Childbearing among older women--the message is cautiously optimistic.
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Adult↗
Biomedical subjects
F G Cunningham
Publications and source records attributed to F G Cunningham.
A comparison of magnesium sulfate with phenytoin for the prevention of eclampsia.
BACKGROUND: Magnesium sulfate is used widely to prevent eclamptic seizures in pregnant women with hypertension, but few studies have compared the efficacy of magnesium sulfate with that of other drugs. Anticonvulsant prophylaxis with phenytoin for eclampsia has been recommended, but there are virtually no data to support its efficacy. Our objective was to compare magnesium sulfate with phenytoin in preventing seizures in hypertensive women during labor. METHODS: We randomly assigned women with hypertension who were admitted for delivery to receive either magnesium sulfate or phenytoin. The magnesium sulfate regimen consisted of a 10-g intramuscular loading dose followed by a maintenance dose of 5 g given intramuscularly every four hours. For women with severe preeclampsia, an additional 4-g loading dose was given intravenously. The phenytoin regimen included a 1000-mg loading dose infused over a period of 1 hour, followed by a 500-mg oral dose 10 hours later. With either regimen, anticonvulsant therapy was continued for 24 hours post partum. RESULTS: Ten of 1089 women randomly assigned to the phenytoin regimen had eclamptic convulsions, as compared with none of 1049 women randomly assigned to magnesium sulfate (P = 0.004). There were no significant differences in any risk factors for eclampsia between the two study groups. Maternal and infant outcomes were also similar in the two study groups. CONCLUSIONS: Magnesium sulfate is superior to phenytoin for the prevention of eclampsia in hypertensive pregnant women. These results validate the long-practiced use of magnesium sulfate in the prevention of eclampsia.
Adolescent↗
Acute pancreatitis in pregnancy.
OBJECTIVE: Our purpose was to determine the cause and describe the natural history of acute pancreatitis complicating pregnancy and its effect on maternal and perinatal outcomes. STUDY DESIGN: Over the last decade we admitted 43 pregnant women with acute pancreatitis to our hospital. We reviewed presentation, diagnosis, management, and maternal and perinatal outcomes. RESULTS: The incidence of acute pancreatitis was one in 3333 pregnancies. The mean age of these 43 women was 24 years, 31 (72%) were multiparous, and pancreatitis was associated with biliary disease in 29 (68%). All had a favorable response to supportive therapy that included bowel rest, intravenous hydration, and antimicrobial therapy. Cholecystectomy was performed for persistent or recurrent biliary or pancreatic disease ante partum in eight women and post partum in another 12. Of 39 women who were delivered at our hospital, 32 were at term and their infants did well. The other six infants were delivered preterm; two were stillborn and another died after birth. One woman underwent a therapeutic abortion. CONCLUSIONS: Most pregnant women with acute pancreatitis have associated biliary tract disease. With prompt hospitalization, supportive care, and surgical intervention when indicated, maternal and fetal morbidity and mortality are not prohibitive. Fetal death and preterm delivery may result from severe disease.
Acute Disease↗
Blindness associated with preeclampsia and eclampsia.
OBJECTIVE: Over a 14-year period at Parkland Hospital, the clinical courses of 15 women with severe preeclampsia or eclampsia were further complicated by blindness. Our purpose is to describe their management and outcome, as well as to offer insight to the pathophysiologic characteristics of blindness complicating pregnancy-induced hypertension. STUDY DESIGN: Prospective ascertainment of women with blindness and pregnancy-induced hypertension was done. These cases were managed according to the standardized preeclampsia-eclampsia regimen used at our hospital since 1955. Briefly, this regimen includes magnesium sulfate given intramuscularly to prevent or control seizures, hydralazine to lower dangerously elevated blood pressure, intravenous fluid restriction, and delivery. RESULTS: There were 15 women with blindness that persisted from 4 hours to 8 days; it subsequently resolved completely in all. Of the 13 women who underwent computed tomography, 8 had low-density areas localized predominantly in the occipital lobes. Five of these 13 subsequently underwent magnetic resonance imaging and 2 showed corresponding hyperintense lesions in the occipital areas. CONCLUSIONS: On the basis of previously published experiences with computed tomography in women with eclampsia, as well as the experiences described here, we conclude that cortical blindness associated with preeclampsia-eclampsia results from petechial hemorrhages and focal edema in the occipital cortex. These lesions are likely stimulated by disparity in cerebral regional blood flow that is characterized by vasospasm and diminished flow primarily affecting the posterior circulation.
