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Elawad T, Scott G, Bone JN, Elwell H, Lopez CE, Filippi V, Green M, Khalil A, Kinshella MLW, Mistry HD, Pickerill K, Shanmugam R, Singer J, Townsend R, Tsigas EZ, Vidler M, Volvert ML, von Dadelszen P, Magee LA. Risk factors for pre-eclampsia in clinical practice guidelines: Comparison with the evidence. BJOG 2024; 131:46-62. [PMID: 36209504 DOI: 10.1111/1471-0528.17320] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/12/2022] [Accepted: 09/06/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare pre-eclampsia risk factors identified by clinical practice guidelines (CPGs) with risk factors from hierarchical evidence review, to guide pre-eclampsia prevention. DESIGN Our search strategy provided hierarchical evidence of relationships between risk factors and pre-eclampsia using Medline (Ovid), searched from January 2010 to January 2021. SETTING Published studies and CPGs. POPULATION Pregnant women. METHODS We evaluated the strength of association and quality of evidence (GRADE). CPGs (n = 15) were taken from a previous systematic review. MAIN OUTCOME MEASURE Pre-eclampsia. RESULTS Of 78 pre-eclampsia risk factors, 13 (16.5%) arise only during pregnancy. Strength of association was usually 'probable' (n = 40, 51.3%) and the quality of evidence was low (n = 35, 44.9%). The 'major' and 'moderate' risk factors proposed by 8/15 CPGs were not well aligned with the evidence; of the ten 'major' risk factors (alone warranting aspirin prophylaxis), associations with pre-eclampsia were definite (n = 4), probable (n = 5) or possible (n = 1), based on moderate (n = 4), low (n = 5) or very low (n = 1) quality evidence. Obesity ('moderate' risk factor) was definitely associated with pre-eclampsia (high-quality evidence). The other ten 'moderate' risk factors had probable (n = 8), possible (n = 1) or no (n = 1) association with pre-eclampsia, based on evidence of moderate (n = 1), low (n = 5) or very low (n = 4) quality. Three risk factors not identified by the CPGs had probable associations (high quality): being overweight; 'prehypertension' at booking; and blood pressure of 130-139/80-89 mmHg in early pregnancy. CONCLUSIONS Pre-eclampsia risk factors in CPGs are poorly aligned with evidence, particularly for the strongest risk factor of obesity. There is a lack of distinction between risk factors identifiable in early pregnancy and those arising later. A refresh of the strategies advocated by CPGs is needed.
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Affiliation(s)
- Terteel Elawad
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Georgia Scott
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- North West London Foundation School, London, UK
| | - Jeffrey N Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
| | - Helen Elwell
- British Medical Association (BMA) Library, BMA, London, UK
| | - Cristina Escalona Lopez
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | | | - Asma Khalil
- St George's Hospital NHS Foundation Trust, London, UK
| | - Mai-Lei W Kinshella
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
| | - Hiten D Mistry
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Kelly Pickerill
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
| | - Reshma Shanmugam
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- West Midlands Central Foundation School, Birmingham, UK
| | - Joel Singer
- School of Population and Public Health, University of British Columbia, British Columbia, Vancouver, Canada
- Centre for Health Evaluation and Outcome Sciences, University of British Columbia, British Columbia, Vancouver, Canada
| | | | | | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
| | - Marie-Laure Volvert
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Department of Obstetrics and Gynaecology, University of British Columbia, British Columbia, Vancouver, Canada
- BC Children's Hospital Research Institute, University of British Columbia, British Columbia, Vancouver, Canada
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Zambrano MA, Rojas-Suarez JA, Peña-Zarate EE, Carvajal JA, Gutierrez-Puerto LS, Aguilar-Cano F, Santacruz-Arias J, Rodríguez-Lopez M, Fernanda Escobar M. Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis. Hypertens Pregnancy 2023; 42:2272176. [PMID: 38059821 DOI: 10.1080/10641955.2023.2272176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/07/2023] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy. METHODS Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension. RESULTS Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome. CONCLUSION Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.
