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Thielemans L, Peerawaranun P, Mukaka M, Paw MK, Wiladphaingern J, Landier J, Bancone G, Proux S, Elsinga H, Trip-Hoving M, Hanboonkunupakarn B, Htoo TL, Wah TS, Beau C, Nosten F, McGready R, Carrara VI. High levels of pathological jaundice in the first 24 hours and neonatal hyperbilirubinaemia in an epidemiological cohort study on the Thailand-Myanmar border. PLoS One 2021; 16:e0258127. [PMID: 34618852 PMCID: PMC8496801 DOI: 10.1371/journal.pone.0258127] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 09/20/2021] [Indexed: 11/18/2022] Open
Abstract
Population risks for neonatal hyperbilirubinaemia (NH) vary. Knowledge of local risks permits interventions that may reduce the proportion becoming severe. Between January 2015 and May 2016, in a resource-limited setting on the Thailand-Myanmar border, neonates from 28 weeks' gestation were enrolled into a prospective birth cohort. Each neonate had total serum bilirubin measurements: scheduled (24, 48, 72 and 144 hours of life) and clinically indicated; and weekly follow up until 1 month of age. Risk factors for developing NH were evaluated using Cox proportional hazard mixed model. Of 1710 neonates, 22% (376) developed NH (83% preterm, 19% term). All neonates born <35 weeks, four in five born 35-37 weeks, and three in twenty born ≥38 weeks had NH, giving an overall incidence of 249 per 1000 livebirths [95%CI 225, 403]. Mortality from acute bilirubin encephalopathy was 10% (2/20) amongst the 5.3% (20/376) who reached the severe NH threshold. One-quarter (26.3%) of NH occurred within 24 hours. NH onset varied with gestational age: at a median [IQR] 24 hours [24, 30] for neonates born 37 weeks or prematurely vs 59 hours [48, 84] for neonates born ≥38 weeks. Risk factors for NH in the first week of life independent of gestational age were: neonatal G6PD deficiency, birth bruising, Sgaw Karen ethnicity, primigravidae, pre-eclampsia, and prolonged rupture of membranes. The genetic impact of G6PD deficiency on NH was partially interpreted by using the florescent spot test and further genotyping work is in progress. The risk of NH in Sgaw Karen refugees may be overlooked internationally as they are most likely regarded as Burmese in countries of resettlement. Given high levels of pathological jaundice in the first 24 hours and overall high NH burden, guidelines changes were implemented including preventive PT for all neonates <35 weeks and for those 35-37 weeks with risk factors.
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Affiliation(s)
- Laurence Thielemans
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Neonatology-Pediatrics, Université Libre de Bruxelles, Brussels, Belgium
| | - Pimnara Peerawaranun
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Mavuto Mukaka
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Moo Kho Paw
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jacher Wiladphaingern
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Jordi Landier
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- IRD, INSERM, SESSTIM, Aix Marseille University, Marseille, France
| | - Germana Bancone
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephane Proux
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Henrike Elsinga
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Margreet Trip-Hoving
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Borimas Hanboonkunupakarn
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tha Ler Htoo
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Thaw Shee Wah
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Candy Beau
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
| | - Francois Nosten
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Rose McGready
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Verena I. Carrara
- Shoklo Malaria Research Unit, Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Mae Sot, Thailand
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Department of Medicine, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Ijomone OK, Osahon IR, Okoh COA, Akingbade GT, Ijomone OM. Neurovascular dysfunctions in hypertensive disorders of pregnancy. Metab Brain Dis 2021; 36:1109-1117. [PMID: 33704662 DOI: 10.1007/s11011-021-00710-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 03/01/2021] [Indexed: 10/21/2022]
Abstract
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.
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Affiliation(s)
- Olayemi K Ijomone
- The Neuro- Lab, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria.
- Department of Anatomy, Faculty of Basic Medical Sciences, University of Medical Sciences, Ondo, Nigeria.
| | - Itohan R Osahon
- Department of Anatomy, College of Health Sciences, Edo State University, Uzairue, Nigeria
| | - Comfort O A Okoh
- The Neuro- Lab, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria
| | - Grace T Akingbade
- The Neuro- Lab, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria
- Department of Human Anatomy, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria
| | - Omamuyovwi M Ijomone
- The Neuro- Lab, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria.
- Department of Human Anatomy, School of Health and Health Technology, Federal University of Technology, Akure, Nigeria.
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Joshi A, Beyuo T, Oppong SA, Moyer CA, Lawrence ER. Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana. BMC Pregnancy Childbirth 2020; 20:625. [PMID: 33059625 PMCID: PMC7566025 DOI: 10.1186/s12884-020-03316-w] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 10/06/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Preeclampsia/eclampsia is a major cause of maternal morbidity and mortality worldwide, yet patients' perspectives about their diagnosis are not well understood. Our study examines patient knowledge among women with preeclampsia/eclampsia in a large urban hospital in Ghana. METHODS Postpartum women diagnosed with preeclampsia or eclampsia were asked to complete a survey 2-5 days after delivery that assessed demographic information, key obstetric factors, and questions regarding provider counseling. Provider counseling on diagnosis, causes, complications, and future health effects of preeclampsia/eclampsia was quantified on a 4-point scale ('Counseling Composite Score'). Participants also completed an objective knowledge assessment regarding preeclampsia/eclampsia, scored from 0 to 22 points ('Preeclampsia/Eclampsia Knowledge Score' (PEKS)). Linear regression was used to identify predictors of knowledge score. RESULTS A total of 150 participants were recruited, 88.7% (133) with preeclampsia and 11.3% (17) with eclampsia. Participants had a median age of 32 years, median parity of 2, and mean number of 5.4 antenatal visits. Approximately half of participants reported primary education as their highest level of education. While 74% of women reported having a complication during pregnancy, only 32% of participants with preeclampsia were able to correctly identify their diagnosis, and no participants diagnosed with eclampsia could correctly identify their diagnosis. Thirty-one percent of participants reported receiving no counseling from providers, and only 11% received counseling in all four categories. Even when counseled, 40-50% of participants reported incomplete understanding. Out of 22 possible points on a cumulative knowledge assessment scale, participants had a mean score of 12.9 ± 0.38. Adjusting for age, parity, and the number of antenatal visits, higher scores on the knowledge assessment are associated with more provider counseling (β 1.4, SE 0.3, p < 0.001) and higher level of education (β 1.3, SE 0.48, p = 0.008). CONCLUSIONS Counseling by healthcare providers is associated with higher performance on a knowledge assessment about preeclampsia/eclampsia. Patient knowledge about preeclampsia/eclampsia is important for efforts to encourage informed healthcare decisions, promote early antenatal care, and improve self-recognition of warning signs-ultimately improving morbidity and reducing mortality.
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Affiliation(s)
- Avina Joshi
- University of Massachusetts Medical School, 55 N. Lake Ave, Worcester, MA, 01655, USA
| | - Titus Beyuo
- University of Ghana School of Medicine and Dentistry, Slater Avenue, Accra, Ghana.
- Department of Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Guggisberg Avenue, Accra, Ghana.
| | - Samuel A Oppong
- University of Ghana School of Medicine and Dentistry, Slater Avenue, Accra, Ghana
- Department of Obstetrics & Gynaecology, Korle Bu Teaching Hospital, Guggisberg Avenue, Accra, Ghana
| | - Cheryl A Moyer
- Global REACH, University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI, 48109, USA
- Department of Obstetrics & Gynecology, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Emma R Lawrence
- Department of Obstetrics & Gynecology, University of Michigan Medical School, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
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Abdi N, Rozrokh A, Alavi A, Zare S, Vafaei H, Asadi N, Kasraeian M, Hessami K. The effect of aspirin on preeclampsia, intrauterine growth restriction and preterm delivery among healthy pregnancies with a history of preeclampsia. J Chin Med Assoc 2020; 83:852-857. [PMID: 32773581 PMCID: PMC7478204 DOI: 10.1097/jcma.0000000000000400] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Due to the significance of preeclampsia (PE) and its adverse outcomes in the health of both mother and newborn, the present study was carried out to investigate the effect of aspirin on preventing the occurrence of PE, intrauterine growth restriction (IUGR), and preterm delivery in women with a previous history of PE. METHODS The present clinical trial was conducted on 90 pregnant women with a previous history of PE referred to the Khalij Fars Hospital in Bandar Abbas, Hormozgan Province Iran from April 2017 to August 2018. The subjects of the study were randomly assigned into two groups of intervention and control to receive either 80 mg of aspirin or placebo daily during the pregnancy. Patients' information was obtained and recorded upon entering the study, follow-up visits, and childbirth. RESULTS Among participants who entered the clinical trial, 86 patients (95.6%) completed the study. During the pregnancy, systolic blood pressure increased by 8.25 ± 14.83 and 19.06 ± 18.33 mmHg in aspirin and placebo groups, respectively (p = 0.001). Also, the same happened with diastolic blood pressure (6.12 ± 11.46 vs 13.48 ± 13.95 mmHg, p = 0.010). The rate of PE was equal to 27 (62.8%) and 38 (88.4%) in the aspirin and placebo groups, respectively (aOR = 0.23, p = 0.013). In the aspirin group, the rate of IUGR was equal to 27.9% compared with 25.6% of newborns in the control group (aOR = 1.18, p = 0.750). Similarly, there was no significant difference in the rate of preterm delivery between the two groups (p = 0.061). CONCLUSION The findings of the present study conducted exclusively on women with previous documented PE revealed that taking aspirin may have a preventive effect on PE in the current pregnancy.
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Affiliation(s)
- Nazanin Abdi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Afsane Rozrokh
- Student Research Committee, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Azin Alavi
- Fertility and Infertility Research Center, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Shahram Zare
- Epidemiology Department, Hormozgan University of Medical Sciences, Bandar Abbas, Iran
| | - Homeira Vafaei
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Nasrin Asadi
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Maryam Kasraeian
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Kamran Hessami
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
- Address correspondence. Dr. Kamran Hessami, Maternal-Fetal Medicine (Perinatology) Research Center, Shiraz University of Medical Sciences, Hafez Hospital, Chamran Ave., Shiraz, Iran. E-mail address: (K. Hessami)
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Sevene E, Sharma S, Munguambe K, Sacoor C, Vala A, Macuacua S, Boene H, Mark Ansermino J, Augusto O, Bique C, Bone J, Dunsmuir DT, Lee T, Li J, Macete E, Singer J, Wong H, Nathan HL, Payne BA, Sidat M, Shennan AH, Tchavana C, Tu DK, Vidler M, Bhutta ZA, Magee LA, von Dadelszen P. Community-level interventions for pre-eclampsia (CLIP) in Mozambique: A cluster randomised controlled trial. Pregnancy Hypertens 2020; 21:96-105. [PMID: 32464527 PMCID: PMC7471842 DOI: 10.1016/j.preghy.2020.05.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 04/28/2020] [Accepted: 05/09/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES Pregnancy hypertension is the third leading cause of maternal mortality in Mozambique and contributes significantly to fetal and neonatal mortality. The objective of this trial was to assess whether task-sharing care might reduce adverse pregnancy outcomes related to delays in triage, transport, and treatment. STUDY DESIGN The Mozambique Community-Level Interventions for Pre-eclampsia (CLIP) cluster randomised controlled trial (NCT01911494) recruited pregnant women in 12 administrative posts (clusters) in Maputo and Gaza Provinces. The CLIP intervention (6 clusters) consisted of community engagement, community health worker-provided mobile health-guided clinical assessment, initial treatment, and referral to facility either urgently (<4hrs) or non-urgently (<24hrs), dependent on algorithm-defined risk. Treatment effect was estimated by multi-level logistic regression modelling, adjusted for prognostically-significant baseline variables. Predefined secondary analyses included safety and evaluation of the intensity of CLIP contacts. MAIN OUTCOME MEASURES 20% reduction in composite of maternal, fetal, and newborn mortality and major morbidity. RESULTS 15,013 women (15,123 pregnancies) were recruited in intervention (N = 7930; 2·0% loss to follow-up (LTFU)) and control (N = 7190; 2·8% LTFU) clusters. The primary outcome did not differ between intervention and control clusters (adjusted odds ratio (aOR) 1·31, 95% confidence interval (CI) [0·70, 2·48]; p = 0·40). Compared with intervention arm women without CLIP contacts, those with ≥8 contacts experienced fewer primary outcomes (aOR 0·79 (95% CI 0·63, 0·99); p = 0·041), primarily due to improved maternal outcomes (aOR 0·72 (95% CI 0·53, 0·97); p = 0·033). INTERPRETATION As generally implemented, the CLIP intervention did not improve pregnancy outcomes; community implementation of the WHO eight contact model may be beneficial. FUNDING The University of British Columbia (PRE-EMPT), a grantee of the Bill & Melinda Gates Foundation (OPP1017337).
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Affiliation(s)
- Esperança Sevene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique.
