Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis

OBJECTIVE

To quantify the risk of future cardiovascular diseases, cancer, and mortality after pre-eclampsia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

Embase and Medline without language restrictions, including papers published between 1960 and December 2006, and hand searching of reference lists of relevant articles and reviews for additional reports.

REVIEW METHODS

Prospective and retrospective cohort studies were included, providing a dataset of 3,488,160 women, with 198,252 affected by pre-eclampsia (exposure group) and 29,495 episodes of cardiovascular disease and cancer (study outcomes).

RESULTS

After pre-eclampsia women have an increased risk of vascular disease. The relative risks (95% confidence intervals) for hypertension were 3.70 (2.70 to 5.05) after 14.1 years weighted mean follow-up, for ischaemic heart disease 2.16 (1.86 to 2.52) after 11.7 years, for stroke 1.81 (1.45 to 2.27) after 10.4 years, and for venous thromboembolism 1.79 (1.37 to 2.33) after 4.7 years. No increase in risk of any cancer was found (0.96, 0.73 to 1.27), including breast cancer (1.04, 0.78 to 1.39) 17 years after pre-eclampsia. Overall mortality after pre-eclampsia was increased: 1.49 (1.05 to 2.14) after 14.5 years.

CONCLUSIONS

A history of pre-eclampsia should be considered when evaluating risk of cardiovascular disease in women. This association might reflect a common cause for pre-eclampsia and cardiovascular disease, or an effect of pre-eclampsia on disease development, or both. No association was found between pre-eclampsia and future cancer.

[Clinical analysis of 206 pregnant patients with multiple organ dysfunction syndrome]

OBJECTIVE

To analyze 206 cases of pregnant women with multiple organ dysfunction syndrome (MODS) due to different primary diseases and the prognosis.

METHOD

A retrospective study was conducted of 206 cases of pregnant women with MODS who were treated during January 2000 to December 2006 in the Third Affiliated Hospital of Guangzhou Medical College, regarding their primary disease and prognosis.

RESULTS

Fourty-four cases among the 206 pregnant women with MODS died. The main primary causes were postpartum hemorrhage in 63 cases (30.6%), severe preeclampsia or eclampsia 60 cases (29.1%), pregnancy with hepatitis C in 23 cases (11.2%), pregnancy with heart disease in 11 cases (5.3%), 12 cases of ectopic pregnancy (5.8%). The mortality was mainly because of pregnancy complicated with heart disease (63.6%), ectopic pregnancy (41.7%), pregnancy with hepatitis (22.7%), of postpartum hemorrhage (17.5%) and severe preeclampsia-eclampsia (11.7%). The difference was statistically significant (P < 0.05).

CONCLUSION

Primary diseases leading to pregnancy complicated with MODS are mainly due to obstetric factors, accounting for 65.05%. However, dysfunction of different organs can result in a significant difference in mortality, mortality from primary diseases of the heart and brain were higher. It is suggested that preventative and therapeutic measures should be taken according to different primary disease organs.

Magnesium for seizure prophylaxis in patients with mild preeclampsia

OBJECTIVE

To estimate whether magnesium therapy is the optimal management for women with mild preeclampsia.

METHODS

A decision analytic model was designed for women with mild preeclampsia to estimate whether empiric magnesium therapy or no magnesium therapy is the optimal management strategy. The model considered relevant clinical events: seizure, placental abruption, and magnesium toxicity. Modeled outcomes were maternal mortality, neonatal mortality, and neurologic neonatal compromise. The two strategies were compared based on the probability of clinical events and outcomes and the utilities or values assigned to the outcomes by prior research. Probabilities and utilities were derived from the literature.

RESULTS

The base-case analysis showed that although the no-magnesium strategy results in a 15% reduction in neonatal mortality and avoids most maternal drug toxicity, it produces a twofold increase in maternal death and more neurologically compromised neonates compared with empiric magnesium. The two strategies are essentially equivalent with regard to aggregate maternal and neonatal outcomes (0.9792 compared with 0.9781 utilities). Multivariable sensitivity analysis using Monte Carlo simulation confirmed the decision to be a "toss-up," yielding a similar mean utility for no-magnesium and magnesium strategies (0.9789+/-0.1374 compared with 0.9784+/-0.1390, respectively).

CONCLUSION

Our decision model indicates that either strategy, using or not using empiric magnesium sulfate therapy, is acceptable. The clinical decision of whether to use magnesium in patients with mild preeclampsia for seizure prophylaxis should be determined by the physician or institution, considering patient values or preferences and the unique risk-benefit trade-off of each strategy.

Dietary calcium supplementation for prevention of pre-eclampsia and related problems: a systematic review and commentary

BACKGROUND

Calcium supplementation during pregnancy may reduce the risk of hypertensive disorders of pregnancy.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Central Register of Controlled Trials (March 2006).

SELECTION CRITERIA

Randomised trials comparing at least 1 g of calcium daily during pregnancy with placebo. Eligibility and trial quality were assessed.

