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Sampson R, Davis S, Wong R, Baranco N, Silverman RK. Pulse Pressure as a Hemodynamic Parameter in Preeclampsia with Severe Features Accompanied by Fetal Growth Restriction. J Clin Med 2024; 13:4318. [PMID: 39124585 PMCID: PMC11312723 DOI: 10.3390/jcm13154318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
Background: Modern management of preeclampsia can be optimized by tailoring the targeted treatment of hypertension to an individual's hemodynamic profile. Growing evidence suggests different phenotypes of preeclampsia, including those with a hyperdynamic profile and those complicated by uteroplacental insufficiency. Fetal growth restriction (FGR) is believed to be a result of uteroplacental insufficiency. There is a paucity of research examining the characteristics of patients with severe preeclampsia who do and who do not develop FGR. We aimed to elucidate which hemodynamic parameters differed between these two groups. Methods: All patients admitted to a single referral center with severe preeclampsia were identified. Patients were included if they had a live birth at 23 weeks of gestation or higher. Multiple gestations and pregnancies complicated by fetal congenital anomalies and/or HELLP syndrome were excluded. FGR was defined as a sonographic estimation of fetal weight (EFW) < 10th percentile or abdominal circumference (AC) < 10th percentile. Results: There were 76% significantly lower odds of overall pulse pressure upon admission for those with severe preeclampsia comorbid with FGR (aOR = 0.24, 95% CI = 0.07-0.83). Advanced gestational age on admission was associated with lower odds of severely abnormal labs and severely elevated diastolic blood pressure in preeclampsia also complicated by FGR. Conclusions: Subtypes of preeclampsia with and without FGR may be hemodynamically evaluated by assessing pulse pressure on admission.
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Affiliation(s)
- Rachael Sampson
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Sidney Davis
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Roger Wong
- Department of Public Health and Preventive Medicine, Norton College of Medicine, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
- Department of Geriatrics, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Nicholas Baranco
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
| | - Robert K. Silverman
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, State University of New York Upstate Medical University, Syracuse, NY 13210, USA
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2
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Improving treatment of severe hypertension in pregnancy and postpartum using a hypertensive pathway. Pregnancy Hypertens 2022; 30:1-6. [DOI: 10.1016/j.preghy.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 07/25/2022] [Accepted: 07/26/2022] [Indexed: 11/18/2022]
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Umamah F, Santoso B, Yunitasari E, Nisa F, Wulandari Y. The effectiveness of psycho-educational counseling in pregnant women with preeclampsia: A systematic review. J Public Health Res 2022; 11:22799036221104161. [PMID: 35911429 PMCID: PMC9335477 DOI: 10.1177/22799036221104161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 02/20/2022] [Indexed: 11/15/2022] Open
Abstract
Pre-eclampsia is one of the main causes of maternal mortality, premature birth and low birth weight in developing countries. In addition, this condition can lead to chronic diseases (including cardiovascular and renal diseases) in postpartum mothers. The purpose of this study was to review the effectiveness of psycho-educational counseling in pregnant women with preeclampsia. The methods of this study were using PRISMA guidelines, databases from Scopus, PubMed and ScienceDirect, were published 2016 until 2020, yielded 65 articles. The keywords were retrieved from Medical Subject Heading (Mesh). The results showed interventions were given during the treatment period ranges from cognitive-behavioral counseling group that received four 1.5-h counseling sessions and the solution-focused counseling that received three 1.5-h counseling sessions, which were held weekly. This systematic review concludes that improving prenatal empowerment and self-care enable mothers to experience fewer complications in this period of their life. Thus, psycho-educational provides an excellent opportunity for educating and counseling pregnant women to promote maternal and neonatal health and psychological well-being.
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Affiliation(s)
- Faridah Umamah
- Faculty of Nursing, Universitas Airlangga, Surabaya, East Java, Indonesia
- Faculty of Nursing and Midwifery Universitas NU Surabaya, Surabaya, East Java, Indonesia
| | - Budi Santoso
- Faculty of Medicine, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Esti Yunitasari
- Faculty of Nursing, Universitas Airlangga, Surabaya, East Java, Indonesia
| | - Fauziyatun Nisa
- Faculty of Nursing and Midwifery Universitas NU Surabaya, Surabaya, East Java, Indonesia
| | - Yuanita Wulandari
- Faculty of Health Science, Muhammadiyah University of Surabaya, Surabaya, East Java, Indonesia
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4
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Zhang H, Wang W. Risk factors and adverse pregnancy outcomes in older pregnant women with hypertensive disorders of pregnancy. J Obstet Gynaecol Res 2022; 48:1710-1720. [PMID: 35596590 DOI: 10.1111/jog.15295] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 04/02/2022] [Accepted: 05/06/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND To assess the independent risk factors and pregnancy outcomes of hypertensive disorders of pregnancy (HDPs) in Chinese advanced age pregnancy women. DESIGN Secondary analysis of international published data. MATERIALS AND METHODS PubMed, Web of Science, Scopus, Embase, Cochrane library, and Chinese databases from inception to February 23, 2022 were searched to identify eligible studies. Meta-analysis was conducted to provide meaningful summative outcomes. The quality evaluation of included study was performed. The analyses were done with Review Manager 5.3 and Stata 14.0 software. RESULTS Totally, 13 eligible articles were included, among which 3 articles investigated the risk factors, 6 articles studied pregnancy outcomes, and 4 articles examined both risk factors and pregnancy outcomes. Chinese older pregnant women with the HDPs had high pooled incidences of abnormal body mass index, maternal education, family history of hypertension, history of chronic hypertension, gestational diabetes, irregular delivery inspection, psychosocial factors, and primiparity compared to those without HDPs. The incidence of cesarean delivery, placental abruption, premature rupture of membranes, postpartum hemorrhage, preterm birth, fetal asphyxia, fetal distress, fetal growth restriction, and low birth weight in Chinese older pregnant women with HPDs were significantly higher than those without HDPs. CONCLUSION This study identified several possible risk factors which promoted the onset of HDPs in Chinese older pregnant women, and HDPs significantly increases risk of adverse pregnancy outcomes (APOs). Further research is needed to take targeted measures to prevent HDPs and explore efficient management methods to minimize the risk of APOs associated with HDPs in Chinese older pregnant women.
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Affiliation(s)
- Huijuan Zhang
- International Inpatient Department, Zhongshan Hospital Affiliated to Dalian University, Dalian City, Liaoning Province, China
| | - Wei Wang
- International Inpatient Department, Zhongshan Hospital Affiliated to Dalian University, Dalian City, Liaoning Province, China
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Bui LN, Marshall C, Miller-Rosales C, Rodriguez HP. Hospital Adoption of Electronic Decision Support Tools for Preeclampsia Management. Qual Manag Health Care 2022; 31:59-67. [PMID: 34048375 PMCID: PMC8626519 DOI: 10.1097/qmh.0000000000000328] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Electronic health record (EHR)-based clinical decision support tools can improve the use of evidence-based clinical guidelines for preeclampsia management that can reduce maternal mortality and morbidity. No study has investigated the organizational capabilities that enable hospitals to use EHR-based decision support tools to manage preeclampsia. OBJECTIVE To examine the association of organizational capabilities and hospital adoption of EHR-based decision support tools for preeclampsia management. METHODS Cross-sectional analyses of hospitals providing obstetric care in 2017. In total, 739 hospitals responded to the 2017-2018 National Survey of Healthcare Organizations and Systems (NSHOS) and were linked to the 2017 American Hospital Association (AHA) Annual Survey Database and the Area Health Resources File (AHRF). A total of 425 hospitals providing obstetric care across 49 states were included in the analysis. The main outcome was whether a hospital adopted EHR-based clinical decision support tools for preeclampsia management. Hospital organizational capabilities assessed as predictors include EHR functions, adoption of evidence-based clinical treatments, use of quality improvement methods, and dissemination processes to share best patient care practices. Logistic regression estimated the association of hospital organizational capabilities and hospital adoption of EHR-based decision support tools to manage preeclampsia, controlling for hospital structural and patient sociodemographic characteristics. RESULTS Two-thirds of the hospitals (68%) adopted EHR-based decision support tools for preeclampsia, and slightly more than half (56%) of hospitals had a single EHR system. Multivariable regression results indicate that hospitals with a single EHR system were more likely to adopt EHR-based decision support tools for preeclampsia (17.4 percentage points; 95% CI, 1.9 to 33.0; P < .05) than hospitals with a mixture of EHR and paper-based systems. Compared with hospitals having multiple EHRs, on average, hospitals having a single EHR were also more likely to adopt the tools by 9.3 percentage points, but the difference was not statistically significant (95% CI, -1.3 to 19.9). Hospitals with more processes to aid dissemination of best patient care practices were also more likely to adopt EHR-based decision-support tools for preeclampsia (0.4 percentage points; 95% CI, 0.1 to 0.6, for every 1-unit increase in dissemination processes; P < .01). CONCLUSION Standardized EHRs and policies to disseminate evidence are foundational hospital capabilities that can help advance the use of EHR-based decision support tools for preeclampsia management in the approximately one-third of US hospitals that still do not use them.
