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Abstract
BACKGROUND Pre-eclampsia is a pregnancy-specific multi-organ disorder, which is characterised by hypertension and multisystem organ involvement and which has significant maternal and fetal morbidity and mortality. Failure of the placental vascular remodelling and reduced uteroplacental flow form the etiopathological basis of pre-eclampsia. There are several established therapies for pre-eclampsia including antihypertensives and anticonvulsants. Most of these therapies aim at controlling the blood pressure or preventing complications of elevated blood pressure, or both. Epidural therapy aims at blocking the vasomotor tone of the arteries, thereby increasing uteroplacental blood flow. This review was aimed at evaluating the available evidence about the possible benefits and risks of epidural therapy in the management of severe pre-eclampsia, to define the current evidence level of this therapy, and to determine what (if any) further evidence is required. OBJECTIVES To assess the effectiveness, safety and cost of the extended use of epidural therapy for treating severe pre-eclampsia in non-labouring women. This review aims to compare the use of extended epidural therapy with other methods, which include intravenous magnesium sulphate, anticonvulsants other than magnesium sulphate, with or without use of the antihypertensive drugs and adjuncts in the treatment of severe pre-eclampsia.This review only considered the use of epidural anaesthesia in the management of severe pre-eclampsia in the antepartum period and not as pain relief in labour. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (13 July 2017) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing epidural therapy versus traditional therapy for pre-eclampsia in the form of antihypertensives, anticonvulsants, magnesium sulphate, low-dose dopamine, corticosteroids or a combination of these, were eligible for inclusion. Trials using a cluster design, and studies published in abstract form only are also eligible for inclusion in this review. Cross-over trials were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS The two review authors independently assessed trials for inclusion and trial quality. There were no relevant data available for extraction. MAIN RESULTS We included one small study (involving 24 women). The study was a single-centre randomised trial conducted in Mexico. This study compared a control group who received antihypertensive therapy, anticonvulsant therapy, plasma expanders, corticosteroids and dypyridamole with an intervention group that received epidural block instead of the antihypertensives, as well as all the other four drugs. Lumbar epidural block was given using 0.25% bupivacaine, 10 mg bolus and 5 mg each hour on continuous epidural infusion for six hours. This study was at low risk of bias in three domains but was assessed to be high risk of bias in two domains due to lack of allocation concealment and blinding of women and staff, and unclear for random sequence generation and outcome assessor blinding.The included study did not report on any of this review's important outcomes. Meta-analysis was not possible.For the mother, these were: maternal death (death during pregnancy or up to 42 days after the end of the pregnancy, or death more than 42 days after the end of the pregnancy); development of eclampsia or recurrence of seizures; stroke; any serious morbidity: defined as at least one of stroke, kidney failure, liver failure, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulation, pulmonary oedema.For the baby, these were: death: stillbirths (death in utero at or after 20 weeks' gestation), perinatal deaths (stillbirths plus deaths in the first week of life), death before discharge from the hospital, neonatal deaths (death within the first 28 days after birth), deaths after the first 28 days; preterm birth (defined as the birth before 37 completed weeks' gestation); and side effects of the intervention. Reported outcomesThe included study only reported on a single secondary outcome of interest to this review: the Apgar score of the baby at birth and after five minutes and there was no clear difference between the intervention and control groups.The included study also reported a reduction in maternal diastolic arterial pressure. However, the change in maternal mean arterial pressure and systolic arterial pressure, which were the other reported outcomes of this trial, were not significantly different between the two groups. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence from randomised controlled trials to evaluate the effectiveness, safety or cost of using epidural therapy for treating severe pre-eclampsia in non-labouring women.High-quality randomised controlled trials are needed to evaluate the use of epidural agents as therapy for treatment of severe pre-eclampsia. The rationale for the use of epidural is well-founded. However there is insufficient evidence from randomised controlled trials to show that the effect of epidural translates into improved maternal and fetal outcomes. Thus, there is a need for larger, well-designed studies to come to an evidence-based conclusion as to whether the lowering of vasomotor tone by epidural therapy results in better maternal and fetal outcomes and for how long that could be maintained. Another important question that needs to be answered is how long should extended epidural be used to ensure any potential clinical benefits and what could be the associated side effects and costs. Interactions with other modalities of treatment and women's satisfaction could represent other avenues of research.
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Affiliation(s)
- Amita Ray
- DM Wayanad Institute of Medical SciencesDepartment of Obstetrics and GynaecologyNaseera Nagar ,Meppadi (PO)WayanadWayanadKeralaIndia673577
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
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Zenerino C, Nuzzo AM, Giuffrida D, Biolcati M, Zicari A, Todros T, Rolfo A. The HMGB1/RAGE Pro-Inflammatory Axis in the Human Placenta: Modulating Effect of Low Molecular Weight Heparin. Molecules 2017; 22:molecules22111997. [PMID: 29149067 PMCID: PMC6150179 DOI: 10.3390/molecules22111997] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Revised: 11/10/2017] [Accepted: 11/14/2017] [Indexed: 01/11/2023] Open
Abstract
We evaluated whether physiological and pre-eclamptic (PE) placentae, characterized by exacerbated inflammation, presented alterations in pro-inflammatory High Mobility Group Box 1 (HMGB1) and its Receptor of Advanced Glycation End products (RAGE) expression. Moreover, we investigated, in physiological placental tissue, the ability of Low Molecular Weight Heparin (LMWH) to modify HMGB1 structural conformation thus inhibiting RAGE binding and HMGB1/RAGE axis inflammatory activity. HMGB1, RAGE, IL-6 and TNFα (HMGB1/RAGE targets) mRNA expression were assessed by Real Time PCR. HMGB1, RAGE protein levels were assessed by western blot assay. Physiological term placental explants were treated by 0.5 U LMWH for 24 or 48 h. HMGB1 and RAGE expression and association were evaluated in LMWH explants by RAGE immunoprecipitation followed by HMGB1 immunoblot. HMGB1 spatial localization was evaluated by immuofluorescent staining (IF). HMGB1 expression was increased in PE relative to physiological placentae while RAGE was unvaried. 24 h LMWH treatment significantly up-regulated HMGB1 expression but inhibited HMGB1/RAGE complex formation in physiological explants. RAGE expression decreased in treated relative to untreated explants at 48 h. IF showed HMGB1 localization in both cytoplasm and nucleus of mesenchymal and endothelial cells but not in the trophoblast. IL-6 and TNFα gene expression were significantly increased at 24 h relative to controls, while they were significantly down-regulated in 48 h vs. 24 h LMWH explants. Our data depicted a new molecular mechanism through which LMWH exerts its anti-inflammatory effect on PE placentae, underlying the importance of HMGB1/RAGE axis in PE inflammatory response.
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Affiliation(s)
- Cristian Zenerino
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
| | - Anna Maria Nuzzo
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
| | - Domenica Giuffrida
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
| | - Marilisa Biolcati
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
| | - Alessandra Zicari
- Department of Experimental Medicine, Sapienza University of Rome, 00185 Rome, Italy.
| | - Tullia Todros
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
| | - Alessandro Rolfo
- Department of Surgical Sciences, University of Turin, 10126 Turin, Italy.
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Mundle S, Bracken H, Khedikar V, Mulik J, Faragher B, Easterling T, Leigh S, Granby P, Haycox A, Turner MA, Alfirevic Z, Winikoff B, Weeks AD. Foley catheterisation versus oral misoprostol for induction of labour in hypertensive women in India (INFORM): a multicentre, open-label, randomised controlled trial. Lancet 2017; 390:669-680. [PMID: 28668289 DOI: 10.1016/s0140-6736(17)31367-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/19/2017] [Accepted: 02/01/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Between 62 000 and 77 000 women die annually from pre-eclampsia and eclampsia. Prompt delivery, preferably by the vaginal route, is vital for good maternal and neonatal outcomes. Two low-cost interventions-low-dose oral misoprostol tablets and transcervical Foley catheterisation-are already used in low-resource settings. We aimed to compare the relative risks and benefits of these interventions. METHODS We undertook this multicentre, open-label, randomised controlled trial in two public hospitals in Nagpur, India. Women (aged ≥18 years) who were at 20 weeks' gestation or later with a live fetus and required delivery as a result of pre-eclampsia or hypertension were randomly assigned (1:1), via computer-generated block randomisation (block sizes of four, six, and eight) with concealment by use of opaque, sequentially numbered, sealed envelopes, to receive labour induction with either oral misoprostol 25 μg every 2 h (maximum of 12 doses) or a transcervical Foley catheter (silicone, size 18 F with 30 mL balloon). Randomisation was stratified by study centre. The catheter remained in place until active labour started, the catheter fell out, or 12 h had elapsed. If the catheter did not fall out within 12 h, induction continued with artificial membrane rupture and oxytocin, administered through a micro-drip gravity infusion set. Fetal monitoring was by intermittent auscultation. The primary outcome was vaginal birth within 24 h. Due to the nature of the interventions, masking of participants, study investigators, and care providers to group allocation was not possible. We analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT01801410. FINDINGS Between Dec 20, 2013, and June 29, 2015, we randomly assigned 602 women to induction with misoprostol (n=302) or the Foley catheter (n=300; intention-to-treat population). Vaginal birth within 24 h was more common in women in the misoprostol group than in the Foley catheter group (172 [57·0%] vs 141 [47·0%] women; absolute risk difference 10·0%, 95% CI 2·0-17·9; p=0·0136). Rates of uterine hyperstimulation were low in both the misoprostol and Foley catheter groups (two [0·7%] vs one [0·3%] cases; absolute risk difference 0·3%, 95% CI -0·8 to 1·5; p=0·566) and neonatal deaths did not differ significantly between groups (six [2·0%] vs three [1·0%] neonatal deaths; 1·0, -1·04 to 2·97; p=0·322). 17 serious adverse events (3%) were reported during the study: one case of intrapartum convulsion and one case of disseminated intravascular coagulation (both in the Foley group); ten perinatal deaths, including two stillbirths (both in the Foley catheter group) and eight neonatal deaths (n=5 in the misoprostol group and n=3 in the Foley catheter group); and five of neonatal morbidity, comprising birth asphyxia (n=3), septicaemia (n=1), and neonatal convulsion (n=1). INTERPRETATION Oral misoprostol was more effective than transcervical Foley catheterisation for induction of labour in women with pre-eclampsia or hypertension. Future studies are required to assess whether oxytocin augmentation following misoprostol can be replaced by regular doses of oral misoprostol tablets. FUNDING Medical Research Council, Department for International Development, and Wellcome Trust Joint Global Health Trials Scheme.
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Affiliation(s)
- Shuchita Mundle
- Department of Obstetrics and Gynecology, Government Medical College, Nagpur, India
| | | | | | - Jayashree Mulik
- Department of Obstetrics and Gynecology, Government Medical College, Nagpur, India
| | - Brian Faragher
- Medical Statistics Unit, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Thomas Easterling
- Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Simon Leigh
- University of Liverpool Management School, Liverpool, UK
| | - Paul Granby
- University of Liverpool Management School, Liverpool, UK
| | - Alan Haycox
- University of Liverpool Management School, Liverpool, UK
| | - Mark A Turner
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | - Zarko Alfirevic
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK
| | | | - Andrew D Weeks
- Department of Women's and Children's Health, University of Liverpool, Liverpool Women's Hospital, Liverpool, UK.
