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Sentilhes L, Schmitz T, Arthuis C, Barjat T, Berveiller P, Camilleri C, Froeliger A, Garabedian C, Guerby P, Korb D, Lecarpentier E, Mattuizzi A, Sibiude J, Sénat MV, Tsatsaris V. [Preeclampsia: Guidelines for clinical practice from the French College of Obstetricians and Gynecologists]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024; 52:3-44. [PMID: 37891152 DOI: 10.1016/j.gofs.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Abstract
OBJECTIVE To identify strategies to reduce maternal and neonatal morbidity related to preeclampsia. MATERIAL AND METHODS The quality of evidence of the literature was assessed following the GRADE® method with questions formulated in the PICO format (Patients, Intervention, Comparison, Outcome) and outcomes defined a priori and classified according to their importance. An extensive bibliographic search was performed on PubMed, Cochrane, EMBASE and Google Scholar databases. The quality of the evidence was assessed (high, moderate, low, very low) and recommendations were formulated as a (i) strong, (ii) weak or (iii) no recommendation. The recommendations were reviewed in two rounds with external reviewers (Delphi survey) to select the consensus recommendations. RESULTS Preeclampsia is defined by the association of gestational hypertension (systolic blood pressure≥140mmHg and/or diastolic blood pressure≥90mmHg) and proteinuria≥0.3g/24h or a Proteinuria/Creatininuria ratio≥30mg/mmol occurring after 20 weeks of gestation. Data from the literature do not show any benefit in terms of maternal or perinatal health from implementing a broader definition of preeclampsia. Of the 31 questions, there was agreement between the working group and the external reviewers on 31 (100%). In general population, physical activity during pregnancy should be encouraged to reduce the risk of preeclampsia (Strong recommendation, Quality of the evidence low) but an early screening based on algorithms (Weak recommendation, Quality of the evidence low) or aspirin administration (Weak recommendation, Quality of the evidence very low) is not recommended to reduce maternal and neonatal morbidity related to preeclampsia. In women with preexisting diabetes or hypertension or renal disease, or multiple pregnancy, the level of evidence is insufficient to determine whether aspirin administration during pregnancy is useful to reduce maternal and perinatal morbidity (No recommendation, Quality of the evidence low). In women with a history of vasculo-placental disease, low dose of aspirin (Strong recommendation, Quality of the evidence moderate) at a dosage of 100-160mg per day (Weak recommendation, Quality of the evidence low), ideally before 16 weeks of gestation and not after 20 weeks of gestation (Strong recommendation, Quality of the evidence low) until 36 weeks of gestation (Weak recommendation, Quality of the evidence very low) is recommended. In a high-risk population, additional administration of low molecular weight heparin is not recommended (Weak recommendation, Quality of the evidence moderate). In case of preeclampsia (Weak recommendation, Quality of the evidence low) or suspicion of preeclampsia (Weak recommendation, Quality of the evidence moderate, the assessment of PlGF concentration or sFLT-1/PlGF ratio is not routinely recommended) in the only goal to reduce maternal or perinatal morbidity. In women with non-severe preeclampsia antihypertensive agent should be administered orally when the systolic blood pressure is measured between 140 and 159mmHg or diastolic blood pressure is measured between 90 and 109mmHg (Weak recommendation, Quality of the evidence low). In women with non-severe preeclampsia, delivery between 34 and 36+6 weeks of gestation reduces severe maternal hypertension but increases the incidence of moderate prematurity. Taking into account the benefit/risk balance for the mother and the child, it is recommended not to systematically induce birth in women with non-severe preeclampsia between 34 and 36+6 weeks of gestation (Strong recommendation, Quality of evidence high). In women with non-severe preeclampsia diagnosed between 37+0 and 41 weeks of gestation, it is recommended to induce birth to reduce maternal morbidity (Strong recommendation, Low quality of evidence), and to perform a trial of labor in the absence of contraindication (Strong recommendation, Very low quality of evidence). In women with a history of preeclampsia, screening maternal thrombophilia is not recommended (Strong recommendation, Quality of the evidence moderate). Because women with a history of a preeclampsia have an increased lifelong risk of chronic hypertension and cardiovascular complications, they should be informed of the need for medical follow-up to monitor blood pressure and to manage other possible cardiovascular risk factors (Strong recommendation, Quality of the evidence moderate). CONCLUSION The purpose of these recommendations was to reassess the definition of preeclampsia, and to determine the strategies to reduce maternal and perinatal morbidity related to preeclampsia, during pregnancy but also after childbirth. They aim to help health professionals in their daily clinical practice to inform or care for patients who have had or have preeclampsia. Synthetic information documents are also offered for professionals and patients.