DATA COLLECTION AND ANALYSIS

Data were extracted and analysed using Review Manager software.

MAIN RESULTS

Twelve studies (15,528 women) were included, all of good quality. Most women were at low risk and had low dietary calcium. High blood pressure was reduced with calcium supplementation rather than placebo (11 trials, 14,946 women: relative risk [RR] random effects model 0.70; 95% CI 0.57-0.86), as was pre-eclampsia (12 trials, 15,206 women: RR 0.48; 95% CI 0.33-0.69). The effect was greatest for women at high risk (five trials, 587 women: RR 0.22; 95% CI 0.12-0.42) and for those with low baseline calcium intake (seven trials, 10,154 women: RR 0.36; 95% CI 0.18-0.70). There was heterogeneity, with less effect in the larger trials. The composite outcome maternal death or serious morbidity was reduced (four trials, 9732 women: RR 0.80; 95% CI 0.65-0.97). The syndrome of haemolysis, elevated liver enzymes and low platelets was increased (two trials, 12,901 women: RR 2.67; 95% CI 1.05-6.82). There was no overall effect on the risk of preterm birth or stillbirth or death before discharge from hospital.

CONCLUSIONS

Calcium supplementation appears to reduce the risk of pre-eclampsia and to reduce the rare occurrence of the composite outcome 'maternal death or serious morbidity'. There were no other clear benefits or harms.

COMMENTARY

We present the hypothesis that adequate dietary calcium before and in early pregnancy may be needed to prevent the underlying pathology responsible for pre-eclampsia. We suggest that the research agenda be redirected towards calcium supplementation at a community level.

Instituting Surveillance Guidelines and Adverse Outcomes in Preeclampsia

OBJECTIVE

To assess the incidence of combined adverse maternal and perinatal outcomes in women with preeclampsia before and after introducing standardized assessment and surveillance.

METHODS

This study was a preintervention (retrospective) compared with a postintervention (prospective) cohort comparison in a single-tertiary, perinatal unit that included women admitted to hospital with preeclampsia. We interrogated an existing retrospective 24-month database and then introduced the guidelines, assessing the incidence of the combined adverse maternal and perinatal outcomes for 41 months (September 2003 through February 2007). Tests of organ (dys)function were performed at least as often as on the day of admission, admission day +1, every Monday and Thursday, day of delivery, and delivery day +1. All data were checked for errors. The combined maternal outcome was maternal death or one or more of hepatic failure, hematoma, or rupture, Glasgow coma score of less than 13, stroke, at least two seizures, cortical blindness, need for positive inotrope support, myocardial infarction, infusion of any third antihypertensive, renal dialysis, renal transplantation, at least 50% FIO(2) for greater than 1 hour, intubation, or transfusion of at least 10 units of blood products. The combined perinatal outcome was perinatal or infant mortality, bronchopulmonary dysplasia, necrotizing enterocolitis, grade III/IV intraventricular hemorrhage, cystic periventricular leukomalacia, or stage 3-5 retinopathy of prematurity.

RESULTS

Two hundred ninety-five and 405 women were in the preintervention and postintervention cohorts, respectively. The incidence of adverse maternal outcome fell (5.1% to 0.7%; Fisher P<.001; odds ratio 0.14, 95% confidence interval 0.04-0.49). Perinatal outcomes did not change.

CONCLUSION

Standardized surveillance of women with preeclampsia was associated with reduced maternal risk.

Pre-eclampsia: clinical manifestations and molecular mechanisms

Preeclampsia affects 3-5% of pregnancies and can have a significant impact on health for both mother and fetus. Risk factors include maternal co-morbidities such as obesity and chronic hypertension, paternal factors, and genetic factors. New hypertension and proteinuria during the second half of pregnancy are key diagnostic criteria, but the clinical features and associated prognostic implications are somewhat heterogeneous and may reflect different mechanisms of disease. Renal dysfunction and proteinuria correspond to the pathologic finding of glomerular endotheliosis, and generally resolve after cure of preeclampsia through fetal and placenta delivery. The molecular mechanisms behind this disease are being discovered and refined. The initial etiologic agents are currently unknown. Pathologic studies show abnormal development of an ischemic placenta with a high-resistance vasculature, which cannot deliver an adequate blood supply to the fetoplacental unit. Endothelial dysfunction plays a central role in the pathogenesis of the maternal syndrome. Dysfunctional endothelial cells produce altered quantities of vasoactive mediators, which lead to a tip in the balance towards vasoconstriction. An imbalance in circulating angiogenic factors is emerging as a prominent mechanism that mediates the endothelial dysfunction and the clinical signs and symptoms of preeclampsia. Soluble fms-like tyrosine kinase 1 (sFlt1), an endogenous anti-angiogenic factor that is a potent vascular endothelial growth factor (VEGF) antagonist, is highly elevated in preeclampsia. VEGF is not only important in angiogenesis, but also in maintaining endothelial health including the formation of endothelial fenestrae (a hallmark of the glomerular vascular endothelium). sFlt1 overexpression in animals induces glomerular endotheliosis with the loss of endothelial fenestrae that resembles the renal histological lesions of preeclampsia. More severe forms of preeclampsia, including the HELLP syndrome, may be explained by a concomitant elevation in both sFlt1 and soluble endoglin, another anti-angiogenic factor. Unraveling of the molecular mechanisms behind preeclampsia may help to expand our armamentarium to treat patients in a more directed fashion, as current management consists of supportive care and expedited delivery. Finally, long-term outcomes of women with preeclampsia include a significantly increased risk for hypertension and cardiovascular disease, including mortality, which may warrant more aggressive screening and treatment in this population.