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Khátia Munguambe
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Charfudin Sacoor
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Anifa Vala
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Salésio Macuacua
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Direcção Provincial de Saúde, Ministério da Saúde, Av. Eduardo Mondlane n(o) 1008, CP 264 Maputo, Mozambique
| | - Helena Boene
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - J Mark Ansermino
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Orvalho Augusto
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Cassimo Bique
- Departamento de Ginecologia e Obstetrícia, Hospital Central de Maputo, Av. Agostinho Neto n(o) 167, CP 1164 Maputo, Mozambique
| | - Jeffrey Bone
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Dustin T Dunsmuir
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Jing Li
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Eusébio Macete
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique; Instituto Nacional de Saúde, Ministério da Saúde, Distrito de Marracuene, Estrada Nacional N(o) 1, Maputo, Mozambique
| | - Joel Singer
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Hubert Wong
- Centre for Health Evaluation and Outcome Sciences, Providence Health Care Research Institute, University of British Columbia, 588 - 1081 Burrard Street, St. Paul's Hospital, Vancouver V6Z 1Y6, Canada
| | - Hannah L Nathan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Beth A Payne
- Centre for International Child Health, University of British Columbia, 305 - 4088 Cambie Street, Vancouver V5Z 2X8, Canada
| | - Mohsin Sidat
- Faculdade de Medicina, Universidade Eduardo Mondlane, Av. Salvador Allende nr. 702, Maputo, Mozambique
| | - Andrew H Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Corssino Tchavana
- Centro de Investigação em Saúde da Manhiça (CISM), Rua 12, Cambeve, Manhiça, CP 1929 Maputo, Mozambique
| | - Domena K Tu
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, 525 University Avenue, Suite 702, Toronto M5G 2L3, Canada
| | - Laura A Magee
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
| | - Peter von Dadelszen
- Department of Obstetrics and Gynaecology, University of British Columbia, Suite 930, 1125 Howe Street, Vancouver V6Z 2K8, Canada; Department of Women and Children's Health, School of Life Course Sciences, Faculty of Medicine and Life Sciences, King's College London, 1 Lambeth Place Road, London SE1 7EH, UK
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Villalaín C, Herraiz I, Valle L, Mendoza M, Delgado JL, Vázquez‐Fernández M, Martínez‐Uriarte J, Melchor Í, Caamiña S, Fernández‐Oliva A, Villar OP, Galindo A. Maternal and Perinatal Outcomes Associated With Extremely High Values for the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio. J Am Heart Assoc 2020; 9:e015548. [PMID: 32248765 PMCID: PMC7428600 DOI: 10.1161/jaha.119.015548] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Accepted: 03/02/2020] [Indexed: 12/19/2022]
Abstract
Background There is little knowledge about the significance of extremely high values (>655) for the ratio of sFlt-1 (soluble fms-like tyrosine kinase 1) to PlGF (placental growth factor). We aim to describe the time-to-delivery interval and maternal and perinatal outcomes when such values are demonstrated while assessing suspected or confirmed placental dysfunction based on clinical or sonographic criteria. Methods and Results A multicenter retrospective cohort study was performed on 237 singleton gestations between 20+0 and 37+0 weeks included at the time of first demonstrating a sFlt-1/PlGF ratio >655. Clinicians were aware of this result, but standard protocols were followed for delivery indication. Main outcomes were compared for women with and without preeclampsia at inclusion. In those with preeclampsia (n=185, of whom 77.3% had fetal growth restriction), severe preeclampsia features and fetal growth restriction in stages III or IV were present in 49.2% and 13.5% cases, respectively, at inclusion and in 77.3% and 28.6% cases, respectively, at delivery. In the group without preeclampsia (n=52, 82.7% had fetal growth restriction), these figures were 0% and 30.8%, respectively, at inclusion and 21.2% and 50%, respectively, at delivery. Interestingly, 28% of women without initial preeclampsia developed it later. The median time to delivery was 4 days (interquartile range: 1-6 days) and 7 days (interquartile range: 3-12 days), respectively (P<0.01). Overall, perinatal mortality was 62.1% before 24 weeks; severe morbidity surpassed 50% before 29 weeks but became absent from 34 weeks. Maternal serious morbidity was high at any gestational age. Conclusions An sFlt-1/PlGF ratio >655 is almost invariably associated with preeclampsia or fetal growth restriction that progresses rapidly. In our tertiary care settings, we observed that maternal adverse outcomes were high throughout gestation, whereas perinatal adverse outcomes diminished as pregnancy advanced.
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Affiliation(s)
- Cecilia Villalaín
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Ignacio Herraiz
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Leonor Valle
- Department of ObstetricsHospital Universitario Materno‐Infantil de Las Palmas de Gran CanariaLas Palmas de Gran CanariaSpain
| | - Manel Mendoza
- Department of ObstetricsMaternal‐Foetal Medicine Unit‐SAMIDVall d’Hebron University HospitalUniversitat Autònoma de BarcelonaBarcelonaSpain
| | - Juan Luis Delgado
- Department of Obstetrics and GynecologyHospital Universitario Virgen de la ArrixacaMurciaSpain
| | | | - Juan Martínez‐Uriarte
- Department of Obstetrics and GynecologyHospital General Universitario Santa LucíaCartagenaSpain
| | - Íñigo Melchor
- Obstetrics and Gynecology DepartmentBiocruces Bizkaia Health Research InstituteCruces University Hospital (UPV/EHU)VizcayaSpain
| | - Sara Caamiña
- Department of Obstetrics and GynecologyHospital Universitario Nuestra Señora de la CandelariaSanta Cruz de TenerifeSpain
| | - Antoni Fernández‐Oliva
- Maternal‐Foetal Medicine UnitDepartment of Obstetrics and GynecologyHospital de la Santa Creu i Sant PauBarcelonaSpain
| | - Olga Patricia Villar
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
| | - Alberto Galindo
- Fetal Medicine Unit‐SAMIDDepartment of Obstetrics and GynaecologyHospital Universitario 12 de OctubreInstituto de Investigación Hospital 12 de Octubre (imas12)Universidad Complutense de MadridMadridSpain
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de Sonnaville CMW, Hukkelhoven CW, Vlemmix F, Groen H, Schutte JM, Mol BW, van Pampus MG. Impact of Hypertension and Preeclampsia Intervention Trial At Near Term-I (HYPITAT-I) on obstetric management and outcome in The Netherlands. Ultrasound Obstet Gynecol 2020; 55:58-67. [PMID: 31486156 DOI: 10.1002/uog.20417] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 05/18/2019] [Accepted: 06/30/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The Hypertension and Preeclampsia Intervention Trial At near Term-I (HYPITAT-I) randomized controlled trial showed that, in women with gestational hypertension or mild pre-eclampsia at term, induction of labor, compared with expectant management, was associated with improved maternal outcome without compromising neonatal outcome. The aim of the current study was to evaluate the impact of these findings on obstetric management and maternal and perinatal outcomes in The Netherlands. METHODS We retrieved data for the period 2000-2014 from the Dutch National Perinatal Registry, including 143 749 women with gestational hypertension or pre-eclampsia and a singleton fetus in cephalic presentation, delivered between 36 + 0 and 40 + 6 weeks of gestation (hypertensive disorder of pregnancy (HDP) group). Pregnant women without HDP were used as the reference group (n = 1 649 510). The HYPITAT-I trial was conducted between 2005 and 2008. To study the impact of HYPITAT-I, we compared rate of induction of labor, mode of delivery and maternal and perinatal outcomes in the periods before (2000-2005) and after (2008-2014) the trial. We also differentiated between hospitals that participated in HYPITAT-I and those that did not. RESULTS In the HDP group, the rate of induction of labor increased from 51.1% before the HYPITAT-I trial to 64.2% after it (relative risk (RR), 1.26; 95% CI, 1.24-1.27). Maternal mortality decreased from 0.022% before the trial to 0.004% after it (RR, 0.20; 95% CI, 0.06-0.70) and perinatal death decreased from 0.49% to 0.27% (RR, 0.54; 95% CI, 0.45-0.65), which was attributable mostly to a decrease in fetal death. Both the increase in induction rate and the reduction in hypertensive complications were more pronounced in hospitals that participated in the HYPITAT-I trial than in those that did not. Following HYPITAT-I, the rate of induction of labor also increased (by 4.6 percentage points) in the reference group; however, the relative increase in the HDP group (13.1 percentage points) was significantly greater (P < 0.001 for the interaction). The reduction in maternal and perinatal deaths did not differ significantly between the HDP and reference groups. There was a decreased incidence of placental abruption in both HDP and reference groups, which was significantly greater in the HDP than in the reference group (P < 0.001 for the interaction). There was also an increased incidence of emergency Cesarean section in both HDP and reference groups; however, this change was significantly greater in the reference than in the HDP group (P < 0.001 for the interaction). CONCLUSION Following the HYPITAT-I trial, there was a higher rate of induction of labor and improved obstetric outcome in term pregnancies complicated by HDP in The Netherlands. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
| | | | - F Vlemmix
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands
| | - H Groen
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J M Schutte
- Department of Obstetrics and Gynecology, Isala Klinieken, Zwolle, The Netherlands
| | - B W Mol
- Department of Obstetrics and Gynecology, Monash University, Melbourne, Australia
| | - M G van Pampus
- Department of Obstetrics and Gynecology, OLVG, Amsterdam, The Netherlands
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Madhi SA, Pathirana J, Baillie V, Cutland C, Adam Y, Izu A, Bassat Q, Blau DM, Breiman RF, Hale M, Johnstone S, Martines RB, Mathunjwa A, Nzenze S, Ordi J, Raghunathan PL, Ritter JM, Solomon F, Wadula J, Zaki SR, Chawana R. An Observational Pilot Study Evaluating the Utility of Minimally Invasive Tissue Sampling to Determine the Cause of Stillbirths in South African Women. Clin Infect Dis 2019; 69:S342-S350. [PMID: 31598656 PMCID: PMC6785671 DOI: 10.1093/cid/ciz573] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Despite approximately 2.6 million stillbirths occurring annually, there is a paucity of systematic biological investigation and consequently knowledge on the causes of these deaths in low- and middle-income countries (LMICs). We investigated the utility of minimally invasive tissue sampling (MITS), placental examination, and clinical history, in attributing the causes of stillbirth in a South African LMIC setting. METHODS This prospective, observational pilot study undertook sampling of brain, lung, and liver tissue using core biopsy needles, blood and cerebrospinal fluid collection, and placental examination. Testing included microbial culture and/or molecular testing and tissue histological examination. The cause of death was determined for each case by an international panel of medical specialists and categorized using the World Health Organization's International Classification of Diseases, Tenth Revision application to perinatal deaths. RESULTS A cause of stillbirth was identifiable for 117 of 129 (90.7%) stillbirths, including an underlying maternal cause in 63.4% (n = 83) and an immediate fetal cause in 79.1% (n = 102) of cases. The leading underlying causes of stillbirth were maternal hypertensive disorders (16.3%), placental separation and hemorrhage (14.0%), and chorioamnionitis (10.9%). The leading immediate causes of fetal death were antepartum hypoxia (35.7%) and fetal infection (37.2%), including due to Escherichia coli (16.3%), Enterococcus species (3.9%), and group B Streptococcus (3.1%). CONCLUSIONS In this pilot, proof-of-concept study, focused investigation of stillbirth provided granular detail on the causes thereof in an LMIC setting, including provisionally highlighting the largely underrecognized role of fetal sepsis as a dominant cause.
