Définitions et conséquences des hypertensions artérielles de la grossesse

Maternal and Perinatal Outcome in Patients With Eclampsia: A Study Done at a Tertiary Care Centre

Background One of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each female having eclampsia and to evaluate the factors that govern the outcomes in females with eclampsia. Aim To decode the fetal and maternal outcomes in subjects having eclampsia and to evaluate various factors that govern the outcomes. Methods This retrospective cohort and epidemiological study commenced at the Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, in January 2016 till April 2017, and included females that either developed eclampsia in hospital stay duration or presented with pre-existing eclampsia. In included females, various fetal and maternal parameters were assessed along with the outcome of pregnancy. The institutional data records and the database were also used to determine the prevalence and incidence of eclampsia. Baseline maternal parameters were recorded from the already-existing institute data. These included the gestational age (in years), socioeconomic status, educational attainment, parity, gravidity, and the number of weeks of gestation present at the time of delivery. Antenatal care data assessed were blood pressure recordings, any proteinuria documented in the data, and the number of antenatal visits by the subjects. Statistical analysis was performed to assess both parameters. Results  In the current investigation, there were 0.34% eclampsia cases among females visiting the institution for deliveries. Incidences of stillbirth were seen in 19.04% and 8% of study participants, respectively. We found 9.52% (n=4) of female infants to have perished from eclampsia. Preterm births, a delayed start to the treatment, and insufficient care were all linked to poor foetal and mother outcomes. The longer the period between the beginning of a fit and delivery, the greater the likelihood of unfavourable results. Seizure onset before or after birth, parity, or subject age had no impact on mother or foetal health. The p-value for statistical significance was kept at 0.05. Conclusion Most of the research participant women, had intrapartum eclampsia, postpartum eclampsia, and antepartum eclampsia, based on the time of the convulsions in relation to the labor. It was highlighted that there was no conclusive evidence linking the date of the fit's beginning to unfavourable results or an elevated risk of complications. Neonatal mortality and stillbirth were observed with vaginal delivery in eclampsia cases. Outcomes in eclampsia can be improved by early treatment initiation, timely and appropriate referral, early disease recognition, and appropriate antenatal care.

Mitochondrial Dysfunction, Mitophagy and Their Correlation with Perinatal Complications: Preeclampsia and Low Birth Weight

Mitochondria are essential organelles and crucial for cellular survival. Mitochondrial biogenesis and mitophagy are dynamic features that are essential for both maintaining the health of the mitochondrial network and cellular demands. The accumulation of damaged mitochondria has been shown to be related to a wide range of pathologies ranging from neurological to musculoskeletal. Mitophagy is the selective autophagy of mitochondria, eliminating dysfunctional mitochondria in cells by engulfment within double-membraned vesicles. Preeclampsia and low birth weight constitute prenatal complications during pregnancy and are leading causes of maternal and fetal mortality and morbidity. Both placental implantation and fetal growth require a large amount of energy, and a defect in the mitochondrial quality control mechanism may be responsible for the pathophysiology of these diseases. In this review, we compiled current studies investigating the role of BNIP3, DRAM1, and FUNDC1, mediators of receptor-mediated mitophagy, in the progression of preeclampsia and the role of mitophagy pathways in the pathophysiology of low birth weight. Recent studies have indicated that mitochondrial dysfunction and accumulation of reactive oxygen species are related to preeclampsia and low birth weight. However, due to the lack of studies in this field, the results are controversial. Therefore, mitophagy-related pathways associated with these pathologies still need to be elucidated. Mitophagy-related pathways are among the promising study targets that can reveal the pathophysiology behind preeclampsia and low birth weight.

Hypertension and Salt-Restrictive Diet Promotes Low Urinary Iodine Concentration in High-Risk Pregnant Women: Results from a Cross-Sectional Study Conducted After Salt Iodination Reduction in Brazil

During pregnancy, the demand for daily iodine increases by 50-70% which occurs to reach around 250 μg/day. Limited information is available on the association of high-risk pregnancy (HRP) with urinary iodine concentration (UIC) and variables such as socioeconomic factors. To analyze iodine nutritional status and socioeconomic, demographic and anthropometric characteristics among women with HRP screened at the main referral public health center at Bahia, Brazil, a cross-sectional study was conducted in 241 women with HRP (15-46 years old) in Salvador, Bahia, Brazil. The median UIC (MUIC) was 119 μg/L (25-75th, 58.7-200.4 μg/L), indicating mild iodine deficiency. Low UIC (< 150 μg/L) was detected in 61.8% (n = 149) - 18.3% between 100 and 150 μg/L, 24.5% between 50 and 100 μg/L, and 19.1% with UIC < 50 μg/L. Overall, 53% (n = 128) of our population adhered to a low-salt diet, and 32.5% (n = 77) had hypertension. Among the 73% of hypertensive women adhering to a salt-restricted diet, there was a 112% increased risk of iodine deficiency observed (OR = 2.127; 95% confidence interval [1.178-3.829]; p = 0.011). Adhering to a salt-restricted diet was associated with iodine deficiency (OR = 1.82; 95% confidence interval [1.073-3.088], p = 0,026). Hypertension and salt restriction diet significantly increased susceptibility for iodine deficiency in HRP. Therefore, low-salt diet when prescribed to pregnant women (PW) might be carefully followed by iodine nutritional status assessment or universal preconception iodine supplementation.

