Hypertensive disorders in pregnancy and child development at 36 months in the All Our Families prospective cohort study

Hypertensive disorders in pregnancy (HDP) are associated with increased risk of offspring neurodevelopmental disorders, suggesting long-term adverse impacts on fetal brain development. However, the relationship between HDP and deficits in general child development is unclear. Our objective was to assess the association between HDP and motor and cognitive developmental delay in children at 36 months of age. We analyzed data from the All Our Families community-based cohort study (n = 1554). Diagnosis of HDP-gestational or chronic hypertension, preeclampsia, or eclampsia-was measured through medical records. Child development was measured by maternal-report on five domains of the Ages and Stages Questionnaire (ASQ-3). Standardized cut-off scores were used to operationalize binary variables for any delay, motor delay, and cognitive delay. We calculated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using logistic regression, sequentially controlling for potential confounders followed by factors suspected to lie on the causal pathway. Overall, 8.0% of women had HDP and hypertension-exposed children had higher prevalence of delay than unexposed children. Hypertension-exposed children had elevated risk for developmental delay, but CIs crossed the null. The aRRs quantifying the fully adjusted effect of HDP on child development were 1.19 (95% CI 0.92, 1.53) for any delay, 1.18 (95% CI 0.86, 1.61) for motor delay, and 1.24 (95% CI 0.83, 1.85) for cognitive delay. We did not find a statistically significant association between HDP and developmental delay. Confidence intervals suggest that children exposed to HDP in utero have either similar or slightly elevated risk of any, motor, and cognitive delay at 36 months after controlling for maternal and obstetric characteristics. The observed direction of association aligns with evidence of biological mechanisms whereby hypertensive pathology can disrupt fetal neurodevelopment; however, more evidence is needed. Findings may have implications for early developmental monitoring and intervention following prenatal hypertension exposure.

Maternal and neonatal outcomes in pregnancies complicated by eclampsia - analysis of cases from 2008-2018

OBJECTIVE

Evaluation of perinatal results in a set of pregnancies complicated by eclampsia.

METHODS

Analysis of 67,304 births performed at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno from 2008-2018. During the given period, eclampsia was dia-gnosed in 16 mothers (0.2). The during the time of eclampsia (week of gestation, prepartum, intrapartum, postpartum) fetal and neonatal status (signs of intrauterine distress, pH of the umbilical artery, Apgar score, intrauterine fetal death, death in the early neonatal period) were evaluated. Symptoms and course of the eclamptic attack, maternal comorbidities, associated obstetric complications (placental abruption, surgical complications, blood loss, hysterectomy) and non-obstetric complications (coagulopathy, renal and hepatic impairment, neurological complications) were monitored.

RESULTS

Out of a total of 16 cases of eclampsia, 13 cases (81.3%) were confirmed during pregnancy, one case (6.2%) during childbirth, and two cases (12.5%) within 24 hours after childbirth. The mean gestational week of eclampsia was 33 weeks and 3 days. The typical course of an eclamptic attack characterized by headache and visual disturbances followed by a rapid onset of convulsions was noted in five cases (31%). Fetal hypoxia with a pH of the umbilical artery less than 7.10 occurred in four cases (25%). The dependence of the decrease in pH value on the time interval from the dia-gnosis of eclampsia to the termination of pregnancy was demonstrated. The pH of the umbilical artery decreased on average by 0.054 every 30 minutes from the onset of the eclamptic attack until the end of pregnancy. There were 3 perinatal deaths in the group (19%). Intrauterine fetal death occurred in one case due to partial abruption of the placenta during an eclamptic attack; two newborns died in the early neonatal period. The cause of death was sepsis in one case and perforation of the intestine in necrotizing enterocolitis in the other. The death of the mother was not recorded in the file. The incidence of preeclampsia in subsequent pregnancies reached 18.8%. Non-obstetric and neurological complications (amaurosis, subarachnoid hemorrhage, amnesia) occurred in the group in three cases (18.8%), and renal failure occurred in two cases (12.5%).

CONCLUSION

The incidence of eclampsia at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno reached 0.2 and was stable for a long time. Associated serious maternal complications occurred in 37.5% of cases and neonatal complications in 31.3% of cases. Early dia-gnosis of eclampsia and minimization of the time delay until the end of pregnancy is a prerequisite for reducing the risk of associated complications. An interdisciplinary approach is needed.

Neurovascular dysfunctions in hypertensive disorders of pregnancy

Hypertensive disorders in pregnancy pose a huge challenge to the socioeconomic stability of a community; being a major cause of maternal and neonatal morbidity and mortality during delivery. Although there have been recent improvements in management strategies, still, the diversified nature of the underlying pathogenesis undermines their effectiveness. Generally, these disorders are categorized into two; hypertensive disorders of pregnancy with proteinuria (pre-eclampsia and eclampsia) and hypertensive disorders of pregnancy without proteinuria (gestational and chronic hypertension). Each of these conditions may present with unique characteristics that have interwoven symptoms. However, the tendency of occurrence heightens in the presence of any pre-existing life-threatening condition(s), environmental, and/or other genetic factors. Investigations into the cerebrovascular system demonstrate changes in the histoarchitectural organization of neurons, the proliferation of glial cells with an associated increase in inflammatory cytokines. These are oxidative stress indicators which impose a deteriorating impact on the structures that form the neurovascular unit and the blood-brain barrier (BBB). Such a pathologic state distorts the homeostatic supply of blood into the brain, and enhances the permeability of toxins/pathogens through a process called hyperperfusion at the BBB. Furthermore, a notable aspect of the pathogenesis of hypertensive disorders of pregnancy is endothelial dysfunction aggravated when signaling of the vasoprotective molecule, nitric oxide, amongst other neurotransmitter regulatory activities are impaired. This review aims to discuss the alterations in cerebrovascular regulation that determine the incidence of hypertension in pregnancy.

Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US

IMPORTANCE

Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge.

OBJECTIVE

To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020.

EXPOSURES

Timing of SMM diagnosis.

MAIN OUTCOMES AND MEASURES

Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention.

RESULTS

A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period.

CONCLUSIONS AND RELEVANCE

In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Associations of Hypothyroxinemia With Risk of Preeclampsia-Eclampsia and Gestational Hypertension

OBJECTIVE

To investigate the association between hypothyroxinemia and the risk of preeclampsia-eclampsia and gestational hypertension.

DESIGN

Historical cohort study.

METHODS

The study included pregnant individuals who delivered live-born singletons and had at least one thyroid function assessment during pregnancy at a tertiary hospital. Hypothyroxinemia was defined as thyroid-stimulating hormone (TSH) levels within the normal reference range and free thyroxine (FT4) levels lower than the tenth percentile. Risk ratios (RRs) with 95% confidence intervals (95% CIs) for preeclampsia-eclampsia and gestational hypertension between women with and without a diagnosis of hypothyroxinemia during pregnancy were estimated using a generalized estimating equation model.

