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Amikam U, Botkovsky Y, Hochberg A, Cohen A, Levin I, Yogev Y, Hiersch L, Lavie A. Risk factors for relaparotomy after a cesarean delivery: a case-control study. BMC Pregnancy Childbirth 2024; 24:284. [PMID: 38632502 PMCID: PMC11022349 DOI: 10.1186/s12884-024-06455-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/27/2024] [Indexed: 04/19/2024] Open
Abstract
BACKGROUND Relaparotomy following a cesarean delivery (CD) is an infrequent complication, with inconsistency regarding risk factors and indications for its occurrence. We therefore aimed to determine risk factors and indications for a relaparotomy following a CD at a single large tertiary center. METHODS A retrospective case-control single-center study (2013-2023). We identified all women who had a relaparotomy up to six weeks following a CD (study group). Maternal characteristics, obstetrical and surgical data were compared to a control group in a 1:2 ratio. Controls were women with a CD before and immediately after each case in the study group, who did not undergo a relaparotomy. Included were CDs occurring after 24 gestational weeks. CD performed at different centers and indications for repeat surgery unrelated to the primary surgery (e.g., appendicitis) were excluded. Logistic regression was used to adjust for potential confounders. RESULTS During the study period, 131,268 women delivered at our institution. Of them, 28,280 (21.5%) had a CD, and 130 patients (0.46%) underwent a relaparotomy. Relaparotomies following a CD occurred during the first 24 h, the first week, and beyond the first week, in 59.2%, 33.1%, and 7.7% of cases, respectively. In the multivariable logistic regression analysis, relaparotomy was significantly associated with Mullerian anomalies (aOR 3.33, 95%CI 1.08-10.24, p = 0.036); uterine fibroids (aOR 3.17, 95%CI 1.11-9.05,p = 0.031); multiple pregnancy (aOR 4.1, 95%CI 1.43-11.79,p = 0.009); hypertensive disorders of pregnancy (aOR 3.46, 95%CI 1.29-9.3,p = 0.014); CD during the second stage of labor (aOR 2.54, 95%CI 1.15-5.88, p = 0.029); complications during CD (aOR 1.62, 95%CI 1.09-3.21,p = 0.045); and excessive bleeding during CD or implementation of bleeding control measures (use of tranexamic acid, a hemostatic agent, or a surgical drain) (aOR 2.23, 95%CI 1.29-4.12,p = 0.012). Indications for relaparotomy differed depending on the time elapsed from the CD, with suspected intra-abdominal bleeding (36.1%) emerging as the primary indication within the initial 24 h. CONCLUSION We detected several pregnancy, intrapartum, and intra-operative risk factors for the need for relaparotomy following a CD. Practitioners may utilize these findings to proactively identify women at risk, thereby potentially reducing their associated morbidity.
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Affiliation(s)
- Uri Amikam
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel.
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Yael Botkovsky
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alyssa Hochberg
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tikva, Israel
| | - Aviad Cohen
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ishai Levin
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yariv Yogev
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Liran Hiersch
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Lavie
- Department of Obstetrics and Gynecology, Lis Hospital for Women's Health, Tel Aviv Sourasky Medical Center, 6 Weizmann St, Tel Aviv, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Elkattawy O, Malke K, Mothy D, Tran A, Elkattawy S, Rab S, Zidat A, Mohamed O, Shamoon F. Ventricular Tachycardia in Patients With Pre-eclampsia: Prevalence, Predictors, and Associated In-Hospital Adverse Events. Cureus 2024; 16:e56717. [PMID: 38646254 PMCID: PMC11032695 DOI: 10.7759/cureus.56717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2024] [Indexed: 04/23/2024] Open
Abstract
Introduction Pre-eclampsia is a pregnancy-associated multisystem disorder; in rare cases, it can be complicated by arrhythmias such as ventricular tachycardia (VT). The purpose of this study was to determine the prevalence and predictors of VT among patients admitted with pre-eclampsia as well as to analyze the independent association of VT with in-hospital outcomes in this population. Methods Data were obtained from the National Inpatient Sample from January 2016 to December 2019. Patients with a primary diagnosis of pre-eclampsia were selected using International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes. Subsequently, the study population was divided into patients who developed VT versus patients who did not develop this complication. We then assessed the predictors of VT in women with pre-eclampsia as well as the independent association of VT with outcomes taking into account confounders such as age, race, and comorbidities. Results Of 255,946 patients with pre-eclampsia, 92 developed VT (0.04%) during their hospital stay. Multivariate logistic regression showed that patients with VT were far more likely to develop cardiac arrest (adjusted odds ratio, or aOR: 92.582, 95% CI: 30.958-276.871, p=0.001), require permanent pacemaker implantation (aOR: 41.866, 95% CI: 14.800-118.432, p=0.001), develop postpartum hemorrhage (aOR: 2.932, 95% CI: 1.655-5.196, p=0.001), and require left heart catheterization (aOR: 19.508, 95% CI: 3.261-116.708, p=0.001). Predictors of VT included being African American (aOR: 1.939, 95% CI: 1.183-3.177, p=0.009), cerebrovascular disease (aOR: 23.109, 95% CI: 6.953-76.802, p=0.001), congestive heart failure (aOR: 50.340, 95% CI: 28.829-87.901, p=0.001), atrial fibrillation (aOR: 20.148, 95% CI: 6.179-65.690, p=0.001), and obstructive sleep apnea, or OSA (aOR: 3.951, 95% CI: 1.486-10.505, p=0.006). Patients in the VT cohort were found to have an increased length of hospital stay compared to the non-VT cohort (7.16 vs. 4.13 days, p=0.001). Conclusion In a large cohort of women admitted with pre-eclampsia, we found the prevalence of VT to be <1%. Predictors of VT included conditions such as atrial fibrillation, congestive heart failure, and OSA and being African American. VT was found to be independently associated with several adverse outcomes as well as an increased length of hospital stay.
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Affiliation(s)
- Omar Elkattawy
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Keanaan Malke
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - David Mothy
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Aaron Tran
- Internal Medicine, Rutgers University New Jersey Medical School, Newark, USA
| | - Sherif Elkattawy
- Cardiology, St. Joseph's University Medical Center, Paterson, USA
| | - Sayeeda Rab
- Internal Medicine, Boston Medical Center, Boston, USA
| | - Ammar Zidat
- Internal Medicine, Lake Erie College of Osteopathic Medicine, Erie, USA
| | - Omar Mohamed
- Medicine, Cooperman Barnabas Medical Center, Livingston, USA
| | - Fayez Shamoon
- Cardiology, St. Joseph's University Medical Center, Paterson, USA
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Liu Z, Chen R, Huang H, Yan J, Jiang C. Predicting risk of postpartum hemorrhage associated with vaginal delivery of twins: A retrospective study. Medicine (Baltimore) 2023; 102:e36307. [PMID: 38115352 PMCID: PMC10727537 DOI: 10.1097/md.0000000000036307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 11/02/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023] Open
Abstract
Many studies have only focused on the risk factors for postpartum hemorrhage (PPH) in singleton vaginal deliveries and twin cesarean deliveries. We analyzed the factors of influencing PPH occurrence in twin vaginal deliveries and developed a nomogram for clinical application. This retrospective study included 274 pregnant women with twin pregnancies who were hospitalized for delivery from January 2014 to December 2018. The patients opted for vaginal delivery and experienced spontaneous labor. Univariate analysis of PPH risk factors was performed. Multivariate analysis was performed using the least absolute shrinkage and selection operator (LASSO) to obtain relevant factors and build a prediction model, which was presented as a nomogram. The model was internally validated by bootstrap self-sampling method. Model accuracy was evaluated with the concordance index (C-index). There were 36 (13.14%) and 238 (86.9%) patients in the PPH and no PPH groups, respectively. Univariate analysis identified twin chorionicity, hypertensive disorders complicating pregnancy (HDCP), anemia in pregnancy, delivery mode of the second twin, oxytocin use during labor, postpartum curettage, cervical laceration, intrapartum fever, fibrinogen degradation products (FDP), and platelet count (PLT) as significant PPH factors. On multivariate analysis, HDCP, anemia in pregnancy, intrapartum fever, oxytocin use during labor, fetal distress, PLT, direct bilirubin, and FDP were noted as significant PPH factors and were included in the prediction model. A C-index of 0.816 was noted after internal validation, and the calibration curve showed good consistency. We developed a model to predict PPH risk in the vaginal delivery of twin pregnancies and visualized it with a nomogram that can be applied clinically to assess PPH risk and aid PPH prevention.
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Affiliation(s)
- Zhaodong Liu
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Rongxin Chen
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Huihui Huang
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jianying Yan
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Caihong Jiang
- Department of Obstetrics and Gynecology, Fujian Maternity and Child Health Hospital, Affiliated Hospital of Fujian Medical University, Fuzhou, China
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Nakajima K, Fujii T, Iriyama T, Ichinose M, Toshimitsu M, Sayama S, Seyama T, Kumasawa K, Ikeda T, Osuga Y. Efficacy of prompt administration of cryoprecipitate in severe postpartum hemorrhage of preeclampsia patients. J Obstet Gynaecol Res 2023; 49:2811-2816. [PMID: 37723942 DOI: 10.1111/jog.15792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 09/01/2023] [Indexed: 09/20/2023]
Abstract
AIM Cryoprecipitate (CRYO) is a concentrated preparation of coagulation factors formulated from fresh frozen plasma (FFP), which can replenish coagulation factors rapidly. Preeclampsia (PE) is frequently associated with postpartum hemorrhage (PPH), and the rapid replenishment of coagulation factors is vital in the management. We conducted a retrospective cohort study to determine the efficacy of administering CRYO irrespective of fibrinogen levels in patients with PE who experienced severe PPH. METHODS Patients with PPH accompanied by PE and those who required red blood cell (RBC) transfusion were included. Cases were divided into two groups: those treated with CRYO (N = 16) and those not treated with CRYO (N = 10). The total transfusion volume, blood loss before and after transfusion initiation, duration of hospitalization, presence of pulmonary edema, and performance of either interventional radiology or hysterectomy were compared. RESULTS The median fibrinogen levels before transfusion were 2.24 and 2.34 g/L in the CRYO group and the not using group, respectively. Although blood loss before transfusion was comparable between the two groups, blood loss after transfusion was significantly less in the CRYO group (median: 520 vs. 2352 mL, p = 0.015), as well as the total blood loss (median: 2285 vs. 3825 mL, p = 0.005) and total transfusion volume (median: RBC 6 vs. 16 U, p = 0.01, FFP 10 vs. 20 U, p = 0.017). CONCLUSION Prompt replenishment of coagulation factors using CRYO to patients with PE who experience severe PPH could decrease further bleeding.
