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Song C, Xu Y, Ding Y, Zhang Y, Liu N, Li L, Li Z, Du J, You H, Ma H, Jin G, Wang X, Shen H, Lin Y, Jiang X, Hu Z. The rates and medical necessity of cesarean delivery in China, 2012-2019: an inspiration from Jiangsu. BMC Med 2021; 19:14. [PMID: 33487165 PMCID: PMC7831243 DOI: 10.1186/s12916-020-01890-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/15/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) in 2015 stated that every effort should be made to provide cesarean delivery (CD) for women in need. In China, the two-child policy largely prompts the number of advanced age childbirth, which raises the possibility of an increasing number of women who need a c-section. The aim of this study was to assess the trends in the overall and medical indication-classified CD rates in the era of the two-child policy in Jiangsu, China. METHODS A retrospective cross-sectional study of 291,448 women who delivered in 11 hospitals in Jiangsu province between 2012 and 2019 was conducted. Medical cesarean indication for each woman was ascertained by manually reviewing the medical records. The 291,448 women were divided into two subgroups according to the presence of the indications: the indicated group (7.80%) and the non-indicated group (92.20%). We then fitted joinpoint regression and log-binomial regression models to estimate trends in the CD rates across the study period. RESULTS The overall CD rate was observed with a declining trend from 52.51% in 2012-2015 to 49.76% in 2016-2019 (adjusted RR, 0.92; 95% CI, 0.91-0.93; P < 0.001), along with an annual percentage change (APC) to be - 1.0 (95% CI, - 2.1 to 0.0) across the period. The participants were then divided into two subgroups according to the presence of medical CD indications: the indicated group (7.80%) and the non-indicated group (92.20%).We found the declining trend was most pronounced in the non-indicated group, with the CD rates decreased from 50.02% in 2012-2015 to 46.27% in 2016-2019 (adjusted RR, 0.90; 95% CI, 0.89-0.90; P < 0.001). By contrast, we observed a steady trend in the CD rate of the indicated group, which maintained from 87.47% in 2012-2015 to 86.57% in 2016-2019 (P = 0.448). In the indicated group, a higher risk of adverse pregnancy outcomes was revealed for those women who delivered vaginally as compared with those who received c-section. We further investigated that women with following specific indications had a higher proportion of vaginal delivery, i.e., pregnancy complications, fetal macrosomia, and pregnancy complicated with tumor (34.70%, 10.84%, and 16.34%, respectively). Women with the above 3 indications were observed with a higher risk of adverse pregnancy outcomes if delivered vaginally. The incidence rates of the medical indications among the general population increased considerably over the 8-year period (P < 0.001). CONCLUSIONS Although the overall CD rate apparently decreased in the recent years, along with the decline of the unnecessary CD rate, a considerable proportion of indicated women were not provided with CD service in Jiangsu, China. Instead of targeting the overall CD rate, we need to take actions to reduce unnecessary CD rate and provide adequate c-section service for women with indications, particularly for those with underlying diseases and suspected fetal macrosomia.
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Affiliation(s)
- Ci Song
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yan Xu
- Department of Maternal and Child Health, Jiangsu Commission of Health, Nanjing, 210008, China
| | - Yuqing Ding
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yanfang Zhang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Na Liu
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Lin Li
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Zhun Li
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Jiangbo Du
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Hua You
- Department of Social Medicine & Health Education, Nanjing Medical University, Nanjing, 211166, China
| | - Hongxia Ma
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Guangfu Jin
- Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Xudong Wang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China
| | - Hongbing Shen
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China.,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China
| | - Yuan Lin
- Department of Maternal, Child and Adolescent Health, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
| | - Xiaoqing Jiang
- Department of Group Health, Women and Children Branch Hospital of Jiangsu Province Hospital/Jiangsu Women and Children Health Hospital, Nanjing Medical University, Nanjing, 210036, China.
| | - Zhibin Hu
- State Key Laboratory of Reproductive Medicine, Nanjing Medical University, Nanjing, 211166, China. .,Department of Epidemiology, School of Public Health, Nanjing Medical University, Nanjing, 211166, China.
