Diagnosis, prevention, and management of eclampsia

Assessment of transcranial Doppler indices after MgSO4 administration in severe preeclamptic women with neurologic symptoms

PURPOSE

To investigate the effect of intravenous MgSO4 on maternal cerebral hemodynamics as well as the association between altered Doppler indices of the ophthalmic arteries and ocular lesions in patients with preeclampsia.

METHODS

After each of the 15 included patients was diagnosed with preeclampsia, MgSO4 was infused followed by transcranial Doppler tests of the indices of the ophthalmic, anterior, middle, posterior cerebral, vertebral, and basilar arteries, followed by a second MgSO4 infusion. The peak, mean, diastolic velocity, and pulsatile and resistance indices of each artery were automatically measured during testing. Based on the emergent data, the cerebral perfusion pressure, resistance-area product, and cerebral flow index were calculated.

RESULTS

The cerebral perfusion pressure of the posterior cerebral arteries significantly decreased following the infusion of MgSO4 (p < 0.05). Before the infusion of MgSO4, cerebral perfusion pressure and cerebral flow index of the ophthalmic arteries were significantly increased (p < 0.05) in the preeclamptic pregnant patients with ocular lesions compared those without ocular lesions. After the infusion of MgSO4, the cerebral perfusion pressure and cerebral flow index of both ophthalmic arteries were slightly decreased, but the difference was not significant.

CONCLUSIONS

Altered Doppler indices following the infusion of MgSO4 suggest significant changes in the hemodynamics of the posterior cerebral and ophthalmic arteries that are particularly related to the neurological signs and symptoms of women with preeclampsia. These findings may improve the understanding of the mechanism of the cerebral complications of preeclampsia. Advancing comprehension of these underlying mechanisms is postulated to play a pivotal role in the mitigation of hypertensive encephalopathy associated with preeclampsia.

Dual Tragedy of Fetal and Maternal Loss: A Case of Acute Liver Failure in the Third Trimester

The traditional criteria for diagnosing preeclampsia include a new onset of hypertension and new-onset proteinuria at 20 weeks gestation. However recent studies suggest preeclampsia and even eclampsia may develop in the absence of either proteinuria or hypertension. This paper reports a dual tragedy of maternal and fetal loss after 36 weeks in the third trimester. Autopsy findings revealed an enlarged liver with multiple patchy hemorrhages, and histopathology confirmed submassive hepatic necrosis. Early diagnosis with timely referrals to higher centers is always helpful for the patients in such cases.

Atypical eclampsia in a normotensive patient with altered mental status and severely elevated transaminases: Case report and review

Classically, pre-eclampsia and eclampsia are considered hypertensive disorders of pregnancy, and current diagnostic criteria include hypertension with proteinuria or other laboratory abnormalities or symptoms suggestive of end-organ damage. However, atypical presentations can occur in the absence of elevated blood pressures. We present the case of a pregnant patient who developed status epilepticus at 24 weeks and 4 days of gestation, followed by altered mental status and severely elevated transaminases. She had no elevated blood pressures during her prenatal care or hospital course. Following delivery, she experienced normalization of transaminase levels and a return to her baseline mental status. Pre-eclampsia and eclampsia can occur in the absence of elevated blood pressures, which highlights the limitations of using standard diagnostic criteria in normotensive patients with end-organ damage. In such cases, it is important to include pre-eclampsia and eclampsia in the differential diagnosis, as the diagnosis usually warrants preterm delivery to minimize maternal morbidity and mortality.

Standardized Clinical Assessment and Management Plan to Reduce Readmissions for Postpartum Hypertension

OBJECTIVE

To evaluate the effect of a postpartum hypertension standardized clinical assessment and management plan on postpartum readmissions and emergency department (ED) visits.

METHODS

We conducted a prospective cohort study of patients with postpartum hypertension (either chronic hypertension or hypertensive disorders of pregnancy) who delivered at a single tertiary care center for 6 months after enacting an institution-wide standardized clinical assessment and management plan (postintervention group). Patients in the postintervention group were compared with patients in a historical control group. The standardized clinical assessment and management plan included 1) initiation or uptitration of medication for any blood pressure (BP) higher than 150/100 mm Hg or any two BPs higher than 140/90 mm Hg within a 24-hour period, with the goal of achieving normotension (BP lower than 140/90 mm Hg) in the 12 hours before discharge; and 2) enrollment in a remote BP monitoring system on discharge. The primary outcome was postpartum readmission or ED visit for hypertension. Multivariable logistic regression was used to evaluate the association between standardized clinical assessment and management plan and the selected outcomes. A sensitivity analysis was performed with propensity score weighting. A planned subanalysis in the postintervention cohort identified risk factors associated with requiring antihypertensive uptitration after discharge. For all analyses, the level of statistical significance was set at P<.05.

RESULTS

Overall, 390 patients in the postintervention cohort were compared with 390 patients in a historical control group. Baseline demographics were similar between groups with the exception of lower prevalence of chronic hypertension in the postintervention cohort (23.1% vs 32.1%, P=.005). The primary outcome occurred in 2.8% of patients in the postintervention group and in 11.0% of patients in the historical control group (adjusted odds ratio [aOR] 0.24, 95% CI 0.12-0.49, P<.001). A matched propensity score analysis controlling for chronic hypertension similarly demonstrated a significant reduction in the incidence of the primary outcome. Of the 255 patients (65.4%) who were compliant with outpatient remote BP monitoring, 53 (20.8%) had medication adjustments made per protocol at a median of 6 days (interquartile range 5-8 days) from delivery. Non-Hispanic Black race (aOR 3.42, 95% CI 1.68-6.97), chronic hypertension (aOR 2.09, 95% CI 1.13-3.89), having private insurance (aOR 3.04, 95% CI 1.06-8.72), and discharge on antihypertensive medications (aOR 2.39, 95% CI 1.33-4.30) were associated with requiring outpatient adjustments.

CONCLUSION

A standardized clinical assessment and management plan significantly reduced postpartum readmissions and ED visits for patients with hypertension. Close outpatient follow-up to ensure appropriate medication titration after discharge may be especially important in groups at high risk for readmission.

Neurological Complications in Pregnancy and the Puerperium: Methodology for a Clinical Diagnosis

Neurological complications in pregnancy and the puerperium deserve particular attention from specialists due to the worsening of the clinical picture for both the mother and the fetus. This narrative review of existing data in the literature aims to analyze the most common "red flag symptoms" attributable to neurological complications such as pre-eclampsia (PE), eclampsia, HELLP syndrome, posterior reversible encephalopathy syndrome (PRES), cerebral vasoconstriction syndrome (RCVS), stroke, CVS thrombosis, pituitary apoplexy, amniotic fluid embolism and cerebral aneurysm rupture, with the aim of providing a rapid diagnostic algorithm useful for the early diagnosis and treatment of these complications. The data were derived through the use of PubMed. The results and conclusions of our review are that neurological complications of a vascular nature in pregnancy and the puerperium are conditions that are often difficult to diagnose and manage clinically. For the obstetrics specialist who is faced with these situations, it is always important to have a guide in mind in order to be able to unravel the difficulties of clinical reasoning and promptly arrive at a diagnostic hypothesis.

Analysing patient-generated data to understand behaviours and characteristics of women with epilepsy of childbearing years: A prospective cohort study

BACKGROUND

Women with epilepsy (WWE) are vulnerable in pregnancy, with increased risks to mother and baby including teratogenic risks, especially from valproate. The free EpSMon mobile-phone app allows self-monitoring to afford patient-centred feedback on seizure related risks, such as sudden death in epilepsy (SUDEP) to its users. We sought to generate insights into various seizure related risks and its treatments in WWE of childbearing age (16 to 60 years ) using EpSMon.

