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Tlaye KG, Endalifer ML, Getu MA, Nigatu AG, Kebede ET. A five-year trend in pre-eclampsia admission and factors associated with inpatient eclampsia: a retrospective study from a resource-limited hospital in northeast Ethiopia. BMJ Open 2021; 11:e040594. [PMID: 33550234 PMCID: PMC7925853 DOI: 10.1136/bmjopen-2020-040594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE To investigate the 5-year trend of pre-eclampsia admission, magnitude and factor associated with inpatient eclampsia among deliveries involving pre-eclampsia which have been attended at one of the resource-limited public hospitals in northeast Ethiopia. DESIGN Retrospective medical record review study. SETTING Woldia General Hospital Medical archive, Woldia town, Ethiopia. PARTICIPANTS All antenatal admission and deliveries involving pre-eclampsia attended from 2011 to 2016 at the hospital were included in the review. PRIMARY AND SECONDARY OUTCOME MEASURES Trend of pre-eclampsia admission was determined using non-parametric Mann-Kendall correlation. Case management, clinical and patient-related factors were tested for possible association with the development of inpatient eclampsia using binary logistic regression. P value less than 0.05 considered significant. RESULT Across the 5-year period, there were 8764 deliveries attended at the hospital's labour and delivery ward, of them 241 (2.76%) were co-diagnosed with pre-eclampsia. The trend showed marginal decrement through years (tau-b correlation coefficient (Tb)=-0.4, p=0.035) with the highest caseload (4.4%) observed on year 2013/2014. The rate of inpatient eclampsia was 19.6 per 10 000 births and the likelihood of its occurrence among pre-eclamptic women was 7.1% (95% CI 2.7% to 11.5%). In multivariate analysis, being multigravida (adjusted OR (AOR) 0.154, 95% CI 0.029 to 0.831) and spontaneous onset of labour (AOR 5.628, 95% CI 1.1247 to 9.401) were associated with inpatient eclampsia. CONCLUSION In the study setting, the overall magnitude of pre-eclampsia admission was comparable with the global average, but its yearly trend showed marginal decrement from 2011 to 2016. High rate of inpatient eclampsia might indicate undertreatment which alarms further study and/or corrective measures. Waiting for spontaneous onset of labour could increase the risk of developing inpatient eclampsia whereas neither type of anticonvulsant nor duration of its usage has made significant association.
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Affiliation(s)
- Kenean Getaneh Tlaye
- Department of Nursing, College of Health Science, Woldia University, Woldia, Ethiopia
| | | | - Mikiyas Amare Getu
- Department of Nursing, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Addisu Getie Nigatu
- Department of Nursing, College of Health Science, Woldia University, Woldia, Ethiopia
| | - Eleni Tesfaye Kebede
- Department of Midwifery, College of Health Science, Selale University, Fiche, Ethiopia
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Tantillo GB, Jetté N, Yoo JY, Stone J, Egerman M, Dhamoon MS. Pregnancy-related complications and risk of postpartum readmission for seizures and epilepsy: A national study. Epilepsia 2020; 61:1990-1998. [PMID: 32785951 DOI: 10.1111/epi.16641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/23/2020] [Accepted: 07/20/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Peripartum seizures remain a leading cause of maternal morbidity and mortality worldwide. Therefore, recognition of high-risk individuals is essential. We aimed to determine the rate and identify risk factors for postpartum seizure/epilepsy readmissions. METHODS In this retrospective cohort study, the Nationwide Readmissions Database was used to identify index admissions for delivery and readmissions for seizures in the year 2013, defined by International Classification of Disease, Ninth Revision, Clinical Modification codes for epilepsy, convulsions, and eclampsia in the primary diagnostic position. Logistic regression analysis was used to examine 30-day readmission for seizures as well as associations between demographic, medical, psychiatric, and pregnancy-related factors. RESULTS There were 1 633 714 index admissions for delivery, with a 30-day readmission rate for seizures/epilepsy of 19.69 per 100 000 index admissions. The mean age of index participants was 28.6 years (SD = 5.8). Postpartum 30-day readmissions for eclampsia represented 80% of seizure/epilepsy readmissions. Higher income was associated with lower odds of seizure/epilepsy readmission (odds ratio [OR] = 0.50, 95% confidence interval [CI] = 0.34-0.72, P = .03) for the highest income group. Eclampsia (OR = 19.9, 95% CI = 9.38-42.2, P < .001), preexisting epilepsy (OR = 10.63, 95% CI = 6.43-17.56, P < .001), pre-eclampsia (OR = 3.23, 95% CI = 2.31-4.51, P < .001), and gestational hypertension (OR = 2.78, 95% CI = 1.94-3.98, P < .001) were associated with readmission for seizures. SIGNIFICANCE Readmissions for seizures are fortunately rare, but are important to minimize given morbidity and mortality. Most seizure readmissions occurring within 30 days postpartum were coded as eclampsia rather than convulsions or pre-existing epilepsy. These findings suggest that early identification of women with pre-eclampsia and eclampsia may play a role in the prevention of postpartum seizures. Women with these risk factors should be identified to optimize care and monitored closely for seizure-associated complications.
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Affiliation(s)
- Gabriela B Tantillo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nathalie Jetté
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joanne Stone
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marc Egerman
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Uludag SZ, Gokmen Karasu AF, Kutuk MS, Takmaz T. Incidence and outcomes of eclampsia: a single-center 30-year study. Hypertens Pregnancy 2019; 38:119-123. [PMID: 30880504 DOI: 10.1080/10641955.2019.1590719] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Accepted: 03/01/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We aimed to determine the incidence of eclampsia at Erciyes University Hospital which is a tertiary referral center situated at central Anatolia. Additionally, we investigated eclampsia-associated maternal and perinatal outcomes for the 30-year study period. METHODS A retrospective review was performed for all women who were diagnosed with eclampsia and admitted to the Erciyes University Medical School, Department of Obstetrics and Gynecology from January 1985 to December 2015. Improvement in management gained over time was determined by comparing the results of the years 2005-2015 with data which were already published from years 1985-1999 and 2000-2004. RESULTS Eclampsia prevalence was 289/46,928 (% 0.61). Maternal age at the time of diagnosis did not differ statistically; however, gestational age at diagnosis and birth weight decreased significantly throughout the years (p < 0.005). The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238). Maternal mortality rate also decreased throughout the years; it was 1.7% in 2005-2009 and 0 % in 2010-2015 (p = 0.246). CONCLUSION The prevalence of eclampsia cases has decreased over the years. Maternal mortality attributed to eclampsia has also declined. The early diagnosis and treatment of eclampsia have resulted in the increase of premature deliveries. The perinatal mortality rate showed a slight decrease throughout the years (p = 0.238); however, it is not at a desirable rate compared to developed countries.