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Shepherd E, Salam RA, Middleton P, Makrides M, McIntyre S, Badawi N, Crowther CA. Antenatal and intrapartum interventions for preventing cerebral palsy: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2017; 8:CD012077. [PMID: 28786098 PMCID: PMC6483544 DOI: 10.1002/14651858.cd012077.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Cerebral palsy is an umbrella term encompassing disorders of movement and posture, attributed to non-progressive disturbances occurring in the developing fetal or infant brain. As there are diverse risk factors and causes, no one strategy will prevent all cerebral palsy. Therefore, there is a need to systematically consider all potentially relevant interventions for their contribution to prevention. OBJECTIVES To summarise the evidence from Cochrane reviews regarding the effects of antenatal and intrapartum interventions for preventing cerebral palsy. METHODS We searched the Cochrane Database of Systematic Reviews on 7 August 2016, for reviews of antenatal or intrapartum interventions reporting on cerebral palsy. Two authors assessed reviews for inclusion, extracted data, assessed review quality, using AMSTAR and ROBIS, and quality of the evidence, using the GRADE approach. We organised reviews by topic, and summarised findings in text and tables. We categorised interventions as effective (high-quality evidence of effectiveness); possibly effective (moderate-quality evidence of effectiveness); ineffective (high-quality evidence of harm or of lack of effectiveness); probably ineffective (moderate-quality evidence of harm or of lack of effectiveness); and no conclusions possible (low- to very low-quality evidence). MAIN RESULTS We included 15 Cochrane reviews. A further 62 reviews pre-specified the outcome cerebral palsy in their methods, but none of the included randomised controlled trials (RCTs) reported this outcome. The included reviews were high quality and at low risk of bias. They included 279 RCTs; data for cerebral palsy were available from 27 (10%) RCTs, involving 32,490 children. They considered interventions for: treating mild to moderate hypertension (two) and pre-eclampsia (two); diagnosing and preventing fetal compromise in labour (one); preventing preterm birth (four); preterm fetal maturation or neuroprotection (five); and managing preterm fetal compromise (one). Quality of evidence ranged from very low to high. Effective interventions: high-quality evidence of effectiveness There was a reduction in cerebral palsy in children born to women at risk of preterm birth who received magnesium sulphate for neuroprotection of the fetus compared with placebo (risk ratio (RR) 0.68, 95% confidence interval (CI) 0.54 to 0.87; five RCTs; 6145 children). Probably ineffective interventions: moderate-quality evidence of harm There was an increase in cerebral palsy in children born to mothers in preterm labour with intact membranes who received any prophylactic antibiotics versus no antibiotics (RR 1.82, 95% CI 0.99 to 3.34; one RCT; 3173 children). There was an increase in cerebral palsy in children, who as preterm babies with suspected fetal compromise, were born immediately compared with those for whom birth was deferred (RR 5.88, 95% CI 1.33 to 26.02; one RCT; 507 children). Probably ineffective interventions: moderate-quality evidence of lack of effectiveness There was no clear difference in the presence of cerebral palsy in children born to women at risk of preterm birth who received repeat doses of corticosteroids compared with a single course (RR 1.03, 95% CI 0.71 to 1.50; four RCTs; 3800 children). No conclusions possible: low- to very low-quality evidence Low-quality evidence found there was a possible reduction in cerebral palsy for children born to women at risk of preterm birth who received antenatal corticosteroids for accelerating fetal lung maturation compared with placebo (RR 0.60, 95% CI 0.34 to 1.03; five RCTs; 904 children). There was no clear difference in the presence of cerebral palsy with interventionist care for severe pre-eclampsia versus expectant care (RR 6.01, 95% CI 0.75 to 48.14; one RCT; 262 children); magnesium sulphate for pre-eclampsia versus placebo (RR 0.34, 95% CI 0.09 to 1.26; one RCT; 2895 children); continuous cardiotocography for fetal assessment during labour versus intermittent auscultation (average RR 1.75, 95% CI 0.84 to 3.63; two RCTs; 13,252 children); prenatal progesterone for prevention of preterm birth versus placebo (RR 0.14, 95% CI 0.01 to 3.48; one RCT; 274 children); and betamimetics for inhibiting preterm labour versus placebo (RR 0.19, 95% CI 0.02 to 1.63; one RCT; 246 children).Very low-quality found no clear difference for the presence of cerebral palsy with any antihypertensive drug (oral beta-blockers) for treatment of mild to moderate hypertension versus placebo (RR 0.33, 95% CI 0.01 to 8.01; one RCT; 110 children); magnesium sulphate for prevention of preterm birth versus other tocolytic agents (RR 0.13, 95% CI 0.01 to 2.51; one RCT; 106 children); and vitamin K and phenobarbital prior to preterm birth for prevention of neonatal periventricular haemorrhage versus placebo (RR 0.77, 95% CI 0.33 to 1.76; one RCT; 299 children). AUTHORS' CONCLUSIONS This overview summarises evidence from Cochrane reviews on the effects of antenatal and intrapartum interventions on cerebral palsy, and can be used by researchers, funding bodies, policy makers, clinicians and consumers to aid decision-making and evidence translation. We recommend that readers consult the included Cochrane reviews to formally assess other benefits or harms of included interventions, including impacts on risk factors for cerebral palsy (such as the reduction in intraventricular haemorrhage for preterm babies following exposure to antenatal corticosteroids).Magnesium sulphate for women at risk of preterm birth for fetal neuroprotection can prevent cerebral palsy. Prophylactic antibiotics for women in preterm labour with intact membranes, and immediate rather than deferred birth of preterm babies with suspected fetal compromise, may increase the risk of cerebral palsy. Repeat doses compared with a single course of antenatal corticosteroids for women at risk of preterm birth do not clearly impact the risk of cerebral palsy.Cerebral palsy is rarely diagnosed at birth, has diverse risk factors and causes, and is diagnosed in approximately one in 500 children. To date, only a small proportion of Cochrane reviews assessing antenatal and intrapartum interventions have been able to report on this outcome. There is an urgent need for long-term follow-up of RCTs of interventions addressing risk factors for cerebral palsy, and consideration of the use of relatively new interim assessments (including the General Movements Assessment). Such RCTs must be rigorous in their design, and aim for consistency in cerebral palsy outcome measurement and reporting to facilitate pooling of data, to focus research efforts on prevention.
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Affiliation(s)
- Emily Shepherd
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
| | - Rehana A Salam
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiSindPakistan74800
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteAdelaideAustralia
| | - Philippa Middleton
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteAdelaideAustralia
| | - Maria Makrides
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research InstituteAdelaideAustralia
| | - Sarah McIntyre
- University of SydneyResearch Institute, Cerebral Palsy Alliance187 Allambie Road, Allambie HeightsSydneyAustralia2100
| | - Nadia Badawi
- University of SydneyResearch Institute, Cerebral Palsy Alliance187 Allambie Road, Allambie HeightsSydneyAustralia2100
- The Children's Hospital at WestmeadGrace Centre for Newborn CareSydneyAustralia
| | - Caroline A Crowther
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and GynaecologyAdelaideSouth AustraliaAustralia5006
- The University of AucklandLiggins InstitutePrivate Bag 9201985 Park RoadAucklandNew Zealand
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Bernstein PS, Martin JN, Barton JR, Shields LE, Druzin ML, Scavone BM, Frost J, Morton CH, Ruhl C, Slager J, Tsigas EZ, Jaffer S, Menard MK. Consensus Bundle on Severe Hypertension During Pregnancy and the Postpartum Period. J Midwifery Womens Health 2017; 62:493-501. [PMID: 28697534 DOI: 10.1111/jmwh.12647] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 05/26/2017] [Indexed: 11/29/2022]
Abstract
Complications arising from hypertensive disorders of pregnancy are among the leading causes of preventable severe maternal morbidity and mortality. Timely and appropriate treatment has the potential to significantly reduce hypertension-related complications. To assist health care providers in achieving this goal, this patient safety bundle provides guidance to coordinate and standardize the care provided to women with severe hypertension during pregnancy and the postpartum period. This is one of several patient safety bundles developed by multidisciplinary work groups of the National Partnership for Maternal Safety under the guidance of the Council on Patient Safety in Women's Health Care. These safety bundles outline critical clinical practices that should be implemented in every maternity care setting. Similar to other bundles that have been developed and promoted by the Partnership, the hypertension safety bundle is organized into four domains: Readiness, Recognition and Prevention, Response, and Reporting and Systems Learning. Although the bundle components may be adapted to meet the resources available in individual facilities, standardization within an institution is strongly encouraged. This commentary provides information to assist with bundle implementation.
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Affiliation(s)
- Nisha I Parikh
- Cardiovascular Division, Department of Medicine, University of California, San Francisco2Pregnancy and Cardiac Treatment (PACT) Program, University of California, San Francisco3The Preterm Birth Initiative (PTBi), University of California, San Francisco
| | - Juan Gonzalez
- Pregnancy and Cardiac Treatment (PACT) Program, University of California, San Francisco4Maternal Fetal Medicine Division, Department of Obstetrics and Gynecology and Reproductive Sciences, University of California, San Francisco
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Salvig JD. [Pre-eclampsia – a pregnancy complication with many facets]. Ugeskr Laeger 2017; 179:V68968. [PMID: 28416065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Bellad MB, Vidler M, Honnungar NV, Mallapur A, Ramadurg U, Charanthimath U, Katageri G, Bannale S, Kavi A, Karadiguddi C, Sharma S, Lee T, Li J, Payne B, Magee L, von Dadelszen P, Derman R, Goudar SS. Maternal and Newborn Health in Karnataka State, India: The Community Level Interventions for Pre-Eclampsia (CLIP) Trial's Baseline Study Results. PLoS One 2017; 12:e0166623. [PMID: 28107350 PMCID: PMC5249209 DOI: 10.1371/journal.pone.0166623] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 11/01/2016] [Indexed: 01/11/2023] Open
Abstract
Existing vital health statistics registries in India have been unable to provide reliable estimates of maternal and newborn mortality and morbidity, and region-specific health estimates are essential to the planning and monitoring of health interventions. This study was designed to assess baseline rates as the precursor to a community-based cluster randomized control trial (cRCT)–Community Level Interventions for Pre-eclampsia (CLIP) Trial (NCT01911494; CTRI/2014/01/004352). The objective was to describe baseline demographics and health outcomes prior to initiation of the CLIP trial and to improve knowledge of population-level health, in particular of maternal and neonatal outcomes related to hypertensive disorders of pregnancy, in northern districts the state of Karnataka, India. The prospective population-based survey was conducted in eight clusters in Belgaum and Bagalkot districts in Karnataka State from 2013–2014. Data collection was undertaken by adapting the Maternal and Newborn Health registry platform, developed by the Global Network for Women’s and Child Health Studies. Descriptive statistics were completed using SAS and R. During the period of 2013–2014, prospective data was collected on 5,469 pregnant women with an average age of 23.2 (+/-3.3) years. Delivery outcomes were collected from 5,448 completed pregnancies. A majority of the women reported institutional deliveries (96.0%), largely attended by skilled birth attendants. The maternal mortality ratio of 103 (per 100,000 livebirths) was observed during this study, neonatal mortality ratio was 25 per 1,000 livebirths, and perinatal mortality ratio was 50 per 1,000 livebirths. Despite a high number of institutional deliveries, rates of stillbirth were 2.86%. Early enrollment and close follow-up and monitoring procedures established by the Maternal and Newborn Health registry allowed for negligible lost to follow-up. This population-level study provides regional rates of maternal and newborn health in Belgaum and Bagalkot in Karnataka over 2013–14. The mortality ratios and morbidity information can be used in planning interventions and monitoring indicators of effectiveness to inform policy and practice. Comprehensive regional epidemiologic data, such as that provided here, is essential to gauge improvements and challenges in maternal health, as well as track disparities found in rural areas.