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Affiliation(s)
| | - Jose A Rojas-Suarez
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
- GINUMED Research Group, Corporación Universitaria Rafael Núñez, Cartagena, Colombia
| | - Evelyn E Peña-Zarate
- Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, Colombia
| | - Javier Andres Carvajal
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
| | | | | | - Jose Santacruz-Arias
- Intensive Care and Obstetric Research Group (GRICIO), Universidad de Cartagena, Cartagena, Colombia
| | | | - María Fernanda Escobar
- Facultad de Ciencias de la Salud, Universidad Icesi, Cali, Colombia
- Unidad de Alta Complejidad Obstétrica, Departamento de Obstetricia y Ginecología, Fundación Valle del Lili, Cali, Colombia
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Shongwe ZB. Implementation of maternal guidelines for gravid teenagers with hypertensive disorders in KwaZulu-Natal. Curationis 2023; 46:e1-e7. [PMID: 36744473 PMCID: PMC9982488 DOI: 10.4102/curationis.v46i1.2395] [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: 07/28/2022] [Revised: 10/14/2022] [Accepted: 11/15/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The worldwide phenomenon of teenage pregnancy among 13-9-year-olds is complicated by obstetric conditions. Among the top three causes of maternal mortality, hypertension is the third in South Africa. Quality maternal care is assured by obstetric practitioners (OPs) implementing guidelines specific for management of hypertension in pregnancy. OBJECTIVE The objective of this study was to investigate implementation of maternal guidelines for hypertension in pregnancy among teenagers. METHODS As a retrospective quantitative research design was used, 173 maternal records of pregnant teenagers from 13 to 19 years were sampled from six district hospitals and Community Health Centres (CHCs) between 01 January 2017 and 31 December 2019 to undergo systematic random sampling. A pretested structured checklist was used to record data from sampled maternal records. Statistical Package for Social Sciences (SPSS) version 26 was used for data analysis, and results were presented using simple descriptive statistics. RESULTS Research results indicated that teenagers who suffered from hypertension intrapartum and postpartum did not receive maternal care according to the guidelines for maternity care in South Africa. Blood pressure was not measured of six (3.47%) intrapartum and five (2.9%) postpartum teenagers. Seventeen (9.8%) hypertensive postpartum teenagers received their antihypertensives. CONCLUSION Public health institutions (PHIs) compromised provision of quality maternal care among teenagers, evidenced by incomplete intrapartum and postpartum assessment, diagnosis and management of hypertensive disorders in pregnancy (HDP).Contribution: This study contributed to facilitating adherence to guidelines improving healthcare of teenagers in government facilities.
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Affiliation(s)
- Zwelihle B. Shongwe
- Department of Health, KwaZulu-Natal College of Nursing, Empangeni, South Africa,Department of Health Studies, College of Human Sciences, University of South Africa, Pretoria, South Africa
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Lu HW, Hsu HS. Detecting Preeclampsia Severity Using Maternal-Obstetrical Characteristics and Complete Blood Cell Counts. Int J Gen Med 2022; 15:8715-8726. [PMID: 36582253 PMCID: PMC9793784 DOI: 10.2147/ijgm.s392915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 12/18/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose This study aimed to use the combination of maternal-obstetrical characteristics (MOCs) and complete blood cell counts (CBCs) with different red blood cell (RBC) indices as an alternative tool to detect preeclampsia (PE) severity immediately before delivery. Patients and Methods This retrospective study included all singleton pregnancies delivered after 24 weeks of gestation from April 2016 to April 2020. Patients were divided into four different groups: non-hypertensive (NH), gestational hypertension (GH), PE, and severe PE (SPE). Univariate and forward stepwise multivariate logistic regression analysis was conducted using MOCs, CBCs, and RBC indices. The calculation was performed between SPE and other non-hypertensive and hypertensive (GH, PE) groups. Moreover, the area under the curve (AUC) for the receiver operating characteristic curve, sensitivity, and specificity were estimated. Results The combined variables for differentiating SPE from NH were maternal age >29.5 years, weight >27.24, gestational age <272 days at the time of blood withdrawal, platelet count <217.5×103/μL, Srivastava indices <6.35, and Siradah indices <43.02 (AUC, 0.834; 95% confidence interval [CI], 0.773-0.895). The combined variables for differentiating SPE from GH were maternal age >29.5 years, body mass index >25.28, gestational age <268.5 days at the time of blood withdrawal, mean corpuscular volume <78.85 fL, and platelet count <234.5×103/μL (AUC, 0777; 95% CI, 0.703-0.852). The combined variables for differentiating SPE from PE were maternal age >32.5 years, mean corpuscular hemoglobin concentration >34.55 g/dL, and Siradah indices <40.05 (AUC, 0.745; 95% CI, 0.656-0.833). Conclusion The combination of selected variables from MOCs and CBCs with RBC indices before delivery showed satisfactory results for detecting PE severity.