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Affiliation(s)
- Loïc Sentilhes
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France.
| | - Thomas Schmitz
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
| | - Chloé Arthuis
- Service d'obstétrique et de médecine fœtale, Elsan Santé Atlantique, 44819 Saint-Herblain, France
| | - Tiphaine Barjat
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Saint-Etienne, Saint-Etienne, France
| | - Paul Berveiller
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Poissy St-Germain, Poissy, France
| | - Céline Camilleri
- Association grossesse santé contre la pré-éclampsie, Paris, France
| | - Alizée Froeliger
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - Charles Garabedian
- Service de gynécologie-obstétrique, University Lille, ULR 2694-METRICS, CHU de Lille, 59000 Lille, France
| | - Paul Guerby
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Toulouse, Toulouse, France
| | - Diane Korb
- Service de gynécologie-obstétrique, hôpital Robert-Debré, AP-HP, Paris, France
| | - Edouard Lecarpentier
- Service de gynécologie-obstétrique, centre hospitalier intercommunal de Créteil, Créteil, France
| | - Aurélien Mattuizzi
- Service de gynécologie-obstétrique, centre hospitalier universitaire de Bordeaux, Bordeaux, France
| | - Jeanne Sibiude
- Service de gynécologie-obstétrique, hôpital Louis-Mourier, AP-HP, Colombes, France
| | - Marie-Victoire Sénat
- Service de gynécologie-obstétrique, hôpital Bicêtre, AP-HP, Le Kremlin-Bicêtre, France
| | - Vassilis Tsatsaris
- Maternité Port-Royal, hôpital Cochin, GHU Centre Paris cité, AP-HP, FHU PREMA, Paris, France
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Li Z, Chen S, Tan Y, Lv J, Zhao M, Chen Q, He Y. Twenty-four-hour proteinuria levels are associated with adverse pregnancy outcomes among women with CKD. Clin Kidney J 2023; 16:1634-1643. [PMID: 37779840 PMCID: PMC10539237 DOI: 10.1093/ckj/sfad044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Indexed: 10/03/2023] Open
Abstract
Background Proteinuria is commonly measured to assess the renal status of chronic kidney disease (CKD) patients before the 20th week of gestation during pregnancy. High levels of proteiuria have been associated with adverse pregnancy outcomes. However, researchers have not clearly determined what baseline proteinuria levels would be associated with adverse pregnancy outcomes. This study aimed to analyse associations between proteinuria levels and adverse pregnancy outcomes among CKD patients treated with or without steroids/immunosuppressive therapy in early pregnancy. Methods This retrospective study included the clinical information of 557 pregnant patients with CKD from 1 January 2009 to 31 December 2021. A multivariable logistic regression analysis was conducted to evaluate the risk of adverse pregnancy outcomes across various proteinuria ranges, which were further stratified by whether the patients were receiving steroids/immunosuppressive therapy. Results (i) Proteinuria was assessed on 24-h urine collection. The median (quartile) baseline proteinuria levels were 0.83 g (0.20, 1.92) and 0.25 g (0.06, 0.80) in the steroids/immunosuppressive therapy and therapy-free groups, respectively. (ii) CKD patients with adverse pregnancy outcomes had significantly higher proteinuria levels in the first trimester than patients without adverse pregnancy outcomes. (iii) The risk of adverse pregnancy outcomes increased with increasing baseline proteinuria levels (P < .001). (iv) In the early-pregnancy steroids/immunosuppressive therapy group, the risk of severe preeclampsia was higher in patients with higher baseline proteinuria levels (P < .007) [odds ratio (OR) 30.86 for proteinuria ≥5.00 g/24 h]; in the therapy-free group, the risks of severe preeclampsia, very-low-birth-weight infants, early preterm birth and foetal-neonatal death were higher in patients with higher baseline proteinuria levels (OR 53.16 for proteinuria ≥5.00 g/24 h; OR 37.83 for proteinuria ≥5.00 g/24 h; OR 15.30 for proteinuria ≥5.00 g/24 h; and OR 18.83 for proteinuria ≥5.00 g/24 h, respectively; P < .001, P < .001, P < .001 and P = .006, respectively). Conclusions As shown in the present study, a baseline 24-h proteinuria level >1.00 g was associated with adverse maternal outcomes. Furthermore, a 24-h proteinuria level >2.00 g increased the incidence of adverse foetal events among CKD patients.