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Success of labor induction for pre-eclampsia at preterm and term gestational ages. J Perinatol 2017; 37:636-640. [PMID: 28358381 DOI: 10.1038/jp.2017.31] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Revised: 02/09/2017] [Accepted: 02/20/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Determine the impact of gestational age (GA) on vaginal delivery following induction of labor (IOL) for pre-eclampsia, and evaluate factors that influence successful induction. STUDY DESIGN Population-based retrospective cohort of 1 034 552 live births in Ohio (2006-2012). The rate of vaginal delivery in women with pre-eclampsia who underwent induction was calculated with 95% confidence intervals, stratified by week of GA at birth. Factors associated with the decision to undergo IOL, and success of IOL were evaluated, and multivariable logistic regression estimated the strength of association. RESULTS 18 296 (71.3%) of the patients who underwent IOL had a vaginal delivery. The majority achieved vaginal delivery at both preterm (66% at 23-36 weeks) and term GAs (72%). Factors most strongly associated with vaginal delivery following IOL for pre-eclampsia included prior vaginal delivery and young maternal age. CONCLUSION The majority of women with pre-eclampsia who undergo IOL achieve vaginal birth, even at early GAs.
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Abstract
Induction of labor will affect almost a quarter of all pregnancies, but historically there has been no generally accepted definition of failed induction of labor. Only recently have studies analyzed the lengths of latent labor that are associated with successful labor induction ending in a vaginal delivery, and recommendations for uniformity in the diagnosis of failed induction have largely resulted from this data. This review assesses the most recent and inclusive definition for failed induction, risk factors associated with failure, complications, and special populations that may be at risk for a failed induction.
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Affiliation(s)
- Corina Schoen
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical School at Thomas Jefferson University, 833 Chestnut St, 1st floor, Philadelphia, PA 19107; Department of Obstetrics and Gynecology, Christiana Care Hospital, Newark, DE.
| | - Reshama Navathe
- Department of Obstetrics and Gynecology, Sidney Kimmel Medical School at Thomas Jefferson University, 833 Chestnut St, 1st floor, Philadelphia, PA 19107; Department of Obstetrics and Gynecology, Christiana Care Hospital, Newark, DE
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Berkley E, Meng C, Rayburn WF. Success rates with low dose misoprostol before induction of labor for nulliparas with severe preeclampsia at various gestational ages. J Matern Fetal Neonatal Med 2009; 20:825-31. [DOI: 10.1080/14767050701578303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: a best-evidence review. BJOG 2009; 116:626-36. [PMID: 19191776 DOI: 10.1111/j.1471-0528.2008.02065.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Rates of labour induction are increasing. OBJECTIVES To review the evidence supporting indications for induction. SEARCH STRATEGY We listed indications for labour induction and then reviewed the evidence. We searched MEDLINE and the Cochrane Library between 1980 and April 2008 using several terms and combinations, including induction of labour, premature rupture of membranes, post-term pregnancy, preterm prelabour rupture of membranes (PROM), multiple gestation, suspected macrosomia, diabetes, gestational diabetes mellitus, cardiac disease, fetal anomalies, systemic lupus erythematosis, oligohydramnios, alloimmunization, rhesus disease, intrahepatic cholestasis of pregnancy (IHCP), and intrauterine growth restriction (IUGR). We performed a review of the literature supporting each indication. SELECTION CRITERIA We identified 1387 abstracts and reviewed 418 full text articles. We preferentially included high-quality systematic reviews or large randomised trials. Where no such studies existed, we included the best evidence available from smaller randomised trials and observational studies. MAIN RESULTS We included 34 full text articles. For each indication, we assigned levels of evidence and grades of recommendation based upon the GRADE system. Recommendations for induction of labour for post-term gestation, PROM at term, and premature rupture of membranes near term with pulmonary maturity are supported by the evidence. Induction for IUGR before term reduces intrauterine fetal death, but increases caesarean deliveries and neonatal deaths. Evidence is insufficient to support induction for women with insulin-requiring diabetes, twin gestation, fetal macrosomia, oligohydramnios, cholestasis of pregnancy, maternal cardiac disease and fetal gastroschisis. AUTHORS' CONCLUSIONS Research is needed to determine risks and benefits of induction for many commonly advocated clinical indications.
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Affiliation(s)
- E Mozurkewich
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA.