METHODS

The study utilizes a prospective real-world cohort of 5.5 years. Patient reported data on demographics, medication taken, diagnoses, seizure types and recognised biological, psychological, and social factors of seizure related harm were extracted. Data was stratified according to frequent and infrequent users and those scoring lower and higher risk scores. Multivariate logistic regression and different statistical tests were conducted.

FINDINGS

Data from 2158 WWE of childbearing age encompassing 4016 self-assessments were analysed. Overall risk awareness was 25.3% for pregnancy and 54.1% for SUDEP. Frequent users were more aware of pregnancy risks but not of SUDEP. Repeated EpSMon use increased SUDEP awareness but not pregnancy risks. Valproate was used by 11% of WWE, ranging from 6.5% of younger to 31.5% of older women.

CONCLUSIONS

The awareness to risks to pregnancy, SUDEP and valproate is low. Valproate is being used by a significant minority. It is imperative risk communication continues for WWE based on their individual situation and need. This is unlikely to be delivered by current clinical models. Digital solutions hold promise but require work done to raise implementation and acceptability.

A Study of the Fluid Intake, Hydration Status, and Health Effects among Pregnant Women in Their Second Trimester in China: A Cross-Sectional Study

The fluid intake and hydration status during pregnancy may influence the health outcomes of both the mother and the fetus. However, there are few studies related to this. The aim of the present study was to investigate fluid intake behaviors among pregnant women in their second trimester, to evaluate their hydration status and pregnancy complications, and to further explore the association of fluid intake and the amniotic fluid index (AFI). Participants’ total fluid intake (TFI) levels were determined using a 7-day 24 h fluid intake questionnaire. The levels of water intake from food were not recorded or measured. Morning urine samples were collected, and both urine osmolality levels and urine specific gravity (USG) were tested to evaluate their hydration status. Fasting blood samples were also collected and measured for osmolality and complete blood count (CBC). A total of 324 participants completed the study. They were divided into four groups based on quartiles of TFI, including participants with lower (LFI1 and LFI2) and higher (HFI1 and HFI2) fluid intake levels. The median TFI was 1485 mL, and the median values of the four groups with different TFI levels were 1348, 1449, 1530, and 1609 mL, respectively. Only 3.4% of the participants attained the recommended value following an adequate water intake (1.7 L) level for pregnant women in China. Plain water was the main TFI resource (78.8~100.00%), and differences in the plain water intake levels among the four groups were evident (χ2 = 222.027, p < 0.05). The urine osmolality decreased sequentially with increasing TFI values from the LFI1 to HFI2 group, and significant differences in the urine osmolality levels among the four groups were evident (p < 0.05). Meanwhile, the percentage of dehydrated participants decreased from 26.8% in the LFI1 group to 0.0% in the HFI2 group (χ2 = 131.241, p < 0.05). Participants with higher TFI values had higher AFI values (χ2 = 58.386, all p < 0.05), and moderate-intensity correlations were found between TFI and urine osmolality, hydration status, and AFI (all p < 0.05). A large proportion of the participants had insufficient TFIs during the second trimester of pregnancy, and a proportion of the participants were dehydrated. The preliminary analysis showed that the AFI was correlated with the TFI during the second trimester of pregnancy. A sufficient TFI is necessary for pregnant women to improve their hydration status and may have effects on their health. The results can provide appropriate scientific references for the development of beneficial recommendations concerning adequate water intake levels for pregnant women in China.

Preeclampsia pathophysiology and adverse outcomes during pregnancy and postpartum

Background

Preeclampsia is a disease with far-reaching consequences that extend beyond the immediate postpartum period and have a significant impact later in life. Preeclampsia exerts an effect on most organ systems in the body. These sequelae are mediated in part by the incompletely elucidated pathophysiology of preeclampsia and the associated vascular changes.

Content

Current research focuses on unraveling the pathophysiology of preeclampsia with the goal of implementing accurate screening and treatment modalities based on disease development and progression. Preeclampsia causes significant short- and long-term maternal morbidity and mortality, not only in the cardiovascular system but also in other organ systems throughout the body. This impact persists beyond pregnancy and the immediate postpartum period.

Summary

The goal of this review is to discuss the current understanding of the pathophysiology of preeclampsia as it relates to the adverse health consequences in patients impacted by this disease, along with a brief discussion of ways to improve overall outcomes.

Hypertension in Pregnancy: What We Now Know

PURPOSE OF REVIEW

Hypertensive disorders of pregnancy remain a highly morbid condition that affects both the mother and fetus, complicate approximately 10% of pregnancies worldwide, and contribute to immediate and long-term cardiovascular outcomes. There is still much to learn regarding pathogenesis and treatment goals.

RECENT FINDINGS

There is updated information on the pathogenesis of preeclampsia and treatment thresholds for HTN in pregnancy. l-Kynurenine, a metabolite of the essential amino acid l-tryptophan, has been implicated in preeclampsia as decreased levels were found in a uninephrectomized pregnant mouse model of preeclampsia, where replacement of l-kynurenine rescued the preeclamptic state. Further, data from CHIPS (The Control of HTN in Pregnancy Study) and CHAP (Chronic HTN and Pregnancy) trials demonstrate not only the safety of lowering blood pressure to either a diastolic goal of 85 mmHg (CHIPS) or less than 160/105 mmHg (CHAP) without detriment to the fetus but the CHAPS trial has also shown a decrease in the rate of preeclampsia in the treatment group.

SUMMARY

We will summarize the different types of hypertensive disorders in pregnancy, updates on the pathogenesis of preeclampsia, and appropriate HTN management based on the latest evidence in order to better care for mother and child.

Hypertensive Disorders of Pregnancy

Hypertensive disorders in pregnancy are a leading cause of global maternal and fetal morbidity. The four hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. A careful history, review of systems, physical examination, and laboratory analysis can help differentiate these disorders and quantify the severity of the disease, which holds important implications for disease management. This article reviews the different types of disorders of hypertension in pregnancy and how to diagnose and manage these patients, with special attention paid to any recent changes made to this management algorithm.

Case fatality and factors associated with Maternal mortality in patients with eclampsia: A retrospective review of 761 cases in a tertiary institution in Nigeria

To determine the case fatality and factors associated with maternal mortality in patients with eclampsia in UMTH, we conducted a retrospective review of 761 consecutive cases of eclampsia managed UMTH, Nigeria, from 2005 to 2020. Case fatality was 7.6%, most being unbooked primigravidae with no formal education. Common causes of death identified were aspiration, cerebrovascular accident, and haemorrhage. Admission delayed >10 hours was found to be independently associated with maternal death, and Caesarean delivery.

Unfolding the role of placental-derived Extracellular Vesicles in Pregnancy: From homeostasis to pathophysiology

The human placenta is a critical structure with multiple roles in pregnancy, including fetal nutrition and support, immunological, mechanical and chemical barrier as well as an endocrine activity. Besides, a growing body of evidence highlight the relevance of this organ on the maternofetal wellbeing not only during gestation, but also from birth onwards. Extracellular vesicles (EVs) are complex macromolecular structures of different size and content, acting as carriers of a diverse set of molecules and information from donor to recipient cells. Since its early development, the production and function of placental-derived EVs are essential to ensure an adequate progress of pregnancy. In turn, the fetus receives and produce their own EVs, highlighting the importance of these components in the maternofetal communication. Moreover, several studies have shown the clinical relevance of EVs in different obstetric pathologies such as preeclampsia, infectious diseases or gestational diabetes, among others, suggesting that they could be used as pathophysiological biomarkers of these diseases. Overall, the aim of this article is to present an updated review of the published basic and translational knowledge focusing on the role of placental-derived EVs in normal and pathological pregnancies. We suggest as well future lines of research to take in this novel and promising field.

Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine

OBJECTIVE

To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol.

METHODS

This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity.

RESULTS

Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99).

CONCLUSION

Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.