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Affiliation(s)
- Zheng Li
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Shi Chen
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Ying Tan
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Jicheng Lv
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Minghui Zhao
- Renal Division, Department of Medicine, Peking University, First Hospital, Peking University Institute of Nephrology, Beijing, P.R. China
| | - Qian Chen
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
| | - Yingdong He
- Department of Obstetrics and Gynecology, Peking University, First Hospital, Beijing, P.R. China
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Fishel Bartal M, Lindheimer MD, Sibai BM. Proteinuria during pregnancy: definition, pathophysiology, methodology, and clinical significance. Am J Obstet Gynecol 2022; 226:S819-S834. [PMID: 32882208 DOI: 10.1016/j.ajog.2020.08.108] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Revised: 08/24/2020] [Accepted: 08/27/2020] [Indexed: 12/31/2022]
Abstract
Qualitative and quantitative measurement of urine protein excretion is one of the most common tests performed during pregnancy. For more than 100 years, proteinuria was necessary for the diagnosis of preeclampsia, but recent guidelines recommend that proteinuria is sufficient but not necessary for the diagnosis. Still, in clinical practice, most patients with gestational hypertension will be diagnosed as having preeclampsia based on the presence of proteinuria. Although the reference standard for measuring urinary protein excretion is a 24-hour urine collection, spot urine protein-to-creatinine ratio is a reasonable "rule-out" test for proteinuria. Urine dipstick screening for proteinuria does not provide any clinical benefit and should not be used to diagnose proteinuria. The classic cutoff cited to define proteinuria during pregnancy is a value of >300 mg/24 hours or a urine protein-to-creatinine ratio of at least 0.3. Using this cutoff, the rate of isolated proteinuria in pregnancy may reach 8%, whereas preeclampsia occurs among 3% to 8% of pregnancies. Although this threshold is widely accepted, its origin is not based on evidence on adverse pregnancy outcomes but rather on expert opinion and results of small studies. After reviewing the available data, the most important factor that influences maternal and neonatal outcome is the severity of blood pressures and presence of end organ damage, rather than the excess protein excretion. Because the management of gestational hypertension and preeclampsia without severe features is almost identical in frequency of surveillance and timing of delivery, the separation into 2 disorders is unnecessary. If the management of women with gestational hypertension with a positive assessment of proteinuria will not change, we believe that urine assessment for proteinuria is unnecessary in women who develop new-onset blood pressure at or after 20 weeks' gestation. Furthermore, we do not recommend repeated measurement of proteinuria for women with preeclampsia, the amount of proteinuria does not seem to be related to poor maternal and neonatal outcomes, and monitoring proteinuria may lead to unindicated preterm deliveries and related neonatal complications. Our current diagnosis of preeclampsia in women with chronic kidney disease may be based on a change in protein excretion, a baseline protein excretion evaluation is critical in certain conditions such as chronic hypertension, diabetes, and autoimmune or other renal disorders. The current definition of superimposed preeclampsia possesses a diagnostic dilemma, and it is unclear whether a change in the baseline proteinuria reflects another systemic disease such as preeclampsia or whether women with chronic disease such as chronic hypertension or diabetes will experience a different "normal" pattern of protein excretion during pregnancy. Finally, limited data are available regarding angiogenic and other biomarkers in women with chronic kidney disease as a potential aid in distinguishing the worsening of baseline chronic kidney disease and chronic hypertension from superimposed preeclampsia.
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Morikawa M, Mayama M, Noshiro K, Saito Y, Nakagawa-Akabane K, Umazume T, Chiba K, Kawaguchi S, Watari H. Earlier onset of proteinuria or hypertension is a predictor of progression from gestational hypertension or gestational proteinuria to preeclampsia. Sci Rep 2021; 11:12708. [PMID: 34135442 PMCID: PMC8209055 DOI: 10.1038/s41598-021-92189-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 06/07/2021] [Indexed: 11/25/2022] Open
Abstract
Although gestational hypertension (GH) is a well-known disorder, gestational proteinuria (GP) has been far less emphasized. According to international criteria, hypertensive disorders of pregnancy include GH but not GP. Previous studies have not revealed the predictors of progression from GP to preeclampsia or those of progression from GH to preeclampsia. We aimed to determine both sets of predictors. A retrospective cohort study was conducted with singleton pregnant women who delivered at 22 gestational weeks or later. Preeclampsia was divided into three types: new onset of hypertension/proteinuria at 20 gestational weeks or later and additional new onset of other symptoms at < 7 days or at ≥ 7 days later. Of 94 women with preeclampsia, 20 exhibited proteinuria before preeclampsia, 14 experienced hypertension before preeclampsia, and 60 exhibited simultaneous new onset of both hypertension and proteinuria before preeclampsia; the outcomes of all types were similar. Of 34 women with presumptive GP, 58.8% developed preeclampsia; this proportion was significantly higher than that of 89 women with presumptive GH who developed preeclampsia (15.7%). According to multivariate logistic regression models, earlier onset of hypertension/proteinuria (before or at 34.7/33.9 gestational weeks) was a predicator for progression from presumptive GH/GP to preeclampsia (odds ratios: 1.21/1.21, P value: 0.0044/0.0477, respectively).
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan.
| | - Michinori Mayama
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Kiwamu Noshiro
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Yoshihiro Saito
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Kinuko Nakagawa-Akabane
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Takeshi Umazume
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Kentaro Chiba
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Satoshi Kawaguchi
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
| | - Hidemichi Watari
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan
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Yuksel S, Ozyurek SE, Acar DK, Ozdemir C, Guler S, Kiyak H, Gedikbasi A. Urinary neutrophil gelatinase-associated lipocalin is associated with preeclampsia in a cohort of Turkish women. Hypertens Pregnancy 2019; 38:157-162. [DOI: 10.1080/10641955.2019.1621887] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- Semra Yuksel
- Department of Obstetrics and Gynecology, GOP Taksim Training and Research Hospital, Istanbul, Turkey
| | - Sefik Eser Ozyurek
- Department of Obstetrics and Gynecology, Bagcilar Training and Research Hospital, Istanbul, Turkey
| | - Deniz Kanber Acar
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Cagdas Ozdemir
- Department of Obstetrics and Gynecology, Tunceli State Hospital, Tunceli, Turkey
| | - Sebile Guler
- Department of Obstetrics and Gynecology, School of Medicine, VKV Koc University, Istanbul, Turkey
| | - Huseyin Kiyak
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
| | - Ali Gedikbasi
- Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkey
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Efficacy of expectant management of severe preeclampsia and preeclampsia superimposed on chronic hypertension before 34 weeks gestation. Pregnancy Hypertens 2019; 15:177-180. [PMID: 30825918 DOI: 10.1016/j.preghy.2019.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 01/04/2019] [Accepted: 01/20/2019] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate the effect of chronic hypertension on expectant management for preeclampsia (PE). STUDY DESIGN Pregnant women who were diagnosed with severe PE before 34 weeks of gestation between 2005 and 2016 and managed at a tertiary center were the subjects of the study. Mothers were classified into two groups: a severe superimposed PE (SSP) group and a severe PE (SP) group. We compared the groups in terms of perinatal outcomes. MAIN OUTCOME MEASURES Pregnancy prolongation from the diagnosis of severe PE to delivery. RESULTS The SSP group included 30 women whereas the SP group included 79 women. Expectant management could be performed in 24 subjects (80.0%) in the SSP group and 49 (62.0%) in the SP group (P = 0.110). Gestational age at diagnosis of PE (P = 0.016) and gestational age at delivery (P = 0.031) were significantly lower in the SSP group than in the SP group. There were no significant differences between the groups in terms of pregnancy prolongation (SSP, 8.5 days versus SP, 6.0 days; P = 0.25) or maternal and neonatal complications. CONCLUSIONS Compared to severe PE, severe PE superimposed on chronic hypertension does not increase the prevalence of maternal complications, and an equivalent pregnancy prolongation was obtained. Expectant management was possible in severe superimposed PE on chronic hypertension, as it was in severe PE.