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Affiliation(s)
- Linh N. Bui
- Center for Healthcare Organizational and Innovation Research (Drs Bui, Rodriguez, and Miller-Rosales) and Maternal, Child, and Adolescent Health Program (Dr Marshall), School of Public Health, University of California, Berkeley
| | - Cassondra Marshall
- Center for Healthcare Organizational and Innovation Research (Drs Bui, Rodriguez, and Miller-Rosales) and Maternal, Child, and Adolescent Health Program (Dr Marshall), School of Public Health, University of California, Berkeley
| | - Chris Miller-Rosales
- Center for Healthcare Organizational and Innovation Research (Drs Bui, Rodriguez, and Miller-Rosales) and Maternal, Child, and Adolescent Health Program (Dr Marshall), School of Public Health, University of California, Berkeley
| | - Hector P. Rodriguez
- Center for Healthcare Organizational and Innovation Research (Drs Bui, Rodriguez, and Miller-Rosales) and Maternal, Child, and Adolescent Health Program (Dr Marshall), School of Public Health, University of California, Berkeley
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Zhu H, Yang Y, Xu Y, Deng X, Yan J, Li T, Sang H, Li X, Hu R, Gu W. Effect of a quality improvement intervention with safety-based checklists for perinatal health of hypertension disorders in pregnancy. Int J Gynaecol Obstet 2021; 157:375-382. [PMID: 34368966 DOI: 10.1002/ijgo.13862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 08/06/2021] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To improve perinatal management for hypertensive disorders in pregnancy (HDP) using checklists. METHODS A pre-post evaluation of the implementation of checklists was performed. The checklist for HDP was adapted for the local context through expert consultations and had been used within peripartum since September 2017. Data of 763 women with singleton pregnancies diagnosed with HDP were collected between April 2016 and March 2019 at the Obstetrics & Gynecology Hospital of Fudan University. The monitoring and control groups consisted of 394 and 369 cases, respectively. Analysis was carried out by intention-to-treat with respect to maternal and fetal complications and delivery outcomes. RESULTS After the implementation of the checklists, patients had a significant reduction in anti-hypertensive treatment both orally (P = 0.028) and intravenously (P = 0.003), and increased utilization rate of MgSO4 management (P < 0.001). Gestation was prolonged in the expectant treatment (P = 0.012) and the rate of elective and intrapartum cesarean delivery decreased (P < 0.001 and P = 0.001, respectively). The neonates of these patients had a low rate of admission to the neonatal intensive care unit (P < 0.001). CONCLUSION National clinical guidelines complied critically after the implementation of the checklists. These checklists could be used for improving the quality of the clinical strategy and treatment, which benefitted perinatal management.
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Affiliation(s)
- Hao Zhu
- Department of Obstetrics, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Yijia Yang
- Department of Obstetrics, Shanghai Changning Maternity & Infant Health Hospital, Shanghai, China
| | - Yi Xu
- Department of Obstetrics, Zhengzhou Maternity & Infant Health Hospital, Henan, China
| | - Xia Deng
- Department of Obstetrics, Cixi Maternity & Infant Health Hospital, Zhejiang, China
| | - Jie Yan
- Department of Obstetrics, The Second Affiliated Hospital of Sichuan University, Sichuan, China
| | - Tao Li
- Department of Obstetrics, The Second Affiliated Hospital of Sichuan University, Sichuan, China
| | - Huige Sang
- Department of Obstetrics, The Second People's Hospital of Pingdingshan, Henan, China
| | - Xiaotian Li
- Department of Obstetrics, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Rong Hu
- Department of Obstetrics, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
| | - Weirong Gu
- Department of Obstetrics, Obstetrics & Gynecology Hospital of Fudan University, Shanghai, China
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Mullan SJ, Vricella LK, Edwards AM, Powel JE, Ong SK, Li X, Tomlinson TM. Pulse pressure as a predictor of response to treatment for severe hypertension in pregnancy. Am J Obstet Gynecol MFM 2021; 3:100455. [PMID: 34375751 DOI: 10.1016/j.ajogmf.2021.100455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Pulse pressure is a proposed means of tailoring antihypertensive therapy for treatment of acute-onset, severe hypertension in pregnancy. OBJECTIVE This study aimed to determine whether pulse pressure predicts response to the various first-line antihypertensive medications. STUDY DESIGN This is a retrospective cohort study from a single academic tertiary care center between 2015 and 2018. Patients were screened for inclusion if they had severe hypertension (defined as systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg) lasting at least 15 minutes and were initially treated with intravenous labetalol, intravenous hydralazine, or immediate-release oral nifedipine. If a patient had multiple episodes of acute treatment during the pregnancy, only one episode was included in the analysis. The primary outcome was time to resolution (in minutes) of severe hypertension. To adjust for factors that may have affected time to resolution, we first compared baseline characteristics on the basis of the antihypertensive agent received. We then assessed the association between baseline characteristics and resolution of severe hypertension within 60 minutes of treatment. Regression analysis incorporated pulse pressure and antihypertensive agents into a model to predict resolution within 60 minutes of onset of severe hypertension. RESULTS A total of 479 women hospitalized with severe maternal hypertension met the inclusion criteria. Hydralazine was the initial antihypertensive agent administered to 113 women, whereas 233 received labetalol, and 133 received nifedipine. Those who initially received nifedipine had a shorter mean time to resolution of severe hypertension (32.6 minutes vs 46.3 for hydralazine and 50.3 for labetalol; P<.01) and were more likely to have resolution of severe hypertension within 60 minutes (91.0% vs 77.9% for hydralazine and 76.8% for labetalol; P<.01). Nifedipine also resulted in a lower mean posttreatment blood pressure. Regression analysis revealed that a lack of resolution of severe hypertension within 60 minutes was independently associated with 2 measures of hypertension severity (mean arterial pressure of ≥125 mm Hg and the need for ≥2 doses of medication) and pulse pressure of >75 mm Hg at the time of treatment, initial treatment with labetalol, and gestational age of <37 weeks at the time of the hypertensive event (or at delivery if treatment was after delivery). The model's bias-corrected bootstrapped area under the receiver operating characteristic curve was 0.85 (95% confidence interval, 0.79-0.88). Interaction terms between pulse pressure and each antihypertensive agent were not significant and therefore not incorporated into the final model. CONCLUSION Pulse pressure did not predict response to the various first-line antihypertensive agents. Initial treatment with oral nifedipine was associated with a higher likelihood of resolution of severe hypertension within 60 minutes of treatment than with intravenous labetalol.
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Affiliation(s)
- Samantha J Mullan
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO.
| | - Laura K Vricella
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Alexandra M Edwards
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Jennifer E Powel
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Samantha K Ong
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Xujia Li
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
| | - Tracy M Tomlinson
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Women's Health, Saint Louis University School of Medicine, Saint Louis, MO
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Schneider P, Lee King PA, Keenan-Devlin L, Borders AEB. Improving the Timely Delivery of Antihypertensive Medication for Severe Perinatal Hypertension in Pregnancy and Postpartum. Am J Perinatol 2021; 38:983-992. [PMID: 33934326 DOI: 10.1055/s-0041-1728835] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Sustained blood pressures ≥160/110 during pregnancy and the postpartum period require timely antihypertensive therapy. Hospital-level experiences outlining the efforts to improve timely delivery of care within 60 minutes have not been described. The objective of this analysis was to assess changes in care practices of an inpatient obstetrical health care team following the implementation of a quality improvement initiative for severe perinatal hypertension during pregnancy and the postpartum period. STUDY DESIGN In January 2016, NorthShore University HealthSystem Evanston Hospital launched a quality improvement initiative focusing on perinatal hypertension, as part of a larger, statewide quality initiative via the Illinois Perinatal Quality Collaborative. We performed a retrospective cohort study of all pregnant and postpartum patients with sustained severely elevated blood pressure (two severely elevated blood pressures ≤15 minutes apart) with baseline data from 2015 and data collected during the project from 2016 through 2017. Changes in clinical practice and outcomes were compared before and after the start of the project. Statistical process control charts were used to demonstrate process-behavior changes over time. RESULTS Comparing the baseline to the last quarter of 2017, there was a significant increase in the administration of medication within 60 minutes for severe perinatal hypertension (p <0.001). Implementation of a protocol for event-specific debriefing for each severe perinatal hypertension episode was associated with increased odds of the care team administering medication within 60 minutes of the diagnosis of severe perinatal hypertension (adjusted odds ratio 3.20, 95% confidence interval 1.73-5.91, p < 0.01). CONCLUSION Implementation of a quality improvement initiative for perinatal hypertension associated with pregnancy and postpartum improved the delivery of appropriate and timely therapy for severely elevated blood pressures and demonstrated the impact of interdisciplinary communication in the process. KEY POINTS · Process of hospital-level implementation of a state quality improvement initiative.. · Evidence of improvement in care delivery for severe perinatal hypertension (HTN).. · Episode related debriefing by the clinical team improved perinatal HTN care..
