- Email: [email protected]
HELLP syndrome and severe preeclampsia disease acuity: Is race a factor?
further education and strict faculty vigilance could improve protocol utilization and adherence. Methods: After identifying poor performance on GBS screening, documentation, and prophylaxis, we initiated a program of education and encouragement in an attempt to improve compliance. We reminded the faculty and residents of our institutional protocol for GBS screening and prophylaxis both verbally (lectures and announcements) and in written format (complete protocol and brief synopsis for pocket use). Reasons for protocol failure were identified and remedied. Rates of screening and antibiotic utilization following intervention were analyzed for comparison to the previous data. Results: All deliveries at University Hospital from August to October 1997 were analyzed (n = 679) and compared to prior data (January to July 1997). Group B streptococci screening was performed in 74% (prior data 65%; P = O.OOOl), with 12% of the screening results pending at delivery. Reasons for failure of screening included lack of prenatal care (9%), preterm delivery (19%), and care outside our system (62%) (85% of women with prenatal care in our system were screened). Twenty-one percent of those screened were GBS positive (prior data, 12%; P = 0.0001). Antibiotic prophylaxis was performed in 78% of the known GBS-positive cases (81% previously; P = NS). Reasons for failure to provide prophylaxis included imminent delivery, unavailable results, provider error, and elective cesarean delivery. Conclusions: A program of resident education and increased faculty vigilance resulted in improved utilization of a GBS screening and prophylaxis protocol. Utilization, however, remains incomplete due in part to the time required for performance of cultures and the time required for antibiotic administration prior to delivery.
and occurrence of respiratory distress (clinically diagnosed and requiring oxygen for at least 24 hours). Results: A total of 1,845 infants were delivered before 37 weeks (14.5%), with 952 before 35 weeks (7.5%); respiratory distress syndrome occurred in 19.1% and 34.4% of these infants. Respiratory distress syndrome declined progressively from 30 weeks (P
HELLP SYNDROME AND SEVERE PREECLAMPSIA DISEASE ACUITY:
CORTICOSTEROID USE BEFORE
Is RACE A FACTOR?
PRETERM BIRTH
Brian K. Rinehart, MD, Warren L. May, PhD, Dom A. Terrone, MD, Christy M. Isler, MD, Everett F. Magann, MD, and JamesN. Martin, Jr, MD
Brian Mercer, MD, Teresa Carr, RN, Robert Egerman, MD, and Baha Sibai, MD University ofTennesseeSchoolof Medicine, Memphis, TN Objective: The American College of Obstetricians and Gynecologists and the National Institute for Child Health and Human Development have recommended antenatal corticosteroids (CSRx) with delivery before 35 weeks to reduce infant morbidity. Before this, CSRx before preterm birth was surprisingly uncommon. The purpose of this study was to evaluate current practice and obstacles to CSRx before preterm birth. Study design: We reviewed all deliveries resulting in a preterm birth at six Shelby County hospitals over 1 year starting February 1,1997. The occurrence and timing of CSRx was documented in addition to maternal clinical characteristics, gestational age, duration of membrane rupture and labor,
voL.
93,No.4
(SWPLEMENT),APRIL
1999
Unizwsify
ofMississippi Medical Center, lackson, MS
Objective: To determine if the disease acuity of severe preeclampsia with or without HELLP syndrome differs significantly between African-Americans (AA) and Caucasians (C). Methods: Retrospective analysis of a single tertiary center experience involving 970 women with severe preeclampsia: 193 without HELLP syndrome and 777 with HELLP, as demonstrated by hemolysis/hepatic dysfunction (lactate dehydrogenase 2600 IU/L; aspartate aminotransferase Z40 lU/L; and/or alanine aminotransferae 240 IU/L) and thrombocytopenia (class 1 platelet nadir ~50,000, n = 201; class 2 >50,000 but ~lOO,OOO/~L, n = 276). The ethnic background of each patient was determined.