Identification of patients at risk for early onset and/or severe preeclampsia with the use of uterine artery Doppler velocimetry and placental growth factor

OBJECTIVE

Preeclampsia has been proposed to be an antiangiogenic state that may be detected by the determination of the concentrations of the soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) and placental growth factor (PlGF) in maternal blood even before the clinical development of the disease. The purpose of this study was to determine the role of the combined use of uterine artery Doppler velocimetry (UADV) and maternal plasma PlGF and sVEGFR-1 concentrations in the second trimester for the identification of patients at risk for severe and/or early onset preeclampsia.

STUDY DESIGN

A prospective cohort study was designed to examine the relationship between abnormal UADV and plasma concentrations of PlGF and sVEGFR-1 in 3348 pregnant women. Plasma samples were obtained between 22 and 26 weeks of gestation at the time of ultrasound examination. Abnormal UADV was defined as the presence of bilateral uterine artery notches and/or a mean pulsatility index above the 95th percentile for the gestational age. Maternal plasma PlGF and sVEGFR-1 concentrations were determined with the use of sensitive and specific immunoassays. The primary outcome was the development of early onset preeclampsia (< or = 34 weeks of gestation) and/or severe preeclampsia. Secondary outcomes included preeclampsia, the delivery of a small for gestational age (SGA) neonate without preeclampsia, spontaneous preterm birth at < or = 32 and < or = 35 weeks of gestation, and a composite of severe neonatal morbidity. Contingency tables, chi-square test, receiver operating characteristic curve, and multivariate logistic regression were used for statistical analyses. A probability value of < .05 was considered significant.

RESULTS

(1) The prevalence of preeclampsia, severe preeclampsia, and early onset preeclampsia were 3.4% (113/3296), 1.0% (33/3296), and 0.8% (25/3208), respectively. UADV was performed in 95.4% (3146/3296) and maternal plasma PlGF concentrations were determined in 93.5% (3081/3296) of the study population. (2) Abnormal UADV and a maternal plasma PlGF of < 280 pg/mL were independent risk factors for the occurrence of preeclampsia, severe preeclampsia, early onset preeclampsia, and SGA without preeclampsia. (3) Among patients with abnormal UADV, maternal plasma PlGF concentration contributed significantly in the identification of patients destined to develop early onset preeclampsia (area under the curve, 0.80; P < .001) and severe preeclampsia (area under the curve, 0.77; P < .001). (4) In contrast, maternal plasma sVEGFR-1 concentration was of limited use in the prediction of early onset and/or severe preeclampsia. (5) The combination of abnormal UADV and maternal plasma PlGF of < 280 pg/mL was associated with an odds ratio (OR) of 43.8 (95% CI, 18.48-103.89) for the development of early onset preeclampsia, an OR of 37.4 (95% CI, 17.64-79.07) for the development of severe preeclampsia, an OR of 8.6 (95% CI, 5.35-13.74) for the development of preeclampsia, and an OR of 2.7 (95% CI, 1.73-4.26) for the delivery of a SGA neonate in the absence of preeclampsia.

CONCLUSION

The combination of abnormal UADV and maternal plasma PlGF concentration of < 280 pg/mL in the second trimester is associated with a high risk for preeclampsia and early onset and/or severe preeclampsia in a low-risk population. Among those with abnormal UADV, a maternal plasma concentration of PlGF of < 280 pg/mL identifies most patients who will experience early onset and/or severe preeclampsia.

Risk factors of maternal death in Mexico

BACKGROUND

One of the United Nations' Millennium Development Goals for 2015 is to reduce the maternal mortality ratio by three fourths. Ninety-nine percent of maternal deaths occur in developing countries, and the World Health Organization encourages investigations in these settings to determine the risk factors of maternal deaths. Our aim was to identify these risk factors in a hospital-based study in Mexico.

METHODS

The study was conducted at the Hospital of Obstetrics and Gynecology at the Mexican Institute of Social Security in Leon, Guanajuato, Mexico, from January 1, 1992, to March 31, 2004. Women were divided into groups of 110 individuals who had died during pregnancy, delivery, or postpartum, and 440 women who survived the postpartum period. We used a logistic regression analysis to find the significant risk factors for maternal deaths. Odds ratios with 95% t confidence intervals were estimated.