Emergencies in obstetric anaesthesia: a narrative review

We conducted a narrative review in six areas of obstetric emergencies: category-1 caesarean section; difficult and failed airway; massive obstetric haemorrhage; hypertensive crisis; emergencies related to neuraxial anaesthesia; and maternal cardiac arrest. These areas represent significant research published within the last five years, with emphasis on large multicentre randomised trials, national or international practice guidelines and recommendations from major professional societies. Key topics discussed: prevention and management of failed neuraxial technique; role of high-flow nasal oxygenation and choice of neuromuscular drug in obstetric patients; prevention of accidental awareness during general anaesthesia; management of the difficult and failed obstetric airway; current perspectives on the use of tranexamic acid, fibrinogen concentrate and cell salvage; guidance on neuraxial placement in a thrombocytopenic obstetric patient; management of neuraxial drug errors, local anaesthetic systemic toxicity and unusually prolonged neuraxial block regression; and extracorporeal membrane oxygenation use in maternal cardiac arrest.

Effects of donor sperm on perinatal and neonatal outcomes resulting from in vitro fertilization-intracytoplasmic sperm injection and embryo transfer cycles: a retrospective cohort study

Background

The impact of donor sperm on pregnancy outcomes is controversial. The aim of this study was to investigate whether donor sperm in in vitro fertilization (IVF)/intracytoplasmic sperm injection (ICSI) treatment could reduce the rate of live births or increase the incidence of adverse pregnancy outcomes and birth defects in neonates.

Methods

This single-centre, retrospective cohort study included 1,559 patients with infertility who received donor sperm at our hospital from 2015 to 2019. All the patients received fresh embryos and underwent first-cycle transfer. After propensity score matching, 4,677 controls who received their partners’ sperm were matched at 1:3. Clinical pregnancy, perinatal, and neonatal outcomes were compared between the donor sperm and partner sperm groups.

Results

The embryo development was better in the donor sperm group than in the partner sperm group. The high-quality embryo and available embryo rates were significantly higher in the donor sperm group (P<0.05 for both groups). The rate of high-quality embryos transferred from the donor sperm group was higher than that from the partner sperm group (P<0.05). The clinical pregnancy (62.99% vs. 59.65%; P=0.02) and live birth (54.65% vs. 51.59%; P=0.036) rates were higher in the donor sperm group. After adjusting for confounding factors, no significant difference in live birth rates was observed between the two groups (adjusted P=0.057). The low birthweight (18.21% vs. 21.39%; P=0.023) and small for gestational age (SGA) (7.60% vs. 11.97%; P<0.001) rates were lower in the donor sperm group. To exclude the effect of multiple pregnancies, we evaluated neonatal outcomes of singleton pregnancies. No significant differences were noted in preterm and very preterm birth, SGA, mean birthweight, high birthweight, and low birth weight (LBW) and very low birth weight (VLBW) rates (P>0.05 for both groups). Further, no significant between group differences were observed in the ectopic pregnancy rate, early and late spontaneous abortion rates, gestational age, rate of large for gestational age (LGA), and neonatal defects.

Conclusions

Compared with partner sperm, donor sperm did not reduce live birth rate and did not increase neonatal LBW or low birth defects.

An exposure-response meta-analysis of ambient PM2.5 during pregnancy and preeclampsia

Relationships between PM_2.5 exposure and preeclampsia have been the focus of four recent systematic reviews and meta-analyses. We expand on knowledge gaps in these reviews by characterizing the shape of the exposure-outcome relationship, and by assessing the heterogeneity in these associations by study characteristics. Studies of PM_2.5 and preeclampsia were identified from reviews, and confounder-adjusted estimates were extracted. Estimates were derived using a random-effects model. Potential non-linearity was evaluated using a one-stage dose-response meta-analysis. Contrary to previous meta-analyses reporting stronger relationships, the overall adjusted relative risk (RR) for a 10 μg/m³ average increase in PM_2.5 during pregnancy and preeclampsia was modest and not statistically significant (RR: 1.07, 95% CI: 0.99-1.15). This was mainly attributable to inclusion/exclusion decisions for studies made during this review. In addition, there was no evidence of non-linearity, and no important sub-group differences by characteristics such as region, exposure assessment, participant exclusions, and early versus late-onset preeclampsia. Overall, our analysis suggests a modest relationship between ambient PM_2.5 and preeclampsia. We provide details on inclusion and exclusion decisions that were lacking in previous studies, and report novel investigations of non-linearity and heterogeneity.

Readmission for postpartum eclampsia in the United States

OBJECTIVE

To characterize the contemporary prevalence of eclampsia in the United States and determine whether eclampsia is taking place during the delivery hospitalization or a postpartum readmission.

STUDY DESIGN

We conducted a retrospective cohort using the 2016 Nationwide Readmission Database, a discharge database of all hospitalizations in 27 states in the U.S. Through the database, we identified women with an admission for delivery of a neonate > 20 weeks gestation. We also identified readmissions that occurred within 6 weeks after discharge from that delivery admission. ICD-10-CM codes were used to identify deliveries, eclampsia and co-morbidities. The primary outcome was timing of eclampsia relative to discharge from the delivery admission.

RESULTS

We identified 1,590,563 deliveries of which 2955 (0.19%) were complicated by eclampsia during the delivery admission or a postpartum readmission. Of these cases of eclampsia, 1575 (53.5%) occurred during the delivery admission, 1354 (45.8%) during a postpartum readmission and 26 (0.88%) during both the delivery and a postpartum readmission. Of the 1380 readmissions with eclampsia, 1117 (81%) occurred within the first week after delivery discharge. Another 194 (14%) occurred in the second week after discharge. Women with readmissions for eclampsia were older (30.1 vs. 28.8 years; p < .01), delivered earlier (37.7 vs. 38.5 weeks; p < .01), and more likely to have a cesarean delivery (48.4 vs. 32.4%; p < .01) or multiple gestation (4.0 vs. 1.8%; p < .01) as compared to those not readmitted for eclampsia and 44% had any hypertensive disorder during the delivery admission (vs. 12.2% without an eclampsia readmission; p < .01).

CONCLUSION

Of the 2955 cases of eclampsia identified, almost half of them occurred after discharge from the delivery admission, 95% of which occurred within the first 2 weeks after discharge, demonstrating the prominence of postpartum eclampsia which may warrant new strategies for prevention and education targeted at postpartum patients after delivery hospitalization.

High risk and low prevalence diseases: Eclampsia

INTRODUCTION

Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality.

OBJECTIVE

This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED).

DISCUSSION

Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required.

CONCLUSIONS

An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

Fetal Heart Rate Tracings Associated with Eclamptic Seizures

BACKGROUND

Although there is a well-known association of fetal bradycardia associated with maternal eclampsia, the characteristics of fetal heart rate tracings following an eclamptic seizure have not previously been thoroughly described. Fetal heart rate changes are thought to be related to maternal lactic acidemia caused by vasospasm and uterine hyperactivity leading to placental hypoperfusion and fetal hypoxia. The decision to intervene in the case of an abnormal fetal heart rate tracing following an eclamptic seizure is often difficult, however, maternal resuscitation should be the primary focus.

OBJECTIVE

Our aim was to quantify and characterize fetal heart rate changes associated with maternal eclamptic seizure. We also sought to document subsequent obstetrical management following these seizures complicated by fetal heart rate decelerations.

STUDY DESIGN

This was a retrospective study of fetal heart rate tracings associated with eclampsia during a 13-year period at a single institution. Eclampsia was diagnosed in accordance with criteria of the 2013 Executive Summary of the American College of Obstetricians and Gynecologists. Tracings were independently reviewed and classified by three physicians using National Institute of Child Health and Human Development Criteria. Hospital records were reviewed to ascertain obstetric management subsequent to the eclamptic seizure.