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Affiliation(s)
- Patrick Schneider
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, Evanston Hospital, NorthShore University HealthSystem/University of Chicago, Evanston, Illinois
| | - Patricia Ann Lee King
- Feinberg School of Medicine, Center for HealthCare Studies, Northwestern University, Chicago, Illinois
| | - Lauren Keenan-Devlin
- Department of Obstetrics and Gynecology, NorthShore University HealthSystem, Evanston, Illinois
| | - Ann E B Borders
- Department of Obstetrics and Gynecology, Pritzker School of Medicine, Evanston Hospital, NorthShore University HealthSystem/University of Chicago, Evanston, Illinois
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von Dadelszen P, Vidler M, Tsigas E, Magee LA. Management of Preeclampsia in Low- and Middle-Income Countries: Lessons to Date, and Questions Arising, from the PRE-EMPT and Related Initiatives. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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10
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Nicholson WK, Stones W, Visser GHA, Barnea ER, Nassar AH. Don't forget eclampsia in the efforts to reduce maternal morbidity and mortality. Int J Gynaecol Obstet 2021; 152:165-171. [PMID: 33314067 DOI: 10.1002/ijgo.13530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/09/2020] [Accepted: 12/09/2020] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Wanda K Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
| | - William Stones
- Departments of Public Health and Obstetrics and Gynecology, Malawi College of Medicine, Blantyre, Malawi
| | | | - Eytan R Barnea
- SIEP, The Society for the Investigation of Early Pregnancy, New York, NY, USA
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
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- International Federation of Gynecology and Obstetrics (FIGO), London, UK
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Ota E, da Silva Lopes K, Middleton P, Flenady V, Wariki WM, Rahman MO, Tobe-Gai R, Mori R. Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2020; 12:CD009599. [PMID: 33336827 PMCID: PMC8078228 DOI: 10.1002/14651858.cd009599.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women. METHODS We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence. MAIN RESULTS We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. AUTHORS' CONCLUSIONS While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.
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Affiliation(s)
- Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University , Tokyo, Japan
| | | | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Australia
| | - Windy Mv Wariki
- Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
| | - Md Obaidur Rahman
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | | | - Rintaro Mori
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Kantorowska A, Heiselman CJ, Halpern TA, Akerman MB, Elsayad A, Muscat JC, Sicuranza GB, Vintzileos AM, Heo HJ. Identification of factors associated with delayed treatment of obstetric hypertensive emergencies. Am J Obstet Gynecol 2020; 223:250.e1-250.e11. [PMID: 32067968 DOI: 10.1016/j.ajog.2020.02.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND Obstetric hypertensive emergency is defined as having systolic blood pressure ≥160 mm Hg or diastolic blood pressure ≥110 mm Hg, confirmed 15 minutes apart. The American College of Obstetricians and Gynecologists recommends that acute-onset, severe hypertension be treated with first line-therapy (intravenous labetalol, intravenous hydralazine or oral nifedipine) within 60 minutes to reduce risk of maternal morbidity and death. OBJECTIVE Our objective was to identify barriers that lead to delayed treatment of obstetric hypertensive emergency. STUDY DESIGN A retrospective cohort study was performed that compared women who were treated appropriately within 60 minutes vs those with delay in first-line therapy. We identified 604 patients with discharge diagnoses of chronic hypertension, gestational hypertension, or preeclampsia using International Classification of Diseases-10 codes and obstetric antihypertensive usage in a pharmacy database at 1 academic institution from January 2017 through June 2018. Of these, 267 women (44.2%) experienced obstetric hypertensive emergency in the intrapartum period or within 2 days of delivery; the results from 213 women were used for analysis. We evaluated maternal characteristics, presenting symptoms and circumstances, timing of hypertensive emergency, gestational age at presentation, and administered medications. Chi square, Fisher's exact, Wilcoxon rank-sum, and sample t-tests were used to compare the 2 groups. Univariable logistic regression was applied to determine predictors of delayed treatment. Multivariable regression model was also performed; C-statistic and Hosmer and Lemeshow goodness-of-fit test were used to assess the model fit. A result was considered statistically significant at P<.05. RESULTS Of the 213 women, 110 (51.6%) had delayed treatment vs 103 (48.4%) who were treated within 60 minutes. Patients who had delayed treatment were 3.2 times more likely to have an initial blood pressure in the nonsevere range vs those who had timely treatment (odds ratio, 3.24; 95% confidence interval, 1.85-5.68). Timeliness of treatment was associated with presence or absence of preeclampsia symptoms; patients without preeclampsia symptoms were 2.7 times more likely to have delayed treatment (odds ratio, 2.68; 95% confidence interval, 1.50-4.80). Patients with hypertensive emergencies that occurred overnight between 10 pm and 6 am were 2.7 times more likely to have delayed treatment vs those emergencies that occurred between 6 am and 10 pm (odds ratio, 2.72; 95% confidence interval, 1.27-5.83). Delayed treatment also had an association with race, with white patients being 1.8 times more likely to have delayed treatment (odds ratio, 1.79; 95% confidence interval, 1.04-3.08). Patients who were treated at <60 minutes had a lower gestational age at presentation vs those with delayed treatment (34.6±5 vs 36.6±4 weeks, respectively; P<.001). For every 1-week increase in gestational age at presentation, there was a 9% increase in the likelihood of delayed treatment (odds ratio, 1.11; 95% confidence interval, 1.04-1.19). Another factor that was associated with delay of treatment was having a complaint of labor symptoms, which made patients 2.2 times as likely to experience treatment delay (odds ratio, 2.17; 95% confidence interval, 1.07-4.41). CONCLUSION Initial blood pressure in the nonsevere range, absence of preeclampsia symptoms, presentation overnight, white race, having complaint of labor symptoms, and increasing gestational age at presentation are barriers that lead to a delay in the treatment of obstetric hypertensive emergency. Quality improvement initiatives that target these barriers should be instituted to improve timely treatment.
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Hogg JP, Szczepanski JL, Collier C, Martin JN. Immediate postpartum management of patients with severe hypertensive disorders of pregnancy: pathophysiology guiding practice. J Matern Fetal Neonatal Med 2020; 35:2009-2019. [PMID: 32519919 DOI: 10.1080/14767058.2020.1776251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Developing clinically-focused evidence and experience-based approaches to improve maternity care is a national priority. Safety and quality collaborative initiatives related to management of hypertensive disorders of pregnancy are vital in the implementation of improved care. We reviewed the obstetric literature to construct a concise summary of the core pathophysiologic issues, practice principles and clinical interventions which are foundational for physicians providing immediate postpartum care for patients with severe pregnancy-related hypertension (including those with eclampsia, HELLP syndrome, and superimposed preeclampsia inclusive of those with gestational hypertension that develop severe range blood pressures). While based largely upon the American College of Obstetrics and Gynecology (ACOG) Hypertension Task Force Guidelines released in 2013 as well as updated 2018 guidelines set forth by ACOG for hypertensive disorders of pregnancy, this summary goes beyond the basic safety bundles for hypertension management and lays a pathophysiologic foundation for the immediate postpartum care of patients with severe hypertensive disorders of pregnancy.