RESULTS

A total of 59,463 women with live-born singletons were included in the analysis. Logistic regression models with restricted cubic spline suggested that there was a U-shaped association between FT4 levels and preeclampsia-eclampsia risk. Compared with euthyroid women, those with hypothyroxinemia had an increased risk of preeclampsia-eclampsia (RR = 1.16, 95% CI: 1.02-1.31), and the risk increased with the increasing severity of hypothyroxinemia (p for trend < 0.001). Moreover, persistent hypothyroxinemia from the first to second trimesters was associated with an increased risk of preeclampsia-eclampsia (RR = 1.37, 95% CI: 1.03-1.83), especially for women with severe hypothyroxinemia (RR = 1.70, 95% CI: 1.12-2.58). In contrast, there was no association between hypothyroxinemia and gestational hypertension.

CONCLUSION

Our study suggested that hypothyroxinemia was only associated with an increased risk of preeclampsia-eclampsia, especially in women with persistent hypothyroxinemia in the first half of pregnancy. Analyses of the associated risk of gestational hypertension with hypothyroxinemia were not significant.

[HYPERTENSION OF PREGNANCY ASSOCIATED WITH HYPERGOMOCYSTEINEMIA OF THE FIRST TRIMESTER OF PREGNANCY]

In this study, the association of high homocysteine concentrations (>10 μmol/L) of pregnant women with hypertensive disorders during pregnancy was studied, as well as other complications of pregnancy, such as loss of pregnancy in the first half, premature birth, intrauterine growth retardation, congenital malformations development of the fetus. A single-center prospective cohort study was conducted. Depending on the concentration of homocysteine detected by the immunoenzyme assay with monoclonal antibodies Homocysteine EIA ELISA (Axis-Shield Diagnostics Ltd, Scotland), for a period of up to 14 weeks, the subjects were divided into 2 groups: with high concentrations (>10 μmol/L) and normal levels (<10 μmol/L). We controlled complications of pregnancy: loss of pregnancy in the first half, premature birth, delayed fetal growth, congenital malformations of the fetus, gestational hypertension, mild and severe preeclampsia, eclampsia and HELLP syndrome. The results of the study showed that at a level of homocysteine I trimester >10 μmol/l spontaneous abortion, premature birth, gestational hypertension, mild preeclampsia develop more often. There were no differences in the groups for delaying intrauterine growth of the fetus, congenital malformations, severe preeclampsia.

Risk factors and outcome of patients with eclampsia at a tertiary hospital in Egypt

BACKGROUND

Eclampsia is a major cause of maternal and neonatal morbidity and mortality in low and middle income countries. The aim of this study was to assess the risk factors and maternal and perinatal outcome in patients with eclampsia in order to get reliable data that helps in reducing the incidence and improving the outcome in an area with high incidence of eclampsia.

METHODS

Retrospective study including 250 patients diagnosed with eclampsia at Minia Maternity University Hopsital, Minia, Egypt in the period between January 2013 and December 2014.We analyzed the data obtained from medical records of these patients including patient characteristics, medical, obstetric, current pregnancy history, data on hospital admission, treatment given at hospital and maternal and perinatal outcome. Statistical analysis was done using SPSS version 21.

RESULTS

During the study period, 21690 women gave birth in the hospital; of which 250 cases of eclampsia were diagnosed (1.2%).Four women died (case fatality rate 1.6%). The main risk factors identified were young age, nulliparity, low level of education, poor ante-natal attendance and pre-existing medical problems. The most common complication was HELLP syndrome (15.6%). Magnesium sulphate therapy was given to all patients but there was lack of parenteral anti-hypertensive therapy. Forty six cases delivered vaginally (18.4%). Assisted delivery was performed in 22 (8.8%) cases and caesarean section in 177 (70.8%) cases; 151(60.4%) primary caesarean sections and 26 (10.4%) intra-partum. Perinatal deaths occurred in 11.9% on cases. Prematurity and poor neonatal services were the main cause.

CONCLUSION

Morbidity and mortality from eclampsia are high in our setting. Improving ante-natal and emergency obstetric and neonatal care is mandatory to improve the outcome.

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis

BACKGROUND

Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear.

OBJECTIVE

To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia.

SEARCH STRATEGY

MEDLINE, EMBASE and LILACS were searched (inception to July 2015).

SELECTION CRITERIA

Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia.

MAIN RESULTS

We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I(2) 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I(2) 0 %] with intervals longer than 4 years.

CONCLUSION

Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.

Circulating MicroRNAs as Potential Molecular Biomarkers in Pathophysiological Evolution of Pregnancy

MicroRNAs represent nonprotein coding small RNA molecules that are very stable to degradation and responsible for gene silencing in most eukaryotic cells. Increased evidence has been accumulating over the years about their potential value as biomarkers for several diseases. MicroRNAs were predicted to be involved in nearly all biological processes from development to oncogenesis. In this review, we address the importance of circulating microRNAs in different conditions associated with pregnancy starting with the implantation period to preeclampsia and we shortly describe the correlation between placental circulating miRNAs and pregnancy status. We also discuss the importance of microRNAs in recurrent abortion and ectopic pregnancy.

Outcome of pregnancy in patients with systemic lupus erythematosis at Korle-bu Teaching Hospital

OBJECTIVE

To study maternal and fetal outcomes in Ghanaian women with systemic lupus erythematosus (SLE).

METHODS

Retrospective study of pregnancies in women with SLE in a single centre in Ghana.

RESULTS

The mean age was 30.1 years and all were nulliparous. Two out of the seven pregnancies were in disease remission at the time of booking. Nephritis without renal impairment was present in 7 pregnancies (6 women). One woman developed intrapartum eclampsia. Two women had secondary antiphospholipid syndrome (APS). Two suffered early fetal losses and one late fetal loss at 32 weeks. All three who lost their fetus had uncontrolled hypertension. Six had mild flares mainly joint pains during pregnancy. There was no maternal mortality. The median gestational age at delivery was 38 weeks (range, 16 to 40 weeks) and the mean birth weight was 3017 g; the median Apgar scores were 8 and 9 at 1 and 5 minutes of life, respectively. There were no cases of intrauterine growth restriction (IUGR). There were no cases of congenital heart block or neonatal lupus.

CONCLUSION

Good pregnancy outcomes are possible in women with SLE even in resource poor settings. . All pregnancies should still be considered high risk and be managed jointly between the obstetricians, the perinatologists and the rheumatologists, in particular, those with renal involvement and hypertension. Long term follow up of a larger cohort is needed.

FUNDING

None declared.

[Anesthetic Management of a Parturient with Eclampsia, Posterior Reversible Encephalopathy Syndrome and Pulmonary Edema due to Pregnancy-induced Hypertension]

A 27-year-old woman with mental retardation was admitted to a nearby hospital for an abrupt onset of seizure. Physical examination revealed remarkable hypertension and pregnancy with estimated gestational age of 28th week. Severe pulmonary edema and hypoxia led to a diagnosis of pregnancy-induced hypertension (PIH) accompanied by eclampsia. She was orotracheally intubated because of refractory seizure and hypoxemia, and transferred to our hospital for further treatment. Besides severe hypoxia and hypercapnea, an enhanced lesion was detected in the left posterior cerebrum by brain MRI. No abnormal findings were detected in the fetus, with heart rate of 150 beats x min. She was diagnosed with posterior reversible encephalopathy syndrome (PRES) caused by PIH and emergency cesarean section under general anesthesia was scheduled. A male newborn was delivered with Apgar score of 1/4 (1/5 min), followed by starting continuous infusion of nicardipine for controlling hypertension. Chest X-P on completion of surgery revealed remarkably alleviated pulmonary edema. She received intensive treatment and continued positive pressure ventilation for four days after delivery. She recovered with no neurological deficits and her child was well without any complications.