[Maternal and perinatal prognosis of eclampsia at the Timbuktu Hospital in Mali]

Eclampsia is one of the leading causes of maternal death worldwide. The purpose of our study was to determine maternal and perinatal prognosis of eclampsia at the Timbuktu Hospital in Mali. We conducted a descriptive, retrospective study of patients with eclampsia during pregnancy or delivery at the Timbuktu Hospital from January 1, 2013 to December 31, 2017. Out of 4.951 deliveries, 116 were marked by eclampsia, reflecting an overall rate of 2.3%. These patients were mainly women younger than 26 years (85.3%), primiparous (81%), admitted on average 8 hours after the first crisis. Cesarean section was performed in 77.6% of cases. Magnesium sulphate was used in 75% of cases. Maternal and perinatal mortality accounted for 4.3% and 21.5%, respectively. Poor maternal prognosis factor was Glasgow score ≤ 8 on admission (p: 0.004). Poor perinatal prognosis factors were to be resident outside the city of Timbuktu (p: 0.000), the absence of antenatal consultation (p: 0.020) and vaginal delivery (p: 0.012). Thus, improving maternal and perinatal prognosis requires proper monitoring of pregnancies and reduction of delays in accessing adequate care.

Abnormal steroidogenesis and aromatase activity in preeclampsia

INTRODUCTION

Estrogens and progesterone play critical roles in angiogenesis and vasodilation. Moreover, placental aromatase deficiency is detected in women with preeclampsia (PE) at delivery. We hypothesized that abnormal steroidogenesis occurs much earlier than typical PE diagnosis. Thus, we investigated whether the circulating steroid profile was already disturbed at 24-29 weeks of gestation in women with subsequent PE, and compared the profile with that of women with "placental" small gestational age (SGA) without PE.

METHODS

We selected nulliparous women (n = 90) from the MOMA trial, including women with PE (n = 25), SGA (n = 25), and controls (NP; n = 40), for plasma steroid profiling by gas chromatography/mass spectrometry and to measure placental growth factor and soluble fms-like tyrosine kinase-1. Placental aromatase expression was evaluated in a new set of women.

RESULTS

Compared with that of controls, the women with PE had a significantly lower estrone/androstenedione ratio, and exhibited a decreasing trend for estradiol and estrone levels. Lower estriol levels were observed in the SGA group compared to the NP group. Compared with that of controls, the women with PE and SGA had significantly higher levels of 20α-dihydroprogesterone (20α-DHP) and 20α-DHP/progesterone ratios. Pregnenolone sulfate levels were lower in the PE group than in the NP and SGA groups. Decreased expression of aromatase was observed in the PE group compared to the control group.

DISCUSSION

Preeclampsia appears to be characterized by specific steroidogenesis dysregulation long before PE diagnosis, highlighting potential new biomarkers of PE.

Current approaches in the clinical management of pregnancy-associated breast cancer-pros and cons

Malignancies are one of the leading causes of mortality in women during their reproductive life. Treatment of gynecological malignant tumors during pregnancy is possible but not simple, since it creates a conflict between care of the mother and the fetus. BC is the most prevalent malignancy diagnosed in pregnancy, ranking up to 21% of all pregnancy-related malignancies. Due to its stets increasing prevalence, aggressive cancer subtype, and severe ethical and psychological aspects linked to the disease, experts raise an alarm for an acute necessity to improve the overall management of the PABC-the issue which has strongly motivated our current paper. Comprehensive research data and clinical experience accumulated in recent years have advanced our understanding of the disease complexity. PABC treatment must be individualized with an emphasis on optimal care of the mother, while observing standard treatment protocols with regard to safety of the fetus. Treatment protocols should be elaborated based on the individualized patient profile, bearing in mind the acute danger to the mother, maximizing the therapy efficacy and minimizing harmful effects to the fetus. Complex consulting on treatment options, their impacts on pregnancy and potential teratogenic effects requires tight "doctor-patient" collaboration. Complications that may arise due to the treatment of breast cancer in pregnancy require a multiprofessional expertise including oncologists, neonatologists, perinatologists, obstetricians, teratologists, and toxicologists, and an extensive psychological support throughout the pregnancy and after giving birth. Thereby, specifically psychological aspects of PABC diagnosis and follow-up are frequently neglected, being not yet adequately explored in the entire disease management approach. Herewith, we update the status quo regarding the currently available diagnostic modalities, complex treatment algorithms, and novel clinical approaches which altogether argue for an urgent necessity of a paradigm shift moving away from reactive to predictive, preventive, and personalized medical approach in the overall management of PABC meeting the needs of young populations, persons at high risk, affected patients, and families as the society at large.