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Affiliation(s)
- Hsiao-Wen Lu
- Department of Obstetrics and Gynecology, Cardinal Tien Hospital, New Taipei City, Taiwan,Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Han-Shui Hsu
- Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan,Correspondence: Han-Shui Hsu, Institute of Emergency and Critical Care Medicine, School of Medicine, National Yang Ming Chiao Tung University, No. 155, Sec. 2, Linong St, Beitou Dist, Taipei, 112, Taiwan, Tel +886-2-22875-7546, Email
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Escobar MF, Echavarria MP, Vasquez H, Nasner D, Ramos I, Hincapié MA, Pabon S, Kusanovic JP, Martínez-Ruíz DM, Carvajal JA. Experience of a telehealth and education program with maternal and perinatal outcomes in a low-resource region in Colombia. BMC Pregnancy Childbirth 2022; 22:604. [PMID: 35906534 PMCID: PMC9336139 DOI: 10.1186/s12884-022-04935-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Maternal morbidity and mortality rates associated with perinatal care remain a significant public health concern. Rural populations from low and middle-income countries have multiple barriers to access that contribute to a lack of adherence to prenatal care, and high rates of maternal mortality and morbidity. An intervention model based on telehealth and education was implemented between a tertiary high complex care hospital and a second-level hospital from a limited source region. OBJECTIVES We sought to identify an association in maternal and perinatal care quality indicators after implementing a model based on telehealth and education for patients with obstetric emergencies between two hospitals in a southwestern region of Colombia. METHODS We conducted an ecological study between 2017 and 2019 to compare before and after obstetric emergency care through telemedicine from a secondary care center (Hospital Francisco de Paula Santander-HFPS) to the referral center (Fundación Valle del Lili-FVL). The intervention included verification visits to determine the installed capacity of care, a concerted improvement plan, and on-site educational training modules in obstetric and perinatal care. RESULTS There were 102 and 148 patients treated before and after telemedicine implementation respectively. Clinical indicators after model implementation showed a reduction in perinatal mortality of 29%. In addition, a reduction in the need for transfusion of blood products due to postpartum hemorrhage was observed as well as the rate of eclampsia. CONCLUSIONS Implementing a model based on telehealth and education between secondary and tertiary care centers allowed the strengthening of the security of care in obstetric emergencies and had a positive effect on perinatal mortality.
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Affiliation(s)
- María Fernanda Escobar
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia.
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia.
| | - María Paula Echavarria
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Hilda Vasquez
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Daniela Nasner
- Department of Telemedicine, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Isabella Ramos
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - María Antonia Hincapié
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Stephanie Pabon
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago, Chile
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | - Javier Andrés Carvajal
- High Complexity Obstetric Unit, Department of Obstetrics and Gynecology, Fundación Valle del Lili, Cra 98 Nro.18-49, Cali, 760032, Colombia
- Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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Scott G, Gillon TE, Pels A, von Dadelszen P, Magee LA. Guidelines-similarities and dissimilarities: a systematic review of international clinical practice guidelines for pregnancy hypertension. Am J Obstet Gynecol 2022; 226:S1222-S1236. [PMID: 32828743 DOI: 10.1016/j.ajog.2020.08.018] [Citation(s) in RCA: 58] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/15/2020] [Accepted: 08/10/2020] [Indexed: 01/20/2023]
Abstract
OBJECTIVE This study aimed to review pregnancy hypertension clinical practice guidelines to inform international clinical practice and research priorities. STUDY ELIGIBILITY CRITERIA Relevant national and international clinical practice guidelines, 2009-19, published in English, French, Dutch or German. STUDY APPRAISAL AND SYNTHESIS METHODS Following published methods and prospective registration (CRD42019123787), a literature search was updated. CPGs were identified by 2 authors independently who scored quality and usefulness for practice (Appraisal of Guidelines for Research and Evaluation II instrument), abstracted data, and resolved any disagreement by consensus. RESULTS Of note, 15 of 17 identified clinical practice guidelines (4 international) were deemed "clinically useful" and had recommendations abstracted. The highest Appraisal of Guidelines for Research and Evaluation II scores were from government organizations, and scores have improved over time. The following were consistently recommended: (1) automated blood pressure measurement with devices validated for pregnancy and preeclampsia, reflecting increasing recognition of the prevalence of white-coat hypertension and the potential usefulness of home blood pressure monitoring; (2) use of dipstick proteinuria testing for screening followed by quantitative testing by urinary protein-to-creatinine ratio or 24-hour urine collection; (3) key definitions and most aspects of classification, including a broad definition of preeclampsia (which includes proteinuria and maternal end-organ dysfunction, including headache and visual symptoms and laboratory abnormalities of platelets, creatinine, or liver enzymes) and a recognition that it can worsen after delivery; (4) preeclampsia prevention with aspirin; (5) treatment of severe hypertension, most commonly with intravenous labetalol, oral nifedipine, or intravenous hydralazine; (6) treatment for nonsevere hypertension when undertaken, with oral labetalol (in particular), methyldopa, or nifedipine, with recommendations against the use of renin-angiotensin-aldosterone inhibitors; (7) magnesium sulfate for eclampsia treatment and prevention among women with "severe" preeclampsia; (8) antenatal corticosteroids for preterm birth but not hemolysis, elevated liver enzymes, and low platelet count syndrome; (9) delivery at term for preeclampsia; (10) a focus on usual labor and delivery care but avoidance of ergometrine; and (11) an appreciation that long-term health complications are increased in incidence, mandating lifestyle change and risk factor modification. Lack of uniformity was seen in the following areas: (1) the components of a broad preeclampsia definition (specifically respiratory and gastrointestinal symptoms, fetal manifestations, and biomarkers), what constitutes severe preeclampsia, and whether the definition has utility because at present what constitutes severe preeclampsia by some guidelines that mandate proteinuria now defines any preeclampsia for most other clinical practice guidelines; (2) how preeclampsia risk should be identified early in pregnancy, and aspirin administered for preeclampsia prevention, because multivariable models (with biomarkers and ultrasonography added to clinical risk markers) used in this way to guide aspirin therapy can substantially reduce the incidence of preterm preeclampsia; (3) the value of calcium added to aspirin for preeclampsia prevention, particularly for women with low intake and at increased risk of preeclampsia; (4) emerging recommendations to normalize blood pressure with antihypertensive agents even in the absence of comorbidities; (5) fetal neuroprotection as an indication for magnesium sulfate in the absence of "severe" preeclampsia; and (6) timing of birth for chronic and gestational hypertension and preterm preeclampsia. CONCLUSION Consistent recommendations should be implemented and audited. Inconsistencies should be the focus of research.