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Affiliation(s)
- Shabir A Madhi
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Jayani Pathirana
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Vicky Baillie
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Clare Cutland
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Yasmin Adam
- Department of Obstetrics and Gynaecology, Chris Hani Baragwanath Academic Hospital, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Alane Izu
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Quique Bassat
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
- Catalan Institution for Research and Advanced Studies (ICREA), Barcelona, Spain
- Pediatric Infectious Diseases Unit, Pediatrics Department, Hospital de Sant Joan de Deu, University of Barcelona, Barcelona, Spain
- Consorcio de Investigacion Biomedica en Red de Epidemiologia y Salud, Madrid, Spain
| | - Dianna M Blau
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Robert F Breiman
- Emory Global Health Institute, Emory University, Atlanta, Georgia, USA
| | - Martin Hale
- National Health Laboratory Service, Department of Anatomical Pathology, School of Pathology, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Siobhan Johnstone
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Roosecelis B Martines
- Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Azwifarwi Mathunjwa
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Susan Nzenze
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Jaume Ordi
- ISGlobal, Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
- Centro de Investigação em Saúde de Manhiça (CISM), Maputo, Mozambique
| | - Pratima L Raghunathan
- Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Jana M Ritter
- Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Fatima Solomon
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
| | - Jeannette Wadula
- National Health Laboratory Service, Department of Microbiology and Infectious Diseases, School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Sherif R Zaki
- Infectious Diseases Pathology Branch, Division of High-Consequence Pathogens and Pathology, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Richard Chawana
- Medical Research Council: Respiratory and Meningeal Pathogens Research Unit, University of the Witwatersrand, Faculty of Health Science, Johannesburg, South Africa
- Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Faculty of Health Sciences, Johannesburg, South Africa
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Barjaktarovic M, Korevaar TIM, Jaddoe VWV, de Rijke YB, Peeters RP, Steegers EAP. Human chorionic gonadotropin and risk of pre-eclampsia: prospective population-based cohort study. Ultrasound Obstet Gynecol 2019; 54:477-483. [PMID: 30834627 PMCID: PMC6856821 DOI: 10.1002/uog.20256] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 02/20/2019] [Accepted: 02/27/2019] [Indexed: 05/13/2023]
Abstract
OBJECTIVES Abnormal placentation in early pregnancy may play a role in the pathogenesis of pre-eclampsia. Human chorionic gonadotropin (hCG) regulates placental development and angiogenesis and may affect the ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) in the serum. The aims of this study were to investigate the association of total hCG with the risk of pre-eclampsia and to examine the potential effect of pro- and anti-angiogenic factors on this association. METHODS This was a population-based prospective cohort study of 7754 women with a singleton pregnancy. Total hCG was measured in the first available sample (median gestational age, 14.4 weeks; 95% range, 10.1-26.1 weeks) and sFlt-1 and PlGF concentrations in early (< 18 weeks; median, 13.2 weeks; 95% range, 9.6-17.6 weeks) and in mid- (18-25 weeks; median, 20.4 weeks; 95% range, 18.5-23.5 weeks) pregnancy. We tested the association of hCG concentration and risk of pre-eclampsia using regression analysis, adjusting for maternal age, ethnicity, body mass index, parity, education level, smoking status and fetal sex. Additionally, we assessed whether this association was affected by the sFlt-1/PlGF ratio. RESULTS High hCG concentration was associated with a 1.5-2.7-fold increased risk of pre-eclampsia (P = 0.0001), depending on the cut-off used, and with increased sFlt-1/PlGF ratio during early pregnancy (P < 0.0001). The association between high hCG and pre-eclampsia attenuated by roughly 40% after adjustment for early-pregnancy sFlt-1/PlGF ratio (β-estimate change from 0.19 ± 0.10 (P = 0.052) to 0.12 ± 0.10 (P = 0.22)). CONCLUSIONS High total hCG concentration in early pregnancy is associated with an increased risk of pre-eclampsia. The effect of high hCG concentration on the balance between pro- and anti-angiogenic factors during pregnancy may have a role in the pathophysiology of pre-eclampsia. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M. Barjaktarovic
- The Generation R Study GroupErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
- Department of Internal Medicine, Academic Center for Thyroid DiseasesErasmus Medical Center, Sophia Diseases, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - T. I. M. Korevaar
- The Generation R Study GroupErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
- Department of Internal Medicine, Academic Center for Thyroid DiseasesErasmus Medical Center, Sophia Diseases, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - V. W. V. Jaddoe
- The Generation R Study GroupErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
- Department of Epidemiology and PediatricsErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - Y. B. de Rijke
- Department of Internal Medicine, Academic Center for Thyroid DiseasesErasmus Medical Center, Sophia Diseases, Sophia Children's Hospital, Rotterdam, The Netherlands
- Department of Clinical ChemistryErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
| | - R. P. Peeters
- The Generation R Study GroupErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
- Department of Internal Medicine, Academic Center for Thyroid DiseasesErasmus Medical Center, Sophia Diseases, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - E. A. P. Steegers
- The Generation R Study GroupErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
- Department of Obstetrics and GynecologyErasmus Medical Center, Sophia Children's HospitalRotterdamThe Netherlands
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Grunewald C, Esscher A, Lutvica A, Parén L, Saltvedt S. [Maternal deaths in Sweden: Diagnostics and clinical management could be improved]. Lakartidningen 2019; 116:FPL4. [PMID: 31573669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
MM-ARG, the Swedish maternal maternity mortality group within SFOG (Swedish Society of Obstetrics and Gynecology) has, since 2008, surveyed and analysed maternal deaths in Sweden with the aim to find and give feedback on lessons learned to the medical professions. MM-ARG consists of obstetricians, midwives and anesthetists and the strength of the working model is that the profession itself takes responsibility for the scrutiny. A summary of 67 known maternal deaths from 2007‒2017 is presented. Direct causes of death are dominated by hypertensive disease/preeclampsia, followed by thromboembolic disease, sepsis and obstetric bleeding. Indirect death, where a known or unknown underlying disease is exacerbated by pregnancy, is dominated by cardiovascular disease. This review shows that the diagnostics and clinical management could be improved. Besides obstetrics/gynecology, maternal mortality affects other specialties and thus holds important lessons to many.
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Affiliation(s)
- Charlotta Grunewald
- Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden
| | - Annika Esscher
- Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden
| | - Ajlana Lutvica
- Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden Uppsala Universitet - Kvinnosjukvården Uppsala, Sweden
| | - Lisa Parén
- Sahlgrenska universitetssjukhuset - Obstetriken Goteborg, Sweden Sahlgrenska universitetssjukhuset - Obstetriken Goteborg, Sweden
| | - Sissel Saltvedt
- Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden Karolinska Universitetssjukhuset - PO Graviditet och Förlossning Stockholm, Sweden
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Hassan HES, Azzam H, Othman M, Hassan M, Selim T. Soluble E-selectin, platelet count and mean platelet volume as biomarkers for pre-eclampsia. Pregnancy Hypertens 2019; 17:1-4. [PMID: 31487622 DOI: 10.1016/j.preghy.2019.04.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 04/20/2019] [Accepted: 04/25/2019] [Indexed: 11/19/2022]
Abstract
OBJECTIVES Preeclampsia remains a major cause of maternal mortality and morbidity worldwide with increased risk for cardiovascular disease later in life. Many previous studies have examined several biomarkers including E-selectin. We aimed to assess the role of sE-selectin together with platelet count and mean platelet volume (MPV) as biomarkers for the prediction of preeclampsia. STUDY DESIGN AND MAJOR OUTCOME MEASURES This case-control study included 85 pregnant women; 40 healthy (mean age 27.1 ± 4.8 years) and 45 with preeclampsia (mean age 26.8 ± 6.7 years), recruited at the third trimester of pregnancy and subjected to full clinical and laboratory testing. This included complete blood picture, urine analysis and plasma sE-selectin using ELISA. RESULTS A significant decrease in platelet count (P = 0.003), and a significant increase in MPV (P < 0.001) were seen in patients versus controls. Plasma sE-selectin levels were significantly higher in patients versus control (P = 0.002). ROC curve showed the best cut-off values for sE-selectin was 64.3 ng/mL, with 58% sensitivity 80.0% specificity. Positive predictive value was 76.5; negative predictive value was 62.7 and accuracy was 68.2 with a statically significant area under curve (P = 0.002). Platelet count, MPV and sE-selectin were significantly associated with PE in univariate analysis. In multivariate analysis, only MPV and sE-selectin were independent risk factors for PE development. Higher MPV or sE-selectin were associated with PE development (P < 0.001). CONCLUSION The simultaneous use of sE-selectin and platelet count and volume may help earlier recognition of preeclampsia and thus appropriate and more efficient therapy. Larger studies are likely to help verify data and justify wider application of these markers.
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Affiliation(s)
| | - Hanan Azzam
- Clinical Pathology Dept., Italy Elbarood General Hospital, El Behera, Egypt
| | - Maha Othman
- Biomedical and Molecular Sciences Dept., Faculty of Medicine, Queen's University, Canada.
| | - Mohammad Hassan
- Gynaecology & Obstetrics Dept., Faculty of Medicine, Mansoura University, Egypt
| | - Tarek Selim
- Clinical Pathology Dept., Italy Elbarood General Hospital, El Behera, Egypt
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12
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Burgess A, Feliu K. Women's Knowledge of Cardiovascular Risk After Preeclampsia. Nurs Womens Health 2019; 23:424-432. [PMID: 31445987 DOI: 10.1016/j.nwh.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 05/19/2019] [Accepted: 07/01/2019] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine women's self-reported knowledge of the association between preeclampsia and cardiovascular disease and to determine if they received appropriate education on the recommendations of the American Heart Association for follow-up and for cardiovascular risk reduction strategies after preeclampsia. DESIGN Cross-sectional descriptive study using an online survey. SETTING/LOCAL PROBLEM A survey link was placed on the Facebook pages for two preeclampsia support groups. PARTICIPANTS A total of 241 women who were members of these Facebook groups completed the online survey. INTERVENTION/MEASUREMENTS An online survey was created using Campus Labs software. Most questions were closed response. Participants were asked to answer survey questions about their first pregnancy with preeclampsia and the education/referrals they received specific to the association between preeclampsia and cardiovascular risk. RESULTS Of all those who responded, 36.9% (n = 89) reported being unaware of the association between preeclampsia and cardiovascular disease. Of those who gave birth since the American Heart Association issued recommendations for follow-up after preeclampsia, 43.9% (n = 61) reported that they received no counseling regarding incorporating healthful lifestyle changes or follow-up after their diagnosis of preeclampsia. CONCLUSION Women with a history of preeclampsia may not be receiving adequate education on its association with cardiovascular disease. Nurses can work to fill this gap through collaboration with cardiovascular and primary care providers to orchestrate seamless cardioprotective follow-up for this population of women.
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Abstract
INTRODUCTION Pre-eclampsia is a hypertensive disorder in pregnancy. Maternal sequelae that may occur include impaired liver function, disseminated intravascular coagulation, seizures (eclampsia), stroke, and death. Thus, providers should know how to recognize (diagnose) and treat pre-eclampsia and eclampsia. METHODS A simulator with noninvasive blood pressure monitoring was used. Transducers for fetal heart rate and contraction monitoring were placed on the simulator, which represented the patient. After obtaining a history and performing a physical examination, resident physician (postgraduate years 1-4) and nurse learners had to diagnose pre-eclampsia and treat this condition. They also had to treat severe-range blood pressures and manage eclampsia. Learner performance was assessed with a checklist. Debriefing followed the simulation. RESULTS Thirty resident learners participated in the study. Nurses did not participate. All resident learners indicated familiarity with the diagnosis and management of pre-eclampsia and emergent hypertension and managed these conditions correctly. All resident learners reported not being confident in managing eclampsia. None of the learners were able to stop the eclamptic seizure. All resident learners were more confident in managing eclampsia after the scenario compared with before (mean confidence level 3.6 ± 0.5 vs. 1.1 ± 0.4, p < .001). DISCUSSION Resident learners were familiar with the management of pre-eclampsia and emergent hypertension but not with eclampsia. We recommend that eclampsia simulations occur in a laboratory and in situ on the labor and delivery floor with interprofessional team members including obstetricians, nurses, anesthesiologists, emergency and family medicine physicians, nurse practitioners, and physician assistants.
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Affiliation(s)
- Cynthia Abraham
- Assistant Professor, Hofstra University–Northwell Health System–Staten Island University Hospital, Patient Safety Institute
| | - Natalya Kusheleva
- Senior Director Ambulatory Care Services, Hofstra University–Northwell Health System–Staten Island University Hospital, Patient Safety Institute
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Lee JH, Zhang G, Harvey S, Nakagawa K. Temporal Trends of Hospitalization, Mortality, and Financial Impact Related to Preeclampsia with Severe Features in Hawai'i and the United States. Hawaii J Health Soc Welf 2019; 78:252-257. [PMID: 31463474 PMCID: PMC6695341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The temporal trend of hospitalizations, cost, and outcomes associated with preeclampsia with severe features have been inadequately studied. The publicly available Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS) database was accessed to examine the temporal trend of total number of discharges, age, death, and mean charges per admission associated with preeclampsia with severe features. Eleven-year temporal trends (2004 to 2014) of these measures were compared using linear regression and run charts using the statistical process control rule. From 2004 to 2014, the total number of discharges related to preeclampsia with severe features increased both for Hawai'i and the U.S. (United States) (Hawai'i: 104 to 231; U.S.: 35,082 to 55,235; both P<.0001). The corresponding rates of discharges per 100,000 population also both increased (Hawai'i: 8.2 to 16.3; U.S.: 12.0 to 17.3; both P<.0001). Comparing the temporal trends between Hawai'i and the U.S., Hawai'i had a significantly higher average annual increase in the rate of incidence than the national level (an annual increase rate of 9.2% in Hawai'i vs 4.2% nationally; P=.0004). The cost of hospitalization for preeclampsia with severe features also showed an increased trend for both Hawai'i and the U.S. (Hawai'i: 33.1% increase, P=.0005; U.S.: 41.1% increase, P<.0001). In the U.S., in-hospital mortality rates associated with this condition decreased from 0.09% in 2004 to 0.02% in 2014 (P=.03). In conclusion, the number of discharges related to preeclampsia with severe features increased over an 11-year period in Hawai'i and the U.S., and the rate of increase was higher in Hawai'i than the U.S. Maternal mortality rates from this condition also declined over the study period.
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Affiliation(s)
- Ji Hae Lee
- Harvard University, Cambridge, MA (JHL)
- The Queen's Medical Center, Honolulu, HI (GZ, SH, KN)
- Department of Obstetrics and Gynecology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (SH)
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KN)
| | - Guangxiang Zhang
- Harvard University, Cambridge, MA (JHL)
- The Queen's Medical Center, Honolulu, HI (GZ, SH, KN)
- Department of Obstetrics and Gynecology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (SH)
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KN)
| | - Scott Harvey
- Harvard University, Cambridge, MA (JHL)
- The Queen's Medical Center, Honolulu, HI (GZ, SH, KN)
- Department of Obstetrics and Gynecology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (SH)
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KN)
| | - Kazuma Nakagawa
- Harvard University, Cambridge, MA (JHL)
- The Queen's Medical Center, Honolulu, HI (GZ, SH, KN)
- Department of Obstetrics and Gynecology, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (SH)
- Department of Medicine, John A. Burns School of Medicine, University of Hawai'i, Honolulu, HI (KN)
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Affiliation(s)
- Sonia S Hassan
- Office of Women's Health, Integrative Biosciences Center, Department of Obstetrics and Gynecology and the Department of Physiology, Wayne State University, Detroit, MI 48201, USA.
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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Sheikh S, Qureshi RN, Raza F, Memon J, Ahmed I, Vidler M, Payne BA, Lee T, Sawchuck D, Magee L, von Dadelszen P, Bhutta Z. Self-reported maternal morbidity: Results from the community level interventions for pre-eclampsia (CLIP) baseline survey in Sindh, Pakistan. Pregnancy Hypertens 2019; 17:113-120. [PMID: 31487626 PMCID: PMC6734112 DOI: 10.1016/j.preghy.2019.05.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 04/24/2019] [Accepted: 05/17/2019] [Indexed: 11/30/2022]
Abstract
Community-based estimates of maternal/perinatal death and morbidity are reported. Stillbirth led to increased self-report of hypertensive complications in the index pregnancy. Self-reported seizure and pregnancy hypertension is prone to error in regions of low literacy.