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Affiliation(s)
- Semih Zeki Uludag
- a Department of Obstetrics and Gynecology , Erciyes University Medical Faculty , Kayseri , Turkey
| | - Ayse Filiz Gokmen Karasu
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
| | - Mehmet Serdar Kutuk
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
| | - Taha Takmaz
- b Department of Obstetrics and Gynecology , Bezmialem Vakif University Medical Faculty , Istanbul , Turkey
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Mahran A, Fares H, Elkhateeb R, Ibrahim M, Bahaa H, Sanad A, Gamal A, Zeeneldin M, Khalifa E, Abdelghany A. Risk factors and outcome of patients with eclampsia at a tertiary hospital in Egypt. BMC Pregnancy Childbirth 2017; 17:435. [PMID: 29272998 PMCID: PMC5741945 DOI: 10.1186/s12884-017-1619-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 12/07/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Eclampsia is a major cause of maternal and neonatal morbidity and mortality in low and middle income countries. The aim of this study was to assess the risk factors and maternal and perinatal outcome in patients with eclampsia in order to get reliable data that helps in reducing the incidence and improving the outcome in an area with high incidence of eclampsia. METHODS Retrospective study including 250 patients diagnosed with eclampsia at Minia Maternity University Hopsital, Minia, Egypt in the period between January 2013 and December 2014.We analyzed the data obtained from medical records of these patients including patient characteristics, medical, obstetric, current pregnancy history, data on hospital admission, treatment given at hospital and maternal and perinatal outcome. Statistical analysis was done using SPSS version 21. RESULTS During the study period, 21690 women gave birth in the hospital; of which 250 cases of eclampsia were diagnosed (1.2%).Four women died (case fatality rate 1.6%). The main risk factors identified were young age, nulliparity, low level of education, poor ante-natal attendance and pre-existing medical problems. The most common complication was HELLP syndrome (15.6%). Magnesium sulphate therapy was given to all patients but there was lack of parenteral anti-hypertensive therapy. Forty six cases delivered vaginally (18.4%). Assisted delivery was performed in 22 (8.8%) cases and caesarean section in 177 (70.8%) cases; 151(60.4%) primary caesarean sections and 26 (10.4%) intra-partum. Perinatal deaths occurred in 11.9% on cases. Prematurity and poor neonatal services were the main cause. CONCLUSION Morbidity and mortality from eclampsia are high in our setting. Improving ante-natal and emergency obstetric and neonatal care is mandatory to improve the outcome.
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Affiliation(s)
- Ahmad Mahran
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Hashem Fares
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Reham Elkhateeb
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mahmoud Ibrahim
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Haitham Bahaa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmad Sanad
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Alaa Gamal
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Mohamed Zeeneldin
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Eissa Khalifa
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
| | - Ahmed Abdelghany
- Department of Obstetrics and Gynecology, Faculty of Medicine, Minia University, Minia, Egypt
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Mekuria T, Abdosh A. A one year review of eclampsia in an Ethiopian Tertiary Care Center (Saint Paul's Hospital Millennium Medical College, SPHMMC). J Perinat Med 2017; 45:903-907. [PMID: 28708577 DOI: 10.1515/jpm-2017-0118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/26/2017] [Indexed: 11/15/2022]
Abstract
Eclampsia remains one of the five major causes of maternal mortality in developing countries. Advances in diagnosis and management have led to a significant reduction in maternal mortality and morbidity from this disease in developed countries. In developing countries the incidence of maternal death attributed to eclampsia remains high and, in Ethiopia, maternal mortality from this complication has instead risen over the last decade. The purpose of this study was to review the incidence of eclampsia at the largest feto-maternal center in the country over 1 year in an attempt to determine what quality improvement measures are needed and could realistically be implemented within the system to decrease this complication. There were a total of 104 eclamptic patients during the study period. The hospital incidence of eclampsia was 82/10,000 deliveries excluding those arriving to the hospital in the postpartum period (28 cases). There were eight maternal deaths making the case fatality rate one in 13 cases. The median convulsion to arrival time, referral to arrival time and magnesium sulphate administration time were found to be 3, 2 and 3 h, respectively. The probability of multiple seizures (≥3 episodes) was increased significantly with the prolongation of these time variables. Occurrence of multiple seizures was in turn significantly associated with adverse maternal outcomes (ICU admission, morbidities and mortalities). As expected, there was a high incidence of eclampsia and eclampsia related maternal death in the hospital. We recommend a thorough assessment of the referral system, upgrading and capacity building of more health facilities, organizing trainings and drills in health facilities; and availing magnesium sulphate in all health centers among others.
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Mounier-Vehier C, Amar J, Boivin JM, Denolle T, Fauvel JP, Plu-Bureau G, Tsatsaris V, Blacher J. Hypertension and pregnancy: expert consensus statement from the French Society of Hypertension, an affiliate of the French Society of Cardiology. Fundam Clin Pharmacol 2016; 31:83-103. [DOI: 10.1111/fcp.12254] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2016] [Accepted: 11/10/2016] [Indexed: 01/13/2023]
Affiliation(s)
| | - Jacques Amar
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Jean-Marc Boivin
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Thierry Denolle
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Jean-Pierre Fauvel
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
| | - Geneviève Plu-Bureau
- College of Medical Gynecology Teachers; Hôpital Port-Royal; Unité de Gynécologie médicale; 123 boulevard Port-Royal 75014 Paris France
| | - Vassilis Tsatsaris
- French National College of Gynecologists-Obstetricians; 91 Boulevard de Sébastopol 75002 Paris France
| | - Jacques Blacher
- French Society of Hypertension; 5 rue des Colonnes du Trône 75012 Paris France
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Nakimuli A, Nakubulwa S, Kakaire O, Osinde MO, Mbalinda SN, Kakande N, Nabirye RC, Kaye DK. The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: a prospective cohort study from Uganda. BMC Pregnancy Childbirth 2016; 16:205. [PMID: 27492552 PMCID: PMC4973370 DOI: 10.1186/s12884-016-1001-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Accepted: 07/30/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a major cause of morbidity and mortality. The objective was to estimate the disease burden attributable to hypertensive disorders of pregnancy in two referral hospitals in Uganda. METHODS Through a prospective cohort study conducted in Jinja and Mulago hospitals in Uganda from March 1, 2013 and February 28, 2014, hypertension-related cases were analyzed. Maternal near miss cases were defined according to the WHO criteria. Maternal deaths were also analyzed. The maternal near miss incidence ratio, the case-specific severe maternal outcome ratio, the case-specific maternal mortality ratio and the case-fatality ratio were computed. RESULTS Of 403 women with hypertensive disorders of pregnancy, 218 (54.1 %) had severe preeclampsia, 172 (42.7 %) had eclampsia, and 13 had chronic hypertension or Hemolysis, elevated liver enzymes or low platelets (HELLP) syndrome. The case-specific maternal near miss incidence ratios was 8.60 per 1,000 live births for all hypertensive disorders, 3.06 per 1,000 live births for severe preeclampsia and 5.11 per 1,000 live births for eclampsia. The case-specific severe maternal outcome ratio was 9.37 per 1,000 live births for all hypertensive disorders, and was 3.25 per 1,000 live births for severe preeclampsia and 5.61 per 1,000 live births for eclampsia. The case-specific maternal mortality ratio was 780 per 100,000 live births for all hypertensive disorders, and was 1940 per 100,000 live births for severe preeclampsia and 501 per 100,000 live births for eclampsia. The case-fatality ratio was 5.1 % overall (for all hypertensive disorders), but was 8 times higher for eclampsia compared to severe preeclampsia. Cyanosis, abnormal respiration, oliguria, circulatory collapse, coagulopathy, thrombocytopenia, and elevated serum lactate were significantly associated with severe maternal outcomes. CONCLUSION There is high morbidity attributable to hypertensive disorders in pregnancy. Since some of the complications associated with morbidity can be recognized early, it is possible to prevent severe morbidity through early intervention with delivery, antihypertensive therapy and prophylactic magnesium sulphate treatment. The findings highlight the feasibility of implementing a facility-based surveillance system for severe maternal morbidity due to hypertensive disorders.