Effect of indoor air pollution from biomass and solid fuel combustion on symptoms of preeclampsia/eclampsia in Indian women

Available evidence concerning the association between indoor air pollution (IAP) from biomass and solid fuel combustion and preeclampsia/eclampsia is not available in developing countries. We investigated the association between exposure to IAP from biomass and solid fuel combustion and symptoms of preeclampsia/eclampsia in Indian women by analyzing cross-sectional data from India's third National Family Health Survey (NFHS-3, 2005-2006). Self-reported symptoms of preeclampsia/eclampsia during pregnancy such as convulsions (not from fever), swelling of legs, body or face, excessive fatigue or vision difficulty during daylight, were obtained from 39,657 women aged 15-49 years who had a live birth in the previous 5 years. Effects of exposure to cooking smoke, ascertained by type of fuel used for cooking on preeclampsia/eclampsia risk, were estimated using logistic regression after adjusting for various confounders. Results indicate that women living in households using biomass and solid fuels have two times higher likelihood of reporting preeclampsia/eclampsia symptoms than do those living in households using cleaner fuels (OR = 2.21; 95%: 1.26-3.87; P = 0.006), even after controlling for the effects of a number of potentially confounding factors. This study is the first to empirically estimate the associations of IAP from biomass and solid fuel combustion and reported symptoms suggestive of preeclampsia/eclampsia in a large nationally representative sample of Indian women and we observed increased risk. These findings have important program and policy implications for countries such as India, where large proportions of the population rely on polluting biomass fuels for cooking and space heating. More epidemiological research with detailed exposure assessments and clinical measures of preeclampsia/eclampsia is needed in a developing country setting to validate these findings.

Effect of indoor air pollution from biomass and solid fuel combustion on symptoms of preeclampsia/eclampsia in Indian women

Available evidence concerning the association between indoor air pollution (IAP) from biomass and solid fuel combustion and preeclampsia/eclampsia is not available in developing countries. We investigated the association between exposure to IAP from biomass and solid fuel combustion and symptoms of preeclampsia/eclampsia in Indian women by analyzing cross-sectional data from India's third National Family Health Survey (NFHS-3, 2005-2006). Self-reported symptoms of preeclampsia/eclampsia during pregnancy such as convulsions (not from fever), swelling of legs, body or face, excessive fatigue or vision difficulty during daylight, were obtained from 39,657 women aged 15-49 years who had a live birth in the previous 5 years. Effects of exposure to cooking smoke, ascertained by type of fuel used for cooking on preeclampsia/eclampsia risk, were estimated using logistic regression after adjusting for various confounders. Results indicate that women living in households using biomass and solid fuels have two times higher likelihood of reporting preeclampsia/eclampsia symptoms than do those living in households using cleaner fuels (OR = 2.21; 95%: 1.26-3.87; P = 0.006), even after controlling for the effects of a number of potentially confounding factors. This study is the first to empirically estimate the associations of IAP from biomass and solid fuel combustion and reported symptoms suggestive of preeclampsia/eclampsia in a large nationally representative sample of Indian women and we observed increased risk. These findings have important program and policy implications for countries such as India, where large proportions of the population rely on polluting biomass fuels for cooking and space heating. More epidemiological research with detailed exposure assessments and clinical measures of preeclampsia/eclampsia is needed in a developing country setting to validate these findings.

Evaluation of maternal mortality ratio and causes in a university hospital in eastern Turkey

AIM

To investigate the maternal mortality ratio (MMR) and causes of maternal death in order to decrease these deaths.

MATERIALS AND METHODS

The number of live births, maternal deaths, and the causes of deaths in Yuzuncu Yil University were recorded between 2004 and 2013.

RESULTS

The MMR was 268 per 100,000. Forty-nine maternal deaths were examined in terms of cause. The most frequent cause of death is eclampsia (33%) and associated intracerebral complications. The antenatal follow-up rate was 23.3%. The majority of patients had low income (92.3%), 72.2% were from rural areas, and 95.5% were illiterate.

CONCLUSION

The high MMR may arise from the high incidence of pregnancy complications in eastern Turkey, the rareness of antenatal follow-ups, and the present hospital being a referral hospital. The most frequent cause of maternal mortality is eclampsia and associated complications, followed by bleeding.

[HELLP syndrome]

HELLP syndrome (hemolysis, elevated liver enzymes, low platelet count) is a relatively rare complication of pregnancy. It usually develops in the IIId trimester or after delivery. HELLP syndrome is associated with increased maternal (placental abruption, disseminated intravascular coagulation, hepatic hematomas and rupture, and acute kidney injury) and neonatal (prematurity, low birth weight) risk complications. In this article the diagnosis, clinical picture and treatment of this disease have been shortly reviewed.

Posterior reversible encephalopathy syndrome complicating postpartum eclampsia in a Nigerian: case report

AIMS AND OBJECTIVES

This is a case of posterior reversible encephalopathy syndrome (PRES) associated with postpartum eclampsia in a primiparous Nigerian.

CASE PRESENTATION

A 20-year-old primiparous woman presented to the emergency unit of the department of obstetrics and gynaecology of our hospital with symptoms and signs consistent with postpartum eclampsia. While being managed for this, she developed weakness of the left limbs with associated altered sensorium. Significant findings on physical examination were hypertension, left-sided hemiparesis and cortical blindness. She had a computed tomographic (CT) scan of the brain which showed features consistent with posterior reversible encephalopathy syndrome. She was given full supportive care with control of her blood pressure and she made a significant improvement. She was discharged home about 3 weeks after admission with improvement in clinical condition and is currently being followed up in our neurology clinic.

CONCLUSION

PRES complicating eclampsia is a clinicoradiological diagnosis. In most cases neurological symptoms improve with good supportive care and adequate treatment of the underlying condition as was the case in this patient. However permanent neurological sequelae can result from delayed diagnosis and treatment; therefore a high index of suspicion, early diagnosis and treatment are essential.

Posterior reversible encephalopathy syndrome in obstetric patients. Report of three cases with literature review

Posterior reversible encephalopathy syndrome (PRES) is a serious clinico-neuroradiological maternal complication in pregnancy. Although it has various etiologies such as hypertensive encephalopathy, renal failure, autoimmune disorders, sepsis, multiple organ failure, and treatment with immunosuppressant or cytotoxic agents, pregnancy and postpartum complicated by hypertensive disorders more frequently lead to this condition. PRES is clinically characterized by headache, confusion, seizures, vomiting, and visual disturbances with radiographic vasogenic edema especially affecting symmetrical parietal and occipital lobes. The underlying pathophysiology is still a matter of debate. Prompt recognition and early intervention greatly improve the prognosis, so that obstetricians should be well aware of this rare entity. Timely imaging is of crucial importance especially in patients with an uncertain diagnosis for determining the appropriate treatment and preventing the possible development of neurologic deficits. In the present report, three cases of PRES are presented with clinical and radiological findings in pregnancies complicated by severe pre-eclampsia and eclampsia. The latest literature in the field is also carefully reviewed.

