Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003

Perinatal outcomes and their determinants among women with eclampsia and severe preeclampsia in selected tertiary hospitals, Eastern Ethiopia

BACKGROUND

Neonatal complications and deaths are still increasing worldwide. Therefore, this study aimed to assess perinatal outcomes and their determinants among women with eclampsia and severe preeclampsia admitted to selected tertiary hospitals Eastern Ethiopia.

METHODS

The prospective observational study was conducted among 245 foetal born to women with eclampsia and severe preeclampsia admitted to selected Hospitals. Data were collected from patients' charts and maternal interviews using questionnaires and telephone follow-ups from April 01 to September 30, 2022. Then, Cox regression were used to determine the predictors of perinatal clinical outcomes by SPSS (version 21.0®). Hazard ratios with a two-sided P-value < 0.05 were considered statistically significant.

RESULT

Of 245 deliveries, perinatal mortality was 26.1 % and about 57.4 % of newborns developed neonatal complications. Fifth-minute Apgar score (AHR: 10.3; 95 % C.I: 3.8-28.1; P: 0.0001) was statistically a determinant to perinatal mortality whereas maternal parity (AHR: 1.7; 95 % CI: 1.0-2.86; P: 0.05), maternal diagnosis (AHR: 2.1; 95 % C.I:1.17-3.66; P: 0.012), maternal complications (AHR: 1.96; 95 % C.I: 1.13-3.41; P: 0.018) and fifth-minute Apgar score (AHR: 2.0; 95 % C.I: 1.29-3.19; P: 0.002) were found to be determinants for neonatal complications.

CONCLUSION

Despite the inclusion of magnesium sulphate into the national drug list of Ethiopia to reduce maternal and perinatal morbidity and mortality, the perinatal condition remained a severe concern and worse among patients with eclampsia. Interventions to reduce the incidence of eclampsia, better antenatal care, early recognition, prompt treatment of severe preeclampsia, and enhanced neonatal care have to be initiated for patients.

Clinical tools and biomarkers to predict preeclampsia

Preeclampsia is pregnancy-specific, and significantly contributes to maternal, and perinatal morbidity and mortality worldwide. An effective predictive test for preeclampsia would facilitate early diagnosis, targeted surveillance and timely delivery; however limited options currently exist. A first-trimester screening algorithm has been developed and validated to predict preterm preeclampsia, with poor utility for term disease, where the greatest burden lies. Biomarkers such as sFlt-1 and placental growth factor are also now being used clinically in cases of suspected preterm preeclampsia; their high negative predictive value enables confident exclusion of disease in women with normal results, but sensitivity is modest. There has been a concerted effort to identify potential novel biomarkers that might improve prediction. These largely originate from organs involved in preeclampsia's pathogenesis, including placental, cardiovascular and urinary biomarkers. This review outlines the clinical imperative for an effective test and those already in use and summarises current preeclampsia biomarker research.

Correlation of platelet parameters with adverse maternal and neonatal outcomes in severe preeclampsia: A case-control study

BACKGROUND

Pre-eclampsia (PET) is a potentially devastating multi-systemic disorder resulting in the generation of oxidative stress. Platelet activation causes vasoconstriction and release of inflammatory cytokines, resulting in an intensified inflammatory response, endothelial damage, and coagulopathy which culminate in adverse pregnancy outcomes.

AIM

To compare the platelet parameters between preeclamptic and normotensive pregnant women and their relationship to adverse outcomes in women with pre-eclampsia.

MATERIALS AND METHODS

This was a case-control study of platelet indices of 60 pre-eclamptic and 60 normotensive pregnant women recruited at 28 weeks and followed till delivery. A blood sample was collected at entry into the study and just before delivery. The sample was analyzed within 1 h of collection using the Mythic 18 hematological auto-analyzer. Data were analyzed using IBM-SPSS version 22. A P-value of <0.05 was considered statistically significant.

RESULTS

The mean platelet count, Platelet distribution width (PDW), plateletcrit were statistically significantly different between normotensive and severe preeclamptic participants (p= <0.001). Statistically significant differences were not present in any of the platelet parameters between mild and severe PET. The odds of developing eclampsia was low at higher mean platelet count and plateletcrit levels above 161.36 ± 73.74 × 109/L [p = 0.02, AOR = 0.27, 95% CI (0.08-0.88)] and 0.13 ± 0.05% [p = 0.001, AOR = 0.22, 95% CI (0.08-0.58)] respectively. Eclampsia was strongly associated with P-LCR (platelet-large cell ratio) above 23.15 ± 4.92% [p = 0.004, AOR = 11.00, 95%CI (1.48-89.02)]. Abruptio placentae had low odds at lower levels of mean plateletcrit. Pre-term birth was significantly lower at mean plateletcrit levels above 0.14 ± 0.05%; admission into neonatal intensive care unit was strongly associated with a mean PLC ratio above 22.73 ± 5.91%.

CONCLUSION

This study demonstrated significant differences in platelet count, plateletcrit, platelet distribution width, and P-LCR between pre-eclamptic and normotensive women. Increase in P-LCR is a risk factor for eclampsia although the effect size is low.

Incidence and determinants of adverse outcomes among women who were managed for eclampsia in the University of Gondar Comprehensive Specialized Hospital, Northwest Ethiopia

Background

The incidence of eclampsia and its adverse maternal outcomes are very high in developing countries, particularly in Subsaharan African Countries. Identifying predictors for adverse maternal outcomes of eclampsia has paramount importance for helping health care providers to optimize their management outcomes. Therefore, this study aimed to assess the incidence of adverse maternal outcomes of eclampsia and its determinant factors.

Methods

A retrospective follow-up study design was applied. The data were extracted from patient charts using a structured, pre-tested, questionnaire. Descriptive analyses (frequencies, means, and standard deviation) were calculated, and bi-variable and multivariable logistic regression models were used to testing the association between independent variables and an outcome variable. After the data were coded and entered into Epi-Info Version 7.2 Software, the data were analyzed using STATA Version 14 Statistical Software.

Results

The magnitude of eclampsia was 5.36 per 1000 pregnancies (95% CI: 4.72, 6.10). The incidence of adverse maternal outcomes in eclamptic mothers was 53.7% (95% CI: 47.02, 60.24%). After adjusting for covariates maternal age 30–34, AOR 5.4 [95% CI = 1.02, 28.6]; age above 34, AOR 10.5 [95% CI = 1.3, 88.6]; gravidity 2–4, AOR 0.3 [95% CI = 0.1, 0.9]; 10 or more convulsions, AOR 4.6 [95% CI = 1.4, 14.9]; mild pyrexia, AOR 20.4 [95% CI = 3.7, 112.7]; moderate pyrexia, AOR 14.6 [95% CI = 1.7125.1]; platelet count below 50,000 cells/mm³, AOR 34.9 [95% CI = 3.6, 336.2]; platelet count between 50,000 and 99,000 cells/mm³, AOR 24.5 [95%CI = 5.4111.6]; and stillbirth of the current pregnancy, AOR 23.2 [95%CI = 2.1257.5] were strong predictors of adverse maternal outcomes in eclamptic mothers.

Conclusions

The incidence of adverse maternal outcomes of eclampsia was found to be high compared to similar studies discussed in this study. This study recommends early identification of patients with the risk factors (having many convulsions, high body temperature, low platelet count, patient age above 30 years, and 2–4 pregnancies), strengthening the referral system, and advocation of research on the area of adverse maternal outcomes and thereby encourage evidence-based medicine.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04199-1.

Historical and Recent Changes in Maternal Mortality Due to Hypertensive Disorders in the United States, 1979 to 2018

[Figure: see text].

Hypertensive Disorders of Pregnancy

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.

