Avenir obstétrical après une première grossesse compliquée d’une prééclampsie sévère avec accouchement avant 34 SA

Common pathogenesis of early and late preeclampsia: evidence from recurrences and review of the literature

OBJECTIVE

To investigate whether there is an association between the gestational age at the onset of preeclampsia in recurrent cases and the gestational age at the onset of preeclampsia in previous pregnancies.

METHODS

This retrospective nested case-control study was designed to investigate whether gestational age at diagnosis and at delivery in recurrent cases of preeclampsia correlates with gestational age at diagnosis and delivery in the previous cases of preeclampsia in the same individuals. The database of a Ukrainian research network was used to find patients with the diagnosis of preeclampsia between 2019 and 2021. The database was further queried to identify those with a history of preeclampsia in a previous pregnancy. The comparison was made using the Pearson correlation coefficient.

RESULTS

One hundred and three patients who were diagnosed with preeclampsia were identified. Of those, 15 had recurrent preeclampsia, 2 of whom had preeclampsia in 2 previous pregnancies. There was no statistically significant correlation: based on gestational age at delivery R = - 0.28 (P = 0.30; 95% confidence interval (- 0.69 to 0.28) and based on gestational age at the time of diagnosis R = - 0.14 (P = 0.62; - 0.60 to 0.41).

CONCLUSION

Our data do not find an association between the gestational age of recurrent preeclampsia and preeclampsia diagnosed in a previous pregnancy. This supports the idea that there is single pathogenesis for preeclampsia regardless of the gestational age. It suggests that there are variations in the course of preeclampsia that may be determined by the capacity of the compensatory mechanisms.

Physiologic blood pressure patterns in pregnancies with mild chronic hypertension

OBJECTIVES

To assess physiologic blood pressure (BP) changes throughout pregnancy in patients with mild chronic hypertension (CHTN) who do and do not develop preeclampsia (PEC), compared to patients with normal BP.

STUDY DESIGN

Retrospective cohort of singleton gestations with CHTN at a single tertiary center from 2000 to 2014 and a randomly selected cohort of patients without CHTN and normal pregnancy outcomes (NML) in the same time period with BP measurements available <12 weeks gestational age.

MAIN OUTCOME MEASURES

The primary outcome was gestational age (GA) at nadir of systolic and diastolic BP. Secondary outcomes included perinatal death, umbilical cord pH, maternal and neonatal length of stay, GA at delivery, and mode of delivery. Quadratic mixed models were used to estimate SBP and DBP throughout gestation.

RESULTS

Of 367 pregnancies with CHTN, 268 (73%) had CHTN without PEC and 99 (27%) had CHTN with PEC; 198 NML pregnancies were used as a comparison group. The median GA nadir for patients in the NML, CHTN without PEC, and CHTN with PEC for SBP were 20, 24, and 21, respectively. For DBP, the median GA nadir were 22, 24, and 21 for patients in the NML, CHTN without PEC, and CHTN with PEC cohorts, respectively. Adverse secondary outcomes were more frequent in patients with CHTN who developed PEC.

CONCLUSIONS

BP trajectories in pregnancy are different between patients with CHTN with PEC, CHTN without PEC, and patients with normal BP. These findings may be useful in assessing patients' risks for developing preeclampsia during pregnancy.

Recurrent Severe Maternal Morbidity in an Obstetric Population With a High Comorbidity Burden

OBJECTIVE

To evaluate the risk of severe maternal morbidity (SMM) in subsequent pregnancies in patients who experienced SMM in a previous pregnancy compared with those who did not.

METHODS

We conducted a retrospective cohort study of patients with two or more deliveries at 23 or more weeks of gestation at a single Southeastern U.S. tertiary care center between 2015 and 2018. The primary exposure was SMM including transfusion (transfusion SMM) in a previous pregnancy, as defined by the Centers for Disease Control and Prevention, using International Classification of Diseases, Ninth or Tenth Revision codes. The primary outcome was transfusion SMM in any subsequent pregnancy in the study time frame. Generalized estimating equation models were used to estimate the relative risk (RR) and associated 95% CIs of transfusion SMM in patients with transfusion SMM in a prior pregnancy compared with patients without transfusion SMM in a previous pregnancy. Severe maternal morbidity without transfusion (nontransfusion SMM) and cross-analysis to determine risk of a different type of SMM after a history of SMM were analyzed similarly.

RESULTS

Of 852 included patients, transfusion SMM and nontransfusion SMM occurred in 90 (10.6%) and 18 (2.1%), respectively, in the first captured pregnancy and in 79 (9.3%) and 9 (1.1%), respectively, in subsequent pregnancies. Anemia (34.6-40.0%), obesity (33.4-40.4%), substance use disorder (14.2-14.6%), and preeclampsia (12.0-11.4%) were the most prevalent morbidities at first captured and subsequent pregnancies, respectively. There was a 16-fold higher risk of transfusion SMM in a subsequent pregnancy after experiencing transfusion SMM in the first captured pregnancy (57.8% vs 3.5%, RR 16.3 95% CI, 10.8-24.6). Nontransfusion SMM was similarly higher in patients with nontransfusion SMM in their first captured pregnancy compared with those without (16.7% vs 0.7%, RR 23.2 95% CI, 6.3-85.4). Additionally, patients who experienced transfusion SMM in their first captured pregnancies were at sixfold higher risk of developing nontransfusion SMM in a subsequent pregnancy (RR 6.2, 95% CI, 1.7-22.6). However, in cross-analysis of patients who experienced nontransfusion SMM, the risk of transfusion SMM in a subsequent pregnancy was not statistically significant.