Do uterotonic drugs increase risk of abruptio placentae and eclampsia?

PURPOSE

To determine whether the use of uterotonics, including oxytocin and prostaglandins, increases the risk of abruptio placentae and eclampsia.

MATERIALS AND METHODS

A retrospective analysis was conducted among 260,174 Japanese women at term. Demographic characteristics were studied as possible candidates for risk factors of abruptio placentae and eclampsia using multivariate logistic regression analyses.

RESULTS

A total of 1,058 (0.41 %) and 147 (0.06 %) women developed abruptio placentae and eclampsia, respectively. Abruptio placentae and eclampsia occurred in 177 (0.29 %) and 42 (0.07 %) of the 61,857 women treated with uterotonics, respectively. Multivariate regression analyses indicated that uterotonics did not increase risk of developing either abruptio placentae or eclampsia. Primiparity [odds ratio (95 % confidence interval) 1.41 (1.24-1.60)], age ≥35 years [1.17 (1.03-1.33)], and presence of hypertension [2.42 (1.93-3.03)] were significant independent risk factors for abruptio placentae, while advancing gestation [0.67 (0.63-0.71)] decreased risk of abruptio placentae. Primiparity [odds ratio (95 % confidence interval) 4.06 (2.49-6.63)], age <20 years [2.44 (1.07-5.58)], presence of hypertension [28.7 (20.5-40.1)], and advancing gestation [1.28 (1.11-1.47)] were significant independent risk factors for eclampsia.

CONCLUSION

The use of uterotonics did not increase the risk of abruptio placentae and eclampsia.

Serum trace elements levels in preeclampsia and eclampsia: correlation with the pregnancy disorder

Preeclampsia and eclampsia are fatal medical complications of pregnancy accounting for 20-80 % of increased maternal death in developing countries. Their aetiologies are still under investigation. Serum trace elements have been suggested to be involved in the pathogenesis of preeclampsia. Aim of this study was to address the correlation of serum trace elements with preeclampsia and eclampsia. It was a comparative cross-sectional study conducted on conveniently recruited 44 preeclampsia, 33 eclampsia and 27 normotensive pregnant patients. Atomic absorption spectrometry was employed to analyse serum concentrations of Ca, Mg, Cu, Zn and Fe. Data were analysed by Student's t test, one-way analysis of variance and multinomial logistic and binary regression analyses. p < 0.05 was considered as a level of significance. In preeclampsia, the serum Ca and Mg were significantly lower than those in eclampsia, while Cu and Zn values were higher. Significant changes of Ca, Mg and Cu were noted among preeclampsia, eclampsia and pregnant control. Serum Ca and Mg indicated a positive association, and Cu gave a negative association in preeclampsia. Cu/Fe ratio was high in eclampsia. Significant correlations of Mg with Zn in eclampsia and Mg with Fe in preeclampsia and eclampsia were predicted. Significant changes in serum trace element levels were present in preeclampsia and eclampsia that may have a link with the pathogenesis of pregnancy disorder.

[A case of HELLP syndrome resulting in eclampsia with non-aneurysmal subarachnoid hemorrhage]

It is known that hemorrhagic stroke at the perinatal period are caused by specifics conditions like eclampsia as well as by the existing abnormal vessels. We treated a case of HELLP syndrome resulting in eclampsia with non-aneurysmal, convexity subarachnoid hemorrhage. A 34-year-old female, who had been pointed out to have a high level of urinal protein at the 37th week, was seen in the emergency department because of severe headache, vomiting and respiratory discomfort. Her systolic blood pressure was over 190mmHg, and caesarean section was selected. On the way to the operating room, she had a generalized convulsion with loss of consciousness. The delivery was carried out. The CT immediately after the caesarean section revealed faint and localized subarachnoid hemorrhage in the bilateral convexity areas. Additionally, the FLAIR image of MRI demonstrated increased intensity in the bilateral cerebellar hemispheres, basal ganglion and subcortical area, suggesting vasogenic edema. The patient had a good clinical course and the abnormal signal of MRI also recovered by treatment with oral iron and zinc. Here, we report a speculation for the mechanism of this case and precautions against stroke in the perinatal period.

Pregnancy complications among women born preterm

BACKGROUND

Adults who were born with low birth weights are at increased risk of cardiovascular and metabolic conditions, including pregnancy complications. Low birth weight can result from intrauterine growth restriction, preterm birth or both. We examined the relation between preterm birth and pregnancy complications later in life.

METHODS

We conducted a population-based cohort study in the province of Quebec involving 7405 women born preterm (554 < 32 weeks, 6851 at 32-36 weeks) and a matched cohort of 16 714 born at term between 1976 and 1995 who had a live birth or stillbirth between 1987 and 2008. The primary outcome measures were pregnancy complications (gestational diabetes, gestational hypertension, and preeclampsia or eclampsia).

RESULTS

Overall, 19.9% of women born at less than 32 weeks, 13.2% born at 32-36 weeks and 11.7% born at term had at least 1 pregnancy complication at least once during the study period (p < 0.001). Women born small for gestational age (both term and preterm) had increased odds of having at least 1 pregnancy complication compared with women born at term and at appropriate weight for gestational age. After adjustment for various factors, including birth weight for gestational age, the odds of pregnancy complications associated with preterm birth was elevated by 1.95-fold (95% confidence interval [CI] 1.54-2.47) among women born before 32 weeks' gestation and 1.14-fold (95% CI 1.03-1.25) among those born at 32-36 weeks' gestation relative to women born at term.

INTERPRETATION

Being born preterm, in addition to, and independent of, being small for gestational age, was associated with a significantly increased risk of later having pregnancy complications.

Patient with antiphospholipid syndrome accompanied by pre-eclampsia who developed hellp syndrome and eclampsia after abortion

Antiphospholipid syndrome (APS) refers to a group of clinical symptoms and signs caused by antiphospholipid antibody (aPLA). We reported a rare case of poor outcome of a pregnant woman with APS. The pregnant woman had APS, hemolytic anemia, elevated liver function and low platelet count (HELLP) syndrome, and eclampsia and had a poor outcome from a second pregnancy. She was treated with antispasmodics, sedatives, and anti-hypertensive agents, along with anticoagulant therapy and infusion of immunoglobulin. APS during pregnancy often makes pregnancy even more complex and risky. Obstetricians should carry out anticoagulation treatment throughout the perinatal period.

