[Reverse flow in fetal vessels and perinatal events]

BACKGROUND/PATIENTS: A reverse flow in the umbilical artery and/or fetal aorta is associated with a higher perinatal and neonatal mortality. 30 fetuses showed a reverse flow using pulsed wave Doppler sonography (group I). A matched-pair control group including 30 fetuses with the same gestational age as well as a normal Doppler flow pattern in the umbilical artery and/or fetal aorta was taken for comparison (group II).

RESULTS

In the group with reverse flow the rates of pregnancies with pre-eclampsia (n = 19/30, p < 0.0001), intrauterine growth retardation (n = 25/30, p < 0.0001), oligohydramnios (n = 21/30, p < 0.0001) and nicotine abuse (n = 15/30, p < 0.01) were significantly higher compared to the control group. Postnatal data showed significantly lower pH values in group I (p < 0.01). 40 % of the fetuses with reverse flow died in utero whereas in 67 % the reverse flow was accompanied by an insufficiency of the placenta (IUGR, oligohydramnios, histopathological abnormalities of the placenta). None of the fetuses in the control group died in utero. The incidence of IUGR (< 5ht percentile) was 83 % in group I but only 3 % in group II. The perinatal and overall mortality (including neonatal mortality 7 - 28 days after birth) amounted to 27 % and 53 % in group I, respectively, compared to 3 % and 0 % in the control group (p < 0.001). In addition cerebral anomalies could be found by ultrasound in 50 % of the neonates who presented a reverse flow prenatally. In 28 % of the surviving newborns an intracerebral hemorrhage (ICH) could be detected. None of the newborns of group II developed an ICH.

CONCLUSIONS

Pregnancies with a reverse flow in the umbilical artery and/or fetal aorta have to be considered as a high risk group with a poor prognosis. The reverse flow is mainly caused by chronic placental insufficiency with IUGR. With respect to the further neuromotor development the incidence and severity of cerebral lesions in affected fetuses should be considered when discussing the perinatal situation with the parents.

Maternal deaths and their causes in Ankara, Turkey, 1982-2001

This study was carried out to determine the incidence and causes of maternal deaths about a 20-year period at the Zekai Tahir Burak Women's Health Education and Research Hospital (ZTBWHERH), Ankara, Turkey. All maternal deaths from January 1982 to July 2001 were reviewed and classified retrospectively. Using a computer-generated list, 348 patients admitted to the Labour Department of ZTBWHERH during 1982-2001 were selected as controls. Medical records were reviewed for demographic data, history of antenatal care, route of delivery, referral history, and perinatal mortality. Cases and controls were compared, and standard tests were used for calculating odds ratio (OR) and 95% confidence interval (CI) for the association of demographic and delivery characteristics. During this period, there were 174 maternal deaths and 430,559 livebirths, giving a maternal mortality ratio of 40.4/100,000 livebirths. The mortality rate declined from 85.1/100,000 in 1982 to 11.6/100,000 in 2001. One hundred thirty (74.7%) deaths were due to direct obstetric causes and 24 (13.7%) were abortion-related, while 20 (11.4%) were due to indirect obstetric causes. The most common cause of direct obstetric deaths was pre-eclampsia/eclampsia, followed by obstetric haemorrhage and embolism. Abortion-related sepsis and haemorrhage, anesthesia-related deaths, obstetric sepsis, acute fatty liver of pregnancy, and ectopic pregnancy accounted for other causes of deaths. Cardiovascular disease was the leading indirect cause of death. Referral, lack of antenatal care, and foetal death at admittance were associated with 8-, 3-, and 6-fold increased risk of maternal mortality respectively (OR 8.89, 95% CI 5.7-13.8; OR 3.74, 95% CI 2.5-5.5; OR 6.38, 95% CI 3.1-13.1). Although maternal mortality ratios have declined at the hospital, especially in the past five years, the rate is still high, and further improvements are needed. The problem of maternal mortality remains multifactorial. Short-term objectives should be focused on improving both medical and administrative practices. Improving the status of women will necessarily remain a long-term objective.

