Management of mild preeclampsia

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

A Proposed Plan for Prenatal Care to Minimize Risks of COVID-19 to Patients and Providers: Focus on Hypertensive Disorders of Pregnancy

Hypertensive disorders are the most common medical complications of pregnancy and a major cause of maternal and perinatal morbidity and death. The detection of elevated blood pressure during pregnancy is one of the cardinal aspects of optimal antenatal care. With the outbreak of novel coronavirus disease 2019 (COVID-19) and the risk for person-to-person spread of the virus, there is a desire to minimize unnecessary visits to health care facilities. Women should be classified as low risk or high risk for hypertensive disorders of pregnancy and adjustments can be accordingly made in the frequency of maternal and fetal surveillance. During this pandemic, all pregnant women should be encouraged to obtain a sphygmomanometer. Patients monitored for hypertension as an outpatient should receive written instructions on the important signs and symptoms of disease progression and provided contact information to report the development of any concern for change in status. As the clinical management of gestational hypertension and preeclampsia is the same, assessment of urinary protein is unnecessary in the management once a diagnosis of a hypertensive disorder of pregnancy is made. Pregnant women with suspected hypertensive disorders of pregnancy and signs and symptoms associated with the severe end of the disease spectrum (e.g., headaches, visual symptoms, epigastric pain, and pulmonary edema) should have an evaluation including complete blood count, serum creatinine level, and liver transaminases (aspartate aminotransferase and alanine aminotransferase). Further, if there is any evidence of disease progression or if acute severe hypertension develops, prompt hospitalization is suggested. Current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and The Society for Maternal-Fetal Medicine (SMFM) for management of preeclampsia with severe features suggest delivery after 34 ^0/7 weeks of gestation. With the outbreak of COVID-19, however, adjustments to this algorithm should be considered including delivery by 30 ^0/7 weeks of gestation in the setting of preeclampsia with severe features. KEY POINTS: · Outbreak of novel coronavirus disease 2019 (COVID-19) warrants fewer office visits.. · Women should be classified for hypertension risk in pregnancy.. · Earlier delivery suggested with COVID-19 and hypertensive disorder..

Does cesarean section prevent mortality and cerebral ultrasound abnormalities in preterm newborns?

OBJECTIVE

Despite the increased use of the cesarean section (CS), the rates of cerebral palsy, a frequent consequence of brain damage, have remained stable over the last decades. Whether an actual decrease in cerebral palsy has been masked by increased survival of infants delivered by CS or not, remains undefined. To investigate the role of CS, we compared risks of mortality and brain damage, as defined by ultrasound (US) abnormalities, in preterm newborns by mode of delivery.

METHODS

Information on fetal, maternal, and neonatal risk factors was collected from the paired clinical records of preterm newborns and mothers. Crude and adjusted odds ratios (OR) of mortality and ultrasound abnormalities, according to mode of delivery (i.e., vaginal, elective CS, and emergency CS) were calculated. All the analyses were controlled for possible confounding by indication.

RESULTS

In newborns of gestational age <32 weeks, no effect of CS on cerebral US abnormalities was found (OR 0.71 and 0.73 for emergency CS and elective CS, respectively). None of the maternal and neonatal factors were associated with both cerebral US abnormalities and mode of delivery. Among newborns of gestational age >or=32 weeks, after controlling for known and potential confounders in a multivariate model, the adjusted ORs remained close to one for both elective CS and emergency CS.

CONCLUSIONS

CS does not reduce overall mortality in preterm newborns. No protective effect of CS on US abnormalities was found after stratifying by gestational age and controlling for possible confounding. These results do not encourage the widespread use of CS in preterm labor.

Does uric acid provide information about maternal condition and fetal outcome in pregnant women with hypertension?

OBJECTIVE

To evaluate associations between maternal serum uric acid (UA) levels, maternal status, and fetal outcome.

METHODS

Maternal UA, urinary protein-creatinine ratio (P/C), blood pressure (BP), gestational age at delivery, and birth weight were evaluated in hypertensive pregnant women (n = 58). These were divided into two groups: high UA (> or =357 micromol/L) or normal UA (<357 micromol/L).

RESULTS

Maternal diastolic BP and P/C ratio were higher in pregnant women with elevated UA levels. Systolic BP, gestational age and birth weight were not significantly different.

CONCLUSION

UA equal or above 357 micromol/L in pregnant hypertensive women was associated with proteinuria and diastolic BP, but not with fetal outcome.

Pregnancy-associated hospitalizations in the United States, 1999-2000

OBJECTIVE

The purpose of this study was to examine nondelivery, pregnancy-associated hospitalizations in the United States and the factors associated with them.

STUDY DESIGN

Population-based nondelivery hospitalizations during pregnancy were obtained from the 1999 and 2000 National Hospital Discharge Survey. Ratios of hospitalizations per 100 deliveries were calculated and analyzed by age, race, and payment source.

