Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy.

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.

Eclampsia in the 21st century.

The reported incidence of eclampsia is 1.6 to 10 per 10,000 deliveries in developed countries, whereas it is 50 to 151 per 10,000 deliveries in developing countries. In addition, low-resource countries have substantially higher rates of maternal and perinatal mortalities and morbidities. This disparity in incidence and pregnancy outcomes may be related to universal access to prenatal care, early detection of preeclampsia, timely delivery, and availability of healthcare resources in developed countries compared to developing countries. Because of its infrequency in developed countries, many obstetrical providers and maternity units have minimal to no experience in the acute management of eclampsia and its complications. Therefore, clear protocols for prevention of eclampsia in those with severe preeclampsia and acute treatment of eclamptic seizures at all levels of healthcare are required for better maternal and neonatal outcomes. Eclamptic seizure will occur in 2% of women with preeclampsia with severe features who are not receiving magnesium sulfate and in <0.6% in those receiving magnesium sulfate. The pathogenesis of an eclamptic seizure is not well understood; however, the blood-brain barrier disruption with the passage of fluid, ions, and plasma protein into the brain parenchyma remains the leading theory. New data suggest that blood-brain barrier permeability may increase by circulating factors found in preeclamptic women plasma, such as vascular endothelial growth factor and placental growth factor. The management of an eclamptic seizure will include supportive care to prevent serious maternal injury, magnesium sulfate for prevention of recurrent seizures, and promoting delivery. Although routine imagining following an eclamptic seizure is not recommended, the classic finding is referred to as the posterior reversible encephalopathy syndrome. Most patients with posterior reversible encephalopathy syndrome will show complete resolution of the imaging finding within 1 to 2 weeks, but routine imaging follow-up is unnecessary unless there are findings of intracranial hemorrhage, infraction, or ongoing neurologic deficit. Eclampsia is associated with increased risk of maternal mortality and morbidity, such as placental abruption, disseminated intravascular coagulation, pulmonary edema, aspiration pneumonia, cardiopulmonary arrest, and acute renal failure. Furthermore, a history of eclamptic seizures may be related to long-term cardiovascular risk and cognitive difficulties related to memory and concentration years after the index pregnancy. Finally, limited data suggest that placental growth factor levels in women with preeclampsia are superior to clinical markers in prediction of adverse pregnancy outcomes. This data may be extrapolated to the prediction of eclampsia in future studies. This summary of available evidence provides data and expert opinion on possible pathogenesis of eclampsia, imaging findings, differential diagnosis, and stepwise approach regarding the management of eclampsia before delivery and after delivery as well as current recommendations for the prevention of eclamptic seizures in women with preeclampsia.

High risk and low prevalence diseases: Eclampsia.

INTRODUCTION: Eclampsia is a rare partum and puerperal condition that carries a high rate of morbidity and mortality. OBJECTIVE: This review highlights the pearls and pitfalls of the care of patients with eclampsia, including presentation, evaluation, and evidence-based management in the emergency department (ED). DISCUSSION: Eclampsia is a hypertensive disease of pregnancy defined by new onset tonic-clonic, focal, or multifocal seizures or unexplained altered mental status in a pregnant or postpartum patient in the absence of other causative etiologies. However, signs and symptoms of preeclampsia and prodromes of eclampsia are often subtle and non-specific, making the diagnosis difficult. Thus, it should be considered in pregnant and postpartum patients who present to the ED. Laboratory testing including complete blood cell count, renal and liver function panels, electrolytes, glucose, coagulation panel, fibrinogen, lactate dehydrogenase, uric acid, and urinalysis, as well as imaging to include head computed tomography, can assist, but these evaluations should not delay management. Components of treatment include emergent obstetric specialist consultation, magnesium administration, and blood pressure control in patients with hypertension. Definitive treatment of eclampsia requires emergent delivery in pregnant patients. If consultants are not in-house, emergent stabilization and immediate transfer are required. CONCLUSIONS: An understanding of eclampsia can assist emergency clinicians in rapid recognition and timely management of this potentially deadly disease.

Knowledge and skills of pre-eclampsia management among healthcare providers working in antenatal clinics in Zanzibar.