Admission pattern and outcome in critical care obstetric patients

We undertook a six-year retrospective study to determine the pattern of admission and outcome for obstetric patients admitted to the intensive care unit of the University of Nigeria Teaching Hospital, Enugu. The hospital records (case notes and intensive care unit records) were used to extract the necessary data. A total of 816 patients were admitted to the intensive care unit during the period under review. Eighteen (2.2%) were obstetric patients. Nine (50%) were preeclamptic and eclamptic patients. Four patients (22.2%) had obstetric haemorrhage. Five others presented with the following: asthma, postoperative respiratory distress, cervical incompetence, gestational diabetes and hypertension, and caesarean section for terminal carcinoma of the breast. There were six deaths (mortality rate 33.3%). Preeclampsia/eclampsia accounted for four deaths (44% mortality rate amongst preeclamptics/eclamptics), while two deaths accounted for a 50% mortality rate in the obstetric haemorrhage group. This study confirmed similar reports from the advanced nations and Asia that preeclampsia/eclampsia and obstetric haemorrhage are the leading causes of admission to the intensive care unit. The mortality rate in this study is however higher.

The Prediction of Adverse Maternal Outcomes in Preeclampsia

OBJECTIVES

(1) To evaluate whether clinical variables reflecting the multiorgan dysfunctions of preeclampsia can predict adverse maternal outcomes of preeclampsia; (2) to determine the usefulness of the mean platelet volume (MPV):platelet ratio as a novel measure of platelet consumption in predicting the severity of preeclampsia.

METHOD

A retrospective chart review was conducted of cases of preeclampsia seen in 3 tertiary level units from January 2001 to December 2001. Candidate predictors of adverse maternal outcome were gestational age (GA) on admission to hospital, blood pressure, proteinuria, urine output, uric acid, creatinine, aspartate transaminase (AST), lactate dehydrogenase, bilirubin, albumin, fraction of inspired oxygen:oxygen saturation (FIO2:SaO2) ratio, platelet count, MPV, MPV:platelet ratio, fibrinogen, and seizures. The combined adverse maternal outcomes included maternal death; 1 or more of hepatic failure, hematoma, or rupture; Glasgow coma scale <13; stroke; 2 or more seizures; cortical blindness; positive inotrope support; myocardial infarction; infusion of any third antihypertensive; dialysis; renal transplantation; > or =50% FIO2 for >1 hour; intubation; or transfusion of > or =10 units of blood products. Descriptive, univariable, and multivariable analyses were performed, with significance set at P < .05.

RESULTS

Of a total of 594 women with preeclampsia, 60 (10.1%) developed at least 1 element of the combined adverse outcome; 1 of these 60 women died. The most common outcomes were increased oxygen requirements, the use of a third infused antihypertensive, and transfusion >10 units. In women who developed an adverse outcome, GA and fibrinogen were lower, and total leukocyte count, creatinine, and AST were greater. Multivariable logistic regression revealed that admission GA (odds ratio [OR], 0.91), dipstick protein (OR, 1.31), and MPV:platelet ratio (OR, 391.0) independently predicted the outcome.

CONCLUSIONS

Several promising markers were identified: admission GA, dipstick proteinuria, and the MPV:platelet ratio. MPV:platelet ratio also showed promise as a marker of platelet consumption. A prospective study is required to develop a clinical prediction model for preeclampsia.

Offspring sex ratio at population level versus early and late onset preeclampsia

Male dominance being higher at preterm than term delivery was described in a population-based study by Vatten and Skjaerven [Early Hum. Dev. 76 (2004) 47]. A so-called "reversion" and "cross-over" in the sex ratio took place in preeclamptic gestations. These phenomena occurred earlier and stronger when associated with perinatal mortality and are in line with the overripeness ovopathy concept.

[Maternal mortality in rural areas of China]

OBJECTIVE

To understand with clearness the trend and epidemiological characteristics of maternal mortality, as well as the leading causes of maternal deaths in rural areas of China from 1996 to 2001.

METHODS

The data analyzed were those from the population-based epidemiological survey conducted by the national maternal mortality surveillance network which covered a total population of about 35,000,000 in China.

RESULTS

The maternal mortality ratio (MMR) in rural areas of China dropped by 28.4% from 86.4 per 100,000 live births in 1996 to 61.9 in 2001. The leading causes of maternal deaths were obstetric hemorrhage, preeclampsia and embolism of amniotic fluid. The MMR for obstetric hemorrhage decreased from 48.3 per 100,000 live births in 1996 to 33.0 in 2001. The pregnant women mainly gave childbirths and died in their home, accounting for 44.6% and 30.1% respectively in 2001.

CONCLUSION

The MMR showed a downward trend in rural areas of China during the period from 1996 to 2000, and so also did the MMR for obstetric hemorrhage. Reducing obstetric hemorrhage and increasing the rate of hospitalized delivery are the most important methods for reducing the MMR in rural areas in China.

