The West Midlands "Severe Hypertensive Illness in Pregnancy" (SHIP) audit

Criteria-based audit of quality of care to women with severe pre-eclampsia and eclampsia in a referral hospital in Accra, Ghana

OBJECTIVES

Severe pre-eclampsia and eclampsia are one of the major causes of maternal mortality globally. Reducing maternal morbidity and mortality demands optimizing quality of care. Criteria-based audits are a tool to define, assess and improve quality of care. The aim of this study was to determine applicability of a criteria-based audit to assess quality of care delivered to women with severe hypertensive disorders in pregnancy, and to assess adherence to protocols and quality of care provided at a regional hospital in Accra, Ghana.

METHODS

Checklists for management of severe preeclampsia, hypertensive emergency and eclampsia were developed in an audit cycle based on nine existing key clinical care protocols. Fifty cases were audited to assess quality of care, defined as adherence to protocols. Analysis was stratified for complicated cases, defined as (imminent) eclampsia, perinatal mortality and/or one or more WHO maternal near miss C-criteria.

RESULTS

Mean adherence to the nine protocols ranged from 15-85%. Protocols for 'plan for delivery' and 'magnesium sulphate administration' were best adhered to (85%), followed by adherence to protocols for 'eclampsia' (64%), 'severe pre-eclampsia at admission' (60%), 'severe pre-eclampsia ward follow-up' (53%) and 'hypertensive emergency' (53%). Protocols for monitoring were least adhered to (15%). No difference was observed for severe disease. Increased awareness, protocol-based training of staff, and clear task assignment were identified as contributors to better adherence.

CONCLUSION

A criteria-based audit is an effective tool to determine quality of care, identify gaps in standard of care, and allow for monitoring and evaluation in a health facility, ultimately resulting in improved quality of care provided and reduced maternal morbidity and mortality. In our audit, good adherence was observed for plan for delivery and treatment with magnesium sulphate. Substandard adherence to a number of protocols was identified, and points towards opportunities for targeted improvement strategies.

Maternal outcomes of hypertensive disorders in pregnancy at Korle Bu Teaching Hospital, Ghana

OBJECTIVE

To determine maternal outcomes of hypertensive disorders in pregnancy at Korle Bu Teaching Hospital (KBTH) in Accra, Ghana.

METHODS

A cross-sectional study was conducted between January 1 and February 28, 2013. All women delivering at KBTH whose pregnancies were complicated by hypertensive disorders were identified. A structured questionnaire was administered, and the women were followed up on a daily basis until discharge from hospital. Medical records were also reviewed to identify any complications of hypertensive disorders.

RESULTS

A total of 368 women were analyzed. Of 10 maternal deaths, 3 (30.0%) were due to hypertensive disorders in pregnancy, and specifically pre-eclampsia. Overall, 168 (45.7%) women with hypertensive disorders in pregnancy delivered by cesarean, 16 (4.3%) had placental abruption, 11 (3.0%) had pulmonary edema, 3 (0.8%) had HELLP syndrome, 2 (0.5%) had acute renal failure, 3 (0.8%) had an intracerebral hemorrhage or cerebrovascular accident, 21 (5.7%) were admitted to the intensive care unit, 7 (1.9%) had disseminated intravascular coagulation, and 58 (15.8%) had eclampsia. Cesarean delivery, admission to intensive care unit, and eclampsia were significantly more common in women with pre-eclampsia than in those with other hypertensive disorders.

CONCLUSION

Hypertensive disorders in pregnancy are associated with high incidences of adverse maternal outcomes in Ghana, with significantly increased frequencies in women with pre-eclampsia.

Hydralazine vs labetalol for the treatment of severe hypertensive disorders of pregnancy. A randomized, controlled trial

Hydralazine and labetalol for intravenous use are equally effective in the management of hypertensive crisis in pregnant patients (24weeks or more) with severe hypertensive disorders of pregnancy, showing a similar frequency of adverse effects in both groups.

The Effect of Glyceryl Trinitrate on Hypertension in Women with Severe Preeclampsia, HELLP Syndrome, and Eclampsia

OBJECTIVE

The goal of this study is to evaluate the effect of glyceryl trinitrate (GTN) in the management of hypertension in women with preeclampsia, eclampsia, and HELLP syndrome.

STUDY DESIGN

Fifty five women with preeclampsia, eclampsia, and HELLP syndrome administered GTN infusion for the management of hypertension were studied. Demographic, clinical, and perinatal outcome findings were collected for analyses. We recorded initial and maintenance doses of GTN, and duration of its use in prepartum and postpartum periods. We collected systolic and diastolic blood pressures (BPs) at admission and before the administration of GTN infusion. During the GTN infusion, we calculated average diastolic and systolic blood pressures 6 hours apart on the first day, 12 hours apart on the second day, and 24 hours apart on the third day.

RESULTS

Of 55 women, 24 with severe preeclampsia, 16 with HELLP syndrome, and 15 with eclampsia were included in this study. In severe preeclampsia group, GTN infusion significantly reduced systolic and diastolic BPs beginning from the second quarter and third quarter, respectively, of first day (p < 0.05). In the HELLP syndrome group, GTN infusion significantly decreased systolic and diastolic blood pressures beginning from the third quarter and second quarter, respectively, of the first day (p < 0.05). In the eclampsia group, GTN infusion significantly reduced systolic and diastolic blood pressures beginning from the third quarter and first quarter, respectively, of the first day (p < 0.05).

CONCLUSION

In women with severe preeclampsia, eclampsia, and HELLP syndrome, infusion of GTN can be used as an alternative agent to well-known drugs and causes no significant adverse effect to the mother and fetus.