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Beucher G, Simonet T, Dreyfus M. Prise en charge du HELLP syndrome. ACTA ACUST UNITED AC 2008; 36:1175-90. [DOI: 10.1016/j.gyobfe.2008.08.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2008] [Accepted: 08/09/2008] [Indexed: 11/26/2022]
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Martin JN, Rose CH, Briery CM. Understanding and managing HELLP syndrome: the integral role of aggressive glucocorticoids for mother and child. Am J Obstet Gynecol 2006; 195:914-34. [PMID: 16631593 DOI: 10.1016/j.ajog.2005.08.044] [Citation(s) in RCA: 145] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2005] [Revised: 07/13/2005] [Accepted: 08/18/2005] [Indexed: 11/16/2022]
Abstract
Antepartum or postpartum HELLP syndrome constitutes an obstetric emergency that requires expert knowledge and management skills. The insidious and variable nature of disease presentation and progression challenges the clinician and complicates consensus on universally accepted diagnostic and classification criteria. A critical review of published research about this variant form of severe preeclampsia, focused primarily on what is known about the pathogenesis of this disorder as it relates to patient experience with corticosteroids for its management, leads to the conclusion that there is maternal-fetal benefit realized when potent glucocorticoids are aggressively used for its treatment. Although acknowledging the need for definitive multicenter trials to better define the limits of benefit and the presence of any maternal or fetal risk, and given an understanding of the nature of the disorder with its potential to cause considerable maternal morbidity and mortality, we recommend for the present that aggressively used potent glucocorticoids constitute the cornerstone of management for patients considered to have HELLP syndrome.
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Affiliation(s)
- James N Martin
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS, USA
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Ben-Haroush A, Yogev Y, Glickman H, Kaplan B, Hod M, Bar J. Mode of delivery in pregnant women with hypertensive disorders and unfavorable cervix following induction of labor with vaginal application of prostaglandin E. Acta Obstet Gynecol Scand 2005; 84:665-71. [PMID: 15954877 DOI: 10.1111/j.0001-6349.2005.00681.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Our aim was to evaluate the mode of delivery in pregnant women with hypertensive disorders and unfavorable cervix following induction of labor with vaginal application of prostaglandin E(2) (PGE(2)) near or at term, and to define the predictors of successful vaginal delivery in such women. METHODS In a retrospective case-controlled study, pregnant women with hypertension, who underwent labor induction with PGE(2) tablets (study group, n = 284), were compared with women, who underwent elective induction of labor (group 2, n = 115), and women with normal spontaneous onset of labor (group 3, n = 510). RESULTS The rate of cesarean section (CS) was significantly higher in the study group (25.3%) than in group 2 (14.8%) and in group 3 (9%). Exclusion of the nulliparous women from the study and control groups yielded similar CS rates in the study group (16.9%) and in group 2 (11.1%). Women with pre-eclampsia and the women with chronic hypertension or pregnancy-induced hypertension had similar rates of CS. In logistic regression model, nulliparity, induction of labor with PGE(2), and maternal age, but not hypertensive disorders, were independently and significantly associated with increased risk of CS. CONCLUSIONS PGE(2) induction of labor is successful in approximately 75% of patients with hypertensive disorders and unfavorable cervix, with apparently no serious maternal or fetal complications. The induction of labor by itself, and not the hypertensive disorders in pregnancy, is independent risk factor for CS.
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Affiliation(s)
- Avi Ben-Haroush
- Perinatal Division and WHO Collaborating Center for Perinatal Care, Department of Obstetrics and Gynecology, Rabin Medical Center, Beilinson Campus, Petah Tiqva, Israel.