BACKGROUND: Pre-eclampsia and eclampsia are the leading causes of perinatal morbidity and mortality worldwide. Early detection and treatment of preeclampsia is lifesaving; however, evidence suggests that the majority of women in low and middle income-countries are not routinely screened for high blood pressure during antenatal care, that those with severe and mild pre-eclampsia are not monitored for blood pressure and proteinuria as needed, and the magnesium sulphate is not administered as needed. The purpose of this study was therefore to assess knowledge and skills in pre-eclampsia and eclampsia management and their associated factors among healthcare providers working in antenatal clinics in Zanzibar. METHODS: This was a cross-sectional analytical study conducted in all levels of healthcare facilities in Zanzibar. The study involved 176 healthcare providers (nurses and doctors) who were randomly selected. A self-administered questionnaire was used to collect data and descriptive and inferential statistics were used in the analysis whereby logistic regression models were employed. The Chi-square coefficient, odds ratio, and 95% confidence intervals were reported, and the level of significance was set at p < 0.05. RESULTS: The mean age of healthcare providers was 35.94 (SD ± 7.83) years. The proportion of healthcare providers with adequate knowledge was 49.0%, and 47% had adequate skills. Knowledge level was predicted by working in higher healthcare facility levels (AOR: 3.28, 95% CI: 1.29-8.29), and having attended on-the-job training on pre-eclampsia (AOR: 7.8, 95% CI: 2.74 - 22.75). Skills were predicted by having attended on-job training (AOR: 8.6, 95% CI: 2.45 - 30.16), having working experience of five years or above in antenatal care units (AOR: 27.89, 95% CI: 5.28 - 148.89) and being a medical doctor or assistant medical doctor (AOR: 18.9, 95% CI: 2.1-166). CONCLUSION: Approximately half of Zanzibar's ANC healthcare workers demonstrated inadequate knowledge and skills in preeclampsia care, indicating a critical need for targeted interventions to reduce maternal morbidity and mortality. Knowledge is predicted by attending on-the-job training and working in higher healthcare facility level, while skills is predicted by attending on job training, more years of working experience in antenatal care units and being a medical doctor or assistant medical doctor The study recommends the healthcare facility institutions to provide on-the-job training to for the healthcare providers working in lower healthcare facility levels.

Impact of the ICD-9-CM to ICD-10-CM transition on the incidence of severe maternal morbidity among delivery hospitalizations in the United States.

BACKGROUND: Surveillance of maternal mortality and severe maternal morbidity is important to identify temporal trends, evaluate the impact of clinical practice changes or interventions, and monitor quality of care. A common source for severe maternal morbidity surveillance is hospital discharge data. On October 1, 2015, all hospitals in the United States transitioned from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for diagnoses and procedures. OBJECTIVE: This study aimed to evaluate the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding systems on the incidence of severe maternal morbidity in the United States in hospital discharge data. STUDY DESIGN: Using data from the National Inpatient Sample, obstetrical deliveries between January 1, 2012, and December 31, 2017, were identified using a validated case definition. Severe maternal morbidity was defined using the International Classification of Diseases, Ninth Revision, Clinical Modification (January 1, 2012, to September 30, 2015) and the International Classification of Diseases, Tenth Revision, Clinical Modification (October 1, 2015, to December 31, 2017) codes provided by the Centers for Disease Control and Prevention. An interrupted time series and segmented regression analysis was used to assess the impact of the transition from the International Classification of Diseases, Ninth Revision, Clinical Modification to the International Classification of Diseases, Tenth Revision, Clinical Modification coding on the incidence of severe maternal morbidity per 1000 obstetrical deliveries. RESULTS: From 22,751,941 deliveries, the incidence of severe maternal morbidity in the International Classification of Diseases, Ninth Revision, Clinical Modification coding era was 19.04 per 1000 obstetrical deliveries and decreased to 17.39 per 1000 obstetrical deliveries in the International Classification of Diseases, Tenth Revision, Clinical Modification coding era (P<.001). The transition to International Classification of Diseases, Tenth Revision, Clinical Modification coding led to an immediate decrease in the incidence of severe maternal morbidity (-2.26 cases of 1000 obstetrical deliveries) (P<.001). When blood products transfusion was removed from the case definition, the magnitude of the decrease in the incidence of SMM was much smaller (-0.60 cases/1000 obstetric deliveries), but still significant (P<.001). CONCLUSION: After the transition to the International Classification of Diseases, Tenth Revision, Clinical Modification coding for health diagnoses and procedures in the United States, there was an abrupt statistically significant and clinically meaningful decrease in the incidence of severe maternal morbidity in hospital discharge data. Changes in the underlying health of the obstetrical population are unlikely to explain the sudden change in severe maternal morbidity. Although much work has been done to validate the International Classification of Diseases, Ninth Revision, Clinical Modification codes for severe maternal morbidity, it is critical that validation studies be undertaken to validate the International Classification of Diseases, Tenth Revision, Clinical Modification codes for severe maternal morbidity to permit ongoing surveillance, quality improvement, and research activities that rely on hospital discharge data.