Maternal and Perinatal Outcomes of Eclampsia: Nova Scotia, 1981-2000

OBJECTIVE

To determine the prevalence of eclampsia and the associated maternal and perinatal outcomes in the province of Nova Scotia.

METHODS

From the Nova Scotia Atlee Perinatal Database, the population-based rates of preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome for the period 1988 to 2000 were determined. A retrospective case review was then performed of all women with eclampsia at the tertiary maternity hospital in Halifax, Nova Scotia, Women's Hospital, IWK Health Centre, for the years 1981 to 2000.

RESULTS

In the province of Nova Scotia from 1988 to 2000, there were 142,362 births. Thirty-nine women developed eclampsia (0.27/1000). Over this time interval, the prevalence of severe preeclampsia fell from 2.08% to 1.63%, and the diagnosis of HELLP syndrome increased from 0.03% to 0.31%. At the Women's Hospital, IWK Health Centre, between 1981 and 2000, there were 31 cases of eclampsia in 105,651 deliveries (0.29/1000). Sixty-one percent of first convulsions occurred antepartum, 13% occurred intrapartum, and 26% occurred postpartum. Eighty-one percent of women reported prodromal symptoms. Sixty-one percent of the women received anti-hypertensive therapies, 48% received antiepileptic therapies, and 97% received magnesium sulfate. Ten percent of the women had convulsions while on magnesium sulfate therapy. Antepartum eclampsia was associated with increased rates of general anaesthesia (26%) and Caesarean section (79%). There were no maternal deaths, but the rate of major maternal complications was 32%. The perinatal mortality rate was 64 in 1000 deliveries, and the rate of severe perinatal complications was 56%.

CONCLUSION

The incidence of eclampsia in Nova Scotia is 0.27 per 1000 deliveries. Although rare, this condition is associated with significant maternal and perinatal morbidity.

Regional Anaesthesia in Pre-eclampsia

Pre-eclampsia is a multisystemic disorder that is characterised by endothelial cell dysfunction as a consequence of abnormal genetic and immunological mechanisms. Despite active research for years, the exact aetiology of this potentially fatal disorder remains unknown. Although understanding of the pathophysiology of pre-eclampsia has improved, management has not changed significantly over the years. Anaesthetic management of these patients remains a challenge. Although general anaesthesia can be used safely in pre-eclamptic women, it is fraught with greater maternal morbidity and mortality. Currently, the safety of regional anaesthesia techniques is well established and they can provide better obstetrical outcome when chosen properly. Thus, regional anaesthesia is extensively used for the management of pain and labour in women with pre-eclampsia. This article highlights the advantages and disadvantages of regional anaesthetic techniques including epidural, spinal and combined spinal-epidural analgesia, used as a part of the management of pre-eclampsia. The problems associated with general anaesthesia and controversies in relation to obstetric regional anaesthesia are discussed.

Subclassification of preeclampsia

Preeclampsia is a heterogeneous disorder, and as with other diseases (e.g., type I and type II diabetes), progress in the understanding of this disorder would be assisted greatly if subtypes could be characterized. We suggest that a first step would be to subdivide preeclampsia into early-onset disease (< 34 + 0 weeks') and late onset disease (> 34 + 0 weeks').

[Maternal and perinatal surgical complications in low platelet count for HELLP syndrome in severe preeclampsia-eclampsia in intensive care]

The preeclampsia is the first cause of maternal morbility, with increase in the obstetric complications when it is associated to HELLP syndrome, for the low platelets that even involves to the neonate. This study was carried out in the patients accepted in the intensive Adults Cares Unit in the period of one year, surgical complications and the perinatal results were determined in women with low platelet count for HELLP syndrome in preeclampsia-eclampsia. Three groups were formed according to the platelets account and then were analyzed using chi square to determine association among these groups of patients, as well as mean and standard deviation (M +/- DE) to describe results. Forty patients were studied with low platelets by HELLP syndrome in preeclampsia-eclampsia, where the distribution for the group with platelets < 50,000 were 12 patients (30%), in the group among 51,000-100,000 of 18 cases (45%), and of 101,000-150,000 were of 10 cases (25%). The mean of gestas was of 2.3 +/- 1.2, more frequent delivery was for cesarean section in 39 cases (97.5%) and a single case for vaginal via (2.5%), a maternal death was presented (8.3%). The surgical reintervention was observed with more frequency in the group of < 50,000 platelets, the most frequent cause in these reinterventions was the hipovolemic shock. Also in this group the perinatal mortality was presented in 3 cases (25%) and the asphyxia at the birth with Apgar < 6 was presented in 5 cases (41.7%). A bigger morbility was observed inversely proportional to the account platelets, being the renal failure the cause most frequent of this morbility in the three groups. The low platelets account contribute in a direct way in the obstetric complications, since there are more surgical reinterventions, with bled in the transsurgical and increase in the days of intrahospitalary stay. Also with smaller account platelet, there are bigger prematural index, asphyxia and perinatal mortality in the newborn of mothers with HELLP syndrome.

