Natural history of chronic proteinuria complicating pregnancy

Preeclampsia epidemiology(ies) and pathophysiology(ies)

Preeclampsia/eclampsia was first described 2000 years ago. Concepts guiding diagnosis have changed over time making longitudinal studies challenging. Similarly, concepts of pathophysiology have evolved from eclampsia as a pregnancy seizure disorder to preeclampsia as a hypertensive and renal disorder to our current concept of a preeclampsia as a pregnancy specific, multisystemic inflammatory disorder. Although preeclampsia is pregnancy specific and many pathophysiologic findings begin to resolve with delivery, its impact extends beyond pregnancy. The risk of cardiovascular and neurological disease is increased after pregnancy in women who have had preeclampsia. The disorder is not a disease, but a syndrome and emerging data indicate multiple pathways to the syndrome. It is likely that our failure to have a major impact on prediction and prevention despite a large increase in understanding is due to the existence of multiple subtypes of preeclampsia. This concept should guide future research.

A Case of a Pregnant Woman with IgA Nephropathy Showing Histological Preeclampsia Findings without Hypertension Treated with Steroids: A Case Report and Literature Review

A 35-year-old woman pregnant with twins developed nephrotic syndrome (NS) at 33 weeks' gestation, but her blood pressure remained within the normal range throughout gestation and puerperium. At 34 weeks' gestation, she delivered healthy twins via Caesarean section. After delivery, she developed massive proteinuria (21.1 g/day) and severe hypoalbuminemia (1.0 g/dL). A renal biopsy performed 19 days after delivery revealed IgA nephropathy (IgAN) and preeclampsia. She was treated with steroids, and the NS gradually resolved. This is a rare case of massive gestational proteinuria with IgAN and preeclampsia pathologically that did not meet the clinical criteria for preeclampsia.

The impact of baseline proteinuria in pregnant women with pregestational diabetes mellitus

BACKGROUND

The incidence of diabetes in pregnancy has increased dramatically with the rising rates of obesity. Because there are a number of recognized adverse maternal and fetal outcomes associated with diabetes, there have been several attempts to classify this disorder for perinatal risk stratification. One of the first classification systems for pregnancy was developed by White nearly 70 years ago. More recently, efforts to stratify diabetic disease severity according to vasculopathy have been adopted. Regardless of classification system, vasculopathy-associated effects have been associated with worsening pregnancy outcomes. Defining vasculopathy within an organ system, however, has not been consistent. For example, definitions of diabetic kidney disease differ from the previously used threshold of ≥500 mg/d by White for pregnancy to varying thresholds of albuminuria by the American Diabetes Association.

OBJECTIVE

To evaluate a proteinuria threshold that was a relevant determinant of perinatal risk in a cohort of women with type 2 diabetes.

MATERIALS AND METHODS

This was a retrospective cohort study of women with pregestational diabetes delivered of nonanomalous, singleton, liveborn infants. All women were assessed for baseline maternal disease burden with a 24-hour proteinuria quantification performed before 20 weeks' gestation. Women with <500 mg/d on 24-hour urine collections were included. Perinatal outcomes were analyzed according to the following protein excretion values: 50-100, 101-200, 201-300, and 301-499 mg/d. Based on trends noted in these results and using the prior definition of the American Diabetes Association of 300 mg/d of albumin for diabetic kidney disease, women were then analyzed according to 24-hour urine collections of ≤300 or >300 mg/d.

RESULTS

Between 2009 and 2016, a total of 594 women with pregestational diabetes were found to meet study criteria. When analyzed according to protein excretion values 50-100, 101-200, 201-300, and 301-499 mg/d, there were no differences in maternal demographics. The rate of preeclampsia with severe features (P for trend = .02), preterm birth at <37 weeks (P for trend <.001), and birthweight <10^th percentile (P for trend = .02) were significantly associated with increasing proteinuria excretion, with the highest rates in the >300 mg/d group. Perinatal outcomes were then examined in the context of 24-hour urine protein excretion values of ≤300 or >300 mg/d, with no differences in maternal demographics. Protein excretion values >300 mg/d were significantly associated with preterm birth <37 weeks (P = .003), preeclampsia with severe features (P = .002), and birthweight <10^th percentile (P = .048).