Adolescent↗
Puerperal seizures after post-dural puncture headache.
OBJECTIVE: To describe eight cases of postpartum women who developed seizures associated with post-dural puncture headache. METHODS: Between the years 1982-1991, more than 19,000 women at our institution underwent subarachnoid analgesia for delivery or puerperal tubal sterilization. In eight of these women, grand mal seizures developed after spinal headache. RESULTS: In all eight women, typical post-dural puncture headaches were followed by visual disturbances that progressed to cortical blindness in three. These headaches and visual disturbances culminated in generalized tonic-clonic seizures 2-7 days after dural puncture. Although some of these women had transient hypertension at the time of seizure, none had preeclampsia. In three of the women evaluated, there was evidence of regional blood flow changes; two had diffuse cerebral artery vasospasm seen on angiography, and the third had diminished blood flow detected by a xenon-flow study. CONCLUSION: We propose that cerebral vasoconstriction is the mechanism for post-dural puncture headaches and seizures. Anatomic brain displacement may incite this vasospasm. This mechanism could also be the cause of cranial nerve palsies that have been described after dural puncture.
Adult↗
Randomized comparison of general and regional anesthesia for cesarean delivery in pregnancies complicated by severe preeclampsia.
OBJECTIVE: To evaluate the maternal and fetal effects of three anesthetic methods used randomly in women with severe preeclampsia who required cesarean delivery. METHODS: Eighty women with severe preeclampsia, who were to be delivered by cesarean, were randomized to general (26 women), epidural (27), or combined spinal-epidural (27) anesthesia. The mean preoperative blood pressure (BP) was approximately 170/110 mmHg, and all women had proteinuria. Anesthetic and obstetric management included antihypertensive drug therapy and limited intravenous (IV) fluid and drug therapy. RESULTS: The mean gestational age at delivery was 34.8 weeks. All infants were born in good condition as assessed by Apgar scores and umbilical arterial blood gas determinations. Maternal hypotension resulting from regional anesthesia was managed without excessive IV fluid administration. Similarly, maternal BP was managed without severe hypertensive effects in women undergoing general anesthesia. There were no serious maternal or fetal complications attributable to any of the three anesthetic methods. CONCLUSION: General as well as regional anesthetic methods are equally acceptable for cesarean delivery in pregnancies complicated by severe preeclampsia if steps are taken to ensure a careful approach to either method.
Adult↗
Ultrasonographic evaluation of central and end-organ hemodynamics in antepartum pyelonephritis.
OBJECTIVE: Our purpose was to evaluate central and end-organ hemodynamic effects of antepartum pyelonephritis. STUDY DESIGN: Daily duplex ultrasonographic assessments of maternal cardiac output and resistive index values of the maternal renal and uterine arteries and the fetal umbilical arteries were performed in pregnant women admitted for acute pyelonephritis. For comparison, the same measures were repeated within 2 weeks after discharge. RESULTS: Thirty-seven women with antepartum pyelonephritis underwent serial 2-dimensional real-time and Doppler evaluation of maternal heart and duplex Doppler evaluation of maternal renal and uterine and fetal umbilical arteries. Significant differences in temperature, mean arterial pressure, and heart rate were observed during hospitalization compared with the follow-up visit. Total peripheral resistance was significantly decreased and cardiac output increased during acute infection. In women with unilateral signs and symptoms an increased resistive index was observed in the symptomatic kidney compared with the nonsymptomatic side; this difference disappeared on the follow-up study. No changes were observed in maternal uterine or fetal umbilical arteries. CONCLUSIONS: Uncomplicated pyelonephritis is associated with measurable depression of systemic vascular resistance. This likely represents an effect of infection that in the extreme would be the septic shock syndrome. It seems reasonable to attribute the increased resistive index of the symptomatic kidney to local effects of infection.