Incidence and Predictors of Pre-Eclampsia Among Pregnant Women Attending Antenatal Care at Debre Markos Referral Hospital, North West Ethiopia: Prospective Cohort Study

Background

Pre-eclampsia is a pregnancy-induced hypertension that occurs after 20 weeks of gestation. It is the leading cause of maternal and perinatal morbidity and mortality globally, but it is higher in developing countries. In Ethiopia, conducting research on the incidence and predictors of pre-eclampsia is crucial due to the paucity of information.

Methods

A prospective cohort study was undertaken using 242 pregnant women between November 1, 2018 and March 30, 2019 at Debre Markos Referral Hospital. All eligible women who fulfilled the inclusion criteria were included in this study. Data were entered into the epic-data Version 4.2 and analyzed using the STATA Version 14.0 software. The Cox-proportional hazard regression model was fitted and Cox-Snell residual test was used to assess the goodness of fit. Pre-eclampsia free survival time was estimated using the Kaplan–Meier survival curve. Both bivariable and multivariable Cox-proportional hazard regression models were fitted to identify predictors of pre-eclampsia.

Results

The overall incidence rate of pre-eclampsia was 3.35 per 100 person-years. Having a pre-existing history of diabetes mellitus [AHR=2.7 (95% CI=1.43–8.81)], having a history of multiple pregnancy [AHR=3.4 (95% CI=2.8–6.9)] and being ≥35 years old age [AHR=2.5 (95% CI=1.42–3.54)] were the significant predictors of pre-eclampsia.

Conclusion

The incidence of pre-eclampsia was high in this study. Having (pre-existing diabetes and multiple pregnancy) and being ≥35 years old age were the significant predictors of pre-eclampsia. Inspiring pregnant women’s health-seeking behavior should provide a chance to diagnose pre-eclampsia early to prevent the medical complication of pre-eclampsia.

Admission into intensive care unit in preeclampsia: a four-year population-based study in Reunion Island

INTRODUCTION

Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. The objective of our study was to study risk factors and complications associated with severe preeclampsia requiring intensive care unit (ICU) admission.

METHODS

Retrospective comparative study over a period from 1st of January 2015 to 1st of January 2019 in the University's maternity unit of South Reunion (Indian Ocean). Our sampling included all preeclamptic patients who delivered in the Southern part of the island. Patients admitted to intensive care unit (ICU) and those who remained in the maternity unit (controls) were reviewed.

RESULTS

Out of 482 preeclampsia cases, 94 women (19.5%) needed a transfer in ICU, of which only 21 (4.3%) needed invasive intensive care. Mean length of stay was 2.4 ± 2.1 days. ICU admission was associated with HELLP syndrome (OR 8.5 [4.9-14.9], p<.001), severe post-partum hemorrhage (OR 5.86 [1.29-26.70], p=.01) and early onset of preeclampsia (<34 weeks gestation), 2.97 [1.9-4.7], p<.001), leading to higher rate of C-section (OR 2.83 [1.67-4.78], p<.001). There were three patients with a history of eclampsia and no case of maternal death was reported. Fetal prognosis was much poorer in maternal ICU admissions than in controls, with outcomes including lower birth weight (1776 vs. 2304 g, p<.001) and higher perinatal morbidity (infant respiratory distress syndrome 3.70 [1.94-7.05], p<.001) and mortality (<.001).

CONCLUSIONS

Women needing invasive ICU represented 4.3% of preeclampsia cases. This experience is of interest for lower resource settings such as in countries like Madagascar where very intensive ICU means are very poor, but simpler ICU surveillance is possible. Fetal prognosis was poor though no maternal death was reported. Thus, a multidisciplinary approach of patients with preeclampsia should be encouraged; admission into ICU should be facilitated, as soon as any sign of severity and complications appears.

Second-Trimester Maternal Serum Beta-Human Chorionic Gonadotropin and Lipid Profile as a Predictor of Gestational Hypertension, Preeclampsia, and Eclampsia: A Prospective Observational Study

Background:

Hypertensive disorders of pregnancy are important complications of pregnancy and are associated with high maternal and perinatal mortality and morbidity. Early diagnosis may improve maternal and perinatal outcome by ensuring appropriate management.

Aim:

Our aim is to assess the serum beta-human chorionic gonadotropin (hCG) and serum lipid profile in the early and late trimesters of at-risk mothers and to analyze whether these parameters can be used to predict pregnancy-induced hypertension (PIH) and its time of onset.

Materials and Methods:

A prospective observational study was conducted in the Department of Obstetrics and Gynecology, Tata Main Hospital, Jamshedpur, India. Two hundred antenatal women were screened for serum beta-hCG and lipid profile in their early (14–18 weeks) and late (24–28 weeks) second trimesters. All patients were followed up till delivery and observed for the development of PIH. Results were evaluated and analyzed statistically.

Results:

The incidence of PIH in our study was 14.67% (n = 27). Most of the patients had late-onset PIH (88.88%, n = 27), whereas 11.12% (n = 3) had an early onset of the disease. Of 27 patients, 6 patients developed preeclampsia and none had eclampsia. The mean beta-hCG level in the study population at the early second trimester was 91,723.97, whereas in the late second trimester, it was 22,456.25. In PIH patients, a significant increase in the level of serum cholesterol, triglyceride, and very-low-density lipoprotein was noted in both the early and late second trimesters.

Conclusion:

This study showed that serum beta-hCG and lipid profile in the second trimester are useful indicators to identify women who are likely to develop PIH, preeclampsia, or eclampsia.

ACOG Committee Opinion No. 767: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period

Acute-onset, severe systolic hypertension; severe diastolic hypertension; or both can occur during the prenatal, intrapartum, or postpartum periods. Pregnant women or women in the postpartum period with acute-onset, severe systolic hypertension; severe diastolic hypertension; or both require urgent antihypertensive therapy. Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency. Treatment with first-line agents should be expeditious and occur as soon as possible within 30-60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. Intravenous labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available. In the rare circumstance that intravenous bolus labetalol, hydralazine, or immediate release oral nifedipine fails to relieve acute-onset, severe hypertension and is given in successive appropriate doses, emergent consultation with an anesthesiologist, maternal-fetal medicine subspecialist, or critical care subspecialist to discuss second-line intervention is recommended.

Oral antihypertensive regimens (nifedipine retard, labetalol, and methyldopa) for management of severe hypertension in pregnancy: an open-label, randomised controlled trial

BACKGROUND

Hypertension is the most common medical disorder in pregnancy, complicating one in ten pregnancies. Treatment of severely increased blood pressure is widely recommended to reduce the risk for maternal complications. Regimens for the acute treatment of severe hypertension typically include intravenous medications. Although effective, these drugs require venous access and careful fetal monitoring and might not be feasible in busy or low-resource environments. We therefore aimed to compare the efficacy and safety of three oral drugs, labetalol, nifedipine retard, and methyldopa for the management of severe hypertension in pregnancy.

METHODS

In this multicentre, parallel-group, open-label, randomised controlled trial, we compared these oral antihypertensives in two public hospitals in Nagpur, India. Pregnant women were eligible for the trial if they were aged at least 18 years; they were pregnant with fetuses that had reached a gestational age of at least 28 weeks; they required pharmacological blood pressure control for severe hypertension (systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg); and were able to swallow oral medications. Women were randomly assigned to receive 10 mg oral nifedipine, 200 mg oral labetalol (hourly, in both of which the dose could be escalated if hypertension was maintained), or 1000 mg methyldopa (a single dose, without dose escalation). Masking of participants, study investigators, and care providers to group allocation was not possible because of different escalation protocols in the study groups. The primary outcome was blood pressure control (defined as 120-150 mm Hg systolic blood pressure and 70-100 mm Hg diastolic blood pressure) within 6 h with no adverse outcomes. This study is registered with ClinicalTrials.gov, number NCT01912677, and the Clinical Trial Registry, India, number ctri/2013/08/003866.