Time to recovery from Eclampsia and its determinants in east Gojjam zone hospitals, Amhara, Ethiopia, 2017/18.

BACKGROUND: Eclampsia is a tonic clonic type of seizure among pre-eclamptic mothers. Time to recovery from eclampsia is to mean that the time when the mother recovered from severity features of pre-eclampsia. As far as the mother is not free from severity features, she is in a potential to end-up with repeated seizure (eclampsia). Therefore, combating eclampsia through controlling severity features is crucial to enhance maternal health quality, reduce maternal morbidity and mortality, and improve prenatal outcomes. There was no literature that describes the recovery time of eclampsia and its determinants in Ethiopia. Therefore, this study aimed to assess the recovery time from eclampsia and its determinants in East Gojjam zone hospitals. METHODS: An institutional based retrospective follow up study was conducted between January 2014 and December 2017 among 608 eclamptic mothers in East Gojjam zone Hospitals. Simple random sampling technique was used. Data were coded and entered to Epidata version 3.1 and was exported to SPSS version 20 and then to Stata 14. We used the adjusted hazard ratio (AHR) with 95% confidence interval at p-value less than 0.05 to measure strength of association. RESULT: The median recovery time of eclampsia was 12 h with inter-quartile range of (1-48 h). The rate of recovery from eclampsia among mothers aged more than 20 years was reduced by half (AHR 0.50 (0.28, 0.89)) than the teenagers. The rate of recovery from eclampsia among mothers who had prolonged labor was 1.3 times (AHR 1.26 (1.01, 1.57)) than those whose labor was less than 12 h. About 32% of mothers with multiple convulsions recoverd later than (AHR 0.68 (0.52, 0.87)) those who had single convulsion. As compared to antepartum convulsion, the rate of recovery from postpartum eclampsia was 1.8 times faster (AHR 1.81(1.17, 2.81)). CONCLUSION: The median recovery time from severity features among eclamptic mothers in East Gojjam zone hospitals was half a day. It is affected by age, duration of labor, number of convulsions and time of occurrence of the event. Special attention for elders, prevent recurrent convulsion and faster termination for the antepartum eclamptic mothers are recommended from this follow-up study.

Preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at Korle Bu Teaching Hospital in Accra, Ghana.

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 (ß 1.4, SE 0.3, p < 0.001) and higher level of education (ß 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.

SARS-COV-2 infection during pregnancy, a risk factor for eclampsia or neurological manifestations of COVID-19? Case report.

BACKGROUND: There are no published cases of tonic-clonic seizures and posterior bilateral blindness during pregnancy and Severe Acute Respiratory Syndrome (SARS) Coronavirus (COV) 2 (SARS-COV-2) infection. We do not just face new and unknown manifestations, but also how different patient groups are affected by SARS-COV-2 infection, such as pregnant women. Coronavirus Disease 2019 (COVID-19), preeclampsia, eclampsia and posterior reversible leukoencephalopathy share endothelium damage and similar pathophysiology. CASE PRESENTATION: A 35-year-old pregnant woman was admitted for tonic-clonic seizures and SARS-COV-2 infection. She had a normal pregnancy control and no other symptoms before tonic-clonic seizures development. After a Caesarean section (C-section) she developed high blood pressure, and we initiated antihypertensive treatment with labetalol, amlodipine and captopril. Few hours later she developed symptoms of cortical blindness that resolved in 72 h with normal brain computed tomography (CT) angiography. CONCLUSION: The authors conclude that SARS COV-2 infection could promote brain endothelial damage and facilitate neurological complications during pregnancy.