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Affiliation(s)
- Keisuke Nakajima
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Fujii
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takayuki Iriyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Mari Ichinose
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masatake Toshimitsu
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Seisuke Sayama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takahiro Seyama
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Keiichi Kumasawa
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshiyuki Ikeda
- Department of Blood Transfusion, The University of Tokyo Hospital, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Jiao A, Sun Y, Avila C, Chiu V, Slezak J, Sacks DA, Abatzoglou JT, Molitor J, Chen JC, Benmarhnia T, Getahun D, Wu J. Analysis of Heat Exposure During Pregnancy and Severe Maternal Morbidity. JAMA Netw Open 2023; 6:e2332780. [PMID: 37676659 PMCID: PMC10485728 DOI: 10.1001/jamanetworkopen.2023.32780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 07/31/2023] [Indexed: 09/08/2023] Open
Abstract
Importance The rate of severe maternal morbidity (SMM) is continuously increasing in the US. Evidence regarding the associations of climate-related exposure, such as environmental heat, with SMM is lacking. Objective To examine associations between long- and short-term maternal heat exposure and SMM. Design, Setting, and Participants This retrospective population-based epidemiological cohort study took place at a large integrated health care organization, Kaiser Permanente Southern California, between January 1, 2008, and December 31, 2018. Data were analyzed from February to April 2023. Singleton pregnancies with data on SMM diagnosis status were included. Exposures Moderate, high, and extreme heat days, defined as daily maximum temperatures exceeding the 75th, 90th, and 95th percentiles of the time series data from May through September 2007 to 2018 in Southern California, respectively. Long-term exposures were measured by the proportions of different heat days during pregnancy and by trimester. Short-term exposures were represented by binary variables of heatwaves with 9 different definitions (combining percentile thresholds with 3 durations; ie, ≥2, ≥3, and ≥4 consecutive days) during the last gestational week. Main Outcomes and Measures The primary outcome was SMM during delivery hospitalization, measured by 20 subconditions excluding blood transfusion. Discrete-time logistic regression was used to estimate associations with long- and short-term heat exposure. Effect modification by maternal characteristics and green space exposure was examined using interaction terms. Results There were 3446 SMM cases (0.9%) among 403 602 pregnancies (mean [SD] age, 30.3 [5.7] years). Significant associations were observed with long-term heat exposure during pregnancy and during the third trimester. High exposure (≥80th percentile of the proportions) to extreme heat days during pregnancy and during the third trimester were associated with a 27% (95% CI, 17%-37%; P < .001) and 28% (95% CI, 17%-41%; P < .001) increase in risk of SMM, respectively. Elevated SMM risks were significantly associated with short-term heatwave exposure under all heatwave definitions. The magnitude of associations generally increased from the least severe (HWD1: daily maximum temperature >75th percentile lasting for ≥2 days; odds ratio [OR], 1.32; 95% CI, 1.17-1.48; P < .001) to the most severe heatwave exposure (HWD9: daily maximum temperature >95th percentile lasting for ≥4 days; OR, 2.39; 95% CI, 1.62-3.54; P < .001). Greater associations were observed among mothers with lower educational attainment (OR for high exposure to extreme heat days during pregnancy, 1.43; 95% CI, 1.26-1.63; P < .001) or whose pregnancies started in the cold season (November through April; OR, 1.37; 95% CI, 1.24-1.53; P < .001). Conclusions and Relevance In this retrospective cohort study, long- and short-term heat exposure during pregnancy was associated with higher risk of SMM. These results might have important implications for SMM prevention, particularly in a changing climate.
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Affiliation(s)
- Anqi Jiao
- Department of Environmental and Occupational Health, Program in Public Health, University of California, Irvine
| | - Yi Sun
- Department of Environmental and Occupational Health, Program in Public Health, University of California, Irvine
- Institute of Medical Information, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chantal Avila
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Vicki Chiu
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - Jeff Slezak
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
| | - David A. Sacks
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Obstetrics and Gynecology, University of Southern California, Keck School of Medicine, Los Angeles
| | | | - John Molitor
- College of Public Health and Human Sciences, Oregon State University, Corvallis
| | - Jiu-Chiuan Chen
- Department of Population and Public Health Sciences, University of Southern California, Los Angeles
| | - Tarik Benmarhnia
- Scripps Institution of Oceanography, University of California, San Diego
| | - Darios Getahun
- Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California
| | - Jun Wu
- Department of Environmental and Occupational Health, Program in Public Health, University of California, Irvine
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Agbani EO, Chow L, Nicholas J, Skeith L, Schneider P, Gregory A, Mahe E, Yamaura L, Young D, Dufour A, Paul PP, Walker AM, Mukherjee PG, Poole AW, Poon MC, Lee A. Overexpression of facilitative glucose transporter-3 and membrane procoagulation in maternal platelets of preeclamptic pregnancy. J Thromb Haemost 2023; 21:1903-1919. [PMID: 36963633 DOI: 10.1016/j.jtha.2023.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 01/19/2023] [Accepted: 03/03/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Preeclampsia (PE) is a hypertensive disorder during pregnancy that results in significant adverse maternal and neonatal outcomes. Platelet activation is present in PE and contributes to the thrombo-hemorrhagic states of the disorder. However, the mechanisms that initiate and/or sustain platelet activation in PE are ill-defined. OBJECTIVES We aimed to characterise this mechanism and the procoagulant potentials of platelets in PE. METHODS In this quantitative observational study, we analyzed platelet procoagulant membrane dynamics in patients with PE (n = 21) compared with age-matched normotensive pregnancies (n = 20), gestational hypertension (n = 10), and non-pregnant female controls (n = 19). We analyzed fluorescently labeled indicators of platelet activation, bioenergetics, and procoagulation (phosphatidylserine exposure and thrombin generation), coupled with high-resolution imaging and thrombelastography. We then validated our findings using flow cytometry, immunoassays, classical pharmacology, and convolutional neural network analysis. RESULTS PE platelets showed significant ultra-structural remodeling, are more extensively preactivated than in healthy pregnancies and can circulate as microaggregates. Preactivated platelets of PE externalized phosphatidylserine and thrombin formed on the platelet membranes. Platelets' expression of facilitative glucose transporter-1 increased in all pregnant groups. However, PE platelets additionally overexpress glucose transporter-3 to enhance glucose uptake and sustain activation and secretion events. Although preeclampsia platelets exposed to subendothelial collagen showed incremental activation, the absolute hemostatic response to collagen was diminished, and likely contributed to greater blood loss perioperatively. CONCLUSIONS We revealed 2 bioenergetic mediators in the mechanism of sustained platelet procoagulation in preeclampsia. Although glucose transporter-1 and glucose transporter-3 remain elusive antiprocoagulant targets, they may be sensitive monitors of PE onset and progression.
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Affiliation(s)
- Ejaife O Agbani
- Department of Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, Alberta, Canada; Libin Cardiovascular Institute, Calgary, Alberta, Canada.
| | - Lorraine Chow
- Department of Anaesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Joshua Nicholas
- Department of Anaesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Leslie Skeith
- Libin Cardiovascular Institute, Calgary, Alberta, Canada; Division of Hematology & Hematological Malignancies, Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Prism Schneider
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Alberta, Canada
| | - Alexander Gregory
- Libin Cardiovascular Institute, Calgary, Alberta, Canada; Department of Anaesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Etienne Mahe
- Division of Hematology & Hematological Malignancies, Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Pathology & Laboratory Medicine, University of Calgary, Alberta, Canada
| | - Lisa Yamaura
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Alberta, Canada
| | - Daniel Young
- McCaig Institute for Bone and Joint Health, University of Calgary, Alberta, Canada
| | - Antoine Dufour
- Department of Physiology & Pharmacology, Cumming School of Medicine, University of Calgary, Alberta, Canada; McCaig Institute for Bone and Joint Health, University of Calgary, Alberta, Canada
| | - Padma Polash Paul
- Braintoy Inc Calgary and Computational Neuroscience Lab, University of Oxford, England, United Kingdom
| | - Andrew M Walker
- Department of Anaesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | | | - Alastair W Poole
- School of Physiology, Pharmacology, and Neuroscience, University of Bristol, England, United Kingdom
| | - Man-Chiu Poon
- Division of Hematology & Hematological Malignancies, Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Arnie Charbonneau Cancer Institute, Calgary, Alberta, Canada
| | - Adrienne Lee
- Division of Hematology & Hematological Malignancies, Department of Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Division of Hematology, Department of Medicine/Medical Oncology, University of British Columbia, Island Health, Victoria, Canada
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Strijbos LTM, Hendrix MLE, Al-Nasiry S, Smits LJM, Scheepers HCJ. Which first-trimester risk assessment method for preeclampsia is most suitable? A model-based impact study. Am J Obstet Gynecol MFM 2023; 5:100974. [PMID: 37062507 DOI: 10.1016/j.ajogmf.2023.100974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 03/09/2023] [Accepted: 04/10/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Low-dose aspirin treatment reduces the risk of preeclampsia among high-risk pregnant women. Internationally, several first-trimester risk-calculation methods are applied. OBJECTIVE This study aimed to assess the costs and benefits of different first-trimester preeclampsia risk estimation algorithms: EXPECT (an algorithmic prediction model based on maternal characteristics), National Institute for Health and Care Excellence (a checklist of risk factors), and the Fetal Medicine Foundation (a prediction model using additional uterine artery Doppler measurement and laboratory testing) models, coupled with low-dose aspirin treatment, in comparison with no risk assessment. STUDY DESIGN We constructed a decision analytical model estimating the number of cases of preeclampsia with each strategy and the costs of risk assessment for preeclampsia and early aspirin treatment, expressed in euros (€) in a hypothetical population of 100,000 women. We performed 1-way sensitivity analyses to assess the impact of adherence rates on model outcomes. RESULTS Application of the EXPECT, National Institute for Health and Care Excellence, and Fetal Medicine Foundation models results in respectively 1.98%, 2.55%, and 1.90% of the women developing preeclampsia, as opposed to 3.00% of women in the case of no risk assessment. Overall, the net financial benefits of the EXPECT, National Institute for Health and Care Excellence, and Fetal Medicine Foundation models relative to no risk assessment are €144, €43, and €38 per patient, respectively. The respective percentages of women receiving aspirin treatment are 18.6%, 10.2%, and 6.0% for the 3 risk assessment methods. CONCLUSION The EXPECT and Fetal Medicine Foundation model are comparable with regard to numbers of prevented preeclampsia cases, and both are superior to the National Institute for Health and Care Excellence model and to no risk assessment. EXPECT is less resource-demanding and results in the highest cost savings, but also requires the highest number of women to be treated with aspirin. When deciding which strategy is preferable, cost savings and easier use have to be weighed against the degree of overtreatment, although low-dose aspirin has no clear disadvantages during pregnancy.