CONCLUSION

White's classification in 1949 was developed to stratify perinatal risks based on maternal disease burden, and it was found that urinary protein excretion of >500 mg/d was associated with adverse pregnancy outcomes. In a contemporary cohort of pregnant women, proteinuria >300 mg/d was associated with preterm birth, preeclampsia with severe features, and birthweight <10^th percentile.

Outcome of pregnancy with new onset proteinuria and progression to pre-eclampsia: A retrospective analysis

OBJECTIVE

To examine maternal and neonatal outcomes of gestational proteinuria, and to identify maternal characteristics for progression to pre-eclampsia.

STUDY DESIGN

Retrospective cohort. Included all pregnant women who delivered between Jan 2014-Feb 2017 with new onset proteinuria in a single obstetric unit. Demographic, maternal and neonatal outcomes were compared.

RESULTS

Eighteen (25%) out of 73 women with new onset gestational proteinuria developed pre-eclampsia. The incidence of gestational proteinuria was 0.54%. Compared with women that remained normotensive, those that developed hypertension had delivery at earlier gestation (p = .02), increased risk of fetal growth restriction (p = .01) and lower newborn birthweight (p = .002). Maximal proteinuria and fetal growth restriction were independent factors associated with development of pre-eclampsia. In particular, high proteinuria level ≥ 2 g/d constitute a major predictor for progression (p = .03).

CONCLUSION

Increased vigilance for antenatal surveillance is important in women with gestational proteinuria as a substantial portion progress to pre-eclampsia. Serial growth scan and proteinuria assay are suggested to predict possible pre-eclampsia development.

A Multicenter Cohort Study of Histologic Findings and Long-Term Outcomes of Kidney Disease in Women Who Have Been Pregnant

BACKGROUND AND OBJECTIVES

For many women pregnancy is the first contact with health services, thus providing an opportunity to identify renal disease. This study compares causes and long-term renal outcomes of biopsy-proven renal disease identified during pregnancy or within 1 year postpartum, with nonpregnant women.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Native renal biopsies (1997-2012), in women of childbearing age (16 to <50 years), from 21 hospitals were studied. The pregnancy-related diagnosis group included those women with abnormal urinalysis/raised creatinine identified during pregnancy or within 1 year postpartum. Pregnancy-related and control biopsies were matched for age and ethnicity (black versus nonblack).

RESULTS

One hundred and seventy-three pregnancy-related biopsies (19 antenatal, 154 postpregnancy) were identified and matched with 1000 controls. FSGS was more common in pregnancy-related biopsies (32.4%) than controls (9.7%) (P<0.001) but there were no differences in Columbia classification. Women with a pregnancy-related diagnosis were younger (32.1 versus 34.2 years; P=0.004) and more likely to be black (26.0% versus 13.3%; P<0.001) than controls, although there were no differences in ethnicities in women with FSGS. The pregnancy-related group (excluding antenatal biopsies) was more likely to have a decline in Chronic Kidney Disease Epidemiology Collaboration eGFR in the follow-up period than the control group (odds ratio, 1.67; 95% confidence interval, 1.03 to 2.71; P=0.04), and this decline appeared to be more rapid (-1.33 versus -0.56 ml/min per 1.73 m2 per year, respectively; P=0.045). However, there were no differences between groups in those who required RRT or who died.

CONCLUSIONS

Pregnancy is an opportunity to detect kidney disease. FSGS is more common in women who have been pregnant than in controls, and disease identified in pregnancy or within 1 year postpartum is more likely to show a subsequent decline in renal function. Further work is required to determine whether pregnancy initiates, exacerbates, or reveals renal disease.

Maternal and fetal outcome in women with gestational hypertension in comparison to gestational proteinuria: A 3-year observational study

OBJECTIVE

To assess the maternal and fetal outcome in women with gestational hypertension in comparison to gestational proteinuria.

