Critical care in obstetrics: pregnancy-specific conditions

The Association of Pregnancy With Outcomes Among Critically Ill Reproductive-Aged Women: A Propensity Score-Matched Retrospective Cohort Analysis

BACKGROUND

The maternal mortality rate in the United States is unacceptably high. However, the relative contribution of pregnancy to these outcomes is unknown. Studies comparing outcomes among pregnant vs nonpregnant critically ill patients show mixed results and are limited by small sample sizes.

RESEARCH QUESTION

What is the association of pregnancy with critical illness outcomes?

STUDY DESIGN AND METHODS

We performed a retrospective cohort study of women 18 to 55 years of age who received invasive mechanical ventilation (MV) on hospital day 0 or 1 or who demonstrated sepsis on admission (infection with organ failure) discharged from Premier Healthcare Database hospitals from 2008 through 2021. The exposure was pregnancy. The primary outcome was in-hospital mortality. We created propensity scores for pregnancy (using patient and hospital characteristics) and performed 1:1 propensity score matching without replacement within age strata (to ensure exact age matching). We performed multilevel multivariable mixed-effects logistic regression for propensity-matched pairs with pair as a random effect.

RESULTS

Three thousand ninety-three pairs were included in the matched MV cohort, and 13,002 pairs were included in the sepsis cohort. The characteristics of both cohorts were well balanced (all standard mean differences, < 0.1). Among matched pairs, unadjusted mortality was 8.0% vs 13.8% for MV and 1.4% vs 2.3% for sepsis among pregnant and nonpregnant patients, respectively. In adjusted regression, pregnancy was associated with lower odds of in-hospital mortality (MV: OR, 0.50; 95% CI, 0.41-0.60; P < .001; sepsis: OR, 0.52; 95% CI, 0.40-0.67; P < .001).

INTERPRETATION

In this large US cohort, critically ill pregnant women receiving MV or with sepsis showed better survival than propensity score-matched nonpregnant women. These findings must be interpreted in the context of likely residual confounding.

Peripartum Cardiomyopathy: Current Understanding of Pathophysiology, Diagnostic Workup, Management, and Outcomes

Peripartum cardiomyopathy (PPCM) is a relatively rare, potentially life-threatening, idiopathic form of cardiomyopathy that affects previously healthy young women during late pregnancy or in the early postpartum period and is characterized by left ventricular (LV) systolic dysfunction in the absence of any other identifiable cardiac causes. Morbidity and mortality with PPCM are remarkably high and it continues to be one of the leading causes of maternal death. Although remarkable advances have been made in our understanding of PPCM in the last few decades, unanswered questions remain regarding its pathophysiology, diagnostic workup, and management options. In this article, we will complete an updated, comprehensive review of PPCM, including the epidemiology and risk factors, proposed etiology, presentation and complications, management, prognostic indicators and outcomes. In addition, we will identify current challenges and gaps in knowledge.

Case report: the management for a gestational hypertensive woman with influenza A virus pneumonia and peripartum cardiomyopathy

Background

Peripartum cardiomyopathy (PPCM) is defined as an idiopathic cardiomyopathy occurring in the last month of pregnancy or the first 6 months postpartum without an identifiable cause. PPCM is suspected to be triggered by the generation of a cardiotoxic fragment of prolactin and the secretion of a potent antiangiogenic protein from the placental, but no single factor has been identified or defined as the underlying cause of the disease. Influenza virus can cause PPCM through immune-mediated response induced by proinflammatory cytokines from host immunity and endothelial cell dysfunction. We report a case in a parturient woman undergoing a cesarean delivery, who had influenza A pneumonia and PPCM.

Case presentation

A parturient woman at 40 weeks and 1 day of gestation who had experienced gestational hypertension accompanied by pulmonary edema developed hypotension after undergoing an emergency cesarean delivery. An elevation of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was noted, and echocardiography revealed a left ventricular ejection fraction of 20%. She underwent a nasopharyngeal swab test, in which influenza A antigen was positive. She was diagnosed as having PPCM and received anti-viral treatment. After antiviral treatment, hemodynamic dysfunction stabilized. We present and discuss the details of this event.

Conclusion

PPCM is a heart disease that is often overlooked by medical personnel. Rapid swab tests, serum creatine kinase measurement, and echocardiography are imperative diagnostic approaches for the timely recognition of virus-associated cardiomyopathy in peripartum women with influenza-like disease and worsening dyspnea, especially during the epidemic season. Prompt antiviral treatment should be considered, particularly after PPCM is diagnosed.