RESULTS

The maternal mortality ratio was 47.3 per 100,000 live births. The main causes of death were hemorrhage (30.9%), preeclampsia/eclampsia (28.2%), and septic shock (10.9%). Six factors were significantly associated with maternal death: age (OR = 1.09, 95% CI = 1.00-1.18), marital status (OR = 16.2, 95% CI = 1.3-196.1), number of antenatal visits (OR = 1.3, 95% CI = 1.0-1.6), preexisting medical conditions (OR = 23.3, 95% CI = 6.6-81.6), obstetric complications in previous pregnancies (OR = 28.3, 95% CI = 4.9-163.0), and mode of delivery (OR = 1.6, 95% CI = 1.0-2.4).

CONCLUSIONS

Socioeconomic, medical, and obstetric risk factors are associated with maternal deaths in Mexico.

[Analysis of death maternal cases during a 10-year period]

OBJECTIVES

To determine the clinical features, as well as to present an analysis of the cases of maternal death during a period of ten years.

PATIENTS AND METHODS

A descriptive, transverse, retrospective and cases series research was carried out. There was a revision of the expedients of maternal death occurred at the Regional General Hospital number 36 in Puebla, from January 1st, 1996 to December 31st, 2005. They were selected the patients who passed away because of obstetric death. The data collection included the following variables: age, body mass index, education, number of gestations, type of labour, prenatal control, basic cause of dead, and the month and the year in which it occurred. The descriptive statistics was used with central tendency and dispersion measurements.

RESULTS

75 maternal deaths were registered; one of them was excluded because it was not an obstetric cause. The maternal death rate was 63.46 per 100,000 born alive. The 17.5% corresponded to indirect obstetric causes and 82.5% to direct obstetric causes; the 73% were preventable, 27% were no preventable. Forty-eight cases corresponded to ages between 21 and 34 years. Forty-six cases corresponded to mothers with 2 to 4 pregnancies. In 43 cases they had a level of education which ranks between elementary and junior high school. In 31 cases they had a body mass index of 21 to 26. The eclampsia was the cause of maternal death in 20 cases and the obstetric haemorrhage in 16 cases. There were appropriate prenatal controls in 38 cases.

CONCLUSIONS

The maternal death cases corresponded to an average age women, multigravidas, no obese, and apparently appropriate prenatal control. During this period there was a tendency to the decrease of obstetric haemorrhage and an increase of the preeclampsia-eclampsia as causes of maternal death.

Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

AIM

To report the occurrence of morbidity and mortality associated with carefully phenotyped pre-eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease.

METHODS

A phenotyping database of 180 nulliparous women with pre-eclampsia and 180 nulliparous normotensive pregnant women who were recruited for a study into genetics of pre-eclampsia was analyzed.

RESULTS

Women who developed pre-eclampsia had significantly higher systolic blood pressure (SBP; P = 0.002) and diastolic blood pressure (DBP; P = 0.002) at booking (at approximately 13 weeks of gestation). 38.3%, 28.3% and 33.3% of women delivered at <34 weeks, at 34-36 weeks, and at term, respectively. 78% required a cesarean section. Complications included SBP > or = 160 mmHg (75.5%); DBP > or = 110 mmHg (83.8%); proteinuria > or =3 + (150 mg/dL) in the urine protein heat coagulation test (87%); renal failure requiring dialysis (2%); platelet counts <100 x 10(9)/L (13%); > or =70 U/L in aspartate and/or alanine aminotransaminase (15%); placental abruption (4%); eclampsia (9%); and one maternal death. Maternal complications indicative of severe disease, apart from the incidence of SBP > or = 160 mmHg and DBP > or = 110 mmHg, were not significantly different in early and late-onset pre-eclampsia; fetal outcome was better with late-onset disease. 48% of babies were small for gestational age. Only 80 of 135 babies of women with pre-eclampsia whose condition could be confirmed at 6 weeks post-partum were alive.

CONCLUSIONS

Pre-eclampsia in Sinhalese women is associated with severe maternal morbidity and fetal morbidity and mortality, suggesting that modification of the Western diagnostic criteria and/or guidelines for medical care may be necessary. There is an urgent need to improve neonatal intensive care services in Sri Lanka.

Causes of stillbirths and early neonatal deaths: data from 7993 pregnancies in six developing countries

OBJECTIVE

To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women.

METHODS

A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10).

FINDINGS

Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%).

CONCLUSIONS

Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.

The Magpie Trial: a randomised trial comparing magnesium sulphate with placebo for pre-eclampsia. Outcome for women at 2 years

Objective

The aim of this study was to assess long-term effects for women following the use of magnesium sulphate for pre-eclampsia.

Design

Assessment at 2–3 years after delivery for women recruited to the Magpie Trial (recruitment in 1998–2001, ISRCTN 86938761), which compared magnesium sulphate with placebo for pre-eclampsia.

Setting

Follow up after discharge from hospital at 125 centres in 19 countries across five continents.

Population

A total of 7927 women were randomised at the follow-up centres. Of these women, 2544 were not included for logistic reasons and 601 excluded (109 at a centre where <20% of women were contacted, 466 discharged without a surviving child and 26 opted out). Therefore, 4782 women were selected for follow-up, of whom 3375 (71%) were traced.