FINDINGS

Between April 1, 2015, and Aug 21, 2017, we screened 2307 women for their inclusion in the study. We excluded 1413 (61%) women who were ineligible, declined to participate, had impending eclampsia, were in active labour, or had a combination of these factors. 11 (4%) women in the nifedipine group, ten (3%) women in the labetalol group, and 11 (4%) women in the methyldopa group were ineligible for treatment (because they had only one qualifying blood pressure measurement) or had treatment stopped (because of delivery or transfer elsewhere). 894 (39%) women were randomly assigned to a treatment group and were included in the intention-to-treat analysis: 298 (33%) women were assigned to receive nifedipine, 295 (33%) women were assigned to receive labetalol, and 301 (33%) women were assigned to receive methyldopa. The primary outcome was significantly more common in women in the nifedipine group than in those in the methyldopa group (249 [84%] women vs 230 [76%] women; p=0·03). However, the primary outcome did not differ between the nifedipine and labetalol groups (249 [84%] women vs 228 [77%] women; p=0·05) or the labetalol and methyldopa groups (p=0·80). Seven serious adverse events (1% of births) were reported during the study: one (<1%) woman in the labetalol group had an intrapartum seizure and six (1%) neonates (one [<1%] neonate in the nifedipine group, two [1%] neonates in the labetalol group, and three [1%] neonates in the methyldopa group) were stillborn. No birth had more than one adverse event.

INTERPRETATION

All oral antihypertensives reduced blood pressure to the reference range in most women. As single drugs, nifedipine retard use resulted in a greater frequency of primary outcome attainment than labetalol or methyldopa use. All three oral drugs-methyldopa, nifedipine, and labetalol-are viable initial options for treating severe hypertension in low-resource settings.

FUNDING

PREEMPT (University of British Columbia, Vancouver, BC, Canada; grantee of Bill & Melinda Gates Foundation).

Pre-eclampsia through the eyes of the obstetrician and anesthesiologist

Due to the high risk of morbidity and mortality from unrecognized and untreated pre-eclampsia, clinicians should have a high index of suspicion to evaluate, treat and monitor patients presenting with signs concerning for pre-eclampsia. Early blood pressure management and seizure prophylaxis during labor are critical for maternal safety. Intrapartum, special anesthetic considerations should be employed to ensure the safety of the parturient and fetus. Patients who have pre-eclampsia should be aware that they are at high risk for the future development of cardiovascular disease.

Pharmacotherapy for hypertension in pregnant patients: special considerations

INTRODUCTION

Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated.

AREAS COVERED

This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP.

EXPERT OPINION

Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.

Outcomes of patients admitted to the intensive care unit for complications of hypertensive disorders of pregnancy at a South African tertiary hospital - a 4-year retrospective review

Background

Hypertensive disorders of pregnancy (HDP) are a major cause of maternal mortality and adverse outcomes. A previous study in the intensive care unit (ICU) at King Edward VIII Hospital, Durban, South Africa, in 2000 found 10.5% mortality among eclampsia patients.

Objectives

To describe the mortality and adverse neurological outcomes associated with HDP in a tertiary ICU, compare these with results from 2000 and describe factors associated therewith.

Methods

The data of 85 patients admitted with HDP to ICU at King Edward VIII Hospital from 2010 to 2013 were retrospectively reviewed. Mortality and adverse neurological outcome (Glasgow Coma Scale (GCS) ≤14 on discharge from ICU) were assessed. Two sets of analyses were conducted. The first compared those alive on discharge from ICU with those who died in ICU. The second compared good neurological outcome with poor outcome (adverse neurological outcome, or death).

Results

The mortality was 11.6%, and overall, 9% had adverse neurological outcomes. There was no significant difference in mortality between patients with eclampsia in 2010 - 2013 (11.0%) and those in 2000 (10.5%) (p=0.9). Factors associated with mortality were: intra- or postpartum onset of seizures; twins; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; respiratory failure; and lower respiratory tract infections. Factors associated with poor outcomes (adverse neurological outcome, or death) were: parity (better outcomes in primiparous patients); time of antenatal onset of hypertension (worse if earlier onset); HIV infection; failure to perform operative delivery when indicated; lowest GCS score <10; failure to use magnesium sulphate when indicated; use of anticonvulsants other than magnesium sulphate or benzodiazepines in eclampsia.

Conclusion

The lack of improvement in ICU eclampsia mortality demonstrates a need to develop and implement a protocol for HDP management.

Contributions of the study

The study provides a comparison of present mortality among eclamptic patients with hyperensive disorders of pregnancy (HDP) with the mortality of eclamptic patients described in an article from the year 2000. It further looks at adverse maternal outcomes, specifically adverse neurological outcomes.In addition, it analyses other factors that may affect outcomes in HDP patients. This information is useful in making recommendations in an attempt to improve the outcomes.

State-of-the-Art Diagnosis and Treatment of Hypertension in Pregnancy

Hypertension complicates up to 10% of pregnancies worldwide. Pregnancy hypertension is defined as systolic blood pressure (BP) equal to or greater than 140 mm Hg or diastolic BP equal to or greater than 90 mm Hg, usually on the basis of measurements in office/clinic settings and using various BP devices. Hypertensive disorders of pregnancy are classified into (1) chronic hypertension diagnosed before pregnancy or before 20 weeks' gestation, (2) gestational hypertension diagnosed at equal to or greater than 20 weeks, or (3) preeclampsia, defined restrictively as gestational hypertension with proteinuria or broadly as gestational hypertension with proteinuria or an end-organ manifestation consistent with preeclampsia. Absolute BP values equal to or greater than 140/90 mm Hg are associated with increased maternal and perinatal risks, particularly with preeclampsia. This review focuses on antihypertensive therapy of hypertensive disorders of pregnancy as a specific management strategy. Underpinning this therapy is the need for accurate measurement of BP, agreed-upon classification of pregnancy hypertension, agreed-upon BP thresholds for enhanced surveillance and antihypertensive treatment, and collaborative teamwork in management. Challenges relate to the methodology of studies on which care is based, as well as aspects of the care itself, particularly the unregulated use of home BP monitoring. Pitfalls include the unsubstantiated belief that nifedipine and magnesium sulfate cannot be used together and the perception that severe hypertension and nonsevere hypertension are separate entities rather than lying along a spectrum of BP values. The following must be addressed by future research: guidance for nuanced care as women transition between severe and nonsevere hypertension, personalized antihypertensive therapy, and incorporation of women's values into research priorities and clinical practice when antihypertensive care is chosen.

Are Women With Threatened Preterm Labor More Dehydrated Than Women Without It?

OBJECTIVE

To determine if women who present to the labor and delivery unit at 23 0/7 to 36 6/7 weeks gestation with threatened preterm labor (TPTL) are more likely to be dehydrated than women who present at the same gestational age for other reasons.

DESIGN

Retrospective cohort study.

SETTING

An academic medical center in the northeastern United States.

PARTICIPANTS

All women at preterm gestational ages 23 0/7 to 36 6/7 weeks who presented to the labor and delivery unit for care in 2014.

METHODS

We compared hydration status by urine specific gravity of women with TPTL to that of women with other chief complaints. Women for whom data were missing and those with hypertension, diabetes, renal disease, vaginal bleeding, ruptured membranes, advanced dilation (>3 cm), multiple gestation, or fetal demise were excluded. Chi-square statistic and a receiver operating characteristic (ROC) curve were used for data analysis.

RESULTS

A total of 840 women at 23 0/7 to 36 6/7 weeks gestation presented during the study period; 188 of these had TPTL, 261 had other chief complaints, and 391 were excluded. The proportion of women diagnosed with dehydration was similar between those with TPTL (39%) and those with other complaints (46%, p = .12). An ROC curve showed no association between TPTL and hydration status (area under the curve = 0.57, 95% confidence interval [0.46, 0.67]).

CONCLUSION

At 23 0/7 to 36 6/7 weeks gestation, the hydration status of women with TPTL was not different from those without TPTL. Because there is no relationship, it is unlikely that hydration is a worthwhile therapy for women with TPTL, although additional prospective study is warranted.