Results of the pregnancies with HELLP syndrome

In this study, clinical features, developing complications, and results of thirty-six patients, which were followed up in our Obstetrics and Gynecology and Nephrology departments between 1997 and 2001, with the diagnosis of HELLP syndrome were searched retrospectively. The mean age of the cases followed up with diagnosis of HELLP syndrome were 30.2 +/- 5.9 (17-46) years. HELLP syndrome was diagnosed on average in the 32.6 +/- 4.8th (23-41) week of gestations. Seventy percent of the cases were with severe preeclampsia and 30% of the cases were with mild preeclampsia. Eleven cases (30%) were nullipara and twenty-five cases (70%) multipara. The average of arterial systolic blood pressure of the cases were 161.6 +/- 26 mmHg, and that of diastolic blood pressure was 98.5 +/- 16.8 mmHg. In thirteen cases (36%) acute renal failure (ARF), six cases (17%) placenta detachment, two cases disseminate intravascular coagulation (DIC), one case Adult Respiratory Distress Syndrome (ARDS) were developed. In seven cases (19%) intrauterine dead fetuses were detected. In twenty-three cases by cesarian section (64%), in thirteen cases by induction (36%) the pregnancies were terminated in 72 h after diagnosing HELLP syndrome. Birth weights of eleven babies (30%) were below 1500 g. Five of the eleven babies were dead in the neonatal period. Six of the thirteen patients who had ARF were given hemodialysis. Two patients died because of the development of ARF + DIC and ARDS. No predicting factors for the development of HELLP syndrome could be detected, but severe preeclampsia. Therefore we think that preeclamptic pregnancies must be followed up very closely and if HELLP syndrome develops, termination of the pregnancy would be proper as soon as possible.

Intrauterine growth restriction, preeclampsia, and intrauterine mortality at high altitude in Bolivia

Infant mortality and stillbirth rates in Bolivia are high and birth weights are low compared with other South American countries. Most Bolivians live at altitudes of 2500 m or higher. We sought to determine the impact of high altitude on the frequency of preeclampsia, gestational hypertension, and other pregnancy-related complications in Bolivia. We then asked whether increased preeclampsia and gestational hypertension at high altitude contributed to low birth weight and increased stillbirths. We performed a retrospective cohort study of women receiving prenatal care at low (300 m, Santa Cruz, n = 813) and high altitude (3600 m, La Paz, n = 1607) in Bolivia from 1996 to 1999. Compared with babies born at low altitude, high-altitude babies weighed less (3084 +/- 12 g versus 3366 +/- 18 g, p < 0.01) and had a greater occurrence of intrauterine growth restriction [16.8%; 95% confidence interval (CI): 14.9-18.6 versus 5.9%; 95% CI: 4.2-7.5; p < 0.01]. Preeclampsia and gestational hypertension were 1.7 times (95% CI: 1.3-2.3) more frequent at high altitude and 2.2 times (95% CI: 1.4-3.5) more frequent among primiparous women. Both high altitude and hypertensive complications independently reduced birth weight. All maternal, fetal, and neonatal complications surveyed were more frequent at high than low altitude, including fetal distress (odds ratio, 7.3; 95% CI: 3.9-13.6) and newborn respiratory distress (odds ratio, 7.3; 95% CI: 3.9-13.6; p < 0.01). Hypertensive complications of pregnancy raised the risk of stillbirth at high (odds ratio, 6.0; 95% CI: 2.2-16.2) but not at low altitude (odds ratio, 1.9; 95% CI: 0.2-17.5). These findings suggest that high altitude is an important factor worsening intrauterine mortality and maternal and infant health in Bolivia.