RESULTS

The pregnancy-associated hospitalization ratio for 1999 through 2000 was 12.8 per 100 deliveries (95% CI, 11.8-13.8). Hospitalizations were highest among young women, African American women, and women without private insurance. Preterm labor, nausea and/or vomiting, and genitourinary complications accounted for one half of antenatal hospitalizations.

CONCLUSION

Pregnancy-associated hospitalizations declined during the 1990s. This may represent a decline in maternal morbidity or a change in management of pregnancy complications. Future research should be expanded to assess trends in morbidity treated in settings outside of hospitals.

Regional Anaesthesia in Pre-eclampsia

Pre-eclampsia is a multisystemic disorder that is characterised by endothelial cell dysfunction as a consequence of abnormal genetic and immunological mechanisms. Despite active research for years, the exact aetiology of this potentially fatal disorder remains unknown. Although understanding of the pathophysiology of pre-eclampsia has improved, management has not changed significantly over the years. Anaesthetic management of these patients remains a challenge. Although general anaesthesia can be used safely in pre-eclamptic women, it is fraught with greater maternal morbidity and mortality. Currently, the safety of regional anaesthesia techniques is well established and they can provide better obstetrical outcome when chosen properly. Thus, regional anaesthesia is extensively used for the management of pain and labour in women with pre-eclampsia. This article highlights the advantages and disadvantages of regional anaesthetic techniques including epidural, spinal and combined spinal-epidural analgesia, used as a part of the management of pre-eclampsia. The problems associated with general anaesthesia and controversies in relation to obstetric regional anaesthesia are discussed.

Critical care obstetrics and gynecology

The critical care aspects of obstetrics and pregnancy are varied and demand that critical care practitioners have a thorough knowledge of fetal and maternal changes in physiology as pregnancy progresses. Pregnancy can affect every organ system; and organ-specific conditions as well as syndromes that span multiple organ systems were described. Care of the critically ill, pregnant patient requires a true multidisciplinary approach for optimal outcomes. A review of the current concepts and suggestions for therapy were presented.

[Criteria of pregnancy termination in women with preeclampsia]

Preeclampsia remains an important cause of maternal and neonatal mortality and morbidity. Delivery is always the appropriate therapy for the mother but may be responsible for neonatal adverse outcomes, particularly when it occurs at less than < 34 weeks' gestation. In women with severe preeclampsia at < 34 weeks expectant management to improve neonatal mortality and morbidity may be performed under close monitoring of both the mother and the fetus. Any severe condition of the mother (HELLP syndrome, abruptio placentae, eclampsia) or the fetus (abnormal fetal heart rate) should lead to prompt delivery. In women with mild preeclampsia, expectant management should be performed until 38 weeks gestation.

Late postpartum eclampsia: a preventable disease?

OBJECTIVE

The purpose of this study was to determine whether there is a shift in the timing of eclampsia in relation to delivery and whether traditional symptoms precede impending postpartum eclampsia.

STUDY DESIGN

A multicenter analysis of data from patients with eclampsia from March 1996 through February 2001 at the University of Cincinnati, the University of Tennessee, Memphis, and Central Baptist Hospital, Lexington. Data were collected regarding the relationship of the patient's first seizure to delivery, prodromal symptoms, neuroimaging studies, use of magnesium sulfate, antihypertensive therapy, and follow-up medical care. The analysis focused on women who had late postpartum eclampsia.

RESULTS

During the study period, 89 patients were diagnosed with eclampsia. Twenty-nine women (33%) had postpartum eclampsia, of whom 23 women (79%) had late onset (>48 hours). Interestingly, only 5 of these 23 women (22%) had been previously diagnosed with preeclampsia. Twenty-one patients (91%) with late postpartum eclampsia had at least 1 prodromal symptom, and 12 patients (52%) had >1 symptom that heralded the seizure: 20 women (87%) had headache; 10 women (44%) had visual changes; 5 women (22%) had nausea or vomiting; and 2 women (9%) experienced epigastric pain. Only 7 of these 21 women (33%) sought care for their symptoms, of whom 6 women (86%) had clinical evidence of preeclampsia that was not considered by the treating physician. Among all patients with eclampsia, there were 7 cases of aspiration pneumonia, 3 cases of pulmonary edema, 3 cases of pleural effusion, 2 cases of disseminated intravascular coagulation, and no cases of maternal death.

CONCLUSION

Current obstetric treatment in the United States has resulted in a shift of eclampsia toward the postpartum period, with most cases being seen as late post partum. To reduce the rate of late postpartum eclampsia, efforts should be directed to the education of the health care providers and patients regarding the importance of prompt reporting and evaluation of symptoms of preeclampsia during the postpartum period.