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Affiliation(s)
- Mrutynjaya B. Bellad
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
- * E-mail:
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Narayan V. Honnungar
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | | | - Umesh Ramadurg
- S Nijalingappa Medical College, Balgalkot, Karnataka, India
| | - Umesh Charanthimath
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | | | - Shashidhar Bannale
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Avinash Kavi
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Chandrashekhar Karadiguddi
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Beth Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Laura Magee
- Molecular and Clinical Sciences Research Institute, St George’s, University of London and Department of Obstetrics and Gynaecology, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Peter von Dadelszen
- Molecular and Clinical Sciences Research Institute, St George’s, University of London and Department of Obstetrics and Gynaecology, St George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Richard Derman
- Department Obstetrics and Gynaecology and Global Health Research Thomas Jefferson University, Philadelphia, Pennsylvania, United States of America
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE’s Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
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Khowaja AR, Mitton C, Qureshi R, Bryan S, Magee LA, von Dadelszen P, Bhutta ZA. SOCIETAL PERSPECTIVE ON COST DRIVERS FOR HEALTH TECHNOLOGY ASSESSMENT IN SINDH, PAKISTAN. Int J Technol Assess Health Care 2017; 33:192-198. [PMID: 28587686 PMCID: PMC5934709 DOI: 10.1017/s0266462317000320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Understanding cost-drivers and estimating societal costs are important challenges for economic evaluation of health technologies in low- and middle-income countries (LMICs). This study assessed community experiences of health resource usage and perceived cost-drivers from a societal perspective to inform the design of an economic model for the Community Level Interventions for Pre-eclampsia (CLIP) trials. METHODS Qualitative research was undertaken alongside the CLIP trial in two districts of Sindh province, Pakistan. Nine focus groups were conducted with a wide range of stakeholders, including pregnant women, mothers-in-law, husbands, fathers-in-law, healthcare providers at community and health facility-levels, and health decision/policy makers at district-level. The societal perspective included out-of-pocket (OOP), health system, and program implementation costs related to CLIP. Thematic analysis was performed using NVivo software. RESULTS Most pregnant women and male decision makers reported a large burden of OOP costs for in- and out-patient care, informal care from traditional healers, self-medication, childbirth, newborn care, transport to health facility, and missed wages by caretakers. Many healthcare providers identified health system costs associated with human resources for hypertension risk assessment, transport, and communication about patient referrals. Health decision/policy makers recognized program implementation costs (such as the mobile health infrastructure, staff training, and monitoring/supervision) as major investments for the health system. CONCLUSIONS Our investigation of care-seeking practices revealed financial implications for families of pregnant women, and program implementation costs for the health system. The societal perspective provided comprehensive knowledge of cost drivers to guide an economic appraisal of the CLIP trial in Sindh, Pakistan.
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Affiliation(s)
- Asif Raza Khowaja
- Department of Obstetrics and Gynaecology,and British Columbia Children's Hospital,University of British Columbia,Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,Division of Women & Child Health,Aga Khan University
| | - Craig Mitton
- Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,School of Population and Public Health,University of British Columbia,
| | - Rahat Qureshi
- Division of Women & Child Health,Aga Khan University
| | - Stirling Bryan
- Centre for Clinical Epidemiology and Evaluation,Vancouver Coastal Health Research Institute,School of Population and Public Health,University of British Columbia
| | - Laura A Magee
- Molecular and Clinical Sciences Research Institute,St George's,University of London,Department of Obstetrics and Gynaecology,St George's University Hospitals NHS Foundation Trust
| | - Peter von Dadelszen
- Molecular and Clinical Sciences Research Institute,St George's,University of London,Department of Obstetrics and Gynaecology,St George's University Hospitals NHS Foundation Trust
| | - Zulfiqar A Bhutta
- Division of Women & Child Health,Aga Khan University,Program for Global Pediatric Research,Hospital For Sick Children,Toronto
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Wang ZM, Zhu QY, Zhang JF, Wu JL, Yang R, Wang DM. Changes of platelet parameters in early severe preeclampsia. CLIN EXP OBSTET GYN 2017; 44:259-263. [PMID: 29746034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
UNLABELLED 3ummary Objective: The aim of this study was to investigate the changes and clinical values of platelet parameters in different types of severe preeclampsia (SP). MATERIALS AND METHODS The pregnant women with SP or normal conditions were selected for the study, the platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW). and plateletcrit (PCT) were tested every four weeks, starting from 12(+1) to 16 gestational weeks, to compare the difference in platelet parameters between SP and normal pregnant women. RESULTS PLT, MPV, and PDW of the early onset group exhibited statistically significant differences than the normal group from 20(+1) gestational weeks, and PCT of the early onset group exhibited statistically significant differences than the normal group from 28(+1) gestational weeks (p < 0.05); PLT, MPV, and PDW of the late onset group exhibited statistically significant differences than the normal group (p < 0.05), while PCT of the late onset group exhibited no statistically significant difference than the normal group from 12(+1) gestational weeks until childbirth (p > 0.05). The comparison between the early onset group and the late onset group revealed that there existed statistically significant differences in PLT, MPV, and PDW (p < 0.05), but PCT showed no statistically significant difference throughout the pregnancy period (p < 0.05). CONCLUSIONS The changes of platelet parameters in early onset SP patients were earlier than the late onset group, and the difference was statistically significant (p < 0.05). Measuring the platelet parameters could better reveal early-stage SP, thus guiding more personalized clinical treatments to better protect maternal and child safety.
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von Dadelszen P, Magee LA. Preventing deaths due to the hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2016; 36:83-102. [PMID: 27531686 PMCID: PMC5096310 DOI: 10.1016/j.bpobgyn.2016.05.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 05/25/2016] [Accepted: 05/29/2016] [Indexed: 02/08/2023]
Abstract
In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.
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Affiliation(s)
- Peter von Dadelszen
- Institute of Cardiovascular and Cell Sciences, St George's University of London, UK; Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK.
| | - Laura A Magee
- Institute of Cardiovascular and Cell Sciences, St George's University of London, UK; Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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Acestor N, Goett J, Lee A, Herrick TM, Engelbrecht SM, Harner-Jay CM, Howell BJ, Weigl BH. Towards biomarker-based tests that can facilitate decisions about prevention and management of preeclampsia in low-resource settings. Clin Chem Lab Med 2016; 54:17-27. [PMID: 25992513 DOI: 10.1515/cclm-2015-0069] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 04/10/2015] [Indexed: 01/28/2023]
Abstract
In recent years, an increasing amount of literature is emerging on candidate urine and blood-based biomarkers associated with incidence and severity of preeclampsia (PE) in pregnant women. While enthusiasm on the usefulness of several of these markers in predicting PE is evolving, essentially all work so far has focused on the needs of high-resource settings and high-income countries, resulting primarily in multi-parameter laboratory assays based on proteomic and metabolomics analysis techniques. These highly complex methods, however, require laboratory capabilities that are rarely available or affordable in low-resource settings (LRS). The importance of quantifying maternal and perinatal risks and identifying which pregnancies can be safely prolonged is also much greater in LRS, where intensive care facilities that can rapidly respond to PE-related health threats for women and infants are limited. For these reasons, simple, low cost, sensitive, and specific point-of-care (POC) tests are needed that can be performed by antenatal health care providers in LRS and that can facilitate decisions about detection and management of PE. Our study aims to provide a comprehensive systematic review of current and emerging blood and urine biomarkers for PE, not only on the basis of their clinical performance, but also of their suitability to be used in LRS-compatible test formats, such as lateral flow and other variants of POC rapid assays.
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Phillips C, Boyd M. Assessment, Management, and Health Implications of Early-Onset Preeclampsia. Nurs Womens Health 2016; 20:400-414. [PMID: 27520604 DOI: 10.1016/j.nwh.2016.07.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 02/09/2016] [Indexed: 06/06/2023]
Abstract
Early-onset preeclampsia is a serious condition of pregnancy with the potential for adverse maternal and fetal health outcomes. A strong body of evidence supports the need for postpartum follow-up and health counseling, because these women and their offspring are at risk for future cardiovascular disease; nurses play a key role in this education. An understanding of the diagnosis, risk screening for, pathogenesis, and management of severe preeclampsia and its sequelae, such as intrauterine growth restriction and pulmonary edema, enables nurses to develop a comprehensive plan of care that will support women and their families through this challenging and dynamic complication of pregnancy.
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Abstract
Preeclampsia is becoming an increasingly common diagnosis in the developed world and remains a high cause of maternal and fetal morbidity and mortality in the developing world. Delay in childbearing in the developed world feeds into the risk factors associated with preeclampsia, which include older maternal age, obesity, and/or vascular diseases. Inadequate prenatal care partially explains the persistent high prevalence in the developing world. In this review, we begin by presenting the most recent concepts in the pathogenesis of preeclampsia. Upstream triggers of the well described angiogenic pathways, such as the heme oxygenase and hydrogen sulfide pathways, as well as the roles of autoantibodies, misfolded proteins, nitric oxide, and oxidative stress will be described. We also detail updated definitions, classification schema, and treatment targets of hypertensive disorders of pregnancy put forth by obstetric and hypertensive societies throughout the world. The shift has been made to view preeclampsia as a systemic disease with widespread endothelial damage and the potential to affect future cardiovascular diseases rather than a self-limited occurrence. At the very least, we now know that preeclampsia does not end with delivery of the placenta. We conclude by summarizing the latest strategies for prevention and treatment of preeclampsia. A better understanding of this entity will help in the care of at-risk women before delivery and for decades after.
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Affiliation(s)
- Elizabeth Phipps
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
| | - Devika Prasanna
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
| | - Wunnie Brima
- Department of Medicine, James J. Peters Veterans Affairs Medical Center, New York, New York
| | - Belinda Jim
- Department of Nephrology/Medicine, Jacobi Medical Center at Albert Einstein College of Medicine, Bronx, New York; and
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Ituk US, Cooter M, Habib AS. Retrospective comparison of ephedrine and phenylephrine for the treatment of spinal anesthesia induced hypotension in pre-eclamptic patients. Curr Med Res Opin 2016; 32:1083-6. [PMID: 26928367 DOI: 10.1185/03007995.2016.1159953] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To compare neonatal acid base status in parturients who underwent cesarean delivery and received either ephedrine or phenylephrine boluses for the treatment of spinal anesthesia induced hypotension. RESEARCH DESIGN AND METHODS After institutional review board approval, the perioperative database of the University of Iowa Hospitals and Clinics was used to identify all women diagnosed with pre-eclampsia and had cesarean delivery under spinal anesthesia for the period 1 January 2005 to 31 July 2014. Data retrieved included patient demographics, indication for cesarean delivery, severity of pre-eclampsia, dose of vasopressor, neonatal umbilical artery pH and Apgar scores. MAIN OUTCOME MEASURES Primary outcome was umbilical artery pH. RESULTS Data for 146 patients was included in the analysis. Ephedrine was used in 57 patients (group E) and phenylephrine in 89 (group PE) patients. The median umbilical artery pH was 7.30 (IQR 7.20-7.30) and 7.30 (IQR 7.20-7.30) in the ephedrine and phenylephrine groups respectively (P = 0.41). Non-reassuring fetal heart trace was the only factor significantly associated with lower umbilical artery pH on multivariable regression analysis (β = -0.09, P = 0.002). CONCLUSIONS We found no difference in neonatal umbilical artery pH between ephedrine and phenylephrine when used to treat spinal anesthesia induced hypotension during cesarean delivery in pre-eclamptic patients. Limitations of the study include its retrospective single center design and the fact that the choice of vasopressor was not randomized.