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Rose CH, Thigpen BD, Bofill JA, Cushman J, May WL, Martin JN. Obstetric implications of antepartum corticosteroid therapy for HELLP syndrome. Obstet Gynecol 2004; 104:1011-4. [PMID: 15516393 DOI: 10.1097/01.aog.0000143262.85124.e8] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We reviewed the impact of intravenous high-dose corticosteroid administration for preterm hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome on vaginal delivery rate and degree of clinically significant thrombocytopenia. METHODS Retrospective analysis of 1991-2000 HELLP syndrome (platelets < 100,000/uL, lactate dehydrogenase > 600 IU/L, aspartate aminotransferase and/or alanine aminotransferase > 70 IU/L) data focusing on labor inductions for gestations of less than 34 weeks and increase in platelet count sufficient to permit regional anesthetic techniques. RESULTS Antepartum high-dose corticosteroid use increased from 32% (1991-1995) to 67% (1996-2000) for 350 patients studied (n = 199, < 34 weeks; n = 151, > 34 weeks). Corresponding vaginal delivery rates were 32% for gestations of less than 30 weeks, 61% at 30-31 weeks, and 62% at 32-33 weeks. Similarly, 27% of patients with a platelet count of less than 75,000/uL and 52% with a platelet count of less than 100,000/uL who received high-dose corticosteroids during the study interval subsequently achieved a 100,000/uL threshold in time to perform regional anesthesia for delivery. CONCLUSION Administration of intravenous high-dose corticosteroids for preterm HELLP syndrome increases probability of successful labor induction and candidacy for regional anesthesia. LEVEL OF EVIDENCE II-3.
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Affiliation(s)
- Carl H Rose
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, Mississippi 39216-4505, USA.
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Mostello D, Droll DA, Bierig SM, Cruz-Flores S, Leet T. Tertiary care improves the chance for vaginal delivery in women with preeclampsia. Am J Obstet Gynecol 2003; 189:824-9. [PMID: 14526323 DOI: 10.1067/s0002-9378(03)00713-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The purpose of this study was to determine whether the level of hospital care affects cesarean delivery rates for women with preeclampsia. STUDY DESIGN We conducted a population-based cohort study using Missouri birth certificate data for 1993 through 1999. Logistic regression was used to analyze data from 13,646 nulliparous women with preeclampsia who were delivered of singleton live births. RESULTS After adjustment was made for gestational age and birth weight, the data showed that women with preeclampsia at primary and secondary hospitals were more likely to be delivered by cesarean delivery (odds ratio, 1.37; 95% CI, 1.24,1.51; and odds ratio, 1.16; 95% CI, 1.07,1.26, respectively) than at tertiary hospitals. For women who were delivered at >or=37 weeks of gestation, cesarean delivery rates were 38.0%, 33.7%, and 30.0% for primary, secondary, and tertiary hospitals, respectively. Dysfunctional labor, cephalopelvic disproportion, and fetal distress were more commonly noted at primary and secondary hospitals (P<.001). CONCLUSION Levels of expertise and staffing at tertiary hospitals may allow greater attempts and success with vaginal delivery among women with preeclampsia compared with primary or secondary hospitals.
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Affiliation(s)
- Dorothea Mostello
- Department of Obstetrics, Gynecology, and Women's Health, Division of Maternal-Fetal Medicine, Saint Louis University, MO, USA
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Hnat M, Sibai B. Severe Preeclampsia Remote from Term. Hypertens Pregnancy 2002. [DOI: 10.1201/b14088-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
Caesarean section rates are rising. Caesarean section confers an increase in maternal mortality and morbidity as well as having considerable financial implications. Caesarean section is usually justified by the assumed benefit for the fetus. These benefits are often unquantified and based on scanty evidence. The changing trends in the rates of caesarean section for various indications may be explained partly by improved anaesthetic and neonatal techniques. Cultural changes and expectations in the general population and obstetricians' fear of litigation may have made the changing rate and indications for caesarean section seem more acceptable. There is little research evidence in this area. The evidence that caesarean section is the optimal mode of delivery for various major indications is critically examined. The obstetrician is under an obligation to share the evidence that caesarean section is the optimum mode of delivery with the pregnant woman and her birth attendants to allow the woman to make wise decisions about her management.
