[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.

[Fibrinolytic therapy of pulmonary embolism in pregnant women]

Fibrinolytic therapy has an established position in the treatment of pulmonary embolism. Its use has proven to decrease patients' mortality. However, in pregnant women such treatment is considered risky, due to possible fatal haemorrhagic events. In spite of such disadvantages, fibrinolytic therapy has been used in pregnant women with good results: from definite improvement of clinical status to complete recovery. No severe haemorrhagic events were observed in these cases and overall mortality was significantly decreased. These findings show that the use of fibrinolytic therapy in emergency situations is an efficient and safe method, when applied in accordance with standard procedures. In this publication we present the general review of current knowledge regarding the use of fibrinolytic therapy in pregnant women.

Pregnancy in congenital cardiac disease: an increasing challenge for cardiologists and obstetricians -- a prospective multicenter study

OBJECTIVES

Aim of this study was to assess the occurrence of pregnancy-related complications of mother and child during pregnancy, delivery and puerperium in women with CCD prospectively. STUDY DESIGN, POPULATION: This prospective multicenter study included 122 pregnancies in 106 women with CCD (72 with, 34 without previous cardiac surgery). Patient age was 17-44, median 26 years. Cardiac and non-cardiac complications, mode of delivery, abortion, and CCD of the newborn were assessed.

RESULTS

Initially all women were in Functional Class I or II. Worsening during pregnancy occurred in 25.5% (n=27), mainly during the second and third trimester. Significant problems due to bleeding, hypertension, rhythm disturbances, endocarditis, liver congestion, increasing cyanosis or death, occurred in 11.3%. Twelve per cent of deliveries were premature. Five women had therapeutic abortion, nine spontaneous abortions, nine preterm births, and one intrauterine death. Seventy-nine per cent (n=85) delivered spontaneously; 21.3% (n=23) had caesarean section. Of the 111 live born children, 5.4% (n=6) had a CCD.

CONCLUSIONS

Most women with CCD and a good functional class before pregnancy tolerate pregnancy without major problems. However, pregnancy may induce serious cardiac and obstetric complications. The specific risks require an individualized multidisciplinary patient-management by experienced physicians.

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.

[A report of fourteen cases with hemolysis, elevated liver enzymes and low platelet count syndrome]

OBJECTIVE

To summarize the incidence, diagnosis, treatment and prognosis of patients with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome.

METHODS

The clinical data of fourteen cases with HELLP syndrome complicated by severe pregnancy-induced hypertension were analyzed retrospectively during the past seven years.

RESULTS

The incidence of HELLP syndrome was 8% in the patients with severe pregnancy-induced hypertension. According to the diagnosis criteria used by Tennessee University, there were eight cases with complete HELLP syndrome and six cases with partial HELLP syndrome. The major therapeutic way were intensive maternal and fetal monitoring, active management of preeclampsia and eclampsia, administration of corticosteroids and termination the pregnancy as fast as possible. The major complications were DIC, placental abruption, pneumonedema and acute renal failure. The maternal and perinatal mortality were 7% and 29%, respectively.

CONCLUSIONS

HELLP syndrome was a serious life-threatening complication of severe pregnancy-induced hypertension. In order to decrease the maternal and perinatal mortality rate, HELLP syndrome should be diagnosed and treated as fast as possible.

Outcome of prenatally diagnosed congenital heart disease: an update

The objective of this study was to compare the outcome of prenatally diagnosed congenital heart disease (CHD) in a recent time period with previously reported experience. All cases of fetal CHD during the time period 1993 to 1999 were analyzed in terms of their outcome. During this time frame, 408 cases of fetal CHD were detected. Of these, 84% of mothers were referred because of suspicion of a cardiac anomaly during an obstetric scan. The mean gestational age at diagnosis was 26 weeks. Termination of pregnancy occurred in 98 cases. There were 92 deaths in the continuing pregnancies and a survival rate of 60%. The detection rate of CHD prenatally continues to increase as obstetric screening for cardiac malformations becomes more widespread. Diagnostic categories continue to be skewed toward more complex forms of malformation, although comparisons with previous studies show some trends. In particular, there are proportionately fewer pregnancies with extracardiac malformations. In addition, the outcome in continuing pregnancies is substantially improved from previous reports.