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Affiliation(s)
- Unyime S Ituk
- a Department of Anesthesia , University of Iowa , Iowa City , IA , USA
| | - Mary Cooter
- b Department of Anesthesiology , Duke University Medical Center , Durham , NC , USA
| | - Ashraf S Habib
- b Department of Anesthesiology , Duke University Medical Center , Durham , NC , USA
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Klein E, Schlembach D, Ramoni A, Langer E, Bahlmann F, Grill S, Schaffenrath H, van der Does R, Messinger D, Verhagen-Kamerbeek WDJ, Reim M, Hund M, Stepan H. Influence of the sFlt-1/PlGF Ratio on Clinical Decision-Making in Women with Suspected Preeclampsia. PLoS One 2016; 11:e0156013. [PMID: 27243815 PMCID: PMC4887119 DOI: 10.1371/journal.pone.0156013] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Accepted: 05/09/2016] [Indexed: 12/03/2022] Open
Abstract
Objective To evaluate the influence of the soluble fms-like tyrosine kinase 1/placental growth factor ratio in physicians’ decision making in pregnant women with signs and symptoms of preeclampsia in routine clinical practice. Methods A multicenter, prospective, open, non-interventional study enrolled pregnant women presenting with preeclampsia signs and symptoms in several European perinatal care centers. Before the soluble fms-like tyrosine kinase 1/placental growth factor ratio result was known, physicians documented intended clinical procedures using an iPad® application (data locked/time stamped). After the result was available, clinical decisions were confirmed or revised and documented. An independent adjudication committee evaluated the appropriateness of decisions based on maternal/fetal outcomes. Clinician decision making with regard to hospitalization was the primary outcome. Results In 16.9% of mothers (20/118) the hospitalization decision was changed after knowledge of the ratio. In 13 women (11.0%), the initial decision to hospitalize was changed to no hospitalization. In seven women (5.9%) the revised decision was hospitalization. All revised decisions were considered appropriate by the panel of adjudicators (McNemar test; p < 0.0001). Conclusions The use of the soluble fms-like tyrosine kinase 1/placental growth factor test influenced clinical decision making towards appropriate hospitalization in a considerable proportion of women with suspected preeclampsia. This is the first study to demonstrate the impact of angiogenic biomarkers on decision making in a routine clinical practice.
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Affiliation(s)
- Evelyn Klein
- Department of Gynecology and Obstetrics, Klinikum Rechts der Isar, TU München, Munich, Germany
| | | | - Angela Ramoni
- Department of Obstetrics and Gynecology, University Hospital of Innsbruck, Innsbruck, Austria
| | - Elena Langer
- Department of Obstetrics, Leipzig University, Leipzig, Germany
| | - Franz Bahlmann
- Department of Obstetrics, Bürgerhospital, Frankfurt, Germany
| | - Sabine Grill
- Department of Gynecology and Obstetrics, Klinikum Rechts der Isar, TU München, Munich, Germany
| | - Helene Schaffenrath
- Department of Obstetrics and Gynecology, University Hospital of Innsbruck, Innsbruck, Austria
| | | | | | | | - Manfred Reim
- Medical and Scientific Affairs, Roche Diagnostics GmbH, Penzberg, Germany
| | - Martin Hund
- Medical and Scientific Affairs, Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Holger Stepan
- Department of Obstetrics, Leipzig University, Leipzig, Germany
- * E-mail:
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Abstract
Pre-eclampsia affects 3-5% of pregnancies and is traditionally diagnosed by the combined presentation of high blood pressure and proteinuria. New definitions also include maternal organ dysfunction, such as renal insufficiency, liver involvement, neurological or haematological complications, uteroplacental dysfunction, or fetal growth restriction. When left untreated, pre-eclampsia can be lethal, and in low-resource settings, this disorder is one of the main causes of maternal and child mortality. In the absence of curative treatment, the management of pre-eclampsia involves stabilisation of the mother and fetus, followed by delivery at an optimal time. Although algorithms to predict pre-eclampsia are promising, they have yet to become validated. Simple preventive measures, such as low-dose aspirin, calcium, and diet and lifestyle interventions, show potential but small benefit. Because pre-eclampsia predisposes mothers to cardiovascular disease later in life, pregnancy is also a window for future health. A collaborative approach to discovery and assessment of the available treatments will hasten our understanding of pre-eclampsia and is an effort much needed by the women and babies affected by its complications.
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Affiliation(s)
- Ben W J Mol
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, SA, Australia.
| | - Claire T Roberts
- The Robinson Research Institute, School of Paediatrics and Reproductive Health, University of Adelaide, SA, Australia
| | - Shakila Thangaratinam
- Women's Health Research Unit, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Laura A Magee
- BC Women's Hospital and Health Centre, Vancouver, BC, Canada
| | | | - G Justus Hofmeyr
- Effective Care Research Unit, University of the Witwatersrand, University of Fort Hare, and Eastern Cape Department of Health, East London, South Africa
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119
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Vázquez-Rodríguez JG, Rico-Trejo EI. [Maternal complications in preeclamptic patients with hyperuricemia managed in Intensive Care Unit]. Ginecol Obstet Mex 2016; 84:143-149. [PMID: 27424440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Hyperuricemia is a factor related to a higher frequency of complications in patients with preeclampsia. OBJECTIVES To determine maternal complications in preeclamptic patients with hyperuricemia managed in the intensive care unit of a high-specialty hospital. MATERIAL AND METHODS Cross-sectional study. Clinical files of 127 preeclamptic patients with criteria of severe disease were reviewed. Maternal complications were studied only in patients with hyperuricemia defined as a serum uric acid (UA) level > 4 mg/dL upon admission. Descriptive statistics were used. RESULTS Frequency of patients with hyperuricemia was 88.1% (112 cases). Median value of UA was 6.6 ± 1.5 mg/dL (range 4.6-12.4), maternal age 28.1 ± 5.98 years, parity 2 and gestational age 32.9 ± 3.7 weeks. Cesarean section was performed in 98.21%. Frequency of maternal complications was 50% (56 cases): HELLP syndrome 40.1% (45 cases), acute renal injury 6.2% (7 cases), abruptio placentae 1 .7% (2 cases), hemorrhage due to uterine atony 0.8% (1 case) and acute pulmonary edema 0.8% (1 case). There were no cases of multiorgan failure syndrome and maternal mortality was 0%. None of the patients experienced worsening of their condition. CONCLUSIONS There was an elevated frequency of patients with hyperuricemia and maternal complications. Reported complications were different from those reported in previous studies. All patients were successfully intervened with the administered medical treatment and may be a reflection of the beneficial effect of intensive care treatment.
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Affiliation(s)
- Anna Dietl
- Department of Obstetrics and Gynaecology, University Medical Centre Freiburg, 79106 Freiburg, Germany.
| | - Juliane Farthmann
- Department of Obstetrics and Gynaecology, University Medical Centre Freiburg, 79106 Freiburg, Germany
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121
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Broekhuijsen K, Groen H, van den Berg PP, Mol BWJ, Franssen MTM, Langenveld J. Gestational hypertension and advanced maternal age - Authors' reply. Lancet 2015; 386:1628. [PMID: 26595632 DOI: 10.1016/s0140-6736(15)00533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Kim Broekhuijsen
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, Netherlands.
| | - Henk Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Paul P van den Berg
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, Netherlands
| | - Ben W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - Maureen T M Franssen
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, 9700 RB Groningen, Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Heerlen, Netherlands
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Thangaratinam S. Immediate delivery in women with non-severe hypertensive disorders at 34-37 weeks' gestation does not reduce maternal complications, and increases neonatal risks more than under expectant management. Evid Based Med 2015; 20:184-185. [PMID: 26265745 DOI: 10.1136/ebmed-2015-110219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Shakila Thangaratinam
- Women's Health Research Unit, Centre for Primary Care and Public Health, Blizard Institute, Barts and The London School of Medicine and Dentistry, London, UK
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Abstract
BACKGROUND Pre-eclampsia is a pregnancy complication affecting both mother and fetus. Although there is no proven effective method to prevent pre-eclampsia, early identification of women at risk of pre-eclampsia could enhance appropriate application of antenatal care, management and treatment. Very little is known about the cost effectiveness of these and other tests for pre-eclampsia, mainly because there is no clear treatment path. The aim of this study was to provide a comprehensive overview of the existing evidence on the health economics of screening, diagnosis and treatment options in pre-eclampsia. METHODS We searched three electronic databases (PubMed, EMBASE and the Cochrane Library) for studies on screening, diagnosis, treatment or prevention of pre-eclampsia, published between 1994 and 2014. Only full papers written in English containing complete economic assessments in pre-eclampsia were included. RESULTS From an initial total of 138 references, six papers fulfilled the inclusion criteria. Three studies were on the cost effectiveness of treatment of pre-eclampsia, two of which evaluated magnesium sulphate for prevention of seizures and the third evaluated the cost effectiveness of induction of labour versus expectant monitoring. The other three studies were aimed at screening and diagnosis, in combination with subsequent preventive measures. The two studies on magnesium sulphate were equivocal on the cost effectiveness in non-severe cases, and the other study suggested that induction of labour in term pre-eclampsia was more cost effective than expectant monitoring. The screening studies were quite diverse in their objectives as well as in their conclusions. One study concluded that screening is probably not worthwhile, while two other studies stated that in certain scenarios it may be cost effective to screen all pregnant women and prophylactically treat those who are found to be at high risk of developing pre-eclampsia. DISCUSSION This study is the first to provide a comprehensive overview on the economic aspects of pre-eclampsia in its broadest sense, ranging from screening to treatment options. The main limitation of the present study lies in the variety of topics in combination with the limited number of papers that could be included; this restricted the comparisons that could be made. In conclusion, novel biomarkers in screening for and diagnosing pre-eclampsia show promise, but their accuracy is a major driver of cost effectiveness, as is prevalence. Universal screening for pre-eclampsia, using a biomarker, will be feasible only when accuracy is significantly increased.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
| | - Maarten J Postma
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands
- Health Technology Assessment Unit, Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands
| | - Philip N Baker
- Institute of Science and Technology in Medicine, Keele University, Staffordshire, UK
| | - Antoinette D I van Asselt
- Unit of PharmacoEpidemiology and PharmacoEconomics, Department of Pharmacy, University of Groningen, A. Deusinglaan 1, 9713 AV, Groningen, The Netherlands.
- Health Technology Assessment Unit, Department of Epidemiology, University Medical Center Groningen, Groningen, The Netherlands.