Tuesday Posters 45s
Results: Nine hundred twenty-three of 970 patients (95.2%) were either AA (n = 751,81%) or C (n = 172,19%). Important comparisons are tabulated:
Category
AA
C
P-Value
Epigastric/abdominal pain Nausea/vomiting Maternal age (y) BP: peak ante systolic BF: peak ante diastolic BP: peak post systolic BP: peak post diastolic Infection
27% 21% 23 k 6.1 177 k 23 109 k 13 169 _t 21 106 2 12 248 (33%)
35% 30% 24 t 5.8 169 + 23 104 + 13 163 + 19 102 2 10 39 (23%)
0.027 0.010 0.036
weeks. Mean GA at delivery was 35.2 -C 2.1 weeks, with a mean GA at stop of SQT at 34.9 + 2.0 weeks. Recurrent PTL and preterm delivery while on SQT occurred in 26.9%. Overall PI’ for both therapies was 7.6 + 3.1 weeks, or 95% of desired prolongation; 93.7% of achieved PI’ was on an outpatient basis. The comparison of therapies, using paired t and Wilcoxon signed-rank tests, is summarized in the table (data mean ? SD).
PP (wk) PP index (PI?)’
PO (n = 386)
SQT (n = 386)
P-Value
2.8 + 2.2 0.33 t 0.21
4.9 + 2.8 0.79 + 0.26
* PPI = ratio of actual to desired prolongation (to 36 weeks).
Conclusion: Despite some differences between groups (symptoms/blood pressures), these do not translate into significant differences in major morbidities as HELLI’ syndrome disease expression between these two races except for a higher incidence of infection despite fewer cesarean deliveries in AA patients.
Conclusion: Women with twin gestations whose pregnancies were complicated by recurrent PTL achieved greater PP with SQT versus PO.
ASSOCIATION BETWEEN PRETERM PREGNANCY PROLONGATION IN 386
BIRTH AND THE USE OF PROTEASE
TWIN GESTATIONS TREATED WITH
INHIBITORS
ORAL AND SUBCUTANEOUS
Phillip Goldstein, MD,* Rene Smit, RN, CNM, Monique Stevens,MD, and John Sever,MD, PhD
TERBUTALINE’
*Washington Hospital Cenfer, Washington, DC
Fung Lam, MD, Niki Bergauer, RN, Debbie Jacques,MPH, and Gay Stanziano, MD California-Pacific Medical Center, San Francisco,CA
Objective: To compare pregnancy prolongation (PI’) achieved with oral terbutaline (PO) to continuous subcutaneous terbutaline (SQT) in patients with twin gestations in preterm labor (PTL). Methods: In a retrospective cohort design, patients were identified by inclusion criteria applied to a nationwide perinatal database. These criteria were: enrollment in a PTL surveillance program, no maintenance tocolysis at program start, initiation of PO after an episode of PTL, and further recurrence of PTL symptoms resulting in treatment with SQT. Patients were used as their own control to assess individual response to change in route of tocolysis. Results: Characteristics of 386 patients meeting criteria include: age 29.9 + 5.2 years, 79.3% white, 89.4% married, and 30.1% primigravid. The mean gestational age (GA) at program start was 25.0 2 3.5 weeks. The mean GA for initiation
was 27.6 ? 3.0 weeks and for initiation
of PO
of SQT 30.3 ? 2.8
’ This document includes a discussion of use of a product that is unapproved by the U.S. Food and Drug Administration.