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Affiliation(s)
- Annettee Nakimuli
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Sarah Nakubulwa
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Othman Kakaire
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | | | - Scovia Nalugo Mbalinda
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Nelson Kakande
- Clinical, Operations and Health Services Research Program, Joint Clinical Research Centre, P. O. Box 10005, Kampala, Uganda
| | - Rose Chalo Nabirye
- Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Dan Kabonge Kaye
- Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda.
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Fauvel JP. [Hypertension during pregnancy: Epidemiology, definition]. Presse Med 2016; 45:618-21. [PMID: 27476778 DOI: 10.1016/j.lpm.2016.05.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/23/2016] [Indexed: 11/30/2022] Open
Abstract
Hypertension in pregnancy has several forms that differ by their mechanisms and their consequences for mothers and fetus. Chronic hypertension is defined by SBP≥140mm Hg or DBP≥90mm Hg before pregnancy or before the 20th week of amenorrhea. Gestational hypertension is defined by SBP≥140mm Hg or DBP≥90mm Hg during or after the 20th week of amenorrhea. Preeclampsia is the occurrence of hypertension and proteinuria after 20weeks of amenorrhea. Severe preeclampsia is accompanied by clinical signs and symptoms indicating visceral pain. The HELLP syndrome is a severe preeclampsia accompanied by intravascular hemolysis and hepatic cytolysis. Eclampsia is characterized by seizures of the tonic-clonic type. A chronic hypertension is observed in 1-5% of pregnancies. Gestational hypertension without proteinuria appears in 5-6% of pregnancies. A preeclampsia develops in 1-2% of pregnancies, but much more frequently (up 34%) in the presence of risk factors. High blood pressure during pregnancy remains, by its complications, the leading cause of maternal morbidity and mortality.
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Affiliation(s)
- Jean-Pierre Fauvel
- Hôpital E.-Herriot, université C.-Bernard-Lyon 1, service de néphrologie, hypertension et dialyse, 69437 Lyon, France.
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Mounier-Vehier C, Amar J, Boivin JM, Denolle T, Fauvel JP, Plu-Bureau G, Tsatsaris V, Blacher J. Hypertension artérielle et grossesse. Consensus d’experts de la Société française d’hypertension artérielle, filiale de la Société française de cardiologie. Presse Med 2016; 45:682-99. [DOI: 10.1016/j.lpm.2016.05.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Accepted: 05/10/2016] [Indexed: 01/17/2023] Open
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Chibber R, Al-Hijji J, Amen A, Fouda M, Kaleemullah ZM, El-Saleh E, Mohammed AT. Maternal and perinatal outcome of eclampsia over a decade at a tertiary hospital in Kuwait. J Matern Fetal Neonatal Med 2015; 29:3132-7. [PMID: 26616117 DOI: 10.3109/14767058.2015.1114095] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS To determine maternal and perinatal outcome of eclampsia patients over a decade. METHODS Analysis of case records of all eclampsia cases from January 2005 to December 2014. RESULTS There were 30 cases of eclampsia. The most significant risk factors for developing pre-eclampsia are unbooked cases (97%), nulliparity, young age, marriage ≤4 months, history of pre-eclampsia in previous pregnancy, remarriage, preexisting diabetes mellitus, interval between pregnancies ≥10 years, positive family history. The incidence of eclampsia was 0.05%, antepartum eclampsia 15 (50%), intrapartum 6 (20%) and postpartum 9 (30%) with no maternal deaths, and 1 perinatal death. Perinatal mortality was 33.3/1000. 22 (73%) patients received magnesium sulphate (MgSO4) and 8 patients (27%) received Diazepam, of which 1 had recurrence of convulsions. All 15 antepartum cases were delivered by cesarean section as were 2 intrapartum. 13 (43%) of women delivered vaginally. Only 6 (20%) patients were of low socio-economic status and were primary school educated. Severe maternal complications occurred in 8 (27%), with abruptio placentae being the most common 3 (38%). CONCLUSIONS Incidence of eclampsia was low, with no maternal deaths. MgSO4 was found to be highly effective. Lack of antenatal care is a major risk factor.
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Affiliation(s)
- Rachana Chibber
- a Department of Obstetrics & Gynaecology , Faculty of Medicine, Kuwait University , Kuwait City , Kuwait and.,b Department of Obstetrics & Gynaecology , Al-Adan Hospital , Kuwait
| | - Jassim Al-Hijji
- b Department of Obstetrics & Gynaecology , Al-Adan Hospital , Kuwait
| | - Ali Amen
- b Department of Obstetrics & Gynaecology , Al-Adan Hospital , Kuwait
| | - Mohamed Fouda
- b Department of Obstetrics & Gynaecology , Al-Adan Hospital , Kuwait
| | | | - Eyad El-Saleh
- a Department of Obstetrics & Gynaecology , Faculty of Medicine, Kuwait University , Kuwait City , Kuwait and
| | - Asiya Tasneem Mohammed
- a Department of Obstetrics & Gynaecology , Faculty of Medicine, Kuwait University , Kuwait City , Kuwait and
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Ohno Y, Terauchi M, Tamakoshi K, Shiozaki A, Saito S. The risk factors for labor onset hypertension. Hypertens Res 2015; 39:260-5. [PMID: 26490090 DOI: 10.1038/hr.2015.112] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Revised: 05/28/2015] [Accepted: 08/26/2015] [Indexed: 11/09/2022]
Abstract
Our aim was to clarify the perinatal outcomes of and risk factors for hypertension that is first detected after labor onset (labor onset hypertension, LOH), which may be a risk factor for eclampsia and stroke during labor. A total of 1349 parturient women who did not exhibit preeclampsia or gestational hypertension prior to labor were examined. The patients were classified into four groups: the normotensive (n=1023) (whose systolic blood pressure (SBP) remained below 140 mm Hg throughout labor), mild LOH (n=241) (whose maximum SBP during labor ranged from 140 to 159 mm Hg), severe LOH (n=66) (whose maximum SBP during labor ranged from 160 to 179 mm Hg) and emergent LOH groups (n=19) (whose maximum SBP during labor was greater than 180 mm Hg). The perinatal outcomes and patient characteristics of the four groups were compared. Twenty-four percent of the pregnant women who remained normotensive throughout pregnancy developed hypertension during labor. One of the patients in the emergent LOH group developed eclampsia. The blood pressure at delivery and frequencies of hypotensor use, interventional delivery and low Apgar scores differed significantly among the four groups. The following risk factors for severe/emergent LOH were extracted: being over 35 years old, a body mass index at delivery of >30, an SBP at 36 weeks' gestation of 130-134 mm Hg, an SBP at admission of 130-139 mm Hg, proteinuria (a score of 2+ on the dipstick test) and severe edema. The risk factors for severe/emergent LOH were identified in this study. In high risk cases, repeatedly measuring maternal blood pressure during delivery might help detect critical hypertension early.