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Affiliation(s)
- Lynn T M Strijbos
- Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands (Drs. Strijbos).
| | - Manouk L E Hendrix
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, Maastricht, The Netherlands (Dr. Hendrix, Dr. Al-Nasiry, and Dr Scheepers)
| | - Salwan Al-Nasiry
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, Maastricht, The Netherlands (Dr. Hendrix, Dr. Al-Nasiry, and Dr Scheepers); GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands (XX Al-Nasiry and XX Scheepers)
| | - Luc J M Smits
- Department of Epidemiology, Care and Public Health Research Institute, Maastricht University, Maastricht, The Netherlands (Prof. Smits)
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, Maastricht University Medical Center+, Maastricht, The Netherlands (Dr. Hendrix, Dr. Al-Nasiry, and Dr Scheepers); GROW School for Oncology and Reproduction, Maastricht University, Maastricht, The Netherlands (XX Al-Nasiry and XX Scheepers)
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Muluye G, Gashaw A, Woretaw L, Girma B, Tumebo T. Risk factors of primary postpartum hemorrhage among postnatal mothers in the public hospital of southern Tigray, Ethiopia, 2019: A case-control study. Front Glob Womens Health 2023; 4:1039749. [PMID: 36865926 PMCID: PMC9971984 DOI: 10.3389/fgwh.2023.1039749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 01/09/2023] [Indexed: 02/16/2023] Open
Abstract
Background Postpartum hemorrhage is the most common direct cause of maternal mortality and morbidity; among them, primary postpartum hemorrhages are an enormous element. Although it has an incredible impact on maternal lifestyle, this is the most neglected area in Ethiopia and there is a lack of studies achieved within the study area. So this study aimed to identify the risk factors of primary postpartum hemorrhage among postnatal mothers in public hospitals in southern Tigray, Ethiopia, 2019. Methods Institution-based unmatched case-control study design was conducted on 318 (106 case and 212 controls) postnatal mothers in public hospitals of Southern Tigray from January to October 2019. We used a pretested, structured interviewer-administered questionnaire and a chart review to collect the data. Bivariate and multivariable logistic regression models were used to identify the risk factors. P-value ≤ 0.05 was considered statically significant for both steps and an odds ratio with a 95% confidence level was used to see the strength of association. Results Abnormal third stage of labor [adjusted odds ratio = 5.86, 95% confidence interval (2.55-13.43), P = 000], cesarean section [adjusted odds ratio = 5.61, 95% confidence interval (2.79-11.30), P = 0.000], lack of active management of third-stage labor [adjusted odds ratio = 3.88; 95% confidence interval (1.29-11.60), P = 0.015], absence of labor monitoring by partograph [adjusted odds ratio = 3.82, 95% confidence interval (1.31-11.09), P = 0.014], lack of antenatal care [adjusted odds ratio = 2.76, 95% confidence interval (1.13-6.75), P = 0.026] and complications during pregnancy [adjusted odds ratio = 2.79, 95% confidence interval (1.34-5.83), P = 0.006] were found to be risk factors for primary postpartum hemorrhage. Conclusion In this study complications and lack of maternal health interventions in the course of the antepartum and the intrapartum period were found to be risk factors for primary postpartum hemorrhage. A strategy for improving essential maternal health services and detecting and handling complications in a timely manner will help to prevent primary postpartum hemorrhage.
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Affiliation(s)
- Getachew Muluye
- Department of Midwifery, College of Health Sciences, Mekelle University, Mekelle, Ethiopia,Correspondence: Getachew Muluye
| | - Abeba Gashaw
- Department of Maternal and Child Health, Amdework Primary Hospital, Amdework, Ethiopia
| | - Lebasie Woretaw
- Department of Environmental Health, College of Medicine and Health Sciences, Wollo University, Dessie, Ethiopia
| | - Biniam Girma
- Department of Maternal and Child Health, Amdework Primary Hospital, Amdework, Ethiopia
| | - Tarekegn Tumebo
- Department of Midwifery, College of Medicine and Health Sciences, Wachemo University, Hosaena, Ethiopia
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9
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Young S, Wang MJ, Srivastava A, Abbas D, Alexander M, Claus L, Tummala S, Yarrington C, Comfort A. Intrapartum magnesium sulfate exposure and obstetric hemorrhage risk. J Matern Fetal Neonatal Med 2022; 35:10036-10043. [PMID: 35704050 DOI: 10.1080/14767058.2022.2086796] [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: 10/18/2022]
Abstract
BACKGROUND The gold standard intrapartum treatment for preeclampsia with severe features is magnesium sulfate in order to provide prophylaxis against eclampsia. However, though magnesium sulfate is known to have a relaxant effect on uterine muscle, there have been variable reports in the literature in regard to the association between magnesium and obstetric hemorrhage (OBH). OBJECTIVE We aim to compare OBH incidence in patients with hypertensive disease of pregnancy (HDP) with or without exposure to intrapartum magnesium sulfate. METHODS We performed a retrospective cohort study of all deliveries at our institution associated with a diagnosis of hypertensive disease of pregnancy (HDP) (e.g. chronic and gestational hypertension, preeclampsia with or without severe features, eclampsia, or HELLP) from January 1, 2018 to December 31, 2019. The category of HDP diagnosis was determined by a detailed chart review by trained chart abstractors. The primary outcome was total quantitative blood loss (QBL) and the rate of obstetric hemorrhage. Secondary outcomes included a composite of obstetric hemorrhage-related maternal morbidity outcomes (OBH-M), the individual composite components and the incidence of additional hemorrhage-related interventions (e.g. uterotonics and surgical interventions). We also examined the same primary and secondary outcomes in a stratified analysis based on delivery mode (i.e. vaginal deliveries only and cesarean deliveries only). RESULTS Of 791 patients with a diagnosis of HDP, 411 patients received magnesium sulfate for eclampsia prophylaxis and 380 patients did not receive magnesium sulfate. For all delivery modes, there was a significantly higher QBL (p < .01), increased rate of OBH (p = .04) and increased OBH-M (p < .01) in deliveries associated with intrapartum exposure to magnesium compared to those without. However, our stratified analysis by delivery mode demonstrated that magnesium-related hemorrhage risk only persisted for vaginal deliveries (QBL p < .01; OBH aOR 1.47, 95% CI: 0.75-2.85; OBH-M aOR 1.47, 95% CI 1.00-7.55) with no significant hemorrhage-related differences among cesareans with or without magnesium exposure (QBL p = .51; OBH aOR 1.45, 95% CI: 0.85-2.47; OBH-M 1.50 95% CI: 0.70-3.23). CONCLUSION Intrapartum exposure to magnesium sulfate use was associated with an increase in QBL and risk of OBH-M in vaginal deliveries, but not associated with any hemorrhage-related outcome differences in cesarean deliveries. More research is needed to explore the effects of hypertensive disease, magnesium exposure, and delivery mode on obstetric hemorrhage risk.
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Affiliation(s)
- Sara Young
- Boston University School of Medicine, Boston, MA, USA
| | - Michelle J Wang
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA
| | | | - Diana Abbas
- Boston University School of Medicine, Boston, MA, USA
| | | | - Lindsey Claus
- Boston University School of Medicine, Boston, MA, USA
| | | | - Christina Yarrington
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA
| | - Ashley Comfort
- Boston University School of Medicine, Boston, MA, USA.,Boston Medical Center, Department of Obstetrics and Gynecology, Boston, MA, USA
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10
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Zakiyah N, Tuytten R, Baker PN, Kenny LC, Postma MJ, van Asselt ADI. Early cost-effectiveness analysis of screening for preeclampsia in nulliparous women: A modelling approach in European high-income settings. PLoS One 2022; 17:e0267313. [PMID: 35446907 PMCID: PMC9022877 DOI: 10.1371/journal.pone.0267313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 04/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background Preeclampsia causes substantial maternal and perinatal morbidity and mortality and significant societal economic impact. Effective screening would facilitate timely and appropriate prevention and management of preeclampsia. Objectives To develop an early cost-effectiveness analysis to assess both costs and health outcomes of a new screening test for preeclampsia from a healthcare payer perspective, in the United Kingdom (UK), Ireland, the Netherlands and Sweden. Methods A decision tree over a 9-month time horizon was developed to explore the cost-effectiveness of the new screening test for preeclampsia compared to the current screening strategy. The new test strategy is being developed so that it can stratify healthy low risk nulliparous women early in pregnancy to either a high-risk group with a risk of 1 in 6 or more of developing preeclampsia, or a low-risk group with a risk of 1 in 100 or less. The model simulated 25 plausible scenarios in a hypothetical cohort of 100,000 pregnant women, in which the sensitivity and specificity of the new test were varied to set a benchmark for the minimum test performance that is needed for the test to become cost-effective. The input parameters and costs were mainly derived from published literature. The main outcome was incremental costs per preeclampsia case averted, expressed as an incremental cost-effectiveness ratio (ICER). Deterministic and probabilistic sensitivity analyses were conducted to assess uncertainty. Results Base case results showed that the new test strategy would be more effective and less costly compared to the current situation in the UK. In the Netherlands, the majority of scenarios would be cost-effective from a threshold of €50,000 per preeclampsia case averted, while in Ireland and Sweden, the vast majority of scenarios would be considered cost-effective only when a threshold of €100,000 was used. In the best case analyses, ICERs were more favourable in all four participating countries. Aspirin effectiveness, prevalence of preeclampsia, accuracy of the new screening test and cost of regular antenatal care were identified as driving factors for the cost-effectiveness of screening for preeclampsia. Conclusion The results indicate that the new screening test for preeclampsia has potential to be cost-effective. Further studies based on proven accuracy of the test will confirm whether the new screening test is a cost-effective additional option to the current situation.