Trends in maternal mortality and assessment of substandard care in a tertiary care hospital

OBJECTIVE

To assess the trends in maternal mortality and factors affecting substandard care at a tertiary care hospital in a developing country.

METHOD

All maternal deaths during a period of 11 years in a tertiary care hospital were studied. Maternal deaths were defined according to ICD-10. The principal cause and category of death, chief contributory factor, nature of care (standard or substandard), relationship to outcome and responsibility for substandard care (if any) were determined.

RESULTS

Among the 133 maternal deaths, 92 (69%) were due to direct causes, 38 (29%) were indirect and 3 (2%) were accidental deaths. Genital tract sepsis (26%), hypertension in pregnancy (24%) and obstetric hemorrhage (20%) accounted for over 70% of deaths. In 79% of deaths, the care was substandard and in 73% of deaths substandard care was felt to have influenced the adverse outcome. Overall maternal mortality rate was 98.5 per 100,000 deliveries. An increasing but insignificant (P=0.08) trend in maternal mortality was noted after 1991.

CONCLUSIONS

The majority of maternal deaths remain due to preventable and treatable obstetric complications. Maternal death enquiries of this nature facilitate identification of factors contributing to substandard care. It is important to ascertain that life threatening obstetric complications receive high quality emergency obstetric care at all levels.

Maternal deaths due to pre-existing cardiac disease

Heart disease in pregnancy is an uncommon problem in the developed world, but reaches a high prevalence in poor countries. In South Africa 0.65% of all pregnant women have heart disease, and there is an unacceptably high morbidity and mortality rate (9.5% ). Rheumatic heart disease accounts for most of this mortality, mitral stenosis being the commonest lesion. In April 2000 the National Committee on Confidential Enquiries into Maternal Deaths (NCCEMD) reported that close to half of non-obstetric maternal deaths in South Africa were due to cardiac disease. Several preventable factors were identified that precipitated decompensation and could have accounted for this high mortality. Among them, lack of adequate antenatal evaluation, uncontrolled fluid infusion, failure to identify the patient at risk, and failure to recognise the risk of autotransfusion in the postpartum phase, were contributing factors. This report of the problems seeks to address ways in which these difficulties may be rectified.

Peripartum cardiomyopathy: mortality outcomes

Mortality estimates of peripartum cardiomyopathy have been reported to be between 18 and 56% without reference to time frames. Although this is an unusual impairment, medical directors need accurate information to meet the gold standard of underwriting: decisions must be based on sound underwriting and actuarial principles reasonably related to actual or anticipated loss experience. In an insurance purchasing population, the excess mortality in peripartum cardiomyopathy can be nearly eliminated by not insuring those with the impairment within the first 6 months postpartum or until all abnormal physiologic parameters have resolved. Thereafter, the risk is probably negligible. This abstract illustrates the challenge to determine expected mortality when the study population exhibits strong racial diversity and when available expected life tables contain raw data of only alive and dead at each yearly interval.

[Open heart surgery with extracorporeal circulation during pregnancy]

The incidence of heart disease in pregnancy has been gradually falling during the last three decades. Cardiopathy still remains a prominent cause of maternal and fetal morbidity and mortality. Most patients know about their heart disease long before conception, even though the potential risk factors of deteriorating cardiac function during pregnancy are generally not emphasized. These women when pregnant may develop heart failure due to the increased cardiorespiratory requirements. When medical therapy proves insufficient heart surgery becomes mandatory to save the patient's life. The pregnant state is not optimal for cardiac surgery as the principle interest of the mother and the fetus is different. We report on two pregnant patients who underwent unavoidable heart surgery with cardiopulmonary bypass and review the literature regarding the optimal management of open-heart operation in pregnancy aiming to decrease the feto-maternal mortality. The successful outcome of the cardiac surgery on pregnant women is determined by the severity of the preexisting disease, the surgical techniques, and the circumstances of the cardiopulmonary bypass. The best possible results can be achieved by providing preconceptional counseling for the cardiopathic patients regarding the relation between the preexisting risk factors and the adverse maternal and neonatal outcome. When heart surgery is mandatory in pregnancy the careful technical precautions and the continuous cardiotocography help to minimize fetal complications during the cardiopulmonary bypass (CPB).