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Ukah UV, De Silva DA, Payne B, Magee LA, Hutcheon JA, Brown H, Ansermino JM, Lee T, von Dadelszen P. Prediction of adverse maternal outcomes from pre-eclampsia and other hypertensive disorders of pregnancy: A systematic review. Pregnancy Hypertens 2017; 11:115-123. [PMID: 29198742 DOI: 10.1016/j.preghy.2017.11.006] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 11/03/2017] [Accepted: 11/20/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND The hypertensive disorders of pregnancy are a leading cause of maternal and perinatal mortality and morbidity. The ability to predict these complications using simple tests could aid in management and improve outcomes. We aimed to systematically review studies that reported on potential predictors of adverse maternal outcomes among women with a hypertensive disorder of pregnancy. METHODS We searched MEDLINE, Embase and CINAHL (inception - December 2016) for studies of predictors of severe maternal complications among women with a hypertensive disorder of pregnancy. Studies were selected in a two-stage process by two independent reviewers, excluding those reporting only on adverse fetal outcomes. We extracted data on study and test(s) characteristics and outcomes. Accuracy of prediction was assessed using sensitivity, specificity, likelihood ratios and area under the receiver operating curve (AUROC). Strong evidence of prediction was taken to be a positive likelihood ratio >10 or a negative likelihood ratio <0.1, and for multivariable models, an AUROC ≥0.70. Bivariate random effects models were used to summarise performance when possible. RESULTS Of 32 studies included, 28 presented only model development and four examined external validation. Tests included symptoms and signs, laboratory tests and biomarkers. No single test was a strong independent predictor of outcome. The most promising prediction was with multivariable models, especially when oxygen saturation, or chest pain/dyspnea were included. CONCLUSION Future studies should investigate combinations of tests in multivariable models (rather than single predictors) to improve identification of women at high risk of adverse outcomes in the setting of the hypertensive disorders of pregnancy.
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Affiliation(s)
- U Vivian Ukah
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Healthy Starts Theme, BC Children's Hospital Research, Vancouver, BC, Canada.
| | - Dane A De Silva
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Beth Payne
- Healthy Starts Theme, BC Children's Hospital Research, Vancouver, BC, Canada; Department of Anaesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Laura A Magee
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada
| | - Helen Brown
- Woodward Library, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Healthy Starts Theme, BC Children's Hospital Research, Vancouver, BC, Canada
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada; Healthy Starts Theme, BC Children's Hospital Research, Vancouver, BC, Canada
| | - Peter von Dadelszen
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
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Mateus J, Newman R, Sibai BM, Li Q, Barton JR, Combs CA, Guzman E, Boggess KA, Gyamfi C, von Dadelszen P, Woelkers D. Massive Urinary Protein Excretion Associated with Greater Neonatal Risk in Preeclampsia. AJP Rep 2017; 7:e49-e58. [PMID: 28348923 PMCID: PMC5365400 DOI: 10.1055/s-0037-1601866] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Objective The objective of this study was to compare clinical outcomes of preeclamptic pregnancies according to the proteinuria level. Study Design Secondary analysis of a multicenter prospective cohort study of women with preeclampsia (PE) symptomatology. Nonproteinuria, mild-proteinuria, and massive-proteinuria PEs were defined as: < 165 mg in 12 hours or < 300 mg in 24 hours, 165 mg to 2.69 g in 12 hours or 300 mg to 4.99 g in 24 hours, and ≥ 2.7 g in 12 hours or ≥ 5.0 g in 24 hours, respectively. Individual and composite maternal, fetal, and neonatal outcomes were compared among the PE groups. Results Of the 406 analyzed pregnancies, 36 (8.8%) had massive-proteinuria PE, 268 (66.0%) mild-proteinuria PE, and 102 (25.1%) nonproteinuria PE. Compared with the other groups, massive-proteinuria PE women had significantly higher blood pressures (p < 0.001), epigastric pain (p = 0.007), and uric acid serum levels (p < 0.001) prior to delivery. Composite maternal morbidity was similar across the groups. Delivery < 340/7 weeks occurred in 80.6, 49.3, and 22.5% of massive-proteinuria, mild-proteinuria, and nonproteinuria PE groups, respectively (p < 0.0001). Composite adverse neonatal outcomes were significantly higher in the massive-proteinuria PE compared with the other groups (p = 0.001). Conclusion While potentially not important diagnostically, massive proteinuria is associated with more severe clinical manifestations of PE prompting earlier delivery.