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Affiliation(s)
- James P Hogg
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Jamie L Szczepanski
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlene Collier
- Department of Obstetrics and Gynecology, Division of Women's Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - James N Martin
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Bellad MB, Goudar SS, Mallapur AA, Sharma S, Bone J, Charantimath US, Katageri GM, Ramadurg UY, Mark Ansermino J, Derman RJ, Dunsmuir DT, Honnungar NV, Karadiguddi C, Kavi AJ, Kodkany BS, Lee T, Li J, Nathan HL, Payne BA, Revankar AP, Shennan AH, Singer J, Tu DK, Vidler M, Wong H, Bhutta ZA, Magee LA, von Dadelszen P. Community level interventions for pre-eclampsia (CLIP) in India: A cluster randomised controlled trial. Pregnancy Hypertens 2020; 21:166-175. [PMID: 32554291 PMCID: PMC7471838 DOI: 10.1016/j.preghy.2020.05.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/27/2020] [Accepted: 05/09/2020] [Indexed: 11/01/2022]
Abstract
OBJECTIVES Pregnancy hypertension is associated with 7.1% of maternal deaths in India. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment. STUDY DESIGN The Indian Community-Level Interventions for Pre-eclampsia (CLIP) open-label cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 clusters (initial four-cluster internal pilot) in Belagavi and Bagalkote, Karnataka. The CLIP intervention (6 clusters) consisted of community engagement, community health workers (CHW) provided mobile health (mHeath)-guided clinical assessment, initial treatment, and referral to facility either urgently (<4 h) or non-urgently (<24 h), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of mHealth-guided CHW-provided contacts. MAIN OUTCOME MEASURES 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity. RESULTS All 14,783 recruited pregnancies (7839 intervention, 6944 control) were followed-up. The primary outcome did not differ between intervention and control arms (adjusted odds ratio (aOR) 0.92 [95% confidence interval 0.74, 1.15]; p = 0.47; intraclass correlation coefficient 0.013). There were no intervention-related safety concerns following administration of either methyldopa or MgSO4, and 401 facility referrals. Compared with intervention arm women without CLIP contacts, those with ≥8 contacts suffered fewer stillbirths (aOR 0.19 [0.10, 0.35]; p < 0.001), at the probable expense of survivable neonatal morbidity (aOR 1.39 [0.97, 1.99]; p = 0.072). CONCLUSIONS As implemented, solely community-level interventions focussed on pre-eclampsia did not improve outcomes in northwest Karnataka.
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Affiliation(s)
- Mrutunjaya B Bellad
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India.
| | - Shivaprasad S Goudar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Ashalata A Mallapur
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Umesh S Charantimath
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Geetanjali M Katageri
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - Umesh Y Ramadurg
- S Nijalingappa Medical College, HSK (Hanagal Shree Kumareshwar) Hospital and Research Centre, Navanagar, Bagalkot, 587102 Karnataka, India
| | - J Mark Ansermino
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Richard J Derman
- Global Affairs, 1020 Walnut Street, Thomas Jefferson University, Philadelphia 19107, USA
| | - Dustin T Dunsmuir
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Narayan V Honnungar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Chandrashekhar Karadiguddi
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Avinash J Kavi
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Bhalachandra S Kodkany
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Tang Lee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Beth A Payne
- Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Amit P Revankar
- KLE Academy of Higher Education and Research's J N Medical College, Nehru Nagar, Belagavi, 590010 Karnataka, India
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Domena K Tu
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Centre for International Child Health, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto M5G 2L3, Canada; Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver, BC V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, St. Thomas' Hospital, Westminster Bridge Road, London SE1 7EH, UK
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Boutot M, Margueritte F, Boukeffa N, Coste Mazeau P, Aubard Y, Gauthier T. [External validation of FullPIERS model for prediction of adverse outcomes among women with pre-eclampsia in French maternity of 2014 to 2018]. ACTA ACUST UNITED AC 2020; 48:167-173. [PMID: 31923643 DOI: 10.1016/j.gofs.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Indexed: 11/24/2022]
Abstract
OBJECTIVES FullPIERS score (Pre-eclampsia Integrated Estimate of RiSk) is built in order to predict maternal outcomes among women with preeclampsia. Our objective is to assess external validity of this score among a population of French women. METHODS A retrospective study was conducted for all patients with pre-eclampsia (severe or not) admitted to a tertiary hospital center. A receiver operating characteristic (ROC) curve was constructed to determine accuracy of the model at 48 hours and 7 days after admittance and area under the curve (AUC) was calculated. RESULTS In total, 276 patients meet inclusions criterion. Among them, 217 were included and 61 (28 %) had one or more complication. Only 8 patients had two complications at two different moments (one at 48 hours and one at 7 days). The FullPiers score predicted maternels events at 48 hours with an area under the curve at 0.80 (IC95 % [0.74-0.85]). At 4.2 cut off, the sensitivity was 71 % and specifity 88 %. At 7 days, the area under the curve was 0.74 (IC95 % [0.67-0.79]), admiting a cutoff point for FullPIERS probability of 3.4, sensitivity was 59 % and specificity 85 %. CONCLUSIONS Our study show utility of FullPIERS score in french maternity. This model might be a useful tool for predicting complications in women with pre-eclampsia. Using of this score in clinical practice might help improving optimization of patient's care.
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Affiliation(s)
- M Boutot
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France.
| | - F Margueritte
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France
| | - N Boukeffa
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France
| | - P Coste Mazeau
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France
| | - Y Aubard
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France
| | - T Gauthier
- Service de gynécologie obstétrique, hôpital de la Mère et de l'Enfant, 87000 Limoges, France
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Geary M, Chibwesha C, Stringer E. Contemporary Issues in Women's Health. Int J Gynaecol Obstet 2019; 148:3-5. [PMID: 31736061 DOI: 10.1002/ijgo.13026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Michael Geary
- Department of Obstetrics and Gynecology, Rotunda Hospital, Dublin, Ireland
| | - Carla Chibwesha
- Institute for Global Health and Infectious Diseases, University of North Carolina, Chapel Hill, NC, USA
| | - Elizabeth Stringer
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC, USA
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ACOG Committee Opinion No. 767: Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol 2019; 133:e174-e180. [PMID: 30575639 DOI: 10.1097/aog.0000000000003075] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Acute-onset, severe systolic hypertension; severe diastolic hypertension; or both can occur during the prenatal, intrapartum, or postpartum periods. Pregnant women or women in the postpartum period with acute-onset, severe systolic hypertension; severe diastolic hypertension; or both require urgent antihypertensive therapy. Introducing standardized, evidence-based clinical guidelines for the management of patients with preeclampsia and eclampsia has been demonstrated to reduce the incidence of adverse maternal outcomes. Individuals and institutions should have mechanisms in place to initiate the prompt administration of medication when a patient presents with a hypertensive emergency. Treatment with first-line agents should be expeditious and occur as soon as possible within 30-60 minutes of confirmed severe hypertension to reduce the risk of maternal stroke. Intravenous labetalol and hydralazine have long been considered first-line medications for the management of acute-onset, severe hypertension in pregnant women and women in the postpartum period. Although relatively less information currently exists for the use of calcium channel blockers for this clinical indication, the available evidence suggests that immediate release oral nifedipine also may be considered as a first-line therapy, particularly when intravenous access is not available. In the rare circumstance that intravenous bolus labetalol, hydralazine, or immediate release oral nifedipine fails to relieve acute-onset, severe hypertension and is given in successive appropriate doses, emergent consultation with an anesthesiologist, maternal-fetal medicine subspecialist, or critical care subspecialist to discuss second-line intervention is recommended.
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Pre-eclampsia Educational Tool Impact on Knowledge, Anxiety, and Satisfaction in Pregnant Women: A Randomized Trial. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:960-970. [DOI: 10.1016/j.jogc.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 08/27/2018] [Accepted: 10/20/2018] [Indexed: 11/22/2022]
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Gudeta TA, Regassa TM. Pregnancy Induced Hypertension and Associated Factors among Women Attending Delivery Service at Mizan-Tepi University Teaching Hospital, Tepi General Hospital and Gebretsadik Shawo Hospital, Southwest, Ethiopia. Ethiop J Health Sci 2019; 29:831-840. [PMID: 30700950 PMCID: PMC6341446 DOI: 10.4314/ejhs.v29i1.4] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Disorders of pregnancy induced hypertensive are a major health problem in the obstetric population as they are one of the leading causes of maternal and perinatal morbidity and mortality. The World Health Organization estimates that at least one woman dies every seven minutes from complications of hypertensive disorders of pregnancy. The objective of this study is to assess pregnancy induced hypertension and its associated factors among women attending delivery service at Mizan-Tepi University Teaching Hospital, Gebretsadikshawo Hospital and Tepi General Hospital. Methods A health facility based cross-sectional study was carried out from October 01 to November 30/2016. The total sample size (422) was proportionally allocated to the three hospitals. Systematic sampling technique was used to select study participants. Variables with p-value of less than 0.25 in binary logistic regression were entered into the multivariable logistic regression to control cofounding. Odds ratio with 95% confidence interval was used. P-value less than 0.05 was considered as statistically significant. Results The prevalence of pregnancy induced hypertension was 33(7.9%); of which 5(15.2%) were gestational hypertension, 12 (36.4%) were mild preeclampsia, 15(45.5%) were severe preeclampsia and 1 (3%) eclampsia. Positive family history of pregnancy induced hypertension [AOR5.25 (1.39-19.86)], kidney diseases (AOR 3.32(1.04-10.58)), having asthma [AOR 37.95(1.41-1021)] and gestational age (AOR 0.096(0.04-.23)) were predictors of pregnancy induced hypertension. Conclusion The prevalence of pregnancy induced hypertension among women attending delivery service was 7.9%. Having family history of pregnancy induced hypertension, chronic kidney diseases and gestational age were predictors of pregnancy induced hypertension.