METHODS

This was a prospective 3-year observational study carried out at Menoufia University Hospital and included 106 patients with gestational hypertension and 124 patients with gestational proteinuria after 20 weeks' gestation. Enrolled patients were followed to assess the maternal and fetal outcome. Data were collected and tabulated.

RESULTS

There was a highly significant difference between the two groups regarding the development of preeclampsia (PE) and persistence of the condition after the end of the puerperium (p < 0.001) with more women progressed to PE and lower number suffered persistence of the disorder in the gestational hypertension group. There was no significant difference between the two groups regarding other maternal complications (p > 0.05). There was a significant difference between the two groups regarding preterm delivery, admission to NICU, and neonatal mortality (p < 0.05) which were higher in the gestational proteinuria group. There was no significant difference between the two groups regarding other fetal and neonatal complications (p > 0.05).

CONCLUSIONS

Although gestational hypertension progressed more frequently to PE than gestational proteinuria, poorer fetal outcome was more encountered in women with gestational proteinuria. Larger studies are warranted to confirm these findings.

Isolated proteinuria is a risk factor for pre-eclampsia: a retrospective analysis of the maternal and neonatal outcomes in women presenting with isolated gestational proteinuria

OBJECTIVE

To examine maternal and neonatal outcomes of isolated proteinuria and define maternal characteristics for progression to pre-eclampsia.

STUDY DESIGN

Retrospective cohort study. Data from all hospitalized pregnant women between 2009 and 2014 with new onset isolated proteinuria of over 300 mg/24 h at admission were obtained. Follow-up was performed from the time of admission to the hospital to the time of discharge postpartum. Obstetrical, maternal and neonatal outcomes were obtained.

RESULT

Ninety-five pregnant women diagnosed with new onset isolated proteinuria were followed to term. Thirteen women developed pre-eclampsia during pregnancy and eight developed pre-eclampsia postpartum. Maternal characteristics for progression to pre-eclampsia were greater maximal values of proteinuria. Earlier pre-eclampsia onset was associated with early-onset proteinuria and multiple gestation. Although greater values of proteinuria were associated with increased risk for intrauterine growth restriction and lower Apgar scores, maternal outcome was favorable, regardless of pre-eclampsia progression. Isolated proteinuria progressing to pre-eclampsia was associated with late pre-eclampsia onset and favorable maternal and neonatal outcomes.

CONCLUSION

A significant proportion of women with new onset isolated proteinuria will develop pre-eclampsia. In these women, close follow-up is recommended until after delivery.

Balance of antiangiogenic and angiogenic factors in the context of the etiology of preeclampsia

The "two-stage disorder" theory that is assumed for the etiology of preeclampsia hypothesizes that antiangiogenic and angiogenic factors and/or placental debris play an important role in this disorder. The physiological actions of placental debris occur via the balance between antiangiogenic and angiogenic factors. Accordingly, this balance between antiangiogenic and angiogenic factors should be investigated to elucidate the various pathological features of preeclampsia. Their accurate evaluation is needed to investigate not only antiangiogenic factors (such as sFlt-1 and sEng) and angiogenic factors (such as vascular endothelial growth factor, placental growth factor and transforming growth factor-β) but also the expression level of their receptors such as Flt-1 and Eng. However, it is ethically and technically difficult to investigate the above-mentioned factors at antepartum in human patients. The examination of the ratios of sFlt-1/vascular endothelial growth factor receptor ligands and sEng/transforming vascular endothelial growth factor-β and the use of experimental animal models may help in elucidating various unresolved issues in preeclampsia.

Predictive value of 3+ spot urinary protein value measured by dipstick in hypertensive pregnant patients

OBJECTIVE

To evaluate whether the spot urinary protein (SUP) level has predictive value on pregnancy outcomes in hypertensive pregnant patients.

METHODS

Retrospective case-control study of 109 pregnant patients with hypertension and spot urinary proteinuria measured by dipstick.