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Spencer L, Bubner T, Bain E, Middleton P. Screening and subsequent management for thyroid dysfunction pre-pregnancy and during pregnancy for improving maternal and infant health. Cochrane Database Syst Rev 2015; 2015:CD011263. [PMID: 26387772 PMCID: PMC9233937 DOI: 10.1002/14651858.cd011263.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Thyroid dysfunction pre-pregnancy and during pregnancy (both hyper- and hypothyroidism) is associated with increased risk of adverse outcomes for mothers and infants in the short- and long-term. Managing the thyroid dysfunction (e.g. thyroxine for hypothyroidism, or antithyroid medication for hyperthyroidism) may improve outcomes. The best method of screening to identify and subsequently manage thyroid dysfunction pre-pregnancy and during pregnancy is unknown. OBJECTIVES To assess the effects of different screening methods (and subsequent management) for thyroid dysfunction pre-pregnancy and during pregnancy on maternal and infant outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (14 July 2015) and reference lists of retrieved studies. SELECTION CRITERIA Randomised or quasi-randomised controlled trials, comparing any screening method (e.g. tool, program, guideline/protocol) for detecting thyroid dysfunction (including hypothyroidism, hyperthyroidism, and/or thyroid autoimmunity) pre-pregnancy or during pregnancy with no screening, or alternative screening methods. DATA COLLECTION AND ANALYSIS Two review authors independently assessed eligibility of studies, extracted and checked data accuracy, and assessed the risk of bias of included studies. MAIN RESULTS We included two randomised controlled trials (involving 26,408 women) - these trials were considered to be at low risk of bias. Universal screening (screening all women) versus case finding (screening only those at perceived increased risk) in pregnancy for thyroid dysfunctionOne trial (4562 women) compared universal screening with case finding for thyroid dysfunction. Before 11 weeks' gestation, women in the universal screening group, and 'high-risk' women in the case finding group had their sera tested for TSH (thyroid stimulating hormone), fT4 (free thyroxine) and TPO-Ab (thyroid peroxidase antibody); women with hypothyroidism (TSH > 2.5 mIU/litre) received levothyroxine; women with hyperthyroidism (undetectable TSH and elevated fT4) received antithyroid medication.In regards to this review's primary outcomes, compared with the case finding group, more women in the universal screening group were diagnosed with hypothyroidism (risk ratio (RR) 3.15, 95% confidence interval (CI) 1.91 to 5.20; 4562 women; GRADE: high quality evidence), with a trend towards more women being diagnosed with hyperthyroidism (RR 4.50, 95% CI 0.97 to 20.82; 4562 women; P = 0.05; GRADE: moderate quality evidence). No clear differences were seen in the risks of pre-eclampsia (RR 0.87, 95% CI 0.64 to 1.18; 4516 women; GRADE: moderate quality evidence), or preterm birth (RR 0.99, 95% CI 0.80 to 1.24; 4516 women; GRADE: high quality evidence) between groups. This trial did not report on neurosensory disability for the infant as a child.Considering this review's secondary outcomes, more women in the universal screening group received pharmacological treatment for thyroid dysfunction (RR 3.15, 95% CI 1.91 to 5.20; 4562 women). No clear differences between groups were observed for miscarriage (RR 0.90, 95% CI 0.68 to 1.19; 4516 women; GRADE: moderate quality evidence), fetal and neonatal death (RR 0.92, 95% CI 0.42 to 2.02; 4516 infants; GRADE: moderate quality evidence), or other secondary outcomes: pregnancy-induced hypertension, gestational diabetes, congestive heart failure, thyroid storm, mode of birth (caesarean section), preterm labour, placental abruption, respiratory distress syndrome, low birthweight, neonatal intensive care unit admission, or other congenital malformations. The trial did not report on a number of outcomes including adverse effects associated with the intervention. Universal screening versus no screening in pregnancy for hypothyroidismOne trial (21,846 women) compared universal screening with no screening for hypothyroidism. Before 15 + 6 weeks' gestation, women in the universal screening group had their sera tested; women who screened 'positive' (TSH > 97.5th percentile, fT4 < 2.5th percentile, or both) received levothyroxine.Considering primary review outcomes, compared with the no screening group, more women in the universal screening screened 'positive' for hypothyroidism (RR 998.18, 95% CI 62.36 to 15,978.48; 21,839 women; GRADE: high quality evidence). No data were provided for the outcome pre-eclampsia, and for preterm birth, the trial reported rates of 5.6% and 7.9% for the screening and no screening groups respectively (it was unclear if these percentages related to the entire cohort or women who screened positive). No clear difference was seen for neurosensory disability for the infant as a child (three-year follow-up IQ score < 85) (RR 0.85, 95% CI 0.60 to 1.22; 794 infants; GRADE: moderate quality evidence).More women in the universal screening group received pharmacological treatment for thyroid dysfunction (RR 1102.90, 95% CI 69.07 to 17,610.46; 1050 women); 10% had their dose lowered because of low TSH, high fT4 or minor side effects. No clear differences were observed for other secondary outcomes, including developmental delay/intellectual impairment at three years. Most of our secondary outcomes, including miscarriage, fetal or neonatal death were not reported. AUTHORS' CONCLUSIONS Based on the existing evidence, though universal screening for thyroid dysfunction in pregnancy increases the number of women diagnosed with hypothyroidism who can be subsequently treated, it does not clearly impact (benefit or harm) maternal and infant outcomes.While universal screening versus case finding for thyroid dysfunction increased diagnosis and subsequent treatment, we found no clear differences for the primary outcomes: pre-eclampsia or preterm birth. No clear differences were seen for secondary outcomes, including miscarriage and fetal or neonatal death; data were lacking for the primary outcome: neurosensory disability for the infant as a child, and for many secondary outcomes. Though universal screening versus no screening for hypothyroidism similarly increased diagnosis and subsequent treatment, no clear difference was seen for the primary outcome: neurosensory disability for the infant as a child (IQ < 85 at three years); data were lacking for the other primary outcomes: pre-eclampsia and preterm birth, and for the majority of secondary outcomes.For outcomes assessed using the GRADE approach the evidence was considered to be moderate or high quality, with any downgrading of the evidence based on the presence of wide confidence intervals crossing the line of no effect.More evidence is needed to assess the benefits or harms of different screening methods for thyroid dysfunction in pregnancy, on maternal, infant and child health outcomes. Future trials should assess impacts on use of health services and costs, and be adequately powered to evaluate the effects on short- and long-term outcomes.
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Affiliation(s)
- Laura Spencer
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSAAustralia5006
| | - Tanya Bubner
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSAAustralia5006
| | - Emily Bain
- The University of AdelaideARCH: Australian Research Centre for Health of Women and Babies, Robinson Research Institute, Discipline of Obstetrics and Gynaecology72 King William RoadAdelaideSAAustralia5006
| | - Philippa Middleton
- The University of AdelaideWomen's and Children's Research InstituteWomen's and Children's Hospital72 King William RoadAdelaideSouth AustraliaAustralia5006
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Bailit JL, Grobman WA, McGee P, Reddy UM, Wapner RJ, Varner MW, Thorp JM, Leveno KJ, Iams JD, Tita ATN, Saade G, Sorokin Y, Rouse DJ, Blackwell SC. Does the presence of a condition-specific obstetric protocol lead to detectable improvements in pregnancy outcomes? Am J Obstet Gynecol 2015; 213:86.e1-86.e6. [PMID: 25659468 DOI: 10.1016/j.ajog.2015.01.055] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 12/16/2014] [Accepted: 01/29/2015] [Indexed: 11/16/2022]
Abstract
OBJECTIVE We sought to evaluate whether the presence of condition-specific obstetric protocols within a hospital was associated with better maternal and neonatal outcomes. STUDY DESIGN This was a cohort study of a random sample of deliveries performed at 25 hospitals over 3 years. Condition-specific protocols were collected from all hospitals and categorized independently by 2 authors. Data on maternal and neonatal outcomes, as well as data necessary for risk adjustment were collected. Risk-adjusted outcomes were compared according to whether the patient delivered in a hospital with condition-specific obstetric protocols at the time of delivery. RESULTS Hemorrhage-specific protocols were not associated with a lower rate of postpartum hemorrhage or with fewer cases of estimated blood loss >1000 mL. Similarly, in the presence of a shoulder dystocia protocol, there were no differences in the frequency of shoulder dystocia or number of shoulder dystocia maneuvers used. Conversely, preeclampsia-specific protocols were associated with fewer intensive care unit admissions (odds ratio, 0.28; 95% confidence interval, 0.18-0.44) and fewer cases of severe maternal hypertension (odds ratio, 0.86; 95% confidence interval, 0.77-0.96). CONCLUSION The presence of condition-specific obstetric protocols was not consistently shown to be associated with improved risk-adjusted outcomes. Our study would suggest that the presence or absence of a protocol does not matter and regulations to require protocols are not fruitful.
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Affiliation(s)
- Jennifer L Bailit
- Department of Obstetrics and Gynecology, Case Western Reserve University-MetroHealth Medical Center, Cleveland, OH.
| | - William A Grobman
- Department of Obstetrics and Gynecology, Prentice Women's Hospital, Northwestern University, Chicago, IL
| | - Paula McGee
- Department of Obstetrics and Gynecology, George Washington University Biostatistics Center, Washington, DC
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, College of Physicians and Surgeons, Columbia University, New York, NY
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health Sciences Center, Salt Lake City, UT
| | - John M Thorp
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC
| | - Kenneth J Leveno
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Jay D Iams
- Department of Obstetrics and Gynecology, Ohio State University, Columbus, OH
| | - Alan T N Tita
- Department of Obstetrics and Gynecology, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - George Saade
- Department of Obstetrics and Gynecology, University of Texas Medical Branch, Galveston, TX
| | - Yoram Sorokin
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI
| | - Dwight J Rouse
- Department of Obstetrics and Gynecology, Alpert Medical School, Brown University, Providence, RI
| | - Sean C Blackwell
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, TX
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Thornton J, Duley L. Gestational hypertension before term: observe or deliver? Lancet 2015; 385:2441-3. [PMID: 25817376 DOI: 10.1016/s0140-6736(14)62454-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Affiliation(s)
- Jim Thornton
- University of Nottingham, Nottingham, UK; Maternity Unit, City Hospital, Nottingham NG5 1PB, UK.
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Broekhuijsen K, van Baaren GJ, van Pampus MG, Ganzevoort W, Sikkema JM, Woiski MD, Oudijk MA, Bloemenkamp KWM, Scheepers HCJ, Bremer HA, Rijnders RJP, van Loon AJ, Perquin DAM, Sporken JMJ, Papatsonis DNM, van Huizen ME, Vredevoogd CB, Brons JTJ, Kaplan M, van Kaam AH, Groen H, Porath MM, van den Berg PP, Mol BWJ, Franssen MTM, Langenveld J. Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial. Lancet 2015; 385:2492-501. [PMID: 25817374 DOI: 10.1016/s0140-6736(14)61998-x] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND There is little evidence to guide the management of women with hypertensive disorders in late preterm pregnancy. We investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. METHODS We did an open-label, randomised controlled trial, in seven academic hospitals and 44 non-academic hospitals in the Netherlands. Women with non-severe hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomly allocated to either induction of labour or caesarean section within 24 h (immediate delivery) or a strategy aimed at prolonging pregnancy until 37 weeks of gestation (expectant monitoring). The primary outcomes were a composite of adverse maternal outcomes (thromboembolic disease, pulmonary oedema, eclampsia, HELLP syndrome, placental abruption, or maternal death), and neonatal respiratory distress syndrome, both analysed by intention-to-treat. This study is registered with the Netherlands Trial Register (NTR1792). FINDINGS Between March 1, 2009, and Feb 21, 2013, 897 women were invited to participate, of whom 703 were enrolled and randomly assigned to immediate delivery (n=352) or expectant monitoring (n=351). The composite adverse maternal outcome occurred in four (1·1%) of 352 women allocated to immediate delivery versus 11 (3·1%) of 351 women allocated to expectant monitoring (relative risk [RR] 0·36, 95% CI 0·12-1·11; p=0·069). Respiratory distress syndrome was diagnosed in 20 (5·7%) of 352 neonates in the immediate delivery group versus six (1·7%) of 351 neonates in the expectant monitoring group (RR 3·3, 95% CI 1·4-8·2; p=0·005). No maternal or perinatal deaths occurred. INTERPRETATION For women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes. However, it significantly increases the risk of neonatal respiratory distress syndrome, therefore, routine immediate delivery does not seem justified and a strategy of expectant monitoring until the clinical situation deteriorates can be considered. FUNDING ZonMw.