Objective Community-based data regarding maternal and perinatal morbidity and mortality are scarce in less-developed countries. The aim of the study was to collect representative community-level demographic health information to provide socio-demographic and health outcome data. Methods A retrospective household survey of women of reproductive age (15–49 years) living in two districts of Sindh Province, Pakistan was conducted. Pregnancy incidence over the past 12 months and during each woman’s lifetime; maternal, fetal, infant and child deaths in the past 12 months; and rates of hypertension and seizures in pregnancy were calculated. Results From June to September 2013, 88,410 households were surveyed with 1.2 (±0.6) women of reproductive age per household. 19,584 women (11.9%) reported pregnancies in the preceding 12 months; 83.0% had live births, 3.5% resulting in stillbirths and 13.6% in miscarriages. 34.2% of deliveries occurred at home. Out of all women who reported a pregnancy in past 12 months, 62.1% reported high blood pressure and 11.9% reported seizures complicating her most recent pregnancy. Blood pressure was not measured during survey to confirm hypertension. The perinatal, neonatal and maternal mortality ratios were 64.7/1000, 39/1000 and 166/100,000 livebirths, respectively. Conclusion This study estimated population-level mortality ratios that can be used for the planning of health interventions in these regions. Self-reported pregnancy hypertension and seizures was inaccurate, reflecting limited community understanding of these disorders. Mortality estimates are comparable to those reported by the World Health Organization for maternal mortality ratio and neonatal mortality rate of 170/100,000 and 36/1000 live births, respectively.
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Affiliation(s)
- Sana Sheikh
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | - Rahat Najam Qureshi
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | - Farrukh Raza
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | - Javed Memon
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | - Imran Ahmed
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan.
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4, Canada.
| | - Beth A Payne
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4, Canada; Centre for International Child Health, BC Children's Hospital Research Institute, 950 W 28th Ave, Vancouver, BC V5Z 4H4, Canada.
| | - Tang Lee
- Department of Obstetrics and Gynaecology, University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4, Canada.
| | - Diane Sawchuck
- Vancouver Island Health Authority, 2334 Trent Street, Suite 643 Victoria, Canada.
| | - Laura Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Strand, London WC2R 2LS, UK.
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, Strand, London WC2R 2LS, UK.
| | - Zulfiqar Bhutta
- Division of Women & Child Health, Department of Obstetrics and Gynaecology, 2(nd) Floor Private Wing, Aga Khan University, Stadium Road, Karachi 74800, Pakistan; Program for Global Pediatric Research, Hospital for Sick Children, 555 University Ave, Toronto, ON M5G 1X8, Canada.
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Toledo-Jaldin L, Bull S, Contag S, Escudero C, Gutierrez P, Heath A, Roberts JM, Scandlyn J, Julian CG, Moore LG. Critical barriers for preeclampsia diagnosis and treatment in low-resource settings: An example from Bolivia. Pregnancy Hypertens 2019; 16:139-144. [PMID: 31056149 DOI: 10.1016/j.preghy.2019.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/26/2019] [Accepted: 03/13/2019] [Indexed: 02/06/2023]
Abstract
The goals of the United Nation's Millennium Summit for reducing maternal mortality have proven difficult to achieve. In Bolivia, where maternal mortality is twice the South American average, improving the diagnosis, treatment and ultimately prevention of preeclampsia is key for achieving targeted reductions. We held a workshop in La Paz, Bolivia to review recent revisions in the diagnosis and treatment of preeclampsia, barriers for their implementation, and means for overcoming them. While physicians are generally aware of current recommendations, substantial barriers exist for their implementation due to geographic factors increasing disease prevalence and limiting health-care access, cultural and economic factors affecting the care provided, and infrastructure deficits impeding diagnosis and treatment. Means for overcoming such barriers include changes in the culture of health care, use of standardized diagnostic protocols, the adoption of low-cost technologies for improving the diagnosis and referral of preeclamptic cases to specialized treatment centers, training programs to foster multidisciplinary team approaches, and efforts to enhance local research capacity. While challenging, the synergistic nature of current barriers for preeclampsia diagnosis and treatment also affords opportunities for making far-reaching improvements in maternal, infant and lifelong health.
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Affiliation(s)
- Lilian Toledo-Jaldin
- Department of Obstetrics, Women's and Infant's Specialty Hospital, La Paz, Bolivia
| | - Sheana Bull
- Colorado School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Stephen Contag
- Department of Obstetrics, Gynecology and Women's Health, University of Minnesota, Minneapolis, MN, USA
| | - Carlos Escudero
- Department of Basic Sciences, Universidad del Bio-Bio, Chillán, Chile
| | | | | | - James M Roberts
- Magee-Women's Research Institute, Department of Obstetrics Gynecology and Reproductive Sciences, Pittsburgh, PA, USA
| | - Jean Scandlyn
- Departments of Health and Behavioral Sciences and Anthropology, University of Colorado Denver, Denver, CO, USA
| | - Colleen G Julian
- Department of Medicine, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Lorna G Moore
- Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
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Zeisler H, Llurba E, Chantraine FJ, Vatish M, Staff AC, Sennström M, Olovsson M, Brennecke SP, Stepan H, Allegranza D, Schoedl M, Grill S, Hund M, Verlohren S. Soluble fms-like tyrosine kinase-1 to placental growth factor ratio: ruling out pre-eclampsia for up to 4 weeks and value of retesting. Ultrasound Obstet Gynecol 2019; 53:367-375. [PMID: 30014562 PMCID: PMC6590225 DOI: 10.1002/uog.19178] [Citation(s) in RCA: 75] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 05/30/2018] [Accepted: 07/06/2018] [Indexed: 05/10/2023]
Abstract
OBJECTIVES The soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is generally elevated some time before and at the clinical onset of pre-eclampsia. The PROGNOSIS study validated a sFlt-1/PlGF ratio cut-off of ≤ 38 to rule out the onset of pre-eclampsia within 1 week of testing in women with suspected disease. The aim of this study was to assess the predictive value of the sFlt-1/PlGF ratio to rule out the onset of pre-eclampsia for up to 4 weeks, and to assess the value of repeat measurements. METHODS This was an exploratory post-hoc analysis of data from the PROGNOSIS study performed in pregnant women aged ≥ 18 years with suspected pre-eclampsia, who were at 24 + 0 to 36 + 6 weeks' gestation at their first clinic visit. Serum samples were collected at the first visit and weekly thereafter. sFlt-1 and PlGF levels were measured using Elecsys® sFlt-1 and PlGF immunoassays. Whether the sFlt-1/PlGF ratio cut-off of ≤ 38 used to rule out the onset of pre-eclampsia within 1 week could predict the absence of pre-eclampsia 2, 3, and 4 weeks post-baseline was assessed. The value of repeat sFlt-1/PlGF testing was assessed by examining the difference in sFlt-1/PlGF ratio 2 and 3 weeks after the first measurement in women with, and those without, pre-eclampsia or adverse fetal outcome. RESULTS On analysis of 550 women, sFlt-1/PlGF ratio ≤ 38 ruled out the onset of pre-eclampsia 2 and 3 weeks post-baseline with high negative predictive values (NPV) of 97.9% and 95.7%, respectively. The onset of pre-eclampsia within 4 weeks was ruled out with a high NPV (94.3%) and high sensitivity and specificity (66.2% and 83.1%, respectively). Compared with women who did not develop pre-eclampsia, those who developed pre-eclampsia had significantly larger median increases in sFlt-1/PlGF ratio at 2 weeks (∆, 31.22 vs 1.45; P < 0.001) and at 3 weeks (∆, 48.97 vs 2.39; P < 0.001) after their initial visit. Women who developed pre-eclampsia and/or adverse fetal outcome compared with those who did not had a significantly greater median increase in sFlt-1/PlGF ratio over the same period (∆, 21.22 vs 1.40; P < 0.001 at 2 weeks; ∆, 34.95 vs 2.30; P < 0.001 at 3 weeks). CONCLUSION The Elecsys® immunoassay sFlt-1/PlGF ratio can help to rule out the onset of pre-eclampsia for 4 weeks in women with suspected pre-eclampsia. © 2018 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- H. Zeisler
- Department of Obstetrics and GynecologyMedical University ViennaViennaAustria
| | - E. Llurba
- Vall d'Hebron University HospitalUniversitat Autònoma de BarcelonaBarcelonaSpain
| | | | | | - A. C. Staff
- Oslo University Hospital and University of OsloOsloNorway
| | | | | | - S. P. Brennecke
- Department of Obstetrics and GynaecologyThe University of Melbourne and Royal Women's HospitalMelbourneAustralia
| | | | - D. Allegranza
- Roche Diagnostics International LtdRotkreuzSwitzerland
| | | | - S. Grill
- Roche Diagnostics GmbHPenzbergGermany
| | - M. Hund
- Roche Diagnostics International LtdRotkreuzSwitzerland
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Asseffa NA, Demissie BW. Perinatal outcomes of hypertensive disorders in pregnancy at a referral hospital, Southern Ethiopia. PLoS One 2019; 14:e0213240. [PMID: 30817780 PMCID: PMC6394918 DOI: 10.1371/journal.pone.0213240] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 02/19/2019] [Indexed: 11/18/2022] Open
Abstract
Introduction Hypertensive Disorders in Pregnancy (HDP) complicate about 10% of pregnancies. It accounts to 50% of maternal death in sub-Saharan Africa and precedes 15% of perinatal deaths worldwide. In this study, we looked at the perinatal outcomes and factors associated with unfavorable perinatal outcomes among women with hypertensive disorders in pregnancy at Wolaita Sodo teaching and referral hospital, southern Ethiopia. Methods A hospital based retrospective cross-sectional study design was employed among women hospitalized for hypertensive disorders in pregnancy. Socio-demographic, obstetrics, clinical laboratory, pregnancy complications and outcome were checked from patient records. Descriptive statistics were used to describe parameters collected from patient records. Bivariate and multiple logistic regressions were done to determine factors associated with unfavorable perinatal outcome. A P-value of less than 0.05 and 95% confidence interval not including 1 were considered statically significant. Results There were 168 (2.3%) cases of HDP of the total 7, 347 deliveries during the period of the study from January 2014-December 2016. 72.5% of mothers (72.5%) had vaginal delivery and 26.1% had Caesarean Section. This study revealed a perinatal mortality rate of 111.1 per 1000 live births. On bivariate logistic regression variables such as referral status, diastolic blood pressure, ANC use, types of HDP, fetal weight at birth, maternal complication and maternal outcome were found to be associated with unfavorable perinatal outcomes. On multiple logistic regression fetal weight at birth and maternal outcome were found to be an independent predictors of unfavorable perinatal outcome. Conclusion Our study shows higher perinatal mortality in a tertiary hospital where emergency obstetric and newborn care is set and quality obstetric care is expected. However, tertiary facilities manage difficult cases which can explain the high PMR. But it is high which means there is enough room for improvement. Hence, the referral hospital and neighboring health facilities should give due emphasis for early detection and management of women with HDP.
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Affiliation(s)
- Netsanet Abera Asseffa
- College of Health Sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia
- * E-mail:
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Macuácua S, Catalão R, Sharma S, Valá A, Vidler M, Macete E, Sidat M, Munguambe K, von Dadelszen P, Sevene E. Policy review on the management of pre-eclampsia and eclampsia by community health workers in Mozambique. Hum Resour Health 2019; 17:15. [PMID: 30819211 PMCID: PMC6396495 DOI: 10.1186/s12960-019-0353-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Accepted: 02/15/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Pre-eclampsia is one of the leading causes of maternal death in Mozambique. Limited access to health care facilities and a lack of skilled health professionals contribute to the high maternal morbidity and mortality rates in Mozambique and indicate a need for community-level interventions. The aim of this review was to identify and characterise health policies related to the role of CHWs in the management of pre-eclampsia and eclampsia in Mozambique. METHODS The policy review was based on three methods: a desk review of relevant documents from the Mozambique Ministry of Health (n = 7), contact with 28 key informants in the field of health policy in Mozambique (n = 5) and literature review (n = 699). Policy documents obtained included peer-reviewed articles, government and institutional policies, reports and action plans. Seven hundred and eleven full-text documents were assessed for eligibility and included based on pre-defined criteria. Qualitative analysis was done to identify main themes using content analysis. RESULTS A total of 56 papers informed the timeline of key events. Three main themes were identified from the qualitative review: establishment of the community health worker programme and early challenges, revitalization of the CHW programme and the integration of maternal health in the community health tasks. In 1978, following the Alma Alta Declaration, the Mozambique government brought in legislation establishing primary health care and the CHW programme. Between the late 1980s and early 1990s, this programme was scaled down due to several factors including a prolonged civil war; however, the decision to revitalise the programme was made in 1995. In 2010, a revitalised programme was re-launched and expanded to include the management of common childhood illnesses, detection of warning signs of pregnancy complications, referrals for maternal health and basic health promotion. To date, their role has not included management of emergency conditions of pregnancy including pre-eclampsia and eclampsia. CONCLUSION The role of CHWs has evolved over the last 40 years to include care of childhood diseases and basic maternal health counselling. Studies to assess the impact of CHWs in providing services to reduce maternal morbidity and mortality are recommended.