Methods

Questionnaire assessment was administered largely by post or in a dedicated clinic. Interview assessment of selected women was performed.

Main outcome measures

Death or serious morbidity potentially related to pre-eclampsia at follow up, other morbidity and use of health service resources.

Results

Median time from delivery to follow up was 26 months (interquartile range 19–36). Fifty-eight of 1650 (3.5%) women allocated magnesium sulphate died or had serious morbidity potentially related to pre-eclampsia compared with 72 of 1725 (4.2%) women allocated placebo (relative risk 0.84, 95% CI 0.60–1.18).

Conclusions

The reduction in the risk of eclampsia following prophylaxis with magnesium sulphate was not associated with an excess of death or disability for the women after 2 years.

Comparisons of maternal and perinatal outcomes in Taiwanese women with complete and partial HELLP syndrome and women with severe pre-eclampsia without HELLP

AIM

To analyze the variations between maternal complications and perinatal outcome among women with complete hemolysis, elevated liver enzyme levels, and low platelet count (HELLP) syndrome, partial HELLP syndrome, and women with severe pre-eclampsia and normal laboratory tests. We also examine the effect of corticosteroid therapy for treatment of HELLP.

METHODS

In this retrospective study, six patients with complete HELLP syndrome and 46 with partial HELLP syndrome, were compared and contrasted with 212 patients with severe pre-eclampsia but without HELLP syndrome.

RESULTS

In Protocol 1, multiple organ dysfunction syndrome (MODS) was the strongest morbidity factor associated with patients among complete HELLP, partial HELLP, and severe pre-eclampsia. After post-hoc analysis, disseminated intravascular coagulation (DIC) was the significant outcome variable between complete and partial HELLP. In Protocol 2, after adjustment, we found that MODS (adjusted OR, 15.2, 95% CI, 6.18-35.53; P < 0.001); Apgar score less than 5 at 1 minute (adjusted OR, 2.17, 95% CI, 0.94-5.01; P = 0.069) and DIC (adjusted OR, 9.51, 95% CI, 1.68-53.7, P = 0.011) remained significantly associated with HELLP syndrome. There was a favorable outcome found in the complete HELLP group. Neither the dexamethasone group nor the aggressive therapy group could benefit from the treatment protocol.

CONCLUSION

The different categories of HELLP syndrome, the protocol 1 and protocol 2 have been noted as differential effects on pregnancy outcome. MODS and DIC would be two significant outcome variables and corticosteroid therapy may not benefit HELLP patients.

Neonatal outcome after preterm delivery in HELLP syndrome

The present study compares neonatal outcome after preterm delivery of infants in pregnancies complicated by the HELLP syndrome or severe preeclampsia (PS). The maternal and neonatal charts of 71 out of a total of 409 pregnancies that were complicated by hypertensive disorders at Severance hospital between January 1995 and December 2004 were reviewed. Twenty-one pregnancies were complicated by HELLP syndrome and 50 pregnancies were complicated by PS. Fifty normotensive (NT) patients who delivered because of preterm labor comprised the control group. Results were analyzed by the chi-square test and ANOVA. Gestational age and maternal age at delivery were matched among the three groups. The neonatal outcomes of the HELLP syndrome group were compared with the PS and NT groups. There were significant differences between the HELLP syndrome group and the PS group in the incidence of intraventricular hemorrhage (IVH) (61.9% vs. 26%, p=0.006), sepsis (85.7% vs. 44%, p =0.003) and mechanical ventilation (MV) rate (81% vs. 54%, p=0.039). There were significant differences between the HELLP syndrome group and the NT group in the incidence of neonatal death (ND) (19.5% vs. 2.0%, p=0.034), respiratory distress syndrome (RDS) (38.1% vs. 8%, p=0.0045), IVH (61.9% vs. 4%, p < 0.0001), sepsis (85.7% vs. 14%, p < 0.0001), intensive care (IC) (85.7% vs. 24%, p < 0.0001) and MV rate (80.1% vs. 14%, p < 0.0001). There were also significant differences between the PS and NT groups in the incidence of ND (20% vs. 2%, p=0.0192), RDS (30% vs. 8%, p=0.0085), IVH (26% vs. 4%, p=0.0070), sepsis (44% vs. 14%, p=0.0015), IC (78% vs. 24%, p < 0.0001), MV rate (54% vs. 14%, p < 0.0001) and low 5-min APGAR score (50% vs. 16%, p=0.0005). This study shows increased morbidity in newborns of mothers complicated with HELLP syndrome and indicates that early, regular and high quality management of these patients is essential to improve both maternal and neonatal outcome.

Characteristics of preeclampsia- and eclampsia-related maternal death in rural Haiti

OBJECTIVE

The maternal mortality ratio in Haiti remains one of the highest in the world at 600/100 000 live births. Preeclampsia- and eclampsia-related complications are one of the leading causes of maternal death. In this resource-limited setting, effective, efficient hospital-based interventions are necessary to reduce this risk. Our objective was to assess the utility of common laboratory and clinical admission data for the determination of preeclampsia- and eclampsia-related maternal death.

