Epidemiological, level III.
INTRODUCTION: In November 2013, the American College of Obstetricians and Gynecologists released the “Hypertension in Pregnancy” guidelines. Hypertensive disorders are a major source of perinatal morbidity and mortality. Our objective was to assess whether these guidelines affected hypertension management at our institution. METHODS: We performed a secondary analysis of a retrospective cohort study on postpartum hypertension from deliveries from 07/09 to 07/16. Inclusion criteria were the presence of a documented hypertensive disorder. Exclusion criteria were discharge home on antihypertensive medication. Study variables include: gestational age at time of induction, delivery method, antihypertensive treatment, maximum systolic/diastolic blood pressures < 24 and 24-72 hours postpartum, rates of attendance to blood pressure check and postpartum visit. Chi-square test was used for categorical variables and Student T-test was used for continuous variables. “Pre-Guidelines” (7/09-10/13) and “Post-Guidelines” (2/13-7/16) were chosen to allow for policy change within our institution. RESULTS: 470 deliveries were pre-guidelines and 237 deliveries post-guidelines. There are increased rates post-guidelines of intrapartum IV antihypertensive treatment (9.8% vs 3.2%, P<.001) and increased attendance to a postpartum blood pressure check post-guidelines (24.1% vs 15.4%, P<.01). There was no difference in all other variables studied. CONCLUSION: Post-guidelines, our institution noted a statistically significant increase in IV intrapartum antihypertensive therapy and postpartum blood pressure checks within two weeks of delivery. There were no statistically significant differences in the time of induction, delivery method, or antihypertensive treatments despite these guideline changes. Further research needs to be done to study the implications of these guideline changes in respect to perinatal morbidity and mortality.
INTRODUCTION: After exclusion of a traumatic etiology, the development of progressive bloody ascites in a patient usually portends an ominous diagnosis. We present a rare, benign case of progressive bloody ascites due to a gynecologic cause. CASE DESCRIPTION/METHODS: A 40 yo healthy African American lady presented with 3 months of worsening abdominal enlargement and nausea. Physical exam and CT scan of the abdomen revealed massive ascites but were otherwise normal. Bloodwork showed a Hgb of 5.7 gm/dL, and normal PLT. Ferritin level, liver panel, hepatitis and HIV studies were all normal. Paracentesis showed 26,000 RBCs, 88 nucleated cells, 79 cholesterol crystals in pigmented macrophages, a SAAG of 0.5, a fluid protein of 5.5 g/dL, and negative cytology. Further testing showed a negative quantiferon-gold along with a normal CEA level and ANA. A CA-125 was mildly elevated at 82 U/mL. CT scan post-paracentesis showed diffusely thickened peritoneum without nodularity, and a 5 cm right pelvic cystic mass. Diagnostic laparoscopy found 4L bloody ascites and complete fibrotic abdominal structure encasement. Peritoneal biopsies and right oophorectomy showed endometriosis. She was treated with a high dose steroid taper and leuprolide with resolution of her ascites. DISCUSSION: Our case is one of a few reports describing endometriosis inducing encapsulating peritoneal sclerosis (EPS), and is the first to show asymptomatic endometriosis as the etiology. (EPS) is a syndrome of intestinal obstruction from diffuse thickened peritoneum. Typical symptoms are intermittent abdominal pain with nausea and vomiting related to the intermittent obstruction and reduced gut motility. Symptoms average 3.9 years before diagnosis. Primary EPS is extremely rare and while secondary EPS is usually due to chronic peritoneal dialysis (PD). Other causes include malignancy, infections, and various rheumatologic conditions. Management is based on the offending cause (e.g., stopping PD) but is largely empiric, based on case reports and series utilizing prednisolone and/or tamoxifen.
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