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Affiliation(s)
- Salésio Macuácua
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Ministério de Saúde, Maputo, Mozambique
| | - Raquel Catalão
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Sumedha Sharma
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Vancouver, British Columbia Canada
| | - Anifa Valá
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
| | - Marianne Vidler
- Department of Obstetrics and Gynaecology, University of British Columbia (UBC), Vancouver, British Columbia Canada
| | - Eusébio Macete
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Ministério de Saúde, Maputo, Mozambique
| | - Mohsin Sidat
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
| | - Khátia Munguambe
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
| | - Peter von Dadelszen
- School of Life Course Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, United Kingdom
| | - Esperança Sevene
- Centro de Investigação em Saúde de Manhiça (CISM), Manhiça, Mozambique
- Universidade Eduardo Mondlane, Faculdade de Medicina, Maputo, Mozambique
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Abstract
BACKGROUND Pre-eclampsia and eclampsia are common causes of serious morbidity and death. Calcium supplementation may reduce the risk of pre-eclampsia, and may help to prevent preterm birth. This is an update of a review last published in 2014. OBJECTIVES To assess the effects of calcium supplementation during pregnancy on hypertensive disorders of pregnancy and related maternal and child outcomes. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (18 September 2017), and reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs), including cluster-randomised trials, comparing high-dose calcium supplementation (at least 1 g daily of calcium) during pregnancy with placebo. For low-dose calcium we included quasi-randomised trials, trials without placebo, trials with cointerventions and dose comparison trials. DATA COLLECTION AND ANALYSIS Two researchers independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. Two researchers assessed the evidence using the GRADE approach. MAIN RESULTS We included 27 studies (18,064 women). We assessed the included studies as being at low risk of bias, although bias was frequently difficult to assess due to poor reporting and inadequate information on methods.High-dose calcium supplementation (≥ 1 g/day) versus placeboFourteen studies examined this comparison, however one study contributed no data. The 13 studies contributed data from 15,730 women to our meta-analyses. The average risk of high blood pressure (BP) was reduced with calcium supplementation compared with placebo (12 trials, 15,470 women: risk ratio (RR) 0.65, 95% confidence interval (CI) 0.53 to 0.81; I² = 74%). There was also a reduction in the risk of pre-eclampsia associated with calcium supplementation (13 trials, 15,730 women: average RR 0.45, 95% CI 0.31 to 0.65; I² = 70%; low-quality evidence). This effect was clear for women with low calcium diets (eight trials, 10,678 women: average RR 0.36, 95% CI 0.20 to 0.65; I² = 76%) but not those with adequate calcium diets. The effect appeared to be greater for women at higher risk of pre-eclampsia, though this may be due to small-study effects (five trials, 587 women: average RR 0.22, 95% CI 0.12 to 0.42). These data should be interpreted with caution because of the possibility of small-study effects or publication bias. In the largest trial, the reduction in pre-eclampsia was modest (8%) and the CI included the possibility of no effect.The composite outcome maternal death or serious morbidity was reduced with calcium supplementation (four trials, 9732 women; RR 0.80, 95% CI 0.66 to 0.98). Maternal deaths were no different (one trial of 8312 women: one death in the calcium group versus six in the placebo group). There was an anomalous increase in the risk of HELLP syndrome in the calcium group (two trials, 12,901 women: RR 2.67, 95% CI 1.05 to 6.82, high-quality evidence), however, the absolute number of events was low (16 versus six).The average risk of preterm birth was reduced in the calcium supplementation group (11 trials, 15,275 women: RR 0.76, 95% CI 0.60 to 0.97; I² = 60%; low-quality evidence); this reduction was greatest amongst women at higher risk of developing pre-eclampsia (four trials, 568 women: average RR 0.45, 95% CI 0.24 to 0.83; I² = 60%). Again, these data should be interpreted with caution because of the possibility of small-study effects or publication bias. There was no clear effect on admission to neonatal intensive care. There was also no clear effect on the risk of stillbirth or infant death before discharge from hospital (11 trials, 15,665 babies: RR 0.90, 95% CI 0.74 to 1.09).One study showed a reduction in childhood systolic BP greater than 95th percentile among children exposed to calcium supplementation in utero (514 children: RR 0.59, 95% CI 0.39 to 0.91). In a subset of these children, dental caries at 12 years old was also reduced (195 children, RR 0.73, 95% CI 0.62 to 0.87).Low-dose calcium supplementation (< 1 g/day) versus placebo or no treatmentTwelve trials (2334 women) evaluated low-dose (usually 500 mg daily) supplementation with calcium alone (four trials) or in association with vitamin D (five trials), linoleic acid (two trials), or antioxidants (one trial). Most studies recruited women at high risk for pre-eclampsia, and were at high risk of bias, thus the results should be interpreted with caution. Supplementation with low doses of calcium reduced the risk of pre-eclampsia (nine trials, 2234 women: RR 0.38, 95% CI 0.28 to 0.52). There was also a reduction in high BP (five trials, 665 women: RR 0.53, 95% CI 0.38 to 0.74), admission to neonatal intensive care unit (one trial, 422 women, RR 0.44, 95% CI 0.20 to 0.99), but not preterm birth (six trials, 1290 women, average RR 0.83, 95% CI 0.34 to 2.03), or stillbirth or death before discharge (five trials, 1025 babies, RR 0.48, 95% CI 0.14 to 1.67).High-dose (=/> 1 g) versus low-dose (< 1 g) calcium supplementationWe included one trial with 262 women, the results of which should be interpreted with caution due to unclear risk of bias. Risk of pre-eclampsia appeared to be reduced in the high-dose group (RR 0.42, 95% CI 0.18 to 0.96). No other differences were found (preterm birth: RR 0.31, 95% CI 0.09 to 1.08; eclampsia: RR 0.32, 95% CI 0.07 to 1.53; stillbirth: RR 0.48, 95% CI 0.13 to 1.83). AUTHORS' CONCLUSIONS High-dose calcium supplementation (≥ 1 g/day) may reduce the risk of pre-eclampsia and preterm birth, particularly for women with low calcium diets (low-quality evidence). The treatment effect may be overestimated due to small-study effects or publication bias. It reduces the occurrence of the composite outcome 'maternal death or serious morbidity', but not stillbirth or neonatal high care admission. There was an increased risk of HELLP syndrome with calcium supplementation, which was small in absolute numbers.The limited evidence on low-dose calcium supplementation suggests a reduction in pre-eclampsia, hypertension and admission to neonatal high care, but needs to be confirmed by larger, high-quality trials.
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Affiliation(s)
- G Justus Hofmeyr
- Walter Sisulu University, University of Fort Hare, University of the Witwatersrand, Eastern Cape Department of HealthEast LondonSouth Africa
| | - Theresa A Lawrie
- 1st Floor Education Centre, Royal United HospitalCochrane Gynaecological, Neuro‐oncology and Orphan Cancer GroupCombe ParkBathUKBA1 3NG
| | - Álvaro N Atallah
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilR. Borges Lagoa, 564 cj 63Vila ClementinoSão PauloSão PauloBrazil04038‐000
| | - Maria Regina Torloni
- Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em SaúdeCochrane BrazilR. Borges Lagoa, 564 cj 63Vila ClementinoSão PauloSão PauloBrazil04038‐000
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Hitti J, Sienas L, Walker S, Benedetti TJ, Easterling T. Contribution of hypertension to severe maternal morbidity. Am J Obstet Gynecol 2018; 219:405.e1-405.e7. [PMID: 30012335 DOI: 10.1016/j.ajog.2018.07.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Maternal mortality and severe maternal morbidity are growing public health concerns in the United States. The Centers for Disease Control and Prevention Severe Maternal Morbidity measure provides insight into processes underlying maternal mortality and may highlight modifiable risk factors for adverse maternal health outcomes. OBJECTIVE The primary objective of this study was to evaluate the association between hypertensive disorders and severe maternal morbidity at a regional perinatal referral center. We hypothesized that women with preeclampsia with severe features would have a higher rate of severe maternal morbidity compared to normotensive women. We also assessed the proportion of severe maternal morbidity diagnoses that were present on admission, in contrast to those arising during the delivery hospitalization. STUDY DESIGN In this retrospective cross-sectional analysis, we assessed rates of severe maternal morbidity diagnoses (eg, renal insufficiency, shock, and sepsis) and procedures (eg, transfusion and hysterectomy) for all 7025 women who delivered at the University of Washington Medical Center from Oct. 1, 2013, through May 31, 2017. Severe maternal morbidity was determined from prespecified International Classification of Diseases diagnosis and procedure codes; all diagnoses were confirmed by chart review. Present-on-admission rates were calculated for each diagnosis through hospital administrative data provided by the Vizient University Health System Consortium. Maternal demographic and clinical characteristics were compared for women with and without severe maternal morbidity. The χ2 and Fisher exact tests were used to determine statistical significance. Odds ratios and 95% confidence intervals were calculated for the associations between maternal demographic and clinical characteristics and severe maternal morbidity. RESULTS Of 7025 deliveries, 284 (4%) had severe maternal morbidity; 154 had transfusion only, 27 had other procedures, and 103 women had 149 severe maternal morbidity diagnoses (26 women had multiple diagnoses). Severe preeclampsia occurred in 438 deliveries (6.2%). Notably, hypertension was associated with severe maternal morbidity in a dose-dependent fashion, with the strongest association observed for preeclampsia with severe features (odds ratio, 5.4; 95% confidence interval, 3.9-7.3). Severe maternal morbidity was also significantly associated with preeclampsia without severe features, chronic hypertension, preterm delivery, pregestational diabetes, and multiple gestation. Among women with severe maternal morbidity, over one third of preterm births were associated with maternal hypertension. American Indian/Alaskan Native women had significantly higher severe maternal morbidity rates compared to other racial/ethnic groups (11.7% vs 3.9% for Whites, P < .01). Overall, 39.6% of severe maternal morbidity diagnoses were present on admission. CONCLUSION Hypertensive disorders in pregnancy are strongly associated with severe maternal morbidity in a dose-dependent relationship, suggesting that strategies to address rising maternal morbidity rates should include early recognition and management of hypertension. Prevention strategies focused on hypertension might also impact medically indicated preterm deliveries. The finding of increased severe maternal morbidity among American Indian/Alaskan Native women, a disadvantaged population in Washington State, underscores the role that socioeconomic factors may play in adverse maternal health outcomes. As 39% of severe maternal morbidity diagnoses were present on admission, this measure should be risk-adjusted if used as a quality metric for comparison between hospitals.
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Affiliation(s)
- Jane Hitti
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA.
| | - Laura Sienas
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
| | - Suzan Walker
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
| | - Thomas J Benedetti
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
| | - Thomas Easterling
- Department of Obstetrics/Gynecology, University of Washington Medical Center, Seattle, WA
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Tenório MB, Ferreira RC, Moura FA, Bueno NB, Goulart MOF, Oliveira ACM. Oral antioxidant therapy for prevention and treatment of preeclampsia: Meta-analysis of randomized controlled trials. Nutr Metab Cardiovasc Dis 2018; 28:865-876. [PMID: 30111493 DOI: 10.1016/j.numecd.2018.06.002] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/18/2018] [Accepted: 06/04/2018] [Indexed: 12/15/2022]
Abstract
AIMS To determine whether oral antioxidant therapies, of various types and doses, are able to prevent or treat women with preeclampsia. DATA SYNTHESIS The following databases were searched: MEDLINE, CENTRAL, LILACS, and Web of Science. Inclusion criteria were: a) randomized clinical trials; b) oral antioxidant supplementation; c) study in pregnant women; d) control group, treated or not with placebo. Papers were excluded if they evaluated antioxidant nutrient supplementation associated with other non-antioxidant therapies. Data were extracted and the risk of bias of each study was assessed. Heterogeneity was analyzed using the Cochran Q test, and I2 statistics and pre-specified sensitivity analyses were performed. Meta-analyses were conducted on prevention and treatment studies, separately. The primary outcome was the incidence of preeclampsia in prevention trials, and of perinatal death in treatment trials. Twenty-nine studies were included in the analysis, 19 for prevention and 10 for treatment. The antioxidants used in these studies were vitamins C and E, selenium, l-arginine, allicin, lycopene and coenzyme Q10, none of which showed beneficial effects on the prevention of preeclampsia (RR: 0.89, CI 95%: [0.79-1.02], P = 0.09; I2 = 39%, P = 0.04) and other outcomes. The antioxidants used in the treatment studies were vitamins C and E, N-acetylcysteine, l-arginine, and resveratrol. A beneficial effect was found in intrauterine growth restriction. CONCLUSIONS Antioxidant therapy had no effects in the prevention of preeclampsia but did show beneficial effects in intrauterine growth restriction, when used in the treatment of this condition.
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Affiliation(s)
- M B Tenório
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - R C Ferreira
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - F A Moura
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - N B Bueno
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - M O F Goulart
- Instituto de Química e Biotecnologia (IQB/UFAL), Rede Nordeste de Biotecnologia (RENORBIO), Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil
| | - A C M Oliveira
- Faculdade de Nutrição, Universidade Federal de Alagoas, Campus A. C. Simões, BR 104 Norte, Km 96,7, Tabuleiro dos Martins, CEP 57.072-970, Maceió, Alagoas, Brazil.
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Abstract
OBJECTIVE Using a simple simulation, we illustrate why associations estimated from studies restricted to preterm births cannot be interpreted causally. DESIGN, SETTING AND POPULATION Data simulation involving a hypothetical cohort of fetuses who may be healthy or have one or more of four pathological factors (termed A through D, increasing in severity) with known effects on gestational length and risk of mortality. We focus on babies born at ≤32 weeks of gestation. METHODS We visually represent the simulated population and compare the association between A (which may represent pre-eclampsia) and neonatal death. We then repeat the exercise with D (standing in for chorioamnionitis) as the exposure of interest. MAIN OUTCOME MEASURES Odds ratios of neonatal death in the simulated data. RESULTS In most weeks, and for both A and D, the calculated odds ratios are substantially biased and underestimate the true risk of neonatal death associated with each pathology. For example, factor A has a true causal odds ratio of 1.50, yet it appears protective among births ≤32 weeks (estimated crude odds ratio 0.39; gestational age-adjusted odds ratio 0.71). CONCLUSIONS Among very preterm births, virtually all babies are born with pathologies that increase the risk of adverse outcomes. Hence, babies exposed to one factor (e.g. pre-eclampsia) are compared with babies who have a mix of other pathologies. Such selection bias affects studies carried out among very preterm births (e.g. where pre-eclampsia appears to reduce risk of adverse neonatal outcomes). TWEETABLE ABSTRACT Selection bias affects studies of preterm births, complicating interpretation.