STUDY DESIGN

We performed an analysis of women presenting to the Hôpital Albert Schweitzer with preeclampsia and eclampsia during a 3-year period. Factors analyzed were: maternal age, parity, gestational age, hematocrit, serum creatinine, urine protein, systolic and diastolic blood pressure, intrauterine fetal death (IUFD), coma on arrival, and address (residence within or outside hospital catchment area). Stepwise logistic regression identified factors predictive of maternal mortality.

RESULTS

Preeclampsia/eclampsia affected 423 of 2295 deliveries (18%) and resulted in 19 deaths. Multivariate analysis identified the following predictors of maternal mortality: IUFD (RR 7.57; 95% CI 2.76-12.69), eclampsia (RR 6.91; 95% CI 2.08-12.64), and oliguria (RR 5.39; 95% CI 1.80-10.69).

CONCLUSION

In this setting, traditional admission laboratory and clinical tests were not useful in maternal mortality prediction. The analysis highlights clinical characteristics of women at highest risk for maternal death.

[Study on different onset patterns and perinatal outcomes in severe preeclampsia]

OBJECTIVE

To explore the different clinical onset patterns in severe preeclampsia.

METHODS

A prospective observational study was conducted in 173 cases of severe preeclampsia. They were divided into two groups according to the onset of gestational age of severe preeclampsia, early onset of severe preeclampsia (S-PE) (onset < or = 34 weeks) and late onset of S-PE (onset > 34 weeks). Then according to the onset pattern they were subdivided into 4 subgroups: early abrupt onset (10) and early onset with gradual progress of severe preeclampsia (87), late abrupt onset (18) and late onset with gradual progress of severe preeclampsia (58). Clinical characteristics in each subgroup were evaluated.

RESULTS

Cases with abrupt onset accounted for 16.2% out of 173 cases of severe preeclampsia (28/173). The incidence of abrupt onset or onset with gradual progress between early and late onset groups was not significantly different (P > 0.05). Whether in early onset group or late onset group, the incidence of serious maternal complications was much higher in abrupt onset subgroups than that in gradual progress subgroups [100.0% (10/10) vs 34.5% (30/87) and 100.0% (18/18) vs 29.3% (17/58); P < 0.001]. The incidence of serious maternal complications was not significantly different between early onset and late onset groups (P > 0.05). The perinatal mortality rate was higher in abrupt onset subgroups compared to gradual progress subgroups both in early onset groups and in late onset ones (72.7% vs 24.3%, P < 0.01; 22.2% vs 4.9%, P < 0.05). The perinatal mortality rate was higher in each subgroups in early onset groups than that in late onset ones respectively (P < 0.01, P < 0.05). The gestational age at delivery was closely associated with perinatal outcomes. When a delimitation of early onset of severe preeclampsia was set at 32-week gestation, perinatal outcome was associated with both gestational age at birth and the onset time of severe preeclampsia. If the cut-off point was set at 34-week gestation, perinatal outcome was associated only with gestational age at birth.

CONCLUSIONS

Approximately 16% pregnant women with severe preeclampsia were attacked abruptly and complicated by serious complications. The clinical delimitation of early onset of severe preeclampsia set at 32-week gestation is significantly associated with poor maternal and perinatal outcomes.

Translating research into policy and practice in developing countries: a case study of magnesium sulphate for pre-eclampsia

Background

The evidence base for improving reproductive health continues to grow. However, concerns remain that the translation of this evidence into appropriate policies is partial and slow. Little is known about the factors affecting the use of evidence by policy makers and clinicians, particularly in developing countries. The objective of this study was to examine the factors that might affect the translation of randomised controlled trial (RCT) findings into policies and practice in developing countries.

Methods

The recent publication of an important RCT on the use of magnesium sulphate to treat pre-eclampsia provided an opportunity to explore how research findings might be translated into policy. A range of research methods, including a survey, group interview and observations with RCT collaborators and a survey of WHO drug information officers, regulatory officials and obstetricians in 12 countries, were undertaken to identify barriers and facilitators to knowledge translation.

Results

It proved difficult to obtain reliable data regarding the availability and use of commonly used drugs in many countries. The perceived barriers to implementing RCT findings regarding the use of magnesium sulphate for pre-eclampsia include drug licensing and availability; inadequate and poorly implemented clinical guidelines; and lack of political support for policy change. However, there were significant regional and national differences in the importance of specific barriers.

Conclusion

The policy changes needed to ensure widespread availability and use of magnesium sulphate are variable and complex. Difficulties in obtaining information on availability and use are combined with the wide range of barriers across settings, including a lack of support from policy makers. This makes it difficult to envisage any single intervention strategy that might be used to promote the uptake of research findings on magnesium sulphate into policy across the study settings. The publication of important trials may therefore not have the impacts on health care that researchers hope for.