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Affiliation(s)
| | | | - Koji Tamakoshi
- Department of Nursing, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Arihiro Shiozaki
- Department of Obstetrics and Gynecology, Toyama University Graduate School of Medicine, Toyama, Japan
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, Toyama University Graduate School of Medicine, Toyama, Japan
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Bergman L, Akhter T, Wikström AK, Wikström J, Naessen T, Åkerud H. Plasma levels of S100B in preeclampsia and association with possible central nervous system effects. Am J Hypertens 2014; 27:1105-11. [PMID: 24610883 PMCID: PMC4125339 DOI: 10.1093/ajh/hpu020] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND S100B is supposed to be a peripheral biomarker of central nervous system (CNS) injury. The purpose of this study was to compare levels of S100B in women with preeclampsia with levels in healthy pregnant control subjects and furthermore to analyze levels of S100B in relation to possible CNS effects. METHODS A cross-sectional case–control study in antenatal care centers in Uppsala, Sweden, was performed. Fifty-three women with preeclampsia and 58 healthy pregnant women were recruited at similar gestational length; women with preeclampsia were recruited at time of diagnosis, and control subjects were recruited during their routine visit to an antenatal clinic. Plasma samples were collected, and levels of S100B were analyzed with an enzyme-linked immunosorbent assay. Information about demographic and clinical characteristics, including symptoms related to CNS affection, was collected from the medical records. The main outcome measures were plasma levels of S100B and possible CNS effects. RESULTS Levels of S100B were significantly higher among women with preeclampsia than among control subjects (0.12 µg/L vs. 0.07 µg/L; P < 0.001). In preeclampsia, there was a significant association between high levels of S100B and visual disturbances (P < 0.05). CONCLUSIONS S100B is increased among women with preeclampsia, and high levels of S100B associate with visual disturbances, which might reflect CNS affection in women with preeclampsia.
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Affiliation(s)
- Lina Bergman
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden; Centre for Clinical Research, Dalarna, Sweden;
| | - Tansim Akhter
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Anna-Karin Wikström
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Johan Wikström
- Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - Tord Naessen
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Helena Åkerud
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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Giordano JC, Parpinelli MA, Cecatti JG, Haddad SM, Costa ML, Surita FG, Pinto e Silva JL, Sousa MH. The burden of eclampsia: results from a multicenter study on surveillance of severe maternal morbidity in Brazil. PLoS One 2014; 9:e97401. [PMID: 24825164 PMCID: PMC4019598 DOI: 10.1371/journal.pone.0097401] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Accepted: 04/19/2014] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Maternal mortality (MM) is a core indicator of disparities in women's rights. The study of Near Miss cases is strategic to identifying the breakdowns in obstetrical care. In absolute numbers, both MM and occurrence of eclampsia are rare events. We aim to assess the obstetric care indicators and main predictors for severe maternal outcome from eclampsia (SMO: maternal death plus maternal near miss). METHODS Secondary analysis of a multicenter, cross-sectional study, including 27 centers from all geographic regions of Brazil, from 2009 to 2010. 426 cases of eclampsia were identified and classified according to the outcomes: SMO and non-SMO. We classified facilities as coming from low- and high-income regions and calculated the WHO's obstetric health indicators. SPSS and Stata softwares were used to calculate the prevalence ratios (PR) and respective 95% confidence interval (CI) to assess maternal characteristics, clinical and obstetrical history, and access to health services as predictors for SMO, subsequently correlating them with the corresponding perinatal outcomes, also applying multiple regression analysis (adjusted for cluster effect). RESULTS Prevalence of and mortality indexes for eclampsia in higher and lower income regions were 0.2%/0.8% and 8.1%/22%, respectively. Difficulties in access to health care showed that ICU admission (adjPR 3.61; 95% CI 1.77-7.35) and inadequate monitoring (adjPR 2.31; 95% CI 1.48-3.59) were associated with SMO. CONCLUSIONS Morbidity and mortality associated with eclampsia were high in Brazil, especially in lower income regions. Promoting quality maternal health care and improving the availability of obstetric emergency care are essential actions to relieve the burden of eclampsia.
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Affiliation(s)
- Juliana C. Giordano
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Mary A. Parpinelli
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
- * E-mail:
| | - Jose G. Cecatti
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
- Center for Studies on Reproductive Health of Campinas (CEMICAMP), Campinas, São Paulo, Brazil
| | - Samira M. Haddad
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Maria L. Costa
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Fernanda G. Surita
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Joao L. Pinto e Silva
- Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas - UNICAMP, Campinas, São Paulo, Brazil
| | - Maria H. Sousa
- Center for Studies on Reproductive Health of Campinas (CEMICAMP), Campinas, São Paulo, Brazil
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Schaap TP, Knight M, Zwart JJ, Kurinczuk JJ, Brocklehurst P, van Roosmalen J, Bloemenkamp KWM. Eclampsia, a comparison within the International Network of Obstetric Survey Systems. BJOG 2014; 121:1521-8. [DOI: 10.1111/1471-0528.12712] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2014] [Indexed: 11/28/2022]
Affiliation(s)
- TP Schaap
- Department of Obstetrics; University Medical Centre Utrecht; Utrecht the Netherlands
| | - M Knight
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
| | - JJ Zwart
- Department of Obstetrics and Gynaecology; Deventer Ziekenhuis; Deventer the Netherlands
| | - JJ Kurinczuk
- National Perinatal Epidemiology Unit; University of Oxford; Oxford UK
| | - P Brocklehurst
- Institute for Women's Health; University College London; London UK
| | - J van Roosmalen
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
- Department of Medical Humanities; EMGO Institute for Health and Care Research; VU University Medical Centre; Amsterdam the Netherlands
| | - KWM Bloemenkamp
- Department of Obstetrics; Leiden University Medical Centre; Leiden the Netherlands
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Ohno Y, Furuhashi M, Ishikawa K, Kondo H, Kaseki S, Kikkawa F. Results of a questionnaire survey on pregnancy-associated stroke from 2005 to 2012 in Aichi Prefecture, Japan. HYPERTENSION RESEARCH IN PREGNANCY 2014. [DOI: 10.14390/jsshp.2.16] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Madoka Furuhashi
- Department of Obstetrics and Gynecology, Nagoya First Red Cross Hospital
| | - Kaoru Ishikawa
- Department of Regeneration of Medicine in Kuwana District, Suzuka University of Medical Science
| | | | | | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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Morikawa M, Cho K, Yamada T, Yamada T, Sato S, Minakami H. Do uterotonic drugs increase risk of abruptio placentae and eclampsia? Arch Gynecol Obstet 2013; 289:987-91. [PMID: 24292106 DOI: 10.1007/s00404-013-3101-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Accepted: 11/18/2013] [Indexed: 11/26/2022]
Abstract
PURPOSE To determine whether the use of uterotonics, including oxytocin and prostaglandins, increases the risk of abruptio placentae and eclampsia. MATERIALS AND METHODS A retrospective analysis was conducted among 260,174 Japanese women at term. Demographic characteristics were studied as possible candidates for risk factors of abruptio placentae and eclampsia using multivariate logistic regression analyses. RESULTS A total of 1,058 (0.41 %) and 147 (0.06 %) women developed abruptio placentae and eclampsia, respectively. Abruptio placentae and eclampsia occurred in 177 (0.29 %) and 42 (0.07 %) of the 61,857 women treated with uterotonics, respectively. Multivariate regression analyses indicated that uterotonics did not increase risk of developing either abruptio placentae or eclampsia. Primiparity [odds ratio (95 % confidence interval) 1.41 (1.24-1.60)], age ≥35 years [1.17 (1.03-1.33)], and presence of hypertension [2.42 (1.93-3.03)] were significant independent risk factors for abruptio placentae, while advancing gestation [0.67 (0.63-0.71)] decreased risk of abruptio placentae. Primiparity [odds ratio (95 % confidence interval) 4.06 (2.49-6.63)], age <20 years [2.44 (1.07-5.58)], presence of hypertension [28.7 (20.5-40.1)], and advancing gestation [1.28 (1.11-1.47)] were significant independent risk factors for eclampsia. CONCLUSION The use of uterotonics did not increase the risk of abruptio placentae and eclampsia.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku N15 W7, Sapporo, 060-8638, Japan,
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The incidence of preeclampsia and eclampsia and associated maternal mortality in Australia from population-linked datasets: 2000-2008. Am J Obstet Gynecol 2013; 208:476.e1-5. [PMID: 23467048 DOI: 10.1016/j.ajog.2013.02.042] [Citation(s) in RCA: 91] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/05/2013] [Accepted: 02/25/2013] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To determine the incidence of preeclampsia and eclampsia and associated mortality in Australia between 2000 and 2008. STUDY DESIGN Analysis of statutorily collected datasets of singleton births in New South Wales using International Classification of Disease coding. Analyzed using cross tabulation, logistic regression, and means testing, where appropriate. RESULTS The overall incidence of preeclampsia was 3.3% with a decrease from 4.6% to 2.3%. The overall rate of eclampsia was 8.6/10,000 births or 2.6% of preeclampsia cases, with an increase from 2.3% to 4.2%. The relative risk of eclampsia in preeclamptic women in 2008 was 1.9 (95% confidence interval, 1.28-2.92) when compared with the year 2000. The relative risk of a woman with preeclampsia/eclampsia dying in the first 12 months following birth compared with normotensive women is 5.1 (95% confidence interval, 3.07-8.60). CONCLUSION Falling rates of preeclampsia have not equated to a decline in the incidence of eclampsia. An accurate rate of both preeclampsia and eclampsia is vital considering the considerable contribution that these diseases make to maternal mortality. The identification and treatment of eclampsia should remain a priority in the clinical setting.