Hypertensive diseases of pregnancy and risk of hypertension and stroke in later life: results from cohort study

OBJECTIVE

To examine the association between hypertensive diseases of pregnancy (gestational hypertension and pre-eclampsia) and the development of circulatory diseases in later life.

DESIGN

Cohort study of women who had pre-eclampsia during their first singleton pregnancy. Two comparison groups were matched for age and year of delivery, one with gestational hypertension and one with no history of raised blood pressure.

SETTING

Maternity services in the Grampian region of Scotland.

PARTICIPANTS

Women selected from the Aberdeen maternity and neonatal databank who were resident in Aberdeen and who delivered a first, live singleton from 1951 to 1970.

MAIN OUTCOME MEASURES

Current vital and cardiovascular health status ascertained through postal questionnaire survey, clinical examination, linkage to hospital discharge, and mortality data.

RESULTS

There were significant positive associations between pre-eclampsia/eclampsia or gestational hypertension and later hypertension in all measures. The adjusted relative risks varied from 1.13-3.72 for gestational hypertension and 1.40-3.98 for pre-eclampsia or eclampsia. The adjusted incident rate ratio for death from stroke for the pre-eclampsia/eclampsia group was 3.59 (95% confidence interval 1.04 to 12.4).

CONCLUSIONS

Hypertensive diseases of pregnancy seem to be associated in later life with diseases related to hypertension. If greater awareness of this association leads to earlier diagnosis and improved management, there may be scope for reducing a proportion of the morbidity and mortality from such diseases.

[Maternal and fetal prognosis of hypertension and pregnancy in Africa (Senegal)]

OBJECTIVES

The aims of this study were to record the different types of hypertension associated with pregnancy and to assess the incidence of hypertension and its gravity in Senegal.

METHODS

Over a two-year period, a cohort of pregnant women with hypertension according to the American working group classification of hypertension and pregnancy, was studied. A group of 47 non hypertensive women were matched for age and parity. Modalities of delivery were studied: maternal death, type of delivery, birth weight.

RESULTS

Among 2,400 deliveries, hypertension was observed in 94 women wih, mean age 33 years. The incidence of hypertension was 3.9% and the incidence of preeclampsia was 2.5%. The different types of hypertension were: Type I: 44 (47%), Type II: 16 (17%), Type III: 18 (19%), Type IV: 16 (17%). Echocardiography showed 30 cases of left ventricle hypertrophy with 3 cases of systolic dysfunction. Thirty-five patients had undergone a caesarean. Forty-seven infants had a birth weight below 2,000 g. Maternal mortality was 12.7%, fetal and neonatal mortality was 50%. There was a 21-fold higher chance of caesarean section in hypertensive women (p<4 x 10-4). Neonatal mortality was 36 times higher (p (4 x 10-6) than in the control group with a birth weight lower birth weight 975 g (p<10-6). Women suffering from toxemia gave birth to children having a lower birth weight (-543 g) (p<5.10-3), but, there was no significant difference concerning caesarean (p<7*10-1) maternal, fetal and neonatal mortality (p<9. 10-1) compared with other sub-groups.

CONCLUSION

In developing countries, hypertension in pregnant women is a severe condition responsible for disease and handicaps which could be avoidable at little cost through a better policy of detection and good quality multidisciplinary management.

Pre-eclampsia and the hypertensive disorders of pregnancy

Pre-eclampsia is a multisystem disorder, of unknown aetiology, usually associated with raised blood pressure and proteinuria. Although outcome for most women and their babies is good, it remains a major cause of morbidity and mortality. A wide range of interventions for prevention and treatment of pre-eclampsia have been evaluated in randomized trials. This evidence provides the basis for a rational approach to care. Overall, there is insufficient evidence for any firm conclusion about the effects of any aspect of diet or lifestyle during pregnancy. Antiplatelet agents are associated with a 19% reduction in the risk of pre-eclampsia (relative risk 0.81; 95% CI 0.75, 0.88), a 7% reduction in the risk of preterm birth (RR 0.93; 95% CI 0.89, 0.98), a 16% reduction in the risk of stillbirth or neonatal death (RR 0.84; 95% CI 0.74, 0.96) and an 8% reduction in the risk of a small for gestational age baby (RR 0.92; 95% CI 0.85, 1.00). For mild to moderate hypertension, trials evaluating bed rest are too small for reliable conclusions about the potential benefits and hazards. Antihypertensive agents halve the risk of progression to severe hypertension (RR 0.52; 95% CI 0.41, 0.64), but with no clear effect on pre-eclampsia (RR 0.99; 95% CI 0.84, 1.18), or any other substantive outcome. For severe hypertension, there is no good evidence that one drug is any better than another. Plasma volume expansion for severe pre-eclampsia seems unlikely to be beneficial, although the trials are small. The optimum timing of delivery for pre-eclampsia before 34 weeks is unclear. Magnesium sulphate more than halves the risk of eclampsia (RR 0.41; 95% CI 0.29, 0.58) and probably reduces the risk of maternal death (RR 0.54; 95% CI 0.26, 1.10). It is also the drug of choice for treatment of eclampsia.