46s
Tuesday Posters
Objective: To evaluate the association between preterm birth and the use of protease inhibitors in human immunodeficiency virus (HIV)-seropositive women during pregnancy. Methods: In this retrospective analysis, all deliveries to HIV-seropositive gravidas occurring at the Washington Hospital Center between January 1, 1995, and June 30,1998, were evaluated for prenatal antiretroviral therapy and neonatal birth weight. Results: There were 10,635 births during our study period, of which 1,441 (14%) were preterm infants. One hundred thirteen (1%) women were identified as HIV positive. Eighty-four of these patients received prenatal antiretroviral therapy. Four patients’ treatment included protease inhibitors. Fifteen (19%) preterm deliveries occurred in the 80 patients whose regimen did not include a protease inhibitor. Three (75%) preterm deliveries occurred in the four patients whose regimen included a protease inhibitor. Conclusion: The possible association of preterm birth and protease inhibitors is validated by our series. Although no cause-and-effect relationship can be established, the National Institutes of Health moratorium on protease inhibitors in pregnancy seems warranted. Further research on many more HIV-seropositive women will be required to establish whether a true cause-and-effect relationship exists.
Obstetrics b Gynecology
and occurrence of respiratory distress (clinically diagnosed and requiring oxygen for at least 24 hours). Results: A total of 1,845 infants were delivered before 37 weeks (14.5%), with 952 before 35 weeks (7.5%); respiratory distress syndrome occurred in 19.1% and 34.4% of these infants. Respiratory distress syndrome declined progressively from 30 weeks (P
HELLP SYNDROME AND SEVERE PREECLAMPSIA DISEASE ACUITY:
CORTICOSTEROID USE BEFORE
Is RACE A FACTOR?
PRETERM BIRTH
Brian K. Rinehart, MD, Warren L. May, PhD, Dom A. Terrone, MD, Christy M. Isler, MD, Everett F. Magann, MD, and JamesN. Martin, Jr, MD
Brian Mercer, MD, Teresa Carr, RN, Robert Egerman, MD, and Baha Sibai, MD University ofTennesseeSchoolof Medicine, Memphis, TN Objective: The American College of Obstetricians and Gynecologists and the National Institute for Child Health and Human Development have recommended antenatal corticosteroids (CSRx) with delivery before 35 weeks to reduce infant morbidity. Before this, CSRx before preterm birth was surprisingly uncommon. The purpose of this study was to evaluate current practice and obstacles to CSRx before preterm birth. Study design: We reviewed all deliveries resulting in a preterm birth at six Shelby County hospitals over 1 year starting February 1,1997. The occurrence and timing of CSRx was documented in addition to maternal clinical characteristics, gestational age, duration of membrane rupture and labor,
voL.
93,No.4
(SWPLEMENT),APRIL
1999
Unizwsify
ofMississippi Medical Center, lackson, MS
Objective: To determine if the disease acuity of severe preeclampsia with or without HELLP syndrome differs significantly between African-Americans (AA) and Caucasians (C). Methods: Retrospective analysis of a single tertiary center experience involving 970 women with severe preeclampsia: 193 without HELLP syndrome and 777 with HELLP, as demonstrated by hemolysis/hepatic dysfunction (lactate dehydrogenase 2600 IU/L; aspartate aminotransferase Z40 lU/L; and/or alanine aminotransferae 240 IU/L) and thrombocytopenia (class 1 platelet nadir ~50,000, n = 201; class 2 >50,000 but ~lOO,OOO/~L, n = 276). The ethnic background of each patient was determined.
Tuesday Posters 45s
Results: Nine hundred twenty-three of 970 patients (95.2%) were either AA (n = 751,81%) or C (n = 172,19%). Important comparisons are tabulated:
Category
AA
C
P-Value
Epigastric/abdominal pain Nausea/vomiting Maternal age (y) BP: peak ante systolic BF: peak ante diastolic BP: peak post systolic BP: peak post diastolic Infection
27% 21% 23 k 6.1 177 k 23 109 k 13 169 _t 21 106 2 12 248 (33%)
35% 30% 24 t 5.8 169 + 23 104 + 13 163 + 19 102 2 10 39 (23%)
0.027 0.010 0.036
weeks. Mean GA at delivery was 35.2 -C 2.1 weeks, with a mean GA at stop of SQT at 34.9 + 2.0 weeks. Recurrent PTL and preterm delivery while on SQT occurred in 26.9%. Overall PI’ for both therapies was 7.6 + 3.1 weeks, or 95% of desired prolongation; 93.7% of achieved PI’ was on an outpatient basis. The comparison of therapies, using paired t and Wilcoxon signed-rank tests, is summarized in the table (data mean ? SD).