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Ohno Y, Ishikawa K, Kaseki S, Kikkawa F. Questionnaire-based study of cerebrovascular complications during pregnancy in Aichi Prefecture, Japan. HYPERTENSION RESEARCH IN PREGNANCY 2013. [DOI: 10.14390/jsshp.1.40] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Kaoru Ishikawa
- Department of Regeneration of Medicine in Kuwana District, Suzuka University of Medical Science
| | | | - Fumitaka Kikkawa
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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Watanabe K, Suzuki Y, Yamamoto T. Incidence of eclampsia in Japanese women. HYPERTENSION RESEARCH IN PREGNANCY 2013. [DOI: 10.14390/jsshp.1.31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kazushi Watanabe
- Department of Obstetrics and Gynecology, Aichi Medical University School of Medicine
| | - Yoshikatsu Suzuki
- Department of Obstetrics and Gynecology, Nagoya City West Medical Center
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OHNO Y, KAWAI M, MORIKAWA S, SAKAKIBARA K, TANAKA K, ISHIKAWA K, KIKKAWA F. Management of Eclampsia and Stroke During Pregnancy. Neurol Med Chir (Tokyo) 2013; 53:513-9. [DOI: 10.2176/nmc.53.513] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
| | - Michiyasu KAWAI
- Department of Obstetrics and Gynecology, Toyohashi Municipal Hospital
| | | | | | - Kanji TANAKA
- Department of Obstetrics and Gynecology, Hirosaki University Graduate School of Medicine
| | - Kaoru ISHIKAWA
- Department of Regenerative Medicine, Suzuka University of Medical Science
| | - Fumitaka KIKKAWA
- Department of Obstetrics and Gynecology, Nagoya University Graduate School of Medicine
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Morikawa M, Cho K, Yamada T, Yamada T, Sato S, Minakami H. Risk factors for eclampsia in Japan between 2005 and 2009. Int J Gynaecol Obstet 2012; 117:66-8. [DOI: 10.1016/j.ijgo.2011.11.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Revised: 11/03/2011] [Accepted: 12/20/2011] [Indexed: 10/14/2022]
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Yamada T, Kuwata T, Matsuda H, Deguchi K, Morikawa M, Yamada T, Furuya K, Matsubara S, Minakami H. Risk factors of eclampsia other than hypertension: pregnancy-induced antithrombin deficiency and extraordinary weight gain. Hypertens Pregnancy 2011; 31:268-77. [PMID: 22149018 DOI: 10.3109/10641955.2011.638957] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE Recent findings suggest that cerebral edema is a characteristic finding on magnetic resonance imaging in women with eclampsia and that pregnancy-induced antithrombin deficiency (PIATD) may reflect enhanced vascular permeability and may allow the retention of excess water in the interstitial space. Whether PIATD and extraordinary weight gain (EOWG) are risk factors for eclampsia remains to be studied. METHODS The medical records of 11 women with eclampsia among 17,522 deliveries were reviewed retrospectively with respect to changes in the laboratory data and the maternal body weight. PIATD was defined as a perinatal antithrombin activity of ≤65% of the normal activity levels with an antenatal decline and/or a prompt postnatal increase. A large net weight gain during the last two antenatal weeks >97.5th percentile value (>4.01 kg) obtained from 272 control women with neither hypertension nor PIATD was defined as EOWG. Relative risk was obtained on the assumption that the prevalences of PIATD and EOWG were 2.0 and 2.5%, respectively, among 17,511 women who did not develop eclampsia. RESULTS The duration of hypertension until an eclamptic fit was within 7 days in all 11 cases. PIATD and EOWG were observed in 6 (54.5%) and 2 (18.2%) cases, yielding a relative risk (95% confidential interval) of 57.9 (17.7-188.7) and 8.65 (1.87-39.91) for eclampsia among women with PIATD and EOWG, respectively. CONCLUSIONS PIATD and EOWG may be risk factors for eclampsia.
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Affiliation(s)
- Takashi Yamada
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Coghill AE, Hansen S, Littman AJ. Risk factors for eclampsia: a population-based study in Washington State, 1987-2007. Am J Obstet Gynecol 2011; 205:553.e1-7. [PMID: 21855842 DOI: 10.1016/j.ajog.2011.06.079] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 05/24/2011] [Accepted: 06/21/2011] [Indexed: 01/08/2023]
Abstract
OBJECTIVE We sought to investigate whether previously identified risk factors are associated with eclampsia in a contemporary, heterogeneous cohort of women. STUDY DESIGN Data were collected from birth certificate and hospital discharge records and used to conduct a population-based case-control study among women giving birth to singletons in Washington State from 1987 through 2007. We used multivariable logistic regression to estimate odds ratios and 95% confidence intervals. Multiple imputation procedures were used to address missing data. RESULTS Risk of eclampsia was greater in nulliparous compared to parous women. Being a young mother (< 20 years) or an older mother (≥ 35 years) were each associated with elevated eclampsia risk. Longer birth interval, low socioeconomic status, gestational diabetes, prepregnancy obesity, and weight gain during pregnancy above or below recommended guidelines were positively associated with eclampsia. Multiparity and smoking were inversely associated with eclampsia risk. CONCLUSION Exposures identified more than a decade ago continue to be associated with eclampsia in contemporary birth cohorts.