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Affiliation(s)
- Kim Broekhuijsen
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands.
| | - Gert-Jan van Baaren
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - Maria G van Pampus
- Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis, Amsterdam, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Academic Medical Centre, Amsterdam, Netherlands
| | - J Marko Sikkema
- Department of Obstetrics and Gynaecology, ZGT Almelo, Almelo, Netherlands
| | - Mallory D Woiski
- Department of Obstetrics and Gynaecology, Radboud University Medical Center, Nijmegen, Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics, University Medical Center Utrecht, Utrecht, Netherlands
| | | | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Grow, School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, Netherlands
| | - Henk A Bremer
- Department of Obstetrics and Gynaecology, Reinier de Graaf Gasthuis, Delft, Netherlands
| | - Robbert J P Rijnders
- Department of Obstetrics and Gynaecology, Jeroen Bosch Hospital, 's-Hertogenbosch, Netherlands
| | - Aren J van Loon
- Department of Obstetrics and Gynaecology, Martini Hospital, Groningen, Netherlands
| | - Denise A M Perquin
- Department of Obstetrics and Gynaecology, Medical Center Leeuwarden, Leeuwarden, Netherlands
| | - Jan M J Sporken
- Department of Obstetrics and Gynaecology, Canisius-Wilhelmina Hospital, Nijmegen, Netherlands
| | | | - Marloes E van Huizen
- Department of Obstetrics and Gynaecology, HagaZiekenhuis, The Hague, Netherlands
| | - Corla B Vredevoogd
- Department of Obstetrics and Gynaecology, Medical Center Haaglanden, The Hague, Netherlands
| | - Jozien T J Brons
- Department of Obstetrics and Gynaecology, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mesrure Kaplan
- Department of Obstetrics and Gynaecology, Röpcke-Zweers Hospital, Hardenberg, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Academic Medical Centre, Amsterdam, Netherlands
| | - Henk Groen
- Department of Epidemiology-HPC FA40, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Martina M Porath
- Department of Obstetrics and Gynaecology, Maxima Medical Center, Veldhoven, Netherlands
| | - Paul P van den Berg
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Ben W J Mol
- The Robinson Institute, School of Paediatrics and Reproductive Health, University of Adelaide, Adelaide, SA, Australia
| | - Maureen T M Franssen
- Department of Obstetrics and Gynaecology, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Josje Langenveld
- Department of Obstetrics and Gynaecology, Atrium Medical Centre Parkstad, Heerlen, Netherlands
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Priso EB, Njamen TN, Tchente CN, Kana AJ, Landry T, Tchawa UFN, Hentchoya R, Beyiha G, Halle MP, Aminde L, Dzudie A. Trend in admissions, clinical features and outcome of preeclampsia and eclampsia as seen from the intensive care unit of the Douala General Hospital, Cameroon. Pan Afr Med J 2015; 21:103. [PMID: 26523163 PMCID: PMC4613832 DOI: 10.11604/pamj.2015.21.103.7061] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2015] [Accepted: 05/25/2015] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Hypertensive disorders in pregnancy (HDP) are a major cause of maternal morbidity and mortality. We aimed at determining the trends in admission, profiles and outcomes of women admitted for preeclampsia and eclampsia to an intensive care unit (ICU) in Cameroon. METHODS A retrospective study involving 74 women admitted to the ICU of the Douala General Hospital for severe preeclampsia and eclampsia from January 2007 to December 2014. Clinical profiles and outcome data were obtained from patient records. Statistical analysis was performed using SPSS version 20. RESULTS Of the 74 women admitted to ICU (72.5% for eclampsia), mean age was 30.2years and the majority (90.5%) were aged 20-39 years. While overall trend in admission for HDP increased over the years, mortality remained stable. Mean gestational age (GA) on admission was 34.0 weeks (33.5 for preeclampsia vs 35.4 for eclampsia). Most patients presented with complications of which acute kidney injury was most frequent (66.7%). Visual problems were more common in patients with eclampsia compared to preeclampsia (p = 0.01). HELLP syndrome and acute pulmonary oedema (APO) were predominant in patients with preeclampsia, while cerebrovascular accidents (CVA) occurred more in patients with eclampsia. Overall mortality was 24.3%. Presence of APO was associated with mortality in multivariable analysis (O.R.= 0.03, p = 0,01). CONCLUSION Trends in admission for HDP were increasing with high but stable mortality rate. Patients presented late most of whom with complications. Interventions improving antenatal care services and multidisciplinary management approach may improve maternal outcome in patients with HDP.
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Affiliation(s)
- Eugene Belley Priso
- Department of Obstetrics and Gynaecology, Douala General Hospital, Douala, Cameroon
| | | | - Charlotte Nguefack Tchente
- Department of Obstetrics and Gynaecology, Douala General Hospital, Douala, Cameroon ; Department of Surgery and Specialties, University of Douala, Douala, Cameroon
| | | | - Tchuenkam Landry
- General intensive care unit, Douala General Hospital, Douala, Cameroon
| | | | - Romuald Hentchoya
- General intensive care unit, Douala General Hospital, Douala, Cameroon
| | - Gerard Beyiha
- General intensive care unit, Douala General Hospital, Douala, Cameroon
| | - Marie Patrice Halle
- Department of Nephrology and Hemodialysis, Douala General Hospital, Douala, Cameroon
| | - Leopold Aminde
- Clinical Research Education, Networking and Consultancy (CRENC), Douala, Cameroon
| | - Anastase Dzudie
- Clinical Research Education, Networking and Consultancy (CRENC), Douala, Cameroon ; Department of Medicine, Faculty of Health Sciences, University of Cape Town, South Africa ; Cardiology unit, Department of Internal Medicine, Douala General Hospital and Faculty of Health Sciences, University of Buea, Buea, Cameroon
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Khowaja AR, Mitton C, Bryan S, Magee LA, Bhutta ZA, von Dadelszen P. Economic evaluation of Community Level Interventions for Pre-eclampsia (CLIP) in South Asian and African countries: a study protocol. Implement Sci 2015; 10:76. [PMID: 26007682 PMCID: PMC4446068 DOI: 10.1186/s13012-015-0266-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 05/15/2015] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Globally, hypertensive disorders of pregnancy, particularly pre-eclampsia and eclampsia, are the leading cause of maternal and neonatal mortality, and impose substantial burdens on the families of pregnant women, their communities, and healthcare systems. The Community Level Interventions for Pre-eclampsia (CLIP) Trial evaluates a package of care applied at both community and primary health centres to reduce maternal and perinatal disabilities and deaths resulting from the failure to identify and manage pre-eclampsia at the community level. Economic evaluation of health interventions can play a pivotal role in priority setting and inform policy decisions for scale-up. At present, there is a paucity of published literature on the methodology of economic evaluation of large, multi-country, community-based interventions in the area of maternal and perinatal health. This study protocol describes the application of methodology for economic evaluation of the CLIP in South Asia and Africa. METHODS A mixed-design approach i.e. cost-effectiveness analysis (CEA) and qualitative thematic analysis will be used alongside the trial to prospectively evaluate the economic impact of CLIP from a societal perspective. Data on health resource utilization, costs, and pregnancy outcomes will be collected through structured questionnaires embedded into the pregnancy surveillance, cross-sectional survey and budgetary reviews. Qualitative data will be collected through focus groups (FGs) with pregnant women, household male-decision makers, care providers, and district level health decision makers. The incremental cost-effectiveness ratio will be calculated for healthcare system and societal perspectives, taking into account the country-specific model inputs (costs and outcome) from the CLIP Trial. Emerging themes from FGs will inform the design of the model, and help to interpret findings of the CEA. DISCUSSION The World Health Organization (WHO) strongly recommends cost-effective interventions as a key aspect of achieving Millennium Development Goal (MDG)-5 (i.e. 75 % reduction in maternal mortality from 1990 levels by 2015). To date, most cost-effectiveness studies in this field have focused specifically on the diagnostic and clinical management of pre-eclampsia, yet rarely on community-based interventions in low-and-middle-income countries (LMICs). This study protocol will be of interest to public health scientists and health economists undertaking community-based trials in the area of maternal and perinatal health, particularly in LMICs. TRIAL REGISTRATION ClinicalTrials.gov: NCT01911494.
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Affiliation(s)
- Asif R Khowaja
- Department of Obstetrics and Gynaecology; and Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
| | - Craig Mitton
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.
| | - Stirling Bryan
- School of Population and Public Health, University of British Columbia, Vancouver, Canada.
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, Canada.
| | - Laura A Magee
- Department of Obstetrics and Gynaecology; and Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, Aga Khan University, Karachi, Pakistan.
- Centre for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, Canada.
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology; and Child and Family Research Institute, University of British Columbia, Vancouver, Canada.
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Jardim LL, Rios DRA, Perucci LO, de Sousa LP, Gomes KB, Dusse LMS. Is the imbalance between pro-angiogenic and anti-angiogenic factors associated with preeclampsia? Clin Chim Acta 2015; 447:34-8. [PMID: 25982781 DOI: 10.1016/j.cca.2015.05.004] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 05/06/2015] [Accepted: 05/07/2015] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preeclampsia (PE) is a multisystem disease characterized by the development of hypertension and proteinuria. Although PE etiology is not fully known, the placenta seems to play a central role in the development of disease. The inadequate placentation process results in a change in angiogenic factors levels, such as vascular endothelial growth factor (VEGF), placental growth factor (PlGF), soluble form of endoglin (s-Eng) and soluble form of vascular endothelial growth factor receptor type 1 (sFlt-1). OBJECTIVE The aim of this review was to clarify if the imbalance between pro-angiogenic and anti-angiogenic factors is associated with PE. CONCLUSION It is known that inadequate placentation process is the primary mechanism suggested for PE occurrence and angiogenic factors are involved in this process. The state-of-the-art suggests that progress in grasp the imbalance of pro-angiogenic and anti-angiogenic factors is essential for the improvement of knowledge about PE. The development of prospective, longitudinal studies with serial determinations of these factors throughout pregnancy is needed to better assess the relevance of these markers for understanding the etiology, prevention, diagnosis, prognosis and treatment of this challenging disease.
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Affiliation(s)
- Letícia Lemos Jardim
- Departamento de Clínica Médica, Faculdade de Medicina, Universidade Federal de Minas Gerais, Brazil
| | | | - Luíza Oliveira Perucci
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Lirlândia Pires de Sousa
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Karina Braga Gomes
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil
| | - Luci Maria S Dusse
- Departamento de Análises Clínicas e Toxicológicas, Faculdade de Farmácia, Universidade Federal de Minas Gerais, Brazil.
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Abstract
The authors discuss a case of inadequate provision of emergency care encountered in expert practice. The analysis of the difficulties currently facing experts engaged in the verification of medical diagnoses is described as exemplified by the patient presenting with the obstetric and gynecological problems and the aggravated medical history. The case under consideration is characterized by the almost total absence of the relevant comprehensive medical documentation concerning a women pregnant with twins. The data are presented needed to perform the expert evaluation and formulate the objective and scientifically sound conclusions about the cause-and-effect relationships between the drawbacks in the provision of medical assistance and the unfavourable outcome of pathological conditions.