Supplementary information

The online version contains supplementary material available at 10.1186/s12884-022-04814-9.

Peripartum Cardiomyopathy

Importance

Peripartum cardiomyopathy is a rare form of heart failure due to left ventricular systolic dysfunction that affects women late in pregnancy and the postpartum period. A diagnosis of exclusion, peripartum cardiomyopathy can be difficult to diagnose in the context of the normal physiologic changes of pregnancy and requires a high index of suspicion.

Evidence Acquisition

Original research articles, review articles, and guidelines on peripartum cardiomyopathy were reviewed.

Results

The etiology of peripartum cardiomyopathy remains poorly defined, but theories include genetic predisposition, as well as myocardial inflammation and angiogenic dysregulation. Risk factors for this condition include hypertensive disorders of pregnancy, Black race, and maternal age older than 30 years. Patients with peripartum cardiomyopathy are at increased risk of acute clinical decompensation, cardiac arrhythmias, thromboembolic complications, and death. Primary treatment modalities include initiation of a medication regimen aimed at the optimization of preload and reduction of afterload. Maternal clinical status is the primary determinant for timing of delivery.

Conclusions

Prompt diagnosis and medical management by an interdisciplinary care team are vital for improving outcomes in patients with peripartum cardiomyopathy.

siRNA-mediated NCAM1 gene silencing suppresses oxidative stress in pre-eclampsia by inhibiting the p38MAPK signaling pathway

Pre-eclampsia (PE), whose pathophysiology and etiology remain undefined, represents a leading consequence of fetal and maternal mortality and morbidity. Oxidative stress (OS) is recognized to involve in this disorder. In this study, we hypothesized that neural cell adhesion molecule 1 (NCAM1) gene silencing would suppress the OS in the pregnancy complicated by PE. Initially, clinical samples were collected for determination of NCAM1 expression in placental tissues and levels of OS products in blood. To assess the regulatory mechanism of NCAM1 knockdown on OS, we used small interfering RNA (siRNA) to silence NCAM1 expression in human umbilical vein endothelial cells (HUVECs). Next, cells were treated with or without hypoxia/reoxygenation to observe the level changes of OS products and p38 mitogen-activated protein kinase (p38MAPK) pathway-related genes. Finally, an evaluation of HUVEC migration and invasion abilities was conducted by wound-healing and transwell assays. Placenta of pregnancy with PE presented significantly increased NCAM1 expression in comparison to placenta of normal pregnancy. Meanwhile, enhanced OS in blood of pregnant women with PE was observed relative to women with normal pregnancy. siRNA-mediated knockdown of NCAM1 gene could inhibit the p38MAPK signaling pathway, repress OS, and promote cell migration and invasion in HUVECs, indicating that NCAM1 inhibition could reduce the influence of PE. Importantly, blocking the p38MAPK signaling pathway reversed the inhibitory role of NCAM1 gene silencing on PE. Collectively, this study defines potential role of NCAM1 gene silencing as a therapeutic target in PE through inhibiting OS and enhancing HUVEC migration and invasion by disrupting the p38MAPK signaling pathway.

Peripartum women with dyspnea in the emergency department: Is it peripartum cardiomyopathy?

Peripartum cardiomyopathy (PPCM) is life-threatening and its diagnosis is a challenge. We highlight the clinical characteristics and bio-markers of PPCM and the proper differential diagnosis of peripartum dyspnea to aim to make an early diagnosis available.We analyzed 262 peripartum patients with dyspnea, and summed up the final diagnosis. The clinical data of the control group and the PPCM group as well as before and after the treatment of the PPCM group were compared.In total, 147 (56%) of the perinatal patients were physiologic dyspnea of pregnancy; only 11 (4%) patients met the PPCM diagnostic criteria. Compared with the basic baseline characteristics between the PPCM group and control group, patients with PPCM had a higher heart rate, and the white blood cell, high-sensitivity C-reactive protein (hs-CRP), and B-type natriuretic peptide (BNP) levels were markedly elevated, whereas PaO2 and left ventricular ejection fraction (LVEF) were lower. The heart rate, CRP and BNP levels were lower at the follow-up compared with the pretreatment. Patients who were followed up showed significant improvements in the LVEF and New York Heart Association function class.We standardized the symptoms of dyspnea for calculating, and analyzed the diagnostic efficacy of laboratory indicators. The research highlighted that the use of echocardiography and disease-specific bio-markers may aid in the diagnosis and management.