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Affiliation(s)
- J M Snowden
- School of Public Health, Oregon Health and Science University/Portland State University, Portland, OR, USA
- Department of Obstetrics & Gynecology, Oregon Health and Science University, Portland, OR, USA
| | - O Basso
- Department of Obstetrics & Gynecology, Research Institute of the McGill University Health Centre, Montreal, QC, Canada
- Department of Epidemiology, Biostatistics & Occupational Health, McGill University, Montreal, QC, Canada
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Bailey PE, Andualem W, Brun M, Freedman L, Gbangbade S, Kante M, Keyes E, Libamba E, Moran AC, Mouniri H, el Joud DO, Singh K. Institutional maternal and perinatal deaths: a review of 40 low and middle income countries. BMC Pregnancy Childbirth 2017; 17:295. [PMID: 28882128 PMCID: PMC5590194 DOI: 10.1186/s12884-017-1479-1] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 08/30/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Understanding the magnitude and clinical causes of maternal and perinatal mortality are basic requirements for positive change. Facility-based information offers a contextualized resource for clinical and organizational quality improvement. We describe the magnitude of institutional maternal mortality, causes of death and cause-specific case fatality rates, as well as stillbirth and pre-discharge neonatal death rates. METHODS This paper draws on secondary data from 40 low and middle income countries that conducted emergency obstetric and newborn care assessments over the last 10 years. We reviewed 6.5 million deliveries, surveyed in 15,411 facilities. Most of the data were extracted from reports and aggregated with excel. RESULTS Hemorrhage and hypertensive diseases contributed to about one third of institutional maternal deaths and indirect causes contributed another third (given the overrepresentation of sub-Saharan African countries with large proportions of indirect causes). The most lethal obstetric complication, across all regions, was ruptured uterus, followed by sepsis in Latin America and the Caribbean and sub-Saharan Africa. Stillbirth rates exceeded pre-discharge neonatal death rates in nearly all countries, possibly because women and their newborns were discharged soon after birth. CONCLUSIONS To a large extent, facility-based findings mirror what population-based systematic reviews have also documented. As coverage of a skilled attendant at birth increases, proportionally more deaths will occur in facilities, making improvements in record-keeping and health management information systems, especially for stillbirths and early neonatal deaths, all the more critical.
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Affiliation(s)
- Patricia E. Bailey
- Global Health Programs, FHI 360, 359 Blackwell Street, Durham, NC 27701 USA
- Averting Maternal Death & Disability, Columbia University, New York, NY USA
| | | | | | - Lynn Freedman
- Averting Maternal Death & Disability, Columbia University, New York, NY USA
| | | | - Malick Kante
- Averting Maternal Death & Disability, Columbia University, New York, NY USA
| | - Emily Keyes
- Global Health Programs, FHI 360, 359 Blackwell Street, Durham, NC 27701 USA
- Averting Maternal Death & Disability, Columbia University, New York, NY USA
| | | | | | | | | | - Kavita Singh
- MEASURE Evaluation, Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC 27516 USA
- Department of Maternal and Child Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599 USA
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Abstract
BACKGROUND Acute kidney injury (AKI) is rare in women during pregnancy and puerperium, however, it is related to increased morbidity and mortality rates. OBJECTIVE The aim of this study was to investigate the incidence, characteristics, and outcomes of AKI during pregnancy and puerperium in a Chinese population. METHODS In this study, pregnant women discharged from hospital between January 2008 and June 2015 were screened. AKI was defined if the level of serum creatitine >70.72umol/l in pregnant women without chronic kidney disease (CKD). Acute-on-CKD was defined as a 50% increase in the level of serum creatinine vs baseline in patients with pre-existed CKD. RESULTS We reported a high incidence (0.81%) of AKI during pregnancy and puerperium. Three hundred and forty-three cases of AKI during pregnancy and puerperium included 21 severe AKI cases and 21 cases with acute-on-CKD. Pre-eclampsia/eclampsia, and postpartum hemorrhage were the most frequent causes of AKI during pregnancy and puerperium. About 17% women with pre-eclampsia/eclampsia and 60% women with HELLP syndrome complicated with AKI. The maternal outcome was good except in the setting of amniotic fluid embolism or hemorrhagic shock, whereas the prenatal outcome was relatively poor. Among the 14 death cases, 7 cases received renal replacement therapy. Amniotic fluid embolism and postpartum hemorrhage were the major causes of death in pregnant women with AKI. CONCLUSION AKI during pregnancy and puerperium is not as rare as we thought. Pre-eclampsia/eclampsia is the most common cause of AKI during pregnancy and puerperium, however, the outcome of pre-eclampsia-related AKI is good. Amniotic fluid embolism and postpartum hemorrhage are the leading causes of maternal mortality. Severe AKI may predict poor outcome.
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Affiliation(s)
- Chunhong Huang
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000 People’s Republic of China
| | - Shanying Chen
- Department of Nephrology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, 363000 People’s Republic of China
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Affiliation(s)
- Andrew H Shennan
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK.
| | | | - Lucy C Chappell
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK
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Abstract
AIM The aim of study was to compare some perinatal outcomes in mothers with type 1 diabetes mellitus (T1DM). MATERIAL AND METHODS All patients with T1DM delivered at the 1st Department of Obstetrics and Gynaecology of Faculty of Medicine, Comenius University in Bratislava from January 1st 2009 to December 31th 2015 were included to the study. RESULTS Out of 118 diabetic mothers, 46.6 % had vasculopathy and 53. 4 % were without microvascular complications. In the vasculopathy group, significantly higher incidence rates of preeclampsia (49. 1 versus 19.1 %; p = 0.002) and caesarean section (89.1 versus 68.3 %; p = 0.017) were found. Neonatal morbidity and mortality rates were higher in vasculopathy group (but not statistically significantly). Preparation for pregnancy improves perinatal and neonatal results. Nevertheless, this preparation in our study group was received only in 9.3 %. Perinatal mortality was 25.4 per 1,000 total births. CONCLUSION For pregnancy of diabetic women to become possible a qualified management must be provided. Good outcomes for both women and newborns are real when preparation for pregnancy and metabolic control before and during whole pregnancy are at adequate level (Tab. 3, Ref. 28).
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So J, Young E, Crnosija N, Chappelle J. The utility of clinical findings to predict laboratory values in hypertensive disorders of pregnancy. J Perinat Med 2016; 44:277-81. [PMID: 26352064 DOI: 10.1515/jpm-2015-0089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/17/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Preeclampsia is the 2nd leading cause of maternal mortality in the United States. Women with new-onset or worsening hypertension are commonly evaluated for laboratory abnormalities. We aim to investigate whether demographic and/or clinical findings correlate with abnormal laboratory values. STUDY DESIGN A retrospective chart review of women who presented for evaluation of hypertension in pregnancy during 2010. Demographic information, medical history, symptoms, vital signs, and laboratory results were collected. Bivariate analysis was used to investigate associations between predictors and the outcome. RESULT Of the 481 women in the sample, 22 were identified as having abnormal laboratory test results (4.6%). Women who reported right upper quadrant pain or tenderness had significantly increased likelihood of having laboratory abnormalities compared to those without the complaint. CONCLUSION Only a small percentage of women evaluated were determined to have abnormal laboratory findings, predominantly among women with severe preeclampsia. Right upper quadrant pain or tenderness was positively correlated with laboratory abnormalities. The restriction of laboratory analysis in women with clinical evidence of severe disease may be warranted - a broader study should, however, first be used to confirm our findings.
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Nakimuli A, Nakubulwa S, Kakaire O, Osinde MO, Mbalinda SN, Nabirye RC, Kakande N, Kaye DK. Maternal near misses from two referral hospitals in Uganda: a prospective cohort study on incidence, determinants and prognostic factors. BMC Pregnancy Childbirth 2016; 16:24. [PMID: 26821716 PMCID: PMC4731977 DOI: 10.1186/s12884-016-0811-5] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 01/21/2016] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Maternal near misses occur more often than maternal deaths and could enable more comprehensive analysis of risk factors, short-term outcomes and prognostic factors of complications during pregnancy and childbirth. The study determined the incidence, determinants and prognostic factors of severe maternal outcomes (near miss or maternal death) in two referral hospitals in Uganda. METHODS A prospective cohort study was conducted between March 1, 2013 and February 28, 2014, where cases of severe pregnancy and childbirth complications were included. The clinical conditions included abortion-related complications, obstetric haemorrhage, hypertensive disorders, obstructed labour, infection and pregnancy-specific complications such as febrile illness, anemia and premature rupture of membranes. Near miss cases were defined according to the WHO criteria. Multivariate logistic regression analysis was conducted to identify prognostic factors for severe maternal outcomes. RESULTS Of 3100 women with severe obstetric complications, 130 (4.2%) were maternal deaths and 695 (22.7%) were near miss cases. Severe pre-eclampsia was the commonest morbidity (incidence ratio (IR) 7.0%, case-fatality rate (CFR) 2.3%), followed by postpartum haemorrhage (IR 6.7%, CFR 7.2%). Uterine rupture (IR 5.5%) caused the highest CFR (17.9%), followed by eclampsia (IR 0.4%, CFR 17.8%). The three groups (maternal deaths, near misses and non-life-threatening obstetric complications) differed significantly regarding gravidity and education level. The commonest diagnostic criteria for maternal near miss were admission to the high dependency unit (HDU) or to the intensive care unit (ICU). Thrombocytopenia, circulatory collapse, referral to a more specialized unit, intubation unrelated to anaesthesia, and cardiopulmonary resuscitation were predictive of maternal death (p < 0.05). Gravidity (ARR 1.4, 95% C1 1.0-1.2); elevated serum lactate levels (ARR 4.5, 95% CI 2.3-8.7); intubation for conditions unrelated to general anaesthesia (ARR 2.6 (95% CI 1.2-5.7), cardiovascular collapse (ARR 4.9, 95% CI 2.5-9.5); transfusion of 4 or more units of blood (ARR 1.9, 95% CI 1.1-3.1); being an emergency referral (ARR 2.6, 95% CI 1.2-5.6); and need for cardiopulmonary resuscitation (ARR 6.1, 95% CI 3.2-11.7), were prognostic factors. CONCLUSIONS The analysis of near misses is a useful tool in the investigation of severe maternal morbidity. The prognostic factors for maternal death, if instituted, might save many women with obstetric complications.
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Affiliation(s)
- Annettee Nakimuli
- />Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Sarah Nakubulwa
- />Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Othman Kakaire
- />Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Michael O. Osinde
- />Department of Obstetrics and Gynecology, Jinja Regional Hospital, Jinja, Uganda
| | - Scovia N. Mbalinda
- />Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Rose C. Nabirye
- />Department of Nursing, School of Health Sciences, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
| | - Nelson Kakande
- />Clinical, Operations and Health Services Research Program, Joint Clinical Research Centre, P. O. Box 10005, Kampala, Uganda
| | - Dan K. Kaye
- />Department of Obstetrics and Gynecology, School of Medicine, College of Health Sciences, Makerere University, P.O. Box 7072, Kampala, Uganda
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Magoma M, Massinde A, Majinge C, Rumanyika R, Kihunrwa A, Gomodoka B. Maternal death reviews at Bugando hospital north-western Tanzania: a 2008-2012 retrospective analysis. BMC Pregnancy Childbirth 2015; 15:333. [PMID: 26670664 PMCID: PMC4681083 DOI: 10.1186/s12884-015-0781-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Accepted: 12/08/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Unacceptably high levels of maternal deaths still occur in many sub-Saharan countries and the health systems may not favour effective use of lessons from maternal death reviews to improve maternal survival. We report results from the analysis of data from maternal death reviews at Bugando Medical Centre north-western Tanzania in the period 2008-2012 and highlight the process, challenges and how the analysis provided a better understanding of maternal deaths. METHODOLOGY Retrospective analysis using maternal death review data and extraction of missing information from patients' files. Analysis was done in STATA statistical package into frequencies and means ± SD and median with 95% CI for categorical and numerical data respectively. RESULTS There were 80 deaths; mean age of the deceased 27.1 ± 6.2 years and a median hospital stay of 11.0 days [95% CI 11.0-15.3]. Most deaths were from direct obstetric causes (90); 60% from eclampsia, severe pre-eclampsia, sepsis, abortion and anaesthetic complications. Information on ANC attendance was recorded in 36.2% of the forms and gestation age of the pregnancy resulting into the death in 23.8%. Sixty one deaths (76.3%) occurred after delivery. The mode of delivery, place of delivery and delivery assistant were recorded in 44 (72.1), 38 (62.3) and 23 (37.7%) respectively. CONCLUSION Routine maternal death reviews in this setting do not involve comprehensive documentation of all relevant information, including actions taken to address some identified systemic weaknesses. Periodic analysis of available data may allow better understanding of vital information to improve the quality of maternity care.
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Affiliation(s)
- Moke Magoma
- Evidence for Action Project Tanzania, P.O.BOX 1371, Dar es salaam, Tanzania.