Posterior reversible encephalopathy syndrome (PRES): presentation, diagnosis and treatment.

Posterior reversible encephalopathy syndrome (PRES) is a neurological disorder which is characterised by variable symptoms, which include visual disturbances, headache, vomiting, seizures and altered consciousness. The exact pathophysiology of PRES has not been completely explained, but hypertension and endothelial injury seem to be almost always present. Vasoconstriction resulting in vasogenic and cytotoxic edema is suspected to be responsible for the clinical symptoms as well as the neuro-radiological presentation. On imaging studies, Symmetrical white matter abnormalities suggestive of edema are seen in the computer tomography (CT) and magnetic resonance imaging (MRI) scans, commonly but not exclusively in the posterior parieto-occipital regions of the cerebral hemispheres. The management is chiefly concerned with stabilization of the patient, adequate and prompt control of blood pressure, prevention of seizures and timely caesarean section in obstetric cases with pre-eclampsia/eclampsia. In conclusion, persistently elevated blood pressures remain the chief culprit for the clinical symptoms as well as the neurological deficits. Early diagnosis by diffusion weighted MRI scans, and differentiation from other causes of altered sensorium i.e. seizures, meningitis and psychosis, is extremely important to initiate treatment and prevent further complications. Although most cases resolve successfully and carry a favorable prognosis, patients with inadequate therapeutic support or delay in treatment may not project a positive outcome.

A national surveillance approach to monitor incidence of eclampsia: The Netherlands Obstetric Surveillance System.

INTRODUCTION: There have been many efforts in the last decade to decrease the incidence of eclampsia and its related complications in the Netherlands, such as lowering thresholds for treatment of hypertension and mandatory professional training. To determine the impact of these policy changes on incidence and outcomes, we performed a nationwide registration of eclampsia, 10 years after the previous registration. MATERIAL AND METHODS: Cases of eclampsia were prospectively collected using the Netherlands Obstetric Surveillance System (NethOSS; 2013-2016) in all hospitals with a maternity unit in the Netherlands. Complete case file copies were obtained for comparative analysis of individual level data with the previous cohort (2004-2006). Primary outcome measure was incidence of eclampsia; main secondary outcomes were antihypertensive and magnesium sulfate use, and maternal and perinatal mortality. RESULTS: NethOSS identified 88 women with eclampsia. The incidence decreased from 6.2/10 000 in 2004-2006 to 1.8/10 000 births (relative risk [RR] 0.28, 95% confidence interval [CI] 0.22-0.36). Increases in the use of antihypertensive medication (61/82 vs 35/216; RR 18.4, 95% CI 9.74-34.70) and magnesium sulfate treatment (82/82 vs 201/216; RR 1.08, 95% CI 1.04-1.12) were observed. There was one intrauterine death following termination of pregnancy. No cases of neonatal mortality were reported in NethOSS compared with 11 in the LEMMoN. Maternal death occurred in one woman compared vs three in the previous registration. CONCLUSIONS: There has been a strong reduction of eclampsia and associated perinatal mortality in the Netherlands over the last decade. Management changes and increased awareness may have contributed to this reduction.

Policy review on the management of pre-eclampsia and eclampsia by community health workers in Mozambique.

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.

Influential factors and clinical significance of an atypical presentation of posterior reversible encephalopathy syndrome in patients with eclampsia.