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Affiliation(s)
- A V Kovalev
- Federal state budgetary institution 'Russian Centre for Forensic Medical Expertise', Russian Ministry of Health, Moscow, Russia, 125284
| | - I V Pletyanova
- Federal state budgetary institution 'Russian Centre for Forensic Medical Expertise', Russian Ministry of Health, Moscow, Russia, 125284
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Schröck R, Heimisch W, Gebhardt K, Mendler N. Hemodilution as a therapeutic procedure in EPH gestosis. Bibl Haematol 2015:86-96. [PMID: 7337676 DOI: 10.1159/000402213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Brenner S, De Allegri M, Gabrysch S, Chinkhumba J, Sarker M, Muula AS. The quality of clinical maternal and neonatal healthcare - a strategy for identifying 'routine care signal functions'. PLoS One 2015; 10:e0123968. [PMID: 25875252 PMCID: PMC4398438 DOI: 10.1371/journal.pone.0123968] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 02/17/2015] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND A variety of clinical process indicators exists to measure the quality of care provided by maternal and neonatal health (MNH) programs. To allow comparison across MNH programs in low- and middle-income countries (LMICs), a core set of essential process indicators is needed. Although such a core set is available for emergency obstetric care (EmOC), the 'EmOC signal functions', a similar approach is currently missing for MNH routine care evaluation. We describe a strategy for identifying core process indicators for routine care and illustrate their usefulness in a field example. METHODS We first developed an indicator selection strategy by combining epidemiological and programmatic aspects relevant to MNH in LMICs. We then identified routine care process indicators meeting our selection criteria by reviewing existing quality of care assessment protocols. We grouped these indicators into three categories based on their main function in addressing risk factors of maternal or neonatal complications. We then tested this indicator set in a study assessing MNH quality of clinical care in 33 health facilities in Malawi. RESULTS Our strategy identified 51 routine care processes: 23 related to initial patient risk assessment, 17 to risk monitoring, 11 to risk prevention. During the clinical performance assessment a total of 82 cases were observed. Birth attendants' adherence to clinical standards was lowest in relation to risk monitoring processes. In relation to major complications, routine care processes addressing fetal and newborn distress were performed relatively consistently, but there were major gaps in the performance of routine care processes addressing bleeding, infection, and pre-eclampsia risks. CONCLUSION The identified set of process indicators could identify major gaps in the quality of obstetric and neonatal care provided during the intra- and immediate postpartum period. We hope our suggested indicators for essential routine care processes will contribute to streamlining MNH program evaluations in LMICs.
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Affiliation(s)
- Stephan Brenner
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Manuela De Allegri
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Sabine Gabrysch
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Jobiba Chinkhumba
- Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi
| | - Malabika Sarker
- Institute of Public Health, Ruprecht-Karls-University, Heidelberg, Germany
| | - Adamson S. Muula
- Department of Community Health, University of Malawi, College of Medicine, Blantyre, Malawi
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135
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Affiliation(s)
- Lucy C Chappell
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK
| | | | - Andrew Shennan
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK
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136
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Klemetti MM, Laivuori H, Tikkanen M, Nuutila M, Hiilesmaa V, Teramo K. Obstetric and perinatal outcome in type 1 diabetes patients with diabetic nephropathy during 1988-2011. Diabetologia 2015; 58:678-86. [PMID: 25575985 DOI: 10.1007/s00125-014-3488-1] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/16/2014] [Indexed: 12/30/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to analyse possible changes in the glycaemic control, BP, markers of renal function, and obstetric and perinatal outcomes of parturients with diabetic nephropathy during 1988-2011. METHODS The most recent childbirth of 108 consecutive type 1 diabetes patients with diabetic nephropathy and a singleton pregnancy were studied. Two periods, 1988-1999 and 2000-2011, were compared. RESULTS The prepregnancy and the first trimester median HbA1c values persisted at high levels (8.2% [66 mmol/mol] vs 8.5% [69 mmol/mol], p = 0.16 and 8.3% [67 mmol/mol] vs 8.4% [68 mmol/mol], p = 0.67, respectively), but decreased by mid-pregnancy (6.7% [50 mmol/mol] vs 6.9% [52 mmol/mol], p = 0.11). Antihypertensive medication usage increased before pregnancy (34% vs 65%, p = 0.002) and in the second and third trimesters of pregnancy (25% vs 47%, p = 0.02, and 36% vs 60%, p = 0.01, respectively). BP exceeded 130/80 mmHg in 62% and 61% (p = 0.87) of patients in the first trimester, and in 95% and 93% (p = 0.69) in the third trimester, respectively. No changes were observed in the markers of renal function. Pre-eclampsia (52% vs 42%, p = 0.29) and preterm birth rates before 32 and 37 gestational weeks (14% vs 21%, p = 0.33, and 71% vs 77%, p = 0.49, respectively) remained high. The elective and emergency Caesarean section rates were 71% and 45% (p = 0.01) and 29% and 48% (p = 0.05), respectively. Neonatal intensive care unit admissions increased from 26% to 49% (p = 0.02). CONCLUSIONS/INTERPRETATION Early pregnancy glycaemic control and hypertension management were suboptimal in both time periods. Pre-eclampsia and preterm delivery rates remained high in patients with diabetic nephropathy.
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Affiliation(s)
- Miira M Klemetti
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Central Hospital, P.O. Box 140, Haartmaninkatu 2, 00029, Helsinki, Finland,
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137
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Bobić MV, Habek D, Habek JČ. Perinatal epidemiological risk factors for preeclampsia. Acta Clin Croat 2015; 54:9-13. [PMID: 26058236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
In the present study, the impact of the potential perinatal epidemiological factors on preeclampsia development was assessed. This clinical study included 55 pregnant women with preeclampsia and control group of 50 healthy pregnant women. Positive family history of cardiovascular disease, diabetes mellitus or thromboembolic disease was recorded in 50% of women with preeclampsia versus 28% of control group women. Positive personal history of this disease was recorded in 15% of women with preeclampsia, whereas all control group women had negative personal history of preeclampsia. Dietary habits, i.e. the intake of meat and meat products, fruit and vegetables, coffee and alcohol drinks were similar in the two groups, without statistically significant differences. The women with preeclampsia and control women reported comparable habits; there was no difference in the consumption of meat, fruit, vegetables, coffee and alcohol, smoking, use of folate and oral hormonal contraception before pregnancy, or in physical activity as the potential risk factors for preeclampsia in current pregnancy. However, personal and family history of vascular disease proved to be significant risk factors for the occurrence of preeclampsia, emphasizing the need of lifestyle and dietary modifications with healthy dietary habits, while avoiding adverse habits in pregnancy.
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138
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von Dadelszen P, Magee LA, Payne BA, Dunsmuir DT, Drebit S, Dumont GA, Miller S, Norman J, Pyne-Mercier L, Shennan AH, Donnay F, Bhutta ZA, Ansermino JM. Moving beyond silos: How do we provide distributed personalized medicine to pregnant women everywhere at scale? Insights from PRE-EMPT. Int J Gynaecol Obstet 2015; 131 Suppl 1:S10-5. [PMID: 26433496 DOI: 10.1016/j.ijgo.2015.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
While we believe that pre-eclampsia matters-because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide-we are convinced that the time has come to look beyond single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will provide evidence-based personalized care to women wherever they encounter the health system. Accurate outcome prediction models are a powerful way to identify individuals at incrementally increased (and decreased) risks associated with a given condition. Integrating models with decision algorithms into mobile health (mHealth) applications could support community and first level facility healthcare providers to identify those women, fetuses, and newborns most at need of facility-based care, and to initiate lifesaving interventions in their communities prior to transportation. In our opinion, this offers the greatest opportunity to provide distributed individualized care at scale, and soon.
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Affiliation(s)
- Peter von Dadelszen
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada.
| | - Laura A Magee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Beth A Payne
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Dustin T Dunsmuir
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Sharla Drebit
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Guy A Dumont
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences and Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Jane Norman
- University of Edinburgh/MRC Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, UK
| | - Lee Pyne-Mercier
- Family Health Team, Bill & Melinda Gates Foundation, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - France Donnay
- Family Health Team, Bill & Melinda Gates Foundation, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, Canada; Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - J Mark Ansermino
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
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139
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Rodriguez O, Cooma R, Cooper M, Roth P. Delivery and management of a preterm infant in the burn unit: a multidisciplinary approach. Burns 2015; 41:e51-5. [PMID: 25704835 DOI: 10.1016/j.burns.2015.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2014] [Revised: 12/29/2014] [Accepted: 01/23/2015] [Indexed: 11/17/2022]
Abstract
Burns during pregnancy can have profound effects on both the mother and her fetus. While the mother can suffer cardiovascular collapse, infection, hemorrhage and inhalation injury with respiratory failure, the fetus is affected through the placenta by all of these changes as well as by the transfer of drugs administered to the mother. We report a case of severely burned female patient at 29 weeks gestation, who, due to deteriorating maternal condition, was delivered and managed at 32 weeks gestation by a multidisciplinary team. To the best of our knowledge this is the first reported case of a preterm infant delivered in a burn unit.
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Affiliation(s)
- Omar Rodriguez
- Department of Pediatrics, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
| | - Ruby Cooma
- Department of Pediatrics, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
| | - Michael Cooper
- Department of Surgery, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
| | - Philip Roth
- Department of Pediatrics, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, United States.
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140
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Jaber B. Common bond. On the limitations of a shared faith. Minn Med 2015; 98:20-21. [PMID: 25771643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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141
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Wang T, Jiang LH, Zhu JB, Wei XY, Li L, Liu B. Effect of hypertonic sodium chloride hydroxyethyl starch 40 on ET, TXB2, 6-keto-PGF1α, and ANP of preeclampsia in caesarean section. CLIN EXP OBSTET GYN 2015; 42:36-39. [PMID: 25864279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVE Preeclampsia is a unique disease of pregnancy. Delivery via caesarean section is the most important way of terminating the pregnancy and treating preeclampsia. Perioperative fluid therapy is performed to maintain the circulatory volume and reduce tissue edema. This study evaluated the effects of hypertonic sodium chloride hydroxyethyl starch 40 (HSH40) as perioperative fluid therapy for preeclampsia patients. MATERIALS AND METHODS Forty preeclamptic women were randomly divided into two groups: the Ringer's solution group and the HSH40 group. Their ECG, HR, MAP, and SPO2 were monitored. Their MVP and HR were recorded at five, eight, and ten minutes after anesthesia induction and at the end of the caesarean section. The corresponding volume of infusion, blood loss, and urine output during the operation were also recorded. Venous samples were collected before HSH40 infusion and 30 min after infusion to measure the plasma concentrations of ET, TXB2, 6-keto-PGF1α, and ANP via a radioimmunoassay. RESULTS HSH40 infusion significantly decreased the plasma ET levels (p < 0.01), significantly changed the plasma ANP and TXB2 levels (p < 0.05), and significantly increased the plasma 6-keto-PGF1α levels (p < 0.01) in the experimental group compared with those before infusion. The plasma levels of ET, ANP, TXB2, and 6-keto-PGF1α did not significantly change in the control group. Compared with T1, MAP decreased significantly at T2, T3, T4, and T5 within groups (p < 0.05) and between the two groups. MAP significantly changed at T2, T3, T4, and T5 (p < 0.05). HR did not significant change at T1, T2, T3, T4, and T5 within or between groups. Volume of infusion and urine volume significantly differed between groups (p < 0.05). CONCLUSION Low-dose HSH40 lowers the plasma levels of vasoconstrictor substances (ET and TXB2) and increases the levels of vasodilator substances (6-keto-PGF1α and ANP) during preeclampsia. It effectively maintains and stabilizes the circulating blood volume, increasing renal blood flow, which improves renal function and increases urine output.