RESULTS

Presence of 24 h proteinuria was higher in patients with 3+ SUP. Gestational age at delivery was significantly lower in patients with 3+ SUP when compared with patients with ≤2+ SUP (p = 0.009). Rate of SGA babies was higher in patients with 3+ SUP when compared with patients with ≤2+ SUP (p < 0.001).

CONCLUSION

Although it cannot replace 24 h urinary protein determination, 3+ proteinuria with dipstick may have a prognostic value, particularly in emergency cases.

Chronic kidney disease in pregnancy

Parturients with renal insufficiency or failure present a significant challenge for the anesthesiologist. Impaired renal function compromises fertility and increases both maternal and fetal morbidity and mortality. Close communication amongst medical specialists, including nephrologists, obstetricians, neonatologists and anesthesiologists is required to ensure the safety of mother and child. Pre-existing diseases should be optimized and close surveillance of maternal and fetal condition is required. Kidney function may deteriorate during pregnancy, necessitating early intervention. The goal is to maintain hemodynamic and physiologic stability while the demands of the pregnancy change. Drugs that may adversely affect the fetus, are nephrotoxic or are dependent on renal elimination should be avoided.

Kidney biopsy in pregnancy: evidence for counselling? A systematic narrative review

BACKGROUND

Kidney diseases, which have a prevalence of 3% in women of childbearing age, are increasingly encountered in pregnancy. Glomerulonephritis may develop or flare up in pregnancy, and a differential diagnosis with pre-eclampsia may be impossible on clinical grounds. Use of kidney biopsy is controversial, but a systematic review has not been carried out to date.

OBJECTIVES

To review the literature on kidney biopsy in pregnancy, with a focus on indications, risks and timing.

SEARCH STRATEGY

Medline, Embase, CHINAL and the Cochrane Library were searched in September 2012, with 'pregnancy' and 'kidney biopsy' used as MESH and free terms, for the period 1980-2012. Results were filtered for 'human' if this option was available.

SELECTION CRITERIA

Biopsies during pregnancy and within 2 months after delivery. Case reports (fewer than five cases) and kidney grafts were excluded. Paper selection was performed in duplicate.

DATA COLLECTION AND ANALYSIS

Data were extracted in duplicate. The high heterogeneity in study design necessitated that the review be narrative, except for data on adverse events, which were analysed with regard to the timing of kidney biopsy.

MAIN RESULTS

Of 949 references, 39 were selected, providing data on 243 biopsies in pregnancy and 1236 after delivery (timing was unclear in 106 women). The main aims of the studies were to define morphology in pre-eclampsia (23 studies), to carry out a risk-benefit analysis of kidney biopsy (11 studies), and to investigate pregnancy-related acute kidney injury (five studies). Four cases of major bleeding complications occurred at 23-26 weeks of gestation. Relevant complications were observed in 7% of women during pregnancy and 1% after delivery (P = 0.001). Kidney biopsy performed for the diagnosis of glomerulonephritis or pre-eclampsia led to therapeutic changes in 66% of cases.

AUTHORS' CONCLUSIONS

The evidence on kidney biopsy in pregnancy is heterogeneous, but a significantly higher risk of complications (relative to postpartum biopsy) was found, with a possible peak at around 25 gestational weeks.

Pregnancy outcome in women with chronic kidney disease: a prospective cohort study

OBJECTIVE

To evaluate pregnancy outcome in women with chronic kidney disease (CKD) or proteinuria in early pregnancy with concomitant risk for preeclampsia (PE).

METHODS

Thirty-six women with CKD (Cr > 100 μmol/L at booking or Cr > 125 μmol/L prepregnancy or proteinuria ≥ 500 mg/24 hours at booking) and 30 women with proteinuria (≥2+) and known clinical risk for PE were enrolled at 14(+0) to 21(+6) weeks. Pregnancy outcomes were assessed.