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Affiliation(s)
- Julio Mateus
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Roger Newman
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina
| | - Baha M Sibai
- Department of Obstetrics and Gynecology, University of Texas Health Science Center at Houston, Houston, Texas
| | - Qing Li
- Center of Behavioral Epidemiology and Community Health (CBEACH), San Diego State University, San Diego, California
| | - John R Barton
- Department of Obstetrics and Gynecology, Central Baptist Hospital, Lexington, Kentucky
| | | | - Edwin Guzman
- Department of Obstetrics and Gynecology, Saint Peter's University Hospital, New Brunswick, New Jersey
| | - Kim A Boggess
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina
| | - Cynthia Gyamfi
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Medical Center, New York
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, St Geroge's, University of London, London, United Kingdom
| | - Doug Woelkers
- Department of Reproductive Medicine, University of California San Diego, La Jolla, California
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Lee AM, Briandet BM, Caranta DG, Zelig CM. Adverse pregnancy outcomes in hypertensive patients: predictive value of protein concentration versus total protein. J Matern Fetal Neonatal Med 2014; 27:1643-5. [PMID: 24484078 DOI: 10.3109/14767058.2014.889112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES To compare the predictive value of protein concentration in a twenty-four hour urine collection to the conventional total protein in a twenty-four hour urine collection for adverse pregnancy outcomes in hypertensive patients. STUDY DESIGN Retrospective cohort study. Hypertensive patients ≥20 weeks estimated gestational age (EGA) who completed twenty-four hour urine protein collections were identified; antepartum and delivery data were examined. For study patients who met criteria for adverse pregnancy outcome, multi-variable analysis was performed and summary receiver operating characteristic (ROC) curves were generated for each model (total protein compared to protein concentration). The models were compared by analyzing the area under the curve (AUC). RESULTS A total of 150 patients were analyzed. Mean gestational age at delivery was 36.7 weeks. Analysis of the ROC curves showed no significant difference between the models (AUCs of 0.668 versus 0.656, p = 0.715). Optimal thresholds were 299.2 mg for total protein and 0.1 mg/ml for protein concentration. CONCLUSION A protein concentration of 0.1 mg/ml on a twenty-four hour urine collection appears equivalent to the traditional 300 mg total protein. If confirmed by prospective studies, this finding would be clinically important in cases where collections fall short of the 300 mg threshold but exceed the 0.1 mg/ml concentration.
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Affiliation(s)
- Amy M Lee
- Department of Obstetrics and Gynecology, Naval Medical Center Portsmouth , Portsmouth, VA , USA and
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Brown RA, Kemp GJ, Walkinshaw SA, Howse M. Pregnancies complicated by preeclampsia and non-preeclampsia-related nephrotic range proteinuria. Obstet Med 2013; 6:159-64. [PMID: 27656249 DOI: 10.1177/1753495x13498382] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE To examine the impact of nephrotic range proteinuria during pregnancy on renal, maternal and fetal outcomes. METHODS A retrospective study of pregnant women with proteinuria greater than 3 g/24 h. Outcome measures included: gestation and mode of delivery, maternal high dependency unit admission, birth weight, maternal blood pressure and proteinuria at time of last follow-up, renal biopsy. RESULTS Two hundred and sixty four pregnancies in 262 women were reviewed. Postnatal data were available in 180; of these 104 (57%) had urinary protein quantified postnatally. Sixty three (60%) were pure preeclampsia and nine (9%) super-imposed preeclampsia. Biopsy-proven renal disease was newly diagnosed in nine (9%). Sixty three per cent required caesarean section and 34% required high dependency unit admission. There were no maternal deaths. Birth weight corrected for gestation was below the fifth centile in 33%. CONCLUSIONS The incidence of underlying renal pathology in this cohort is significant and highlights the importance of careful follow-up.
