Dynamics and incidence patterns of maternal complications in early-onset hypertension of pregnancy

Conservative management of early-onset severe preeclampsia: comparison between randomized and observational studies a systematic review

OBJECTIVE

To compare maternal and perinatal outcomes between randomized trials and observational studies in which conservative management was performed for more than 48 h in patients with early-onset severe preeclampsia.

METHODOLOGY

We searched PubMed, LILACS, Cochrane and Google Scholar. The studies were divided in two groups: randomized and observational studies, from 1990 to 2018 that included patients with severe preeclampsia before 34 weeks of gestation with pregnancy prolongation ≥48 h but that did not include fetal growth restriction or HELLP syndrome at the beginning. The main variables recorded were maternal and perinatal complications.

MAIN RESULTS

Forty-four studies met the inclusion criteria, and 5 of these were randomized. The average pregnancy prolongation was 9 days, with no difference between groups. Maternal complications were significantly more common in observational studies, RR = 0.71, 95% CI (0.54-0.93), p = .009. Perinatal complications were also significantly more common in observational studies (RR = 0.89, 95% CI (0.80-0.98), p = .01) at the expense of stillbirth and neonatal deaths. The percentages of cesarean sections were significantly higher in randomized studies, RR = 1.54, 95% CI (1.46-1.64). There were 2 maternal deaths, both in observational studies.

CONCLUSION

Observational studies in which conservative management of early-onset preeclampsia is performed and do not include patients with fetal growth restriction or patients with HELLP syndrome and where at least 2 days of pregnancy prolongation is achieved are associated with significantly more maternal and perinatal complications.

Adverse maternal and neonatal outcomes among women with preeclampsia with severe features <34 weeks gestation with versus without comorbidity

OBJECTIVES

To determine adverse maternal and neonatal outcomes among women with preeclampsia with severe features who delivered <34 weeks comparing those with versus without a comorbid condition.

STUDY DESIGN

A retrospective analysis from the U.S. Consortium on Safe Labor Study of deliveries <34 weeks with preeclampsia with severe features. We examined the association of each comorbid condition versus none with adverse maternal and neonatal outcomes. The comorbidities (not mutually exclusive) were chronic hypertension, pregestational diabetes, gestational diabetes, twin gestation, and fetal growth restriction.

MAIN OUTCOMES

Maternal outcome: eclampsia, thromboembolism, ICU admission, and/or death; and neonatal outcome: intracranial/periventricular hemorrhage, hypoxic-ischemic encephalopathy/periventricular leukomalacia, stillbirth, and/or perinatal death.

RESULTS

Among 2217 deliveries, 50% had a comorbidity, namely chronic hypertension (30%), pregestational diabetes (8%), gestational diabetes (8%), twin gestation (10%), and fetal growth restriction (7%). Adverse maternal and neonatal outcomes occurred in 10% and 12% of pregnancies, respectively. Pregnancies with preeclampsia with severe features delivered <34 weeks complicated by gestational diabetes (adjusted risk difference, aRD: -4.9%, 95%CI: -9.11 to -0.71), twin gestation (aRD: -5.1%, 95%CI: -8.63 to -1.73), and fetal growth restriction (aRD: -4.7%, 95%CI: -7.96 to -1.62) were less likely to result in adverse maternal outcome compared to pregnancies without comorbidity, but not chronic hypertension and pregestational diabetes. A pregnancy complicated by fetal growth restriction (aRD: 12.2%, 95%CI: 5.48 to 19.03) was more likely to result in adverse neonatal outcome, but not other comorbid conditions.

CONCLUSIONS

Preeclampsia with severe features <34 weeks complicated by comorbidity was generally not associated with an increased risk of adverse maternal and neonatal outcomes, with the exception of fetal growth restriction.

Early-onset fetal growth restriction: A systematic review on mortality and morbidity

INTRODUCTION

Severe early-onset fetal growth restriction is an obstetric condition with significant risks of perinatal mortality, major and minor neonatal morbidity, and long-term health sequelae. The prognosis of a fetus is influenced by the extent of prematurity and fetal weight. Clinical care is individually adjusted. In literature, survival rates vary and studies often only include live-born neonates with missing rates of antenatal death. This systematic review aims to summarize the literature on mortality and morbidity.

MATERIAL AND METHODS

A broad literature search was conducted in OVID MEDLINE from 2000 to 26 April 2019 to identify studies on fetal growth restriction and perinatal death. Studies were excluded when all included children were born before 2000 because (neonatal) health care has considerably improved since this period. Studies were included that described fetal growth restriction diagnosed before 32 weeks of gestation and antenatal mortality and neonatal mortality and/or morbidity as outcome. Quality of evidence was rated with the GRADE instrument.