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Fishel Bartal M, Sibai BM. Eclampsia in the 21st century. Am J Obstet Gynecol 2022; 226:S1237-S1253. [PMID: 32980358 DOI: 10.1016/j.ajog.2020.09.037] [Citation(s) in RCA: 71] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 09/14/2020] [Accepted: 09/22/2020] [Indexed: 12/12/2022]
Abstract
The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.
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Affiliation(s)
- Michal Fishel Bartal
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX.
| | - Baha M Sibai
- Division of Maternal-Fetal Medicine, Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
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Lane-Cordova AD, Wilcox S, Fernhall B, Liu J. Agreement between blood pressure from research study visits versus electronic medical records and associations with hypertensive disorder diagnoses in pregnant women with overweight/obesity. Blood Press Monit 2021; 26:341-347. [PMID: 34001756 PMCID: PMC8419020 DOI: 10.1097/mbp.0000000000000542] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Blood pressure (BP) abstracted from electronic medical records (EMR) is moderately correlated to BP in nonpregnant adults with limited agreement. Little is known about the agreement of research versus EMR BP measured during pregnancy or associations of EMR BP with hypertensive disorder of pregnancy (HDP) diagnoses. METHODS BP was measured according to guidelines at in-person research study visits in 214 women with prepregnancy overweight or obesity (44.4% African American, mean age = 29.8 ± 4.8 years) at weeks 16 and 32 of pregnancy. Clinic BP readings that occurred within 1 week of the study visits were abstracted from the EMR. We assessed correlations between sources using Pearson's coefficients; the agreement was evaluated with Bland-Altman plots. We compared differences in the proportion of women with an HDP diagnosis in the EMR between women with versus without a hypertensive EMR BP measurement. RESULTS SBP and DBP from study visits and the EMR were modestly moderately correlated at both time points; 0.20 < r < 0.44; P < 0.05 for all. The average mean difference was 10.5 mmHg for SBP and <1 mmHg for DBP in early and 7.3 mmHg for SBP and -1.7 mmHg for DBP in late pregnancy. Women with at least one hypertensive BP reading in the EMR were more likely to have an HDP diagnosis recorded in the EMR; 43.5 versus 3.3%; P < 0.01. CONCLUSION EMR SBP was higher but moderately correlated with research quality BP in early and late pregnancy. Women with a hypertensive EMR BP measurement were more likely to have an HDP diagnosis in the EMR.
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Affiliation(s)
- Abbi D Lane-Cordova
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Sara Wilcox
- Department of Exercise Science, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina
| | - Bo Fernhall
- Department of Kinesiology and Nutrition, College of Applied Health Sciences, University of Illinois at Chicago, Chicago, Illinois
| | - Jihong Liu
- Department of Epidemiology and Biostatistics, Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, Columbia, South Carolina, USA
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Malaiyandi D, James E, Peglar L, Karim N, Henkel N, Guilliams K. Neurocritical Care of the Pregnant Patient. Curr Treat Options Neurol 2021; 23:22. [PMID: 34177249 PMCID: PMC8214980 DOI: 10.1007/s11940-021-00676-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/23/2021] [Indexed: 02/07/2023]
Abstract
Purpose of review To summarize recent changes in management and emerging therapies for pregnant neurocritical care patients. Recent findings Diagnostic and treatment options for managing neurologic emergencies in pregnant patients have expanded with both greater understanding of the effects of imaging modalities and medications on pregnancy and application of standard treatments for non-pregnant patients to pregnant populations. Specifically, this includes cerebrovascular diseases (pregnancy-associated ischemic stroke, pregnancy-associated intracerebral hemorrhage, cerebral venous sinus thrombosis), post-maternal cardiac arrest care, seizures and status epilepticus, myasthenia gravis, and fetal somatic support in maternal death by neurologic criteria. Summary With the exception of direct abdominal computed tomography (CT), most imaging studies are reasonably safe in pregnancy. When emergent imaging is needed to prevent maternal morbidity or mortality, any CT sequence with or without contrast is appropriate to pursue. Though new safety data on antiplatelets, antihypertensives, thrombolytics, and antiepileptic drugs have increased options for disease management in pregnancy, unfractionated and low-molecular weight heparin remain the safest options for anticoagulation. Early studies on hypothermia, ketamine, and immunomodulating therapies in pregnancy are promising. In myasthenia gravis, new data on adjunct devices may allow more patients to undergo safe vaginal delivery, avoiding cesarean section and the associated risk of crisis. When difficult decisions regarding preterm delivery arise, recent outcome studies can help inform discussion. Lastly, when the feared complication of maternal death by neurologic criteria occurs, fetal somatic support may help to save at least one life.