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Affiliation(s)
- Neily Zakiyah
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Department of Pharmacology and Clinical Pharmacy, Faculty of Pharmacy, Universitas Padjadjaran, Bandung, Indonesia
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- * E-mail:
| | - Robin Tuytten
- Research & Development, Metabolomic Diagnostics, Little Island, Ireland
| | - Philip N. Baker
- College of Life Sciences, University of Leicester, Leicester, United Kingdom
| | - Louise C. Kenny
- Department of Women’s and Children’s Health, the Faculty of Health and Life Sciences, University of Liverpool, Liverpool, United Kingdom
| | - Maarten J. Postma
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Center of Excellence in Higher Education for Pharmaceutical Care Innovation, Universitas Padjadjaran, Bandung, Indonesia
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Department of Economics, Econometrics & Finance, Faculty of Economics & Business, University of Groningen, Groningen, The Netherlands
| | - Antoinette D. I. van Asselt
- Unit of PharmacoTherapy, Epidemiology & Economics (PTE2), Department of Pharmacy, University of Groningen, Groningen, The Netherlands
- Unit of Global Health, Department of Health Sciences, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- Unit of Patient Centered Health Technology Assessment, Department of Epidemiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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11
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Raia-Barjat T, Edebiri O, Ni Ainle F. Preeclampsia and Venous Thromboembolism: Pathophysiology and Potential Therapy. Front Cardiovasc Med 2022; 9:856923. [PMID: 35345482 PMCID: PMC8957069 DOI: 10.3389/fcvm.2022.856923] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 02/11/2022] [Indexed: 12/23/2022] Open
Abstract
Preeclampsia (PET) is a multisystem inflammatory disorder that represents a leading cause of feto-maternal morbidity and mortality, complicating 2–5% of all pregnancies. PET incurs an increased risk of venous thromboembolism, which is one of the leading causes of death in pregnancy and in the postpartum period. This prothrombotic phenotype is attributable to the maternal phase of PET, which is characterized by a systemic inflammatory response and coagulation activation. Research continues to be undertaken in terms of preventative measures, however, currently revolves around pharmacological low dose aspirin initiated in the first trimester of pregnancy for those with risk factors. Treatment involves antenatal corticosteroids for fetal lung development in preterm birth, parenteral magnesium sulfate for fetal neuroprotection and maternal seizure prophylaxis, and timely birth of the fetus and placenta being the only definitive treatment of PET. Patients with a venous thromboembolism (VTE) risk deemed to be >1–3% are treated with pharmacological thromboprophylaxis in the form of low molecular weight heparin. Completing each woman’s VTE risk assessment is crucial, particularly in the setting of PET, as there is also a proven associated competing hemorrhagic risk.
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Affiliation(s)
- Tiphaine Raia-Barjat
- Department of Gynecology and Obstetrics, Centre Hospitalier Universitaire de Saint-Étienne, Saint-Étienne, France
- INSERM U1059, SAINBIOSE, Université Jean Monnet, Saint-Étienne, France
- *Correspondence: Tiphaine Raia-Barjat,
| | - Osasere Edebiri
- Department of Haematology, Mater Misericordiae University Hospital, Rotunda Hospital, Dublin, Ireland
| | - Fionnuala Ni Ainle
- Department of Haematology, Mater Misericordiae University Hospital, Rotunda Hospital, Dublin, Ireland
- UCD School of Medicine, University College Dublin, Dublin, Ireland
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12
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Aldika Akbar MI, Gumilar KE, Tjokroprawiro BA, Ulhaq RA. Successful management of a pregnant woman with COVID-19 and multiple severe complications. BMJ Case Rep 2021; 14:14/9/e243594. [PMID: 34531234 PMCID: PMC8449948 DOI: 10.1136/bcr-2021-243594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
We report a case of a 36-year-old gravida 2 para 1 woman at 38 weeks of gestation. A caesarean section was performed for severe pre-eclampsia, intrauterine growth restriction and oligohydramnios. The patient suffered postoperative bleeding, and exploratory laparotomy was performed. Uterine atonia, Couvelaire uterus and left adnexal haematoma were found, requiring a supracervical hysterectomy. As COVID-19 pneumonia and superimposed bacterial infection developed, the patient was mechanically ventilated in the intensive care unit. Remdesivir and meropenem were initially administered, but were changed to levofloxacin and ciprofloxacin following antibiotic sensitivity tests. Blood culture grew Enterococcus galinarum. Meanwhile, bleeding of the incisional wound occurred, which was controlled by the cessation of heparin therapy and regular wound care. With intensive monitoring and multidisciplinary management, the patient’s condition improved, and she was discharged from the hospital on day 25 from admission.
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Affiliation(s)
| | - Khanisyah Erza Gumilar
- Department of Obstetrics and Gynecology, Medical Faculty, Universitas Airlangga, Surabaya, Indonesia
| | | | - Renata Alya Ulhaq
- Midwifery Study Program, Medical Faculty, Universitas Airlangga, Surabaya, Indonesia
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Li S, Gao J, Liu J, Hu J, Chen X, He J, Tang Y, Liu X, Cao Y, Liu X, Wang X. Incidence and Risk Factors of Postpartum Hemorrhage in China: A Multicenter Retrospective Study. Front Med (Lausanne) 2021; 8:673500. [PMID: 34497812 PMCID: PMC8419315 DOI: 10.3389/fmed.2021.673500] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2021] [Accepted: 07/31/2021] [Indexed: 12/02/2022] Open
Abstract
Background: Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality worldwide but the incidence and its risk factors in China is limited. The objective of this study is to investigate the incidence and the risk factors of PPH in Chinese women. Methods: A multi-center retrospective study of pregnant women at ≥28 weeks of gestation was conducted. Logistic regression was used to identify potential risk factors of PPH and receiver operating characteristic curve was used to evaluate the predictive performance of the identified risk factors. Subgroup analysis focusing on the number of fetus and the mode of delivery was conducted. Results: A total of 99,253 pregnant women were enrolled and 804 (0.81%) experienced PPH. The subgroup analysis revealed that the incidence of PPH was 0.75, 2.65, 1.40, and 0.31% in singletons, twin pregnancies, cesarean sections, and vaginal deliveries, respectively. Placenta previa and placenta accreta were the predominant risk factors of PPH in the overall population and all subgroups. A twin pregnancy was a risk factor for PPH regardless of the mode of delivery. Obesity, and multiparity were risk factors for PPH in both singletons and cesarean section cases, but the latter predicted a reduced probability of PPH in vaginal deliveries. Macrosomia was associated with increased risk of PPH in singletons or vaginal deliveries. In women who delivered vaginally, preeclampsia was associated with a higher risk of PPH. The areas under the curve for the overall cohort, singletons, twin pregnancies, cesarean section cases, and vaginal deliveries were 0.832 (95% confidence interval [CI] 0.813–0.851), 0.824 (95% CI 0.803–0.845), 0.686 (95% CI 0.617–0.755), 0.854 (95% CI 0.834–0.874), and 0.690 (95% CI 0.646–0.735), respectively. Conclusions: The risk factors of PPH varied slightly based on the number of fetuses and the mode of delivery, while placenta previa and placenta accreta were the two major risk factors. A combination of the identified risk factors yielded a satisfactory predictive performance in determining PPH in the overall cohort, singletons pregnancies, and women who delivered by cesarean section, whereas the performance was moderate in twin pregnancies and in women delivering vaginally.
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Affiliation(s)
- Sijian Li
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jinsong Gao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Juntao Liu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jing Hu
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Xiaoxu Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, National Clinical Research Center for Obstetric and Gynecologic Diseases, Beijing, China
| | - Jing He
- Department of Obstetrics and Gynecology, Women's Hospital, School of Medicine, Zhejiang University, Zhejiang, China
| | - Yabing Tang
- Department of Obstetrics and Gynecology, Hunan Maternal and Child Health Care Hospital, Changsha, China
| | - Xinghui Liu
- Department of Obstetrics and Gynecology, Sichuan University West China Second Hospital, Chengdu, China
| | - Yinli Cao
- Department of Obstetrics and Gynecology, Northwest Women and Children's Hospital, Xi'an, China
| | - Xiaowei Liu
- Department of Obstetrics and Gynecology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
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Tyagi A, Mohan A, Singh Y, Luthra A, Garg D, Malhotra RK. Effective Dose of Prophylactic Oxytocin Infusion During Cesarean Delivery in 90% Population of Nonlaboring Patients With Preeclampsia Receiving Magnesium Sulfate Therapy and Normotensives: An Up-Down Sequential Allocation Dose-Response Study. Anesth Analg 2021; 134:303-311. [PMID: 34469334 DOI: 10.1213/ane.0000000000005701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Oxytocin administration during cesarean delivery is the first-line therapy for the prevention of uterine atony. Patients with preeclampsia may receive magnesium sulfate, a drug with known tocolytic effects, for seizure prophylaxis. However, no study has evaluated the minimum effective dose of oxytocin during cesarean delivery in women with preeclampsia. METHODS This study compared the effective dose in 90% population (ED90) of oxytocin infusion for achieving satisfactory uterine tone during cesarean delivery in nonlaboring patients with preeclampsia who were receiving magnesium sulfate treatment with a control group of normotensives who were not receiving magnesium sulfate. This prospective dual-arm dose-finding study was based on a 9:1 biased sequential allocation design. Oxytocin infusion was initiated at 13 IU/h, on clamping of the umbilical cord, in the first patient of each group. Uterine tone was graded as satisfactory or unsatisfactory by the obstetrician at 4 minutes after initiation of oxytocin infusion. The dose of oxytocin infusion for subsequent patients was decided according to the response exhibited by the previous patient in the group; it was increased by 2 IU/h after unsatisfactory response or decreased by 2 IU/h or maintained at the same level after satisfactory response, in a ratio of 1:9. Oxytocin-associated side effects were also evaluated. Dose-response data for the groups were evaluated using a log-logistic function and ED90 estimates were derived from fitted equations using the delta method. RESULTS The ED90 of oxytocin was significantly greater for the preeclampsia group (n = 27) than for the normotensive group (n = 40) (24.9 IU/h [95% confidence interval {CI}, 22.4-27.5] and 13.9 IU/h [95% CI, 12.4-15.5], respectively); the difference in dose requirement was 10.9 IU/h (95% CI, 7.9-14.0; P < .001). The number of patients with oxytocin-related hypotension, defined as a decrease in systolic blood pressure >20% from baseline or to <90 mm Hg, was significantly greater in the preeclampsia group (92.6% vs 62.5%; P = .030), while other side effects such as ST-T depression, nausea/vomiting, headache, and flushing, were not significantly different. There was no significant difference in the need for additional uterotonic or uterine massage, estimated blood loss, and need for re-exploration for uncontrolled bleeding. CONCLUSIONS Patients with preeclampsia receiving preoperative magnesium therapy need a greater intraoperative dose of oxytocin to achieve satisfactory contraction of the uterus after fetal delivery, as compared to normotensives.