RESULTS

Of the 2604 publications identified, 25 studies, reporting 2895 pregnancies, were included in the systematic review. Overall risk of bias in most studies was judged as low. The quality of evidence was generally rated as very low to moderate, except for 3 large well-designed randomized controlled trials. When combining all data on mortality, in 355 of 2895 pregnancies (12%) the fetus died antenatally, 192 died in the neonatal period (8% of live-born neonates) and 2347 (81% of all pregnancies) children survived. Of the neonatal morbidities recorded, respiratory distress syndrome (34% of the live-born neonates), retinopathy of prematurity (13%) and sepsis (30%) were most common. Of 476 children that underwent neurodevelopmental assessment, 58 (12% of surviving children, 9% of all pregnancies) suffered from cognitive impairment and/or cerebral palsy.

CONCLUSIONS

When combining the data of 25 included studies, survival in fetal growth restriction pregnancies, diagnosed before 32 weeks of gestation, was 81%. Neurodevelopmental impairment was assessed in a minority of surviving children. Individual prognostic counseling on the basis of these results is hampered by differences in patient and pregnancy characteristics within the included patient groups.

SOMANZ guidelines for the management of hypertensive disorders of pregnancy 2014

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.

Prediction of recurrence of hypertensive disorders of pregnancy in the term period, a retrospective cohort study

OBJECTIVES

To assess the recurrence risk of term hypertensive disease of pregnancy and to determine which potential risk factors are predictive of recurrence.

STUDY DESIGN

We performed a retrospective cohort study in two secondary and one tertiary care hospitals in the Netherlands. We identified women with a hypertensive disorder in the index pregnancy and delivery after 37weeks of gestation between January 2000 and December 2002. Data were extracted from medical files and women were approached for additional information on subsequent pregnancies. Adverse outcome was defined as recurrence of a hypertensive disorder in the next subsequent pregnancy.

MAIN OUTCOME MEASURES

The absolute risk of recurrence and a prediction model containing demographic and clinical factors predictive of recurrence.

RESULTS

We identified 638 women for potential inclusion, of whom 503 could be contacted. Of these women, 312 (62%) had a subsequent pregnancy. Hypertensive disorders recurred in 120 (38%, 95% CI 33-44) women, of whom 15 (5%, 95% CI 3-7) delivered preterm. Women undergoing recurrence were more at risk to develop chronic hypertension after pregnancy (35% versus 16%, OR 2.8, 95% CI 1.5-5.3). Body mass index, non-White European origin, chronic hypertension, maximum diastolic blood pressure, no use of anticonvulsive medication and interpregnancy interval were predictors for recurrence.

CONCLUSIONS

Women with hypertensive disorders and term delivery have a substantial chance of recurrence, but a small risk of preterm delivery. A number of predictors for recurrence could be identified and women with a recurrence more often developed chronic hypertension.

Plasma concentrations of angiogenic/anti-angiogenic factors have prognostic value in women presenting with suspected preeclampsia to the obstetrical triage area: a prospective study

OBJECTIVE

To prospectively determine the prognostic value of maternal plasma concentrations of placental growth factor (PlGF), soluble endoglin (sEng) and soluble vascular endothelial growth factor receptors-1 and -2 (sVEGFR-1 and -2) in identifying patients with suspected preeclampsia (PE), who require preterm delivery (PTD) or develop adverse outcomes.

STUDY DESIGN

This prospective cohort study included 85 consecutive patients who presented to the obstetrical triage area at 20-36 weeks with a diagnosis of "rule out PE." Patients were classified as: 1) those who remained stable until term (n = 37); and 2) those who developed severe PE and required PTD (n = 48). Plasma concentrations of PlGF, sEng and sVEGFR-1 and -2 were determined by ELISA.

RESULTS

Patients with PlGF/sVEGFR-1 ≤0.05 multiples of the median (MoM) or PlGF/sEng ≤0.07 MoM were more likely to deliver preterm due to PE [adjusted odd ratio (aOR) 7.4 and 8.8], and to develop maternal (aOR 3.7 and 2.4) or neonatal complications (aOR 10.0 and 10.1). Among patients who presented <34 weeks of gestation, PlGF/sVEGFR-1 ≤ 0.035 MoM or PlGF/sEng ≤0.05 MoM had a sensitivity of 89% (16/18), specificity of 96% (24/25) and likelihood ratio for a positive test of 22 to identify patients who delivered within 2 weeks. The addition of the PlGF/sVEGFR-1 ratio to standard clinical tests improved the sensitivity at a fixed false-positive rate of 3% (p = 0.004) for the identification of patients who were delivered due to PE within 2 weeks. Among patients who had a plasma concentration of PlGF/sVEGFR-1 ratio ≤0.035 MoM, 0.036-0.34 MoM and ≥0.35 MoM, the rates of PTD <34 weeks were 94%, 27% and 7%, respectively.

CONCLUSIONS

The determination of angiogenic/anti-angiogenic factors has prognostic value in patients presenting to the obstetrical triage area with suspected PE for the identification of those requiring preterm delivery and at risk for adverse maternal/neonatal outcomes.