Acute Disease↗
Urinary tract infections complicating pregnancy.
Urinary infections, with a spectrum from covert bacteriuria to severe pyelonephritis, commonly complicate pregnancy. Serious infections follow untreated silent bacteriuria in a fourth of cases, and routine screening can be justified in high-risk populations, particularly in those women from lower socioeconomic strata. Despite an initial salutary response to a number of antimicrobial regimens, covert bacteriuria recurs in one-third of treated women whose risk of pyelonephritis again is at 25%. Acute cystitis may be unrelated to these other infections and responds readily to a number of regimens; however, single-dose therapy is not recommended because early pyelonephritis can be mistaken for uncomplicated cystitis. Pyelonephritis is the most common severe bacterial infection complicating pregnancy. These women are frequently quite ill, and hospitalization is recommended. Since 85-90% respond within 72 h to intravenous fluids and antimicrobials, continued fever and evidence for sepsis should prompt a search for underlying obstruction. Perhaps 20% of women with severe pyelonephritis develop complications that include septic shock syndrome or its presumed variants. These latter include renal dysfunction, haemolysis and thrombocytopenia, and pulmonary capillary injury. In most of these women, continued fluid and antimicrobial therapy result in a salutary outcome, but there is occasional maternal morbidity.
Adult↗
Erythropoietin in pregnancies complicated by pyelonephritis.
OBJECTIVE: To determine whether antepartum pyelonephritis causes an acute or delayed alteration in erythropoietin production. METHODS: Serum erythropoietin concentrations were determined prospectively using an enzyme-linked immunosorbent technique in 36 pregnant women admitted to Parkland Hospital with pyelonephritis. Healthy nonanemic pregnant women served as controls. RESULTS: Serum erythropoietin levels in women with antepartum pyelonephritis were not different from those measured in normal pregnant women. Specifically, there were no differences in erythropoietin levels in women who had anemia at admission (n = 6; 13.8 mU/mL), hemolysis (15.4 versus 12.9 mU/mL), or renal insufficiency (14.5 versus 12.9 mU/mL) secondary to renal infection as compared to controls. CONCLUSION: We conclude that antepartum pyelonephritis does not alter erythropoietin production either acutely or within several days of infection. Because erythropoietin production was not decreased, we suggest that hemolysis is the major factor contributing to anemia associated with renal infection.
Adult↗
Management of eclampsia.
Mrs AB was admitted in the 34th week of pregnancy with eclampsia. Prompt parenteral (intravenous and intramuscular) administration of magnesium sulfate arrested the convulsions and prevented additional seizures. Because of a dangerously elevated blood pressure, intravenous hydralazine was administered to reduce the blood pressure. Unfortunately, the hydralazine was given more frequently than recommended, and the blood pressure was decreased rapidly and too far. This resulted in the development of a serious fetal bradycardia secondary to reduced uteroplacental perfusion. Fortunately, the blood pressure spontaneously recovered as did the fetus. Three hours after admission, Mrs AB was awake and alert. Her fetus had also recovered from the effects of the convulsions and the treatment with hydralazine. Mrs AB's laboratory values had all been reported by this time, and her intravenous intake and urinary output were well regulated. Importantly, because of the presence of significant hemoconcentration (hematocrit at 32 weeks' was 36 and at 34 weeks', 44), a careful search for pulmonary edema was made. Additionally, fluid administration was conservative in order not to produce pulmonary edema. At this point, an induction of labor was commenced. The induction of labor was rapidly successful, and Mrs AB delivered a small but vigorous male infant who subsequently did well. Mrs AB was monitored hourly for the first 12 hours postpartum to ensure adequate blood pressure control and to prevent pulmonary edema. Her subsequent puerperal course was without adverse incident. She diuresed massively, and her blood pressure rapidly returned to normal.