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Affiliation(s)
- Z Penn
- Department of Obstetrics, Chelsea and Westminster Hospital, 369 Fulham Road, London, SW10 9NH, UK
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Ben Letaifa D, Ben Hamada S, Salem N, Ben Jazia K, Slama A, Mansali L, Jegham H. [Maternal and perinatal morbidity and mortality associated with hellp syndrome] . ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 2000; 19:712-8. [PMID: 11200757 DOI: 10.1016/s0750-7658(00)00313-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Our purpose was to describe the effects of serious obstetric complications on maternal and perinatal outcome in pregnancies complicated by Hellp syndrome. STUDY DESIGN Retrospective study. PATIENTS Sixteen patients managed from January 1994 through December 1998 in whom pregnancy was complicated by Hellp Syndrome. RESULTS The incidence of Hellp syndrome among women with severe preeclampsia and/or eclampsia (164 cases) was 9.7%. Fourteen cases occurred before and two after delivery. In nine cases, Hellp occurred before 32 weeks of gestation and later in two other cases. Mean gestational age at delivery was 32.4 weeks. Serious maternal morbidity included acute renal failure (five cases), disseminated intravascular coagulation (two cases), pulmonary oedema (one case), severe ascites (five cases), pleural effusion (three cases), adult respiratory distress syndrome (one case). Abruptio placenta, acute renal failure and disseminated intravascular coagulation were always associated. Ten patients required transfusions with blood products. Caesarean delivery was performed in 15 cases. General anaesthesia was used in all patients. There was one maternal death from multiple organ failure. Perinatal outcome was poor. Six perinatal deaths were related to abruptio placenta, intrauterine asphyxia and extreme prematurity. CONCLUSION The high maternal and perinatal mortality and morbidity reported with the presence of Hellp syndrome requires maternal-fetal follow-up in a tertiary centre where intensive maternal and neonatal care are available.
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Affiliation(s)
- D Ben Letaifa
- Service d'anesthésie-réanimation, CHU Farhat Hached, Sousse, Tunisie
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Hennessey MH, Rayburn WF, Stewart JD, Liles EC. Pre-eclampsia and induction of labor: a randomized comparison of prostaglandin E2 as an intracervical gel, with oxytocin immediately, or as a sustained-release vaginal insert. Am J Obstet Gynecol 1998; 179:1204-9. [PMID: 9822501 DOI: 10.1016/s0002-9378(98)70132-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
OBJECTIVE Our purpose was to compare the efficacy of commercial prostaglandin E2 products, in combination with oxytocin, for the initiation of labor among pregnancies with pre-eclampsia. STUDY DESIGN Patients with pregnancy-induced hypertension and with either proteinuria or other end-organ damage were enrolled if they had an unfavorable Bishop score (</=4) and were eligible to undergo labor. Each was randomly assigned to receive prostaglandin E2 either as a 0. 5-mg intracervical gel (Prepidil) or as a 10-mg controlled-release vaginal insert (Cervidil). Oxytocin was begun either immediately after instillation of the gel or was delayed until after removal of the insert. RESULTS Of the 70 patients, there were no differences between the Prepidil (n = 34) and the Cervidil (n = 36) groups in maternal demographics, gestational age, parity, and predose Bishop score. There was a mean 14.3-hour difference in the duration from beginning therapy until vaginal delivery in the Prepidil group than in the Cervidil group (11.5 +/- 2.3 hours vs 25.8 +/- 6.9 hours, P <. 001). This time difference, which favored use of Prepidil-immediate oxytocin, remained significant after parity (nulliparous: 20 hours, P <.005; multiparous: 12 hours, P <.01) and gestational age were controlled (preterm: 15.5 hours, P <.01; term: 13.3 hours, P <.01). CONCLUSION Use of combined intracervical prostaglandin E2 gel-immediate oxytocin therapy was more effective in shortening the induction-to-vaginal delivery time than use of a controlled-release prostaglandin E2 vaginal insert.
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Affiliation(s)
- M H Hennessey
- Section of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Oklahoma College of Medicine, Oklahoma City, OK 73190, USA
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Saphier CJ, Repke JT. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome: a review of diagnosis and management. Semin Perinatol 1998; 22:118-33. [PMID: 9638906 DOI: 10.1016/s0146-0005(98)80044-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hemolysis, elevated liver enzymes, and low platelet (HELLP) syndrome is a form of severe preeclampsia that threatens the gravida and her fetus. In this report, the diagnostic criteria and maternal and fetal risks of HELLP are defined. Prompt recognition and treatment in tertiary centers is emphasized, because the prognosis can be adversely affected by delayed or less than optimal diagnosis and treatment. Management guidelines are offered for treating this disorder. The potential roles of corticosteroids, plasmapheresis, and expectant management are critically evaluated. Subsequent pregnancy outcome, contraception, and preventative strategies are considered.