CONCLUSION

The risks of SMM in subsequent pregnancies after previous SMM are extremely high and are higher than previous estimates. Future studies should estimate the contributions of comorbidities and other structural determinants including social vulnerability to help design interventions to reduce subsequent pregnancy risks.

Preeclampsia before 26 weeks of gestation: Obstetrical prognosis for the subsequent pregnancy

INTRODUCTION

Gestational age at delivery seems to be a risk factor of recurrence of preeclampsia. The objective of this study was to analyze adverse pregnancy outcomes and recurrence of preeclampsia during the subsequent pregnancy in women with a history of pre-eclampsia delivered before 26 weeks of gestation.

MATERIAL AND METHOD

We performed a retrospective study in two French tertiary care hospitals between 2000 and 2018. Patients with a history of pre-eclampsia delivered before 26 weeks of gestation were analyzed. Information on the immediate subsequent pregnancy was collected. Adverse composite outcome was defined as recurrent preeclampsia, HELLP syndrome, placental abruption, fetal growth restriction <3rd percentile or <10^e percentile with Doppler abnormalities, maternal death and fetal death.

RESULTS

Among the 107 patients who met the criteria, 48 were analyzed for a subsequent pregnancy. Seventeen women (35.4 %) developed an adverse composite outcome, occurring for 15 women (31.2 %) before 34 weeks. Ten women (20.8 %) developed a recurrent preeclampsia occurring for 5 women (10.4 %) before 34 weeks. We related 3 HELLP syndromes, 1 placental abruption, 9 fetal growth restrictions, 3 fetal deaths and no maternal death. Compared to baseline normotensive women, chronic hypertension was significantly associated with an increased risk of adverse composite outcome (19.3 vs 58.8 %, p-value 0.014).

CONCLUSION

In our population, preeclampsia with delivery before 26 weeks is associated with 35.4 % of adverse composite outcomes and 20.8 % of recurrent preeclampsia during the immediate subsequent pregnancy. These results justify the importance of an ongoing monitoring of these patients during subsequent pregnancy.

[Factors associated with first pregnancy in women who gave birth in a maternity hospital in Antananarivo: a retrospective cohort study]

Introduction

Il y a très peu de littératures africaines et Malgaches concernant les détails sur les facteurs de risques qu'encourent les primigestes en général. Le but de notre étude est de déterminer les facteurs de risques potentiels associés à une première grossesse.

Méthodes

Une étude cohorte rétrospective a été menée auprès des femmes primigestes et multigestes de l'hôpital Pavillon sainte Fleur entre Octobre 2014 et Décembre 2016. Les risques relatifs étaient ajustés après contrôle avec les caractéristiques sociodémographiques.

Résultats

Les primigestes étaient beaucoup plus exposées à un travail prolongé de plus de 12h (RRa = 2,28; IC 95% 1,74-3,00), à une césarienne en urgence (RRa = 1,47; IC 95% 1,35-1,60) et à une épisiotomie (RRa = 2,98; IC 95% 2,61-3,40). Leurs enfants étaient plus susceptibles de présenter des signes de souffrance fœtale avec anomalie du rythme cardiaque fœtale au cours de la phase de travail (RRa = 1,96; IC 95% 1,45-2,65) et un risque accru d'être admis dans une unité de soins intensifs après l'accouchement (RRa = 2,08; IC 95% 1,25-3,45).

Conclusion

Les complications survenues pendant le travail auraient exposé les primigestes à d'autres risques en cascades sur l'issue de leurs accouchements et sur la santé de leurs enfants. La prise en charge des primigestes nécessiterait, de la part des personnels médicaux, une attention particulière sur la durée de la phase de travail.

The effects of spinal anaesthesia for elective caesarean section on uterine and umbilical arterial pulsatility indexes in normotensive and chronic hypertensive pregnant women: a prospective, longitudinal study

BACKGROUND

Despite the known effects of neuraxial blockade on major vessel function and the rapid decrease in uterine vascular impedance, it is unclear how the blockade affects the utero-placental circulation in the near-term. We hypothesize that among women with chronic hypertension, a loss of sympathetic tonus consequent to spinal block may cause significant changes in the utero-placental haemodynamics than the changes typical in normal pregnant women. Therefore, the main study objective was to analyse the effect of spinal anaesthesia for caesarean section on uterine and umbilical arterial impedance in pregnant women at term diagnosed with stage-1 chronic hypertension.

METHODS

A prospective, longitudinal study was performed in singleton pregnant women (203 low-risk and 33 with hypertension) scheduled to undergo elective caesarean section. The mean arterial blood pressure and pulsatility indexes for the uterine and umbilical arteries were recorded before and after spinal anaesthesia was performed using 8-9 mg hyperbaric bupivacaine (5 mg/mL) and 2-2.5 μg sufentanil (5 μg/mL). Multiple linear regression models with errors capable of correlation or with unequal variances were fitted using the generalized least squares.

RESULTS

In normotensive women, the mean arterial blood pressure decreased after administering spinal anaesthesia (p < 0.05). The pulsatility index of the uterine and umbilical arteries did not change after spinal anaesthesia. In the hypertensive women, the mean arterial blood pressure (p < 0.05) and uterine artery pulsatility index (p < 0.05) decreased. In both groups, the umbilical artery pulsatility index did not change after spinal anaesthesia.

CONCLUSIONS

In stage-1 chronic hypertensive pregnant women at term, spinal anaesthesia for caesarean section reduces uterine artery impedance but not umbilical artery impedance.