RESULTS

A total of 107 women were diagnosed with eclampsia from January 2009 to December 2021. Of these, 31 women experienced 34 intrapartum seizures during which time electronic fetal heart rate monitoring was ongoing. During the 34 seizures, fetal heart rate decelerations were documented in 79 percent. The mean duration of bradycardia was 5.8 ± 2.98 minutes with a range of 2 to 15 minutes. Fetal heart decelerations occurred on average 2.7 ± 1.6 minutes after the onset of the eclamptic seizure. In half of fetuses with fetal heart rate changes, fetal tachycardia followed, and in 48% there was minimal variability noted. As a result of the fetal heart rate tracings and clinical findings, 4 women underwent an emergent cesarean delivery including 2 that were diagnosed with a placental abruption. In this cohort, there were 4 cases of abruption. The mean duration from the seizure to delivery was 299 minutes ± 353 minutes. The mean neonatal cord pH was 7.2 ± 0.11 with a mean base excess of -8.6 mmol/L ± 4.4. There were no perinatal deaths.

CONCLUSION

Following an eclamptic seizure, 79 percent of fetuses demonstrated prolonged decelerations and half developedfetal tachycardia following recovery from the episode of bradycardia. Despite these periods of fetal heart rate decelerations associated with eclampsia, prioritization of maternal support and stabilization resulted in a favorable perinatal outcome without immediate operative intervention in over two-thirds of the cases..

Managing puerperium in patients with systemic autoimmune diseases: an update

INTRODUCTION

Puerperium is a critical period for patients affected by autoimmune rheumatic diseases for the risk of disease's flares and difficulties in treating lactating mothers. We want to summarize the literature data about psychological and pharmacological management of these patients and possible risk factors of disease's flares.

AREAS COVERED

We made a narrative review on recent studies about puerperium in rheumatic autoimmune diseases patients.

EXPERT OPINION

The physicians involved in management of patients during puerperium and in the follow-up of babies need to agree on maternal treatment because they need to reassure mothers about the safety of the prescribed medications. Furthermore, women with rheumatic diseases could present some musculoskeletal limitations and psychological problems, such as postpartum depression, which can lead to a sense of inadequacy to the mother's task. Families and physicians should be aware of these possible complications and support the new mothers providing correct counseling and practical help.

A One-Year Cross Sectional Analysis of Emergency Medical Services Utilization and Its Association with Hypertension in Pregnancy

Objective: To evaluate the prehospital obstetric population that utilizes emergency medical services (EMS) and their association with hypertensive disorders of pregnancy.Methods: We conducted a retrospective evaluation of one year of all medical calls from a large, municipal, midwestern fire department. Inclusion criteria included all pregnant patients transported to a hospital by EMS. Descriptive statistics were calculated to evaluate prehospital event information (e.g., zip code, time, and duration of call), patient characteristics, and clinical management data regarding blood pressure. Census data were used to compare neighborhood information with poverty rates.Results: Of the 1,575 identified patients, 64.4% (1015/1575) presented with obstetric complaints, 57.4% (700/1220) were in their third trimester and 72.7% (686/944) were multiparous. The median call duration was 17 (interquartile range 12-22) minutes. In the areas where EMS usage was highest, one quarter of individuals lived below the poverty level. Of the studied population, 32.0% (504/1575) were found to be hypertensive; 14.9% (75/504) of hypertensive patients were found to have severe hypertension. Only one patient (1/1575, 0.06%) presented with a chief complaint of hypertension; the rest were discovered by EMS. The highest rates of hypertension were noted in wealthier areas of the city. Patients with severe hypertension were more likely to present with seizures, consistent with eclampsia.Conclusion: Hypertension is common in the obstetric population using EMS. Prehospital management of hypertensive disorders of pregnancy may focus on identification and treatment of severe pre-eclampsia or eclampsia. Areas with longer call times may consider treatment of severe hypertension. Prehospital treatment of hypertensive disorders of pregnancy could be optimized.

Incidence and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm and term gestation: a population-based study

BACKGROUND

The majority of previous studies on severe preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome were hospital-based or included a relatively small number of women. Large, population-based studies examining gestational age-specific incidence patterns and risk factors for these severe pregnancy complications are lacking.

OBJECTIVE

This study aimed to assess the gestational age-specific incidence rates and risk factors for severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia.

STUDY DESIGN

We carried out a retrospective, population-based cohort study that included all women with a singleton hospital birth in Canada (excluding Quebec) from 2012 to 2016 (N=1,078,323). Data on the primary outcomes (ie, severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia) were obtained from delivery hospitalization records abstracted by the Canadian Institute for Health Information. A Cox regression was used to assess independent risk factors (eg, maternal age and chronic comorbidity) for each primary outcome and to assess differences in the effects at preterm vs term gestation (<37 vs ≥37 weeks).

RESULTS

The rates of severe preeclampsia (n=2533), hemolysis, elevated liver enzymes, and low platelet count syndrome (n=2663), and eclampsia (n=465) were 2.35, 2.47, and 0.43 per 1000 singleton pregnancies, respectively. The cumulative incidence of term-onset severe preeclampsia was lower than that of preterm-onset severe preeclampsia (0.87 vs 1.54 per 1000; rate ratio, 0.57; 95% confidence intervals, 0.53-0.62), the rates of hemolysis, elevated liver enzymes, and low platelet count syndrome were similar (1.32 vs 1.23 per 1000; rate ratio, 0.93; 95% confidence interval, 0.86-1.00), and the preterm-onset eclampsia rate was lower than the term-onset rate (0.12 vs 0.33 per 1000; rate ratio, 2.64; 95% confidence interval, 2.16-3.23). For each primary outcome, chronic comorbidity and congenital anomalies were stronger risk factors for preterm- vs term-onset disease. Younger mothers (aged <25 years) were at higher risk for severe preeclampsia at term and for eclampsia at all gestational ages, whereas older mothers (aged ≥35 years) had elevated risks for severe preeclampsia and hemolysis, elevated liver enzymes, and low platelet count syndrome. Regardless of gestational age, nulliparity was a risk factor for all outcomes, whereas socioeconomic status was inversely associated with severe preeclampsia.

CONCLUSION

The risk for severe preeclampsia declined at term, eclampsia risk increased at term, and hemolysis, elevated liver enzymes, and low platelet count syndrome risk was similar for preterm and term gestation. Young maternal age was associated with an increased risk for eclampsia and term-onset severe preeclampsia. Prepregnancy comorbidity and fetal congenital anomalies were more strongly associated with severe preeclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, and eclampsia at preterm gestation.

Disruption of the Blood-Brain Barrier by Extracellular Vesicles From Preeclampsia Plasma and Hypoxic Placentae: Attenuation by Magnesium Sulfate

[Figure: see text].

Guidelines for the management of women with severe pre-eclampsia

OBJECTIVE

To provide national guidelines for the management of women with severe pre-eclampsia.

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised.

METHODS

The last SFAR and CNGOF guidelines on the management of women with severe pre-eclampsia were published in 2009. The literature is now sufficient for an update. The aim of this expert panel guidelines is to evaluate the impact of different aspects of the management of women with severe preeclampsia on maternal and neonatal morbidities separately. The experts studied questions within 7 domains. Each question was formulated according to the PICO (Patients Intervention Comparison Outcome) model and the evidence profiles were produced. An extensive literature review and recommendations were carried out and analysed according to the GRADE® methodology.

RESULTS

The SFAR/CNGOF experts panel provided 25 recommendations: 8 have a high level of evidence (GRADE 1+/-), 9 have a moderate level of evidence (GRADE 2+/-), and for 7 recommendations, the GRADE method could not be applied, resulting in expert opinions. No recommendation was provided for 3 questions. After one scoring round, strong agreement was reached between the experts for all the recommendations.

CONCLUSIONS

There was strong agreement among experts who made 25 recommendations to improve practices for the management of women with severe pre-eclampsia.