Successful pregnancy outcomes following liver transplantation is predicted by renal function

Liver transplantation (LT) is a successful treatment for both acute liver failure and end-stage liver disease. The number of women of reproductive age undergoing LT is increasing. Pregnancy outcomes are favorable, but there is still a lack of prognostic markers. We aimed to identify factors predictive of adverse pregnancy outcomes in LT recipients. An analysis of all pregnancies occurring in LT recipients from 1989 to 2016 at King's College Hospital was performed. Clinical data of 162 conceptions in 93 women were reviewed. Descriptive and regression analyses were done to examine associations between laboratory markers and hepatological scores with pregnancy outcomes of live birth and preterm birth. Median age at LT was 23 years (range, 1-41 years), with a median age at conception of 30 years (range, 18-47 years). The live birth rate was 75% (n = 121). Of live births, 35% (n = 39/110 available) were delivered preterm. Preconception creatinine levels were higher in patients who had a preterm birth (85 versus 74 μmol/L; P = 0.008), with a preconception estimated glomerular filtration rate (eGFR) <90 mL/minute significantly associated with preterm delivery (P = 0.04). Progressive decline in eGFR predicted outcome, with gestational length declining with increasing chronic kidney disease (CKD) stage: CKD 0-1 = 39 weeks (median), CKD 2 = 37 weeks, and CKD 3 = 35 weeks. The risk of preterm birth was greatest in women with an eGFR <60 mL/minute (P = 0.004). Moreover, hypertension-related complications during pregnancy, such as gestational hypertension, preeclampsia, or eclampsia, were also associated with prematurity (P = 0.01). Women taking steroid-based immunosuppression had an increased risk of infection during pregnancy or postpartum (15% versus 4%; P = 0.02). In conclusion, although the majority of women have a successful pregnancy outcome after LT, preconception renal function predicts pregnancy outcome and steroids increase risk of infection during pregnancy or postpartum. Liver Transplantation 24 606-615 2018 AASLD.

The influence of fluid management on outcomes in preeclampsia: a systematic review and meta-analysis

BACKGROUND

The optimal fluid management strategy to ensure best outcomes in preeclamptic patients remains a controversial issue, with little evidence to support any one approach.

OBJECTIVE

The aim of this systematic review was to investigate the effect of various fluid management strategies on clinical outcomes, haemodynamic indices and biochemical markers in preeclamptic women and their babies. Primary outcome measures were the occurrence of pulmonary oedema and/or the development of renal impairment.

METHODS

A systematic review of randomised fluid management strategies was conducted. Five electronic databases were searched using the expanded search terms: 'intravenous fluid', 'plasma substitutes', 'intravenous fluid management', 'intravenous fluid therapy', plasma volume expansion', 'fluid restriction', 'oncotic therapy', 'crystalloids', 'colloids', 'preeclampsia', 'toxemia of pregnancy', 'pregnancy-induced hypertension', 'eclampsia' and 'gestational proteinuric hypertension'.

RESULTS

Six randomised controlled trials (RCTs), from nine publications, were included in the final analysis. There were no differences between groups with respect to the incidence of pulmonary oedema, perinatal mortality, preterm delivery and caesarean section. Colloid volume expansion was associated with a significantly lower systolic and diastolic blood pressure, but had no effect on heart rate or cardiac index. Data on systemic vascular resistance (SVR), serum atrial natriuretic peptide (ANP) and urine volume could not be aggregated.

CONCLUSION

Data on the ideal fluid strategy in women with preeclampsia is limited, and insufficient to make any strong recommendations. Further randomised controlled studies are needed to provide more evidence for which fluid management strategies are best suited to this heterogeneous patient group.

Severe preeclampsia and eclampsia: incidence, complications, and perinatal outcomes at a low-resource setting, Mpilo Central Hospital, Bulawayo, Zimbabwe

Background

Severe preeclampsia is a disorder of pregnancy characterized by high blood pressure and significant proteinuria after 20 weeks gestation. Severe preeclampsia and eclampsia have considerable adverse impacts on maternal, fetal, and neonatal health especially in low-resource countries. Hypertensive disorders of pregnancy are the third leading cause of maternal deaths in Sub-Saharan Africa. Significant avoidable maternal and neonatal morbidity and mortality may result.

Objectives

This study aimed 1) to determine the incidence of severe preeclampsia/eclampsia in a low-resource setting; 2) to determine the maternal complications of severe preeclampsia/eclampsia in a low-resource setting; 3) to determine the perinatal outcomes of severe preeclampsia/eclampsia in a low-resource setting.

Methods

This was a retrospective descriptive cohort study carried out at Mpilo Central Hospital, a tertiary teaching referral government hospital in a low-resource setting in Bulawayo, Zimbabwe. Data were obtained from the birth registers in labor ward, intensive care unit, and neonatal intensive care unit of patients who had a diagnosis of severe preeclampsia or eclampsia for the period January 1, 2016, to December 31, 2016. The case notes were retrieved and the demographic, clinical, and outcome data were gathered.

Results

There were 9,086 deliveries at the institution during the period January 1, 2016, to December 31, 2016. There were 121 cases of severe preeclampsia/eclampsia. The incidence of severe preeclampsia/eclampsia was 1.3% at Mpilo Central Hospital. The most common major complication was HELLP syndrome (9.1%). Maternal mortality was 1.7%. There were 127 babies born with six sets of twins, 49.6% of the babies were lost through stillbirths and early neonatal deaths.

Conclusion

The incidence of severe preeclampsia/eclampsia at Mpilo Central Hospital was 1.3%. The most common maternal complication was hemolysis elevated liver enzymes low platelet syndrome. Maternal mortality was 1.7% due to acute renal failure. Nearly half (49.6%) of the babies born were lost to stillbirths and early neonatal deaths.

Improving the quality of obstetric care for women with obstructed labour in the national referral hospital in Uganda: lessons learnt from criteria based audit

Background

Obstructed labour remains a major cause of maternal morbidity and mortality whose complications can be reduced with improved quality of obstetric care. The objective was to assess whether criteria-based audit improves quality of obstetric care provided to women with obstructed labour in Mulago hospital, Uganda.

Methods

Using criteria-based audit, management of obstructed labour was analyzed prospectively in two audits. Six standards of care were compared. An initial audit of 180 patients was conducted in September/October 2013. The Audit results were shared with key stakeholders. Gaps in patient management were identified and recommendations for improving obstetric care initiated. Six standards of care (intravenous fluids, intravenous antibiotics, monitoring of maternal vital signs, bladder catheterization, delivery within two hours, and blood grouping and cross matching) were implemented. A re-audit of 180 patients with obstructed labour was conducted four months later to evaluate the impact of these recommendations. The results of the two audits were compared. In-depth interviews and focus group discussions were conducted among healthcare providers to identify factors that could have influenced the audit results.

Results

There was improvement in two standards of care (intravenous fluids and intravenous antibiotic administration) 58.9 % vs. 86.1 %; p < 0.001 and 21.7 % vs. 50.5 %; P < 0.001 respectively after the second audit. There was no improvement in vital sign monitoring, delivery within two hours or blood grouping and cross matching. There was a decline in bladder catheterization (94 % vs. 68.9 %; p < 0.001. The overall mean care score in the first and second audits was 55.1 and 48.2 % respectively, p = 0.19. Healthcare factors (negative attitude, low numbers, poor team work, low motivation), facility factors (poor supervision, stock-outs of essential supplies, absence of protocols) and patient factors (high patient load, poor compliance to instructions) contributed to poor quality of care.

Conclusion

Introduction of criteria based audit in the management of obstructed labour led to measurable improvements in only two out of six standards of care. The extent to which criteria based audit may improve quality of obstetric care depends on having basic effective healthcare systems in place.