Maternal and fetal outcomes of subsequent pregnancies in women with peripartum cardiomyopathy

BACKGROUND

Peripartum cardiomyopathy is a rare and sometimes fatal form of heart failure. Little is known about the outcomes of subsequent pregnancies in women who have had the disorder.

METHODS

Through a survey of members of the American College of Cardiology, we identified 44 women who had had peripartum cardiomyopathy and had a total of 60 subsequent pregnancies. We then reviewed the medical records of these women and interviewed the women or their physicians.

RESULTS

Among the first subsequent pregnancies in the 44 women, 28 occurred in women in whom left ventricular function had returned to normal (group 1) and 16 occurred in women with persistent left ventricular dysfunction (group 2). The pregnancies were associated with a reduction in the mean (+/-SD) left ventricular ejection fraction both in the total cohort (from 49+/-12 percent to 42+/-13 percent, P<0.001) and in each group separately (from 56+/-7 percent to 49+/-10 percent in group 1, P=0.002; and from 36+/-9 percent to 32+/-11 percent in group 2, P=0.08). During these pregnancies, a decrease of more than 20 percent in the left ventricular ejection fraction occurred in 21 percent of the women in group 1 and 25 percent of those in group 2, and symptoms of heart failure occurred in 21 percent of the women in group 1 and 44 percent of those in group 2. The mortality rate was 0 percent in group 1 and 19 percent in group 2 (P=0.06). In addition, the frequency of premature delivery was higher in group 2 (37 percent vs. 11 percent), as was that of therapeutic abortions (25 percent vs. 4 percent).

CONCLUSIONS

Subsequent pregnancy in women with a history of peripartum cardiomyopathy is associated with a significant decrease in left ventricular function and can result in clinical deterioration and even death.

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.

Prediction of adverse outcomes by common definitions of hypertension in pregnancy

OBJECTIVE

To examine the ability of five common definitions of hypertension in pregnancy to predict adverse maternal and perinatal outcomes.

METHODS

We studied 9133 singleton nulliparous pregnancies with early prenatal care from the Collaborative Perinatal Project, a large cohort study conducted between 1959 and 1965. Definitions from five different groups were evaluated. Severe maternal and perinatal morbidity and mortality were used as the outcome measurements. Sensitivity, specificity, and positive predictive value for outcomes were compared across various definitions.

RESULTS

Blood pressure alone had very poor discriminatory power to predict adverse outcomes. Positive predictive values of adverse outcomes by the diagnosis of preeclampsia were 18-20% based on antepartum and intrapartum blood pressures and 22-36% based on antepartum blood pressure only. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension were not associated with adverse outcomes. Similarly, an increase in diastolic blood pressure of 15 mmHg that did not achieve an absolute value of 90 mmHg did not predict adverse outcome.

CONCLUSION

Neither blood pressure nor blood pressure and proteinuria are accurate predictors of severe adverse maternal and perinatal outcomes. Mild hypertension occurring for the first time in labor and isolated mild systolic hypertension should not be considered indicators for hypertensive disorders in pregnancy in a research definition.