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Affiliation(s)
- Asha Tyagi
- From the Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi, India
| | - Aparna Mohan
- From the Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi, India
| | - Yuvraj Singh
- From the Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi, India
| | - Ankit Luthra
- From the Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi, India
| | - Devansh Garg
- From the Department of Anaesthesiology & Critical Care, University College of Medical Sciences & Guru Teg Bahadur Hospital, New Delhi, India
| | - Rajeev Kumar Malhotra
- Delhi Cancer Registry, Dr BR Ambedkar Institute-Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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15
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Association of Gestational Age with Postpartum Hemorrhage: An International Cohort Study. Anesthesiology 2021; 134:874-886. [PMID: 33760074 DOI: 10.1097/aln.0000000000003730] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Risk factors for postpartum hemorrhage, such as chorioamnionitis and multiple gestation, have been identified in previous epidemiologic studies. However, existing data describing the association between gestational age at delivery and postpartum hemorrhage are conflicting. The aim of this study was to assess the association between gestational age at delivery and postpartum hemorrhage. METHODS The authors conducted a population-based retrospective cohort study of women who underwent live birth delivery in Sweden between 2014 and 2017 and in California between 2011 and 2015. The primary exposure was gestational age at delivery. The primary outcome was postpartum hemorrhage, classified using International Classification of Diseases, Ninth Revision-Clinical Modification codes for California births and a blood loss greater than 1,000 ml for Swedish births. The authors accounted for demographic and obstetric factors as potential confounders in the analyses. RESULTS The incidences of postpartum hemorrhage in Sweden (23,323/328,729; 7.1%) and in California (66,583/2,079,637; 3.2%) were not comparable. In Sweden and California, the incidence of postpartum hemorrhage was highest for deliveries between 41 and 42 weeks' gestation (7,186/75,539 [9.5%] and 8,921/160,267 [5.6%], respectively). Compared to deliveries between 37 and 38 weeks, deliveries between 41 and 42 weeks had the highest adjusted odds of postpartum hemorrhage (1.62 [95% CI, 1.56 to 1.69] in Sweden and 2.04 [95% CI, 1.98 to 2.09] in California). In both cohorts, the authors observed a nonlinear (J-shaped) association between gestational age and postpartum hemorrhage risk, with 39 weeks as the nadir. In the sensitivity analyses, similar findings were observed among cesarean deliveries only, when postpartum hemorrhage was classified only by International Classification of Diseases, Tenth Revision-Clinical Modification codes, and after excluding women with abnormal placentation disorders. CONCLUSIONS The postpartum hemorrhage incidence in Sweden and California was not comparable. When assessing a woman's risk for postpartum hemorrhage, clinicians should be aware of the heightened odds in women who deliver between 41 and 42 weeks' gestation. EDITOR’S PERSPECTIVE
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Shinohara S, Okuda Y, Hirata S, Suzuki K. Adenomyosis as a Potential Risk Factor for Adverse Pregnancy Outcomes: A Multicenter Case-Control Study. TOHOKU J EXP MED 2021; 251:231-239. [PMID: 32684535 DOI: 10.1620/tjem.251.231] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
As the number of women who postpone their first pregnancy until their late 30s or early 40s is increasing, adenomyosis is more frequently encountered by obstetricians. Some studies have reported on the relationship between adenomyosis and pregnancy complications. We aimed to investigate the effect of adenomyosis on pregnancy complications and outcomes and associations between adenomyosis type and pregnancy outcomes. This multicenter retrospective 1:4 case-control study included 61 women with singleton pregnancies diagnosed with adenomyosis. The control group included women with singleton pregnancies without adenomyosis; these women were matched to those with adenomyosis using propensity scores. The incidence of obstetric complications, delivery, and neonatal outcomes were compared. The adenomyosis group (n = 61) had significantly higher incidence of preterm delivery (21.3% vs. 9.4%), hypertensive disorders of pregnancy (13.1% vs. 5.3%), cesarean delivery (46.0% vs. 20.9%), and postpartum hemorrhage (57.3% vs. 36.8%) than the control group (n = 244). Subgroup analysis by the adenomyosis type revealed that the diffuse adenomyosis group (n = 41) was significantly more likely to experience preterm labor (29.3% vs. 7.3%), hypertensive disorders of pregnancy (17.0% vs. 5.5%), severe hypertensive disorders of pregnancy (12.2% vs. 1.8%), preterm premature rupture of membranes (12.2% vs. 2.4%), cesarean delivery (61.3% vs. 18.9%), and postpartum hemorrhage (70.7% vs. 44.5%) than the control group (n = 164). The focal adenomyosis (n = 20) group was not statistically different from the control group (n = 80) with respect to obstetric complications. Women with diffuse adenomyosis require more careful perinatal management than previously thought.
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Affiliation(s)
- Satoshi Shinohara
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi
| | - Yasuhiko Okuda
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi
| | - Shuji Hirata
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Yamanashi
| | - Kohta Suzuki
- Department of Health and Psychosocial Medicine, Aichi Medical University School of Medicine
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da Silva WA, Pinheiro AM, Lima PH, Malbouisson LMS. Renal and cardiovascular repercussions in preeclampsia and their impact on fluid management: a literature review. Braz J Anesthesiol 2021; 71:421-428. [PMID: 33845102 PMCID: PMC9373504 DOI: 10.1016/j.bjane.2021.02.052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 02/15/2021] [Accepted: 02/27/2021] [Indexed: 11/25/2022] Open
Abstract
Preeclampsia is a multifactorial condition associated with significant morbidity and mortality. Fluid therapy in these patients is challenging since volume expansion may precipitate pulmonary edema, and fluid restriction may worsen renal function. Furthermore, cardiac impairment may introduce an additional component to the hemodynamic management. This article reviews the repercussions of preeclampsia on renal and cardiovascular systems and the development of pulmonary edema, as well as to discuss fluid management, focusing on the mitigation of adverse outcomes and monitoring alternatives. The literature review was carried out using PubMed, Embase, and Google Scholar databases from May 2019 to March 2020. Papers addressing the subjects of interest were included regardless of the publication language. There is a current trend towards restricting the administration of fluids in women with non-complicated preeclampsia. However, patients with preeclampsia may experience hemorrhagic shock, requiring volume resuscitation. In this case, hemodynamic monitoring is recommended to guide fluid therapy while avoiding complications.
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Affiliation(s)
- Wallace Andrino da Silva
- Universidade de São Paulo (USP), Hospital das Clínicas, Faculdade de Medicina, São Paulo, SP, Brazil; Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil.
| | - Aline Macedo Pinheiro
- Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil
| | - Paulo Henrique Lima
- Universidade Federal do Rio Grande do Norte (UFRN), Hospital Universitário Onofre Lopes (HUOL), Natal, RN, Brazil
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18
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Kodan LR, Verschueren KJC, Prüst ZD, Zuithoff NPA, Rijken MJ, Browne JL, Klipstein-Grobusch K, Bloemenkamp KWM, Grunberg AW. Postpartum hemorrhage in Suriname: A national descriptive study of hospital births and an audit of case management. PLoS One 2020; 15:e0244087. [PMID: 33338049 PMCID: PMC7748130 DOI: 10.1371/journal.pone.0244087] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 12/02/2020] [Indexed: 12/17/2022] Open
Abstract
Background Postpartum hemorrhage (PPH) is the leading cause of direct maternal mortality globally and in Suriname. We aimed to study the prevalence, risk indicators, causes, and management of PPH to identify opportunities for PPH reduction. Methods A nationwide retrospective descriptive study of all hospital deliveries in Suriname in 2017 was performed. Logistic regression analysis was applied to identify risk indicators for PPH (≥ 500ml blood loss). Management of severe PPH (blood loss ≥1,000ml or ≥500ml with hypotension or at least three transfusions) was evaluated via a criteria-based audit using the national guideline. Results In 2017, the prevalence of PPH and severe PPH in Suriname was 9.2% (n = 808/8,747) and 2.5% (n = 220/8,747), respectively. PPH varied from 5.8% to 15.8% across the hospitals. Risk indicators associated with severe PPH included being of African descent (Maroon aOR 2.1[95%CI 1.3–3.3], Creole aOR 1.8[95%CI 1.1–3.0]), multiple pregnancy (aOR 3.4[95%CI 1.7–7.1]), delivery in Hospital D (aOR 2.4[95%CI 1.7–3.4]), cesarean section (aOR 3.9[95%CI 2.9–5.3]), stillbirth (aOR 6.4 [95%CI 3.4–12.2]), preterm birth (aOR 2.1[95%CI 1.3–3.2]), and macrosomia (aOR 2.8 [95%CI 1.5–5.0]). Uterine atony (56.7%, n = 102/180[missing 40]) and retained placenta (19.4%, n = 35/180[missing 40]), were the main causes of severe PPH. A criteria-based audit revealed that women with severe PPH received prophylactic oxytocin in 61.3% (n = 95/155[missing 65]), oxytocin treatment in 68.8% (n = 106/154[missing 66]), and tranexamic acid in 4.9% (n = 5/103[missing 117]). Conclusions PPH prevalence and risk indicators in Suriname were similar to international and regional reports. Inconsistent blood loss measurement, varied maternal and perinatal characteristics, and variable guideline adherence contributed to interhospital prevalence variation. PPH reduction in Suriname can be achieved through prevention by practicing active management of the third stage of labor in every birth and considering risk factors, early recognition by objective and consistent blood loss measurement, and prompt treatment by adequate administration of oxytocin and tranexamic acid according to national guidelines.
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Affiliation(s)
- Lachmi R. Kodan
- Department of Obstetrics and Gynecology, Academic Hospital Paramaribo, Paramaribo, Suriname, South Africa
- Division Women and Baby, Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- * E-mail:
| | - Kim J. C. Verschueren
- Division Women and Baby, Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Zita D. Prüst
- Division Women and Baby, Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Nicolaas P. A. Zuithoff
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Marcus J. Rijken
- Division Women and Baby, Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Joyce L. Browne
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Kerstin Klipstein-Grobusch
- Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
- Division of Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Kitty W. M. Bloemenkamp
- Division Women and Baby, Department of Obstetrics, Birth Centre Wilhelmina’s Children Hospital, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Antoon W. Grunberg
- Board of Doctoral Graduations and Honorary Doctorate Awards, Anton de Kom University, Paramaribo, Suriname, South Africa
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19
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Placental abruption in each phenotype of hypertensive disorders of pregnancy: a retrospective cohort study using a national inpatient database in Japan. Hypertens Res 2020; 44:250-252. [PMID: 33028989 DOI: 10.1038/s41440-020-00557-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/09/2022]
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20
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Zhang N, Tan J, Yang H, Khalil RA. Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world. Biochem Pharmacol 2020; 182:114247. [PMID: 32986983 DOI: 10.1016/j.bcp.2020.114247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022]
Abstract
Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.
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Affiliation(s)
- Ning Zhang
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jing Tan
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - HaiFeng Yang
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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21
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Thompson J, Onyenaka C, Oduguwa E, Dongarwar D, Gendra S, Coker V, Kutse S, Blanco M, Nwangwu O, King C, Enamorado E, Bakare O, Ajewole VB, Spooner KK, Salemi JL, Aliyu MH, Salihu HM, Olaleye OA. Trends and Racial/Ethnic Disparities in the Rates of Pre-eclampsia by HIV Status in the US. J Racial Ethn Health Disparities 2020; 8:670-677. [PMID: 32754847 DOI: 10.1007/s40615-020-00826-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 07/06/2020] [Accepted: 07/14/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Preeclampsia and HIV account for a significant proportion of the global burden of disease and pose severe maternal-fetal risks. There is a dearth of literature regarding racial/ethnic disparities in preeclampsia associated with HIV/AIDS in the US. METHODS We retrospectively analyzed data from the National Inpatient Sample (NIS) database from 2002 to 2015 on a cohort of hospitalized pregnant women with or without preeclampsia and HIV. Joinpoint regression models were used to identify trends in the rates of preeclampsia among pregnant women living with or without HIV, stratified by race/ethnicity over the study period. We also assessed the association between preeclampsia and various socio-demographic factors. RESULTS We analyzed over 60 million pregnancy-related hospitalizations, of which 3665 had diagnoses of preeclampsia and HIV, corresponding to a rate of 0.61 per 10,000. There was an increasing trend in the diagnosis of preeclampsia among hospitalized, pregnant women without HIV across each racial/ethnic category. The highest prevalence of preeclampsia was among non-Hispanic (NH) Blacks, regardless of HIV status. CONCLUSION The increase in rates of pre-eclampsia between 2002 and 2015 was mostly noted among pregnant women without HIV. Regardless of HIV status, NH-Blacks experienced the highest discharge prevalence of preeclampsia.