BACKGROUND AND PURPOSE: Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity for which eclampsia is one of the most common predisposing conditions. Despite the imaging changes typically reported, the predisposing factors and clinical implications of atypical presentations have yet to be fully clarified. METHODS: A total of 56 patients with PRES were selected for study. Demographic, clinical, and laboratory data were analyzed, focusing on atypical presentations of PRES. Multiple logistic regression was applied to identify factors impacting such atypical presentations, and functional outcomes were assessed upon patient discharge. RESULTS: Overall, 22 of the 56 patients (39.3%) displayed features of atypical PRES. By multiple logistic regression, headache (OR = 5.39; 95% CI, 1.24-23.51; p = 0.025) and frequent convulsions (OR = 4.41; 95% CI, 1.09-17.91; p = 0.038) proved to be independent factors associated with atypical PRES. Ultimately, outcomes of 18 patients were gauged as poor, based on the modified Rankin Scale (mRS). Logistic regression indicated that visual disturbances (OR = 9.02; 95% CI, 1.37-59.35; p = 0.02), frequent convulsions (OR = 9.47; 95% CI, 1.67-53.63; p = 0.01), and restricted diffusion on imaging (OR = 11.96; 95% CI, 1.76-81.11; p = 0.01) were independently associated with poor outcomes in patients with eclampsia-related PRES. CONCLUSION: Headache and frequent convulsions are independently associated with atypical presentations of PRES. If present, restricted diffusion may help in predicting poor outcomes of such patients upon discharge.

Intracerebral Hemorrhage in Women: A Review with Special Attention to Pregnancy and the Post-Partum Period.

Non-traumatic intracranial hemorrhage includes subarachnoid hemorrhage, subdural hemorrhage, and intracerebral hemorrhage (ICH), which can be classified as primary or secondary. Primary ICH is due to arterial hypertension or cerebral amyloid angiopathy, and secondary ICH is due to cerebral vascular malformations, coagulopathies, infectious complications, brain tumors, and illicit stimulant drug use. This review explores the epidemiology and management of non-traumatic ICH in women, with a focus on pregnancy and the post-partum period, defined as 6 weeks post-delivery.

Status epilepticus related to pregnancy: Devising a protocol for use in the intensive care unit.

BACKGROUND: Status epilepticus (SE) related to pregnancy is rare and carries a significant risk to both the mother and the fetus. OBJECTIVES: We conducted this study to devise a protocol for the management of SE related to pregnancy in a cohort of female patients admitted with SE during pregnancy. MATERIALS AND METHODS: All women who developed SE related to pregnancy (gestation, labor, and puerperium) between January 2000 and December 2016 were included. Data was collected using a structured proforma. RESULTS: There were 17 women who had SE related to pregnancy, of whom 10 had refractory SE. The various causes of refractory SE were eclampsia (N = 2), posterior reversible encephalopathy syndrome (PRES) due to various causes other than eclampsia (N = 3), cortical venous thrombosis (CVT) [N = 3], subarachnoid hemorrhage (SAH) [N = 1], and N-methyl-D-aspartate (NMDA) receptor antibody-mediated encephalitis (N = 1). Six out of 10 women with refractory SE (60%) and five out of 10 fetuses (50%) had a good outcome. CONCLUSION: There is a dearth of literature with regards to SE related to pregnancy and little or no guidelines exist for its management. Awareness about the diverse etiologies other than eclampsia is important. A protocol-based approach to the diagnosis and management of SE is necessary to ensure best outcomes.

Clinical and radiological features of posterior reversible encephalopathy syndrome in patients with pre-eclampsia and eclampsia.