[Role of uric acid in preeclampsia-eclampsia]

Uric acid is a terminal metabolite of the degradation of nucleotides, which increases their blood levels in patients with preeclampsia-eclampsia, increasing its synthesis by damage and death of trophoblastic cells in proliferation and decreased urinary excretion due a lower glomerular filtration rate and increased absorption in the proximal tubule. Hyperuricemia (> 4.5 mg/dL) is the first biomarker of the clinical chemistry considered as an early evidence of disease (< or = 20 weeks gestation). Uric acid concentrations are not only a criterion for establishing the correct diagnosis and the differential with other hypertensive states, but an indication of termination of pregnancy, often by cesarean section. Hyperuricemia has also demonstrated its usefulness as a predictor of maternal and fetal complications and maternal sequelae of late postpartum. Several studies have demonstrated its influence on the genesis of preeclampsia-eclampsia, either alone or jointly with other known processes (metabolic syndrome, oxidative stress, inflammation cascade, angiogenesis) that have a proven role in perpetuating the endothelial damage and maternal vascular smooth muscle cells. Further research is needed in large-scale clinical and experimental studies that expand our knowledge about the usefulness of uric acid as a biomarker of preeclampsia-eclampsia to allow early prevention and reducing the prevalence.

[Hypertensive emergency and urgency: clinical update]

Hypertensive crises (i.e., blood pressure > 180/120 mmHg) are common issues in the emergency department. This term is used to indicate both emergencies and urgencies, characterized by presence and absence of target organ damage, respectively. A wide range of therapeutic options are available. The aim of this article is to review current knowledge and treatment trends in the literature to provide clinicians with diagnostic and therapeutic tools.

The Use of Standard Dose of Magnesium Sulphate in Prophylaxis of Eclamptic Seizures: Do Body Mass Index Alterations Have Any Effect on Success?

OBJECTIVE

We anticipated that the universal use of a standard magnesium sulfate infusion to prevent eclamptic convulsions in preeclamptic patients would result in alterations in circulating magnesium levels that were negatively correlated with the patient's body mass index. We postulated that the highest failure rate with seizure prophylaxis would occur in patients with the highest body mass index.

MATERIALS AND METHODS

After discarding 6 patients, this study was performed in 194 of 200 preeclamptic patients admitted to our high risk pregnancy unit between February 2000 and August 2000, who were divided into four groups determined by body mass indices. A standard magnesium sulfate infusion protocol (loading dose 4.5 g/15 minutes followed by 1.8 g/hour) was administered to 194 preeclamptic patients. One hundred and thirty-eight severe preeclamptic patients received magnesium sulfate during both antepartum and postpartum periods. The remaining 56 patients only received the therapy during the postpartum period. Serial serum magnesium levels of each groups were recorded and compared.

RESULTS

The 1.8 g infusion rate produced acceptable magnesium levels in the majority of patients but most were in the lower 50% of the therapeutic range. Levels were lowest in patients with high body mass indices (this group recorded most of the subtherapeutic levels, particularly when patient were infused antepartum). Apart from 13 referred patients who had convulsed prior to admission no eclampsia occurred during the antepartum period while seizures occurred in nine women during the postpartum period. Two hours after the initiation of the therapy, magnesium levels were inversely related to the body mass index (BMI) both during the ante- and postpartum periods (Prepartum; group I: 5.97 mg/dl, group II: 4.90 mg/dl, group III: 4.35 mg/dl, group IV: 3.88 mg/dl; Postpartum; group I: 5.89 mg/dl, group II: 5.71 mg/dl, group III: 4.82 mg/dl and group IV: 4.61 mg/dl, Table 4). Although the lowest levels were detected in patients with high body mass indices, in contrast to our hypothesis, eclamptic seizures occurred in four patients with low body mass indices. Furthermore therapeutic serum magnesium levels were detected in three of these patients. There was no association between treatment failures and body mass or with magnesium levels.

CONCLUSION

The infusion regimen described herein resulted in therapeutic levels in the majority of patients that correlated inversely with body mass index. However most levels fell within the lower range of what many studies consider "therapeutic" suggesting that maintenance infusion rates of at least 2-2.5 g/hour would be more appropriate. This would be particularly true in patients with body mass indices exceeding 30, where subtherapeutic levels occurred most frequently. The study's limited power prevents conclusions on outcomes but what is of interest is that eclamptic convulsions did not correlate with either body mass index or circulating plasma magnesium levels.

[Profile of serum soluble endoglin in pregnant women with severe pre-eclampsia and eclampsia]

OBJECTIVE

To discuss the serum endoglin expression in severe pre-eclampsia and eclampsia women and their relationships.

METHODS

Forty-two severe pre-eclamptic patients and 4 eclamptic patients in Peking University First Hospital from Dec. 2005 to Dec. 2007 were enrolled in the study group, with the mean gestational week of 35 +/- 4, the mean age of 29.3 +/- 5.7 and the mean BMI (30.1 +/- 4.1) kg/m(2). This group included 25 cases of early onset pre-eclampsia, 21 cases of late onset pre-eclampsia, 8 cases of fetal growth restriction and 5 cases of HELLP syndrome. The control group included 29 cases of normal pregnant women during the same period, with the mean gestational week of 33 +/- 4, the mean age of 30.7 +/- 3.4 and the mean BMI (27.2 +/- 2.2) kg/m(2). Peripheral serum endoglin was determined by ELISA in these two groups.

RESULTS

(1) There is positive correlation between serum soluble endoglin level and the gestational weeks during 27 to 37 gestational weeks in the control group (r = 0.79, P < 0.05), but there is no distinct relationship in the study group (r = 0.31, P > 0.05). (2) Serum endoglin level of severe pre-eclampsia group was higher than the normal group [(14.2 +/- 5.6) microg/L vs. (10.9 +/- 4.2) microg/L, P < 0.05]. (3) Serum endoglin level of early onset group did not differ from late onset group [(14.3 +/- 5.7) microg/L vs. (13.6 +/- 5.0) microg/L, P > 0.05]. (4) No difference of serum endoglin between HELLP group and non-HELLP group was found [(10.1 +/- 2.9) microg/L vs. (14.4 +/- 5.4) microg/L, P > 0.05]. (5) Serum endoglin level of FGR sub group was higher than non-FGR sub group [(17.3 +/- 6.1) microg/L vs. (13.0 +/- 4.8) microg/L, P < 0.05] in the stady group.

CONCLUSION

The elevated peripheral serum endoglin level may contributes to the pathogenesis of severe pre-eclampsia and FGR, but not the week of the onset of the disease.

Obesity subtypes and risk of spontaneous versus medically indicated preterm births in singletons and twins

Using data from the Missouri maternally linked files (1989-1997), the authors examined the association among maternal obesity, obesity subtypes, and spontaneous and medically indicated preterm (<37 weeks) and very preterm (<33 weeks) births in singletons and twins. Adjusted odds ratios were obtained with correction for intracluster correlation. The prevalence of obesity increased by 77% over the study period (p(trend) < 0.001). Obese mothers had a lower risk for spontaneous preterm birth, and this was more pronounced among twins (odds ratio = 0.68, 95% confidence interval: 0.62, 0.75) than singletons (odds ratio = 0.84, 95% confidence interval: 0.82, 0.87). However, this association was present only among obese women who gained less than 0.69 kg/week for singletons and between 0.23 and 0.69 kg/week for twins. By contrast, obese mothers with singleton gestation had about 50% greater odds of medically indicated preterm (odds ratio = 1.46, 95% confidence interval: 1.39, 1.54) and very preterm (odds ratio = 1.49, 95% confidence interval: 1.34, 1.65) births, and the risk increases with ascending severity of obesity (p(trend) < 0.01). For extreme obesity, the risk of medically indicated preterm and very preterm births was almost double that for nonobese women. Similar findings were observed in twins. These data suggest that obesity increases the risk for medically indicated but not spontaneous preterm birth in both singletons and twins.