Hyperhomocysteinemia in pregnant rats: effects on arterial pressure, kidneys and fetal growth

OBJECTIVE

This study aimed to test the hypothesis that hyperhomocysteinemia plays a role in the development of pathological changes similar to human preeclampsia in pregnant rats.

STUDY DESIGN

Arterial pressure and 24-h urinary excretion of proteins and electrolytes were measured during pre-pregnancy, pregnancy and postpartum periods in control (n = 12) and methionine-treated (2.0 g/kg/day, n = 11) Sprague-Dawley rats. Rats were then sacrificed at the end of this protocol and renal histological examination was performed. In another protocol, control (n = 6) and methionine-treated (n = 6) rats were anaesthetized at day 20 of gestation and pregnancy outcome was assessed. Hemodynamic and renal excretory differences between groups were analyzed using ANOVA and differences in renal histology and gestation outcome using t-test.

RESULTS

Serum homocysteine in the methionine group (24.0+/-2.0 micromol/L) was significantly higher compared with controls (8.5+/-0.5 micromol/L). Systolic pressure, urinary protein excretion and renal histological changes were not significantly different between the two groups. However, fetal weights were significantly smaller and percent of dead fetuses were 15% higher in methionine-treated compared with control rats.

CONCLUSION

Hyperhomocysteinemia is unlikely to cause maternal hypertension, proteinuria or renal damage in pregnant rats. However, hyperhomocysteinemia may restrict fetal growth and increase fetal mortality.

[Clinical delimitation and expectant management of early onset of severe pre-eclampsia]

OBJECTIVE

To determine the clinical delimitation and to investigate the difference of maternal and perinatal outcome with expectant management of women with early onset of severe preeclampsia.

METHODS

Two hundred and fifty-five cases meeting the criteria of severe pre-eclampsia who underwent expectant management were enrolled in this study. Patients were divided into 4 groups: group A (n = 24) with onset before 28 weeks of gestation, group B (n = 50) with onset during 28 - 31 weeks of gestation, group C (n = 34) with onset during 32 - 33 gestational weeks, and group D (n = 147) with onset >or= 34 weeks of gestation. Main outcome measures included prolongation of gestation, perinatal mortality rate, and small for gestational age as well as major complications.

RESULTS

The average pregnancy prolongation was (9 +/- 3) days (range 1 to 40), (11 +/- 8) (range 1 to 28), (8 +/- 6) (range 1 to 21), and (5 +/- 4) (range 1 to 21), respectively in groups A, B, C and D. The gestational age at delivery was closely associated with the perinatal outcome. When a cut-off point was set at 34-week gestation, perinatal outcome was only associated with the gestational age at birth. If the cut-off point was set at 32-week gestation, perinatal morbidity and mortality were associated with both gestational age at birth and the onset of severe preeclampsia during pregnancy.

CONCLUSIONS

The clinical delimitation of early onset of severe preeclampsia at 32-week gestation is significantly associated with poor maternal and perinatal outcome. Expectant management should be carried out in well-selected patients with severe preeclampsia remote from term, individually.

Maternal and fetal outcome of anaesthesia for caesarean delivery in preeclampsia/eclampsia in Enugu, Nigeria: a retrospective observational study

BACKGROUND

Maternal mortality, for which preeclampsia is a major cause, is a problem in Nigeria. Accurate data are available for caesarean sections in the University of Nigeria Teaching Hospital, Enugu. We therefore studied the outcome of caesarean section among these high-risk patients.

METHOD

We conducted a retrospective survey of hospital records of patients with preeclampsia/eclampsia who had caesarean delivery in this unit over a four-year span from July 1998 to June 2002.

RESULTS

There were 3926 deliveries and 4036 births (3611 live births), with 898 women (23%) delivered by caesarean section. Of these, 125 (14%) had preeclampsia/eclampsia, 103 (82.4%) presenting for emergency caesarean delivery and 22 (17.6%) elective. General anaesthesia was used in 116 patients (92.8%) and spinal in nine. The major indications for surgery were severe preeclampsia/eclampsia in patients with unfavourable cervix (68%), fetal distress/intrauterine growth restriction (7.2%) and previous caesarean section (6.4%). There were six maternal deaths, all with general anaesthesia, giving a case fatality rate of 5.2% of general anaesthetics or 4.8% of caesarean deliveries. The cause of death was anaesthetic in three patients, cerebrovascular accident and pulmonary oedema in two and intraoperative haemorrhage in one. There were 13 stillbirths and 10 neonatal deaths.

CONCLUSION

Maternal and fetal mortality were high. Poverty, late presentation, lack of equipment and inexperienced management were major contributory factors. Use of spinal anaesthesia should be encouraged in view of recent favourable reviews and cheaper cost.