From Pregnancy to Preeclampsia: A Key Role for Estrogens

Preeclampsia (PE) results in placental dysfunction and is one of the primary causes of maternal and fetal mortality and morbidity. During pregnancy, estrogen is produced primarily in the placenta by conversion of androgen precursors originating from maternal and fetal adrenal glands. These processes lead to increased plasma estrogen concentrations compared with levels in nonpregnant women. Aberrant production of estrogens could play a key role in PE symptoms because they are exclusively produced by the placenta and they promote angiogenesis and vasodilation. Previous assessments of estrogen synthesis during PE yielded conflicting results, possibly because of the lack of specificity of the assays. However, with the introduction of reliable analytical protocols using liquid chromatography/mass spectrometry or gas chromatography/mass spectrometry, more recent studies suggest a marked decrease in estradiol levels in PE. The aim of this review is to summarize current knowledge of estrogen synthesis, regulation in the placenta, and biological effects during pregnancy and PE. Moreover, this review highlights the links among the occurrence of PE, estrogen biosynthesis, angiogenic factors, and cardiovascular risk factors. A close link between estrogen dysregulation and PE occurrence might validate estrogen levels as a biomarker but could also reveal a potential approach for prevention or cure of PE.

Carbetocin for prevention of postcesarean hemorrhage in women with severe preeclampsia: a before-after cohort comparison with oxytocin

STUDY OBJECTIVE

The aim of the study was to compare the incidence of the use of additional uterotonics before and after the change of carbetocin to oxytocin for the prevention of postpartum hemorrhage after cesarean delivery in women with severe preeclampsia.

DESIGN

This was an observational retrospective before-and-after study.

SETTING

Operating room, postoperative recovery area.

PATIENTS

Sixty women with severe preeclampsia undergoing cesarean delivery under spinal anesthesia; American Society of Anesthesiologists 3.

INTERVENTIONS

Observational study.

MEASUREMENTS

Blood pressure, heart rate, and biological data (hemoglobin, platelets, haptoglobin, prothrombin time index, activated partial thromboplastin time ratio, blood uric acid, aspartate aminotransferase, alanine aminotransferase, serum urea, serum creatinine, and albumin).

MAIN RESULTS

The incidence of additional uterotonic administration in the carbetocin and oxytocin groups was 15% and 10%, respectively (P=.70).

CONCLUSIONS

As carbetocin appears to be as effective and safe as oxytocin in preeclamptic women, its advantages make it a good uterotonic option in this particular setting.

Maternal and fetal outcome in pre-eclampsia in a secondary care hospital in South India

BACKGROUND

Hypertensive disorders in pregnancy are one of the common causes for perinatal and maternal morbidity and mortality in developing countries. Pre-eclampsia is a condition which typically occurs after 20 weeks of gestation and has high blood pressure as the main contributing factor. The aim was to study the effects of pre-eclampsia on the mother and the fetus in rural South Indian population.

MATERIALS AND METHODS

This was a descriptive study conducted in a secondary level hospital in rural South India. A total of 1900 antenatal women were screened for pre-eclampsia during the period August 2010 to July 2011 to study the effects on the mother and fetus.

RESULTS

Of the 1900 women screened 93 were detected with pre-eclampsia in the study. Among these, 46.23% were primigravida, 30.1% belonged to socio-economic class 4 and 48.8% were among those with BMI 26-30. The incidence of severe pre-eclampsia was higher in the unregistered women. The most common maternal complication was antepartum hemorrhage (13.9%) and the most common neonatal complication was prematurity (23.65%).

CONCLUSIONS

Treating anemia and improving socioeconomic status will improve maternal and neonatal outcome in pre-eclampsia. Antenatal care and educating women on significance of symptoms will markedly improve perinatal morbidity and mortality. Prematurity, growth restriction and low birth weight are neonatal complications to be anticipated and dealt with when the mother has pre-eclampsia. A good neonatal intensive care unit will help improve neonatal outcomes.

C3F gene mutation is involved in the susceptibility to pre-eclampsia

OBJECTIVE

The aim of this study was to analyze the functional polymorphism of exon 3 of the gene of complement component C3 (rs 2230199) to identify the potential involvement of the mutated gene C3F in the genesis of pre-eclampsia.