Neurologic complications in critically ill pregnant patients

Neurologic complications in a critically ill pregnant woman are uncommon but some of the complications (such as eclampsia) are unique to pregnancy and the puerperal period. Other neurologic complications (such as seizures in the setting of epilepsy) may worsen during pregnancy. Clinical signs and symptoms such as seizure, headache, weakness, focal neurologic deficits, and decreased level of consciousness require careful consideration of potential causes to ensure prompt treatment measures are instituted to prevent ongoing neurologic injury. Clinicians should be familiar with syndromes such as pre-eclampsia, eclampsia, stroke, posterior reversible encephalopathy syndrome, and reversible cerebral vasoconstriction syndrome. Necessary imaging studies can usually be performed safely in pregnancy. Scoring systems for predicting maternal mortality are inadequate, as are recommendations for neurorehabilitation. Tensions can arise when there is conflict between the interests of the mother and the interests of the fetus, but in general maternal health is prioritized. The complexity of care requires a multidisciplinary and multiprofessional approach to achieve best outcome in an often unexpected situation.

Peripartum Cardiomyopathy in Intensive Care Unit: An Update

Peripartum cardiomyopathy (PPCM) is a systolic heart failure that occurs during the last month of pregnancy or within 5 months after delivery. It is an uncommon disease of unknown etiopathogenesis and has a very high rate of maternal mortality. Because of similarity between symptoms of PPCM and physiological discomforts during pregnancy, the early diagnosis of PPCM presents a major challenge. Since hemodynamic changes during PPCM can vitally jeopardize the mother and the fetus, patients with severe forms of PPCM require a multidisciplinary approach in intensive care units. This review summarizes the current state of knowledge about the diagnosis, monitoring, and the treatment of PPCM. Having reviewed the recent researches, it gives insight into the new treatment strategies of this rare disease.

Treatment for disseminated intravascular coagulation in patients with acute and chronic leukemia

BACKGROUND

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the bloodstream. It may occur in patients with acute and chronic leukemia and is particularly associated with acute promyelocytic leukemia (a subtype of acute myeloid leukemia).

OBJECTIVES

To assess the clinical benefits and harms of any pharmacological intervention for treating DIC in patients with acute or chronic leukemia.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2015, Issue 05), MEDLINE (1946 to 7 May 2015), LILACS (1982 to 7 May 2015) and African Index Medicus (7 May 2015). There was no language restrictions. We sought additional randomized controlled trials (RCTs) from the World Health Organization International Clinical Trials Registry Platform and the reference lists of primary studies identified.

SELECTION CRITERIA

RCTs assessing the clinical benefits and harms of interventions for treating DIC in patients with acute and chronic leukemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed trial selection, 'Risk of bias' assessment and data extraction. Primary outcomes were overall mortality, in-hospital mortality from any cause (15-day and 30-day) and adverse events.

MAIN RESULTS

In this Cochrane Review update we did not include any new RCT compared with the first review version. Accordingly, four RCTs (388 participants) met the inclusion criteria. These trials evaluated the human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate. Included trials reported data on mortality and bleeding. The studies were conducted in Japan, Italy and the Netherlands. We classified the included trials as: 1) including patients with or without leukemia which did not report data for the leukemia subgroup (366 participants); and 2) only including patients with leukemia (22 participants). Overall, the risk of bias of the included trials was high, since the trial authors did not provide a detailed description about trial design and execution.According to the GRADE recommendations, we judged the overall quality of the body of evidence for all prefixed outcomes as 'very low', due to methodological limitations and very small sample size.One trial, including 10 participants with leukemia and comparing dermatan sulphate with heparin, reported no deaths during trial treatment.In terms of bleeding data, we were unable to pool results from two studies that were only conducted with leukemia patients due to the inconsistency in the measurement and reporting of this outcome. One trial, including 12 participants with leukemia, found very low quality evidence that tranexamic acid can reduce the cumulative hemorrhagic score in participants compared with those assigned to placebo (P = 0.0015, very low quality evidence). On the contrary, there is no evidence that dermatan sulphate compared with placebo reduces new events of hemorrhagic diathesis (1/5 (20%) versus 2/5 (40%); RR 0.50; 95% CI 0.06 to 3.91; P = 0.51, very low quality evidence).No thromboembolic complications were reported in either trial that included patients with leukemia only (very low quality evidence). The safety profile was inconclusive.The included trials did not assess overall mortality, resolution of respiratory failure, renal failure or shock.