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Affiliation(s)
- C J Saphier
- Department of Obstetrics, Gynecology, and Reproductive Biology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Affiliation(s)
- M Geary
- University College London Medical School, Department of Obstetrics and Gynaecology
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Gilson G, Golden P, Izquierdo L, Curet L. Pregnancy-Associated Hemolysis, Elevated Liver Functions, Low Platelets (HELLP) Syndrome: An Obstetric Disease in the Intensive Care Unit. J Intensive Care Med 1996. [DOI: 10.1177/088506669601100304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We reviewed the experience with hemolysis, elevated liver functions, low platelets (HELLP) syndrome at the University of New Mexico Hospital over the past 10 years to delineate the epidemiology and the clinical course of the disease. A retrospective chart review of a large, university-based, largely indigent, pregnant population was undertaken with attention to diagnostic features of the syndrome and maternal and infant outcomes of affected pregnancies. Comparisons were made with other large reported clinical series. Preeclampsia complicated 5.6% of deliveries in this study, and the HELLP syndrome occurred in 116 patients (0.3% of all deliveries). Epigastric pain, nausea, vomiting, and malaise usually heralded the syndrome. Signs and symptoms of preeclampsia (e.g., hypertension, proteinuria, and edema) were most often not striking at the time of presentation. The mean platelet count at diagnosis was 60 ± 25 × 103. Initial signs of hemolysis were usually minimal, although the hematocrit decreased a mean of 11.5 ± 5 vol% over the course of the disease. Moderate elevations of hepatic enzyme levels, specifically lactic dehydrogenase, were common; hyperbilirubinemia was usually mild and late. Maternal complications included disseminated intravascular coagulation, eclampsia, pulmonary edema, adult respiratory distress syndrome, and hepatic hematoma. Eight stillbirths and 7 neonatal deaths occurred (perinatal mortality, 126/1,000). HELLP syndrome is a relatively infrequent but serious development in the evolution of preeclampsia/eclampsia. Variations in onset and severity of hemolysis, hepatic dysfunction, and thrombocytopenia are common. Maternal complications and the perinatal mortality rate are high. Pregnant patients with right upper quadrant or epigastric pain and thrombocytopenia, even in the absence of significant hypertension and proteinuria, are most likely to have HELLP syndrome, rather than some other medical condition. Awareness of the variable presentations of this syndrome permit the prompt recognition and management necessary to optimize maternal and neonatal outcomes.
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Affiliation(s)
- George Gilson
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Pamela Golden
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Luis Izquierdo
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
| | - Luis Curet
- Department of Obstetrics and Gynecology, University of New Mexico School of Medicine, Albuquerque, NM
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Abstract
Liver pathology is one of the main features of HELLP syndrome and develops on the basis of a generalised activation of intravascular coagulation. Fibrin deposits and haemorrhagic necrosis predominantly develop in the periportal areas and may eventually lead to subcapsular haematomas or even rupture of the liver. While the compensated form of activation of intravascular coagulation, which is diagnosed by a decrease in antithrombin III and an increase in thrombin-antithrombin III complex (TAT) and the appearance of fibrin, monomers and D-dimers, is found in almost all cases of HELLP syndrome, the decompensated form of intravascular coagulation with prolonged bleeding time (PT, PTT) and drop in fibrinogen is found only in the most severe forms. The development of a decompensation of coagulation correlates with the appearance of severe complications such as liver haematoma, abruptio placentae, renal failure and pulmonary oedema. The best prophylaxis against the development of life-threatening complications is early diagnosis and termination of pregnancy after stabilisation of the maternal condition, consisting of magnesium sulphate infusion, antihypertensive treatment with dihydralazine or calcium antagonists, steroids etc. Severe complications of HELLP syndrome have occasionally been observed in the postpartum period. As prophylaxis against postpartal worsening of HELLP syndrome, curettage of the uterus and continuation of the treatment with calcium antagonists and dexamethasone have been recommended.
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Affiliation(s)
- H Schneider
- Universitäts-Frauenklinik, Bern, Switzerland
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