PP (wk) PP index (PI?)’
PO (n = 386)
SQT (n = 386)
P-Value
2.8 + 2.2 0.33 t 0.21
4.9 + 2.8 0.79 + 0.26
* PPI = ratio of actual to desired prolongation (to 36 weeks).
Conclusion: Despite some differences between groups (symptoms/blood pressures), these do not translate into significant differences in major morbidities as HELLI’ syndrome disease expression between these two races except for a higher incidence of infection despite fewer cesarean deliveries in AA patients.
Conclusion: Women with twin gestations whose pregnancies were complicated by recurrent PTL achieved greater PP with SQT versus PO.
ASSOCIATION BETWEEN PRETERM PREGNANCY PROLONGATION IN 386
BIRTH AND THE USE OF PROTEASE
TWIN GESTATIONS TREATED WITH
INHIBITORS
ORAL AND SUBCUTANEOUS
Phillip Goldstein, MD,* Rene Smit, RN, CNM, Monique Stevens,MD, and John Sever,MD, PhD
TERBUTALINE’
*Washington Hospital Cenfer, Washington, DC
Fung Lam, MD, Niki Bergauer, RN, Debbie Jacques,MPH, and Gay Stanziano, MD California-Pacific Medical Center, San Francisco,CA
Objective: To compare pregnancy prolongation (PI’) achieved with oral terbutaline (PO) to continuous subcutaneous terbutaline (SQT) in patients with twin gestations in preterm labor (PTL). Methods: In a retrospective cohort design, patients were identified by inclusion criteria applied to a nationwide perinatal database. These criteria were: enrollment in a PTL surveillance program, no maintenance tocolysis at program start, initiation of PO after an episode of PTL, and further recurrence of PTL symptoms resulting in treatment with SQT. Patients were used as their own control to assess individual response to change in route of tocolysis. Results: Characteristics of 386 patients meeting criteria include: age 29.9 + 5.2 years, 79.3% white, 89.4% married, and 30.1% primigravid. The mean gestational age (GA) at program start was 25.0 2 3.5 weeks. The mean GA for initiation
was 27.6 ? 3.0 weeks and for initiation
of PO
of SQT 30.3 ? 2.8
’ This document includes a discussion of use of a product that is unapproved by the U.S. Food and Drug Administration.
46s
Tuesday Posters
Objective: To evaluate the association between preterm birth and the use of protease inhibitors in human immunodeficiency virus (HIV)-seropositive women during pregnancy. Methods: In this retrospective analysis, all deliveries to HIV-seropositive gravidas occurring at the Washington Hospital Center between January 1, 1995, and June 30,1998, were evaluated for prenatal antiretroviral therapy and neonatal birth weight. Results: There were 10,635 births during our study period, of which 1,441 (14%) were preterm infants. One hundred thirteen (1%) women were identified as HIV positive. Eighty-four of these patients received prenatal antiretroviral therapy. Four patients’ treatment included protease inhibitors. Fifteen (19%) preterm deliveries occurred in the 80 patients whose regimen did not include a protease inhibitor. Three (75%) preterm deliveries occurred in the four patients whose regimen included a protease inhibitor. Conclusion: The possible association of preterm birth and protease inhibitors is validated by our series. Although no cause-and-effect relationship can be established, the National Institutes of Health moratorium on protease inhibitors in pregnancy seems warranted. Further research on many more HIV-seropositive women will be required to establish whether a true cause-and-effect relationship exists.
Obstetrics b Gynecology