RESUMO
OBJECTIVES: The University Hospital Basel implemented delayed umbilical cord clamping of 30-60â¯s in all laboring women on April 1, 2020. This practice has been widely researched showing substantial benefit for the neonate. Few studies focused on maternal blood loss. The objective of our retrospective comparative study was to assess the impact of immediate vs. delayed cord clamping on maternal blood loss in primary scheduled cesarean sections. METHODS: We analyzed data of 98 women with singleton gestations undergoing primary scheduled cesarean section at term. Data from procedures with early cord clamping (ECC) were compared to those after implementation of delayed cord clamping (DCC). Primary outcomes were perioperative change in maternal hemoglobin levels, estimated and calculated blood loss. Secondary outcomes included duration of cesarean section and neonatal data. RESULTS: There was a statistically significant difference in the mean perioperative decline of hemoglobin of 10.4â¯g/L (SD=7.92) and 18.7â¯g/L (SD=10.4) between the ECC and DCC group, respectively (p<0.001). The estimated (482â¯mL in ECC vs. 566â¯mL in DCC (p=0.011)) and the calculated blood loss (438â¯mL in ECC vs. 715â¯mL in DCC (p=0.002)) also differed significantly. Secondary outcomes showed no significant differences. CONCLUSIONS: In our study DCC resulted in a statistically significant higher maternal blood loss. In our opinion the widely researched neonatal benefit of DCC outweighs the risk of higher maternal blood loss in low-risk patients. However, maternal risks must be minimized, improvements to preoperative blood management and operative techniques are required.
Assuntos
Perda Sanguínea Cirúrgica , Cesárea , Clampeamento do Cordão Umbilical , Humanos , Feminino , Estudos Retrospectivos , Cesárea/efeitos adversos , Cesárea/métodos , Cesárea/estatística & dados numéricos , Gravidez , Adulto , Clampeamento do Cordão Umbilical/métodos , Perda Sanguínea Cirúrgica/estatística & dados numéricos , Perda Sanguínea Cirúrgica/prevenção & controle , Fatores de Tempo , Recém-Nascido , Hemoglobinas/análise , Cordão Umbilical/cirurgiaRESUMO
BACKGROUND: Fetal ultrasound organ screening has become a standard of care in most high-income countries. This has resulted in increased detection of congenital abnormalities, which may lead to major uncertainty and anxiety in expectant parents, even though many of them are of minor relevance. In order to optimize prenatal counselling, we introduced an interdisciplinary approach for all pregnant women referred to our center by private obstetricians for a co-assessment of suspected relevant fetal abnormalities of the kidney or urinary tract, involving both experienced prenatal ultrasound specialists and a pediatric nephrologist or urologist. METHODS: In a retrospective analysis, we evaluated reports of intrauterine evaluation and postnatal follow-up in order to assess accuracy of explicit intrauterine diagnoses and outcome of hydronephroses according to their severity in this setting. RESULTS: A total of 175 fetuses were examined between 2012 and 2019 and followed postnatally at our Pediatric Nephrology or Urology Department. There was a high concordance (85.9%) between explicit intrauterine and final diagnoses. Resolution rate of hydronephrosis was higher in patients with intrauterine low-grade than high-grade hydronephrosis (61.8% versus 11.9%). An etiological diagnosis was found in 62.5%, 52.0%, and 11.1% of patients with intrauterine bilateral high-grade, unilateral high-grade, and unilateral high-grade with contralateral low-grade hydronephrosis, respectively, but in none of the patients with intrauterine low-grade hydronephrosis. CONCLUSIONS: The results of our study demonstrate that, through interdisciplinary teamwork, intrauterine assessment of the fetal kidneys and urinary tract is highly accurate and allows a good discrimination between relevant and transient/physiological hydronephroses. A higher resolution version of the Graphical abstract is available as Supplementary information.
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Hidronefrose , Rim , Ultrassonografia Pré-Natal , Sistema Urinário , Feminino , Humanos , Hidronefrose/congênito , Hidronefrose/diagnóstico por imagem , Rim/anormalidades , Rim/diagnóstico por imagem , Gravidez , Estudos Retrospectivos , Centros de Atenção Terciária , Sistema Urinário/anormalidades , Sistema Urinário/diagnóstico por imagemRESUMO
Pregnancy is associated with elevated maternal levels of cell-free DNA of neutrophil extracellular trap (NET) origin, as circulatory neutrophils exhibit increased spontaneous NET formation, mainly driven by G-CSF and finely modulated by sex hormones. The postpartum period, on the other hand, involves physiological alterations consistent with the need for protection against infections and fatal haemorrhage. Our findings indicate that all relevant serum markers of neutrophil degranulation and NET release are substantially augmented postpartum. Neutrophil pro-NETotic activity in vitro is also upregulated particularly in post-delivery neutrophils. Moreover, maternal puerperal neutrophils exhibit a strong pro-NETotic phenotype, associated with increased levels of all key players in the generation of NETs, namely citH3, MPO, NE, and ROS, compared to non-pregnant and pregnant controls. Intriguingly, post-delivery NET formation is independent of G-CSF in contrast to late gestation and complemented by the presence of TF on the NETs, alterations in the platelet activity status, and activation of the coagulation cascade, triggered by circulating microparticles. Taken together, our results reveal the highly pro-NETotic and potentially procoagulant nature of postpartum neutrophils, bridging an overt immune activation with possible harmful thrombotic incidence.