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Affiliation(s)
- R A Brown
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
| | - G J Kemp
- Institute of Ageing and Chronic Disease, University of Liverpool, UK
| | | | - Mlp Howse
- Royal Liverpool and Broadgreen University Hospitals NHS Trust, UK
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Kucukgoz Gulec U, Ozgunen FT, Buyukkurt S, Guzel AB, Urunsak IF, Demir SC, Evruke IC. Comparison of clinical and laboratory findings in early- and late-onset preeclampsia. J Matern Fetal Neonatal Med 2013; 26:1228-33. [DOI: 10.3109/14767058.2013.776533] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gooding C, Hall DR, Kidd M, Ziskind A. Macular thickness measured by optical coherence tomography correlates with proteinuria in pre-eclampsia. Pregnancy Hypertens 2012; 2:387-92. [DOI: 10.1016/j.preghy.2012.02.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2011] [Revised: 02/08/2012] [Accepted: 02/12/2012] [Indexed: 11/25/2022]
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Sibai BM. Evaluation and management of severe preeclampsia before 34 weeks' gestation. Am J Obstet Gynecol 2011; 205:191-8. [PMID: 22071049 DOI: 10.1016/j.ajog.2011.07.017] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2011] [Accepted: 07/07/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE We sought to review the risks and benefits of expectant management of severe preeclampsia remote from term, and to provide recommendations for expectant management, maternal and fetal evaluation, treatment, and indications for delivery. METHODS Studies were identified through a search of the MEDLINE database for relevant peer-reviewed articles published in the English language from January 1980 through December 2010. Additionally, the Cochrane Library, guidelines by organizations, and studies identified through review of the above documents and review articles were utilized to identify relevant articles. Where reliable data were not available, opinions of respected authorities were used. RESULTS AND RECOMMENDATIONS Published randomized trials and observational studies regarding management of severe preeclampsia occurring <34 weeks of gestation suggest that expectant management of selected patients can improve neonatal outcomes but that delivery is often required for worsening maternal or fetal condition. Patients who are not candidates for expectant management include women with eclampsia, pulmonary edema, disseminated intravascular coagulation, renal insufficiency, abruptio placentae, abnormal fetal testing, HELLP syndrome, or persistent symptoms of severe preeclampsia. For women with severe preeclampsia before the limit of viability, expectant management has been associated with frequent maternal morbidity with minimal or no benefits to the newborn. Expectant management of a select group of women with severe preeclampsia occurring <34 weeks' gestation may improve newborn outcomes but requires careful in-hospital maternal and fetal surveillance.
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Payne B, Magee LA, Côté AM, Hutcheon JA, Li J, Kyle PM, Menzies JM, Peter Moore M, Parker C, Pullar B, von Dadelszen P, Walters BN, von Dadelszen P, Magee L, Douglas M, Walley K, Russell J, Lee S, Gruslin A, Smith G, Côté A, Moutquin JM, Brown M, Davis G, Walters B, Sass N, Duan T, Zhou J, Mahajan S, Noovao A, McCowan L, Kyle P, Moore M, Bhutta S, Bhutta Z, Hall, Steyn D, Broughton Pipkin F, Loughna P, Robson S, de Swiet M, Walker J, Grobman W, Lindheimer M, Roberts J, Mark Ansermino J, Benton S, Cundiff G, Hugo D, Joseph K, Lalji S, Li J, Lott P, Ouellet AB, Shaw D, Keith Still D, Tawagi G, Wagner B, Biryabarema C, Mirembe F, Nakimuli A, Tsigas E, Merialdi M, Widmer M. PIERS Proteinuria: Relationship With Adverse Maternal and Perinatal Outcome. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:588-597. [DOI: 10.1016/s1701-2163(16)34907-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Magee L, Yong P, Espinosa V, Côté A, Chen I, von Dadelszen P. Expectant Management of Severe Preeclampsia Remote from Term: A Structured Systematic Review. Hypertens Pregnancy 2009; 28:312-47. [DOI: 10.1080/10641950802601252] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
The main objective of expectant management in women with severe pre-eclampsia (PE) remote from term is to improve neonatal outcome. Maternal conditions, however, may worsen during expectant management. This highlights the importance of balancing the risks between maternal and perinatal outcomes. Traditionally, women with severe PE remote from term are delivered expeditiously, regardless of gestational age. We here have reported several retrospective, case-control, observational, prospective, or randomized trials in which expectant management in women with severe PE was feasible in well-selected patients without prejudicing maternal safety, and we have described our rationale and guidelines for this management.
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Affiliation(s)
- Bassam Haddad
- Department of Obstetrics and Gynecology, University Paris XII, Creteil, France.
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Thangaratinam S, Coomarasamy A, O'Mahony F, Sharp S, Zamora J, Khan KS, Ismail KMK. Estimation of proteinuria as a predictor of complications of pre-eclampsia: a systematic review. BMC Med 2009; 7:10. [PMID: 19317889 PMCID: PMC2670320 DOI: 10.1186/1741-7015-7-10] [Citation(s) in RCA: 99] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2008] [Accepted: 03/24/2009] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Proteinuria is one of the essential criteria for the clinical diagnosis of pre-eclampsia. Increasing levels of proteinuria is considered to be associated with adverse maternal and fetal outcomes. We aim to determine the accuracy with which the amount of proteinuria predicts maternal and fetal complications in women with pre-eclampsia by systematic quantitative review of test accuracy studies. METHODS We conducted electronic searches in MEDLINE (1951 to 2007), EMBASE (1980 to 2007), the Cochrane Library (2007) and the MEDION database to identify relevant articles and hand-search of selected specialist journals and reference lists of articles. There were no language restrictions for any of these searches. Two reviewers independently selected those articles in which the accuracy of proteinuria estimate was evaluated to predict maternal and fetal complications of pre-eclampsia. Data were extracted on study characteristics, quality and accuracy to construct 2 x 2 tables with maternal and fetal complications as reference standards. RESULTS Sixteen primary articles with a total of 6749 women met the selection criteria with levels of proteinuria estimated by urine dipstick, 24-hour urine proteinuria or urine protein:creatinine ratio as a predictor of complications of pre-eclampsia. All 10 studies predicting maternal outcomes showed that proteinuria is a poor predictor of maternal complications in women with pre-eclampsia. Seventeen studies used laboratory analysis and eight studies bedside analysis to assess the accuracy of proteinuria in predicting fetal and neonatal complications. Summary likelihood ratios of positive and negative tests for the threshold level of 5 g/24 h were 2.0 (95% CI 1.5, 2.7) and 0.53 (95% CI 0.27, 1) for stillbirths, 1.5 (95% CI 0.94, 2.4) and 0.73 (95% CI 0.39, 1.4) for neonatal deaths and 1.5 (95% 1, 2) and 0.78 (95% 0.64, 0.95) for Neonatal Intensive Care Unit admission. CONCLUSION Measure of proteinuria is a poor predictor of either maternal or fetal complications in women with pre-eclampsia.