Eclapmsia: The Major Cause of Maternal Mortality in Eastern India

BACKGROUND

Eclampsia is a very serious complication of pregnancy which is responsible for high maternal and perinatal mortality. Worldwide, it accounts for 50,000 maternal deaths annually. In spite of several global and regional interventions and initiatives from governments and other concerned agencies, maternal mortality is still very high in India, with eclampsia as a major cause. This study was conducted to determine the mode of deaths and incidence of maternal mortality associated with eclampsia and to assess how socio-demographic and clinical characteristics of the women influence the deaths.

MATERIALS AND METHODS

This is a retrospective study of 111 eclampsia related maternal deaths over a period of 5 years from January 2008 to December 2012. Data pertaining to their age, parity, booking status, gestational age at delivery, and time interval from admission to death were also obtained from the records for analysis.

RESULTS

Eclampsia accounted for 43.35% of total maternal deaths, with case fatality of 4.960%. The commonest mode of death in eclampsia is pulmonary oedema. Death due to eclampsia commonly occurs in younger age group of 19-24 years and in primi gravid. Eclampsia related deaths were mostly seen in illiterate and unbooked cases. Maternal deaths were also very common in lower socio economic status.

CONCLUSION

Eclampsia still remains the major cause of maternal mortality in this region resulting from unsupervised pregnancies and deliveries. There is a need to educate and encourage the general public for antenatal care and hospital delivery by which we can defeat this powerful enemy.

Evaluation of Maternal Complications in Severe Preeclampsia in a University Hospital in Tirana

BACKGROUND:

Preeclampsia is a hypertensive multisystem disorder of pregnancy that complicates up to 10% of pregnancies worldwide and is one of the leading causes of maternal and perinatal morbidity and mortality.

AIM:

To evaluate maternal complications associated with severe preeclampsia.

METHODS:

This is a retrospective cross-sectional study conducted in the UHOG “Koço Gliozheni”, in Tirana. Primary outcomes evaluated: maternal death, eclampsia, stroke, HELLP syndrome, and pulmonary edema. Secondary outcomes: renal failure, admission in ICU, caesarean section, placental abruption, and postpartum hemorrhage. Fisher’s exact test and Chi-squared test were used as statistical methods.

RESULTS:

In women with severe preeclampsia we found higher rates of complications comparing to the group with preeclampsia. Eclampsia (1.5% vs. 7.1%, P < 0.001), HELLP syndrome (2.4% vs. 11.0%; P < 0.001), stroke (0.5% vs 1.9%, P = 0.105) pulmonary edema (0.25% vs. 1.3%, P = 0.0035), renal failure (0.9% vs. 2.6%, P = 0.107), admission in ICU (19.5% vs. 71.4%, P = 0.007), caesarean section rates (55.5% vs. 77%, P = 0.508), placental abruption (4.3% vs. 7.8%, P = 0.103) and severe postpartum hemorrhage (3.2% vs. 3.9%, P = 0.628).

CONCLUSION:

Severe preeclampsia is associated with high rates of maternal severe morbidity and early diagnosis and timely intervention can prevent life treating complications.

The Epidemiology of Liver Diseases Unique to Pregnancy in a US Community: A Population-Based Study

BACKGROUND & AIMS

Little is known in the United States about the epidemiology of liver diseases that develop only during (are unique to) pregnancy. We investigated the incidence of liver diseases unique to pregnancy in Olmsted County, Minnesota, and long-term maternal and fetal outcomes.

METHODS

We identified 247 women with liver diseases unique to pregnancy from 1996 through 2010 using the Rochester Epidemiology Project database. The crude incidence rate was calculated by the number of liver disease cases divided by 35,101 pregnancies.

RESULTS

Of pregnant women with liver diseases, 134 had preeclampsia with liver dysfunction, 72 had hemolysis-associated increased levels of liver enzymes and low-platelet (HELLP) syndrome, 26 had intrahepatic cholestasis of pregnancy, 14 had hyperemesis gravidarum with abnormal liver enzymes, and 1 had acute fatty liver of pregnancy. The crude incidence of liver diseases unique to pregnancy was 0.77%. Outcomes were worse among women with HELLP or preeclampsia than the other disorders--of women with HELLP, 70% had a premature delivery, 4% had abruptio placentae, 3% had acute kidney injury, and 3% had infant death. Of women with preeclampsia, 56.0% had a premature delivery, 4% had abruptio placentae, 3% had acute kidney injury, and 0.7% had infant death. After 7 median years of follow-up (range, 0-18 years), 14% of the women developed recurrent liver disease unique to pregnancy; the proportions were highest in women with initial hyperemesis gravidarum (36%) or intrahepatic cholestasis of pregnancy (35%). Women with preeclampsia were more likely to develop subsequent hepatobiliary diseases.

CONCLUSIONS

We found the incidence of liver disease unique to pregnancy in Olmsted County, Minnesota, to be lower than that reported from Europe or US tertiary referral centers. Maternal and fetal outcomes in Olmsted County were better than those reported from other studies, but fetal mortality was still high (0.7%-3.0%). Women with preeclampsia or HELLP are at higher risk for peripartum complications and subsequent development of comorbidities.

Intensive care management and outcome of women with hypertensive diseases of pregnancy

INTRODUCTION

The burden of hypertensive diseases on the health care is enormous given to the high population in Sub-Saharan Africa and related disproportionate representation in global maternal mortality.

MATERIALS AND METHODS

All women with hypertensive diseases of pregnancy who got admitted into the general ICU of the University of Benin Teaching Hospital between January 2006 and December 2010 were studied. Only the records of women who completed 28 weeks of gestation and were admitted during labour and delivery or puerperium to the ICU were examined.

RESULTS

There were 13061 deliveries within the 5-year study period; 9301 by vaginal delivery and 3860 through Caesarean section. 52 (51.5%) of the obstetric patients had hypertensive diseases of pregnancy. Of 52 women with pre-eclampsia and eclampsia, 45/52 had caesarean section and 7/52 had SVD. Admission was mainly postpartum 48/52 (92.3%). 35/52 (67.3%) were transferred to the ward and 17 died (32.7%), giving the ICU maternal mortality rate of 307/1000 deliveries. 30 women developed pulmonary oedema alone or with renal impairment; 14 women were transferred and 16 died while 21 other patients who had renal impairment alone, HELLP, sepsis, etc were transferred out. There was about a 12-fold risk of death in the unit if the patient developed pulmonary oedema when compared to the other factors combined (p = 0.0002, RR = 11.7, 95%CI = 1.7 - 82.).

CONCLUSION

Primiparity, unbooked status and caesarean delivery were leading factors for ICU admission in women with preeclampsia/eclampsia. The women who developed pulmonary oedema in the course of treatment had poor outcome and avoidance of pulmonary oedema may improve ICU outcome in women with preeclampsia/eclampsia.

Fulminant antenatal pulmonary oedema in a woman with hypertension and superimposed preeclampsia

An asymptomatic 40-year-old para 1 black African woman with pre-existing hypertension and a booking blood pressure of 120/80 mm Hg, was admitted with superimposed preeclampsia diagnosed because of worsening hypertension and significant proteinuria at 27+5 weeks gestation. Antenatally, her blood pressure was controlled with labetalol, and blood tests including serum creatinine were within normal limits for pregnancy. Three days later, the patient developed severe hypertension despite treatment, and reported sudden onset severe shortness of breath; oxygen saturations on air dropped to 93%. Auscultation revealed widespread crepitations leading to a working diagnosis of pulmonary oedema. Despite appropriate management, respiratory function continued to deteriorate and she required intubation, ventilation and emergency caesarean section under general anaesthesia. A live male infant was delivered floppy and was intubated and resuscitated. He awaits discharge home on oxygen. The mother's pulmonary oedema resolved postpartum. Echocardiogram showed left ventricular hypertrophy but normal left ventricular function and the patient's hypertension is being controlled on medication.

Labetalol for hypertension in pregnancy

INTRODUCTION

Labetalol is one of the most commonly used antihypertensive medications for the treatment of hypertension during pregnancy, an increasingly common and leading cause of maternal mortality and morbidity worldwide.