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
| | - Antony Massinde
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
| | - Charles Majinge
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
| | - Richard Rumanyika
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
| | - Albert Kihunrwa
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
| | - Balthazar Gomodoka
- Department of Obstetrics & Gynaecology, Bugando Medical Centre, Mwanza, Tanzania.
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Abstract
Each year, the Board of Directors of the Society for Obstetric Anesthesia and Perinatology selects an individual to review a given year's published obstetric anesthesiology literature. This individual then produces a syllabus of the year's most influential publications, delivers the Ostheimer Lecture at the Society's annual meeting, the Hughes Lecture at the following year's Sol Shnider meeting, and writes corresponding review articles. This 2016 Hughes Lecture review article focuses specifically on the 2014 publications that relate to maternal morbidity and mortality. It begins by discussing the 2014 research that was published on severe maternal morbidity and maternal mortality in developed countries. This is followed by a discussion of specific coexisting diseases and specific causes of severe maternal mortality. The review ends with a discussion of worldwide maternal mortality and the 2014 publications that examined the successes and the shortfalls in the work to make childbirth safe for women throughout the entire world.
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Affiliation(s)
- K W Arendt
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
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Bello FA, Adesina OA, Morhason-Bello IO, Adekunle AO. MATERNAL MORTALITY AUDIT IN A TERTIARY HEALTH INSTITUTION IN NIGERIA: LESSONS FROM DIRECT CAUSES AND ITS DRIVERS. Niger J Med 2015; 24:300-306. [PMID: 27487605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION Nigeria has the second highest number of maternal deaths in the world.The study aimed at determining the causes of and non-obstetric contributors to maternal mortality at a tertiary referral hospital. MATERIALS AND METHODS It was a prospective audit of all consecutive maternal deaths in the hospital over a three-year period. Immediately after the death, information wvas retrieved via a data collection form. Data were analysed with SPSS-20. RESULTS Seventy deaths were examined over the study period. Maternal mortality ratio was 1,265/100,000 live births. The annual ratio decreased steadily over the study period. Most of the deaths were of multiparous women who had not received any antenatal care, and were mostly postpartum,within 24 hours of delivery. Most of them were critically ill on admission to the hospital. Major causes of death were haemorrhage (36%), sepsis (17%) and hypertensive disorders (16%).Delays were identified in 34.3% of cases; most (70.1%) were Phase III delays. DISCUSSION Direct causes of maternal mortality are consistent with those found in literature. Steps which the centre has been taken to counter direct and non-obstetric causes are discussed. Possible strategies to improve health financing and referral system are proffered.
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Ditisheim A, Boulvain M, Irion O, Pechère-Bertschi A. [Atypical presentation of preeclampsia]. Rev Med Suisse 2015; 11:1655-1658. [PMID: 26540995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
Preeclampsia is a pregnancy-related syndrome, which still represents one of the major causes of maternal-fetal mortality and morbidity. Diagnosis can be made difficult due to the complexity of the disorder and its wide spectrum of clinical manifestations. In order to provide an efficient diagnostic tool to the clinician, medical societies regularly rethink the definition criteria. However, there are still clinical presentations of preeclampsia that escape the frame of the definition. The present review will address atypical forms of preeclampsia, such as preeclampsia without proteinuria, normotensive preeclampsia, preeclampsia before 20 weeks of gestation and post-partum preeclampsia.
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Affiliation(s)
- Lucy C Chappell
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK
| | | | - Andrew Shennan
- Women's Health Academic Centre, King's College London, London SE1 7EH, UK
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von Dadelszen P, Magee LA, Payne BA, Dunsmuir DT, Drebit S, Dumont GA, Miller S, Norman J, Pyne-Mercier L, Shennan AH, Donnay F, Bhutta ZA, Ansermino JM. Moving beyond silos: How do we provide distributed personalized medicine to pregnant women everywhere at scale? Insights from PRE-EMPT. Int J Gynaecol Obstet 2015; 131 Suppl 1:S10-5. [PMID: 26433496 DOI: 10.1016/j.ijgo.2015.02.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
While we believe that pre-eclampsia matters-because it remains a leading cause of maternal and perinatal morbidity and mortality worldwide-we are convinced that the time has come to look beyond single clinical entities (e.g. pre-eclampsia, postpartum hemorrhage, obstetric sepsis) and to look for an integrated approach that will provide evidence-based personalized care to women wherever they encounter the health system. Accurate outcome prediction models are a powerful way to identify individuals at incrementally increased (and decreased) risks associated with a given condition. Integrating models with decision algorithms into mobile health (mHealth) applications could support community and first level facility healthcare providers to identify those women, fetuses, and newborns most at need of facility-based care, and to initiate lifesaving interventions in their communities prior to transportation. In our opinion, this offers the greatest opportunity to provide distributed individualized care at scale, and soon.
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Affiliation(s)
- Peter von Dadelszen
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada.
| | - Laura A Magee
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Department of Medicine, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Beth A Payne
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Dustin T Dunsmuir
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Sharla Drebit
- Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Guy A Dumont
- Department of Electrical and Computer Engineering, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences and Bixby Center for Global Reproductive Health, University of California, San Francisco, CA, USA
| | - Jane Norman
- University of Edinburgh/MRC Centre for Reproductive Health, The Queen's Medical Research Institute, University of Edinburgh, UK
| | - Lee Pyne-Mercier
- Family Health Team, Bill & Melinda Gates Foundation, USA; Department of Global Health, University of Washington, Seattle, WA, USA
| | | | - France Donnay
- Family Health Team, Bill & Melinda Gates Foundation, USA
| | - Zulfiqar A Bhutta
- Centre for Global Child Health, Hospital for Sick Children, University of Toronto, Toronto, Canada; Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
| | - J Mark Ansermino
- Department of Anesthesia, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada; Child and Family Research Institute, University of British Columbia, Vancouver, BC, Canada
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Bentata Y, Madani H, Berkhli H, Saadi H, Mimouni A, Housni B. Complications and maternal mortality from severe pre-eclampsia during the first 48hours in an intensive care unit in Morocco. Int J Gynaecol Obstet 2015; 129:175-6. [PMID: 25638711 DOI: 10.1016/j.ijgo.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/01/2014] [Accepted: 01/13/2015] [Indexed: 11/17/2022]
Affiliation(s)
- Yassamine Bentata
- Department of Nephrology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco.
| | - Hamid Madani
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Hayat Berkhli
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Hanane Saadi
- Department of Obstetrics and Gynecology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Ahmed Mimouni
- Department of Obstetrics and Gynecology, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
| | - Brahim Housni
- Department of Anesthesia, Medical School of Oujda, University Mohammed the First, Oujda, Morocco
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Pembe AB, Paulo C, D’mello BS, van Roosmalen J. Maternal mortality at Muhimbili National Hospital in Dar-es-Salaam, Tanzania in the year 2011. BMC Pregnancy Childbirth 2014; 14:320. [PMID: 25217326 PMCID: PMC4174678 DOI: 10.1186/1471-2393-14-320] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2014] [Accepted: 09/09/2014] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Improving maternal health is one of the eight millennium development goals adopted at the millennium summit in the year 2000. Within this frame work, the international community is committed to reduce the maternal mortality ratio by 75% between 1990 and 2015. The objective of this study was to determine the maternal mortality ratio, classify causes of maternal deaths and assess substandard care factors at Muhimbili National Hospital (MNH), Dar-es-Salaam in Tanzania. METHODS A retrospective review of all maternal death records of cases that occurred from 1st January to 31st December 2011 was done. RESULTS There were 10,057 live births, 155 maternal deaths and hence MMR of 1,541 per 100,000 live births. Direct causes of maternal deaths were classified in 69.5% of the maternal deaths. Of the direct causes, preeclampsia/eclampsia was the major cause (19.9% of all deaths), followed by post partum haemorrhage (14.9%), abortion complications (9.9%) and sepsis (9.2%). Among the indirect causes anaemia was the leading cause (11.3%) of all deaths, followed by HIV/AIDS (9.9%). Substandard care factors contributing to deaths were identified in 116 (82.3%) of all cases. Among these 28 had patient factors only, 71 medical service factors while 17 had both patient and medical service substandard care factors. The common factors from the woman's side included delay in seeking care (73.3%) and complete lack of antenatal care (11.1%). Of the medical service factors, inadequate (26.1%) or no blood for transfusion (19.3%), delay in receiving treatment (18.3%) and mismanagement (17%) were the common factors. CONCLUSION There is a high maternal mortality ratio at MNH. Hypertensive disorders of pregnancy, post partum haemorrhage and anaemia are the leading causes of maternal deaths in this institution. Multiple substandard care factors identified both at individual and health care service levels that contributed to maternal deaths. There is a need for increasing efforts in the fight to reduce maternal deaths at the institution. A more pro-active role from the referring facilities in the region is needed.
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Affiliation(s)
- Andrea B Pembe
- />Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Chetto Paulo
- />Department of Obstetrics and Gynaecology, School of Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
- />Dodoma Regional Referral Hospital, Dodoma, Tanzania
| | - Brenda S D’mello
- />Maternal and Newborn Health Care, Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, Tanzania
| | - Jos van Roosmalen
- />Department of Obstetrics, Leiden University Medical Centre, Leiden, The Netherlands
- />Department of Medical Humanities, EMGO Institute for Health and Care Research, VU University Medical Centre Amsterdam, Amsterdam, The Netherlands
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Affiliation(s)
- C E Kleinrouweler
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
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Van Dijk MG, García-Rojas M, Contreras X, Krumholz A, García SG, Díaz-Olavarrieta C. Treating patients with severe preeclampsia and eclampsia in Oaxaca, Mexico. Salud Publica Mex 2014; 56:426-427. [PMID: 25604285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Affiliation(s)
| | | | - Xipatl Contreras
- Mexico Office, Population Council, México, Distrito Federal, México
| | - Abigail Krumholz
- Mexico Office, Population Council, México, Distrito Federal, México
| | - Sandra G García
- Mexico Office, Population Council, México, Distrito Federal, México
| | - Claudia Díaz-Olavarrieta
- Research Center for Health Population, Instituto Nacional de Salud Pública, México, Distrito Federal, México,
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Abstract
BACKGROUND Pre-eclampsia and eclampsia are common causes of serious morbidity and death. Calcium supplementation may reduce the risk of pre-eclampsia, and may help to prevent preterm birth. OBJECTIVES To assess the effects of calcium supplementation during pregnancy on hypertensive disorders of pregnancy and related maternal and child outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 March 2013) and contacted study authors for more data where possible. We updated the search in May 2014 and added the results to the 'Awaiting Classification' section of the review. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing high-dose (at least 1 g daily of calcium) or low-dose calcium supplementation during pregnancy with placebo or no calcium. DATA COLLECTION AND ANALYSIS We assessed eligibility and trial quality, extracted and double-entered data. MAIN RESULTS High-dose calcium supplementation (≥1 g/day)We included 14 studies in the review, however one study contributed no data. We included 13 high-quality studies in our meta-analyses (15,730 women). The average risk of high blood pressure (BP) was reduced with calcium supplementation compared with placebo (12 trials, 15,470 women: risk ratio (RR) 0.65, 95% confidence interval (CI) 0.53 to 0.81; I² = 74%). There was also a significant reduction in the risk of pre-eclampsia associated with calcium supplementation (13 trials, 15,730 women: RR 0.45, 95% CI 0.31 to 0.65; I² = 70%). The effect was greatest for women with low calcium diets (eight trials, 10,678 women: average RR 0.36, 95% CI 0.20 to 0.65; I² = 76%) and women at high risk of pre-eclampsia (five trials, 587 women: average RR 0.22, 95% CI 0.12 to 0.42; I² = 0%). These data should be interpreted with caution because of the possibility of small-study effect or publication bias.The composite outcome maternal death or serious morbidity was reduced (four trials, 9732 women; RR 0.80, 95% CI 0.65 to 0.97; I² = 0%). Maternal deaths were not significantly different (one trial of 8312 women: calcium group one death versus placebo group six deaths). There was an anomalous increase in the risk of HELLP (haemolysis, elevated liver enzymes and low platelets) syndrome (two trials, 12,901 women: RR 2.67, 95% CI 1.05 to 6.82; I² = 0%) in the calcium group, however, the absolute number of events was low (16 versus six).The average risk of preterm birth was reduced in the calcium group (11 trials, 15,275 women: RR 0.76, 95% CI 0.60 to 0.97; I² = 60%) and amongst women at high risk of developing pre-eclampsia (four trials, 568 women: average RR 0.45, 95% CI 0.24 to 0.83; I² = 60%), but no significant reduction in neonatal high care admission. There was no overall effect on the risk of stillbirth or infant death before discharge from hospital (11 trials 15,665 babies: RR 0.90, 95% CI 0.74 to 1.09; I² = 0%).One study showed a reduction in childhood systolic BP greater than 95th percentile among children exposed to calcium supplementation in utero (514 children: RR 0.59, 95% CI 0.39 to 0.91). In a subset of these children, dental caries at 12 years old was also reduced (195 children, RR 0.73, 95% CI 0.62 to 0.87). Low-dose calcium supplementation (< 1 g/day)We included 10 trials (2234 women) that evaluated low-dose supplementation with calcium alone (4) or in association with vitamin D (3), linoleic acid (2), or antioxidants (1). Most studies recruited women at high risk for pre-eclampsia, and were at high risk of bias, thus the results should be interpreted with caution. Supplementation with low doses of calcium significantly reduced the risk of pre-eclampsia (RR 0.38, 95% CI 0.28 to 0.52; I² = 0%). There was also a reduction in hypertension, low birthweight and neonatal intensive care unit admission. AUTHORS' CONCLUSIONS Calcium supplementation (≥ 1 g/day) is associated with a significant reduction in the risk of pre-eclampsia, particularly for women with low calcium diets. The treatment effect may be overestimated due to small-study effects or publication bias. It also reduces preterm birth and the occurrence of the composite outcome 'maternal death or serious morbidity'. We considered these benefits to outweigh the increased risk of HELLP syndrome, which was small in absolute numbers. The World Health Organization recommends calcium 1.5 g to 2 g daily for pregnant women with low dietary calcium intake.The limited evidence on low-dose calcium supplementation suggests a reduction in pre-eclampsia, but needs to be confirmed by larger, high-quality trials. Pending such results, in settings of low dietary calcium where high-dose supplementation is not feasible, the option of lower-dose supplements (500 to 600 mg/day) might be considered in preference to no supplementation.