[Eclampsia and total bilateral amaurosis in a woman subsequently diagnosed with reversible posterior leukoencephalopathy syndrome]

Eclampsia is a complication of preeclampsia and is characterized by the appearance of grand mal seizures and/or coma, in the absence of any other neurological abnormalities. Neither focal neurological deficit nor prolonged coma tends to develop following a crisis. Eclampsia should therefore lead us to consider other clinical entities that may require special treatment. We report the case of a pregnant woman who presented total bilateral loss of vision following a grand mal seizure. The patient was subsequently diagnosed with reversible posterior leukoencephalopathy syndrome, which has clinical and radiologic manifestations linked to several causes, such as hypertensive encephalopathy, eclampsia, kidney failure, and immunosuppressant therapy. The syndrome involves headache, altered states of consciousness, changes in vision (including blindness), and seizures; these symptoms generally coincide with a rapid increase in blood pressure. Diagnosis requires neuroimaging, and the typical finding is edema in the posterior zones of the brain hemispheres. The most widely accepted hypothesis concerning the pathophysiologic mechanism underlying this syndrome is failure of cerebral autoregulation with development of vasogenic edema. The prognosis is good and the alterations usually resolve completely with appropriate treatment, which is the same as for the management of eclampsia, with strict monitoring of blood pressure.

Dengue haemorrhagic fever complicated by eclampsia in pregnancy

A 28-year-old primigravida presented at 36 weeks of gestation with a one-week history of fever with myalgia. Diagnosis of dengue fever was made based on viral polymerase chain reaction. She progressed to dengue shock syndrome by day nine and subsequently recovered. She delivered a healthy male baby by the vaginal route, but within 24 hours of delivery, had an eclamptic seizure, which was controlled with intravenous magnesium sulphate. Mother and the baby were well at discharge and on the follow-up visit at three months.

Are clinical symptoms more predictive than laboratory parameters for adverse maternal outcome in HELLP syndrome?

BACKGROUND

To determine the risk factors for adverse maternal outcome among women with HELLP syndrome.

METHODS

Sixty-one pregnancies with hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome diagnosed antenatally were reviewed between 2003 and 2005. Maternal outcomes analyzed included eclampsia, abruptio placentae, disseminated intravascular coagulopathy (DIC), acute renal failure, need for transfusion of blood products, cesarean delivery and maternal death. Risk factors included maternal age, parity, gestational age at diagnosis, mean arterial blood pressure, headache, visual changes, nausea-vomiting, epigastric pain, blood platelet count (<or=50,000 versus >50,000 cells/mm3), and peak serum levels of aspartate aminotransferase.

RESULTS

Eclampsia was present in 52%, abruptio placentae in 11%, and DIC in 8% of 61 women with HELLP syndrome. 23% women required transfusion of blood products, 15% had acute renal failure, and 73% had cesarean section. Women with eclampsia had significantly more headache, nausea-vomiting, visual changes and epigastric pain (p<0.05). Transfusion was significantly more frequent among women with blood platelet counts <or=50,000 cells/mm3 (33 versus 21%; p<0.05). Women with a platelet count <or=50,000 cells/mm3 had a higher rate of DIC compared to women with a platelet count >50,000 cells/mm3 (33.3 versus 3.8%; p<0.05). In women with acute renal failure and abruptio placentae, there were no significant differences in all the variables studied between those with and without these complications.

CONCLUSIONS

Clinical symptoms, such as headache, visual changes, epigastric pain and nausea-vomiting, are more predictive than laboratory parameters for adverse maternal outcomes.

Extracellular calcium and magnesium in preeclampsia and eclampsia

The cause of preeclampsia remains unknown and calcium and magnesium supplement are being suggested as means of prevention. The objective of this study was to assess magnesium and calcium in the plasma and cerebrospinal fluid of Nigerian women with preeclampsia and eclampsia. Setting was University of Benin Teaching Hospital, in Nigeria. It was a cross-sectional study comprising of eleven patients and twenty-three controls. The mean, standard deviation and Standard Error of Mean (SEM) were calculated. Student 't' test method was applied. Plasma calcium was significantly lower in patients than controls (9.2 +/- 1.02 Vs 9.98 +/- 0.87mg/dl, P 0.043) "t" test. The CSF calcium and magnesium levels were lower in patients than controls, (5.66 +/- 1.22 vs 6.67 +/- 1.15 mg/ dl, P 0.043 and 1.75 +/- 0.56 vs 1.91 +/- 0.19 mg/dl, P 0. < 0.0001) respectively. There is extracellular calcium and magnesium reduction in patients with preeclampsia and eclampsia. This reduction may have a cause and effect relationship with these disorders.

L'éclampsie du post-partum: épidémiologie et pronostic

INTRODUCTION

The post-partum eclampsia occurs usually in the first 48 hours, its incidence is between 13 and 37% of all eclampsia. The goal of this prospective study was to analyse the epidemiologic data and the prognosis of this complication in the post-partum stage.

MATERIALS AND METHODS

We enrolled between January 1st 2000 to December 31st 2003 all eclampsia admitted to the intensive care unit of the maternity of the university hospital centre Ibn Rochd of Casablanca, Morocco. We noted for each patient epidemiologic, clinical, biological and radiologic data. We releaved outcomoe also. Two groups are individualized: 1) group 1 (N=247): when eclampsia diagnosed in the prepartum stage; 2) group 2 (N=58): when crisis diagnosed in the post-partum stage. We compared the groups (student test), p<0.05 was significative.

RESULTS

The incidence of eclampsia in the post-partum in this study was 19% (58 over 305). Eighty-two percent had the crisis in the first 24 hours; we noted a crisis in the sixth, seventh and lately in the sixtieth day. The major proportion of patients are nulliparous (64%), young (mean age: 24 years), without prenatal care, and has high blood pressure (48%), low GCS (mean: 12) and massive proteinuria>3 g/24 hours (37%). The post-partum eclampsia has best out come than these occurring in prepartum, with significantly (p<0.05) less high blood pressure, hellp syndrome and less placental abruption.

CONCLUSION

Eclampsia is still frequent in our service; it seems less bad when occurring in the post-partum stage. We must give more attention for severe preeclamptic patient in this period.