Factors associated with anti-seizure medication utilization for eclamptic seizures: 1995-2015

OBJECTIVE

We sought to ascertain the drivers of the use of anti-seizure medications (ASMs) other than magnesium sulfate (MgSO4) in seizure management in a cohort of pregnant and postpartum women with eclamptic seizure.

METHODS

Cases of seizure activity attributed to eclampsia from 1995-2015 at 2 large urban academic medical centers were identified and reviewed by a neurologist and an obstetrician. Analyses focused on patterns of ASM utilization among women according to timing, recurrence, posterior reversible encephalopathy syndrome, and specialty consultation with additional sub-analysis focusing on recurrent seizures only.

RESULTS

93 cases of eclampsia were identified. 100% of subjects received MgSO4. 52% of women received an ASM in addition to MgSO4. Subjects with seizures occurring post-partum, with >1 seizure, or who had a formal neurology consult were more likely to receive an ASM in addition (risk ratio [RR] 3.05 [95% confidence interval [CI] [1.30-7.11], RR 3.01 [95% CI 1.29-7.02], and RR 6.29 [2.37, 16.71] respectively). Postpartum recurrent seizures or those receiving a neurology consult were also more likely to be treated with ASMs compared to recurrent or comanaged seizures occurring before delivery (RR 1.55 [1.02, 2.37] and 1.65 [1.02, 2.69]).

CONCLUSIONS

In this retrospective cohort, patients with atypical seizure presentation (e.g., postpartum and/or recurrent) and women who were comanaged with a neurologist were more likely to receive an ASM other than MgSO4.

Neurocritical care of the pregnant patient

INTRODUCTION

An estimated 0.1%-0.8% of obstetric patients require admission to an intensive care unit (ICU) during pregnancy or the puerperium. When neurologic emergencies occur in pregnancy, collaboration between the neurointensivist, obstetric anesthesiologist, and obstetrician is key in minimizing morbidity and mortality.

PRINCIPLES

Care of the critically ill pregnant patient mirrors that of the critically ill nonpregnant patient with some minor exceptions. Special care must be taken to consider the normal physiologic changes of pregnancy as well as possible fetal exposure to medical interventions. Timing and method of delivery must be carefully considered when caring for patients with neurologic emergencies. Common neurologic emergencies in pregnancy include hypertensive disorders of pregnancy, intracranial neoplasms, noneclamptic seizures, cerebrovascular disorders, and ventriculoperitoneal shunt malfunctions.

CONCLUSION

While neurologic emergencies in pregnancy are overall rare, when they do occur, they can be devastating. As in the nonpregnant population, prompt recognition and rapid intervention are crucial in optimizing patient outcomes. When neurologic emergencies occur in pregnancy, maternal and fetal care is optimized through a multidisciplinary care team.

Preeclampsia: The Need for a Biological Definition and Diagnosis

The centuries-old approach to the prevention of eclampsia and its associated maternal morbidity and mortality is based on the recognition of the presence of premonitory signs and symptoms such as hypertension and proteinuria. The spectrum of preceding signs and symptoms came to be known as preeclampsia, which is debatably considered to be an early stage on a clinical continuum possibly leading to eclampsia. The premonitory signs and symptoms were then construed as diagnostic criteria for the poorly understood syndrome of preeclampsia, and this led to a perpetual debate that remains subject to wide disagreement and periodic updates. In this commentary, we will draw attention to the fact that the criteria for preeclampsia should be viewed from the prism of a screening test rather than as diagnostic of a condition in itself. Focusing research on developing better diagnostic and screening methods for what is clinically important, namely maternal and perinatal morbidity and mortality from hypertensive disorders of pregnancy, a long overdue upgrade from what was possible centuries ago, will ultimately lead to better management approaches to what really matters.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Early-onset preeclampsia - The impact of antiphospholipid antibodies on disease severity

OBJECTIVES

Antiphospholipid antibodies have been associated with various obstetric complications, including recurrent pregnancy loss, preeclampsia, intrauterine growth restriction, placental insufficiency, and late fetal loss. Despite the amassed body of evidence emphasizing the association between antiphospholipid antibodies and preeclampsia, the severity of preeclampsia with regard to antiphospholipid antibodies status has not been elucidated. This study aimed to evaluate whether early-onset preeclampsia with severe features before 34 weeks' gestation is clinically different when associated with antiphospholipid antibodies.

STUDY DESIGN

In this retrospective case-control study, we collected data on pregnancy outcomes of 101 women with singleton pregnancies who delivered prior to 34 weeks of gestation due to preeclampsia with severe features. The antiphospholipid antibodies status of 55 of these women was available for analysis. The study group comprised 20 women with positive antiphospholipid antibodies (positive-aPL group), while the control group comprised 35 women without antiphospholipid antibodies (negative-aPL group). Obstetric and neonatal outcomes, laboratory results and pregnancy complications were extracted from medical records.

RESULTS

In the clinical setting of early-onset preeclampsia with severe features necessitating delivery before 34 weeks gestation, positive-aPL women were hospitalized earlier (29, IQR 26.3-32, vs. 32, IQR 28-33 weeks gestation, P = 0.05), gave birth at a significantly earlier gestational age (30, IQR 28.3-32.8 vs. 33, IQR 30-34, P = 0.02) with a lower mean birth-weight (1266.7 ± 579.6 vs. 1567.3 ± 539.7 g, P = 0.058) compared with negative-aPL women. Furthermore, platelet nadir was significantly lower for positive-aPL compared with negative-aPL women (97 ± 49×10³/µL vs. 141 ± 61×10³/µL, P < 0.001) and maximal serum creatinine was higher (1.0 ± 0.3 mg/dL vs. 0.9 ± 0.1 mg/dL, P = 0.03). Rates of neonatal complications were low and comparable between groups, except for higher rates of retinopathy of prematurity requiring treatment in the study group (30.0% vs. 5.7%, p = 0.02), and there was a trend for higher perinatal mortality among study group infants.

CONCLUSIONS

The presence of antiphospholipid antibodies in women with early-onset preeclampsia with severe features is associated with earlier, more severe disease course. Expedited screening for antiphospholipid antibodies in cases of early-onset severe preeclampsia may be considered, along with close monitoring for pregnant women with positive antibodies.

Acid Sensing Ion Channel 2a Is Reduced in the Reduced Uterine Perfusion Pressure Mouse Model and Increases Seizure Susceptibility in Pregnant Mice

Eclampsia is diagnosed in pregnant women who develop novel seizures. Our laboratory showed that the reduced uterine perfusion pressure (RUPP) rat model of preeclampsia displays reduced latency to drug-induced seizures. While acid sensing ion channels (ASIC1a and 3) are important for reducing seizure longevity and severity, the role of ASIC2a in mediating seizure sensitivity in pregnancy has not been investigated. We hypothesized that 1) RUPP reduces hippocampal ASIC2a, and 2) pregnant mice with reduced ASIC2a (ASIC2a+/-) have increased seizure sensitivity. On gestational day 18.5, hippocampi from sham and RUPP C57BL/6 mice were harvested, and ASIC2a was assessed using Western blot. Pregnant wild-type and ASIC2a+/- mice received 40 mg/kg of pentylenetetrazol (i.p.) and were video recorded for 30 min. Behaviors were scored using a modified Racine scale (0-7: 0 = no seizure; 7 = respiratory arrest/death). Seizure severity was classified as mild (score = 1-3) or severe (score = 4-7). RUPP mice had reduced hippocampal and placental ASIC2a protein. ASIC2a+/- mice had reduced latency to seizures, increased seizure duration, increased severe seizure duration, and higher maximum seizure scores. Reduced hippocampal ASIC2a in RUPP mice and increased seizure activity in pregnant ASIC2a+/- mice support the hypothesis that reduced ASIC2a increases seizure sensitivity associated with the RUPP.