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Affiliation(s)
- Deepa Malaiyandi
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,University of Toledo/ProMedica Neurosciences Center, 2130 W Central Ave, Ste. 201, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Elysia James
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA.,ProMedica Toledo Hospital, Toledo, OH USA
| | - Lindsay Peglar
- Department of Neurology, Washington University, St. Louis, MO USA
| | - Nurose Karim
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Nicholas Henkel
- Department of Neurology, Division of Neurocritical Care, University of Toledo College of Medicine, Toledo, OH USA
| | - Kristin Guilliams
- Department of Neurology, Washington University, St. Louis, MO USA.,Department of Pediatrics, Washington University, St. Louis, MO USA
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10
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Park K, Bairey Merz CN, Bello NA, Davis M, Duvernoy C, Elgendy IY, Ferdinand KC, Hameed A, Itchhaporia D, Minissian MB, Reynolds H, Mehta P, Russo AM, Shah RU, Volgman AS, Wei J, Wenger NK, Pepine CJ, Lindley KJ. Management of Women With Acquired Cardiovascular Disease From Pre-Conception Through Pregnancy and Postpartum: JACC Focus Seminar 3/5. J Am Coll Cardiol 2021; 77:1799-1812. [PMID: 33832606 PMCID: PMC8061780 DOI: 10.1016/j.jacc.2021.01.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/19/2021] [Accepted: 01/28/2021] [Indexed: 01/08/2023]
Abstract
Acquired cardiovascular conditions are a leading cause of maternal morbidity and mortality. A growing number of pregnant women have acquired and heritable cardiovascular conditions and cardiovascular risk factors. As the average age of childbearing women increases, the prevalence of acute coronary syndromes, cardiomyopathy, and other cardiovascular complications in pregnancy are also expected to increase. This document, the third of a 5-part series, aims to provide practical guidance on the management of such conditions encompassing pre-conception through acute management and considerations for delivery.
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Affiliation(s)
- Ki Park
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - C Noel Bairey Merz
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Melinda Davis
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Claire Duvernoy
- Division of Cardiology, VA Ann Arbor Healthcare System and University of Michigan, Ann Arbor, Michigan, USA
| | - Islam Y Elgendy
- Division of Cardiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Keith C Ferdinand
- Tulane University Heart and Vascular Institute, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Afshan Hameed
- Department of Obstetrics, University of California Irvine, Irvine, California, USA
| | - Dipti Itchhaporia
- Jeffrey M. Carlton Heart & Vascular Institute, Hoag Memorial Hospital Presbyterian, Newport Beach, California, USA
| | - Margo B Minissian
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Harmony Reynolds
- Sarah Ross Soter Center for Women's Cardiovascular Research, Leon H Charney Division of Cardiology Department of Medicine, NYU Grossman School of Medicine, New York, New York, USA
| | - Puja Mehta
- Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, Georgia, USA
| | - Andrea M Russo
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Rashmee U Shah
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, University of Utah, Salt Lake City, Utah, USA
| | | | - Janet Wei
- Barbra Streisand Women's Heart Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA
| | - Nanette K Wenger
- Emory University School of Medicine, Emory Heart and Vascular Center, Emory Women's Heart Center, Atlanta, Georgia, USA
| | - Carl J Pepine
- Division of Cardiovascular Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kathryn J Lindley
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
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11
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Abstract
Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.