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Affiliation(s)
- Tesfaye Abera Gudeta
- MizanTepi University, College of Health science, Department of Nursing, Maternal Health Nursing Unit
| | - Tilahun Mekonnen Regassa
- MizanTepi University, College of Health Science, Department of Nursing, adult Health Hursing Unit
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O'brien L, Duong J, Winterton T, Haring A, Kuhlmann Z. Management of Hypertension on the Labor and Delivery Unit: Delivering Care in the Era of Protocols and Algorithms. Perm J 2018; 22:17-170. [PMID: 30227906 DOI: 10.7812/tpp/17-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Preeclampsia with severe hypertension, which occurs in 5% to 8% of pregnancies, is a leading cause of maternal and perinatal morbidity and mortality in the US. Early recognition and treatment of hypertensive crises can significantly reduce poor outcomes. A protocol to ensure prompt treatment with antihypertensive medication (intravenous labetalol) was implemented at our institution. OBJECTIVE To determine adherence to this protocol on the Labor and Delivery Unit. DESIGN Retrospective chart review was performed for patients admitted to the Labor and Delivery Unit between April 2015 and June 2015. Charts were reviewed if the patient had a diagnosis of chronic hypertension, gestational hypertension, superimposed preeclampsia, preeclampsia with severe features, eclampsia, or stroke in pregnancy. Only patients with confirmed severe blood pressures, in which the protocol would be initiated, were included in the final analysis. MAIN OUTCOME MEASURE Overall compliance with the entire protocol. RESULTS Of 178 cases reviewed, 58 (32.6%) had confirmed severe blood pressures. Most patients (n = 46, 79.3%) received a diagnosis of preeclampsia with severe features, and most delivered via cesarean delivery (n = 38, 65.5%). No cases were compliant with the entire labetalol protocol. Of 58 patients, 2 (3.5) adequately repeated a confirmation blood pressure within 5 minutes, and 34 (58.6%) were adequately treated with intravenous labetalol according to protocol requirements. CONCLUSION Labetalol treatment was appropriately initiated in many cases; however, protocol adherence could greatly improve. Potential factors affecting protocol compliance include shift changes, communication issues, and conflicting protocols. Institutions should review protocol compliance to improve care.
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Affiliation(s)
- Lauren O'brien
- Obstetrician/Gynecologist at Avera Medical Group Marshall in Marshall, MN (lauren.o')
| | - Jennifer Duong
- Research Associate in the Department of Obstetrics and Gynecology at the University of Kansas School of Medicine in Wichita
| | - Tessa Winterton
- Resident Physician in the Department of Obstetrics and Gynecology at the University of Kansas School of Medicine in Wichita
| | - Anna Haring
- Resident Physician in the Department of Obstetrics and Gynecology at the University of Kansas School of Medicine in Wichita
| | - Zachary Kuhlmann
- Clinical Associate Professor in the Department of Obstetrics and Gynecology at the University of Kansas School of Medicine in Wichita
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Emergent Therapy for Acute-Onset, Severe Hypertension During Pregnancy and the Postpartum Period. Obstet Gynecol 2017; 129:e90-e95. [DOI: 10.1097/aog.0000000000002019] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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El Gatit A, Abdul Razeq M, El Snaini F, Saad K, Zaiton A. Reversible Cortical Blindness Following Successful Surgical Repair Of Two Stab Wounds In The Heart. Libyan J Med 2016. [DOI: 10.3402/ljm.v3i1.4752] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- A. El Gatit
- Departments of Surgery, Cardiothoracic & Vascular Surgery Unit
| | | | | | - K. Saad
- Department of Medicine, Al Batnan Medical Centre, Faculty of Medicine, Omar Al Mokhtar University, Tobruk, Libya
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ElFarra J, Bean C, Martin JN. Management of Hypertensive Crisis for the Obstetrician/Gynecologist. Obstet Gynecol Clin North Am 2016; 43:623-637. [DOI: 10.1016/j.ogc.2016.07.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Thornton C, Tooher J, Ogle R, von Dadelszen P, Makris A, Hennessy A. Benchmarking the Hypertensive Disorders of Pregnancy. Pregnancy Hypertens 2016; 6:279-284. [DOI: 10.1016/j.preghy.2016.04.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 04/29/2016] [Indexed: 11/15/2022]
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Nwanodi OB. Preeclampsia-Eclampsia Adverse Outcomes Reduction: The Preeclampsia-Eclampsia Checklist. Healthcare (Basel) 2016; 4:healthcare4020026. [PMID: 27417614 PMCID: PMC4934579 DOI: 10.3390/healthcare4020026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2016] [Revised: 05/05/2016] [Accepted: 05/06/2016] [Indexed: 12/17/2022] Open
Abstract
Globally, preeclampsia-eclampsia (PE-E) is a major cause of puerperal intensive care unit admission, accounting for up to 10% of maternal deaths. PE-E primary prevention is possible. Antepartum low-dose aspirin prophylaxis, costing USD $10–24 can cut the incidence of PE-E in half. Antepartum low molecular weight heparin combined with low-dose aspirin prophylaxis can cut the incidence of early onset PE-E and fetuses that are small for their gestational age in half. Despite predictive antepartum models for PE-E prophylaxis, said prophylaxis is not routinely provided. Therefore, magnesium sulfate secondary prevention of eclampsia remains the globally recommended intervention. Implementation of a PE-E checklist is a continuous quality improvement (CQI) tool facilitating appropriate antepartum PE-E prophylaxis and maternal care from the first trimester through the postpartum fourth trimester inter-partum interval. A novel clinical PE-E checklist and implementation strategy are presented below. CQI PE-E checklist implementation and appropriate PE-E prophylaxis provides clinicians and healthcare systems an opportunity to achieve Millennium Development Goals 4 and 5, reducing child mortality and improving maternal health. While CQI checklist implementation may be a tedious ongoing process requiring healthcare team resiliency, improved healthcare outcomes are well worth the effort.
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Affiliation(s)
- Oroma B Nwanodi
- College of Graduate Health Studies, A. T. Still University, Mesa, AZ 85206, USA.
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Salam RA, Das JK, Ali A, Bhaumik S, Lassi ZS. Diagnosis and management of preeclampsia in community settings in low and middle-income countries. J Family Med Prim Care 2016; 4:501-6. [PMID: 26985406 PMCID: PMC4776599 DOI: 10.4103/2249-4863.174265] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Hypertensive disorders of pregnancy contribute significantly to maternal mortality and morbidity. Preeclampsia belongs to the spectrum of hypertensive disorders of pregnancy and if undiagnosed and/or untreated leads to fatal consequences for both the mother and the baby. Early detection and prevention of preeclampsia is limited by uncertainty in the knowledge about its etiopathogenesis. While much work has been done in establishing clinical guidelines for management of preeclampsia in the hospital or tertiary care settings, there is considerable lack of work in the domain of evidence-based guidelines for screening, identification and management of preeclampsia at the community-level. The article reviews these issues with special considerations and to challenges faced in low and middle-income countries. There is a need to focus on low-cost screening and interventions in the community to achieve a significant impact on preventable maternal and fetal mortality in order to control the burden of preeclampsia significantly as well as investing on more research at primary care level to improve the evidence base for community-level interventions.
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Affiliation(s)
- Rehana A Salam
- Department of Paediatrics, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Jai K Das
- Department of Paediatrics, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - Anum Ali
- Department of Paediatrics, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Zohra S Lassi
- Department of Paediatrics, Division of Women and Child Health, Aga Khan University, Karachi, Pakistan; Department of Obstetrics and Gynecology, Australian Research Centre for Health of Women and Babies, Robinson Research Institute, School of Paediatrics and Reproductive Health, The University of Adelaide, Adelaide, Australia
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Lowe SA, Bowyer L, Lust K, McMahon LP, Morton M, North RA, Paech M, Said JM. SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014. Aust N Z J Obstet Gynaecol 2015; 55:e1-29. [PMID: 26412014 DOI: 10.1111/ajo.12399] [Citation(s) in RCA: 173] [Impact Index Per Article: 19.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Accepted: 07/21/2015] [Indexed: 02/06/2023]
Abstract
This guideline is an evidence based, practical clinical approach to the management of Hypertensive Disorders of Pregnancy. Since the previous SOMANZ guideline published in 2008, there has been significant international progress towards harmonisation of definitions in relation to both the diagnosis and management of preeclampsia and gestational hypertension. This reflects increasing knowledge of the pathophysiology of these conditions, as well as their clinical manifestations. In addition, the guideline includes the management of chronic hypertension in pregnancy, an approach to screening, advice regarding prevention of hypertensive disorders of pregnancy, and discussion of recurrence risks and long term risk to maternal health. The literature reviewed included the previous SOMANZ Hypertensive Disorders of Pregnancy guideline from 2008 and its reference list, plus all other published National and International Guidelines on this subject. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT), National Institute for Health and Care Excellence (NICE) Evidence Search, and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2007 and March, 2014.