[Preeclampsia and eclampsia]

Preeclampsia is a multisystem disorder after the 20(th) week of gestation, that is usually associated with raised blood pressure, proteinuria, and pathologic edema. Eclampsia is defined as the occurrence of conculsions in association with the syndrome of preeclampsia. In Europe and other developed countries eclampsia complicates approximately 1 in 2,000 deliveries, while in developing countries estimates vary between 1 in 100 to 1 in 1,700. 44% of seizures occur postnatally, the remainder being antepartum (38%) or intrapartum (18%). Although rare, eclampsia probably accounts for 50,000 maternal deaths a year world-wide. In this review article we discussed conditions, which are associated with a higher incidence of preeclampsia, pathophysiology, findings at physical examination, principles of treatment (blood pressure control, anticonvulsant therapy, and fluid management), post-partum management, complications, maternal morbidity and mortality, as well as prevention.

[Clinical analysis of 80 perinatal death from hepatic diseases in pregnancy]

OBJECTIVE

To explore the factors associated with perinatal death of hepatic diseases in pregnancy (HDIP) and make feasible suggestions and measures for perinatal care of high risk patients.

METHODS

The 80 perinatal death cases of hepatic diseases in pregnancy (HDIP) during 1991-2000 in our hospital were analyzed retrospectively.

RESULTS

The perinatal mortality of HDIP in our hospital during the last 10 years was 17.99 approximately 65% was in utero death. Perinatal mortality was different between male (21.64%) and female (10.11%) (P<0.01). Compared first 5 years with last 5 years author found that the perinatal mortality of HDIP had no significant decrease (P>0.05). The perinatal mortality in city and suburbs had decreased, while in the floating population from other provinces the perinatal mortality had increased. The perinatal death was mainly caused by pregnancy induced hypertension (PIH) and asphyxia. But for the HBV carrier mothers the causes of death included umbilical cord problems, premature rupture of membrane and asphyxia.

CONCLUSIONS

The perinatal death mortality was increased by HDIP, deaths were essentially associated with pregnancy induced hypertension and asphyxia and the floating population and male gender were high risks. To enhance the management of HDIP or immigration, take effective therapies of hepatitis and improvement of resuscitation of newborns are critically important.

[Fatal complications in pre-eclampsia and eclampsia]

OBJECTIVE

Analysis of preeclampsia and eclampsia--one of the major contributor to life-threatening maternal morbidity frequently leading to maternal mortality in the Czech Republic till late 70's. Our goal was to mention major causal links in clinical courses of individual maternal death and to highlight main mistakes and faults, and to provide frequencies and basic characteristics of risk groups.

DESIGN

Retrospective epidemiological study.

SETTING

Department of Obstetrics and Gynecology of the 1st Medical School of Charles University and General University Hospital, Prague. Institute for the Care of Mother and Child, Prague-Podoli; 1st Intern Department of the 1st Medical School of Charles University and General University Hospital, Prague.

METHODS

Analysis of 31 cases of maternal deaths associated with severe preeclampsia and eclampsia in the Czech Republic during 1978-2000, using a database of 470 maternal deaths during the observed period. We analyzed clinical course with special attention to obstetrical surgery and clinical management. We considered timelines of life-threatening events, age of mother, parity, and place of death.

