Mean Arterial Pressure and Neonatal Outcomes in Pregnancies Complicated by Mild Chronic Hypertension

OBJECTIVE

To estimate the association between mean arterial pressure during pregnancy and neonatal outcomes in participants with chronic hypertension using data from the CHAP (Chronic Hypertension and Pregnancy) trial.

METHODS

A secondary analysis of the CHAP trial, an open-label, multicenter randomized trial of antihypertensive treatment in pregnancy, was conducted. The CHAP trial enrolled participants with mild chronic hypertension (blood pressure [BP] 140-159/90-104 mm Hg) and singleton pregnancies less than 23 weeks of gestation, randomizing them to active treatment (maintained on antihypertensive therapy with a goal BP below 140/90 mm Hg) or standard treatment (control; antihypertensives withheld unless BP reached 160 mm Hg systolic BP or higher or 105 mm Hg diastolic BP or higher). We used logistic regression to measure the strength of association between mean arterial pressure (average and highest across study visits) and to select neonatal outcomes. Unadjusted and adjusted odds ratios (per 1-unit increase in millimeters of mercury) of the primary neonatal composite outcome (bronchopulmonary dysplasia, retinopathy of prematurity, necrotizing enterocolitis, or intraventricular hemorrhage grade 3 or 4) and individual secondary outcomes (neonatal intensive care unit admission [NICU], low birth weight [LBW] below 2,500 g, and small for gestational age [SGA]) were calculated.

RESULTS

A total of 2,284 participants were included: 1,155 active and 1,129 control. Adjusted models controlling for randomization group demonstrated that increasing average mean arterial pressure per millimeter of mercury was associated with an increase in each neonatal outcome examined except NEC, specifically neonatal composite (adjusted odds ratio [aOR] 1.12, 95% CI, 1.09-1.16), NICU admission (aOR 1.07, 95% CI, 1.06-1.08), LBW (aOR 1.12, 95% CI, 1.11-1.14), SGA below the fifth percentile (aOR 1.03, 95% CI, 1.01-1.06), and SGA below the 10th percentile (aOR 1.02, 95% CI, 1.01-1.04). Models using the highest mean arterial pressure as opposed to average mean arterial pressure also demonstrated consistent associations.

CONCLUSION

Increasing mean arterial pressure was positively associated with most adverse neonatal outcomes except NEC. Given that the relationship between mean arterial pressure and adverse pregnancy outcomes may not be consistent at all mean arterial pressure levels, future work should attempt to further elucidate whether there is an absolute threshold or relative change in mean arterial pressure at which fetal benefits are optimized along with maternal benefits.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT02299414.

Evolution of AOA Specialty Board Certification

The launch of Osteopathic Continuous Certification (OCC) signifes the next stage of the osteopathic board certification process. The OCC process replaces the old recertification system for all osteopathic physicians who earned time-limited certificates from American Osteopathic Association (AOA) certifying boards. All 18 AOA certifying boards are now engaged in the continuous certification process. With the advent of any new system, many questions and concerns will arise. The AOA Bureau of Osteopathic Specialists continues to evaluate its new certification system and prepare for modi-fcations in response to this feedback. J Am Osteopath Assoc. 2015;115(4):265-267 doi:10.7556/jaoa.2015.051

Folic acid supplementation use among women who contact a teratology information service

OBJECTIVE

The purpose of this study was to determine the percentage of the women who call a teratology information service who take folic acid before conception.

STUDY DESIGN

A pilot-tested questionnaire was used to survey women who called a teratology information service about their use of folic acid supplementation. Frequencies were generated by pregnancy status, age, race, and parity.

RESULTS

Of the 693 pregnant callers, 42% of the women initiated folic acid use 6 weeks before pregnancy, 35% of the women initiated folic acid use during pregnancy. Thirty-seven percent of the total caller population reported taking folic acid. Forty-seven percent of pregnant white women versus 27% of pregnant black women reported preconceptional folic acid use (P =.005). Thirty-nine percent of pregnant women who were <30 years old reported preconceptional folic acid use versus 48% of women who were >30 years old (P =.018).

CONCLUSION

Most pregnant women take folic acid; however, only a minority of them start before conception. The use of preconceptional folic acid, although higher than the national average of 30%, was still low. Many women start taking folic acid in their pregnancy after the neural tube is closed.

Prenatal presentation of congenital chloride diarrhea: clinical report and review of the literature

A case of congenital chloride diarrhea was diagnosed after delivery in a patient whose antenatal course was notable for massively dilated small and large bowel and persistent, severe hydramnios refractory to therapy. The pathophysiologic mechanism is a dysfunctional chloride-bicarbonate exchange in the brush border of the ileum. Antenatal presentation, prenatal diagnosis, and a review of the current literature are discussed.

Management of midtrimester oligohydramnios: a case for amnioinfusion

Ultrasonic evaluation and diagnosis in cases of severe oligohydramnios is extremely difficult, and management problems exist. With appropriate diagnostic procedures, management becomes less of a dilemma. Amnioinfusion, which is the instillation of fluid into the amniotic cavity, enhances ultrasonic resolution necessary for observation of fetal anatomy and behavior. The cases of severe oligohydramnios reviewed typify those in which amnioinfusion was used to diagnose and manage mid-trimester pregnancies. This technique enabled the practitioner to define the specific cause of the oligohydramnios. Interventions, risks, and outcomes of the cases are discussed.

Laboratory diagnosis of boutonneuse fever by enzyme-linked immunosorbent assay

Little is known about the use of the enzyme-linked immunosorbent assay (ELISA) in the diagnosis of boutonneuse fever, and the reports which do exist have concerned the use of a strain of African origin and a peroxidase-labelled conjugate. We have used, as antigen, a Sicilian strain of Rickettsia conorii recently isolated from a patient with boutonneuse fever and anti-human immunoglobulins G and M labelled with alkaline phosphatase as conjugate. 432 (84.6%) of 500 sera from patients with boutonneuse fever, 4.4% of 384 sera from patients with various other pathologies, and 2.9% of 204 sera from blood donors gave positive reactions. The ELISA was highly sensitive and specific in the diagnosis of boutonneuse fever, and seems to be the test of choice for sero-epidemiological investigations, and when a large number of specimens must be examined. The test is more sensitive than the indirect immunofluorescence test, at least in the early stage of the disease (44.9% vs 21.3% positive respectively), and a long time after an acute attack.