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Affiliation(s)
- Sandra A Lowe
- Department of Medicine, Royal Hospital for Women, Sydney, New South Wales, Australia.,School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Lucy Bowyer
- School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Karin Lust
- Department of Obstetric Medicine and Internal Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | | | - Mark Morton
- Women's and Children's Hospital, Adelaide, South Australia, Australia
| | | | - Michael Paech
- Department of Anaesthesia and Pain Medicine, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia
| | - Joanne M Said
- Sunshine Hospital and University of Melbourne, Melbourne, Victoria, Australia
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Angiogenesis-Related Biomarkers (sFlt-1/PLGF) in the Prediction and Diagnosis of Placental Dysfunction: An Approach for Clinical Integration. Int J Mol Sci 2015; 16:19009-26. [PMID: 26287164 PMCID: PMC4581283 DOI: 10.3390/ijms160819009] [Citation(s) in RCA: 68] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/27/2015] [Accepted: 08/03/2015] [Indexed: 11/26/2022] Open
Abstract
Placental dysfunction is involved in a group of obstetrical conditions including preeclampsia, intrauterine growth restriction, and placental abruption. Their timely and accurate recognition is often a challenge since diagnostic criteria are still based on nonspecific signs and symptoms. The discovering of the role of angiogenic-related factors (sFlt-1/PlGF) in the underlying pathophysiology of placental dysfunction, taking into account that angiogenesis-related biomarkers are not specific to any particular placental insufficiency-related disease, has marked an important step for improving their early diagnosis and prognosis assessment. However, sFlt-1/PlGF has not been yet established as a part of most guidelines. We will review the current evidence on the clinical utility of sFlt-1/PlGF and propose a new protocol for its clinical integration.
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Abstract
Shoulder dystocia is an obstetric emergency that has been reported to occur in 0.2-3% of all vaginal deliveries. Several characteristics of shoulder dystocia make it a particular challenge to manage effectively. It is relatively infrequent, the diagnosis cannot be made according to a single objective criterion that can be recognized to exist by all members of the care team who are present, it is unpredictable, and there is the need for coordinated actions of all members of the health care team who have come together on the day of the delivery and may not have worked together before or specifically during a shoulder dystocia. In general, there is evidence from different medical disciplines that checklists/protocols and simulation may be used to enhance team performance. There is also some evidence, albeit limited, that such techniques may be used to improve shoulder dystocia outcomes.
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Affiliation(s)
- William A Grobman
- Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL; Center for Healthcare Studies, Feinberg School of Medicine, Northwestern University, Chicago, IL.
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Grobman WA, Bailit JL, Rice MM, Wapner RJ, Reddy UM, Varner MW, Thorp JM, Leveno KJ, Caritis SN, Iams JD, Tita AT, Saade G, Sorokin Y, Rouse DJ, Blackwell SC, Tolosa JE, Van Dorsten JP. Frequency of and factors associated with severe maternal morbidity. Obstet Gynecol 2014; 123:804-10. [PMID: 24785608 PMCID: PMC4116103 DOI: 10.1097/aog.0000000000000173] [Citation(s) in RCA: 149] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To estimate the frequency of severe maternal morbidity, assess its underlying etiologies, and develop a scoring system to predict its occurrence.Supplemental Digital Content is Available in the Text. METHODS This was a secondary analysis of a Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network cohort of 115,502 women and their neonates born in 25 hospitals across the United States over a 3-year period. Women were classified as having severe maternal morbidity according to a scoring system that takes into account the occurrence of red blood cell transfusion (more than three units), intubation, unanticipated surgical intervention, organ failure, and intensive care unit admission. The frequency of severe maternal morbidity was calculated and the underlying etiologies determined. Multivariable analysis identified patient factors present on admission that were independently associated with severe maternal morbidity; these were used to develop a prediction model for severe maternal morbidity. RESULTS Among 115,502 women who delivered during the study period, 332 (2.9/1,000 births, 95% confidence interval 2.6-3.2) experienced severe maternal morbidity. Postpartum hemorrhage was responsible for approximately half of severe maternal morbidity. Multiple patient factors were found to be independently associated with severe maternal morbidity and were used to develop a predictive model with an area under the receiver operating characteristic curve of 0.80. CONCLUSION Severe maternal morbidity occurs in approximately 2.9 per 1,000 births, is most commonly the result of postpartum hemorrhage, and occurs more commonly in association with several identifiable patient characteristics. LEVEL OF EVIDENCE : II.
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Affiliation(s)
- William A Grobman
- Departments of Obstetrics and Gynecology, Northwestern University, Chicago, Illinois, Case Western Reserve University-MetroHealth Medical Center, Cleveland, Ohio, Columbia University, New York, New York, the University of Utah Health Sciences Center, Salt Lake City, Utah, the University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, the University of Texas Southwestern Medical Center, Dallas, Texas, the University of Pittsburgh, Pittsburgh, Pennsylvania, The Ohio State University, Columbus, Ohio, the University of Alabama at Birmingham, Birmingham, Alabama, the University of Texas Medical Branch, Galveston, Texas, Wayne State University, Detroit, Michigan, Brown University, Providence, Rhode Island, the University of Texas Health Science Center at Houston-Children's Memorial Hermann Hospital, Houston, Texas, Oregon Health & Science University, Portland, Oregon, and the Medical University of South Carolina, Charleston, South Carolina; the George Washington University Biostatistics Center, Washington, DC; and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Abstract
PURPOSE OF REVIEW The incidence of hypertensive disorders in pregnancy is increasing and is associated with maternal mortality worldwide. This review provides the obstetrician with an update of the current issues concerning hypertension and maternal mortality. RECENT FINDINGS Preeclampsia affects about 3% of pregnancies, and all other hypertensive disorders complicate approximately 5-10% of pregnancies in the United States. In industrialized countries, rates of preeclampsia, gestational hypertension, and chronic hypertension have increased as rates of eclampsia have decreased following widespread antenatal care and magnesium sulfate use. Increased maternal mortality is associated with eclampsia, hemolysis, elevated liver enzymes, and low platelet count syndrome, hepatic or central nervous system hemorrhage, and vascular insult to the cardiopulmonary or renal system. Diagnosis and acute management of severe hypertension is central to reducing maternal mortality. African-American women have a higher risk of mortality from hypertensive disorders of pregnancy compared with Hispanic, American Indian/Alaska Native, Asian/Pacific Islander, and Caucasian women. SUMMARY Hypertensive disorders in pregnancy are a leading cause of maternal mortality worldwide. The incidence of hypertension in pregnancy continues to increase. Currently, we are unable to determine which patient will develop superimposed preeclampsia or identify subsets of preeclampsia syndrome. Opportunities for research in this area exist to better define treatment aimed at improving maternal outcomes.
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Abstract
Seizures during pregnancy complicate <1% of all gestations; however, they are associated with increased adverse maternal and perinatal outcomes (acute and long term). The differential diagnosis of seizures in pregnancy is extensive. Determining the underlying etiology is crucial in the management of these patients. Medical providers caring for pregnant women should be educated about possible etiologies of seizures during pregnancy and the importance of prompt management of these women in a timely fashion. Evaluation and management should be performed in a stepwise fashion and may require a multidisciplinary approach with other specialties such as neurology. The objective of this review is to increase awareness and to provide a stepwise approach toward the diagnosis and management of pregnancies complicated by seizures.
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Affiliation(s)
- Laura A Hart
- Division of Maternal Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
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von Dadelszen P, Firoz T, Donnay F, Gordon R, Justus Hofmeyr G, Lalani S, Payne BA, Roberts JM, Teela KC, Vidler M, Sawchuck D, Magee LA. Preeclampsia in Low and Middle Income Countries—Health Services Lessons Learned From the PRE-EMPT (PRE-Eclampsia–Eclampsia Monitoring, Prevention & Treatment) Project. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:917-926. [DOI: 10.1016/s1701-2163(16)35405-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Improving maternal and perinatal outcomes in the hypertensive disorders of pregnancy: a vision of a community-focused approach. Int J Gynaecol Obstet 2012; 119 Suppl 1:S30-S34. [PMID: 22884823 DOI: 10.1016/j.ijgo.2012.03.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The hypertensive disorders of pregnancy (HDP; pre-existing hypertension, gestational hypertension, and pre-eclampsia) remain important causes of maternal morbidity and mortality, especially in low- and middle-income countries. The paper summarizes the current state of evidence around possible technologies to support community-based improvements in maternal and perinatal outcomes for women with pre-eclampsia. Through the testing and, where proven, introduction of these technologies, we believe that HDP-related progress toward achieving Millennium Development Goal 5 can best be accelerated. The evidence and discussion are presented under the following headings: (1) prediction; (2) prevention; (3) diagnosis; (4) risk stratification; (5) decision aids; (6) treatment; (7) geographic information systems; (8) communication; and (9) community and patient education.