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Affiliation(s)
- Shakila Thangaratinam
- Academic Unit of Obstetrics and Gynaecology, Birmingham Women's Hospital, Birmingham, UK.
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Norwitz ER, Funai EF. Expectant management of severe preeclampsia remote from term: hope for the best, but expect the worst. Am J Obstet Gynecol 2008; 199:209-12. [PMID: 18771969 DOI: 10.1016/j.ajog.2008.06.084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2008] [Accepted: 06/25/2008] [Indexed: 11/28/2022]
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Steyn DW, Odendaal HJ, Hall DR. Diurnal blood pressure variation in the evaluation of early onset severe pre-eclampsia. Eur J Obstet Gynecol Reprod Biol 2008; 138:141-6. [PMID: 17913329 DOI: 10.1016/j.ejogrb.2007.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2005] [Revised: 06/27/2007] [Accepted: 08/09/2007] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To study the association between diurnal variation in blood pressure, the mean daily blood pressure and various complications of pregnancy in patients presenting with severe pre-eclampsia before 34 weeks' gestation. STUDY DESIGN Forty-four women presenting to a tertiary hospital in South Africa with severe pre-eclampsia between 28 and 34 weeks' gestation were managed expectantly for at least 8 days. We measured maternal blood pressure every 30 min with the pregnancy validated Spacelabs 90209 automated blood pressure monitor for 24h periods on alternative days. The mean 24-h diastolic blood pressure measurement, the mean diastolic blood pressure for daytime and nighttime, the day-night blood pressure difference and the night-day ratio were compared with the occurrence of abruptio placentae, gestational age at delivery, neonatal intensive care unit admission, birth weight, abnormal umbilical artery Doppler FVW and reason for delivery. RESULTS One hundred and seventy-six 24-h studies were analyzed. The day-night blood pressure difference decreased with increasing mean diastolic blood pressure (r=-0.323, p<0.0001). A combination of normal mean diastolic blood pressure and normal day-night blood pressure difference was associated with increased gestational age and lower caesarean section rates. CONCLUSION The combination of mean diastolic blood pressure and day-night blood pressure difference may be a supplementary measurement of disease severity in early onset severe pre-eclampsia and seems to be of prognostic value.
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Affiliation(s)
- Daniël W Steyn
- Department of Obstetrics and Gynaecology, Tygerberg Hospital and the University of Stellenbosch, Tygerberg 7505, South Africa.
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Côté AM, Brown MA, Lam E, von Dadelszen P, Firoz T, Liston RM, Magee LA. Diagnostic accuracy of urinary spot protein:creatinine ratio for proteinuria in hypertensive pregnant women: systematic review. BMJ 2008; 336:1003-6. [PMID: 18403498 PMCID: PMC2364863 DOI: 10.1136/bmj.39532.543947.be] [Citation(s) in RCA: 149] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/12/2008] [Indexed: 01/11/2023]
Abstract
OBJECTIVE To review the spot protein:creatinine ratio and albumin:creatinine ratio as diagnostic tests for significant proteinuria in hypertensive pregnant women. DESIGN Systematic review. DATA SOURCES Medline and Embase, the Cochrane Library, reference lists, and experts. Review methods Literature search (1980-2007) for articles of the spot protein:creatinine ratio or albumin:creatinine ratio in hypertensive pregnancy, with 24 hour proteinuria as the comparator. RESULTS 13 studies concerned the spot protein:creatinine ratio (1214 women with primarily gestational hypertension). Nine studies reported sensitivity and specificity for eight cut-off points, median 24 mg/mmol (range 17-57 mg/mmol; 0.15-0.50 mg/mg). Laboratory assays were not well described. Diagnostic test characteristics were recalculated for a cut-off point of 30 mg/mmol. No significant heterogeneity in cut-off points was found between studies over a range of proteinuria. Pooled values gave a sensitivity of 83.6% (95% confidence interval 77.5% to 89.7%), specificity of 76.3% (72.6% to 80.0%), positive likelihood ratio of 3.53 (2.83 to 4.49), and negative likelihood ratio of 0.21 (0.13 to 0.31) (nine studies, 1003 women). Two studies of the spot albumin:creatinine ratio (225 women) found optimal cut-off points of 2 mg/mmol for proteinuria of 0.3 g/day or more and 27 mg/mmol for albuminuria. CONCLUSION The spot protein:creatinine ratio is a reasonable "rule-out" test for detecting proteinuria of 0.3 g/day or more in hypertensive pregnancy. Information on use of the albumin:creatinine ratio in these women is insufficient.