RESULTS

Women with mild CKD (prepregnancy Cr < 125 µmol/Cr > 100 µmol at booking; n = 22) had high rates of preeclampsia (40%), preterm delivery (<37 weeks' gestation; 54%), SGA infants (<10th adjusted centile; 64%)and perinatal death (5%). Women with moderate/severe CKD (prepregnancy creatinine > 125 µmol; n = 14) had poor perinatal outcomes: preterm delivery (86%) and perinatal death (14%). Women with proteinuria (≥2+) and concomitant risk of PE also had high rates of pre-eclampsia (60%), preterm delivery (40%), and SGA infants (27%).

CONCLUSIONS

Pregnancy complications for women with CKD remain high. Women with risk factors for PE with proteinuria (≥2+) at booking are also high-risk.

PROTEINURIA IN PREECLAMPSIA: FROM BENCH TO BEDSIDE

Pre-eclampsia (PE) remains the leading cause of maternal and fetal mortality in the developed world and parts of the developing world. Morbidity and mortality from PE is increased in the developing world compared to the developed world, as availability and access to antenatal care and pathology services are limited.

Circulating angiogenic factors in gestational proteinuria without hypertension

OBJECTIVE

Our goal was to determine whether obstetric outcomes and serum angiogenic factors are altered in women with gestational proteinuria without hypertension.

STUDY DESIGN

We performed a nested case-control study of 108 women with gestational proteinuria and compared them with 1564 randomly selected women with normotension without proteinuria during pregnancy (control subjects) and with 319 women who experienced preeclampsia.

RESULTS

Women with gestational proteinuria had greater body-mass index and higher blood pressure at study enrollment. Adverse obstetric outcomes were infrequent. Levels of free placental growth factor were lower than control levels beginning early in gestation. Compared with gestational-age matched control subjects, free placental growth factor was reduced beginning 6-8 weeks before proteinuria. Although soluble fms-like tyrosine kinase 1 and soluble endoglin concentrations were elevated 1-2 weeks before proteinuria, these elevations were modest and transient. After the onset of proteinuria, angiogenic factor levels generally did not differ significantly from control levels.

CONCLUSION

Gestational proteinuria in healthy nulliparous women appears to be a mild variant of preeclampsia.

The clinical content of preconception care: women with chronic medical conditions

This article reviews the medical conditions that are associated with adverse pregnancy outcomes for women and their offspring. We also present the degree to which specific preconception interventions and treatments can impact the effects of the condition on birth outcomes. Because avoiding, delaying, or achieving optimal timing of a pregnancy is often an important component of the preconception care of women with medical conditions, contraceptive considerations particular to the medical conditions are also presented.

Prediction and perinatal outcomes of fetal growth restriction

Assessment of fetal growth and wellbeing is one of the major purposes of antenatal care. Some fetuses have smaller than expected growth in utero and while some of these fetuses are constitutionally small, others have failed to meet their growth potential, that is they are growth restricted. While severe growth restriction is uncommon, the consequences of it being undetected may include perinatal death or severe morbidity. It is, therefore, important to have strategies in place to detect the fetus at risk of growth restriction. These would include an assessment of 'prior risk' from maternal history and examination combined with the results of biochemical and ultrasound investigations, the most promising of which are uterine artery Doppler and biochemistry. We discuss some of the factors to consider when stratifying the obstetric population into degrees of likelihood for growth restriction, and discuss aspects of the management and outcome of pregnancies complicated by growth restriction.

Fetal growth restriction and subsequent pregnancy risks

Fetal growth restriction can result from a variety of intrinsic or extrinsic insults, resulting from maternal, fetal, and placental factors. Determining the underlying cause of poor fetal growth can be difficult but is essential for assessing potential risks for future pregnancies. Importantly, recurrence risks greatly depend on these underlying conditions. Understanding these risks can allow more appropriate patient counseling and may influence management strategies to optimize future pregnancies.

Outcome of infants born to women with chronic kidney disease

Pregnancy in women with chronic kidney disease is not uncommon and is not without risk to the mother and child. This article reviews the literature on the outcome of infants from pregnancies in women with chronic kidney disease (CKD), including those receiving dialysis and those living with a functional kidney transplant. Pregnancy in women with CKD and end-stage renal disease (ESRD) is associated with a higher rate of premature birth and small-for-gestational-age (SGA) infants, with resultant increase in neonatal mortality. Although congenital anomalies or long-term developmental issues do not appear to be a significant risk, these areas deserve further study, especially as newer immunosuppressive medications are employed in kidney transplant recipients.