AREAS COVERED

The literature reviewed included the 2014 Canadian national pregnancy hypertension guideline and its references. The additional published literature was retrieved through searches of Medline, CINAHL, and The Cochrane Library using appropriate controlled vocabulary (e.g., pregnancy, hypertension, pre-eclampsia, pregnancy toxemias) and key words (e.g., diagnosis, evaluation, classification, prediction, prevention, prognosis, treatment, and postpartum follow-up).Results were restricted to systematic reviews, randomized controlled trials, controlled clinical trials, and observational studies published in French or English, Jan-Mar/14. The unpublished literature was identified by searching websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. We evaluated the impact of interventions on substantive clinical outcomes for mothers and babies.

EXPERT OPINION

Labetalol is a reasonable choice for treatment of severe or non-severe hypertension in pregnancy. However, we should continue our search for other therapeutic options.

Epidemiology of venous thromboembolism (VTE) associated with pregnancy

This review is focused on the epidemiology of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), associated with pregnancy. Superficial vein thrombosis, a less hazardous and less studied type of thrombosis in pregnant women, is beyond the scope of this review. This study discusses the VTE incidence rate in women from developed countries for both antepartum and postpartum periods and for subpopulations of women affected by additional risk factors, such as thrombophilias, circulatory diseases, preeclampsia of varying degrees of severity, and Caesarean section. To minimize bias due to historical changes in medical and obstetric practices, lifestyle, diet, etc., this review is generally limited to relatively recent studies, i.e., those that cover the last 35 years. The absolute risk or incidence rate was used to ascertain risk of VTE associated with pregnancy. For the studies where the direct incidence rates of VTE were not reported, we calculated an estimate of the observed but not reported absolute incidence rates using the data presented in respective articles.

[Epidemiology of pre-eclampsia in Tizi-ouzou city (Algeria)]

OBJECTIVES

The main objective was to estimate the prevalence of pre-eclampsia (PE) in pregnant women in Tizi-ouzou (Algeria). Secondary objectives were to estimate the frequency of PE risk factors, and the incidence of maternal and fetal complications.

METHODS

Our study was observational, prospective and descriptive, including all pregnant women at the prenatal appointment in the 2 maternity units of Tizi-ouzou, between January 2012 and June 2013. PE was diagnosed if gestational hypertension was associated with proteinuria > 300 mg/24h, after 20 weeks of gestation.

RESULTS

We had 252 cases of PE on 3225 pregnant women. The prevalence of PE was 7.8% (CI 95%: 6.9%-8.7%). The most frequent PE risk factors were nulliparity (56%), age >40 years (27%), obesity (26%) and PE in any previous pregnancy (21%). The incidence of maternal adverse events was 28.7% (CI 95%: 23.1%-34.3%), including 5 deaths. The rates of prematurity, small for gestational age infant and fetal death were 58.2%, 49.7% and 6.7%, respectively.

CONCLUSION

The prevalence of PE in pregnant women in Tizi-ouzou is around 8%. The incidence of maternal and fetal adverse outcomes remains high. Only earlier diagnosis and closer monitoring could improve the prognosis of our patients, since the treatment of PE remains currently childbirth.

Early pregnancy prediction of preeclampsia in nulliparous women, combining clinical risk and biomarkers: the Screening for Pregnancy Endpoints (SCOPE) international cohort study

More than half of all cases of preeclampsia occur in healthy first-time pregnant women. Our aim was to develop a method to predict those at risk by combining clinical factors and measurements of biomarkers in women recruited to the Screening for Pregnancy Endpoints (SCOPE) study of low-risk nulliparous women. Forty-seven biomarkers identified on the basis of (1) association with preeclampsia, (2) a biological role in placentation, or (3) a role in cellular mechanisms involved in the pathogenesis of preeclampsia were measured in plasma sampled at 14 to 16 weeks' gestation from 5623 women. The cohort was randomly divided into training (n=3747) and validation (n=1876) cohorts. Preeclampsia developed in 278 (4.9%) women, of whom 28 (0.5%) developed early-onset preeclampsia. The final model for the prediction of preeclampsia included placental growth factor, mean arterial pressure, and body mass index at 14 to 16 weeks' gestation, the consumption of ≥3 pieces of fruit per day, and mean uterine artery resistance index. The area under the receiver operator curve (95% confidence interval) for this model in training and validation cohorts was 0.73 (0.70-0.77) and 0.68 (0.63-0.74), respectively. A predictive model of early-onset preeclampsia included angiogenin/placental growth factor as a ratio, mean arterial pressure, any pregnancy loss <10 weeks, and mean uterine artery resistance index (area under the receiver operator curve [95% confidence interval] in training and validation cohorts, 0.89 [0.78-1.0] and 0.78 [0.58-0.99], respectively). Neither model included pregnancy-associated plasma protein A, previously reported to predict preeclampsia in populations of mixed parity and risk. In nulliparous women, combining multiple biomarkers and clinical data provided modest prediction of preeclampsia.

The 'immunologic theory' of preeclampsia revisited: a lesson from donor oocyte gestations

OBJECTIVE

To determine the prevalence of placental complications in patients conceived through donor versus autologous oocytes.

STUDY DESIGN

A retrospective cohort study including 2 groups of patients who conceived through in vitro fertilization using: (1) donor oocyte (n = 139) and (2) autologous oocyte (n = 126). Only singleton gestations were included. The rate of placental complications including preeclampsia, gestational hypertension, and intrauterine growth restriction was compared between these 2 groups.

RESULTS

The women who conceived using donor oocytes were older compared with women who conceived using autologous oocytes (median maternal age 45 vs 41, P < .01). The rate of hypertensive diseases of pregnancy including gestational hypertension and preeclampsia was significantly higher in ovum donor recipients compared with women conceived with autologous oocytes (25% vs 10%, P < .01). Similarly, the rate of intrauterine growth restriction was also higher among patients conceived through oocyte donation although it did not reach statistical significance (9.3% vs 4%, P = .08). When maternal age was restricted to ≤45 years, the rate of hypertensive diseases of pregnancy remained significantly higher among ovum donor compared with autologous oocyte recipients (22% vs 10%, P = .02). Adjustment for maternal age, gravidity, parity, and chronic hypertension revealed that oocyte donation was independently associated with higher rate of hypertensive diseases of pregnancy (P = .01).

CONCLUSION

Patients conceived through oocyte donation have an increased risk for placental complications of pregnancy. These findings support the 'immunologic theory' suggesting that immunologic intolerance between the mother and the fetus may play an important role in the pathogenesis of preeclampsia.

Oral antihypertensive therapy for severe hypertension in pregnancy and postpartum: a systematic review

BACKGROUND

Pregnant and postpartum women with severe hypertension are at increased risk of stroke and require blood pressure (BP) reduction. Parenteral antihypertensives have been most commonly studied, but oral agents would be ideal for use in busy and resource-constrained settings.

OBJECTIVES

To review systematically, the effectiveness of oral antihypertensive agents for treatment of severe pregnancy/postpartum hypertension.

SEARCH STRATEGY

A systematic search of MEDLINE, EMBASE and the Cochrane Library was performed.

SELECTION CRITERIA

Randomised controlled trials in pregnancy and postpartum with at least one arm consisting of a single oral antihypertensive agent to treat systolic BP ≥ 160 mmHg and/or diastolic BP ≥ 110 mmHg.

DATA COLLECTION AND ANALYSIS

Cochrane RevMan 5.1 was used to calculate relative risk (RR) and weighted mean difference by random effects.

MAIN RESULTS

We identified 15 randomised controlled trials (915 women) in pregnancy and one postpartum trial. Most trials in pregnancy compared oral/sublingual nifedipine capsules (8-10 mg) with another agent, usually parenteral hydralazine or labetalol. Nifedipine achieved treatment success in most women, similar to hydralazine (84% with nifedipine; relative risk [RR] 1.07, 95% confidence interval [95% CI] 0.98-1.17) or labetalol (100% with nifedipine; RR 1.02, 95% CI 0.95-1.09). Less than 2% of women treated with nifedipine experienced hypotension. There were no differences in adverse maternal or fetal outcomes. Target BP was achieved ~ 50% of the time with oral labetalol (100 mg) or methyldopa (250 mg) (47% labetelol versus 56% methyldopa; RR 0.85 95% CI 0.54-1.33).