AUTHORS' CONCLUSIONS

Due to a lack of new RCTs, our conclusions in this Cochrane Review update are the same as the previous review version. We included four RCTs which reported mortality and bleeding data. It is not possible to determine whether human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate are effective or harmful for patients presenting with DIC related to acute or chronic leukemia. The quality of the evidence was low to very low. Therefore, prescription of these interventions for treating DIC in patients with acute and chronic leukemia can neither be supported nor rejected, unless new evidence from a large high-quality trial alters this conclusion.

[Anesthetic management of severe or worsening postpartum hemorrhage]

INTRODUCTION

Risk factors of maternal morbidity and mortality during postpartum hemorrhage (PPH) include non-optimal anesthetic management. As the anesthetic management of the initial phase is addressed elsewhere, the current chapter is dedicated to the management of severe PPH.

METHODS

A literature search was performed using PubMed and Medline databases, and the Cochrane Library, for articles published from 2003 up to and including 2013. Several keywords related to anesthetic and critical care practice, and obstetrical management were used, in various combinations. Guidelines from several societies and organisations were also read.

RESULTS

When PPH worsens, one should ask for additional team personnel (professional consensus). Patients should be monitored for heart rate, blood pressure, skin and mucosal pallor, bleeding at skin puncture sites, diuresis and the volume of genital bleeding (grade B). Because of the possible rapid worsening of coagulapathy, patients should undergo regular evaluation of coagulation status (professional consensus). Prevention and management of hypothermia should be considered (professional consensus), by warming intravenous fluids and blood products, and by active body warming (grade C). Antibiotics should be given, if not already administered at the initial phase (professional consensus). Vascular fluids must be given (grade B), the choice being left at the physician discretion. Blood products transfusion should be decided based on the clinical severity of PPH (professional consensus). Priority is given to red blood cells (RBC) transfusion, with the aim to maintain Hb concentration>8g/dL. The first round of products could include 3 units of RBC (professional consensus), and the following round 3 units of RBC, and 3 units of fresh frozen plasma (FFP). The FFP:RBC ratio should be kept between 1:2 and 1:1 (professional consensus). Depending on the etiology of PPH, the early administration of FFP is left at the discretion of the physician (professional consensus). Platelet count should be maintained at>50 G/L (professional consensus). During massive PPH, fibrinogen concentration should be maintained at>2g/L (professional consensus). Fibrinogen can be given without prior fibrinogen measurement in case of massive bleeding (professional consensus). General anesthesia should be considered in case of hemodynamic instability, even when an epidural catheter is in place (professional consensus).

CONCLUSION

The anesthetic management aims to restore and maintain optimal respiratory state and circulation, to treat coagulation disorders, and to allow invasive obstetrical and radiologic procedures. Clinical and instrumental monitoring are needed to evaluate the severity of PPH, to guide the choice of therapeutic options, and to assess treatments efficacy.

Hepatobiliary diseases during pregnancy and their management: An update

Liver diseases in pregnancy although rare but they can seriously affect mother and fetus. Signs and symptoms are often not specific and consist of jaundice, nausea, vomiting, and abdominal pain. Although any type of liver disease can develop during pregnancy or pregnancy may occur in a patient already having chronic liver disease. All liver diseases with pregnancy can lead to increased maternal and fetal morbidity and mortality. It is difficult to identify features of liver disease in pregnant women because of physiological changes. Physiological changes of normal pregnancy can be confounding with that of sign and symptoms of liver diseases. Telangiectasia or spider angiomas, palmar erythema, increased alkaline phosphatase due to placental secretion, hypoalbuminemia due to hemodilution. These normal alterations mimic physiological changes in patients with decompensated chronic liver disease. Besides all these pathological changes however, blood flow to the liver remains constant and the liver usually remains impalpable during pregnancy. The diagnosis of liver disease in pregnancy is challenging and relies on laboratory investigations. The underlying disorder can have a significant effect on morbidity and mortality in both mother and fetus, and a diagnostic workup should be initiated promptly. If we see the spectrum of liver disease in pregnancy, in mild form there occur increase in liver enzymes to severe form, where liver failure affecting the entire system or maternal mortality and morbidity. It can not only complicate mother's life but also poses burden of life of fetus to growth restriction. Most of the times termination is only answer to save life of mother but sometimes early detection of diseases, preventive measures and available active treatment is helpful for both of the life. Extreme vigilance in recognizing physical and laboratory abnormalities in pregnancy is a prerequisite for an accurate diagnosis. This could lead to a timely intervention and successful outcome.