Leukocytosis might precede in-hospital eclampsia in preeclamptic women who do not receive magnesium sulfate

In an effort to better define preeclamptic women at risk of eclampsia, we examined the predictive value of maternal demographic characteristics and admission maternal laboratory values for the risk of subsequent development of eclampsia in preeclamptic women, who were not receiving magnesium sulfate during hospitalization. The decision to use magnesium sulfate prophylaxis was at the discretion of the treating physician. Preeclamptic women admitted throughout a 3-year period and treated with a protocol exempting magnesium sulfate therapy were retrospectively included (n=497). Maternal data at admission were recorded and analyzed. Eight women developed an eclamptic seizure during subsequent hospital follow-up. Logistic regression models were used to assess the independent predictive role of each variable on the development of eclampsia. Lower serum fibrinogen values, increased leukocyte counts, and increased diastolic blood pressure at admission were independent predictors of a subsequent in-hospital eclamptic seizure. An initial diastolic blood pressure >or=120 mm Hg, blood leukocyte count >16,000/microL, and serum fibrinogen value <450 mg/dL were associated with a 25.4-, 7.1-, and 26.6-fold increased risk of eclampsia, respectively. We conclude that marked leukocytosis and diastolic blood pressure increment might precede the development of eclampsia. Serum fibrinogen concentrations >450 mg/dL seem to be protective for eclampsia. The association between inflammation and eclampsia merits further investigation.

Pregnancy prevents hypertensive remodeling and decreases myogenic reactivity in posterior cerebral arteries from Dahl salt-sensitive rats: a role in eclampsia?

Previous studies have demonstrated that pregnancy prevents protective hypertension-induced remodeling of cerebral arteries using nitric oxide synthase (NOS) inhibition to raise mean arterial pressure (MAP). In the present study, we investigated whether this effect of pregnancy was specific to NOS inhibition by using the Dahl salt-sensitive (SS) rat as a model of hypertension. Nonpregnant ( n = 16) and late-pregnant ( n = 17) Dahl SS rats were fed either a high-salt diet (8% NaCl) to raise blood pressure or a low-salt diet (<0.7% NaCl). Third-order posterior cerebral arteries were isolated and pressurized in an arteriograph chamber to measure active responses to pressure and passive remodeling. Several vessels from each group were stained for protein gene product 9.5 to determine perivascular nerve density. Blood pressure was elevated in both groups on high salt. The elevated MAP was associated with significantly smaller active and passive diameters ( P < 0.05) and inward remodeling in the nonpregnant hypertensive group only. Whereas no structural changes were observed in the late-pregnant hypertensive animals, both late-pregnant groups had diminished myogenic reactivity ( P < 0.05). Nerve density in both the late-pregnant groups was significantly greater when compared with the nonpregnant groups, suggesting that pregnancy has a trophic influence on perivascular innervation of the posterior cerebral artery. However, hypertension lowered the nerve density in both nonpregnant and late-pregnant animals. It therefore appears that pregnancy has an overall effect to prevent hypertension-induced remodeling regardless of the mode of hypertension. This effect may predispose the brain to autoregulatory breakthrough, hyperperfusion, and eclampsia when MAP is elevated.

Selective magnesium sulfate prophylaxis for the prevention of eclampsia in women with gestational hypertension

OBJECTIVE

To describe the incidence of eclampsia in women with mild gestational hypertension when only women with severe gestational hypertension are given magnesium sulfate prophylaxis.

METHODS

This is a prospective 4(1/2)-year observational study. Those women who met our criteria for severe gestational hypertension received intravenous magnesium sulfate prophylaxis, and women with nonsevere hypertension did not. Data were collected at delivery to ascertain the incidence of eclampsia and maternal and neonatal morbidity.

RESULTS

A total of 72,004 women were delivered during the study period, 6,431 had gestational hypertension, 3,935 met the criteria for severe disease and were given magnesium sulfate prophylaxis, 2,496 women with nonsevere hypertension were not treated. Eighty-seven women developed eclampsia, for an overall incidence of 1 in 828 deliveries, a 50% increase when compared with 5 preceding years where all women with gestational hypertension were given magnesium sulfate prophylaxis. Of the 2,496 women with nonsevere hypertension who were not treated, 27 had eclampsia (1 in 92). Women with eclampsia were more likely to require general anesthesia for cesarean delivery compared with hypertensive women without eclampsia (23% versus 4%, P < .001), but they had no additional morbidity. Infants of eclamptic mothers had more adverse outcomes than those without convulsions (12% versus 1%, P < .04).

CONCLUSION

Selective magnesium sulfate prophylaxis results in an increased overall incidence of eclampsia because of more seizures in women with nonsevere gestational hypertension who are not given magnesium sulfate prophylaxis.

LEVEL OF EVIDENCE

II-3.

Maternal and perinatal outcome of preeclampsia with an onset before 24 weeks’ gestation

OBJECTIVE

Preeclampsia, with an onset before 24 weeks' gestation is a rare but severe condition in pregnancy with little data of maternal and perinatal outcome, particularly after expectant management. We therefore, evaluated pregnancy outcome in these women at our department where temporising management was introduced as the standard policy in early onset preeclampsia.

STUDY DESIGN

We analysed retrospectively all consecutive women with preeclampsia, with an onset before 24 weeks' gestation, between 1 January 1993 and 31 December 2002 at a tertiary university referral center.

RESULTS

Twenty-six pregnancies, of which two were twin pregnancies, resulted in 65% of the women in at least one major maternal complication: maternal death (n=1), HELLP syndrome (n=16), eclampsia (n=5) and pulmonary edema (n=4). Thirty percent of these women presented already with serious morbidity at admission. The median prolongation of the pregnancy was 24 days (range 3-46 days). The overall perinatal mortality was 82%: 19 fetal deaths and 4 neonatal deaths.

CONCLUSION

Early onset preeclampsia, with an onset before 24 weeks' gestation, results in considerable maternal and perinatal morbidity and mortality. Therefore, expectant management should not be considered as a routine treatment option in these patients.

Association of elevated serum heat-shock protein 70 concentration with transient hypertension of pregnancy, preeclampsia and superimposed preeclampsia: a case-control study

Our aim was to investigate the association between serum heat-shock protein (Hsp) 70 concentration and hypertensive disorders of pregnancy. One hundred and forty-two pregnant women with hypertensive disorders (93 with preeclampsia, 29 with transient hypertension of pregnancy and 20 with superimposed preeclampsia) and 127 normotensive, healthy pregnant women were included in the study. Serum Hsp70 concentration was measured using enzyme-linked immunosorbent assay. The serum Hsp70 concentration was significantly higher in patients with transient hypertension of pregnancy, in preeclamptic patients and in patients with superimposed preeclampsia than in the control group (median (25-75 percentile): 0.66 (0.52-0.84), 0.55 (0.42-0.80), 0.61 (0.42-0.91) ng/ml vs 0.31 (0.27-0.39) ng/ml, respectively; P<0.001). Multivariate logistic regression analysis showed independent association of elevated serum Hsp70 level with transient hypertension of pregnancy, preeclampsia and superimposed preeclampsia. The difference in serum Hsp70 concentration between preeclamptic patients and the control group was statistically significant in each gestational age category. In the groups of preeclamptic and superimposed preeclamptic patients, there was no significant difference in serum Hsp70 concentration between mild and severe preeclamptic patients, between patients with late and early onset of the disease, as well as between preeclamptic patients without and with foetal growth restriction. In conclusion, serum Hsp70 concentration is elevated in transient hypertension of pregnancy, in preeclampsia and in superimposed preeclampsia. Circulating Hsp70 may not only be a marker for these conditions, but might also play a role in their pathogenesis. However, further studies are needed to explore its role in the pathogenesis of hypertensive disorders of pregnancy.