AIM: To analyse and summarise clinical and radiological features among patients with posterior reversible encephalopathy syndrome (PRES), to assess related factors with eclampsia and pre-eclampsia, and to compare the different factors between cytotoxic and vasogenic oedema among PRES patients. MATERIALS AND METHODS: The clinical and radiological findings of 237 pre-eclamptic or eclamptic patients with neurological symptoms were evaluated retrospectively. Multiple logistic regression analyses were performed to compare the differences among these parameters. RESULTS: Seventy-six patients (32.07%) were diagnosed with PRES. Multiple logistic regression indicated that seizure (odds ratio [OR], 2.760; 95% confidence interval [CI]: 1.087-7.011; p=0.033), visual disturbances (OR=2.062 95%CI, 1.033-4.115; p=0.004), multiple production history (OR=3.637; 95% CI: 1.068-8.228; p=0.002) were independent risk factors for PRES. PRES+ (OR=3.217; 95%CI, 1.346-7.686; p=0.009), Visual disturbances (OR=4.283; 95% CI: 1.843-9.953; p=0.001) had strong association with eclampsia. Visual disturbances (OR=7.200; 95% CI: 2.116-24.496; p=0.002) had strong correlation with eclampsia among PRES+ patients. Visual disturbances (OR=2.947; 95% CI: 1.135-7.648; p=0.026) were independently related to cytotoxic oedema. CONCLUSIONS: Nearly one-third of pre-eclampsia or eclampsia patients with neurological symptoms have PRES. Visual disturbances, seizure, multiple production history are independent risk factors for PRES. Visual disturbances have a strong association with eclampsia whether patients have PRES or not. Visual disturbances are independently related to cytotoxic oedema among PRES+ patients.

Adaptation of non-technical skills behavioural markers for delivery room simulation.

BACKGROUND: Simulation in healthcare has proved to be a useful method in improving skills and increasing the safety of clinical operations. The debriefing session, after the simulated scenario, is the core of the simulation, since it allows participants to integrate the experience with the theoretical frameworks and the procedural guidelines. There is consistent evidence for the relevance of non-technical skills (NTS) for the safe and efficient accomplishment of operations. However, the observation, assessment and feedback on these skills is particularly complex, because the process needs expert observers and the feedback is often provided in judgmental and ineffective ways. The aim of this study was therefore to develop and test a set of observation and rating forms for the NTS behavioural markers of multi-professional teams involved in delivery room emergency simulations (MINTS-DR, Multi-professional Inventory for Non-Technical Skills in the Delivery Room). METHODS: The MINTS-DR was developed by adapting the existing tools and, when needed, by designing new tools according to the literature. We followed a bottom-up process accompanied by interviews and co-design between practitioners and psychology experts. The forms were specific for anaesthetists, gynaecologists, nurses/midwives, assistants, plus a global team assessment tool. We administered the tools in five editions of a simulation training course that involved 48 practitioners. Ratings on usability and usefulness were collected. RESULTS: The mean ratings of the usability and usefulness of the tools were not statistically different to or higher than 4 on a 5-point rating scale. In either case no significant differences were found across professional categories. CONCLUSION: The MINTS-DR is quick and easy to administer. It is judged to be a useful asset in maximising the learning experience that is provided by the simulation.

Perceived changes in knowledge and confidence of doctors and midwives after the completion of the Standardized Trainings in Obstetrical Emergencies.

BACKGROUND AND OBJECTIVES: There are only few training programs in obstetric emergencies currently in use and only some of them were evaluated with an adequate sample of participants. Therefore, we present the evaluation of the novel Standardized Trainings in Obstetrical Emergencies (STrObE), conducted in Lithuania. The aim of this study was to analyze whether participants' self-reported knowledge and confidence increased after the trainings, and whether the impact of the trainings was long-lasting. MATERIALS AND METHODS: Data was collected across the majority of hospitals providing secondary and tertiary obstetrical care in Lithuania in 2015. A total of 650 obstetricians-gynecologists and midwives attended the trainings; 388 (response rate 59.7%) of them filled in the initial questionnaire before the trainings, 252 (64.9%) immediately after, 160 (41.2%) 6 weeks after, and 160 (41.2%) 6 months after the trainings, which was the final sample for the analyses. Participants used a Likert-type scale to evaluate their knowledge and confidence about management of urgent obstetrical situations: vacuum-assisted vaginal delivery, shoulder dystocia, postpartum hemorrhage, preeclampsia/eclampsia, early preterm labor, and dystocia. We assessed how participants' self-reported knowledge and confidence changed after the trainings (compared to before the trainings) and how long the effect was retained for. RESULTS: The mean score of self-reported knowledge in obstetrical emergencies increased immediately after the trainings comparing to the scores before the trainings (P<0.001) and it did not differ further between the three time points after the trainings (i.e. immediately, 6 weeks, and 6 months; P>0.05). The same pattern was observed for self-reported confidence scores. The increase in self-reported knowledge and confidence after the trainings was stable. Moreover, the self-reported knowledge and confidence gains were greater for those participants with lower work experience, although benefit was seen across all experience levels. CONCLUSIONS: STrObE improved participants' self-reported knowledge and confidence and lasting positive effects were observed for at least 6 months after the initial trainings. Moreover, the trainings were more beneficial for those with lower work experience, although they benefited all the participants.