Near miss: determinants of maternal near miss and perinatal outcomes: a prospective case control study from a tertiary care center of India

BACKGROUND/PURPOSE

To study the causes of maternal near miss and compared maternal and perinatal outcome of maternal near miss cases with controls (women with potential life-threatening complication [PLTC]) and maternal death.

METHODS

Mothers (n = 100) who fulfilled the WHO criteria for maternal near miss (MNM) were identified and enrolled in the study. Two controls for each near miss case were taken. This included the women who had same PLTC but did not reach near miss within one week of enrollment. The comparison of maternal and fetal outcome was done between the two groups and with the maternal death (MD) group, who presented initially as near miss.

RESULTS

Obstetric hemorrhage was the most common potential life-threatening complication in MNM and MD group. On multiple logistic regression analysis, we found that the presence of organ dysfunction was the independent predictor of near miss and need of mechanical ventilation and coagulation dysfunction as an independent predictor of maternal death. A mother in the near miss group or death group had a higher chance of giving birth to a still-born child (p = < 0.001). Risk of neonatal death after NICU admission was numerically more among near miss and death group than controls, although statistically insignificant (p > .05).

CONCLUSION

Despite making tremendous progress in obstetric care facilities at a tertiary level, developing countries need to strengthen primary care infrastructure and referral system. To improve maternal care, there should be the provision of health education for all pregnant women and antenatal services should be improved.

Preeclampsia and Increased Permeability Over the Blood-Brain Barrier: A Role of Vascular Endothelial Growth Receptor 2

BACKGROUND

Cerebral complications in preeclampsia are leading causes of maternal mortality worldwide but pathophysiology is largely unknown and a challenge to study. Using an in vitro model of the human blood-brain barrier (BBB), we explored the role of vascular endothelial growth factor receptor 2 (VEGFR2) in preeclampsia.

METHODS

The human brain endothelial cell line (hCMEC/D3) cultured on Tranwells insert was exposed (12 hours) to plasma from women with preeclampsia (n = 28), normal pregnancy (n = 28), and nonpregnant (n = 16) controls. Transendothelial electrical resistance (TEER) and permeability to 70 kDa fluorescein isothiocyanate (FITC)-dextran were measured for the assessment of BBB integrity. We explored possible underlying mechanisms, with a focus on the expression of tight junction proteins and phosphorylation of 2 tyrosine residues of VEGFR2, associated with vascular permeability and migration (pY951) and cell proliferation (pY1175). Plasma concentrations of soluble FMS-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were also measured.

RESULTS

hCMEC/D3 exposed to plasma from women with preeclampsia exhibited reduced TEER and increased permeability to 70 kDa FITC-dextran. These cells upregulated the messenger ribonucleic acid (mRNA) levels of VEGFR2, and pY951-VEGFR2, but reduced pY1175-VEGFR2 (P < 0.05 in all cases). No difference in mRNA expression of tight junction protein was observed between groups. There was no correlation between angiogenic biomarkers and BBB permeability.

CONCLUSIONS

We present a promising in vitro model of the BBB in preeclampsia. Selective tyrosine phosphorylation of VEGFR2 may participate in the increased BBB permeability in preeclampsia irrespective of plasma concentrations of angiogenic biomarkers.

Don't forget eclampsia in the efforts to reduce maternal morbidity and mortality

Hypertensive disorders are a leading cause of maternal morbidity and mortality worldwide. Despite advances in prevention and clinical management, women in low-resource countries continue to bear the burden of the sequelae of severe pre-eclampsia-eclampsia. Sustainable strategies to improve the care of women with hypertensive disease, to identify those at risk for hypertensive disease, and to reduce the risk of eclampsia will require partnerships between clinicians and health policy makers. Resources are needed to scale up healthcare access and infrastructure, establish evidence-based protocols for care, and ensure an adequate supply of equipment and drugs. Additionally, efforts for a sustained workforce of perinatal clinicians and staff trained in the assessment and management of hypertensive disease are needed. Effective postpartum care and monitoring are essential to prevent morbidity and mortality due to cardiovascular disease. Culturally appropriate strategies are needed to educate women and their families on the symptoms of pre-eclampsia to address delays in seeking care during pregnancy and postpartum. With targeted, sustained efforts and resources, eclampsia and its associated co-morbidities can be preventable.

Hypertensive Disorders of Pregnancy

"Pregnancy-induced hypertension" (HDP) describes a spectrum of disorders, including gestational hypertension, preeclampsia, and chronic hypertension with superimposed preeclampsia. Each of these disease processes can progress to a more pathologic case with worsening hypertensive disease, end-organ damage, and concerning clinical sequelae. Risk factors for HDP include nulliparity, a prior pregnancy complicated by hypertension, and obesity. Close blood pressure monitoring, serologic and urine testing, and prompt clinical follow-up remain the gold standard for antenatal diagnosis and surveillance. Optimizing maternal and neonatal outcomes involves early prenatal diagnosis, a multidisciplinary team-based approach, and referral to an experienced provider for cases with advanced pathology.

Hypertensive Disorders: Prevalence, Perinatal Outcomes and Cesarean Section Rates in Pregnant Women Hospitalized for Delivery

OBJECTIVE

 To evaluate the prevalence of hypertensive disorders, perinatal outcomes (preterm infants, low birthweight infants and Apgar score < 7 at the 5th minute and fetal deaths) and the cesarean rates in pregnant women hospitalized for delivery at the Maternidade Hilda Brandão da Santa Casa de Belo Horizonte, Belo Horizonte, state of Minas Gerais, Brazil, from March 1, 2008 to February 28, 2018.

METHODS

 A case-control study was performed, and the groups selected for comparison were those of pregnant women with and without hypertensive disorders. Out of the 36,724 women, 4,464 were diagnosed with hypertensive disorders and 32,260 did not present hypertensive disorders RESULTS:  The prevalence of hypertensive disorders was 12.16%; the perinatal outcomes and cesarean rates between the 2 groups with and without hypertensive disorders were: preterm infants (21.70% versus 9.66%, odds ratio [OR] 2.59, 95% confidence interval [CI], 2.40-2.80, p < 0.001); low birthweight infants (24.48% versus 10.56%; OR 2.75; 95% CI, 2.55-2.96; p < 0.001); Apgar score < 7 at the 5^th minute (1.40% versus 1.10%; OR 1.27; 95% CI, 0.97-1.67; p = 0.84); dead fetuses diagnosed prior to delivery (1.90% versus 0.91%; OR 2.12; 95% CI, 1.67-2.70; p < 0.001); cesarean rates (60.22% versus 31.21%; OR 3.34; 95% CI, 3.14-3.55; p < 0.001).

CONCLUSION

 Hypertensive disorders are associated with higher rates of cesarean deliveries and higher risk of preterm infants, low birthweight infants and a higher risk of fetal deaths.

Perinatal Survival and Predictors of Mortality among Mothers with Hypertensive Disorders of Pregnancy at Antenatal care Clinics in Gamo Zone Public Hospitals

BACKGROUND

Pregnancy induced hypertension represents a significant public health problem throughout the world, which may complicate 0.5%-10% of all pregnancies. It is the leading cause of maternal as well perinatal mortality and morbidity worldwide. Pregnancy induced hypertension is a multisystem disorder unique to pregnancy and results in high perinatal mortality. The objective of this study was to determine the survival status, incidence and predictors of perinatal mortality among mothers with pregnancy induced hypertension at antenatal clinics of Gamo Zone public hospitals.

METHODS

Facility-based retrospective cohort study was conducted among selected 576(192 exposed and 384 unexposed) antenatal care attendants' record at Gamo Zone public hospitals from 1st January 2018 to 31st December 2018. Data were entered into Epi data version 3.02 and exported to SPSS V 25 for analysis. Kaplan Meier survival curve together with log rank test was fitted to test the survival time. Statistical significance was declared at P-value ≤0.05 using cox proportional hazard model.