MATERIEL AND METHODS

It is a comparative case-control study conducted in the university center of maternity and neonatology of Monastir with collaboration of high institute of biotechnology (Tunisia) on a period of 2 years. Two hundred and fifty patients and 96 newborns divided into pre-eclampsia group (150 parturients with pre-eclampsia and 48 newborns) and control group (100 parturients with normal pregnancy and their 48 infants) are taken. Each patient and control were sampled for the phenotypic study and the molecular analysis. The ARMS-PCR (amplification refractory mutation system) was the standard procedure in our study. A simple observation let to distinguish three cases of genotypes: SS, FF and SF.

RESULTS

In the control group, 56% of parturients had the genotype SS, 38%, the genotype SF and 6%, FF genotype. In the pre-eclamptic population, SS, SF, and FF genotypes were determined, respectively, 40, 45.30 and 14.60% of the patients. There is a sharp increase in the frequency of the FF genotype in pre-eclamptic patients compared to controls (14.60 vs. 6%). The difference was statistically significant (p = 0.01). The frequencies of C3S and alleles C3F determined in controls (respectively, 74 and 26%) were different from those identified in pre-eclamptic patients (respectively, 62.60 and 37.30%). This difference was statistically significant (p = 0.005). The C3S and C3F allele frequencies determined in control newborns (respectively, 83.33 and 16.66%) were slightly different from those identified in newborn issued from pre-eclamptic patients (respectively, 80.2 and 19.79%), but the difference was not statistically significant (p = 0.67).

CONCLUSION

The gene polymorphism of complement component C3 was significantly associated with the onset of pre-eclampsia. These results should be confirmed by other studies looking at larger scale to consider this gene as a new biomarker with predictive potential therapeutic consequences.

[Hypertension and pregnancy in Lome (sub-Saharan Africa): epidemiology, diagnosis and risk factors]

AIM

Describe the epidemiology, diagnosis and risk factors of hypertension in pregnant women in Lome.

METHODS

It was a prospective, descriptive and comparative study during 12 months (October 1st, 2011 to September 31st, 2012) on 200 cases of hypertension among 1620 pregnant women, in the department of gynecology and obstetrics at the Tokoin teaching hospital of Lome.

RESULTS

We had 200 cases of hypertension on 1620 pregnant women. The prevalence of hypertension in pregnant women in Lome was 12.3%. The average age of pregnant women was 30±7 years, with extremes of 15 and 44 years. Hypertension was more common (50%) in ages of 30-39 years. The society the most represented were housewives (33.33%), civil servants (16.67%) and traders (16.66%). Hypertension was found incidentally or during a complication especially during the third trimester of pregnancy. Preeclampsia (44%) and pregnancy-induced hypertension (33%) were the most represented. The main risk factors where primiparity (especially older primipars >30ans), nulliparity, familial history of hypertension, low economic level, history of pregnancy-induced hypertension, age >30 years, twinning, obesity and stress.

CONCLUSION

Hypertension in pregnancy is frequent in Lome. A regular follow-up before and after delivery is important according to fetal and maternal complications, and the risk of heart and kidney disease at mild and long outcome.

[How to manage a patient with chronic arterial hypertension during pregnancy and the postpartum period]

The management of chronic arterial hypertension during pregnancy and postpartum requires first to estimate the risk of the pregnancy, linked with the severity of hypertension, with cardiac and renal involvement, with its cause as well as with the background (obesity, diabetes, possible history of placental vascular pathology). On a very practical approach, antihypertensive drug has to be started or increased if systolic pressure reaches or exceeds 160 mmHg or if diastolic pressure reaches or exceeds 105 mmHg. Below this level, there are no evidence-based medicine data, but it seems reasonable to treat if pressure increases over 150/100 mmHg (140/90 mmHg in case of ambulatory monitoring). Excessive pressure figures control must be avoided as much as insufficient ones: in practice, it is necessary to decrease the treatment dose if figures are below 130/80 mmHg. Three antihypertensive drugs are consensually recommended today: alphametyldopa, calcium-channel blockers and labetalol. Monotherapy is most often sufficient; if needed, two of these drugs can easily be associated, and even three if necessary. Converting enzyme inhibitors and angiotensin receptor II antagonists should not be prescribed to pregnant women. Betablockers and diuretics are not recommended. Whatever is the antihypertensive drug used, it is necessary to detect the signs of bad placenta blood circulation with uterine Doppler ultrasound and regular controls of fetal growth, and to check for appearance of proteinuria, defining then over-imposed pre-eclampsia needing immediate admission to the maternity. After delivery, lacatation suppresion with bromocriptin should not be prescribed.