[Pregnancy and congenital heart defects]

With advanced diagnostic and therapeutic techniques in pediatric cardiology and cardiac surgery, pregnancy can be an option for patients with congenital heart disease. A low overall maternal mortality and a healthy pregnancy require interdisciplinary cooperation between the cardiologist, obstetrician and general practitioner caring for the mother. Treatment and outcome will depend on the type of cardiac malformation, on the functional impairment of the maternal heart (heart failure and/or cyanosis) and on the status of the fetus, with evidence of a better outcome for patients treated in specialized centers. However, even with recent advances in treatment, for women with primary pulmonary hypertension, Eisenmenger's syndrome, left heart obstruction of Marfan syndrome, pregnancy remains associated with a high maternal mortality. Therefore, these are conditions in which pregnancy is still absolutely contraindicated and a patient should be counselled to terminate the pregnancy. The risk of an inherited recurrence of a congenital heart disease is difficult to assess in an individual case because the majority of cardiac malformations are caused by multifactored variables. But for some types of malformations (i.e., atrioventricular canal, Morbus Fallot) the incidence of cardiac malformation in the offspring of affected parents is slightly higher compared to the general population. Consequently, all patients with congenital heart disease should be offered genetic counselling and fetal echocardiography. In general, pregnancy in women with congenital heart disease has no significant long-term adverse effects and a second pregnancy is possible in the majority of the cases.

Approach to pulmonary hypertension

Until recently, many physicians considered pulmonary hypertension a rare and esoteric condition that is difficult to diagnose and nearly impossible to treat. However, pulmonary hypertension can complicate a variety of relatively common diseases and, with the development of new and effective therapies, there is a need for greater awareness of this condition. Pulmonary hypertension should be considered when patients present with unexplained shortness of breath, chest pain, or syncope. The usual delay of 1 to 2 years between onset of symptoms and diagnosis underscores the importance of considering pulmonary hypertension in the differential diagnosis of patients who present with atypical cardiorespiratory symptoms.

Maternal deaths in an urban perinatal network, 1992-1998

OBJECTIVE

The object of this study was to use an in-depth peer-review process to determine the maternal mortality ratio at a single urban perinatal center and to identify factors associated with fatal outcomes to elucidate opportunities for preventive measures to reduce the maternal mortality ratio.

STUDY DESIGN

Between 1992 and 1998 all maternal deaths occurring within our perinatal network were identified. A peer-review committee was established to review all available data for each death to determine the underlying cause of death, whether it was related to pregnancy, and whether the death was potentially preventable.

RESULTS

There were 131,500 births and 42 maternal deaths, for a maternal mortality ratio of 31.9 maternal deaths per 100,000 live births. The adjusted pregnancy-related maternal mortality ratio was 22.8 maternal deaths per 100,000 live births, with 37% of those deaths (11/30) deemed potentially preventable and a provider factor cited in >80% of these. Pulmonary embolus and cardiac disease together accounted for 40% of the pregnancy-related deaths.

CONCLUSION

Local maternal mortality ratios identified through a peer-review process indicate that the magnitude of the problem is much greater than is recognized through national death certificate data. The high proportion of potentially preventable maternal deaths indicates the need for improvement in both patient and provider education if we are to reduce the maternal mortality ratio to 3.3 maternal deaths per 100,000 live births, the stated national health goal of Healthy People 2000.