RESULTS

There were 36 maternal deaths associated with severe preeclampsia and eclampsia in the Czech Republic in 1978-2000, contributing 7.7% to total maternal mortality. Group A1 was 5th most frequent cause of maternal death. We analyzed 31 cases closely related to severe preeclampsia and eclampsia. During 1978-1990 there was 1 death per 74,263 live-born babies in this category, while during 1991-2000 we observed only 1 death per 171,137 live-born babies. Clinical management was not adequate in 15 cases of death (48%) and content of care did not reflect possibilities of prevention, diagnosis and therapy. Severe preeclampsia and eclampsia was more frequent among older women and multiparae. First group (61%) is composed of women with manifest convulsions, 25% of them experienced convulsion after delivery, and only few cases had mild preeclampsia ante partum. Eclampsia with convulsions leading to coma were in 10 cases complicated with DIC, two cases in this group had premature separation of placenta. Besides classic symptoms of preeclampsia there were within this group 5 cases of multiple pregnancy, history of unstable hypertension, hepatopathy in previous pregnancy and chronic nephrosis. The second group (39%) were cases without convulsions. These cases were complicated with severe liver disorders and renal failure, and 5 cases of intra-cranial hemorrhage. Several cases had combination of symptoms. DIC was present in 6 cases. In both groups there were 5 cases with hemorrhagic skin symptoms, thrombopenia, symptoms of DIC and liver and renal failure, which would fall into HELLP syndrome according to current classification. The most of women died during the postpartum period (87%) mostly after emergency operative deliveries. The fact that no women died during pregnancy indicates the effort to perform life-saving operative delivery. Forty two percent of women were in term. Especially at the beginning of observed period we noticed tendency to prolong gestation in order to save the baby. The mortality of fetuses or newborns was 71%. Operative deliveries accounted for 71%, the majority of them were caesarean sections. More than 50% of cases were operated in coma. We indicate major mistakes and failures in organization of care, primary prevention, diagnosis, and consequent care.

CONCLUSION

Positive results in area of maternal deaths in association with severe preeclampsia and eclampsia during last 10 years are due to improved diagnostic and therapeutic measures in our field, especially in neonatology, because obstetricians currently terminate pregnancies early than before while symptoms of preeclampsia get worse. We focus on early recognition of symptoms of coagulopathy in combination with symptoms of preeclampsia, especially on early detection and treatment of HELLP syndrome.

Conservative management of early-onset pre-eclampsia and fetomaternal outcome in Nigerians

The aim of this study was to determine the effect of conservative management of pre-eclampsia with onset in the second trimester on fetomaternal outcome. This was a prospective study of 749 consecutive cases of pre-eclampsia seen over a 5-year period in a tertiary care centre in Enugu, Eastern Nigeria. One hundred and seventy-five (23.4%) of the 749 cases started at less than 30 weeks' gestational age. These early-onset cases formed the study group, while the remaining 574 with onset at 30 weeks' gestation or later (the late-onset cases) served as controls. The two groups were compared for some fetomaternal outcome variables at the 95% confidence level. Ninety-one (52%) of the early-onset group had pure pre-eclampsia while the remaining 84 were thought to have pre-eclampsia superimposed on chronic hypertension. The mean gain in gestational age in the early-onset group was 8.8 +/- 1.5 (range: 0-19) weeks. Compared to the late-onset group, the early-onset group had a twofold increase in maternal mortality ratio and a significantly increased incidence of renal failure and HELLP syndrome. The perinatal mortality rate increased fourfold in the early-onset compared to the late-onset group due principally to prematurity and intrauterine growth restriction. The perinatal mortality rate was, however, comparable to results from similar Caucasian studies. It was concluded that there has been an increased incidence of early-onset pre-eclampsia in Nigerian women. Although conservative management of such cases may improve fetal results, it is associated with increased maternal mortality and morbidity because of institutional delays and non-availability of magnesium sulphate at the time of the study. Minimising institutional delays, providing magnesium sulphate and improving neonatal services will enhance maternal and fetal results in early-onset pre-eclampsia in Nigeria and are recommended.

Long term mortality of mothers and fathers after pre-eclampsia: population based cohort study

OBJECTIVE

To assess whether mothers and fathers have a higher long term risk of death, particularly from cardiovascular disease and cancer, after the mother has had pre-eclampsia.

DESIGN

Population based cohort study of registry data.

SUBJECTS

Mothers and fathers of all 626 272 births that were the mothers' first deliveries, recorded in the Norwegian medical birth registry from 1967 to 1992. Parents were divided into two cohorts based on whether the mother had pre-eclampsia during the pregnancy. Subjects were also stratified by whether the birth was term or preterm, given that pre-eclampsia might be more severe in preterm pregnancies.

MAIN OUTCOME MEASURES

Total mortality and mortality from cardiovascular causes, cancer, and stroke from 1967 to 1992, from data from the Norwegian registry of causes of death.