The Incidence of Severe Complications of Preeclampsia

OBJECTIVES

To examine the incidence of life-threatening (near-miss) complications, including hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome occurring in women with preeclampsia in the Grampian region of Scotland between 1981 and 2000.

SUBJECTS AND METHODS

All women who were resident in a geographically determined region (the Grampian region of Scotland) and who developed moderate to severe preeclampsia in the time period 1981 to 2000 were identified from the Aberdeen Maternity and Neonatal Databank. All complications occurring antepartum, intrapartum, or postpartum in these pregnancies were listed as International Classification of Diseases (ICD) codes and significant complications were identified from these. The cases of HELLP syndrome were identified by case note review. Data were analyzed using Statistical Package for Social Scientists (SPSS).

RESULTS

A total of 4188 cases of preeclampsia were identified over the 20-year period. Six percent (approx. 1 in 16) of preeclamptics developed one or more major systemic complications. The incidence of placental abruption and eclampsia was 2.8% and 1.65%, respectively. Hematological complications were most common, with reduced platelets accounting for about half of these cases; although, a definite diagnosis of HELLP syndrome could only be made in 13 cases over 20 years. After adjusting for gestational age, a woman was 1.14 times more likely to have a caesarean delivery (95% C.I. 1.08, 1.20) if she had complicated preeclampsia. She was also more likely to have a stillbirth [Odds Ratio (O.R.) = 1.45 (95% C.I. (confidence interval) 1.02, 2.29)] or a neonatal death [O.R. = 2.25 (95% C.I. 1.12, 4.260].

CONCLUSIONS

There has been a gradual decline in the rate of preeclampsia in the Grampian region of Scotland over the time period 1986 to 2000; although, the percentage of pre-eclamptics who developed one or more complications has not decreased appreciably. In fact, the incidence of eclampsia and placental abruption has increased in the most recent five years. The presence of complications in preeclampsia is associated with a poor neonatal outcome.

Morbidity and mortality associated with pre-eclampsia at two tertiary care hospitals in Sri Lanka

AIM

To report the occurrence of morbidity and mortality associated with carefully phenotyped pre-eclampsia in a sample of nulliparous Sinhalese women with strictly defined disease.

METHODS

A phenotyping database of 180 nulliparous women with pre-eclampsia and 180 nulliparous normotensive pregnant women who were recruited for a study into genetics of pre-eclampsia was analyzed.

RESULTS

Women who developed pre-eclampsia had significantly higher systolic blood pressure (SBP; P = 0.002) and diastolic blood pressure (DBP; P = 0.002) at booking (at approximately 13 weeks of gestation). 38.3%, 28.3% and 33.3% of women delivered at <34 weeks, at 34-36 weeks, and at term, respectively. 78% required a cesarean section. Complications included SBP > or = 160 mmHg (75.5%); DBP > or = 110 mmHg (83.8%); proteinuria > or =3 + (150 mg/dL) in the urine protein heat coagulation test (87%); renal failure requiring dialysis (2%); platelet counts <100 x 10(9)/L (13%); > or =70 U/L in aspartate and/or alanine aminotransaminase (15%); placental abruption (4%); eclampsia (9%); and one maternal death. Maternal complications indicative of severe disease, apart from the incidence of SBP > or = 160 mmHg and DBP > or = 110 mmHg, were not significantly different in early and late-onset pre-eclampsia; fetal outcome was better with late-onset disease. 48% of babies were small for gestational age. Only 80 of 135 babies of women with pre-eclampsia whose condition could be confirmed at 6 weeks post-partum were alive.

CONCLUSIONS

Pre-eclampsia in Sinhalese women is associated with severe maternal morbidity and fetal morbidity and mortality, suggesting that modification of the Western diagnostic criteria and/or guidelines for medical care may be necessary. There is an urgent need to improve neonatal intensive care services in Sri Lanka.

Synergism between beta 2-adrenoceptor agonists and subtype-selective alpha 1A-adrenoceptor antagonists in the tocolytic effect on pregnant rat uterus in vitro

1. Despite great efforts in recent decades, premature birth is still a leading cause of perinatal morbidity and mortality. beta2-Adrenoceptor agonists are frequently used as tocolytics, although their use is rather controversial. Previous animal studies have revealed that blockade of alpha1A-adrenoceptors results in relaxation of the pregnant rat myometrium. 2. The aim of the present study was to investigate the uterus relaxant effect of the beta2-adrenoceptor agonists (terbutaline, ritodrin) applied together with the subtype-selective alpha1A-adrenoceptor antagonists (WB 4101, 5-methylurapidil) in an in vitro rat model. The main objective of the experiments was to clarify whether there was an additive or a potentiating synergism between the two drug classes. 3. Myometrial rings were taken from female, 22-day pregnant (end-term) Sprague-Dawley rats. Electrical field stimulation (EFS) was used to elicit rhythmical contractions. Non-cumulative concentration-response curves were constructed to the beta2-adrenoceptor agonists and the alpha1A-adrenoceptor antagonists alone and to beta2-adrenoceptor agonists co-administered with the alpha1A-adrenoceptor antagonists. 4. Both groups of drugs inhibited EFS-induced contractions in a dose-dependent way. Administering the beta2-adrenoceptor agonists in combination with the alpha1A-adrenoceptor antagonists resulted in a significant decrease in the EC50 and an increase in the maximal contraction inhibiting effect. 5. The potentiating synergism that has been revealed between beta2-adrenoceptor agonists and alpha1A-adrenoceptor antagonists in the uterus relaxant effect may be of great clinical importance because it could improve the efficacy of therapy of preterm delivery.