RESULT

The incidence of perinatal mortality was 124/1000 births. The cumulative proportion of surviving at the end of 4th, 8th, 12th and 16th weeks of follow-up among the exposed groups was 96.9%, 93.5%, 82.1% and 61.6% respectively whereas it was 99.5%, 98.9% and 98.5% at the end of 4th, 8th and 12th weeks of follow-up for the non-exposed groups respectively. Parity of ≥5(AHR: 6.3; 95%CI: 1.36,10.55), mothers who delivered at <34 weeks of gestation(AHR:7.8; 95%CI: 2.6,23.1), being preterm(AHR:6; 95%CI: 5.3,19.2), perinatal birth weight ≤2500gm(AHR:6.1; 95&CI: 1.01,37.9), vaginal deliveryn(AHR:2.7; 95%CI:1.13,6.84), maternal highest systolic blood pressure level ≥160mmHg (AHR: 2.3; 95%CI: 1.02,5.55) and prepartum onset of pregnancy induced hypertension (AHR: 6; 95%CI: 5.3,19.2) were statistically significant in multivariable analysis.

CONCLUSION

The risk of perinatal mortality was high among the mothers with pregnancy induced hypertension compared to those of pregnancy induced hypertension free mother,s and the perinatal mortality rate was high. High parity, low gestational age, low number of antenatal care visits, low birth weight, vaginal delivery, antepartum onset of pregnancy induced hypertension and highest maternal systolic blood pressure level were the independent predictors of perinatal mortality.

Evaluation of US State-Level Variation in Hypertensive Disorders of Pregnancy

IMPORTANCE

Hypertensive disorders of pregnancy are important causes of maternal and perinatal morbidity in the US. However, the extent of statewide variation in the prevalence of chronic hypertension, pregnancy-induced hypertension or preeclampsia, and eclampsia in the US remains unknown.

OBJECTIVE

To examine the extent of statewide variation in the prevalence of chronic hypertension, hypertensive disorders of pregnancy (including pregnancy-induced hypertension or preeclampsia), and eclampsia in the US.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional study using 2017 US birth certificate data was conducted from September 1, 2019, to February 1, 2020. A population-based sample of 3 659 553 women with a live birth delivery was included.

MAIN OUTCOMES AND MEASURES

State-specific prevalence of chronic hypertension, hypertensive disorders of pregnancy, and eclampsia was assessed using multilevel multivariable logistic regression, with the median odds ratio (MOR) to evaluate statewide variation.

RESULTS

Of the 3 659 553 women, 185 932 women (5.1%) were younger than 20 years, 727 573 women (19.9%) were aged between 20 and 24 years, 1 069 647 women (29.2%) were aged between 25 and 29 years, 1 037 307 women (28.3%) were aged between 30 and 34 years, 523 607 women (14.3%) were aged between 35 and 39 years, and 115 487 women (3.2%) were 40 years or older. Most women had Medicaid (42.8%) or private insurance (49.4%). Hawaii had the lowest adjusted prevalence of chronic hypertension (1.0%; 95% CI, 0.9%-1.2%), and Alaska had the highest (3.4%; 95% CI, 3.0%-3.9%). Massachusetts had the lowest adjusted prevalence of hypertensive disorders of pregnancy (4.3%; 95% CI, 4.1%-4.6%), and Louisiana had the highest (9.3%; 95% CI, 8.9%-9.8%). Delaware had the lowest adjusted prevalence of eclampsia (0.03%; 95% CI, 0.01%-0.09%), and Hawaii had the highest (2.8%; 95% CI, 2.2%-3.4%). The degree of statewide variation was high for eclampsia (MOR, 2.36; 95% CI, 1.88-2.82), indicating that the median odds of eclampsia were 2.4-fold higher if the same woman delivered in a US state with a higher vs lower prevalence of eclampsia. Modest variation between states was observed for chronic hypertension (MOR, 1.27; 95% CI, 1.20-1.33) and hypertensive disorders of pregnancy (MOR, 1.17; 95% CI, 1.13-1.21).

CONCLUSIONS AND RELEVANCE

The findings of this study suggest that after accounting for patient-level and state-level variables, substantial state-level variation exists in the prevalence of eclampsia. These data can inform future public-health inquiries to identify reasons for the eclampsia variability.

The emergence of a change in the prevalence of preeclampsia in a tertiary maternity unit (2004-2016)

BACKGROUND

Pre-eclampsia (PET) affects 2-3% of all pregnancies, rising to 5-7% in nulliparous women. This study aimed to investigate the prevalence of PET over a 13-year period.

METHODS

A retrospective review was performed over a 13-year period (2004-2016) via interrogation of the annual clinical reports of The Rotunda Hospital, Dublin.

RESULTS

There was a fall in the overall incidence of PET (nulliparous and multiparous), from a peak of 3.8% in 2007 to 1.5% in 2015. Comparing the first and second halves of the study time-period this decrease was statistically significant (p < .0001). In nulliparous women, the thirteen-year mean was 4.4% for the study period, with a similar observed reduction from a peak of 5.3% in 2005 to a trough of 2.4% in 2015.

DISCUSSION

In our institution, we have shown a decrease in preeclampsia rates over a 13-year period. While the reason for this trend remains unclear, a similar trend has been observed in another tertiary unit and additional research is required to explain the etiology behind these observations.

Pregnancy-related complications and risk of postpartum readmission for seizures and epilepsy: A national study

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.

Antepartum eclampsia with reversible cerebral vasoconstriction and posterior reversible encephalopathy syndromes

A 39-year-old pregnant woman was experienced thunderclap headache due to reversible cerebral vasoconstriction syndrome (RCVS) as a prodromal symptom. Two days after, she was brought to our hospital after an eclamptic seizure at 35 weeks of gestation. After management with magnesium sulphate, a cesarean delivery was performed, and passed without eclamptic seizure recurrence with calcium channel blocker (CCB) administration for hypertension and prophylaxis of another seizure. Antepartum eclampsia is sometimes complicated by headache as a prodromal symptom. Cerebrovascular diseases in the perinatal period include eclampsia, RCVS and posterior reversible encephalopathy syndrome, which have potentially overlapping pathologies. Here, we first report a case of overlapping those three diseases in the antepartum period. Our best literature review showed that antepartum RCVS is severe and has complications besides thunderclap headache, and there is a case report which CCB administration was shown to be effective in the treatment of antepartum RCVS. If thunderclap headache is recognized, prediction of eclampsia and getting better course of RCVS with CCB administration may be possible.

Clinical and Metabolic Responses to Magnesium Supplementation in Women with Polycystic Ovary Syndrome

We hypothesized that magnesium supplementation might help improve metabolic profiles and clinical symptoms of polycystic ovary syndrome (PCOS) through its role in insulin action. The present study aimed to investigate the effect of magnesium supplementation on metabolic profiles and levels of sex hormones in women with PCOS. In this parallel randomized, double-blind, placebo-controlled clinical trial, 60 women with PCOS aged 20-45 years were recruited. After stratification for body mass index (BMI), age, and types of medications, participants were randomly assigned to consume magnesium supplements (containing 250 mg magnesium oxide) or placebo for 8 weeks. To assess biochemical indicators, a venous blood sample was taken after an overnight fasting. The mean age of study participants was 26.4 years. We found that magnesium supplementation for 8 weeks among women with PCOS had favorable effects on BMI compared with the placebo group (changes from baseline in intervention group: - 0.31 ± 0.07 vs. 0.07 ± 0.09 kg/m² in control group). In addition, the supplementation lead to preventing the increase in waist circumference in intervention group compared with the control group (0.02 vs. 1.15 cm). No significant effects on glycemic variables and lipid profile were seen following the magnesium supplementation. A significant increase in serum LH levels in intervention group and a decrease in placebo group were observed (P = 0.01). Although we found a significant decrease in serum testosterone levels in intervention and placebo groups, comparing the changes between the two groups, a marginally significant difference in serum testosterone levels was found (51.65 vs. 47.80 in intervention, 43.41 vs. 39.46 in placebo, P = 0.08). A significant increase in serum dehydroepiandrogens (DHEA) (136.32 vs. 172.37 intervention, 102.74 vs. 120.15 placebo, P = 0.01) was seen in two groups. Magnesium supplementation had no significant effects on FSH, 17OH-progesteron, sex hormone-binding globulin (SHBG), and free androgen index (FAI) levels. We found evidence indicating that magnesium supplementation did not influence serum lipid profiles and glycemic indicators among women with PCOS. Magnesium supplementation resulted in reduced BMI and testosterone levels as well as increased DHEA concentrations in women with PCOS. Also, magnesium supplementation may increase serum LH levels. ClinicalTrials.gov IRCT registration no. NCT02178150.