Leon C. Chesley and hypertension in pregnant women

Leon C. Chesley's first paper opened with the title 'Pregnancy in the patient with hypertensive disease'(1). Leon C. Chesley PhD, John E. Annitto, MD, MSc (Med), Jersey City, NJ, USA (from the Margaret Hague Maternity Hospital) [Am J Obstet Gynecol 1947;53:372-381]. We quote some lines from this important paper and pioneering work: "We have thought it worth while to survey our experience with pregnancy in women with hypertensive disease. There are relatively few such studies based upon any considerable series, and in most studies extant there has been a selective factor in that therapeutic abortion has been done in the more severely hypertensive patients. It has not been our policy to abort such women, and our large material therefore offers an almost unique opportunity for the study of the natural history of pregnancy in hypertensive women. From the opening of the hospital in October 1931 through to 1944 there were a total of 218 patients in whom recorded blood pressures established the diagnosis of 'hypertensive toxemia,' as defined by the American Committee on Maternal Welfare. A detailed analysis has been made of the 301 pregnancies in which these patients have been seen. The gross fetal loss: in prior pregnancies, 35%; in first hypertensive pregnancy, 38%; in subsequent pregnancies, 40%. Of 47 sisters of these hypertensive patients, who delivered here, 45% had at least one toxic pregnancy. Nearly 40% of the hypertensive patients showed drops in the blood pressure in midpregnancy. Proteinuria of some degree occurred in half of the pregnancies. Renal function was normal in 93% of the pregnancies. Premature separation of the placenta occurred in 5.6% of the pregnancies. Fetal loss increased with: higher initial blood pressure, second trimester rises in blood pressure, higher pressures near delivery, decreased renal function, proteinuria, and superimposed toxemia. There were six immediate maternal mortalities (2.0%) and seven late puerperal deaths. Thus the mortality was 20 times that of the whole hospital experience." From here we will start our "hypertensive journey".

Risks and benefits of beta-receptor blockers for pregnancy hypertension: overview of the randomized trials

OBJECTIVE

Examine the benefits/risks of beta-blockers for pregnancy hypertension.

STUDY DESIGN

Meta-analysis of relevant trials identified by comprehensive literature review (1966-97).

RESULTS

Included were 30 trials for pregnancy hypertension, and four others for perinatal outcomes only. For mild chronic hypertension treated throughout pregnancy (n=2 trials), oral beta-blockers (compared with no therapy) were associated with an inconsistent increase in small for gestational age (SGA) infants (OR 2.46 [1.02, 5.92]). For mild-moderate 'late-onset' pregnancy hypertension (i.e. either chronic treated only late in pregnancy, or pregnancy-induced) (n=8 trials), oral beta-blockers (compared with no therapy) were associated with a decrease in severe hypertension (OR 0.27 [0.16, 0.451), borderline decrease in development of proteinuria (OR 0.69 [0.48, 1.02]), decrease in RDS (OR 0.33 [0.13, 0.85]), but a borderline increase in SGA infants (OR 1.47 [0.96, 2.26]). Beta-blockers were equivalent to other agents (n=15 trials). For severe 'late-onset' pregnancy hypertension (n=5 trials), i.v. labetalol produced less maternal hypotension (OR 0.13 [0.03, 0.71]) and fewer cesareans (OR 0.23 [0.13, 0.63]) than i.v. hydralazine/diazoxide.

CONCLUSIONS

It is not clear that the benefits outweigh the risks when beta-blockers are used to treat mild to moderate chronic or pregnancy-induced hypertension, given the unknown overall effect on perinatal outcomes. For severe 'late-onset' pregnancy hypertension, i.v. labetalol is safer than i.v. hydralazine or diazoxide.

Intracranial haemorrhage as a cause of maternal mortality during 1991-1992 in Japan: a report of the Confidential Inquiry into Maternal Deaths Research Group in Japan

OBJECTIVE

To determine the causes of maternal deaths by intracranial haemorrhage in Japan.

DESIGN

Retrospective analysis of records relating to maternal deaths in 1991 and 1992.

SAMPLES

Two hundred and thirty maternal deaths, including 25 cases of primary intracranial haemorrhage and two cases with secondary bleeding.

METHODS

Attending doctors were interviewed and completed a 600-item data collection instrument for each maternal death. An expert committee reviewed the data for each death to determine whether the maternal deaths could have been prevented.

MAIN OUTCOME MEASURES

Preventability of maternal death from intracranial haemorrhage treated in obstetric and emergency services in Japan.

RESULTS

Half of the primary intracranial haemorrhages occurred during pregnancy, 20% during labour, and 30% in the postnatal period. Neurosurgeons considered that there were only three women in whom surgical drainage was indicated. The committee determined that there was only one maternal death which had a > or = 70% of being prevented. After detailed discussion of each case, 60% of the women (15/25) may have been saved by earlier and more intensive medical intervention.