Adult↗
Management of preeclampsia.
Mrs AB was admitted to the delivery unit during her 35th week of gestation because of severe preeclampsia. She had several laboratory features that suggested the true severity of her disease. The massive proteinuria identified her as having far advanced disease. This was confirmed by the presence of hemoconcentration, hemolysis, and a large number of abnormal laboratory values. Mrs AB's fetus was normally grown (absence of fetal growth retardation), and there was an adequate amniotic fluid volume. Despite these favorable features and the initial presence of long-term fetal heart rate variability, the fetus did not tolerate the induction of labor, and a cesarean delivery was performed. The anesthesia, surgery, and postpartum courses were uncomplicated. Moreover, blood pressure promptly returned to normal after the onset of a brisk diuresis.
Adult↗
Pneumonia complicating pregnancy.
OBJECTIVE: To determine the clinical course and perinatal outcomes of women with pneumonia complicating pregnancy. METHODS: Between 1989 and 1993, we admitted 71 pregnant women for treatment of community-acquired pneumonia. Exposure and outcome variables as well as characteristics of their clinical course were identified and analyzed. Two-sample Wilcoxon rank-sum and Fisher exact tests were used for statistical analyses. RESULTS: Five women had adverse pregnancy outcomes related to pneumonia: two maternal-fetal deaths, one preterm delivery, one fetal death, and one early abortion. Compared with women whose pregnancies went to term, these five women had a significantly lower mean oxygen pressure on admission (68 versus 83 mmHg). Other risk factors for adverse outcome included diffuse radiologic pulmonary involvement and current smoking of more than ten cigarettes per day. Neither illicit drug use nor anemia were risk factors. Although 31 of these 71 women had underlying chronic diseases, these were not associated with negative outcomes. CONCLUSIONS: Despite prompt hospitalization and treatment, antepartum pneumonia is potentially serious, even in young, otherwise healthy women. Although underlying maternal disease appears to be related to the development of antepartum pneumonia, we did not confirm previous reports that suggested its relation to adverse pregnancy outcome.
Adult↗
Beta-adrenergic agonists for preterm labor.
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Adrenergic beta-Agonists↗
Natural history of chronic proteinuria complicating pregnancy.
OBJECTIVE: Although the significance of proteinuria is well-documented for pregnancy complicated by preeclampsia or diabetes, protein excretion of up to 300 mg per day is considered normal for uncomplicated pregnancy. Our purpose was to determine the significance of otherwise "asymptomatic" proteinuria identified during pregnancy. STUDY DESIGN: We reviewed the perinatal outcome of 65 pregnancies in 53 women with the following criteria: (1) proteinuria exceeding 500 mg per day, (2) no previously known renal disease, (3) no reversible renal dysfunction, and (4) no evidence for preeclampsia at discovery. RESULTS: Renal insufficiency coexisted in 62% of women, and 40% had chronic hypertension. Excluding 8 abortions, 53 (93%) of 57 pregnancies resulted in live infants; 45% of infants were delivered preterm and 23% had growth retardation. Of these 57 women, 62% demonstrated clinical evidence compatible with superimposed preeclampsia, and although the incidence of preeclampsia was increased with isolated proteinuria (29%), it was increased even more when there was associated chronic hypertension (incidence 100%) or renal insufficiency (incidence 58%). All 21 women who eventually underwent renal biopsy had histologic evidence of renal disease. To date, with only a limited follow-up of these 53 women, 11 (20%) have progressed to end-stage renal disease. CONCLUSION: "Asymptomatic" proteinuria is associated with a number of adverse pregnancy outcomes and serious long-term maternal morbidity.