Diagnosis, prevention, and management of eclampsia

The pathogenesis of eclamptic convulsions remains unknown. Cerebral imaging suggests that cerebral abnormalities in eclampsia (mostly vasogenic edema) are similar to those found in hypertensive encephalopathy. However, cerebral imaging is not necessary for the diagnosis or management of most women with eclampsia. The onset of eclamptic convulsions can be antepartum (38-53%), intrapartum (18-36%), or postpartum (11-44%). Recent data reveal an increase in the proportion of women who develop eclampsia beyond 48 hours after delivery. Other than early detection of preeclampsia, there are no reliable tests or symptoms for predicting the development of eclampsia. In developed countries, the majority of cases reported in recent series are considered unpreventable. Magnesium sulfate is the drug of choice for reducing the rate of eclampsia developing intrapartum and immediately postpartum. There are 4 large randomized trials comparing magnesium sulfate with no treatment or placebo in patients with severe preeclampsia. The rate of eclampsia was significantly lower in those assigned to magnesium sulfate (0.6% versus 2.0%, relative risk 0.39, 95% confidence interval 0.28-0.55). Thus, the number of women needed to treat to prevent one case of eclampsia is 71. Magnesium sulfate is the drug of choice to prevent recurrent convulsions in eclampsia. The development of eclampsia is associated with increased risk of adverse outcome for both mother and fetus, particularly in the developing nations. Pregnancies complicated by eclampsia require a well-formulated management plan. Women with a history of eclampsia are at increased risk of eclampsia (1-2%) and preeclampsia (22-35%) in subsequent pregnancies. Recommendations for diagnosis, prevention, management, and counseling of these women are provided based on results of recent studies and my own clinical experience.

[Factors associated to maternal mortality among preeclamptic parturients. About 55 cases]

Retrospective study about 55 preeclamptic parturients. Data was collected from the medical files of the patients hospitalized during two consecutive years. Admittance of preeclamptic women in the intensive care unit was 6,37 % (55/689). Mortality rate was 11% (6 deaths). Complications associated with the maternal death were renal failure, disseminated intravascular coagulopathy and Hemorrhagic shock after subcupsular liver hematoma. Advanced maternal age is a factor associated to maternal mortality. All these risk factors of death may be avoided if adequate management was performed.

Long-Term Mortality After Preeclampsia

BACKGROUND

Many believe that preeclampsia is not associated with future morbidity or mortality. We sought to investigate the long-term risk of mortality in women with preeclampsia, focusing on those known to be subsequently normotensive.

STUDY DESIGN

We ascertained deaths during 24-36 years' follow-up in a cohort of 37,061 women who delivered in Jerusalem in 1964-1976, including 1,070 women with preeclampsia. We used Cox proportional hazard models to estimate the risk of mortality associated with preeclampsia while controlling for the woman's age and education, history of diabetes, heart disease and low birth weight birth, the husband's social class, and the calendar year at the start of follow-up.

RESULTS

Compared with women who were not diagnosed with preeclampsia, the relative risk of death after preeclampsia was 2.1 (95% confidence interval = 1.8-2.5). Deaths from cardiovascular disease contributed most strongly to this increase. Among women with preeclampsia who had subsequent births without preeclampsia, the excess risk of mortality became manifest only after 20 years.

CONCLUSIONS

These findings, together with other recent cohort studies, define preeclampsia as a risk marker for mortality from cardiovascular disease. They suggest that the observation of a normal blood pressure after preeclampsia should not discourage the search for other cardiovascular risk factors or abrogate the need for other preventive measures.

[TOLUCA experience in preeclampsia-eclampsia]

INTRODUCTION

Reducing morbidity and mortality due to preeclampsia-eclampsia represents a challenge in health care. Since 1997, in the city of Toluca, Estado de México, a research unit was implemented along with a national expert committee for the study of preeclampsia-eclampsia. This was followed by the development of an educational program and the establishment of a diagnosis and treatment protocol TOLUCA.

MATERIAL AND METHODS

We reviewed the mortality registered in the obstetric ICU of our institute, before and after the implementation of the TOLUCA protocol and including a review of the impact of human resources obtained from our educational program, clinical research and the establishment of a research unit.

RESULTS

During a period of 12 years, 1723 patients were treated, with 102 (5.9%) maternal deaths. Preeclampsia-eclampsia accounted for 49 (48%), obstetric hemorrhage 29 (28%), sepsis 9 (9%) and miscellaneous 15 (15%) of all deaths. Data were chronologically divided from 1992 to 1996 (group A) and from 1997 to 2003 (group B), before and after the implementation of the TOLUCA protocol. Group A included 289 admissions with 39 deceased representing a relative mortality of 13.4% (1 death per 7 admissions). Group B included 1434 admissions with 63 deaths, representing a relative mortality of 4.3% (1/23 admissions). Twenty obstetrician/gynecologists were graduates in clinical medicine, 25 research papers were published, four books on preeclampsia were published including preeclampsia, critical medicine, arterial hypertension and renal failure, six book chapters, and the physical implementation of a research unit with laboratory, physician's office and surgical facility.

CONCLUSIONS

Results obtained using the TOLUCA protocol allow us to propose it as a prototype for application in obstetric-gynecology hospitals in order to improve medical care by establishing a high-level of care with on-going research.