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Affiliation(s)
- Anne-Marie Côté
- BC Women's Hospital and Health Centre, Vancouver, BC, Canada
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Reference. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2008. [DOI: 10.1016/s1701-2163(16)32783-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Gaugler-Senden IPM, Huijssoon AG, Visser W, Steegers EAP, de Groot CJM. Maternal and perinatal outcome of preeclampsia with an onset before 24 weeks’ gestation. Eur J Obstet Gynecol Reprod Biol 2006; 128:216-21. [PMID: 16359774 DOI: 10.1016/j.ejogrb.2005.11.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2005] [Revised: 07/01/2005] [Accepted: 11/11/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Preeclampsia, with an onset before 24 weeks' gestation is a rare but severe condition in pregnancy with little data of maternal and perinatal outcome, particularly after expectant management. We therefore, evaluated pregnancy outcome in these women at our department where temporising management was introduced as the standard policy in early onset preeclampsia. STUDY DESIGN We analysed retrospectively all consecutive women with preeclampsia, with an onset before 24 weeks' gestation, between 1 January 1993 and 31 December 2002 at a tertiary university referral center. RESULTS Twenty-six pregnancies, of which two were twin pregnancies, resulted in 65% of the women in at least one major maternal complication: maternal death (n=1), HELLP syndrome (n=16), eclampsia (n=5) and pulmonary edema (n=4). Thirty percent of these women presented already with serious morbidity at admission. The median prolongation of the pregnancy was 24 days (range 3-46 days). The overall perinatal mortality was 82%: 19 fetal deaths and 4 neonatal deaths. CONCLUSION Early onset preeclampsia, with an onset before 24 weeks' gestation, results in considerable maternal and perinatal morbidity and mortality. Therefore, expectant management should not be considered as a routine treatment option in these patients.
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Affiliation(s)
- Ingrid P M Gaugler-Senden
- Department of Obstetrics and Gynecology, Erasmus MC, University Medical Center Hospital Rotterdam, SKZ 4130, Dr. Molewaterplein 60, 3015 GJ Rotterdam, The Netherlands.
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Hladunewich MA, Derby GC, Lafayette RA, Blouch KL, Druzin ML, Myers BD. Effect of l-Arginine Therapy on the Glomerular Injury of Preeclampsia. Obstet Gynecol 2006; 107:886-95. [PMID: 16582128 DOI: 10.1097/01.aog.0000207637.01824.fe] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess the benefit of l-arginine, the precursor to nitric oxide, on blood pressure and recovery of the glomerular lesion in preeclampsia. METHODS Forty-five women with preeclampsia were randomized to receive either l-arginine or placebo until day 10 postpartum. Primary outcome measures including mean arterial pressure, glomerular filtration rate, and proteinuria were assessed on the third and 10th days postpartum by inulin clearance and albumin-to-creatinine ratio. Nitric oxide, cyclic guanosine 3'5' monophosphate, endothelin-1, and asymmetric-dimethyl-arginine and arginine levels were assayed before delivery and on the third and 10th days postpartum. Healthy gravid women provided control values. Assuming a standard deviation of 10 mm Hg, the study was powered to detect a 10-mm Hg difference in mean arterial pressure (alpha .05, beta .20) between the study groups. RESULTS No significant differences existed between the groups with preeclampsia before randomization. Compared with the gravid control group, women with preeclampsia exhibited significantly increased serum levels of endothelin-1, cyclic guanosine 3'5' monophosphate, and asymmetric-dimethyl-arginine before delivery. Despite a significant increase in postpartum serum arginine levels due to treatment, no differences were found in the corresponding levels of nitric oxide, endothelin-1, cyclic guanosine 3'5' monophosphate, or asymmetric-dimethyl-arginine between the two groups with preeclampsia. Further, there were no significant differences in any of the primary outcome measures with both groups demonstrating similar levels in glomerular filtration rate and equivalent improvements in both blood pressure and proteinuria. CONCLUSION Blood pressure and kidney function improve markedly in preeclampsia by the 10th day postpartum. Supplementation with l-arginine does not hasten this recovery. LEVEL OF EVIDENCE I.
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Affiliation(s)
- M A Hladunewich
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
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Abstract
The hypertensive diseases of pregnancy commonly refer to a group of disorders whose definitions have changed over time within and among professional organizations. Pre-eclampsia, either mild or severe, is managed best with a policy of delivery at or beyond 37 and 34 weeks' gestation, respectively. Similarly, chronic hypertension,gestational hypertension, and chronic hypertension with superimposed pre-eclampsia are conditions wherein it is difficult to justify expectant management beyond 37 weeks' gestation. The approach to management before these gestational ages is subject to interpretation of a limited body of literature.
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Affiliation(s)
- Anthony R Gregg
- Department of Obstetrics and Gynecology, Department of Molecular and Human Genetics, Baylor College of Medicine, 6550 Fannin Suite, 901A, Houston, TX 77030, USA.
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