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Affiliation(s)
- G Justus Hofmeyr
- Department of Obstetrics and Gynaecology, East London Hospital Complex, University of the Witwatersrand, University of Fort Hare, Eastern Cape Department of Health, Frere and Cecilia Makiwane Hospitals, Private Bag X 9047, East London, Eastern Cape, South Africa, 5200
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Bigdeli M, Zafar S, Assad H, Ghaffar A. Health system barriers to access and use of magnesium sulfate for women with severe pre-eclampsia and eclampsia in Pakistan: evidence for policy and practice. PLoS One 2013; 8:e59158. [PMID: 23555626 PMCID: PMC3608621 DOI: 10.1371/journal.pone.0059158] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 02/12/2013] [Indexed: 12/02/2022] Open
Abstract
Severe pre-eclampsia and eclampsia are rare but serious complications of pregnancy that threaten the lives of mothers during childbirth. Evidence supports the use of magnesium sulfate (MgSO4) as the first line treatment option for severe pre-eclampsia and eclampsia. Eclampsia is the third major cause of maternal mortality in Pakistan. As in many other Low- and Middle-Income Countries (LMIC), it is suspected that MgSO4 is critically under-utilized in the country. There is however a lack of information on context-specific health system barriers that prevent optimal use of this life-saving medicine in Pakistan. Combining quantitative and qualitative methods, namely policy document review, key informant interviews, focus group discussions and direct observation at health facility, we explored context-specific health system barriers and enablers that affect access and use of MgSO4 for severe pre-eclampsia and eclampsia in Pakistan. Our study finds that while international recommendations on MgSO4 have been adequately translated in national policies in Pakistan, the gap remains in implementation of national policies into practice. Barriers to access to and effective use of MgSO4 occur at health facility level where the medicine was not available and health staff was reluctant to use it. Low price of the medicine and the small market related to its narrow indications acted as disincentives for effective marketing. Results of our survey were further discussed in a multi-stakeholder round-table meeting and an action plan for increasing access to this life-saving medicine was identified.
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Affiliation(s)
- Maryam Bigdeli
- Alliance for Health Policy and System Research, World Health Organization, Geneva, Switzerland.
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Hollegaard B, Byars SG, Lykke J, Boomsma JJ. Parent-offspring conflict and the persistence of pregnancy-induced hypertension in modern humans. PLoS One 2013; 8:e56821. [PMID: 23451092 PMCID: PMC3581540 DOI: 10.1371/journal.pone.0056821] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2012] [Accepted: 01/14/2013] [Indexed: 11/18/2022] Open
Abstract
Preeclampsia is a major cause of perinatal mortality and disease affecting 5–10% of all pregnancies worldwide, but its etiology remains poorly understood despite considerable research effort. Parent-offspring conflict theory suggests that such hypertensive disorders of pregnancy may have evolved through the ability of fetal genes to increase maternal blood pressure as this enhances general nutrient supply. However, such mechanisms for inducing hypertension in pregnancy would need to incur sufficient offspring health benefits to compensate for the obvious risks for maternal and fetal health towards the end of pregnancy in order to explain why these disorders have not been removed by natural selection in our hunter-gatherer ancestors. We analyzed >750,000 live births in the Danish National Patient Registry and all registered medical diagnoses for up to 30 years after birth. We show that offspring exposed to pregnancy-induced hypertension (PIH) in trimester 1 had significantly reduced overall later-life disease risks, but increased risks when PIH exposure started or developed as preeclampsia in later trimesters. Similar patterns were found for first-year mortality. These results suggest that early PIH leading to improved postpartum survival and health represents a balanced compromise between the reproductive interests of parents and offspring, whereas later onset of PIH may reflect an unbalanced parent-offspring conflict at the detriment of maternal and offspring health.
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Affiliation(s)
- Birgitte Hollegaard
- Centre for Social Evolution, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Sean G. Byars
- Centre for Social Evolution, Department of Biology, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Lykke
- Department of Obstetrics and Gynaecology, Roskilde Hospital, Roskilde, Denmark
| | - Jacobus J. Boomsma
- Centre for Social Evolution, Department of Biology, University of Copenhagen, Copenhagen, Denmark
- * E-mail:
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Carr A, Kershaw T, Brown H, Allen T, Small M. Hypertensive disease in pregnancy: an examination of ethnic differences and the Hispanic paradox. J Neonatal Perinatal Med 2013; 6:11-15. [PMID: 24246453 DOI: 10.3233/npm-1356111] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE The "Hispanic paradox" refers to the epidemiological finding that Hispanics in the US have better health outcomes than the average population despite what their aggregate socioeconomic determinants would predict. The aim of this study was to evaluate obstetric outcomes for a multiethnic population with hypertensive diseases. METHODS We performed a retrospective review of parturients with hypertensive disease delivering at Duke University Medical Center. We analyzed maternal sociodemographic characteristics and ethnic differences in hypertensive disease types using Chi Square tests. RESULTS A total of 3,124 women delivered during a period of one year; 9% of them had hypertensive diseases in pregnancy. Gestational hypertension was more commonly diagnosed in Whites, whereas chronic hypertension and mild preeclampsia were more frequently encountered in Blacks and Hispanics respectively (Chi-square = 39.11, p < 0.001). The overall incidence of preeclampsia was less in Hispanics. However, severe preeclampsia rates were equal across groups. Hispanics were more likely to be uninsured and younger, enter prenatal care later, and least likely to complete high school. There was no significant difference in smoking or parity. Stratified analyses by ethnicity showed that the relationship between severe preeclampsia and comorbidities (intrauterine growth restriction, low birth weight, and need for admission to intensive care nursery) were least pronounced in Hispanics and strongest in Black women. CONCLUSION Despite similar rates of severe preeclampsia and adverse sociodemographic characteristics, Hispanic women with severe preeclampsia had better pregnancy outcomes than Black or White women with the disease.
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Affiliation(s)
- A Carr
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Duke University, Durham, NC, USA
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Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean section rates and indications in sub-Saharan Africa: a multi-country study from Medecins sans Frontieres. PLoS One 2012; 7:e44484. [PMID: 22962616 PMCID: PMC3433452 DOI: 10.1371/journal.pone.0044484] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2012] [Accepted: 08/08/2012] [Indexed: 11/19/2022] Open
Abstract
Objectives The World Health Organization considers Cesarean section rates of 5–15% to be the optimal range for targeted provision of this life saving intervention. However, access to safe Cesarean section in resource-limited settings is much lower, estimated at 1–2% reported in sub-Saharan Africa. This study reports Cesarean sections rates and indications in Democratic Republic of Congo, Burundi, and Sierra Leone, and describe the main parameters associated with maternal and early neonatal mortality. Methods Women undergoing Cesarean section from August 1 2010 to January 31 2011 were included in this prospective study. Logistic regression was used to model determinants of maternal and early neonatal mortality. Results 1276 women underwent a Cesarean section, giving a frequency of 6.2% (range 4.1–16.8%). The most common indications were obstructed labor (399, 31%), poor presentation (233, 18%), previous Cesarean section (184, 14%), and fetal distress (128, 10%), uterine rupture (117, 9%) and antepartum hemorrhage (101, 8%). Parity >6 (adjusted odds ratio [aOR] = 8.6, P = 0.015), uterine rupture (aOR = 20.5; P = .010), antepartum hemorrhage (aOR = 13.1; P = .045), and pre-eclampsia/eclampsia (aOR = 42.9; P = .017) were associated with maternal death. Uterine rupture (aOR = 6.6, P<0.001), anterpartum hemorrhage (aOR = 3.6, P<0.001), and cord prolapse (aOR = 2.7, P = 0.017) were associated with early neonatal death. Conclusions This study demonstrates that target Cesarean section rates can be achieved in sub-Saharan Africa. Identifying the common indications for Cesarean section and associations with mortality can target improvements in antenatal services and emergency obstetric care.
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Affiliation(s)
- Kathryn Chu
- Médecins sans Frontières, Johannesburg, South Africa.
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Savaj S, Vaziri N. An overview of recent advances in pathogenesis and diagnosis of preeclampsia. Iran J Kidney Dis 2012; 6:334-338. [PMID: 22976257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Accepted: 06/29/2012] [Indexed: 06/01/2023]
Abstract
Preeclampsia is a serious complication of pregnancy, which is the cause of 60 000 maternal deaths annually worldwide. In addition to the well-known maternal risk factors such as hypertension, diabetes mellitus, antiphospholipid antibody syndrome, obesity, aging, and multiple pregnancies, recent studies have identified the role of genetic and immunological factors in the pathogenesis of preeclampsia. In particular, imbalance between angiogenic and anti-angiogenic factors, anti-angiotensin II type 1 receptor antibodies and dysregulation of oxygen supplies can cause preeclampsia. A group of biomarkers have been introduced for diagnosis of preeclampsia. Chief among them is the ratio of soluble fms-like tyrosine kinase-1 to placental growth factor, which can be used in clinical practice. Recent studies have shown high specificity and sensitivity of these markers for early diagnosis of preeclampsia, which is critical for prevention of fetal and maternal complications.
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Affiliation(s)
- Shokoufeh Savaj
- Firoozgar Hospital, Tehran University of Medical Sciences, Tehran, Iran.
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Gong YH, Jia J, Lü DH, Dai L, Bai Y, Zhou R. Outcome and risk factors of early onset severe preeclampsia. Chin Med J (Engl) 2012; 125:2623-2627. [PMID: 22882950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Early onset severe preeclampsia is a specific type of severe preeclampsia, which causes high morbidity and mortality of both mothers and fetus. This study aimed to investigate the clinical definition, features, treatment, outcome and risk factors of early onset severe preeclampsia in Chinese women. METHODS Four hundred and thirteen women with severe preeclampsia from June 2006 to June 2009 were divided into three groups according to the gestational age at the onset of preeclampsia as follows: group A (less than 32 weeks, 73 cases), group B (between 32 and 34 weeks, 71 cases), and group C (greater than 34 weeks, 269 cases). The demographic characteristics of the subjects, complications, delivery modes and outcome of pregnancy were analyzed retrospectively. RESULTS The systolic blood pressure at admission and the incidence of severe complications were significantly lower in group C than those in groups A and B, prolonged gestational weeks and days of hospitalization were significantly shorter in group C than those in groups A and B. Liver and kidney dysfunction, pleural and peritoneal effusion, placental abruption and postpartum hemorrhage were more likely to occur in group A compared with the other two groups. Twenty-four-hour urine protein levels at admission, intrauterine fetal death and days of hospitalization were risk factors that affected complications of severe preeclampsia. Gestational week at admission and delivery week were also risk factors that affected perinatal outcome. CONCLUSIONS Early onset severe preeclampsia should be defined as occurring before 34 weeks, and it is featured by more maternal complications and a worse perinatal prognosis compared with that defined as occurring after 34 weeks. Independent risk factors should be used to tailor the optimized individual treatment plan, to balance both maternal and neonatal safety.
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Affiliation(s)
- Yun-Hui Gong
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan 610041, China
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Ande A, Olagbuji B, Ezeanochie M. An audit of maternal deaths from a referral university teaching hospital in Nigeria: the emergence of HIV/AIDS as a leading cause. Niger Postgrad Med J 2012; 19:83-87. [PMID: 22728972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
AIMS AND OBJECTIVES To analyse the characteristics and causes of maternal death in a referral tertiary health facility in Southern Nigeria. MATERIALS AND METHODS This is a facility- based review of 184 maternal deaths that occurred from January 2005 to June 2009. Primary causes of death and factors that contributed to maternal death including delay in accessing health care were identified. RESULTS During the study period, the Maternal Mortality Ratio (MMR) was 2230/100,000 live births. There was a progressive reduction in the annual MMR from 2901/100,000 live birth in 2005 to 1459/100,000 live birth in 2009. More than four fifth (84.9%) of the maternal deaths occurred among women of low socio-economic class (IV and V). The leading causes of direct maternal deaths (64.1%) were Puerperal sepsis (17.8%), Pre-eclampsia/Eclampsia (15.8%) and complications of unsafe abortion (11.4%). HIV/AIDS was the third commonest overall cause of maternal death (15.2%). Half of the women experienced Type 1 delay (50%), Type 2 and 3 delay occurred in 7.6% and 18.5% of maternal deaths respectively. About two thirds of the women (58.2%) experienced more than one form of delay. CONCLUSION Although direct obstetric deaths remain the leading cause of maternal mortality, HIV/AIDS is becoming an important primary cause of maternal mortality in our environment. Organization of health service delivery with an effective referral system and the provision of optimal care for HIV infected women are recommended.
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Affiliation(s)
- Adedapo Ande
- Department of Obstetrics and Gynaecology, University of Benin Teaching Hospital, Benin City, Edo state, Nigeria.
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