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Herraiz I, Escribano D, Gómez-Arriaga PI, Herníndez-García JM, Herraiz MA, Galindo A. Predictive value of sequential models of uterine artery Doppler in pregnancies at high risk for pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2012; 40:68-74. [PMID: 22102516 DOI: 10.1002/uog.10147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the performance of models described previously for the prediction of pre-eclampsia (PE), based on the sequential evaluation of uterine artery resistance at 11-13 weeks and 19-22 weeks, in a high-risk population. METHODS This was a prospective study in 135 women with singleton pregnancies and at least one of the following high-risk conditions: PE and/or intrauterine growth restriction in a previous pregnancy, chronic hypertension, pregestational diabetes, renal disease, body mass index > 30 kg/m(2) , autoimmune disease (systemic lupus erythematosus, antiphospholipid syndrome or rheumatoid arthritis) and thrombophilia. Mean uterine artery pulsatility index (mUtA-PI) at 11-13 and at 19-22 weeks' gestation was measured and analyzed according to quantitative and semi-quantitative models, to predict late PE (resulting in delivery ≥ 34 weeks) and early PE (delivery < 34 weeks). RESULTS Late PE developed in 21 (15.6%) pregnancies and early PE in six (4.4%). Using mUtA-PI, the detection rates of late and early PE for a false-positive rate of 10% were 14.3% and 33.3%, respectively, at 11-13 weeks, and 19.0% and 66.7%, respectively, at 19-22 weeks. Using a semi-quantitative approach, the group of pregnant women with mUtA-PI ≥ 90(th) percentile at both 11-13 and 19-22 weeks had a greater risk for early PE (odds ratio, 21.4 (95% CI, 2.5-184.7)) compared with the group with mUtA-PI < 90(th) percentile at both periods. Using a quantitative approach, there was relative worsening in the mUtA-PI (multiples of the median) from the first to the second trimester in all cases of early PE. CONCLUSION The application of semi-quantitative and especially quantitative models to evaluate sequential changes in uterine artery Doppler findings between the first and second trimesters could be of additional value in assessing high-risk women regarding their true risk of developing early PE.
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Affiliation(s)
- I Herraiz
- Fetal Medicine Unit-SAMID, Department of Obstetrics and Gynaecology, Hospital Universitario 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
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You WB, Wolf MS, Bailey SC, Grobman WA. Improving patient understanding of preeclampsia: a randomized controlled trial. Am J Obstet Gynecol 2012; 206:431.e1-5. [PMID: 22542120 DOI: 10.1016/j.ajog.2012.03.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2011] [Revised: 02/22/2012] [Accepted: 03/09/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We developed a standardized educational tool to inform women about preeclampsia. The objective of this study was to assess whether exposure to this tool led to superior understanding of the syndrome. STUDY DESIGN This was a randomized controlled trial in which 120 women were assigned to (1) a newly developed preeclampsia educational tool, (2) a standard pamphlet addressing preeclampsia that had been created by the American College of Obstetricians and Gynecologists, or (3) no additional information. Preeclampsia knowledge was assessed with the use of a previously validated questionnaire. RESULTS There were no demographic differences among the groups. Patients who received the tool scored significantly better on the preeclampsia questionnaire than those who received the American College of Obstetricians and Gynecologists pamphlet or no additional information (71%, 63%, 49%, respectively; P < .05). This improved understanding was evident equally among women with and without adequate health literacy (interaction: P > .05). CONCLUSION Patients who were exposed to a graphics-based educational tool demonstrated superior preeclampsia-related knowledge, compared with those patients who were exposed to standard materials or no education.
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Affiliation(s)
- Whitney B You
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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The PIERS Experience: Research or Quality Improvement? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 34:379-81. [DOI: 10.1016/s1701-2163(16)35221-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Kozic JR, Benton SJ, Hutcheon JA, Payne BA, Magee LA, von Dadelszen P. Abnormal liver function tests as predictors of adverse maternal outcomes in women with preeclampsia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 33:995-1004. [PMID: 22014776 DOI: 10.1016/s1701-2163(16)35048-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate whether (1) the absolute magnitude of liver function test values, (2) the percentage change in liver function test values over time, or (3) the rate of change in liver function test values over time predicts adverse maternal outcomes in women with preeclampsia. METHODS We used data from the PIERS (Pre-eclampsia Integrated Estimate of RiSk) study, a prospective multicentre cohort study assessing predictors of adverse maternal outcomes in women with preeclampsia. Women with at least one liver function test performed at the time of hospital admission were included. Liver functions were tested by serum concentrations of aspartate amino transferase (AST), alanine amino transferase (ALT), lactate dehydrogenase (LDH), albumin, total bilirubin, and the international normalized prothrombin time ratio. Parameters investigated were absolute levels, change within 48 hours of hospital admission, change from admission to delivery or outcome, and rate of change from admission to delivery or outcome of each liver function test. The ability of these parameters to predict adverse outcomes was assessed using logistic regression analyses and by calculating the receiver operating characteristic (ROC) area under the curve (AUC). RESULTS Of the 2008 women, 1056 (53%) had at least one abnormal liver function test result. The odds of having an adverse maternal outcome were higher in women with any abnormal liver function test than in women with normal results. When test results were stratified into quartiles, women with results in the highest quartile (lowest quartile for albumin) were at higher risk of adverse outcomes than women in the lowest quartile for all parameters (highest for albumin). The absolute magnitude of AST, ALT, and LDH predicted adverse maternal outcomes (AST: ROC AUC 0.73 [95% CI 0.67 to 0.97]; ALT: ROC AUC 0.73 [95% CI 0.67 to 0.79]; LDH: ROC AUC 0.74 [95% CI 0.68 to 0.81]). Neither change of liver function test results, within 48 hours of admission or from admission to delivery or outcome, nor rate of change were predictive. CONCLUSION We found abnormal liver function test results to be associated with an increased risk for adverse maternal outcomes. Levels of AST, ALT, and LDH were found to be modestly predictive of these outcomes.
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Affiliation(s)
- Jennifer R Kozic
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC
| | - Samantha J Benton
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; The CFRI Reproduction and Healthy Pregnancy Cluster, University of British Columbia, Vancouver BC
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; The CFRI Reproduction and Healthy Pregnancy Cluster, University of British Columbia, Vancouver BC; School of Public and Population Health, University of British Columbia, Vancouver BC
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; The CFRI Reproduction and Healthy Pregnancy Cluster, University of British Columbia, Vancouver BC
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; Department of Medicine, University of British Columbia, Vancouver BC; School of Public and Population Health, University of British Columbia, Vancouver BC
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver BC; The CFRI Reproduction and Healthy Pregnancy Cluster, University of British Columbia, Vancouver BC; School of Public and Population Health, University of British Columbia, Vancouver BC
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The role of platelet counts in the assessment of inpatient women with preeclampsia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2012; 33:900-8. [PMID: 21923987 DOI: 10.1016/s1701-2163(16)35015-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Platelet count has been proposed as a screening test for generalized coagulopathy in women with preeclampsia. We performed this study to determine the relationship between platelet counts and the risk of abnormal coagulation and adverse maternal outcomes in women with preeclampsia. METHODS We used data from women in the PIERS (Pre-eclampsia Integrated Estimate of RiSk) database. Abnormal coagulation was defined as either an international normalized ratio result greater than and/or a serum fibrinogen level less than the BC Women's Hospital laboratory's pregnancy-specific normal range. The relationship between platelet counts and adverse maternal outcomes was explored using a logistic regression analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of platelet counts in identifying abnormal coagulation or adverse maternal outcomes were calculated. RESULTS Abnormal coagulation occurred in 105 of 1405 eligible women (7.5%). The odds of having abnormal coagulation were increased for women with platelet counts < 50 × 10(9)/L (OR 7.78; 95% CI 3.36 to 18.03) and between 50 and 99 × 10(9)/L (OR 2.69; 95% CI 1.44 to 5.01) compared with women who had platelet counts above 150 × 10(9)/L. Platelet counts < 100 × 10(9)/L were associated with significantly increased odds of adverse maternal outcomes, most specifically blood transfusion. A platelet count of < 100 × 10(9)/L had good specificity in identifying abnormal coagulation and adverse maternal outcomes (92% [95% CI 91% to 94%] and 92% [95% CI 91% to 94%], respectively), but poor sensitivity (22% [95% CI 15% to 31%] and 16% [95% CI 11% to 23%], respectively). CONCLUSION A platelet count < 100 × 10(9)/L is associated with an increased risk of abnormal coagulation and maternal adverse outcomes in women with preeclampsia. However, the platelet count should not be used in isolation to guide care because of its poor sensitivity. Whether or not a platelet count is normal should not be used to determine whether further coagulation tests are needed.