CONCLUSIONS

These findings suggest that detailed history taking and early diagnosis of intracranial haemorrhage would be helpful. Regionalisation of obstetric emergency systems are necessary to reduce maternal deaths in Japan due to intracranial haemorrhage.

Pregnancy outcome in primigravidae with late onset hypertensive disease

BACKGROUND

The perinatal mortality associated with pre-eclampsia is extremely high and it is mainly associated with early onset disease in multiparous women. Hypertension without proteinuria in late pregnancy may not be associated with high perinatal mortality rates.

OBJECTIVE

To establish the perinatal outcome in primigravidae women with hypertension occurring in late pregnancy, that is, at thirty fourth week or later.

DESIGN

Prospective case-control study.

SETTING

Labour ward of King Edward VIII Hospital, Durban, South Africa.

PATIENTS

Three hundred and twenty two primigravidae consisting of 161 hypertensives and 161 controls.

MAIN OUTCOME MEASURES

Maternal and foetal morbidity and mortality.

RESULTS

The hypertensive group was divided into those with proteinuria (group a) and without proteinuria (group b). The mean birthweight of babies born to proteinuric hypertensives was significantly lower than that of hypertensives without proteinuria and the normotensive group (2.4 kg (a) versus 2.8 kg (b) versus 3.02 kg (c) respectively--a versus b, p = 0.0001; a versus c, p = 0.001; b versus c, p = 0.009). There were nine perinatal deaths and all occurred in the proteinuric hypertension group.

CONCLUSION

Primigravidae with late onset proteinuric hypertension had smaller babies and higher perinatal mortality than their aproteinuric hypertensive and normotensive controls.

The role of inherited thrombophilia in venous thromboembolism associated with pregnancy

Venous thromboembolism is an important cause of maternal morbidity and mortality. The puerperium should be regarded as the period of greatest risk. However, fatalities in early pregnancy emphasise the need to assess thrombotic risk at all stages of pregnancy. In many cases those at increased risk are potentially identifiable on clinical grounds alone such as those with a personal or family history of venous thromboembolism, obesity, or surgery. Identification of women with multiple clinical risks for thrombosis during pregnancy remains the key to reducing the incidence of this condition. In women who present with a personal or family history of proven venous thromboembolism, thrombophilia screening should be performed in early pregnancy, since the results may influence subsequent management during pregnancy. The investigation and management of patients considered at increased risk of venous thrombosis during pregnancy requires close liaison between obstetricians and haematologists familiar with this rapidly expanding and complex field of thrombophilia.

[Hypertensive syndromes in pregnancy. Physiopathology, definition and fetomaternal complications]

A MAJOR CONCERN: Hypertensive syndromes occur in approximately 10 to 15% of all pregnancies and are the cause of 30% of maternal deaths and 20% of fetal and neonatal deaths. Syndromes include gestational hypertension also called pregnancy-induced hypertension, chronic hypertension and preeclampsia.

DEFINITION

In pregnant women, hypertension is defined as blood pressure levels above 140/90 mmHg at two successive measurements at a 4-hour interval. The primum movens is the development, at about 16 weeks gestation, of secondary placental ischemia due to a defect in the second trophoblastic invasion of the spiral arteries of the myometrium. This induces endothelial dysfunction leading to pro-coagulation activation and inhibited physiological vasodilatation.

RISK FACTORS

The risk of vasculoplacental disease increases with age, body mass index, primiparity, stressful working conditions, and personal history of vascular events during pregnancy.

MATERNAL RISKS

Maternal complications include preeclampsia-eclampsia, retroplacental hematoma, acute renal failure, and HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count).

FETAL RISKS

Hypotrophy, in utero death and prematurity may occur. The development of hypertension during pregnancy may also reveal a hypertensive background which could progress to persistent high blood pressure. Preeclampsia is an independent risk factor of cardiovascular disease requiring regular surveillance after delivery.