CONCLUSIONS

Oral nifedipine, and possibly labetalol and methyldopa, are suitable options for treatment of severe hypertension in pregnancy/postpartum.

Hypertensive disorders of pregnancy and the recent increase in obstetric acute renal failure in Canada: population based retrospective cohort study

OBJECTIVE

To examine whether changes in postpartum haemorrhage, hypertensive disorders of pregnancy, or other risk factors explain the increase in obstetric acute renal failure in Canada.

DESIGN

Retrospective cohort study.

SETTING

Canada (excluding the province of Quebec).

PARTICIPANTS

All hospital deliveries from 2003 to 2010 (n=2,193,425).

MAIN OUTCOME MEASURES

Obstetric acute renal failure identified by ICD-10 diagnostic codes.

METHODS

Information on all hospital deliveries in Canada (excluding Quebec) between 2003 and 2010 (n=2,193,425) was obtained from the Canadian Institute for Health Information. Temporal trends in obstetric acute renal failure were assessed among women with and without postpartum haemorrhage, hypertensive disorders of pregnancy, or other risk factors. Logistic regression was used to determine if changes in risk factors explained the temporal increase in obstetric acute renal failure.

RESULTS

Rates of obstetric acute renal failure rose from 1.66 to 2.68 per 10,000 deliveries between 2003-04 and 2009-10 (61% increase, 95% confidence interval 24% to 110%). Adjustment for postpartum haemorrhage, hypertensive disorders, and other factors did not attenuate the increase. The temporal increase in acute renal failure was restricted to deliveries with hypertensive disorders (adjusted increase 95%, 95% confidence interval 38% to 176%), and was especially pronounced among women with gestational hypertension with significant proteinuria (adjusted increase 171%, 71% to 329%). No significant increase occurred among women without hypertensive disorders (adjusted increase 12%, -28 to 72%).

CONCLUSIONS

The increase in obstetric acute renal failure in Canada between 2003 and 2010 was restricted to women with hypertensive disorders and was especially pronounced among women with pre-eclampsia. Further study is required to determine the cause of the increase among women with pre-eclampsia.

Safety of pertussis vaccination in pregnant women in UK: observational study

OBJECTIVE

To examine the safety of pertussis vaccination in pregnancy.

DESIGN

Observational cohort study.

SETTING

The UK Clinical Practice Research Datalink.

PARTICIPANTS

20,074 pregnant women with a median age of 30 who received the pertussis vaccine and a matched historical unvaccinated control group.

MAIN OUTCOME MEASURE

Adverse events identified from clinical diagnoses during pregnancy, with additional data from the matched child record identified through mother-child linkage. The primary event of interest was stillbirth (intrauterine death after 24 weeks' gestation).

RESULTS

There was no evidence of an increased risk of stillbirth in the 14 days immediately after vaccination (incidence rate ratio 0.69, 95% confidence interval 0.23 to 1.62) or later in pregnancy (0.85, 0.44 to 1.61) compared with historical national rates. Compared with a matched historical cohort of unvaccinated pregnant women, there was no evidence that vaccination accelerated the time to delivery (hazard ratio 1.00, 0.97 to 1.02). Furthermore, there was no evidence of an increased risk of stillbirth, maternal or neonatal death, pre-eclampsia or eclampsia, haemorrhage, fetal distress, uterine rupture, placenta or vasa praevia, caesarean delivery, low birth weight, or neonatal renal failure, all serious events that can occur naturally in pregnancy.

CONCLUSION

In women given pertussis vaccination in the third trimester, there is no evidence of an increased risk of any of an extensive predefined list of adverse events related to pregnancy. In particular, there was no evidence of an increased risk of stillbirth. Given the recent increases in the rate of pertussis infection and morbidity and mortality in neonates, these early data provide initial evidence for evaluating the safety of the vaccine in pregnancy for health professionals and the public and can help to inform vaccination policy making.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Absence of association between serum folate and preeclampsia in women exposed to food fortification

OBJECTIVE

To evaluate serum folate concentration early in pregnancy and any association with hypertensive disorders of pregnancy in a population exposed to folic acid supplementation and food fortification.

METHODS

This is a nested case-control study based on a prospective cohort of 7,929 pregnant women recruited in the Quebec City metropolitan area, including 214 participants who developed a hypertensive disorder of pregnancy and 428 normotensive participants in the control group matched for parity, multiple pregnancy, smoking status, gestational, and maternal age at inclusion, and duration of blood sample storage. Serum folate levels were measured at a mean of 14 weeks of gestation.

RESULTS

More than 98% of the participants took folic acid or multivitamins before the end of the first trimester. Mean serum folate levels were accordingly high and there were no differences between women who further developed a hypertensive disorder of pregnancy compared with women in the control group (60.1 nmol/L compared with 57.9 nmol/L; P=.51). The proportion of participants with serum folate below the 10th percentile (less than 22.3 nmol/L) of age-matched women in our outpatient population was similar between groups (P=.66) and no participant had levels generally defined as folate deficiency (less than 10 nmol/L).

CONCLUSION

In a general cohort of pregnant women benefiting from a national policy of folic acid food fortification combined with a high adherence to folic acid supplementation, serum folate levels are high and do not differ between women who develop a hypertensive disorder of pregnancy and women who remain normotensive. Further supplementation with higher doses is unlikely to be beneficial in such populations.

LEVEL OF EVIDENCE

II.

Hypertensive disease of pregnancy and maternal mortality

PURPOSE OF REVIEW

The incidence of hypertensive disorders in pregnancy is increasing and is associated with maternal mortality worldwide. This review provides the obstetrician with an update of the current issues concerning hypertension and maternal mortality.

RECENT FINDINGS

Preeclampsia affects about 3% of pregnancies, and all other hypertensive disorders complicate approximately 5-10% of pregnancies in the United States. In industrialized countries, rates of preeclampsia, gestational hypertension, and chronic hypertension have increased as rates of eclampsia have decreased following widespread antenatal care and magnesium sulfate use. Increased maternal mortality is associated with eclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, hepatic or central nervous system hemorrhage, and vascular insult to the cardiopulmonary or renal system. Diagnosis and acute management of severe hypertension is central to reducing maternal mortality. African-American women have a higher risk of mortality from hypertensive disorders of pregnancy compared with Hispanic, American Indian/Alaska Native, Asian/Pacific Islander, and Caucasian women.

SUMMARY

Hypertensive disorders in pregnancy are a leading cause of maternal mortality worldwide. The incidence of hypertension in pregnancy continues to increase. Currently, we are unable to determine which patient will develop superimposed preeclampsia or identify subsets of preeclampsia syndrome. Opportunities for research in this area exist to better define treatment aimed at improving maternal outcomes.

Maternal plasma concentrations of sST2 and angiogenic/anti-angiogenic factors in preeclampsia

OBJECTIVES

Angiogenic/anti-angiogenic factors have emerged as one of the promising biomarkers for the prediction of preeclampsia. Since not all patients with preeclampsia can be identified by these analytes, the search for additional biomarkers continues. The soluble form of ST2 (sST2), a protein capable of binding to interleukin (IL)-33 and thus contributing to a Th1-biased immune response, has been reported to be elevated in maternal plasma of women with preeclampsia. The aims of this study were to examine: (1) differences in maternal plasma concentrations of sST2 and IL-33 between women diagnosed with preeclampsia and those having uncomplicated pregnancies; (2) the relationship between sST2, umbilical and uterine artery Doppler velocimetry, and the severity of preeclampsia; and (3) the performance of sST2 and angiogenic/anti-angiogenic factors in identifying patients with preeclampsia at the time of diagnosis.