Chronic Renal Disease in Pregnancy

The purpose of this review was to examine the impact of varying degrees of renal insufficiency on pregnancy outcome in women with chronic renal disease. Our search of the literature did not reveal any randomized clinical trials or meta-analyses. The available information is derived from opinion, reviews, retrospective series, and limited observational series. It appears that chronic renal disease in pregnancy is uncommon, occurring in 0.03-0.12% of all pregnancies from two U.S. population-based and registry studies. Maternal complications associated with chronic renal disease include preeclampsia, worsening renal function, preterm delivery, anemia, chronic hypertension, and cesarean delivery. The live birth rate in women with chronic renal disease ranges between 64% and 98% depending on the severity of renal insufficiency and presence of hypertension. Significant proteinuria may be an indicator of underlying renal insufficiency. Management of pregnant women with underlying renal disease should ideally entail a multidisciplinary approach at a tertiary center and include a maternal-fetal medicine specialist and a nephrologist. Such women should receive counseling regarding the pregnancy outcomes in association with maternal chronic renal disease and the effect of pregnancy on renal function, especially within the ensuing 5 years postpartum. These women will require frequent visits and monitoring of renal function during pregnancy. Women whose renal disease is further complicated by hypertension should be counseled regarding the increased risk of adverse outcome and need for blood pressure control. Some antihypertensives, especially angiotensin-converting enzyme inhibitors and angiotensin-receptor blockers, should be avoided during pregnancy, if possible, because of the potential for both teratogenic (hypocalvaria) and fetal effects (renal failure, oliguria, and demise).

Proteinuria in pre-eclampsia: how much matters?

OBJECTIVE

To determine, in women with proteinuric pre-eclampsia, whether a discriminant value of proteinuria at the time of diagnosis predicts the presence or absence of subsequent adverse maternal and fetal outcomes.

DESIGN

Retrospective cohort study.

SETTING

One teaching hospital and two primary referral hospitals in Sydney, Australia.

SAMPLE

Three hundred and twenty-one pregnant women with proteinuric pre-eclampsia, managed according to a uniform management protocol.

METHODS

All women with the diagnosis of proteinuric pre-eclampsia in the years 1998-2001 were studied. After exclusion of women with pre-eclampsia superimposed on pre-existing hypertension, a twin pair, unavailable spot urine results, 353 women were analysed using logistic regression to determine separately the predictors of any adverse maternal or fetal outcomes at the time of delivery. Receiver operating characteristic (ROC) curves, sensitivity and specificity were then calculated from the data.

MAIN OUTCOME MEASURES

Adverse maternal outcomes: severe maternal hypertension (BP > or = 170/110 mmHg), renal insufficiency, liver disease, cerebral irritation, haematological disturbances. Adverse fetal outcomes: small for gestational age, perinatal mortality.

RESULTS

There were 108 (34%) adverse maternal outcomes and 60 (19%) adverse fetal outcomes including two stillbirths. In multivariate analysis, an adverse maternal outcome was significantly associated with higher spot urine protein/creatinine ratio at diagnosis (P < 0.0001) with an odds ratio (OR) of 1.003 per mg/mmol (95% confidence interval [CI] 1.002-1.004) and with older maternal age (P= 0.014) with OR 1.06 per year (95% CI 1.01-1.11). An increased risk of adverse fetal outcome was associated with higher spot urine protein/creatinine (P= 0.013; OR 1.44 per log [mg/mmol], 95% CI 1.08-1.92), gestation at diagnosis <34 weeks (P < 0.0001; OR 3.60, 95% CI 1.90-6.82) and early pregnancy systolic blood pressure < or =115 mmHg (P= 0.0002; OR 3.41, 95% CI 1.77-6.57). The area under the receiver operating characteristic (ROC) curve was 0.67 for adverse maternal outcomes and 0.72 for adverse fetal outcomes.