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Affiliation(s)
- Jamalena Thompson
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Collins Onyenaka
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Emmanuella Oduguwa
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA.
| | - Deepa Dongarwar
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA
| | - Sumaya Gendra
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Vidella Coker
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Seun Kutse
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Mayra Blanco
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Onyinye Nwangwu
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Charlee King
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Elza Enamorado
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Oluwatoyin Bakare
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Veronica B Ajewole
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
| | - Kiara K Spooner
- Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Jason L Salemi
- College of Public Health, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Muktar H Aliyu
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hamisu M Salihu
- Center of Excellence in Health Equity, Training, and Research, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX, 77098, USA.,Department of Family and Community Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Omonike A Olaleye
- College of Pharmacy and Health Sciences, Texas Southern University, Houston, TX, USA
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22
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Asemota O, Bryson L, Fogel J. Neonatal outcomes in obese pregnant women who develop preeclampsia. Pregnancy Hypertens 2020; 21:191-196. [PMID: 32629404 DOI: 10.1016/j.preghy.2020.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/07/2020] [Accepted: 05/27/2020] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Obesity and preeclampsia in pregnant women are each independently associated with poorer neonatal outcomes. We study obesity and preeclampsia alone and also in combination in pregnant women to determine their association with neonatal outcomes. STUDY DESIGN This retrospective study (n = 664) compared four groups: 1) no preeclampsia/no obesity, 2) no preeclampsia/yes obesity, 3) yes preeclampsia/no obesity, and 4) yes preeclampsia/yes obesity. The primary outcome was neonatal intensive care unit (NICU) admission. Secondary outcomes were low birth weight, low Apgar 1 score, and low Apgar 5 score. RESULTS Those with yes preeclampsia/yes obesity (OR:3.06, 95% CI:1.76, 5.32, p < 0.001) and those with yes preeclampsia/no obesity (OR:1.98, 95% CI:1.03, 3.80, p < 0.05) each had significantly higher odds for NICU admission. Those with no preeclampsia/yes obesity were not associated with NICU admission. Yes preeclampsia/yes obesity did not have any significant association with low birth weight, low Apgar 1 score, and low Apgar 5 score. CONCLUSION Patients with preeclampsia alone or preeclampsia/obesity combined are associated with higher odds for NICU admission. However, obesity alone without preeclampsia is not associated with NICU admission. This knowledge can allow the Pediatric service prior to delivery to prepare and mitigate potential poor neonatal complications.
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Affiliation(s)
- Osasumwen Asemota
- Department of Obstetrics & Gynecology, Nassau University Medical Center, East Meadow, NY, USA.
| | - Lennox Bryson
- Department of Obstetrics & Gynecology, Nassau University Medical Center, East Meadow, NY, USA.
| | - Joshua Fogel
- Department of Obstetrics & Gynecology, Nassau University Medical Center, East Meadow, NY, USA; Department of Business Management, Brooklyn College of the City University of New York, Brooklyn, NY, USA.
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23
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Kelliher S, Maguire PB, Szklanna PB, Weiss L, Ewins K, O'Doherty R, Angelov D, Ní Áinle F, Kevane B. Pathophysiology of the Venous Thromboembolism Risk in Preeclampsia. Hamostaseologie 2020; 40:594-604. [PMID: 32450576 DOI: 10.1055/a-1162-3905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
Preeclampsia complicates up to 8% of pregnancies and is a leading cause of fetomaternal morbidity andmortality. Treatment options are limited, with supportive care and delivery of the placenta representing the cornerstone of current management strategies. Derangements in blood coagulation are wellrecognised in this disorder and appear to favour an increased risk of venous thromboembolism among affected women. This risk appears to be most significant in the postpartum period. The mechanisms underlying this increased thrombosis risk remain to be fully elucidated although increased expression of procoagulant factors, endothelial dysfunction, attenuation of endogenous anticoagulant activity and increased platelet activity have been implicated in the prothrombotic tendency. Preeclampsia is also occasionally complicated by life-threatening haemorrhagic events and current evidence suggests that in some severe manifestations of this disease a coagulopathy with a clinical bleeding tendency may be the predominant haemostatic abnormality. Identifying affected women at significant risk of thrombosis and managing the competing thrombotic and haemorrhagic risks continue to be a significant clinical challenge. Derangements in blood coagulation are also implicated in the pathogenesis of preeclampsia; however, the role of antiplatelet or anticoagulant drugs in the prevention and treatment of this disorder remains a source of considerable debate. In addition, the potential role of specific haemostatic markers as diagnostic or screening tools for preeclampsia has also yet to be determined. Further characterisation of the underlying molecular mechanisms would likely be of major translational relevance and could provide insights into the pathogenesis of this disease as well as the associated haemostatic dysfunction.
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Affiliation(s)
- Sarah Kelliher
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland
| | - Patricia B Maguire
- Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Paulina B Szklanna
- UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Luisa Weiss
- UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland
| | - Karl Ewins
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,Department of Haematology, Rotunda Hospital, Dublin, Ireland
| | - Roseann O'Doherty
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Daniel Angelov
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Fionnuala Ní Áinle
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,Department of Haematology, Rotunda Hospital, Dublin, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
| | - Barry Kevane
- Department of Haematology, Mater Misericordiae University Hospital, Dublin, Ireland.,Irish Network for VTE Research (INViTE), Dublin, Ireland.,UCD Conway SPHERE Research Group, Dublin, Ireland.,School of Medicine, University College Dublin (UCD), Dublin, Ireland
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24
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Schaller S, Knippel AJ, Verde PE, Kozlowski P. Concordance-analysis and evaluation of different diagnostic algorithms used in first trimester screening for late-onset preeclampsia. Hypertens Pregnancy 2020; 39:172-185. [PMID: 32306791 DOI: 10.1080/10641955.2020.1750627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: Concordance-analysis and evaluation of existing algorithms detecting late-onset preeclampsia during first trimester screeningMethods: Retrospective cohort study investigating risk algorithms of late-onset preeclampsia during first trimester screening in a German prenatal center. Three previously developed algorithms including anamnestic factors (Apriori) and biophysical markers (BioM) were investigated by using detection rates (DR) with fixed FPR 10% and fixed cutoff >1:100. Furthermore, we set up a concordance-analysis of test results in late-onset preeclampsia cases to examine the effect of influencing factors and to detect potential weaknesses of the algorithms. Therefore, we modeled the probability of discordances as a function of the influencing factors based on a logistic regression, that was fitted using a Bayesian approach.Results: 6,113 pregnancies were considered, whereof 700 have been excluded and 5,413 pregnancies were analyzed. 98 (1.8%) patients developed preeclampsia (79 late-onsets, 19 early-onsets). The Apriori-algorithm reaches a DR of 34.2%, by adding BioM (MAP and UtA-PI) the DR improves to 57.0% (FPR of 10%). In concordance-analysis of Apriori algorithm and Apriori+BioM algorithms, influencing factor BMI<25 increases the chance of discordances sigificantly. Additional, in the subgroup of late-onset preeclampsias with BMI<25 the DR is higher in Apriori+BioM algorithms than in Apriori algorithm alone. If both compared algorithms include BioM, influencing factor MAP decreases the chance of discordances significantly. All other tested influencing factors do not have a statistically significant effect on discordancesConclusion: Normal-weight patients benefit more from the integration of MAP and UtA-PI compared to overweight/obese patients.
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Affiliation(s)
- Sabrina Schaller
- Praenatal-Medizin und Genetik Ärztliche Partnerschaftsgesellschaft Kozlowski und Partner, Düsseldorf
| | | | - Pablo Emilio Verde
- Coordination Center for Clinical Trials, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Peter Kozlowski
- Praenatal-Medizin und Genetik Ärztliche Partnerschaftsgesellschaft Kozlowski und Partner, Düsseldorf
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25
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Tura AK, Scherjon S, Stekelenburg J, van Roosmalen J, van den Akker T, Zwart J. Severe Hypertensive Disorders of Pregnancy in Eastern Ethiopia: Comparing the Original WHO and Adapted sub-Saharan African Maternal Near-Miss Criteria. Int J Womens Health 2020; 12:255-263. [PMID: 32308499 PMCID: PMC7152537 DOI: 10.2147/ijwh.s240355] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 03/21/2020] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVES To assess life-threatening complications among women admitted with severe hypertensive disorders of pregnancy and compare applicability of World Health Organization (WHO) maternal near-miss (MNM) criteria and the recently adapted sub-Saharan African (SSA) MNM criteria in eastern Ethiopia. METHODS Of 1,054 women admitted with potentially life-threatening conditions between January 2016 and April 2017, 562 (53.3%) had severe preeclampsia/eclampsia. We applied the definition of MNM according to the WHO MNM criteria and the SSA MNM criteria. Logistic regression was performed to identify factors associated with severe maternal outcomes (MNMs and maternal deaths). RESULTS The SSA MNM criteria identified 285 cases of severe maternal outcomes: 271 MNMs and 14 maternal deaths (mortality index 4.9%). The WHO criteria identified 50 cases of severe maternal outcomes: 36 MNMs and 14 maternal deaths (mortality index 28%). The MNM ratio was 36.6 per 1,000 livebirths according to the SSA MNM criteria and 4.9 according to the WHO criteria. More than 80% of women in both groups had MNM events on arrival or within 12 hours after admission. Women without antenatal care, from rural areas, referred from other facilities, and with concomitant hemorrhage more often developed severe maternal outcomes. CONCLUSION Regarding hypertensive disorders of pregnancy, the SSA tool is more inclusive than the WHO tool, while still maintaining a considerably high mortality index indicating severity of included cases. This may enable more robust audits. Strengthening the referral system and improving prevention and management of obstetric hemorrhage in women with hypertensive disorders of pregnancy are required to avert severe maternal outcomes.