RESULTS

Women who had pre-eclampsia had a 1.2-fold higher long term risk of death (95% confidence interval 1.02 to 1.37) than women who did not have pre-eclampsia. The risk in women with pre-eclampsia and a preterm delivery was 2.71-fold higher (1.99 to 3.68) than in women who did not have pre-eclampsia and whose pregnancies went to term. In particular, the risk of death from cardiovascular causes among women with pre-eclampsia and a preterm delivery was 8.12-fold higher (4.31 to 15.33). However, these women had a 0.36-fold (not significant) decreased risk of cancer. The long term risk of death was no higher among the fathers of the pre-eclamptic pregnancies than the fathers of pregnancies in which pre-eclampsia did not occur.

CONCLUSIONS

Genetic factors that increase the risk of cardiovascular disease may also be linked to pre-eclampsia. A possible genetic contribution from fathers to the risk of pre-eclampsia was not reflected in increased risks of death from cardiovascular causes or cancer among fathers.

[Maternal mortality: avoidable obstetrical complications]

Since 1996, maternal mortality is registered as part of a permanent confidential inquiry in France. The National Committee has studied all cases recorded to assess the cause of death and the avoidable obstetrical complications involved. Recommendations are proposed. In 1996 and 1997, there were 196 maternal deaths in France; 165 could be analyzed. The cause was obstetrical in 123 cases (74%), non-obstetrical in 26 (16%), and unidentified in 16 (10%). Ninety-seven direct deaths occurred (78% of the obstetrical mortality cases); 31 cases of hemorrhage including 19 post partum, 20 cases of pregnancy-induced hypertension, 10 cases of eclampsia and 7 of pre-eclampsia, 16 cases of amniotic fluid embolism, 11 cases of thromboembolism and 10 cases of sepsis. The National Committee considered that 54% of these deaths were avoidable: 87% for hemorrhage, 80% for sepsis, and 65% for hypertensive diseases. The deaths due to amniotic fluid embolism were not considered avoidable. This mortality stemmed from substandard care, delayed treatment, missed diagnosis, and professional errors. Clinical recommendations are proposed for post partum hemorrhage, pre-eclampsia and eclampsia, prevention of maternal infection, and thromboembolism prophylaxy.

[Pre-eclampsia and eclampsia. Experience at the Centro Médico Nacional de Torreón]

OBJECTIVE

To assess the epidemiological aspects of the patient with preeclampsia assisted in the Centro Medico Nacional Torreón, of the IMSS.

MATERIAL AND METHOD

We carried out a retrospective and descriptive survey of 138 consecutive admissions to the Department of Gynecology and Obstetrics, between January first to December 31, 1997 with diagnosis of preeclampsia according to the criteria of the ACOG. Maternal and perinatal secondary complications of this pathology were determined. Mortality and lethality rates were also estimated. Descriptive statistics were used for the analysis.

RESULTS

The prevalence rate of preeclampsia was 2.1%. The age of the patients was 23.2 years (SD 3.05) and the gestational age at the moment of the diagnosis of preeclampsia of 36.4 weeks (SD 3.2). Only 41.3% of the patients received regular prenatal control. The prevalence rate of maternal complications was 29.0%. Mortality rate was 0.15 x 1,000, lethality rate was 0.72%. The weight average of the new born were 2.011 kg (SD 0.429), the Apgar to the first minute 7.72 (SD 0.98) and 8.66 (SD 1.10) to the fifth minute. The prevalence rate of perinatal complications was 35.5%. There were 15 neonatal deaths (10.9%) and one fetal lost.

CONCLUSIONS

The preeclampsia-eclampsia is still a disorder with a great influence in the maternal and perinatal morbidity and mortality rates. It is necessary to continue working for find out the way of preventing their appearance or modifying their evolution avoiding the eclampsia or other serious forms of this illness.

Eighteen years of maternity care in a new teaching hospital

A new maternity hospital was inaugurated in Trinidad in 1981 to provide access for pregnant women to specialist antenatal care and to trained attendants during childbirth. As an academic tertiary-care institution, it also became a referral centre for high-risk pregnancies and obstetric emergencies. The efficacy of the services provided since inception was evaluated by measurement of mortality statistics, which are the most sensitive indices of maternal care. Over a period of 18 years, there were almost 100,000 births. Although the caesarean section rate was low, the perinatal and maternal mortality rates suggest that there is still a wide gap in obstetric standards between the developed world and this country. Improved vigilance for high-risk groups is required to identify potentially preventable deaths.