CONCLUSIONS

With increasing proteinuria, there is increased risk of adverse maternal and fetal outcomes. Although we did not identify a specific spot protein/creatinine ratio that could be used as a definitive screening value for adverse outcomes, it is possible to utilise data from this study to predict the likelihood of adverse maternal and fetal outcomes. A high spot urine protein/creatinine ratio in pre-eclamptic women of greater than 900 mg/mmol ( approximately 9 g/day), or greater than 500 mg/mmol (approximately 5 g/day) in women over 35 years, is associated with a greatly increased likelihood of adverse maternal outcomes.

Role of diltiazem in pregnant women with chronic renal disease

OBJECTIVE

To determine whether diltiazem therapy decreases proteinuria during pregnancy in women with chronic renal disease, resulting in decreased risk of pre-eclampsia, preterm delivery and intrauterine fetal growth restriction.

METHODS

We undertook retrospective data collection by chart review of pregnant women with chronic renal disease. Women treated with and without diltiazem were compared by independent t test analysis.

RESULTS

Seven women were eligible for inclusion in the study. Individual patient trends revealed decreased or attenuated increase in proteinuria across gestation with diltiazem therapy. Mean arterial pressure was also decreased in the therapy group compared to increased pressure in the third trimester in the group with no therapy. The incidence of fetal growth restriction and need for labor induction were lower in the diltiazem-treated group.

CONCLUSIONS

Diltiazem, a non-dihydropyridine calcium channel antagonist, decreases proteinuria and preserves renal structure and function and should be considered an alternative to angiotensin converting enzyme inhibitors in pregnancy in women with chronic renal disease.

Urinary protein/creatinine ratio in hypertensive pregnant women

OBJECTIVES

To determine the correlation between the protein/creatinine ratio and 24-h proteinuria; to estimate the sensitivity and specificity of this ratio for the diagnosis of significant proteinuria; to establish its cutoff point with the best predictive value for the diagnosis of significant proteinuria in patients with systemic arterial hypertension.

STUDY DESIGN

A cross-sectional study of 47 hypertensive patients who had been pregnant for 20 weeks or more seen at the Maternity of the University Hospital of Porto Alegre. The studied factor was the protein/creatinine ratio measured in a single random urine sample and the outcome was protein determination in 24-h urine. The level of significance was set at 0.05.

RESULTS

The correlation coefficient between the protein/creatinine ratio and 24-h proteinuria was 0.94 when urine was properly collected. A receiver-operator characteristic curve was constructed to determine the sensitivity and specificity of the ratio for the diagnosis of significant proteinuria (> or = 300 mg in 24 h). Specificity and predictive positive value were 100% for a ratio > or = 0.8. The best values for sensitivity, specificity, positive predictive value, and negative predictive value in the diagnosis of proteinuria > or = 300 mg in 24 h were obtained when the protein/creatinine ratio was 0.5 (0.96, 0.96, 0.96, and 0.96, respectively).

CONCLUSION

The protein/creatinine ratio measured in a single urine sample taken at random from hypertensive pregnant women showed good sensitivity and specificity for the diagnosis of 24-h proteinuria > or = 300 mg and was strongly correlated with 24-h proteinuria. A ratio of 0.5 mg/mg is predictive of significant proteinuria and can be used for the diagnosis and follow-up of hypertensive pregnant women.

Etiologies of fetal growth restriction

We have presented here are a long list of conditions associated with an increased incidence of fetal growth restriction. Missing from much of the literature on FGR are data that would allow more informed counseling of patients in terms of predicting their risk of carrying a pregnancy complicated by FGR. For example, very little has been published on the chances of having an infant with FGR in a woman suffering from SLE or chronic hypertension. Future studies of FGR should address these issues so that clinicians may counsel their patients properly.

Factors associated with preterm birth in Cardiff, Wales. I. Univariable and multivariable analysis

OBJECTIVE

Our purpose was to examine the associations of demographic, social, and medical factors with risk of preterm birth.