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Hutcheon JA, Lisonkova S, Joseph K. Epidemiology of pre-eclampsia and the other hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2011; 25:391-403. [DOI: 10.1016/j.bpobgyn.2011.01.006] [Citation(s) in RCA: 613] [Impact Index Per Article: 47.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Accepted: 01/09/2011] [Indexed: 11/27/2022]
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Yamada T, Yamada T, Morikawa M, Takeda M, Nishida R, Akaishi R, Minakami H. Isolated proteinuria as an initial sign of severe preeclampsia. ACTA ACUST UNITED AC 2011. [DOI: 10.4236/ojog.2011.12003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Yamada T, Yamada T, Morikawa M, Takeda M, Akaishi R, Nishida R, Araki N, Koyama T, Minakami H. Do uterotrophic drugs increase the risk of fatal hemorrhagic brain stroke? J Perinat Med 2011; 39:23-6. [PMID: 20954850 DOI: 10.1515/jpm.2010.116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To evaluate whether uterotrophic agents increase the risk of fatal hemorrhagic brain stroke. METHODS Between 1991 and 1992, there were 230 maternal deaths among 2,420,000 pregnant women in Japan and the causes of these deaths was investigated in 1994. Using information provided in this report, we identified 35 women who died from or were assumed to die from hemorrhagic brain stroke. We assumed that 93% of women would have tried vaginal delivery. The risk of fatal hemorrhagic brain stroke after uterotrophic agent use was calculated according to the assumption that 5.0-40% of women received uterotrophic agents. RESULTS Use of uterotrophic agents for induction/augmentation of labor was confirmed in five (14.3%) of the 35 women who died from hemorrhagic brain stroke. The incidence of fatal brain stroke after the use of uterotrophic agents was only significantly higher than that for spontaneous hemorrhagic brain stroke if these agents were administered in ≤ 6.0% of women. CONCLUSIONS Because more than 6.0% of women received uterotrophic agents, these agents are unlikely to increase the risk of fatal hemorrhagic brain stroke.
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Affiliation(s)
- Takashi Yamada
- Department of Obstetrics, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
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Abstract
BACKGROUND Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants are used to control eclamptic fits and to prevent further fits. OBJECTIVES The objective of this review was to assess the effects of magnesium sulphate compared with diazepam when used for the care of women with eclampsia. Magnesium sulphate is compared with phenytoin and with lytic cocktail in other Cochrane reviews. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2010) and CENTRAL (2010, Issue 3). SELECTION CRITERIA Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with diazepam for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS Two authors assessed and extracted data independently. MAIN RESULTS We have included seven trials, involving 1396 women. Three trials (1030 women) were good quality. Magnesium sulphate was associated with a reduction in maternal death (seven trials;1396 women; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.38 to 0.92) and recurrence of seizures (seven trials;1390 women; RR 0.43, 95% CI 0.33 to 0.55) compared to diazepam. There were no clear differences in other measures of maternal morbidity.There was no clear difference in perinatal mortality (four trials; 788 infants; RR 1.04, 95% CI 0.81 to 1.34) or neonatal mortality (four trials; 759 infants; RR 1.18, 95% CI 0.75 to 1.84). In the magnesium sulphate group, fewer liveborn babies had an Apgar score less than seven at one minute (two trials; 597 babies; RR 0.75, 95% CI 0.65 to 0.87) or at five minutes (RR 0.70, 95% CI 0.54 to 0.90), and fewer appeared to need intubation at the place of birth (two trials; 591 infants; RR 0.67, 95% CI 0.45 to 1.00). There was no difference in admission to a special care nursery (four trials; 834 infants; RR 0.91, 95% CI 0.79 to 1.05), but fewer babies in the magnesium sulphate group had a length of stay more than seven days (three trials 631 babies; RR 0.66, 95% CI 0.46 to 0.96). AUTHORS' CONCLUSIONS Magnesium sulphate for women with eclampsia reduces the risk ratio of maternal death and of recurrence of seizures, compared with diazepam.
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Affiliation(s)
- Lelia Duley
- University of LeedsCentre for Epidemiology and BiostatisticsBradford Institute for Health ResearchBradford Royal Infirmary, Duckworth LaneBradfordWest YorkshireUKBD9 6RJ
| | - David J Henderson‐Smart
- Queen Elizabeth II Research InstituteNSW Centre for Perinatal Health Services ResearchBuilding DO2University of SydneySydneyNSWAustralia2006
| | - Godfrey JA Walker
- The University of LiverpoolC/o Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive MedicineFirst Floor, Liverpool Women's NHS Foundation TrustCrown StreetLiverpoolUKL8 7SS
| | - Doris Chou
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Abstract
BACKGROUND Eclampsia, the occurrence of a seizure in association with pre-eclampsia, remains a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures. OBJECTIVES The objective of this review was to assess the effects of magnesium sulphate compared with phenytoin when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with lytic cocktail in other Cochrane reviews. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2010). SELECTION CRITERIA Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with phenytoin for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS Two review authors assessed trial quality and extracted data. MAIN RESULTS We have included data from seven trials, involving 972 women. One large trial (775 women) was of good quality. Magnesium sulphate was associated with a substantial reduction in the recurrence of seizures, when compared to phenytoin (six trials, 972 women; risk ratio (RR) 0.34, 95% confidence interval (CI) 0.24 to 0.49). The trend in maternal mortality favours magnesium sulphate, but the difference does not reach statistical significance (three trials, 847 women; RR 0.50, 95% CI 0.24 to 1.05). There were reductions in the risk of pneumonia (one trial, RR 0.44, 95% CI 0.24 to 0.79), ventilation (one trial, RR 0.68, 95% CI 0.50 to 0.91) and admission to an intensive care unit (one trial, RR 0.67, 95% CI 0.50 to 0.89) associated with the use of magnesium sulphate rather than phenytoin.For the baby, magnesium sulphate was associated with fewer admissions to a special care baby unit (SCBU) (one trial, 518 babies; RR 0.73, 95% CI 0.58 to 0.91) and fewer babies who died or were in SCBU for more than seven days (one trial, 643 babies; RR 0.77, 95% CI 0.63 to 0.95) than phenytoin. There was no clear difference in perinatal deaths (two trials, 665 babies; (RR 0.85, 95% CI 0.67 to 1.09). AUTHORS' CONCLUSIONS Magnesium sulphate, rather than phenytoin, for women with eclampsia reduces the risk ratio of recurrence of seizures, probably reduces the risk of maternal death, and improves outcome for the baby. Magnesium sulphate is the drug of choice for women with eclampsia. The use of phenytoin should be abandoned.
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Affiliation(s)
- Lelia Duley
- Centre for Epidemiology and Biostatistics, University of Leeds, Bradford Institute for Health Research, Bradford Royal Infirmary, Duckworth Lane, Bradford, West Yorkshire, UK, BD9 6RJ
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Abstract
BACKGROUND Eclampsia, the occurrence of a seizure in association with pre-eclampsia, is a rare but serious complication of pregnancy. A number of different anticonvulsants have been used to control eclamptic fits and to prevent further seizures. OBJECTIVES The objective of this review was to assess the effects of magnesium sulphate compared with lytic cocktail (usually chlorpromazine, promethazine and pethidine) when used for the care of women with eclampsia. Magnesium sulphate is compared with diazepam and with phenytoin in other Cochrane reviews. SEARCH STRATEGY We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (July 2010) and the Cochrane Central Register of Trials (The Cochrane Library 2010, Issue 2). SELECTION CRITERIA Randomised trials comparing magnesium sulphate (intravenous or intramuscular administration) with lytic cocktail for women with a clinical diagnosis of eclampsia. DATA COLLECTION AND ANALYSIS Two review authors (L Duley and D Chou) assessed trial quality and extracted data. MAIN RESULTS We included three small trials (total 397 women) of average quality in the review. Magnesium sulphate was associated with fewer maternal deaths (risk ratio (RR) 0.14, 95% confidence interval (CI) 0.03 to 0.59; 3 trials, 397 women) and was better at preventing further seizures (RR 0.06, 95% CI 0.03 to 0.12; 3 trials, 397 women) than lytic cocktail. Magnesium sulphate was also associated with less respiratory depression (RR 0.12, 95% CI 0.02 to 0.91; 2 trials, 198 women), less coma (RR 0.04, 95% CI 0.00 to 0.74; 1 trial, 108 women), and less pneumonia (RR 0.20, 95% CI 0.06 to 0.67; 2 trials, 307 women). There was no clear difference in the RR for any death of the baby (RR 0.35, 95% CI 0.05 to 2.38, random effects; 2 trials, 177 babies). AUTHORS' CONCLUSIONS Magnesium sulphate, rather than lytic cocktail, for women with eclampsia reduces the RR of maternal death, of further seizures and of serious maternal morbidity (respiratory depression, coma, pneumonia). Magnesium sulphate is the anticonvulsant of choice for women with eclampsia; the use of lytic cocktail should be abandoned.