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Ota E, Souza JP, Tobe-Gai R, Mori R, Middleton P, Flenady V. Interventions during the antenatal period for preventing stillbirth: an overview of Cochrane systematic reviews. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009599] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Erika Ota
- Graduate School of Medicine, The University of Tokyo; Department of Global Health Policy; 7-3-1 Hongo Bunkyo-ku Tokyo Japan 113-0011
| | - João Paulo Souza
- World Health Organization; Department of Reproductive Health and Research; 20 Avenue Appia Geneva Switzerland 1211
| | - Ruoyan Tobe-Gai
- School of Public Health, Shandong University; No.44 Wen-Hua-Xi Road Jinan China 250012
| | - Rintaro Mori
- Collaboration for Research in Global Women's and Children's Health; 1-13-10 Matsunoki Suginami-ku Tokyo Tokyo Japan 166-0014
| | - Philippa Middleton
- The University of Adelaide; ARCH: Australian Research Centre for Health of Women and Babies, Discipline of Obstetrics and Gynaecology; Women's and Children's Hospital 72 King William Road Adelaide South Australia Australia 5006
| | - Vicki Flenady
- Mater Health Services; Translating Research Into Practice (TRIP) Centre - Mater Medical Research Institute; Level 2 Quarters Building Annerley Road Woolloongabba Queensland Australia 4102
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Yang CY, Lien R, Yang PH, Chu SM, Hsu JF, Fu RH, Chiang MC. Analysis of incidence and risk factors of retinopathy of prematurity among very-low-birth-weight infants in North Taiwan. Pediatr Neonatol 2011; 52:321-6. [PMID: 22192259 DOI: 10.1016/j.pedneo.2011.08.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2009] [Revised: 11/08/2010] [Accepted: 11/15/2010] [Indexed: 10/15/2022] Open
Abstract
BACKGROUND Although significant advances have been made in perinatal care, retinopathy of prematurity (ROP) remains a serious complication in prematurely born individuals. There have been limited studies on ROP in Taiwan, and most of those existing reports are outdated. METHODS This retrospective study included 252 very-low-birth-weight (VLBW) infants admitted to the neonatal intensive care unit of Chang Gung Children's Hospital over a 2-year period between July 2005 and June 2007. All infants were examined for ROP according to the guidelines published by the American Academy of Pediatrics. The relationship between clinical risk factors and the development of ROP was analyzed. RESULTS Of the 252 VLBW infants, 216 met the screening criteria. Of the 216, 99 (45.8%) had ROP. Compared with neonates born at 29 weeks of gestational age (GA) or later, those very premature infants of ≤25 weeks' and 26-28 weeks' GA had increased odds ratios (OR) of 8.49 and 3.19, respectively, for the development of severe ROP. No ROP was detected in infants of greater than 33 weeks' GA. The simultaneous presence of a low GA, low birth weight (LBW), lower Apgar scores, hypotension, patent ductus arteriosus, septicemia, intraventricular hemorrhage, ventilator dependence, and use of postnatal steroids was associated with severe ROP. Using multiple logistic regression analyses for ROP, only maternal preeclampsia [OR, 2.52; confidence interval (CI), 1.32-4.7]; duration of mechanical ventilation (OR, 1.06; CI, 1.04-1.08); and LBW (OR, 2.62; CI, 1.370-3.375) predicted the development of threshold ROP. CONCLUSION The incidence of ROP among VLBW infants was 45.8%; 19.0% had severe ROP. Infants of lower GAs and/or with LBW, whose mother had preeclampsia or who had a long duration of mechanical ventilation are at risk for the development of threshold ROP.
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Affiliation(s)
- Chang-Yo Yang
- Division of Neonatology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan, Taiwan
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Benoit J, Rey É. Preeclampsia: Should Plasma Albumin Level Be a Criterion for Severity? JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:922-6. [DOI: 10.1016/s1701-2163(16)35017-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Payne B, Magee LA, von Dadelszen P. Assessment, surveillance and prognosis in pre-eclampsia. Best Pract Res Clin Obstet Gynaecol 2011; 25:449-62. [DOI: 10.1016/j.bpobgyn.2011.02.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Revised: 01/25/2011] [Accepted: 02/04/2011] [Indexed: 01/16/2023]
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Millman AL, Payne B, Qu Z, Joanne Douglas M, Hutcheon JA, Lee T, Magee LA, Walley KR, von Dadelszen P. Oxygen Saturation as a Predictor of Adverse Maternal Outcomes in Women with Preeclampsia. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:705-714. [DOI: 10.1016/s1701-2163(16)34955-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Thornton C, Hennessy A, Grobman WA. Benchmarking and patient safety in hypertensive disorders of pregnancy. Best Pract Res Clin Obstet Gynaecol 2011; 25:509-21. [PMID: 21640655 DOI: 10.1016/j.bpobgyn.2011.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2010] [Revised: 02/14/2011] [Accepted: 03/05/2011] [Indexed: 10/18/2022]
Abstract
Hypertensive disorders of pregnancy are a major cause of morbidity and mortality worldwide. Reliable, published individual patient data from units and countries are lacking. Without these data, clinicians are unable to benchmark their incidence, treatments and outcomes, and patient safety is unable to be routinely assessed. Available data suggest that a notable proportion of the adverse events that occur with hypertensive disease of pregnancy may be preventable. Theory and practice indicate several methods that can offer the possibility of averting these preventable adverse events. These methods include benchmarking outcomes, standardisation of care processes, simulation, and enhancement of patient knowledge. However, data on optimal methods to enhance patient safety and quality of care of pregnant women with hypertensive disease remain limited, and further research is required.
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Payne B, Magee LA, Côté AM, Hutcheon JA, Li J, Kyle PM, Menzies JM, Peter Moore M, Parker C, Pullar B, von Dadelszen P, Walters BN, von Dadelszen P, Magee L, Douglas M, Walley K, Russell J, Lee S, Gruslin A, Smith G, Côté A, Moutquin JM, Brown M, Davis G, Walters B, Sass N, Duan T, Zhou J, Mahajan S, Noovao A, McCowan L, Kyle P, Moore M, Bhutta S, Bhutta Z, Hall, Steyn D, Broughton Pipkin F, Loughna P, Robson S, de Swiet M, Walker J, Grobman W, Lindheimer M, Roberts J, Mark Ansermino J, Benton S, Cundiff G, Hugo D, Joseph K, Lalji S, Li J, Lott P, Ouellet AB, Shaw D, Keith Still D, Tawagi G, Wagner B, Biryabarema C, Mirembe F, Nakimuli A, Tsigas E, Merialdi M, Widmer M. PIERS Proteinuria: Relationship With Adverse Maternal and Perinatal Outcome. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2011; 33:588-597. [DOI: 10.1016/s1701-2163(16)34907-6] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Herraiz García I, López Jiménez AE, Gómez Arriaga PI, Escribano Abad D, Galindo Izquierdo A. Doppler de arterias uterinas y marcadores angiogénicos (sFlt-1/PlGF): futuras implicaciones para la predicción y el diagnóstico de la preeclampsia. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.diapre.2010.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Cetin I, Huppertz B, Burton G, Cuckle H, Gonen R, Lapaire O, Mandia L, Nicolaides K, Redman C, Soothill P, Spencer K, Thilaganathan B, Williams D, Meiri H. Pregenesys pre-eclampsia markers consensus meeting: What do we require from markers, risk assessment and model systems to tailor preventive strategies? Placenta 2011; 32 Suppl:S4-16. [DOI: 10.1016/j.placenta.2010.11.022] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2010] [Revised: 11/26/2010] [Accepted: 11/29/2010] [Indexed: 10/18/2022]
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von Dadelszen P, Payne B, Li J, Ansermino JM, Broughton Pipkin F, Côté AM, Douglas MJ, Gruslin A, Hutcheon JA, Joseph KS, Kyle PM, Lee T, Loughna P, Menzies JM, Merialdi M, Millman AL, Moore MP, Moutquin JM, Ouellet AB, Smith GN, Walker JJ, Walley KR, Walters BN, Widmer M, Lee SK, Russell JA, Magee LA. Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model. Lancet 2011; 377:219-27. [PMID: 21185591 DOI: 10.1016/s0140-6736(10)61351-7] [Citation(s) in RCA: 362] [Impact Index Per Article: 27.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
BACKGROUND Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder. METHODS We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting. FINDINGS 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility. INTERPRETATION The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia. FUNDING Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.
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Affiliation(s)
- Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Vancouver, BC, Canada.
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