STUDY DESIGN

By use of the Cardiff Births Survey, a large database of largely homogeneous (white) births in Wales, multivariable analysis by logistic regression examined the relative importance of risk variables associated with preterm birth.

RESULTS

Significant independent associations with preterm birth were found (in decreasing order of magnitude) for late pregnancy bleeding, preeclampsia-proteinuria, low maternal weight, low maternal age, early pregnancy bleeding, history of previous stillbirth, smoking, high parity, low or high hemoglobin concentration, history of previous abortion, low social class, bacteriuria, and nulliparity.

CONCLUSION

In this population demographic, social, and medical characteristics of the pregnancies showed significant associations with preterm birth.

The value of routine urine dipstick screening for protein at each prenatal visit

OBJECTIVE

Our purpose was to determine whether dipstick urinalysis for protein, when performed as a routine screening test at each prenatal visit, predicts subsequent gestational outcome.

STUDY DESIGN

All 3217 low-risk obstetric patients had dipstick urinalysis for protein at each prenatal visit. When there were any objective findings of a possible hypertensive disorder, the urine protein test for that visit was considered an indicated diagnostic test. Otherwise it was considered a routine screening test. Subjects were grouped according to whether those urine tests considered routine screening tests were positive for protein. The groups were then compared with regard to relevant pregnancy outcomes.

RESULTS

There were no significant differences in the measured pregnancy outcomes between the groups.

CONCLUSIONS

In low-risk women with no objective signs of a possible hypertensive disorder, routine dipstick proteinuria screening at each prenatal visit did not provide any clinically important information regarding pregnancy outcome.

The epidemiology of perinatal death in Jamaica

Information from the Jamaican Perinatal Mortality Survey was used to identify features of mothers and their pregnancies that were independently associated with perinatal death. Social, biological, environmental, life style and medical aspects of mothers and their pregnancies were collected on two inter-locking subsamples: (1) all births on the island of Jamaica in the 2 months of September and October 1986, the 'cohort months', and (2) all fetal deaths of weight 500 g or more, together with all neonatal deaths, in the 12-month period from 1 September 1986 to 31 August 1987. Singleton survivors from the cohort months were compared with all perinatal deaths in the 12-month period using logistic regression. The first model omitted items concerning past obstetric history, but these were included in the second model. In total, 21 variables entered the first model and 24 the second. The only item that became non-significant when past obstetric history was included was maternal age. The final model compared 1017 perinatal deaths with 7672 survivors. It consisted of the following: union (marital) status (married being at lower risk, P < 0.01), maternal employment status (housewives at lowest risk, P < 0.001), number of adults in household (the more the higher the risk, P < 0.05), the number of children aged < 11 (the more the lower the risk, P < 0.0001), use of toilet facilities (shared with other households increased risk, P < 0.001), maternal height (tall women at reduced risk, P < 0.001), mother's report that she was trying to get pregnant (P < 0.001), maternal alcohol consumption (drinkers had lower risk, P < 0.05), maternal syphilis (higher risk, P < 0.0001), bleeding before 28 weeks (higher risk, P < 0.0001), bleeding at 28 weeks or more (higher risk, P < 0.0001), first diastolic blood pressure (80 mm + at higher risk, P < 0.0001), highest diastolic blood pressure (100 mm + at increased risk, P < 0.0001), highest proteinuria (++ or more at increased risk, P < 0.0001), vaginal discharge/infection (untreated at increased risk, P < 0.001), pre-eclampsia diagnosed in antenatal period (increased risk, P < 0.01), maternal diabetes (increased risk, P < 0.05), start of antenatal care (first trimester at reduced risk, P < 0.01), iron taken (reduced risk, P < 0.0001), type of perinatal care available in parish of residence (reduced risk if consultant obstetricians and paediatricians available at all times, P < 0.0001), number of miscarriages and terminations (the more the higher the risk, P < 0.0001), previous stillbirth (higher risk, P < 0.0001), previous early neonatal death (higher risk, P < 0.001), previous Caesarean section (higher risk, P < 0.01). The implications for reduction in perinatal mortality rates are discussed.