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Affiliation(s)
- Lelia Duley
- University of NottinghamNottingham Clinical Trials UnitB39, Medical SchoolQueen's Medical Centre CampusNottinghamUKNG7 2UH
| | - A Metin Gülmezoglu
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
| | - Doris Chou
- World Health OrganizationUNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, Department of Reproductive Health and Research20 Avenue AppiaGenevaSwitzerland1211
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Beucher G, Simonet T, Dreyfus M. Devenir à court terme des patientes ayant développé une prééclampsie sévère. ACTA ACUST UNITED AC 2010; 29:e149-54. [DOI: 10.1016/j.annfar.2010.03.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Beucher G, Dreyfus M. [Efficiency of magnesium sulfate for the prevention of eclampsia in women with preeclampsia]. GYNECOLOGIE, OBSTETRIQUE & FERTILITE 2010; 38:155-158. [PMID: 20089436 DOI: 10.1016/j.gyobfe.2009.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- G Beucher
- Service de gynécologie obstétrique et médecine de la reproduction, CHU de Caen, avenue Clémenceau, 14033 Caen cedex, France
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Abstract
Over half a million women die each year from pregnancy related causes, 99% in low and middle income countries. In many low income countries, complications of pregnancy and childbirth are the leading cause of death amongst women of reproductive years. The Millennium Development Goals have placed maternal health at the core of the struggle against poverty and inequality, as a matter of human rights. Ten percent of women have high blood pressure during pregnancy, and preeclampsia complicates 2% to 8% of pregnancies. Preeclampsia can lead to problems in the liver, kidneys, brain and the clotting system. Risks for the baby include poor growth and prematurity. Although outcome is often good, preeclampsia can be devastating and life threatening. Overall, 10% to 15% of direct maternal deaths are associated with preeclampsia and eclampsia. Where maternal mortality is high, most of deaths are attributable to eclampsia, rather than preeclampsia. Perinatal mortality is high following preeclampsia, and even higher following eclampsia. In low and middle income countries many public hospitals have limited access to neonatal intensive care, and so the mortality and morbidity is likely to be considerably higher than in settings where such facilities are available. The only interventions shown to prevent preeclampsia are antiplatelet agents, primarily low dose aspirin, and calcium supplementation. Treatment is largely symptomatic. Antihypertensive drugs are mandatory for very high blood pressure. Plasma volume expansion, corticosteroids and antioxidant agents have been suggested for severe preeclampsia, but trials to date have not shown benefit. Optimal timing for delivery of women with severe preeclampsia before 32 to 34 weeks' gestation remains a dilemma. Magnesium sulfate can prevent and control eclamptic seizures. For preeclampsia, it more than halves the risk of eclampsia (number needed to treat 100, 95% confidence interval 50 to 100) and probably reduces the risk of maternal death. A quarter of women have side effects, primarily flushing. With clinical monitoring serious adverse effects are rare. Magnesium sulfate is the anticonvulsant of choice for treating eclampsia; more effective than diazepam, phenytoin, or lytic cocktail. Although it is a low cost effective treatment, magnesium sulfate is not available in all low and middle income countries; scaling up its use for eclampsia and severe preeclampsia will contribute to achieving the Millennium Development Goals.
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Affiliation(s)
- Lelia Duley
- Centre for Epidemiology and Biostatistics, University of Leeds, Bradford, UK.
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van Roosmalen J, Zwart J. Severe acute maternal morbidity in high-income countries. Best Pract Res Clin Obstet Gynaecol 2009; 23:297-304. [PMID: 19213604 DOI: 10.1016/j.bpobgyn.2009.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 01/14/2009] [Indexed: 10/21/2022]
Abstract
Maternal mortality in high income countries has become low in recent years and therefore analysis of severe acute maternal morbidity has been added to confidential enquiries into the causes of maternal deaths. The major drawback at the moment is the lack of universal definitions of severe acute maternal morbidity. The prevalence of severe acute maternal morbidity in high income countries is between 3.8 and 12 per 1,000 births. Case fatality rates may reflect the quality of maternal health care. Audit is the instrument to analyse whether substandard care factors are present. Guidelines and protocols to provide obstetric critical care may be improved from audit findings and skills and drills training put in place.
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Affiliation(s)
- Jos van Roosmalen
- Department of Obstetrics, Leiden University Medical Centre, The Netherlands.
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Morikawa M, Yamada T, Yamada T, Cho K, Yamada H, Sakuragi N, Minakami H. Pregnancy outcome of women who developed proteinuria in the absence of hypertension after mid-gestation. J Perinat Med 2009; 36:419-24. [PMID: 18605971 DOI: 10.1515/jpm.2008.062] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To characterize the clinical features of women with singleton pregnancies who develop proteinuria in the absence of hypertension after mid-gestation. METHODS Seventy-nine women who developed proteinuria and/or hypertension at and after 20 weeks of gestation were reviewed, focusing on the gestational week at which significant proteinuria (>0.3 g/day) and/or hypertension developed. RESULTS Thirty-seven (47%) women exhibited new-onset proteinuria (>0.3 g/day) in the absence of hypertension, 33 (42%) exhibited new-onset hypertension in the absence of proteinuria, and 9 (11%) exhibited both proteinuria and hypertension. Nineteen (51%) of 37 women who exhibited new proteinuria in the absence of hypertension and 5 (15%) of 33 women who exhibited new hypertension in the absence of proteinuria progressed to preeclampsia (P=0.002). Among women who exhibited new proteinuria, 10 (77%) out of 13 women and 9 (38%) out of 24 women who developed proteinuria at <32 weeks and >or=32 weeks, respectively, progressed to preeclampsia (P=0.022). CONCLUSIONS Women with new-onset proteinuria in the absence of hypertension may be more likely to progress to preeclampsia than women with a presumptive diagnosis of gestational hypertension, and the likelihood of progression may be significantly greater among women with earlier presentation.
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Affiliation(s)
- Mamoru Morikawa
- Department of Obstetrics and Gynecology, Hokkaido University Graduate School of Medicine, Kita-ku, Sapporo, Japan.
