performed to assess objectively safety and efficacy of cesarean section for fetal indications at less than 26 weeks' gestation or less than 750 gm estimated fetal weight.
Attitude of Health Personnel↗
Umbilical artery and uteroplacental velocimetry in pregnancies complicated by idiopathic low birthweight centile.
Umbilical artery and uteroplacental Doppler flow velocity waveforms were studied in 35 pregnancies complicated by idiopathic low birthweight centile. Thirty fetuses (86%) were below the 5th centile birthweight for gestation. Fifteen (43%) had an abnormal umbilical artery systolic to diastolic ratio. Uteroplacental waveforms were recorded in 29 of the 35 pregnancies and five (17%) showed an abnormal systolic to diastolic ratio. Abnormal uteroplacental systolic to diastolic ratios were associated with a significantly earlier gestational age at delivery and significantly more cesarean sections for fetal distress compared with normal uteroplacental systolic to diastolic ratios (p less than or equal to 0.01). The absence of umbilical artery end-diastolic frequencies was associated with a significantly earlier gestational age at delivery compared with the presence of umbilical artery end-diastolic frequencies (p less than 0.005). No differences in pregnancy outcome were observed comparing normal with abnormal amniotic fluid volume assessment. These findings suggest that Doppler studies may be useful in estimating the risk of adverse perinatal outcome for small for gestational age fetuses with no identifiable cause.
Blood Flow Velocity↗
Care of the pregnancy complicated by HELLP syndrome.
Pregnancies complicated by HELLP syndrome require a well-formulated management plan. The development of this syndrome after 34 weeks' gestation or with documentation of fetal lung maturity is an indication for delivery. Vaginal delivery can be accomplished in most cases; however, if cesarean section is required, the use of general anesthesia, subfascial drains, and preoperative platelet transfusion for platelet counts less than 50,000/mm3 can reduce the incidence of complications. It is advisable that patients with complications of HELLP syndrome such as pulmonary edema, acute renal failure, liver rupture, or extreme prematurity be referred to a tertiary care center where maternal and neonatal intensive care facilities are available.
Acute Disease↗
Hypertension in pregnancy.
Pregnancies complicated by hypertension require a well-formulated management plan. Women with chronic hypertension should be evaluated prior to pregnancy. At onset of pregnancy, they should be classified into low-risk and high-risk groups. The majority of pregnant women identified as low-risk hypertensives will have good perinatal outcome without the use of antihypertensive drugs. In general, antihypertensive medications should be reserved for those considered as having high-risk hypertension. In either case, all these women should have close follow-up of maternal and fetal conditions throughout pregnancy. All women with diagnosed preeclampsia should be hospitalized at the time of diagnosis for evaluation of maternal and fetal well-being. Subsequent management will then depend on gestational age and the severity of the disease process. An individualized management plan and a referral to a tertiary care center will improve maternal and perinatal outcome in those women who are remote from term and in those with the HELLP syndrome.
Female↗
Oral nifedipine pharmacokinetics in pregnancy-induced hypertension.
The pharmacokinetics of oral nifedipine were studied in 15 women with pregnancy-induced hypertension in the third trimester of pregnancy to determine if the drug's disposition was different from that in nonpregnant patients. Peak serum concentrations of 38.6 +/- 18 ng/ml occurred at approximately 40 minutes after ingestion of nifedipine 10 mg. The terminal elimination half-life (mean 1.3 +/- 0.5 hrs) was shorter than that reported for normotensive volunteers and nonpregnant hypertensives after oral dosing. Mean +/- SD apparent elimination clearance of 2.0 +/- 0.8 L/hr/kg was more rapid than that in healthy volunteers (mean 0.49 +/- 0.09 L/hr/kg). Random serum concentrations were progressively higher in patients receiving larger daily doses. Nifedipine was detected in samples of fetal cord blood and amniotic fluid at concentrations approximately 93% and 53% those of simultaneous maternal vein samples, respectively. The findings indicate that nifedipine may achieve greater antihypertensive efficacy in pregnant women if administered at shorter intervals.
Administration, Oral↗