Determinants of healthcare facility utilization for childbirth in Kuantan Singingi regency, Riau province, Indonesia 2017

BACKGROUND

Reducing maternal mortality ratio (MMR) is a high priority public health issue in developing countries such as Indonesia. The current MMR in Indonesia is 126/100,000 live births. Optimum use of available healthcare facilities for delivery can avert maternal deaths. This study aimed to determine the factors associated with healthcare facility utilization for childbirth in Kuantan Singingi regency, Riau province, Indonesia 2017.

METHODS

We conducted a community-based cross-sectional study in 15 sub-districts of Kuantan Singingi regency from May-June 2017. We selected 320 mothers from 15 sub-districts who delivered in the last 3 months (February-April 2017). Trained data enumerators collected the relevant data by using a pre-tested semi-structured questionnaire. We used Cox regression analysis to determine the factors associated with delivery at healthcare facilities. Prevalence Ratio (PR) with a 95% confidence interval (CI) for childbirth at healthcare facilities was the key outcome measure.

RESULTS

Only 54.4% (174) of the 320 mothers delivered at healthcare facilities. Knowledge about pregnancy danger signs (PR = 1.59, 95%CI:1.15-2.2), attitude towards healthcare services (PR = 0.79, 95%CI:0.33-1.89), and access to health care services (PR = 0.39, 95%CI:0.18-0.84) were the dominant factors of childbirth at healthcare facilities. There was an interaction between attitude and access to healthcare influencing delivery at healthcare facilities.

CONCLUSIONS

Utilization of healthcare facilities for childbirth was low in Kuantan Singingi regency. Knowledge of pregnancy danger signs was an independent correlate of childbirth at healthcare facilities. Also, the interaction between attitude and access to healthcare showed a significant influence on childbirth at healthcare facilities. We recommend strengthening of existing maternal and child health program with a particular emphasis on complete and quality antenatal care, health education on danger signs of pregnancy and childbirth, and promoting positive attitudes towards healthcare facilities.

Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study

OBJECTIVE

To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE.

STUDY DESIGN

This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission.

RESULTS

In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women.

CONCLUSION

Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.

Exploring the Use of Telemonitoring for Patients at High Risk for Hypertensive Disorders of Pregnancy in the Antepartum and Postpartum Periods: Scoping Review

Background

High blood pressure complicates 2% to 8% of pregnancies, and its complications are present in the antepartum and postpartum periods. Blood pressure during and after pregnancy is routinely monitored during clinic visits. Some guidelines recommend using home blood pressure measurements for the management and treatment of hypertension, with increased frequency of monitoring for high-risk pregnancies. Blood pressure self-monitoring may have a role in identifying those in this high-risk group. Therefore, this high-risk pregnancy group may be well suited for telemonitoring interventions.

Objective

The aim of this study was to explore the use of telemonitoring in patients at high risk for hypertensive disorders of pregnancy (HDP) during the antepartum and postpartum periods. This paper aims to answer the following question: What is the current knowledge base related to the use of telemonitoring interventions for the management of patients at high risk for HDP?

Methods

A literature review following the methodological framework described by Arksey et al and Levac et al was conducted to analyze studies describing the telemonitoring of patients at high risk for HDP. A qualitative study, observational studies, and randomized controlled trials were included in this scoping review.

Results

Of the 3904 articles initially identified, 20 met the inclusion criteria. Most of the studies (13/20, 65%) were published between 2017 and 2018. In total, there were 16 unique interventions described in the 20 articles, all of which provide clinical decision support and 12 of which are also used to facilitate the self-management of HDP. Each intervention’s design and process of implementation varied. Overall, telemonitoring interventions for the management of HDP were found to be feasible and convenient, and they were used to facilitate access to health services. Two unique studies reported significant findings for the telemonitoring group, namely, spontaneous deliveries were more likely, and one study, reported in two papers, described inductions as being less likely to occur compared with the control group. However, the small study sample sizes, nonrandomized groups, and short study durations limit the findings from the included articles.

Conclusions

Although current evidence suggests that telemonitoring could provide benefits for managing patients at high risk for HDP, more research is needed to prove its safety and effectiveness. This review proposes four recommendations for future research: (1) the implementation of large prospective studies to establish the safety and effectiveness of telemonitoring interventions; (2) additional research to determine the context-specific requirements and patient suitability to enhance accessibility to healthcare services for remote regions and underserved populations; (3) the inclusion of privacy and security considerations for telemonitoring interventions to better comply with healthcare information regulations and guidelines; and (4) the implementation of studies to better understand the effective components of telemonitoring interventions.

Associations between hydration state and pregnancy complications, maternal-infant outcomes: protocol of a prospective observational cohort study

BACKGROUND

Water requirements increases with gestational age. Insufficient water intake causes dehydration, which may adversely affect maternal health and birth outcomes. However, few related studies have been conducted. The purposes are to assess the water intake and hydration state among pregnant women, and to investigate the associations with pregnancy complications and maternal and infant outcomes.

METHODS

A prospective observational cohort study will be applied. A total of 380 pregnant women will be recruited from the First Affiliated Hospital of Hainan Medical University. Hydration biomarkers and health outcomes will be tested during 15~17 weeks' gestation, 20~22 weeks' gestation, 30~32 weeks' gestation, during childbirth and 42 days after childbirth. Daily fluid intake will be collected using a 24-h fluid intake record for 7 consecutive days. A semi-quantified food frequency method will be used to assess food intake and water intake from food. Anthropometric measurement will be taken following standardized processes. Intracellular fluid (ICF) and extracellular fluid (ECF) will be measured using a body composition analyzer. Morning fasting urine and blood osmolality will be tested by laboratory physicians using an osmotic pressure molar concentration meter. Pregnancy complications will be assessed and diagnosed throughout pregnancy and childbirth. Maternal-infant outcomes will be monitored using related indicators and technologies. In order to explore the internal mechanism and interactions from the perspective of endocrine, pregnancy related hormones (estradiol, prolactin, progesterone) and the hydration-related hormones (copeptin) will be tested during pregnancy. A mixed model of repeated measures ANOVA will be analyzed using SAS 9.2.

RESULTS

The results may provide basic data on water intake among pregnant women. The association between hydration state and maternal-infant outcomes will also be explored.

CONCLUSIONS

This preliminary exploratory study findings will fill the gaps in the research on water intake, hydration and maternal health, birth outcomes, provide scientific reference data for updating recommendation on water adequate intake among pregnant women, and provide suggestion for developing water intake interventions.

TRIAL REGISTRATION

The protocol has been registered on the website of Chinese Clinical Trial Registry. The Identifier code is ChiCTR1800019284. The Registry date is 3 November, 2018. Registry name is "Study for the correlation between hydration state and pregnancy complications, maternal and infant outcomes during pregnancy".