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Affiliation(s)
- Kristen L Fardelmann
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA.
| | - Aymen Awad Alian
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
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12
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Lee King PA, Henderson ZT, Borders AEB. Advances in Maternal Fetal Medicine: Perinatal Quality Collaboratives Working Together to Improve Maternal Outcomes. Clin Perinatol 2020; 47:779-797. [PMID: 33153662 PMCID: PMC11005004 DOI: 10.1016/j.clp.2020.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
State-based perinatal quality collaboratives (PQCs) address preventable causes of maternal and infant morbidity and mortality by implementing statewide quality improvement (QI) initiatives. They work with hospital clinical teams, obstetric provider and nursing leaders, patients and families, public health officials, and other stakeholders to provide opportunities for collaborative learning, rapid-response data, and QI science support to achieve clinical culture change. PQCs show that the application of collaborative improvement science methods to advance evidence-informed clinical practices using QI strategies contributes to improved perinatal outcomes. With appropriate staffing, infrastructure, and partnerships, PQCs can achieve sustainable improvements in perinatal care.
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Affiliation(s)
- Patricia Ann Lee King
- Feinberg School of Medicine, Center for HealthCare Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University, 633 North St. Clair, 20th Floor, Chicago, IL 60611, USA; Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Zsakeba T Henderson
- Division of Reproductive Health, NCCDPHP, Centers for Disease Control and Prevention, 4770 Buford Highway Northeast, MS S107-2, Atlanta, GA 30341-3724, USA
| | - Ann E B Borders
- Feinberg School of Medicine, Center for HealthCare Services and Outcomes Research, Institute for Public Health and Medicine, Northwestern University, 633 North St. Clair, 20th Floor, Chicago, IL 60611, USA; Pritzker School of Medicine, University of Chicago, Chicago, IL, USA; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, NorthShore University HealthSystem, 2650 Ridge Avenue, Evanston, IL 60201, USA.
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13
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Abstract
Over the past 30 years, maternal mortality has increased in the United States to 18 deaths per 100,000 live births. Obstetric emergencies, including hemorrhage, hypertensive disorders in pregnancy, HELLP syndrome, and amniotic fluid embolism, and anesthesia complications, including high neuraxial blockade, local anesthetic systemic toxicity, and the difficult obstetric airway, contribute to maternal cardiac arrest and maternal and fetal morbidity and mortality. Expeditious intervention by the obstetric anesthesiologist is critical in these emergent scenarios, and knowledge of best practices is essential to improve maternal and fetal outcomes.
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Affiliation(s)
- Kristen L Fardelmann
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA.
| | - Aymen Awad Alian
- Department of Anesthesiology, Yale School of Medicine, 333 Cedar Street, PO Box 208051, New Haven, CT 06520-8051, USA
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14
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Abstract
Hypertension is the most common medical disorder occurring during pregnancy and a leading cause of maternal and perinatal morbidity and mortality. Accurate blood pressure measurement and the diagnosis and treatment of hypertensive disorders during pregnancy and in the postpartum period are pivotal to improve outcomes. This article details hemodynamic adaptations to pregnancy and provides an approach to the prevention, diagnosis, and management of hypertensive disorders of pregnancy (HDP) and hypertensive emergencies. In addition, it reviews optimal strategies for the care of women with hypertension during the fourth trimester and beyond to minimize future cardiovascular risk.
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Affiliation(s)
- Apurva M Khedagi
- Columbia University Vagelos College of Physicians & Surgeons, 622 West 168th Street, PH 3-342, New York, NY 10032, USA
| | - Natalie A Bello
- Department of Medicine, Division of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University Irving Medical Center, 622 West 168th Street, PH 3-342, New York, NY 10032, USA.
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15
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Bajpai D. Preeclampsia for the Nephrologist: Current Understanding in Diagnosis, Management, and Long-term Outcomes. Adv Chronic Kidney Dis 2020; 27:540-550. [PMID: 33328071 DOI: 10.1053/j.ackd.2020.05.001] [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] [Received: 04/07/2020] [Revised: 05/01/2020] [Accepted: 05/04/2020] [Indexed: 11/11/2022]
Abstract
Preeclampsia is a multisystem progressive disorder of pregnancy that can be potentially catastrophic for the mother and the fetus. It involves complex perturbations of the kidney and systemic physiology, along with long-term effects on vascular and kidney health. Thus, the nephrologist plays a key role in the peripartum and long-term management of preeclampsia. Recent translational research has improved our understanding of its pathophysiology, and there is hope for novel therapies. In this review, we discuss the evolution of diagnostic criteria and dilemmas in the diagnosis of hypertensive disorders in pregnancy. We summarize the advances in the pathogenesis and prediction of preeclampsia. We describe the management and prevention of preeclampsia focusing specially on the forthcoming strategies from the nephrologist's perspective. We address the evidence regarding long-term outcomes for the mother and the child. We end with exploring areas warranting future research.