Pregnancy prevents hypertensive remodeling of cerebral arteries: a potential role in the development of eclampsia

We investigated how hypertension during pregnancy affected passive structural (wall:lumen, wall stress) and active (myogenic activity) responses of the cerebral circulation. Female nonpregnant (NP; n=8) Sprague Dawley rats were compared with late-pregnant (LP; day 19 to 20, n=6) rats. Some animals were treated with the NO synthase inhibitor nitro-L-arginine in their drinking water to raise blood pressure. LP rats (n=6) were treated for the last 7 days of pregnancy (last trimester) to mimic preeclampsia and compared with NP rats treated for the same duration (n=8). Active and passive responses were determined on isolated and pressurized third-order posterior cerebral arteries. Nitro-L-arginine treatment significantly raised blood pressure in both groups of animals that was associated with increased wall thickness and wall:lumen ratio in the NP hypertensive animals versus controls (P<0.05). In contrast, this response to pressure was absent in LP animals, which had similar wall measurements. In addition, arteries from NP hypertensive animals had increased myogenic tone and pressure of forced dilatation compared with NP control animals (P<0.01). Again, this response was lacking in the LP hypertensive animals that had similar tone and pressure of forced dilatation as normotensive controls. The increased tone and wall thickness decreased wall stress in the NP hypertensive animals, a response that did not occur in LP hypertensive animals. Because medial hypertrophy is considered a protective response to elevated blood pressure, these results suggest that hypertension in pregnancy may predispose the cerebral circulation to autoregulatory breakthrough and blood-brain-barrier disruption when blood pressure is elevated, as during eclampsia.

Pregnancy-induced up-regulation of aquaporin-4 protein in brain and its role in eclampsia

Neurologic complications of eclampsia are thought to be similar to hypertensive encephalopathy in which an acute, excessive elevation in blood pressure causes blood-brain barrier (BBB) disruption and edema formation. Because women who develop eclampsia are in general normotensive and asymptomatic prior to pregnancy, we hypothesized that pregnancy alone predisposes the brain to edema formation by up-regulation of aquaporin 4 (AQP4), a water channel in the brain that has been shown to positively correlate with edema formation. To test this hypothesis, we compared localization (immunohistochemistry), mRNA (RT-PCR), and protein levels (Western analysis) of AQP4 in brains from Sprague Dawley rats that were nonpregnant (NP, proestrous), mid-pregnant (MP, days 9-10), late-pregnant (LP, days 19-20), and postpartum (PP, days 3-4). AQP4 mRNA was detected in the brains of all the animals and was localized primarily around the brain parenchymal blood vessels, strongly implicating its role in BBB function. Western analysis revealed that the major AQP4 band at approximately 32 kDa was significantly elevated in MP, LP, and PP animals compared with NP by 9-, 22-, and 17-fold, respectively. These results suggest that pregnancy and the postpartum state up-regulate AQP4 protein located around the intraparenchymal blood vessels, a consequence that could promote edema formation when blood pressure is acutely and excessively elevated, as during eclampsia.-Quick, A. M., Cipolla, M. J. Pregnancy-induced up-regulation of aquaporin-4 protein in brain and its role in eclampsia.

Report of 50 cases of eclampsia

AIM

To ascertain the characteristics, clinical features, and maternal fetal outcome in eclampsia in a tertiary referral center with 24 000 deliveries per year.

METHODS

This is a cross-sectional study, in which 50 case notes were retrieved retrospectively and data was analyzed descriptively.

RESULTS

Eclampsia was significant in the Malay primipara patients (n = 14, P = 0.034) and the 20-24-year-old primipara patients (n = 11, P = 0.01). Most were significantly antepartum (64%) and preterm seizures (68%), and 16% were early onset (<31 weeks). Two-thirds were booked and one-third were inpatients. Twenty per cent did not have hypertension or pre-eclampsia antenatally. Most presented with headache (66%) and hyper-reflexia (48%). Only 16% presented with all three prodromal symptoms and 14% were asymptomatic. Half had diastolic blood pressure (DBP) of <110 mmHg and the level of DBP was not significantly associated with the presence of prodromal symptoms and signs. There was increased morbidity, operative intervention, admission to intensive care and more low birth weight babies. Most babies that weighed <2.5 kg had poor Apgar score at 1 min, but most babies had good Apgar score at 5 min (16 babies >2.5 kg, 22 babies < or =2.5 kg, P = 0.006). The corrected perinatal mortality was 40/1000.

CONCLUSION

There was increased maternal and perinatal morbidity but no maternal mortality. Contributing factors are the atypical presentation, early onset of disease and the absence of risk factors. There is a need to develop new methods to identify this group of patients in an effort to further reduce the prevalence of this dangerous condition.

Pregnancy associated complications of mothers with gestational diabetes mellitus

This study was conducted in Mymensingh Medical College and Hospital, Mymensingh. It lasted for one year commencing in July 2003, and was designed to find out and compare the outcomes of gestational diabetes mellitus (GDM) with a view to reducing the complications. Forty cases of GDM with single pregnancy were selected as experimental group, while forty other cases of pregnant women without GDM constituted the control group. Questionnaire and observation chart were the research instrument in this study. Statistical analyses were done manually. It was found that the GDM mothers had a higher risk of complications like pre-eclampsia, hypertension, urinary tract infection and cesarean delivery. On the basis of these findings, however, appropriate measures for prevention, treatment and management of GDM may be adopted for better pregnancy outcomes.

Increased plasma levels of Urotensin-II in preeclampsia–eclampsia: a new mediator in pathogenesis?

OBJECTIVE

To assess the possible role of human Urotensin-II (hU-II), a vasoactive peptide, in the pathophysiology of preeclampsia-eclampsia prospectively.

STUDY DESIGN

Sixty subjects, 30 with a diagnosis of preeclampsia-eclampsia (group I) and 30 control subjects (group II), who had been admitted between January, 2002 and December, 2002, were taken into the study. Patients in group I had an increase in blood pressure after 28th week of gestation, without any history of hypertensive disease and/or preeclampsia or eclampsia. hU-II levels were assessed using a radioimmunoassay method.

RESULTS

No statistically significant difference in terms of age, gestational age, gravidity, abortion and parity was detected among groups (P > 0.05). Plasma hU-II levels in the preeclampsia-eclampsia and control groups were 10.11 +/- 5.94 pg/mL and 3.93 +/- 1.73 pg/mL, respectively. Difference between plasma hU-II levels of the two groups was found to be statistically significant (P < 0.00001). Also there was correlation between hU-II levels and mean arterial pressures in both groups (r = 0.73, P < 0.0001 and r = 0.72, P < 0.0001 for groups I and II, respectively).

CONCLUSION

Results of our study strongly suggest an important role for hU-II in the pathophysiology of preeclampsia-eclampsia. Further studies concerning placenta and cord blood samples will more clearly elucidate the role of Urotensin-II in the pathogenesis of preeclampsia-eclampsia, and its feto-maternal effects.