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Secular trends in the rates of preeclampsia, eclampsia, and gestational hypertension, United States, 1987-2004. Am J Hypertens 2008; 21:521-6. [PMID: 18437143 DOI: 10.1038/ajh.2008.20] [Citation(s) in RCA: 458] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Few studies have reported on population-level incidence of or trends in the hypertensive disorders of pregnancy, and none report on data through 2004. We describe population trends in the incidence rates of preeclampsia, eclampsia, and gestational hypertension in the United States for 1987-2004. METHODS We analyzed public-use data from the National Hospital Discharge Survey (NHDS), which has been conducted by the Centers for Disease Control and Prevention, National Center for Health Statistics since 1965. We calculated crude and age-adjusted incidence rates and estimated the risk associated with available demographic variables using Cox regression modeling. RESULTS Rates of preeclampsia and gestational hypertension increased significantly (by 25 and 184%, respectively) over the study period; in contrast, the rate of eclampsia decreased by 22% (nonsignificant). Women under the age of 20 were at significantly greater risk for all three outcomes. Women in the south of the country were at significantly greater risk for preeclampsia and gestational hypertension when compared to those in the Northeast. CONCLUSIONS The increase in gestational hypertension may be exaggerated because of the revised clinical guidelines published in the 1990s; these same revisions would likely have reduced diagnoses of preeclampsia. Therefore, our observation of a small but consistent increase in preeclampsia is a conservative indication of a true population-level change.
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Yücesoy G, Ozkan S, Bodur H, Tan T, Calişkan E, Vural B, Corakçi A. Maternal and perinatal outcome in pregnancies complicated with hypertensive disorder of pregnancy: a seven year experience of a tertiary care center. Arch Gynecol Obstet 2005; 273:43-9. [PMID: 15834580 DOI: 10.1007/s00404-005-0741-3] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2005] [Accepted: 01/12/2005] [Indexed: 12/27/2022]
Abstract
OBJECTIVE The aim of the study was to determine the risk factors, prevalance, epidemiological parameters and maternal-perinatal outcome in pregnant women with hypertensive disorder. MATERIALS AND METHODS A retrospective analysis was undertaken on 255 consecutive cases of hypertensive disorder in pregnancy who were managed at Kocaeli University, School of Medicine, Department of Obstetrics and Gynecology from June 1997 to November 2004. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally delivery route, indications of cesarean section, fetal and maternal complications were determined. Statistical analysis was performed by SPSS programme using Kruskal Wallis nonparametric test, ANOVA (Analysis of variance) and chi-square tests. RESULTS Of 5,155 deliveries in our clinic during the defined period, 438 cases (8.49%) were managed as hypertensive disorder of pregnancy. Medical records of 255 cases could be avaliable. Of 255 cases, 138 patients (54.11%) were found to have severe preeclampsia while 88 cases (34.50%) were diagnosed as mild preeclampsia. Twenty-nine patients (11.37%) were suffering from chronic hypertension. Of 138 severely preeclamptic cases, 28 cases (11%) had eclamptic convulsion and another 28 patients (11%) were demonstrated to have HELLP syndrome. Intrauterine growth restriction, oligohydramnios, placental ablation were the obstetric complications in 75 (29.4%), 49 (19.2%), 19 (7.5%) cases, respectively. Additionally multiple pregnancy and gestational diabetes mellitus were noted in 5.9% (n:15) and 3.9% (n:10) of the patients. Delivery route was vaginal in 105 patients (41.2%) while 150 patients (58.8%) underwent cesarean section with the most frequent indication to be fetal distress in 69 cases (46%). Cesarean section rate seemed to be the lowest (48.3%) in chronic hypertensive women while the highest (63.8%) in severe preeclamptic patients. Maternal mortality occured in 3 cases (1.2%) and all of those cases were complicated with HELLP syndrome. Intracranial bleeding was the cause of maternal death in one case while the other two cases were lost due to acute renal failure and disseminated intravascular coagulation, respectively. Intrauterine fetal demise was recorded in 24 cases on admission. Ten fetuses died during the intrapartum period. Mean gestational age and birth weight were 28 +/- 3.5 and 1000 +/- 416 g, respectively in this group. In these ten women, five cases were diagnosed as HELLP syndrome, two were severely preeclamptic and three were eclamptic. Perinatal mortality rate was found to be 144/1,000 births CONCLUSION Hypertensive disorder of pregnancy is associated with increased risk of maternal-perinatal adverse outcome. The complications of severe preeclampsia and eclampsia could be prevented by more widespread use of prenatal care, education of primary medical care personnel, prompt diagnosis of high-risk patients and timely referral to tertiary medical centers.
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Affiliation(s)
- Gülseren Yücesoy
- Department of Obstetrics and Gynecology, School of Medicine, University of Kocaeli, Kocaeli, Turkey
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Jelliffe-Pawlowski LL, Hansen RL. Neurodevelopmental outcome at 8 months and 4 years among infants born full-term small-for-gestational-age. J Perinatol 2004; 24:505-14. [PMID: 15129225 DOI: 10.1038/sj.jp.7211111] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVES To examine the association between intrauterine growth restriction and neurodevelopmental outcome among full-term small-for-gestational-age (SGAT) infants at 8 months and 4 years of age. STUDY DESIGN Growth parameters at birth and test scores on measures of neurodevelopmental function for 3922 children born SGAT were compared with those of 29,369 children born appropriately grown-for-gestational-age term from similar economic backgrounds. Additional within-SGAT/economic group comparisons were made for 1684 SGAT infants with symmetric undergrowth at birth and 2034 SGAT infants with asymmetric undergrowth at birth. RESULTS Regardless of socioeconomic background, infants born SGAT were found to be at significantly increased risk for neurodevelopmental difficulties at 8 months and at 4 years of age. Few within SGAT/socioeconomic group differences in neurodevelopmental outcome appeared to be associated with specific pattern of growth restriction at birth. CONCLUSIONS The present findings provide further evidence of the individual and public health impact of SGAT birth.
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Lee W, O'Connell CM, Baskett TF. Maternal and Perinatal Outcomes of Eclampsia: Nova Scotia, 1981-2000. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2004; 26:119-23. [PMID: 14965477 DOI: 10.1016/s1701-2163(16)30487-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the prevalence of eclampsia and the associated maternal and perinatal outcomes in the province of Nova Scotia. METHODS From the Nova Scotia Atlee Perinatal Database, the population-based rates of preeclampsia, eclampsia, and HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome for the period 1988 to 2000 were determined. A retrospective case review was then performed of all women with eclampsia at the tertiary maternity hospital in Halifax, Nova Scotia, Women's Hospital, IWK Health Centre, for the years 1981 to 2000. RESULTS In the province of Nova Scotia from 1988 to 2000, there were 142,362 births. Thirty-nine women developed eclampsia (0.27/1000). Over this time interval, the prevalence of severe preeclampsia fell from 2.08% to 1.63%, and the diagnosis of HELLP syndrome increased from 0.03% to 0.31%. At the Women's Hospital, IWK Health Centre, between 1981 and 2000, there were 31 cases of eclampsia in 105,651 deliveries (0.29/1000). Sixty-one percent of first convulsions occurred antepartum, 13% occurred intrapartum, and 26% occurred postpartum. Eighty-one percent of women reported prodromal symptoms. Sixty-one percent of the women received anti-hypertensive therapies, 48% received antiepileptic therapies, and 97% received magnesium sulfate. Ten percent of the women had convulsions while on magnesium sulfate therapy. Antepartum eclampsia was associated with increased rates of general anaesthesia (26%) and Caesarean section (79%). There were no maternal deaths, but the rate of major maternal complications was 32%. The perinatal mortality rate was 64 in 1000 deliveries, and the rate of severe perinatal complications was 56%. CONCLUSION The incidence of eclampsia in Nova Scotia is 0.27 per 1000 deliveries. Although rare, this condition is associated with significant maternal and perinatal morbidity.
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Affiliation(s)
- Winifred Lee
- The Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, NS
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Affiliation(s)
- Lay-Kok Tan
- Department of Obstetric Medicine, Queen Charlotte's and Chelsea Hospital, London, UK
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