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142
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Lindholm ES, Altman D, Norman M, Blomberg M. Health Care Consumption during Pregnancy in relation to Maternal Body Mass Index: A Swedish Population Based Observational Study. J Obes 2015; 2015:215683. [PMID: 26101664 PMCID: PMC4460241 DOI: 10.1155/2015/215683] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/14/2015] [Accepted: 05/18/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To assess whether antenatal health care consumption is associated with maternal body mass index (BMI). DESIGN A register based observational study. METHODS The Swedish Medical Birth Register, the Maternal Health Care Register, and the Inpatient Register were used to determine antenatal health care consumption according to BMI categories for primiparous women with singleton pregnancies, from 2006 to 2008, n = 71,638. Pairwise comparisons among BMI groups are obtained post hoc by Tukey HSD test. RESULT Obese women were more often admitted for in-patient care (p < 0.001), had longer antenatal hospital stays (p < 0.001), and were more often sick-listed by an obstetrician (p < 0.001) during their pregnancy, compared to women with normal weight women. Preeclampsia was more than four times as common, hypertension five times as common, and gestational diabetes 11 times as common when comparing in-patient care, obese to normal weight women (p < 0.001 for all comparisons). Underweight mothers had longer stay in hospitals (p < 0.05) and hydronephrosis and hyperemesis gravidarum were more than twice as common (both p < 0.001). CONCLUSION Obese and underweight mothers consumed significantly more health care resources and obese women were significantly more often sick-listed during their pregnancy when compared to pregnant women of normal weight.
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Affiliation(s)
- Elisabeth S. Lindholm
- Division of Obstetrics and Gynecology, Department of Clinical Science, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Daniel Altman
- Division of Obstetrics and Gynecology, Department of Clinical Science, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Margareta Norman
- Division of Obstetrics and Gynecology, Department of Clinical Science, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Marie Blomberg
- Department of Obstetrics and Gynecology and Department of Clinical and Experimental Medicine, Linköping University, 581 83 Linköping, Sweden
- *Marie Blomberg:
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143
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Basaran A, Basaran M, Basaran B, Sen C, Martin JN. Controversial clinical practices for patients with preeclampsia or HELLP syndrome: a survey. J Perinat Med 2015; 43:61-6. [PMID: 24810554 DOI: 10.1515/jpm-2014-0109] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 04/11/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND Considerable controversy continues to surround the management of severe preeclampsia and HELLP syndrome. Experts, researchers, and those published in the field were surveyed about their specific practices. MATERIALS AND METHODS An extensive literature search was undertaken to identify the cohort of authors with recent publications on the subjects of preeclampsia (2009-2012) and HELLP syndrome (2005-2012). Online surveys were sent to all authors using the email addresses found in their publications. RESULTS Surveys were delivered by email to 363 authors of preeclampsia publications and 91 authors of HELLP syndrome publications. Completed surveys were received from 61 (13.4%) of the group. Except for consensus about the indication of corticosteroids for the enhancement of fetal lung maturation, there was considerable variation in corticosteroid practice and anesthesia techniques. CONCLUSIONS A marked diversity in practice characterized the clinical care rendered by experts in the field of preeclampsia and HELLP syndrome. Thus, there is an urgent need for well-designed and executed prospective clinical trials to improve the evidence for best consensus practice in this area of obstetrical medicine.
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144
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Sano M, Matsumoto M, Terada H, Wang H, Kurihara Y, Wada N, Yamamoto H, Kira Y, Tachibana D, Koyama M. Increased annexin A2 expression in the placenta of women with acute worsening of preeclampsia. Osaka City Med J 2014; 60:87-93. [PMID: 25803884] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND The aims of present study were to investigate the expression of Annexin A2 in the placenta of patients with preeclampsia (PE) and correlate these data with acute worsening of clinical symptoms. METHODS Placentas were collected from uncomplicated normal pregnancies (n = 9), PE cases without emergency termination of pregnancy (group 1, n = 6), and PE cases with acute worsening of symptoms necessitating immediate pregnancy termination (group 2, n = 7). Immunohistochemistry data were analyzed quantitatively, and placental mRNA expression was measured by Real-time PCR. RESULTS Group 2 had a significantly shorter interval between diagnosis and pregnancy termination compared with group 1 (p = 0.002). Birth weight and placental weight in group 2 were significantly lower compared with the normal group (p = 0.006 and p = 0.03, birth weight and placental weight, respectively), whereas there were no differences in gestational age at delivery between the three groups or the severity of high blood pressure and proteinuria between the PE groups. Placental expression of Annexin A2 as determined by immunohistochemistry was significantly higher in both PE groups compared with the uncomplicated pregnancy group (p < 0.001 and p < 0.001, groups 1 and 2, respectively). Placental Annexin A2 mRNA expression was significantly elevated in group 2 compared with the normal group (p = 0.002) but did not change in group 1. CONCLUSIONS This study is the first to demonstrate increased placental Annexin A2 mRNA expression during the acute phase of PE. Immunohistochemical staining of placental Annexin A2 was high, regardless of PE phase. These findings suggest that worsening of PE might alter Annexin A2 expression at the transcription level.
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145
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Abstract
PURPOSE One of the most common, and most vexing, obstetric complications is preeclampsia-a major cause of maternal and perinatal morbidity. Hallmarked by new-onset hypertension and a myriad of other symptoms, the underlying cause of the disorder remains obscure despite intensive research into its etiology. Although the initiating events are not clear, one common finding in preeclamptic patients is failure to remodel the maternal arteries that supply the placenta, with resulting hypoxia/ischemia. Intensive research over the past 2 decades has identified several categories of molecular dysfunction resulting from placental hypoxia, which, when released into the maternal circulation, are involved in the spectrum of symptoms seen in these patients-in particular, angiogenic imbalance and the activation of innate and adaptive immune responses. Despite these new insights, little in the way of new treatments for the management of these patients has been advanced into clinical practice. Indeed, few therapeutic options exist for the obstetrician treating a case of preeclampsia. Pharmacologic management is typically seizure prophylaxis, and, in severe cases, antihypertensive agents for controlling worsening hypertension. Ultimately, the induction of labor is indicated, making preeclampsia a leading cause of premature birth. Here, the molecular mechanisms linking placental ischemia to the maternal symptoms of preeclampsia are reviewed, and several areas of recent research suggesting new potential therapeutic approaches to the management of preeclampsia are identified.
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Affiliation(s)
- Eric M George
- Departments of Physiology and Biophysics, and Biochemistry, University of Mississippi Medical Center, Jackson, Mississippi.
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146
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Bouet PE, Gillard P, Descamps P, Sentilhes L. [Management of pre-eclampsia]. Rev Prat 2014; 64:1145-1152. [PMID: 25510148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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147
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Abstract
An antiangiogenic state might constitute a terminal pathway for the multiple aetiologies of pre-eclampsia, especially those resulting from placental abnormalities. The levels of angiogenic and antiangiogenic proteins in maternal blood change prior to a diagnosis of pre-eclampsia, correlate with disease severity and have prognostic value in identifying women who will develop maternal and/or perinatal complications. Potential interventions exist to ameliorate the imbalance of angiogenesis and, hence, might provide opportunities to improve maternal and/or perinatal outcomes in pre-eclampsia. Current strategies for managing pre-eclampsia consist of controlling hypertension, preventing seizures and timely delivery of the fetus. Prediction of pre-eclampsia in the first trimester is of great interest, as early administration of aspirin might reduce the risk of pre-eclampsia, albeit modestly. Combinations of biomarkers typically predict pre-eclampsia better than single biomarkers; however, the encouraging initial results of biomarker studies require external validation in other populations before they can be used to facilitate intervention in patients identified as at increased risk. Angiogenic and antiangiogenic factors might also be useful in triage of symptomatic patients with suspected pre-eclampsia, differentiating pre-eclampsia from exacerbations of pre-existing medical conditions and performing risk assessment in asymptomatic women. This Review article discusses the performance of predictive and prognostic biomarkers for pre-eclampsia, current strategies for preventing and managing the condition and its long-term consequences.
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Affiliation(s)
- Tinnakorn Chaiworapongsa
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Piya Chaemsaithong
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Steven J Korzeniewski
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Lami Yeo
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
| | - Roberto Romero
- Perinatology Research Branch, Program for Perinatal Research and Obstetrics, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, 31 Center Drive, Bethesda, MD 20892, USA and 3990 John R Street, Detroit, MI 48201, USA
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148
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Diallo T, Amiel I, Lira E, Borie C, Skhiri A, Hilly J, Dahmani S. [Sub-capsular renal hematoma during severe preeclampsia: clinical case and review of the literature]. ACTA ACUST UNITED AC 2014; 33:536-9. [PMID: 25148716 DOI: 10.1016/j.annfar.2014.06.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 06/12/2014] [Indexed: 11/29/2022]
Abstract
Renal haematoma during severe preeclampsia is a rare uneventful event. It is usually associated with other organ injury such as cerebral or liver haematoma. Imaging (ultrasound or tomodensitometry examination) plays an important role in detecting this complication and following its evolution. In the current case report, we describe an isolated renal haematoma during a severe preeclampsia complicated by a HELLP syndrome. This patient was managed with a conservative treatment (control of arterial pressure and induction of delivery) and an imaging follow-up.
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Affiliation(s)
- T Diallo
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - I Amiel
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - E Lira
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - C Borie
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France; Service de gynécologie et obstétrique, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - A Skhiri
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - J Hilly
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France
| | - S Dahmani
- Département d'anesthésie et de réanimation, DHU PROTECT, faculté de médecine Denis-Diderot Paris VII, hôpital Robert-Debré, 48, boulevard Serurier, 75019 Paris, France.
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149
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Vigil-De Gracia P, Ludmir J. Power analysis for the MEXPRE study. Reply. Am J Obstet Gynecol 2014; 211:182. [PMID: 24607756 DOI: 10.1016/j.ajog.2014.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/02/2014] [Indexed: 11/18/2022]
Affiliation(s)
| | - Jack Ludmir
- Pennsylvania Hospital, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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150
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Owens MY, Thigpen B, Parrish MR, Keiser SD, Sawardecker S, Wallace K, Martin JN. Management of preeclampsia when diagnosed between 34-37 weeks gestation: deliver now or deliberate until 37 weeks? J Miss State Med Assoc 2014; 55:208-211. [PMID: 25252423] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVE To evaluate maternal-newborn outcomes with immediate or expectantly managed preeclampsia first diagnosed at 34-37 weeks. METHODS Late preterm patients with preeclampsia without severe features were randomly assigned to immediate delivery (n=94) or expectant management (n = 75) until 37 weeks gestation or earlier if severe features developed. Data were analyzed by appropriate tests for continuous or categorical outcomes with differences considered significant if p < 0.05. RESULTS The two groups were similar at presentation. 41% of those expectantly managed developed severe features of preeclampsia within 72 hours versus 3% in the immediately delivered group (p < 0.001). Immediate delivery did not significantly increase cesarean delivery or neonatal morbidity. CONCLUSION Immediate delivery of the late preterm patient with preeclampsia significantly lessens her development of severe features without significantly increasing newborn risks. For the expectantly managed late preterm patient with preeclampsia, close surveillance for the first 72 hours following diagnosis and twice weekly thereafter appears prudent.
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