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Affiliation(s)
- Abera Kenay Tura
- School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Sicco Scherjon
- Department of Obstetrics and Gynecology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Jelle Stekelenburg
- Department of Health Sciences, Global Health, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
- Department of Obstetrics and Gynecology, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Jos van Roosmalen
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Thomas van den Akker
- Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Joost Zwart
- Department of Obstetrics and Gynaecology, Deventer Ziekenhuis, Deventer, The Netherlands
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26
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Ramler PI, van den Akker T, Henriquez DDCA, Zwart JJ, van Roosmalen J, van Lith JMM, van der Bom JG. Women receiving massive transfusion due to postpartum hemorrhage: A comparison over time between two nationwide cohort studies. Acta Obstet Gynecol Scand 2019; 98:795-804. [PMID: 30667050 PMCID: PMC6593418 DOI: 10.1111/aogs.13542] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Revised: 01/14/2019] [Accepted: 01/16/2019] [Indexed: 11/29/2022]
Abstract
Introduction Incidence of massive transfusion after birth was high in the Netherlands between 2004 and 2006 compared with other high‐income countries. This study investigated incidence, causes, management and outcome of women receiving massive transfusion due to postpartum hemorrhage in the Netherlands in more recent years. Material and methods Data for all pregnant women who received eight or more units of packed red blood cells from a gestational age of 20 weeks and within the first 24 hours after childbirth, during 2011 and 2012, were obtained from a nationwide retrospective cohort study, including 61 hospitals with a maternity unit in the Netherlands. Results Incidence of massive transfusion due to postpartum hemorrhage decreased to 65 per 100 000 births (95% CI 56‐75) between 2011 and 2012, from 91 per 100 000 births (95% CI 81‐101) between 2004 and 2006, while median blood loss increased from 4500 mL (interquartile range 3250‐6000) to 6000 mL (interquartile range 4500‐8000). Uterine atony remained the leading cause of hemorrhage. Thirty percent (53/176) underwent peripartum hysterectomy between 2011 and 2012, compared with 25% (83/327) between 2004 and 2006. Case fatality rate for women who received massive transfusion due to postpartum hemorrhage was 2.3% (4/176) between 2011 and 2012, compared with 0.9% (3/327) between 2004 and 2006. Conclusions The incidence of postpartum hemorrhage with massive transfusion decreased in the Netherlands between both time frames, but remained an important cause of maternal mortality and morbidity, including peripartum hysterectomy. National surveillance of maternal morbidity and mortality due to postpartum hemorrhage through an improved and continuous registration with confidential enquiries may lead to the identification of clear improvements of maternal care.
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Affiliation(s)
- Paul I Ramler
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Thomas van den Akker
- Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands.,National Perinatal Epidemiology Unit, University of Oxford, Oxford, UK
| | - Dacia D C A Henriquez
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Joost J Zwart
- Obstetrics and Gynecology, Deventer Hospital, Deventer, the Netherlands
| | - Jos van Roosmalen
- Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands.,Athena Institute, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jan M M van Lith
- Obstetrics and Gynecology, Leiden University Medical Center, Leiden, the Netherlands
| | - Johanna G van der Bom
- Center for Clinical Transfusion Research, Sanquin Research, Leiden, the Netherlands.,Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
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27
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Fukami T, Koga H, Goto M, Ando M, Matsuoka S, Tohyama A, Yamamoto H, Nakamura S, Koyanagi T, To Y, Kondo H, Eguchi F, Tsujioka H. Incidence and risk factors for postpartum hemorrhage among transvaginal deliveries at a tertiary perinatal medical facility in Japan. PLoS One 2019; 14:e0208873. [PMID: 30625154 PMCID: PMC6326562 DOI: 10.1371/journal.pone.0208873] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Accepted: 11/27/2018] [Indexed: 11/26/2022] Open
Abstract
Postpartum hemorrhage (PPH) remains a leading cause of maternal death worldwide, and it is important to understand the relative contributions of different risk factors. We assessed the incidence of these among cases of transvaginal delivery. Between June 2013 and July 2016, a prospective cohort study was conducted at a tertiary perinatal medical facility in Japan. Women were administered a questionnaire to ascertain risk factors for PPH, defined as a blood loss of 1,000 ml or more assessed using a calibrated under-buttocks drape and collection vessel at childbirth. We analyzed 1,068 transvaginal deliveries of singleton pregnancies. The incidence of PPH was 8.7%, and of severe PPH (1,500 ml blood loss or more) was 2.1%. Risk factors for postpartum hemorrhage among the deliveries were: fetal macrosomia (over 4000 g); pregnancy-induced hypertension; pregnancy generated by assisted reproductive technology; severe vaginal or perineal lacerations; and weight gain over 15 kg during pregnancy. Such high weight gain significantly increased the incidence of PPH compared with women showing less than 10 kg weight gain during pregnancy. Monitoring these identified risk factors could enable extra vigilance during labor, and preparedness for managing PPH in all women giving birth.
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Affiliation(s)
- Tatsuya Fukami
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Hidenobu Koga
- Department of Health Information Management, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
- Supporting Unit of Medical Research, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Maki Goto
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Miho Ando
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Sakiko Matsuoka
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Atsushi Tohyama
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Hiroko Yamamoto
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Sumie Nakamura
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Takahiro Koyanagi
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Yoko To
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Haruhiko Kondo
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Fuyuki Eguchi
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
| | - Hiroshi Tsujioka
- Department of Obstetrics and Gynecology, ASO Iizuka Hospital, Iizuka, Fukuoka, Japan
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Kallianidis AF, Schutte JM, van Roosmalen J, van den Akker T. Maternal mortality after cesarean section in the Netherlands. Eur J Obstet Gynecol Reprod Biol 2018; 229:148-152. [DOI: 10.1016/j.ejogrb.2018.08.586] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 08/19/2018] [Accepted: 08/27/2018] [Indexed: 10/28/2022]
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Kohn JR, Dildy GA, Eppes CS. Shock index and delta-shock index are superior to existing maternal early warning criteria to identify postpartum hemorrhage and need for intervention. J Matern Fetal Neonatal Med 2018; 32:1238-1244. [DOI: 10.1080/14767058.2017.1402882] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
| | - Gary A. Dildy
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Catherine S. Eppes
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Baylor College of Medicine, Houston, TX, USA
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[Prophylactic use of tranexamic acid in noncardiac surgery : Update 2017]. Med Klin Intensivmed Notfmed 2018; 114:642-649. [PMID: 29368267 DOI: 10.1007/s00063-018-0402-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 11/08/2017] [Accepted: 12/09/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Minimising perioperative bleeding is a key goal of "patient blood management" programs. One component of respective strategies includes preventive inhibition of fibrinolysis using protease inhibitors, such as tranexamic acid (TXA). TXA inhibits plasminogen activation and plasmin-induced fibrin degradation. OBJECTIVES The present article provides an overview of the existing literature and TXA applications in the prophylaxis of perioperative bleeding. METHODS Literature search in PubMed/MEDLINE (U.S. National Library of Medicine®, Bethesda, MD, USA). RESULTS TXA reduces perioperative blood loss and transfusion requirements in several randomized controlled trials (RCTs) and meta-analyses in the field of hip and knee arthroplasty for both intravenous and topical use. Moreover, evidence favours use of TXA in complex spine surgery and reconstructive surgery (e. g. craniosynostosis in children). Single RCTs showed benefits of TXA in abdominal hysterectomy, open prostatectomy, liver surgery and actively bleeding trauma patients. For prophylaxis of peripartum haemorrhage (PPH) following vaginal delivery or Caesarean section, TXA cannot be routinely recommended, although evidence points to benefits in actively bleeding patients. A recommendation exists for the treatment of (active) PPH. For prophylactic perioperative administration, different dosage regimens exist for adults. Most often an initial i. v. bolus of 1 g or 10-15 mg/kg body weight with/without repetition after 6 h or continuous infusions over 8 h is administered. Increased rates of thromboembolic events were not noted. CONCLUSION Protease inhibitors such as TXA reduce perioperative blood loss and transfusion requirements in selected surgical fields.
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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: 62] [Impact Index Per Article: 8.9] [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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Ukah UV, Hutcheon JA, Payne B, Haslam MD, Vatish M, Ansermino JM, Brown H, Magee LA, von Dadelszen P. Placental Growth Factor as a Prognostic Tool in Women With Hypertensive Disorders of Pregnancy: A Systematic Review. Hypertension 2017; 70:1228-1237. [PMID: 29084878 PMCID: PMC5680987 DOI: 10.1161/hypertensionaha.117.10150] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 08/21/2017] [Accepted: 09/27/2017] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. The PlGF (placental growth factor) has been largely demonstrated to be associated with the diagnosis of the hypertensive disorders of pregnancy (HDPs); however, it is unclear how useful it is for the prognosis of the condition. Our objective was to provide a summary of important findings of its prognostic ability by systematically reviewing studies that examined the ability of the PlGF, either independently or combined with other factors, to predict maternal and fetal complications resulting from the HDPs. We included studies published before January 30, 2017, reporting on the use of the PlGF as a prognostic test for women with confirmed HDPs or suspected preeclampsia. Of the 220 abstracts identified through MEDLINE, Embase, and CINAHL (Cumulative Index to Nursing and Allied Health Literature), 17 studies were eligible for our review. Prognostic performance was evaluated by sensitivity, specificity, likelihood ratios, and area under the receiver operating characteristic curve. PlGF showed moderate-to-high evidence (likelihood ratios of ≥5 or ≤0.2 or area under the receiver operating characteristic curves ≥0.70) for identifying women at the highest risk of preterm delivery or neonatal outcomes (10/12 studies) but showed no clinically useful performance for the prediction of adverse maternal outcomes. PlGF may aid in the management of women with HDPs to avert fetal complications. Future studies should determine an optimum threshold for the marker to guide delivery and should examine whether its use for predicting adverse maternal outcomes in women with HDPs can be improved.
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Affiliation(s)
- U Vivian Ukah
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.).
| | - Jennifer A Hutcheon
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Beth Payne
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Matthew D Haslam
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Manu Vatish
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - J Mark Ansermino
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Helen Brown
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Laura A Magee
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
| | - Peter von Dadelszen
- From the Department of Obstetrics and Gynaecology (U.V.U., J.A.H.), Department of Anesthesiology, Pharmacology, and Therapeutics (B.P., J.M.A.), School of Population and Public Health (M.D.H.), and Woodward Library (H.B.), University of British Columbia, Vancouver, Canada; Healthy Starts Theme, BC Children's Hospital Research Institute, Vancouver, Canada (U.V.U., J.A.H., B.P., J.M.A.); Nuffield Department of Obstetrics and Gynaecology, University of Oxford, United Kingdom (M.V.); and School of Life Course Sciences, King's College London, United Kingdom (L.A.M., P.v.D.)