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16
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Abstract
Care of the critically ill pregnant patient is anxiety-provoking for those unprepared, as the emergency physician must consider not only the welfare of the immediate patient, but of the fetus as well. Familiarity with the physiologic changes of pregnancy and how they affect clinical presentation and management is key. Although some medications may be safer in pregnancy than others, stabilizing the pregnant patient is paramount. Emergency physicians should target pregnancy-specific oxygen and ventilation goals and hemodynamics and should be prepared to perform a perimortem cesarean section, should the mother lose pulses, to increase chances for maternal and fetal survival.
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Affiliation(s)
- Kami M Hu
- Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Aleta S Hong
- Department of Internal Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA. https://twitter.com/hong_aleta
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17
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Abstract
Hypertensive diseases of pregnancy remain a leading cause of maternal and neonatal morbidity and mortality. Therefore, we sought to review the management of these conditions in pregnancy. In this review we discuss the most updated definitions, different antihypertensives, delivery recommendations and overall goals of management, including their effects on uteroplacental perfusion. We also highlight different medical situations where one antihypertensive may be preferable over others.
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Affiliation(s)
- Farah Amro
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Baha Sibai
- Department of Obstetrics, Gynecology and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
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18
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Qi H, Qin J, Ren L, Li L, Lan L, Yan Y, Gan S, Zhang Y. Efficacy of low-dose nicardipine for emergent treatment of severe postpartum hypertension in maternal intensive care units: An observational study. Pregnancy Hypertens 2020; 21:43-49. [DOI: 10.1016/j.preghy.2020.04.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2019] [Revised: 03/05/2020] [Accepted: 04/25/2020] [Indexed: 10/24/2022]
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19
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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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20
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21
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Tamargo J. Selecting emergency therapy for patients with pre-eclampsia. Expert Opin Pharmacother 2020; 21:1119-1122. [PMID: 32133877 DOI: 10.1080/14656566.2020.1727444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Instituto De Investigación Sanitaria Gregorio Marañón, Universidad Complutense , Madrid, Spain
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22
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Phillips-Bell G, Holicky A, Macdonald M, Hernandez L, Watson A, Dawit R. Collaboration Between Maternal and Child Health and Chronic Disease Epidemiologists to Identify Strategies to Reduce Hypertension-Related Severe Maternal Morbidity. Prev Chronic Dis 2019; 16:E162. [PMID: 31831105 PMCID: PMC6936670 DOI: 10.5888/pcd16.190045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Introduction Maternal and child health (MCH) and chronic disease programs at state health agencies may not routinely collaborate. The objective of this study was to describe a project that enhanced relationships between MCH and chronic disease epidemiologists at the Florida Department of Health, increased epidemiologic capacity, and informed both programs. Methods We collaborated to assess hypertension-related severe maternal morbidity (H-SMM) and hypertensive disorders (preexisting hypertension, gestational hypertension, and preeclampsia) among women at delivery of their live birth to help determine the burden on health care systems in Florida. We identified ways to improve the health of women before they conceive and to help them manage any chronic diseases during the perinatal period. Results We found differences by maternal characteristics in H-SMM rates among 979,660 women who delivered live births. We proposed strategies to support collaboration between state MCH and chronic disease staff. First, increase the screening, monitoring, and management of hypertension before, during, and after pregnancy. Second, examine H-SMM concurrently with maternal mortality to help find prevention strategies. Third, include reproductive-aged women in ongoing hypertension prevention and intervention efforts. Fourth, expand team-based care to include obstetricians, midwives, and doulas who can work together with primary care providers for hypertension management. And fifth, create and share data products that guide various groups about hypertension and related risk factors among reproductive-aged women. Conclusion The collaboration between the Florida Department of Health MCH and chronic disease epidemiologists produced 1) a program-relevant indicator, H-SMM and 2) strategies for enhancing program and clinical activities, communication, and surveillance to reduce H-SMM rates.
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Affiliation(s)
- Ghasi Phillips-Bell
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida.,Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia.,4052 Bald Cypress Way, Bin A13, Tallahassee, FL 32399-1721.