Molecular genetics of preeclampsia and HELLP syndrome - a review

Preeclampsia is characterised by new onset hypertension and proteinuria and is a major obstetrical problem for both mother and foetus. Haemolysis elevated liver enzymes and low platelets (HELLP) syndrome is an obstetrical emergency and most cases occur in the presence of preeclampsia. Preeclampsia and HELLP are complicated syndromes with a wide variety in severity of clinical symptoms and gestational age at onset. The pathophysiology depends not only on periconceptional conditions and the foetal and placental genotype, but also on the capability of the maternal system to deal with pregnancy. Genetically, preeclampsia is a complex disorder and despite numerous efforts no clear mode of inheritance has been established. A minor fraction of HELLP cases is caused by foetal homozygous LCHAD deficiency, but for most cases the genetic background has not been elucidated yet. At least 178 genes have been described in relation to preeclampsia or HELLP syndrome. Confined placental mosaicism (CPM) is documented to cause early onset preeclampsia in some cases; the overall contribution of CPM to the occurrence of preeclampsia has not been adequately investigated yet. This article is part of a Special Issue entitled: Molecular Genetics of Human Reproductive Failure.

Outcome at 4.5 years of children born after expectant management of early-onset hypertensive disorders of pregnancy

OBJECTIVE

The objective of the study was to describe neurodevelopmental outcome at the age of 4.5 years in 216 children, born after expectant management of severe early-onset hypertensive complications of pregnancy.

STUDY DESIGN

This was a prospective follow-up study until age 4.5 years from maternal admission onward. Developmental outcome measurements included child intelligence quotient and behavioral, motor, and neurological outcome. Abnormal composite outcome (perinatal mortality or abnormal developmental outcome) was studied in relation to gestational age (GA), birthweight (BW), and perinatal variables.

RESULTS

Fetal and neonatal mortality was 9% and 8%, respectively. Of the 178 survivors, 149 (84%) were seen for follow-up. Mean GA was 31.4 weeks and 90% were born growth restricted. Abnormal developmental outcome occurred in 20% and abnormal composite outcome in 37%.

CONCLUSION

Perinatal mortality or abnormal child development occurs in one third of pregnancies with early-onset and severe hypertensive complications and is highest in the lowest GA and BW ranges.

Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study

OBJECTIVE

To determine the outcome of pregnancy in women with rheumatoid arthritis (RA) in relation to disease activity and medication use during the pregnancy.

METHODS

In a prospective study, pregnant women with RA were evaluated before conception (when possible), during each trimester of the pregnancy, and postpartum. Clinical characteristics, disease activity, medication use, and pregnancy outcome were analyzed. To examine the independent influence of prednisone use and disease activity on birth weight, regression analyses were performed, with adjustments for gestational age of the child at delivery, the sex of the newborn, and the mother's smoking status, education level, parity, and use of an assisted reproduction technique. Kaplan-Meier curve analyses were performed to examine the association between medication use and gestational age at delivery.

RESULTS

Data from 152 Caucasian RA patients with singleton pregnancies were available. Both the mean +/- SD birth weight (3,379 +/- 564 gm) and the mean +/- SD birth weight standard deviation score (SDS; +0.1 +/- 1.1), which is the birth weight adjusted for the gestational age and sex of the newborn, were comparable with those in the general population. On multiple linear regression analyses of birth weight and birth weight SDS, both of which were adjusted for covariates, only disease activity was associated with lower birth weight (P = 0.025). The gestational age at delivery was significantly lower in women who were taking prednisone (38.8 versus 39.9 weeks; P = 0.001), and their delivery was more often premature (<37 weeks; P = 0.004).

CONCLUSION

Pregnancy outcome in women with well-controlled RA is comparable with that in the general population. The effect of prednisone on birth weight is mediated by a lower gestational age at delivery, whereas a higher level of disease activity independently influences birth weight negatively, suggesting an immune-mediated mechanism.

Plasma volume expansion for treatment of women with pre-eclampsia

BACKGROUND

Plasma volume is reduced amongst women with pre-eclampsia. This association has led to the suggestion that expanding the plasma volume might improve maternal and uteroplacental circulation, and so potentially improve outcome for both the woman and her baby.

OBJECTIVES

The aim of this review was to assess the effects of plasma volume expansion for the treatment of women with pre-eclampsia.

SEARCH STRATEGY

The register of trials maintained by the Cochrane Pregnancy and Childbirth Group, and the Cochrane Controlled Trials Register Issue 1 1999 were searched for trials meeting the selection criteria.

SELECTION CRITERIA

Randomised trials were included. Quasi-random designs were excluded. Participants were women with hypertension during pregnancy, with or without proteinuria. Women who were postpartum at trial entry were excluded. Interventions were any comparison of plasma volume expansion with no expansion, or of one plasma volume expander with another.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by two reviewers. Discrepancies were resolved by discussion. There was no blinding of authorship or results.

MAIN RESULTS

Three trials involving 61 women were included in this review. All compared a colloid solution with no plasma volume expansion. For every outcome reported, the confidence intervals are very wide and cross the no effect line.

REVIEWER'S CONCLUSIONS

There is insufficient evidence for any reliable estimates of the effects of plasma volume expansion for women with pre-eclampsia.