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Ácidos Nucleicos Livres/sangue , Armadilhas Extracelulares/metabolismo , Neutrófilos/imunologia , Período Pós-Parto/sangue , Adulto , Estudos de Casos e Controles , Armadilhas Extracelulares/genética , Feminino , Fator Estimulador de Colônias de Granulócitos/genética , Humanos , Idade Materna , Ativação de Neutrófilo , Peroxidase , Período Pós-Parto/genética , Período Pós-Parto/metabolismo , Gravidez , Espécies Reativas de Oxigênio/metabolismoRESUMO
BACKGROUND: Preeclampsia is a major pregnancy complication that results in significant maternal and infant mortality, most of which occurs in low and middle-income countries. The accurate and timely diagnosis of preeclampsia is critical in management of affected pregnancies to reduce maternal and fetal/neonatal morbidity and mortality, yet difficulties remain in establishing the rigorous diagnosis of preeclampsia based on clinical parameters alone. Biomarkers that detect biochemical disease have been proposed as complements or alternatives to clinical criteria to improve diagnostic accuracy. This cohort study assessed the performance of several biomarkers, including glycosylated fibronectin (GlyFn), to rule-in or rule-out preeclampsia within 4 weeks in a cohort of women at increased risk for preeclampsia. METHODS: 151 women with risk factors for or clinical signs and symptoms of preeclampsia were selected from a prospective cohort. Maternal serum samples were collected between 20 and 37 weeks of gestation. Clinical suspicion of preeclampsia was defined as presence of new-onset proteinuria, or clinical symptoms of preeclampsia. Subjects with a clinical diagnosis of preeclampsia at the time of enrollment were excluded. GlyFn, pregnancy-associated plasma protein-A2 (PAPPA2), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1) were measured by immunoassay. GlyFn was also determined using a rapid point-of care (POC) test format. Receiver-operating characteristic (ROC) curves derived from logistic regression analysis were used to determine the classification performance for each analyte. RESULTS: 32 of 151 (21%) women developed a clinical diagnosis of preeclampsia within 4 weeks. All biomarkers exhibited good classification performance [GlyFn (area under the curve (AUROC) = 0.94, 91% sensitivity, 86% specificity); PAPPA2 AUC = 0.92, 87% sensitivity, 77% specificity; PlGF AUC = 0.90, 81% sensitivity, 83% specificity; sFlt-1 AUC = 0.92, 84% sensitivity, 91% specificity. The GlyFn immunoassay and the rapid POC test showed a correlation of r = 0.966. CONCLUSIONS: In this prospective cohort, serum biomarkers of biochemical disease were effective in short-term prediction of preeclampsia, and the performance of GlyFn in particular as a POC test may meet the needs of rapid and accurate triage and intervention.
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Fibronectinas/sangue , Pré-Eclâmpsia/sangue , Proteínas da Gravidez/sangue , Adulto , Biomarcadores/sangue , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Idade Gestacional , Produtos Finais de Glicação Avançada , Humanos , Imunoensaio , Fator de Crescimento Placentário/sangue , Gravidez , Estudos Prospectivos , Curva ROC , Fatores de Risco , Sensibilidade e Especificidade , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangueRESUMO
PURPOSE: Foetal ventriculomegaly (VM) is one of the most commonly diagnosed brain abnormalities. The aims of this study were to assess cases with isolated VM, describe the prenatal course and assess short- and long-term follow-up at the age of 2 years. METHODS: We performed a retrospective analysis from our prenatal data base and included all children that were prenatally diagnosed with VM in our unit between 2008 and 2013 (n = 250). Prenatal management, postnatal outcome and neurologic development at the age of 2 years were evaluated. RESULTS: A total of 106 children were born at our institution and were diagnosed prenatally with isolated borderline VM. A total of 1.9% (n = 2/106) was transferred to the neonatal unit. A total of 0.9% (n = 1/106) showed abnormal findings in postnatal brain ultrasound. A total of 1.9% (n = 2/106) showed mild neurologic abnormalities after birth, but none had to be seen by a neuropediatrician. At the follow-up at 2 years, 2.5% (n = 1/40) had an insertion of a shunt. CONCLUSION: Based on our analysis, the majority of isolated borderline VM do not show short- or long-term neurological abnormalities. However, all cases of VM should be referred to a detailed prenatal ultrasound exam by a specialist.