Adult↗
Seroprevalence and risk factors for hepatitis C virus antibody in pregnant women.
OBJECTIVE: To better understand hepatitis C viropathies and seroprevalence by performing an epidemiologic analysis of pregnant women seropositive for antibody against hepatitis C. METHODS: We studied 1013 consecutive obstetric patients at Parkland Memorial Hospital who gave informed consent for detailed interviews and serotesting. Sera were analyzed for antibody to the hepatitis C virus using both C100-3 and RIBA-4 assays. Neonatal assessment was carried out in the immediate postpartum period. RESULTS: Hepatitis C antibody was detected in 2.28% (N = 23) of the 1005 women in whom analysis was completed. Factors associated with seropositivity included intravenous (IV) drug use, sexually transmitted diseases, hepatitis B infection, maternal age greater than 22.5 years, increased parity (eg, greater than 2.1), history of transfusion, and three or more different lifetime sexual partners or a sexual partner who used IV drugs. Maternal and neonatal outcome was not different between hepatitis C antibody-positive and -negative groups. CONCLUSIONS: Epidemiologic data are consistent with sexual and parenteral modes of transmission. Women with hepatitis C antibody did not have excessive perinatal complications compared with antibody-negative women. A model protocol and cost analysis for screening pregnant women for hepatitis C infection are presented. However, routine screening for hepatitis C is not advocated.
Adolescent↗
Pregnancy complicated by hereditary spherocytosis.
Hereditary spherocytosis is a spectrum of inherited erythrocyte membrane defects that result in hemolysis and varying degrees of anemia. Among 50 pregnancies in 23 women with spherocytosis, maternal complications were infrequent except for anemia, and perinatal outcomes were generally good. In six women, blood volume expansion estimated by 51chromium-tagged erythrocytes was similar to that for normal pregnant women. Mean red cell survival measured during seven pregnancies in six women ranged at 30-90 days, consistent with the heterogeneity of this disorder.
Female↗
High- versus low-dose oxytocin for labor stimulation.
The number of cesarean births for dystocia has increased dramatically in the United States. Central to the management of dystocia is correction of ineffective labor by oxytocin administration, and contemporary obstetric practice is to stimulate labor with a low-dose oxytocin regimen. We prospectively compared a low-dose oxytocin regimen (1-mU/minute dosage increments) with a high-dose regimen (6-mU/minute dosage increments) in 2788 consecutive singleton cephalic pregnancies. The low-dose regimen was used first for 5 months in 1251 pregnancies, and the high-dose regimen in 1537 pregnancies during the subsequent 5 months. Indications for oxytocin stimulation were divided into augmentation (N = 1676) and induction (N = 1112). Labor stimulation was more than 3 hours shorter (P less than .0001) with the high-dose oxytocin regimen and associated with a reduction in neonatal sepsis (0.2 versus 1.3%; P less than .01). Uterine hyperstimulation was more common (55 versus 42%; P less than .0001) with the high-dose regimen, but no adverse fetal effects were observed. High-dose augmentation resulted in significantly fewer forceps deliveries (12 versus 16%; P = .03) and fewer cesareans for dystocia (9 versus 12%; P = .04). Similarly, failed induction was less frequent with high-dose compared with low-dose oxytocin (14 versus 19%; P = .05). Although the high-dose induction regimen was associated with a significantly increased cesarean incidence for fetal distress (6 versus 3%; P = .05), the incidence of umbilical artery cord blood acidemia was not increased in this subset. Induction of labor with high-dose oxytocin is problematic because of risk-benefit considerations. Although induction failed less frequently with the high-dose regimen, cesarean for fetal distress was performed more frequently. In contrast, high-dose oxytocin to augment ineffective spontaneous labor minimized the number of cesareans done for dystocia.
Adult↗