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Egenberg S, Masenga G, Bru LE, Eggebø TM, Mushi C, Massay D, Øian P. Impact of multi-professional, scenario-based training on postpartum hemorrhage in Tanzania: a quasi-experimental, pre- vs. post-intervention study. BMC Pregnancy Childbirth 2017; 17:287. [PMID: 28874123 PMCID: PMC5584507 DOI: 10.1186/s12884-017-1478-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 08/30/2017] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Tanzania has a relatively high maternal mortality ratio of 410 per 100,000 live births. Severe postpartum hemorrhage (PPH) is a major cause of maternal deaths, but in most cases, it is preventable. However, most pregnant women that develop PPH, have no known risk factors. Therefore, preventive measures must be offered to all pregnant women. This study investigated the effects of multi-professional, scenario-based training on the prevention and management of PPH at a Tanzanian zonal consultant hospital. We hypothesized that scenario-based training could contribute to improved competence on PPH-management, which would result in improved team efficiency and patient outcome. METHODS This quasi-experimental, pre-vs. post-interventional study involved on-site multi-professional, scenario-based PPH training, conducted in a two-week period in October 2013 and another 2 weeks in November 2014. Training teams included nurses, midwives, doctors, and medical attendants in the Department of Obstetrics and Gynecology. After technical skill training on the birthing simulator MamaNatalie®, the teams practiced in realistic scenarios on PPH. Each scenario was followed by debriefing and repeated scenario. Afterwards, the group swapped roles and the observers became the participants. To evaluate the effects of training, we measured patient outcomes by determining blood transfusion rates. Patient data were collected by randomly sampling Medical birth registry files from the pre-training and post-training study periods (n = 1667 and 1641 files, respectively). Data were analyzed with the Chi-square test, Mann-Whitney U-test, and binary logistic regression. RESULTS The random patient samples (n = 3308) showed that, compared to pre-training, post-training patients had a 47% drop in whole blood transfusion rates and significant increases in cesarean section rates, birth weights, and vacuum deliveries. The logistic regression analysis showed that transfusion rates were significantly associated with the time period (pre- vs. post-training), cesarean section, patients tranferred from other hospitals, maternal age, and female genital mutilation and cutting. CONCLUSIONS We found that multi-professional, scenario-based training was associated with a significant, 47% reduction in whole blood transfusion rates. These results suggested that training that included all levels of maternity staff, repeated sessions with realistic scenarios, and debriefing may have contributed to reduced blood transfusion rates in this high-risk maternity setting.
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Affiliation(s)
- Signe Egenberg
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Gerd-Ragna Bloch Thorsens gate 8, 4011, Stavanger, Norway.
| | - Gileard Masenga
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | - Lars Edvin Bru
- Center for Behavioral Research, University of Stavanger, Stavanger, Norway
| | - Torbjørn Moe Eggebø
- Department of Obstetrics and Gynecology, Stavanger University Hospital, Gerd-Ragna Bloch Thorsens gate 8, 4011, Stavanger, Norway
- National Center for Fetal Medicine, Trondheim University Hospital, Trondheim, Norway
| | - Cecilia Mushi
- Department of Obstetrics and Gynecology, Kilimanjaro Christian Medical Centre, Moshi, Tanzania
| | | | - Pål Øian
- Department of Obstetrics and Gynecology, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, University of Tromsø, Tromsø, Norway
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Meertens LJE, Scheepers HCJ, Willemse JPMM, Spaanderman MEA, Smits LJM. Should women be advised to use calcium supplements during pregnancy? A decision analysis. MATERNAL AND CHILD NUTRITION 2017. [PMID: 28626878 DOI: 10.1111/mcn.12479] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Adequate calcium intake during pregnancy is important in the prevention of pre-eclampsia. A substantial proportion of pregnant women do not meet the recommended daily calcium intake, even in developed countries. Nonetheless, calcium supplementation is not routinely advised to pregnant women in most countries. We aimed to predict the impact of advising pregnant women to use calcium supplements (1,000 mg/day) on the number of cases of pre-eclampsia prevented and related health care costs. By use of a decision-analytic model, we assessed the expected impact of advising calcium supplementation to either (1) all pregnant women, (2) women at high risk of developing pre-eclampsia, or (3) women with a low dietary calcium intake compared with current care. Calculations were performed for a hypothetical cohort of 100,000 pregnant women living in a high-income country, although input parameters of the model can be adjusted so as to fit other settings. The incidence of pre-eclampsia could be reduced by 25%, 8%, or 13% when advising calcium supplementation to all pregnant women, women at high risk of pre-eclampsia, or women with a low dietary calcium intake, respectively. Expected net financial benefits of the three scenarios were of €4,621,465, €2,059,165, or €2,822,115 per 100,000 pregnant women, respectively. Advising pregnant women to use calcium supplements can be expected to cause substantial reductions in the incidence of pre-eclampsia as well as related health care costs. It appears most efficient to advise calcium supplementation to all pregnant women, not subgroups only.
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Affiliation(s)
- Linda J E Meertens
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
| | - Hubertina C J Scheepers
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Jessica P M M Willemse
- Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Marc E A Spaanderman
- Department of Obstetrics and Gynaecology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Luc J M Smits
- Department of Epidemiology, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands
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Ersbøll AS, Johansen M, Damm P, Rasmussen S, Vejlstrup NG, Gustafsson F. Peripartum cardiomyopathy in Denmark: a retrospective, population-based study of incidence, management and outcome. Eur J Heart Fail 2017; 19:1712-1720. [PMID: 28597481 DOI: 10.1002/ejhf.882] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 03/24/2017] [Accepted: 04/10/2017] [Indexed: 12/28/2022] Open
Abstract
AIM Population-based European studies of peripartum cardiomyopathy (PPCM) are few. We aimed to estimate the nationwide incidence and outcome of PPCM in Denmark during 2005-2014. METHODS AND RESULTS The Danish National Birth Register and the Danish National Patient Register were linked and searched for cardiomyopathy and heart failure ICD-10 diagnoses in a period of nine months before to 12 months after a delivery from 1 January 2005 through 31 December 2014. Diagnoses were validated and additional data were extracted from patient charts. A total of 61 women met the inclusion criteria equalling 1 in 10 149 deliveries. The majority recovered left ventricular systolic function within one year, but 14.8% suffered a major adverse event with 3.3% mortality, 8.2% mechanical circulatory support requirement and/or heart transplantation and 4.9% persistent severe heart failure. Half of the women had a concomitant hypertensive disorder of pregnancy, and this subgroup had a milder course of the disease. Baseline left ventricular ejection fraction (LVEF) was the only significant predictor of LVEF 10-14 months after diagnosis, and cabergoline therapy to inhibit lactation predicted the dichotomous outcome of complete recovery (LVEF ≥55%). CONCLUSION The first validated, population-based European estimate of PPCM incidence is 1 in 10 149 deliveries, which places Denmark between American and Japanese estimates. Clinical outcome in the cohort was similar to those reported in recent cohorts. Women with concomitant hypertensive disorder of pregnancy had a milder course of PPCM. Baseline LVEF predicted LVEF 10-14 months after diagnosis and cabergoline predicted complete recovery.
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Affiliation(s)
- Anne S Ersbøll
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Marianne Johansen
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Peter Damm
- Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Niels G Vejlstrup
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Finn Gustafsson
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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Ehrmann Feldman D, Vinet É, Sylvestre MP, Hazel B, Duffy C, Bérard A, Meshefedjian G, Bernatsky S. Postpartum complications in new mothers with juvenile idiopathic arthritis: a population-based cohort study. Rheumatology (Oxford) 2017; 56:1378-1385. [DOI: 10.1093/rheumatology/kex168] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Indexed: 11/13/2022] Open
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Effect of magnesium sulfate on oxytocin-induced contractility in human myometrium: an in vitro study. Can J Anaesth 2017; 64:744-753. [DOI: 10.1007/s12630-017-0867-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 02/01/2017] [Accepted: 03/14/2017] [Indexed: 10/19/2022] Open
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Initial management of postpartum hemorrhage: A cohort study in Benin and Mali. Int J Gynaecol Obstet 2016; 135 Suppl 1:S84-S88. [PMID: 27836091 DOI: 10.1016/j.ijgo.2016.08.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the components of initial management associated with a decreased risk of severe postpartum hemorrhage (PPH) in Benin and Mali. METHODS A cohort study was conducted between May 2013 and September 2014 that included all women who delivered vaginally in seven participating centers and who presented excessive bleeding after birth. Severe PPH was defined as PPH that required surgical treatment (vascular ligature and/or hysterectomy), and/or blood transfusion, and/or transfer to an intensive care unit, and/or an outcome of maternal death. Logistic regression was used to identify the components of initial PPH management that were associated with severe PPH, adjusting for case mix. RESULTS A total of 223 women presented a primary PPH presumably caused by uterine atony. Among those, 88 (39.5%) had severe PPH. Nearly one-third of women (30.4%) had a late injection of oxytocin (>10 minutes) after PPH diagnosis or no injection. Oxytocin injection within 10 minutes after the PPH diagnosis was significantly associated with a decreased risk of severe PPH (adjusted OR=0.3; 95% CI, 0.14-0.77). CONCLUSION Decrease in the delays in oxytocin administration is a key determinant to improve maternal outcomes related to PPH in this context.
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van Stralen G, von Schmidt auf Altenstadt JF, Bloemenkamp KW, van Roosmalen J, Hukkelhoven CW. Increasing incidence of postpartum hemorrhage: the Dutch piece of the puzzle. Acta Obstet Gynecol Scand 2016; 95:1104-10. [DOI: 10.1111/aogs.12950] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2016] [Accepted: 07/09/2016] [Indexed: 11/24/2022]
Affiliation(s)
- Giel van Stralen
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
| | | | - Kitty W.M. Bloemenkamp
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
- Department of Obstetrics; Wilhelmina Children Hospital Birth Center; Division Woman and Baby; University Medical Center Utrecht; Utrecht The Netherlands
| | - Jos van Roosmalen
- Department of Obstetrics; Leiden University Medical Center; Leiden The Netherlands
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Ghazali S, Czuzoj-Shulman N, Spence AR, Mishkin DS, Abenhaim HA. Pregnancy outcomes in liver transplant patients, a population-based study. J Matern Fetal Neonatal Med 2016; 30:261-266. [DOI: 10.3109/14767058.2016.1173671] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Sarah Ghazali
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada,
| | - Nicholas Czuzoj-Shulman
- Center for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada, and
| | - Andrea R. Spence
- Center for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada, and
| | - Daniel S. Mishkin
- Section of Gastroenterology, Boston Medical Center, Granite Medical Group, Boston, MA, USA
| | - Haim A. Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, Quebec, Canada,
- Center for Clinical Epidemiology and Community Studies, Jewish General Hospital, Montreal, Quebec, Canada, and
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From Glomerular Endothelium to Podocyte Pathobiology in Preeclampsia: a Paradigm Shift. Curr Hypertens Rep 2015; 17:54. [DOI: 10.1007/s11906-015-0566-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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