METHODS

This cross-sectional study included women with preeclampsia (n = 106) and women with an uncomplicated pregnancy (n = 131). Plasma concentrations of sST2, IL-33, soluble vascular endothelial growth factor receptor (sVEGFR)-1, soluble endoglin (sEng) and placental growth factor (PlGF) were determined by enzyme linked immune sorbent assay. Area under the receiver operating characteristic curve (AUC) for the identification of preeclampsia was examined for each analyte.

RESULTS

(1) Patients with preeclampsia had a higher mean plasma concentrations of sST2 than those with an uncomplicated pregnancy (p < 0.0001), while no significant difference in the mean plasma concentration of IL-33 between the two groups was observed; (2) the magnitude of this difference was greater in early-onset, compared to late-onset disease, and in severe compared to mild preeclampsia; (3) sST2 plasma concentrations did not correlate with the results of uterine or umbilical artery Doppler velocimetry (p = 0.7 and p = 1, respectively) among women with preeclampsia; (4) sST2 correlated positively with plasma concentrations of sVEGFR1-1 and sEng (Spearman's Rho = 0.72 and 0.63; each p < 0.0001), and negatively with PlGF (Spearman's Rho = -0.56, p < 0.0001); and (5) while the AUC achieved by sST2 and angiogenic/anti-angiogenic factors in identifying women with preeclampsia at the time of diagnosis were non-significantly different prior to term (<37 weeks of gestation), thereafter the AUC achieved by sST2 was significantly less than that achieved by angiogenic/anti-angiogenic factors.

CONCLUSIONS

Preeclampsia is associated with increased maternal plasma concentrations of sST2. The findings that sST2 concentrations do not correlate with uterine or umbilical artery Doppler velocimetry in women with preeclampsia suggest that elevated maternal plasma sST2 concentrations in preeclampsia are not related to the increased impedance to flow in the utero-placental circulation. The performance of sST2 in identifying preeclampsia at the time of diagnosis prior to 37 weeks of gestation was comparable to that of angiogenic/anti-angiogenic factors. It remains to be elucidated if an elevation of maternal plasma sST2 concentrations in pregnancy is specific to preeclampsia.

Maternal plasma concentrations of angiogenic/antiangiogenic factors in the third trimester of pregnancy to identify the patient at risk for stillbirth at or near term and severe late preeclampsia

OBJECTIVE

To determine whether maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng), and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) at 30-34 weeks of gestation can identify patients at risk for stillbirth, late preeclampsia, and delivery of small-for-gestational-age (SGA) neonates.

STUDY DESIGN

A prospective cohort study included 1269 singleton pregnant women from whom blood samples were obtained at 30-34 weeks of gestation and who delivered at >34 weeks of gestation. Plasma concentrations of PlGF, sEng, and sVEGFR-1 were determined by enzyme-linked immunosorbent assay.

RESULTS

The prevalence of late (>34 weeks of gestation) preeclampsia, severe late preeclampsia, stillbirth, and SGA was 3.2% (n = 40), 1.8% (n = 23), 0.4% (n = 5), and 8.5% (n = 108), respectively. A plasma concentration of PlGF/sEng <0.3 MoM was associated with severe late preeclampsia (adjusted odds ratio, 16); the addition of PlGF/sEng to clinical risk factors increased the area under the receiver-operating characteristic curve from 0.76 to 0.88 (P = .03). The ratio of PlGF/sEng or PlGF/sVEGFR-1 in the third trimester outperformed those obtained in the first or second trimester and uterine artery Doppler velocimetry at 20-25 weeks of gestation for the prediction of severe late preeclampsia (comparison of areas under the receiver-operating characteristic curve; each P ≤ .02). Both PlGF/sEng and PlGF/sVEGFR-1 ratios achieved a sensitivity of 74% with a fixed false-positive rate of 15% for the identification of severe late preeclampsia. A plasma concentration of PlGF/sVEGFR-1 <0.12 MoM at 30-34 weeks of gestation had a sensitivity of 80%, a specificity of 94%, and a likelihood ratio of a positive test of 14 for the identification of subsequent stillbirth. Similar findings (sensitivity 80%; specificity 93%) were observed in a separate case-control study.

CONCLUSION

Risk assessment for stillbirth and severe late preeclampsia in the third trimester is possible with the determination of maternal plasma concentrations of angiogenic and antiangiogenic factors at 30-34 weeks of gestation.

Effect of magnesium sulfate on Doppler parameters of fetal umbilical and middle cerebral arteries in women with severe preeclampsia

Objective:

To assess the effect of injecting magnesium sulfate on Doppler parameters of fetal umbilical and middle cerebral arteries (MCA) in women with severe preeclampsia.

Materials and Methods:

A total of 21 patients with severe preeclampsia admitted to Imam Reza Hospital, Kermanshah (Iran), were evaluated. Before and after administration of magnesium sulfate, Doppler ultrasound scan was carried out to measure fetal middle cerebral artery and umbilical artery blood flow. Paired t-test was used for statistical analysis.

Results:

After injection of magnesium sulfate, the mean resistivity index (RI)-umbilical, and pulsatility index (PI)-cerebral showed a statistically significant reduction (P < 0.001). The cerebroumbilical C/U ratio increased after the intervention (P < 0.001). The PI-umbilical (P = 0.1) and pre- and post-RI-cerebral (P = 0.96) did not have statistically significant changes.

Conclusions:

Infusion of magnesium sulfate significantly decreases the flow in the fetus RI-umbilical and PI-MCA, and it increases C/U ratio indices in color Doppler ultrasound.

Improved quality of management of eclampsia patients through criteria based audit at Muhimbili National Hospital, Dar es Salaam, Tanzania. Bridging the quality gap

BACKGROUND

Criteria-based audits (CBA) have been used to improve clinical management in developed countries, but have only recently been introduced in the developing world. This study discusses the use of a CBA to improve quality of care among eclampsia patients admitted at a University teaching hospital in Dar es Salaam Tanzania.

OBJECTIVE

The prevalence of eclampsia in MNH is high (≈6%) with the majority of cases arriving after start of convulsions. In 2004-2005 the case-fatality rate in eclampsia was 5.1% of all pregnant women admitted for delivery (MNH obstetric data base). A criteria-based audit (CBA) was used to evaluate the quality of care for eclamptic mothers admitted at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania after implementation of recommendations of a previous audit.

METHODS

A CBA of eclampsia cases was conducted at MNH. Management practices were evaluated using evidence-based criteria for appropriate care. The Ministry of Health (MOH) guidelines, local management guidelines, the WHO manual supplemented by the WHO Reproductive Health Library, standard textbooks, the Cochrane database and reviews in peer reviewed journals were adopted. At the initial audit in 2006, 389 case notes were assessed and compared with the standards, gaps were identified, recommendations made followed by implementation. A re-audit of 88 cases was conducted in 2009 and compared with the initial audit.

RESULTS

There was significant improvement in quality of patient management and outcome between the initial and re-audit: Review of management plan by senior staff (76% vs. 99%; P=0.001), urine for albumin test (61% vs. 99%; P=0.001), proper use of partogram to monitor labour (75% vs. 95%; P=0.003), treatment with steroids for lung maturity (2.0% vs. 24%; P=0.001), Caesarean section within 2 hours of decision (33% vs. 61%; P=0.005), full blood count (28% vs. 93%; P=0.001), serum urea and creatinine (44% vs. 86%; P=0.001), liver enzymes (4.0% vs. 86%; P=0.001), and specialist review within 2 hours of admission (25% vs. 39%; P=0.018). However, there was no significant change in terms of delivery within 24 hours of admission (69% vs. 63%; P=0.33). There was significant reduction of maternal deaths (7.7% vs. 0%; P=0.001).

CONCLUSION

CBA is applicable in low resource setting and can help to improve quality of care in obstetrics including management of pre-eclampsia and eclampsia.