ACG Clinical Guideline: Liver Disease and Pregnancy.

Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women.

Opportunities for improvement in care among women with severe maternal morbidity.

BACKGROUND: Severe maternal morbidity is increasing in the United States and has been estimated to occur in up to 1.3% of all deliveries. A standardized, multidisciplinary approach has been recommended to identify and review cases of severe maternal morbidity to identify opportunities for improvement in maternal care. OBJECTIVE: The aims of our study were to apply newly described gold standard guidelines to identify true severe maternal morbidity and to utilize a recently recommended multidisciplinary approach to determine the incidence of and characterize opportunities for improvement in care. STUDY DESIGN: We conducted a retrospective cohort study of all women admitted for delivery at Cedars-Sinai Medical Center from Jan. 1, 2012, through June 30, 2014. Electronic medical records were screened for severe maternal morbidity using the following criteria: International Classification of Diseases, Ninth Revision codes for severe illness identified by the Centers for Disease Control and Prevention; prolonged length of stay; intensive care unit admission; transfusion of ≥4 U of packed red blood cells; or hospital readmission within 30 days of discharge. A multidisciplinary team conducted in-depth review of each medical record that screened positive for severe maternal morbidity to determine if true severe maternal morbidity occurred. Each true case of severe maternal morbidity was presented to a multidisciplinary committee to determine a consensus opinion about the morbidity and if opportunities for improvement in care existed. Opportunity for improvement was described as strong, possible, or none. The incidence of opportunity for improvement was determined and categorized as system, provider, and/or patient. Morbidity was classified by primary cause, organ system, and underlying medical condition. RESULTS: There were 16,323 deliveries of which 386 (2%) screened positive for severe maternal morbidity. Following review of each case, true severe maternal morbidity was present in 150 (0.9%) deliveries. We determined by multidisciplinary committee review that there was opportunity for improvement in care in 66 (44%) cases. The 2 most common underlying causes of severe maternal morbidity were hemorrhage (71.3%) and preeclampsia/eclampsia (10.7%). In cases with opportunity for improvement in care, provider factors were present in 78.8%, followed by patient (28.8%) and system (13.6%) factors. CONCLUSION: We demonstrated the feasibility of a recently recommended review process of severe maternal morbidity at a large, academic medical center. We demonstrated that opportunity for improvement in care exists in 44% of cases and that the majority of these cases had contributing provider factors.

Validating Obstetric Emergency Checklists using Simulation: A Randomized Controlled Trial.

Background The World Health Organization's Surgical Safety Checklist has demonstrated significant reduction in surgical morbidity. The American Congress of Obstetricians and Gynecologists District II Safe Motherhood Initiative (SMI) safety bundles include eclampsia and postpartum hemorrhage (PPH) checklists. Objective To determine whether use of the SMI checklists during simulated obstetric emergencies improved completion of critical actions and to elicit feedback to facilitate checklist revision. Study Design During this randomized controlled trial, teams were assigned to use a checklist during one of two emergencies: eclampsia and PPH. Raters scored teams on critical step completion. Feedback was elicited through structured debriefing. Results In total, 30 teams completed 60 scenarios. For eclampsia, trends toward higher completion were noted for blood pressure and airway management. For PPH, trends toward higher completion rates were noted for PPH stage assessment and fundal massage. Feedback resulted in substantial checklist revision. Participants were enthusiastic about using checklists in a clinical emergency. Conclusion Despite trends toward higher rates of completion of critical tasks, teams using checklists did not approach 100% task completion. Teams were interested in the application of checklists and provided feedback necessary to substantially revise the checklists. Intensive implementation planning and training in use of the revised checklists will result in improved patient outcomes.