| | - Abigail Holicky
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida.,Centers for Disease Control and Prevention, Council of State and Territorial Epidemiologists Applied Epidemiology Fellowship, Atlanta, Georgia
| | - Megan Macdonald
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida
| | - Leticia Hernandez
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida
| | - Angel Watson
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida
| | - Rahel Dawit
- Division of Community Health Promotion, Florida Department of Health, Tallahassee, Florida
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23
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Cossler N, Liu J, Porter S, Albertini M, Katz T, Pronovost P. Malpractice litigation, quality improvement, and the University Hospitals Obstetric Quality Network. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2019. [DOI: 10.1177/2516043519877330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Nancy Cossler
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - James Liu
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - Steven Porter
- Case Western Reserve University School of Medicine, Cleveland, USA
- riskLD, LLC, Wilmington, USA
| | - Megan Albertini
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - Tyler Katz
- Case Western Reserve University School of Medicine, Cleveland, USA
| | - Peter Pronovost
- Case Western Reserve University School of Medicine, Cleveland, USA
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24
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In Reply. Obstet Gynecol 2019; 134:880-881. [PMID: 31568351 DOI: 10.1097/aog.0000000000003494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Ainuddin J, Javed F, Kazi S. Oral labetalol versus oral nifedipine for the management of postpartum hypertension a randomized control trial. Pak J Med Sci 2019; 35:1428-1433. [PMID: 31489020 PMCID: PMC6717493 DOI: 10.12669/pjms.35.5.812] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 06/24/2019] [Accepted: 06/26/2019] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the efficacy of oral Labetalol versus oral Nifedipine for the treatment of postpartum hypertension. METHODS A prospective randomized controlled trial with parallel assignment was conducted in the department of Obstetrics and Gynecology, Dow University of Health Sciences Karachi, Pakistan, 124 patients with post partum hypertension were selected and randomized into two groups with 62 patients receiving Labetalol and 62 receiving long acting nifedipine. Initial blood pressures were recorded, and the respective drug was administered. Dose adjustments were performed in the initial 24 hours. The outcome was measured in the form of drug efficacy by lowering of systolic blood pressure less than 140mm of Hg and diastolic less than 90mm of Hg up to 48 hours after starting treatment. Data was entered and analyzed through SPSS version 20. RESULTS Our study randomized 62 women to oral labetalol and 62 women to oral long acting nifedipine. The time required to achieve blood pressure control was 35.6±2.8 hours in labetalol group and 30.4±1.9 hours in nifedipine group (p=0.04).length of hospital stay, need of additional antihypertensive medications were same in both groups. Minor side effects were observed more in nifedipine group. CONCLUSION We conclude that both oral labetalol and oral long acting nifedipine are effective and well tolerated interventions for the management of post-partum hypertension. However we found Nifidipine more effective in the management of postpartum hypertension.
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Affiliation(s)
- Jahanara Ainuddin
- Prof. Dr. Jahanara Ainuddin FCPS, Ph.D. Department of Obstetrics and Gynecology, Dow University of Health Sciences, Karachi, Pakistan
| | - Fariha Javed
- Dr. Fariha Javed, MBBS. Postgraduate Resident, Department of Obstetrics and Gynecology, Dow University of Health Sciences, Karachi, Pakistan
| | - Sarah Kazi
- Dr. Sarah Kazi, MRCOG, FCPS. Associate Professor, Department of Obstetrics and Gynecology, Dow University of Health Sciences, Karachi, Pakistan
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26
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Bijl RC, Valensise H, Novelli GP, Vasapollo B, Wilkinson I, Thilaganathan B, Stöhr EJ, Lees C, van der Marel CD, Cornette JMJ. Methods and considerations concerning cardiac output measurement in pregnant women: recommendations of the International Working Group on Maternal Hemodynamics. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:35-50. [PMID: 30737852 DOI: 10.1002/uog.20231] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 01/18/2019] [Accepted: 01/24/2019] [Indexed: 06/09/2023]
Abstract
Cardiac output (CO), along with blood pressure and vascular resistance, is one of the most important parameters of maternal hemodynamic function. Substantial changes in CO occur in normal pregnancy and in most obstetric complications. With the development of several non-invasive techniques for the measurement of CO, there is a growing interest in the determination of this parameter in pregnancy. These techniques were initially developed for use in critical-care settings and were subsequently adopted in obstetrics, often without appropriate validation for use in pregnancy. In this article, methods and devices for the measurement of CO are described and compared, and recommendations are formulated for their use in pregnancy, with the aim of standardizing the assessment of CO and peripheral vascular resistance in clinical practice and research studies on maternal hemodynamics. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R C Bijl
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - H Valensise
- Department of Obstetrics and Gynecology, Tor Vergata University, Rome, Italy
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - G P Novelli
- Department of Cardiology, San Sebastiano Martire Hospital, Frascati, Italy
| | - B Vasapollo
- Division of Obstetrics and Gynecology, Policlinico Casilino Hospital, Rome, Italy
| | - I Wilkinson
- Division of Experimental Medicine and Immunotherapeutics, University of Cambridge, Cambridge, UK
| | - B Thilaganathan
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - E J Stöhr
- Cardiff School of Sport & Health Sciences, Cardiff Metropolitan University, Cardiff, UK
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, USA
| | - C Lees
- Department of Obstetrics, Imperial College, London, UK
| | - C D van der Marel
- Department of Anesthesiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - J M J Cornette
- Department of Obstetrics and Gynecology, Erasmus Medical Center, Rotterdam, The Netherlands
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27
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Systolic Hypertension, Preeclampsia-Related Mortality, and Stroke in California. Obstet Gynecol 2019; 133:1151-1159. [DOI: 10.1097/aog.0000000000003290] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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28
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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