Trauma during pregnancy

Traumatic injuries in pregnancy are both common and burdensome. Optimal management includes proper triage, maternal resuscitation, fetal monitoring, and diagnostic imaging.

Peripartum cardiomyopathy

Peripartum cardiomyopathy (PPCM) is a rare form of unexplained cardiac failure of unknown origin, unique to the pregnant woman with highly variable outcome associated with high morbidity and mortality. PPCM is fraught with controversies in its definition, epidemiology, pathophysiology, diagnosis and management. PPCM is frequently under diagnosed, inadequately treated and without a laid down follow-up regimen, thus, the aim of this review. Publications on PPCM were accessed using Medline, Google scholar and Pubmed databases. Relevant materials on PPCM, selected references from internet services, journals, textbooks, and lecture notes on PPCM were also accessed and critically reviewed. PPCM is multifactorial in origin. It is a diagnosis of exclusion and should be based on classic echocardiographic criteria. The outcome of PPCM is also highly variable with high morbidity and mortality rates. Future pregnancies are not recommended in women with persistent ventricular dysfunction because the heart cannot tolerate increased cardiovascular workload associated with the pregnancy. Although, multiparity is associated with PPCM, there is an increased risk of fetal prematurity and fetal loss. PPCM is a rare form of dilated cardiomyopathy of unknown origin, unique to pregnant women. The pathophysiology is poorly understood. Echocardiography is central to diagnosis of PPCM and effective treatment monitoring in patients of PPCM. The outcome is highly variable and related to reversal of ventricular dysfunction.

Peripartum cardiomyopathy: review and practice guidelines

Peripartum cardiomyopathy, a type of dilated cardiomyopathy of unknown origin, occurs in previously healthy women in the final month of pregnancy and up to 5 months after delivery. Although the incidence is low-less than 0.1% of pregnancies -morbidity and mortality rates are high at 5% to 32%. The outcome of peripartum cardiomyopathy is also highly variable. For some women, the clinical and echocardiographic status improves and sometimes returns to normal, whereas for others, the disease progresses to severe cardiac failure and even sudden cardiac death. In acute care, treatment may involve the use of intravenous vasodilators, inotropic medications, an intra-aortic balloon pump, ventricular-assist devices, and/or extracorporeal membrane oxygenation. Survivors of peripartum cardiomyopathy often recover from left ventricular dysfunction; however, they may be at risk for recurrence of heart failure and death in subsequent pregnancies. Women with chronic left ventricular dysfunction should be managed according to guidelines of the American College of Cardiology Foundation and the American Heart Association.

Treatment for disseminated intravascular coagulation in patients with acute and chronic leukemia

BACKGROUND

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterized by systemic intravascular activation of coagulation, leading to deposition of fibrin in the bloodstream, that may occur in patients with acute and chronic leukemia.

OBJECTIVES

To assess the clinical effectiveness and safety of any pharmacological intervention for treating DIC in acute or chronic leukemia.

SEARCH STRATEGY

The search strategy included the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 12), MEDLINE (1950 to 28 October 2010), EMBASE (1980 to 10 October 2010), LILACS (1982 to 19 August 2010) and African Index Medicus (1993 to 19 August 2010). There was no language restriction. We sought additional randomized controlled trials (RCTs) from the World Health Organization (WHO) Clinical Trials Registry Platform and by using the reference lists of primary studies found.

SELECTION CRITERIA

RCTs assessing the effectiveness of interventions for treating disseminated intravascular coagulation (DIC) in patients with acute and chronic leukemia.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, risk of bias assessment and data extraction.

MAIN RESULTS

Four RCTs (126 participants) met the inclusion criteria. These trials evaluated the human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate. Included RCTs reported data on mortality and bleeding. The included RCTs were classified as: 1) including patients with or without leukemia, and 2) only including patients with leukemia. However, data were not reported for the leukemia subgroup. We were not able to pool results from studies due to the inconsistency in the measurement and reporting of mortality and bleeding data. The included studies were at high risk of bias.

AUTHORS' CONCLUSIONS

We found four RCTs which reported mortality and bleeding data. It is not possible to determine whether human activated protein C, recombinant human soluble thrombomodulin, tranexamic acid and dermatan sulphate are effective or harmful for patients presenting with DIC related to acute or chronic leukemia. The effects of these interventions need to be tested in sufficiently powered RCTs. Outcome measures should include in-hospital mortality from any cause, overall mortality, incidence of resolution of respiratory failure, renal failure, shock and safety. The definition of bleeding should be standardized in these patients.

Haematological interventions for treating disseminated intravascular coagulation during pregnancy and postpartum

BACKGROUND

Disseminated intravascular coagulation (DIC) is an acquired syndrome characterised by systemic intravascular activation of coagulation. There are several obstetric causes of DIC during pregnancy and postpartum.

OBJECTIVES

To assess the clinical effectiveness and safety of haematological interventions such as heparins (low molecular weight heparin (LMWH) and unfractionated heparin (UFH), danaparoid sodium, synthetic protease inhibitor, antithrombin, human recombinant activated protein C, recombinant human soluble thrombomodulin, recombinant tissue factor pathway inhibitor, recombinant activated factor VIIa and any other types of haematological interventions (except transfusions) for treating DIC during pregnancy and postpartum.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 July 2010), LILACS (1982 to 22 July 2010), ongoing trials registries via the World Health Organization International Clinical Trials Platform Search Portal (22 July 2010), and other relevant websites (22 July 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs) on any haematological interventions for treating DIC during pregnancy and postpartum.

DATA COLLECTION AND ANALYSIS

There were no included studies.

MAIN RESULTS

We could not find any RCTs on haematological interventions (heparins (LMWH and UFH), danaparoid sodium, synthetic protease inhibitor, antithrombin, human recombinant activated protein C, recombinant human soluble thrombomodulin, recombinant tissue factor pathway inhibitor, recombinant activated factor VIIa and any other types of haematological interventions) for treating DIC during pregnancy and postpartum.

AUTHORS' CONCLUSIONS

This review found no RCTs on the safety and efficacy of haematological interventions for treating DIC during pregnancy and postpartum. Such interventions need to be tested in RCTs assessing outcomes such as maternal death, perinatal death and safety.

Cost-effectiveness of recurrence risk guided care versus care as usual in women who suffered from early-onset preeclampsia including HELLP syndrome in their previous pregnancy (the PreCare study)

Background

Preeclampsia and HELLP syndrome may have serious consequences for both mother and fetus. Women who have suffered from preeclampsia or the HELLP syndrome, have an increased risk of developing preeclampsia in a subsequent pregnancy. However, most women will develop no or only minor complications. In this study, we intend to determine cost-effectiveness of recurrence risk guided care versus care as usual in pregnant women with a history of early-onset preeclampsia.

Methods/design

We developed a prediction model to estimate the individual risk of recurrence of early-onset preeclampsia and the HELLP syndrome. In a before-after study, pregnant women with preeclampsia or HELLP syndrome in their previous pregnancy receiving care as usual (before introduction of the prediction model) will be compared with women receiving recurrence risk guided care (after introduction of the prediction model).

Eligible and pregnant women will be recruited at six university hospitals and seven large non-university tertiary referral hospitals in the Netherlands.

The primary outcome measure is the recurrence of early-onset preeclampsia or HELLP syndrome in women allocated to the regular monitoring group.

For the economic evaluation, a modelling approach will be used. Costs and effects of recurrence risk guided care with those of care as usual will be compared by means of a decision model. Two incremental cost-effectiveness ratios will be calculated: 1) cost per Quality Adjusted Life Year (mother unit of analysis) and 2) cost per live born child (child unit of analysis).

Discussion

This is, to our knowledge, the first study that evaluates prospectively the efficacy of a multivariable prediction rule for recurrent hypertensive disease in pregnancy. Results of this study could either be integrated into the current guideline on Hypertensive Disorders in Pregnancy, or be used to develop a new guideline.

Responding to amniotic fluid embolism

Amniotic fluid embolism (AFE), an uncommon disorder with a high fatality rate, is an obstetric emergency that requires swift recognition and intervention to save both the mother's life and that of her child.The high mortality rate and varying theories as to its cause make it difficult to diagnose AFE, which can occur at any point during labor and delivery, including during cesarean birth. These factors make it important for perioperative nurses to understand and recognize AFE when it occurs in the OR. Rapid delivery of the fetus is imperative for the survival of both mother and child. Monitoring and aggressively providing respiratory and circulatory support interventions are required if the mother is to survive AFE.