Assuntos
Hidrocefalia , Malformações do Sistema Nervoso , Ventrículos Cerebrais/diagnóstico por imagem , Criança , Pré-Escolar , Feminino , Feto , Humanos , Hidrocefalia/diagnóstico por imagem , Gravidez , Estudos Retrospectivos , Ultrassonografia Pré-NatalRESUMO
BACKGROUND: To better understand the profound multisystem changes in maternal physiology triggered by parturition, in particular in the underexplored neuronal system, by deploying a panel of pre- vs post-delivery maternal serum biomarkers, most notably the neuronal cytoskeleton constituent neurofilament light chain (NfL). This promising fluid biomarker is not only increasingly applied to investigate disease progression in numerous brain diseases, particularly in proteopathies, but also in detection of traumatic brain injury or monitoring neuroaxonal injury after ischemic stroke. METHODS: The study was nested within a prospective cohort study of pregnant women at risk of developing preeclampsia at the University Hospital of Basel. Paired ante- and postpartum levels of progesterone, soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF), mid-regional pro-atrial natriuretic peptide (MR-proANP), copeptin (CT-proAVP), and NfL were measured in 56 women with complete clinical data. RESULTS: Placental delivery significantly decreased all placental markers: progesterone 4.5-fold, PlGF 2.2-fold, and sFlt-1 1.7-fold. Copeptin and MR-proANP increased slightly (1.4- and 1.2-fold, respectively). Unexpectedly, NfL levels (median [interquartile range]) increased significantly post-partum: 49.4 (34.7-77.8) vs 27.7 (16.7-31.4) pg/ml (p < 0.0001). Antepartum NfL was the sole independent predictor of NfL peri-partum change; mode of delivery, duration of labor, clinical characteristics and other biomarkers were all unrelated. Antepartum NfL levels were themselves independently predicted only by maternal age. CONCLUSIONS: Parturition per se increases maternal serum NfL levels, suggesting a possible impact of parturition on maternal neuronal integrity.
Assuntos
Proteínas de Neurofilamentos/sangue , Parto/sangue , Gravidez de Alto Risco/sangue , Adulto , Fator Natriurético Atrial/sangue , Biomarcadores/sangue , Sistema Cardiovascular , Parto Obstétrico/métodos , Feminino , Glicopeptídeos/sangue , Humanos , Fenômenos Fisiológicos do Sistema Nervoso , Fator de Crescimento Placentário/sangue , Período Pós-Parto/sangue , Pré-Eclâmpsia/etiologia , Gravidez , Progesterona/sangue , Estudos Prospectivos , Fatores de Risco , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangueRESUMO
BACKGROUND: The aim was to evaluate the influence of the new International Association of Diabetes and Pregnancy Study Groups (IADPSG) guidelines for screening of gestational diabetes mellitus (GDM) on GDM prevalence in a cohort from a Swiss tertiary hospital. METHODS: This was a retrospective cohort study involving all pregnant women who were screened for GDM between 24 and 28 weeks of gestation. From 2008 until 2010 (period 1), a two-step approach with 1-h 50 g glucose challenge test (GCT) was used, followed by fasting, 1- and 2-h glucose measurements after a 75 g oral glucose tolerance test (OGTT) in case of a positive GCT. From 2010 until 2013 (period 2), all pregnant women were tested with a one-step 75 g OGTT according to new IADPSG guidelines. In both periods, women with risk factors could be screened directly with a 75 g OGTT in early pregnancy. RESULTS: Overall, 647 women were eligible for the study in period 1 and 720 in period 2. The introduction of the IADPSG criteria resulted in an absolute increase of GDM prevalence of 8.5% (3.3% in period 1 to 11.8% in period 2). CONCLUSIONS: The adoption of the IADPSG criteria resulted in a considerable increase in GDM diagnosis in our Swiss cohort. Further studies are needed to investigate if the screening is cost effective and if treatment of our additionally diagnosed GDM mothers might improve short-term as well as long-term outcome.
Assuntos
Diabetes Gestacional/epidemiologia , Adulto , Índice de Massa Corporal , Estudos de Coortes , Diabetes Gestacional/diagnóstico , Diabetes Gestacional/patologia , Feminino , Macrossomia Fetal/diagnóstico , Teste de Tolerância a Glucose/métodos , Humanos , Recém-Nascido , Masculino , Programas de Rastreamento , Guias de Prática Clínica como Assunto , Gravidez , Resultado da Gravidez , Prevalência , Estudos Retrospectivos , Fatores de Risco , Suíça/epidemiologiaRESUMO
OBJECTIVES: To develop a mathematical, semimechanistic model characterizing physiological weight changes in term neonates, identify and quantify key maternal and neonatal factors influencing weight changes, and provide an online tool to forecast individual weight changes during the first week of life. STUDY DESIGN: Longitudinal weight data from 1335 healthy term neonates exclusively breastfed up to 1 week of life were available. A semimechanistic model was developed to characterize weight changes applying nonlinear mixed-effects modeling. Covariate testing was performed by applying a standard stepwise forward selection-backward deletion approach. The developed model was externally evaluated on 300 additional neonates collected in the same center. RESULTS: Weight changes during first week of life were described as a function of a changing net balance between time-dependent rates of weight gain and weight loss. Males had higher birth weights (WT0) than females. Gestational age had a positive effect on WT0 and weight gain rate, whereas mother's age had a positive effect on WT0 and a negative effect on weight gain rate. The developed model showed good predictive performance when externally validated (bias = 0.011%, precision = 0.52%) and was able to accurately forecast individual weight changes up to 1 week with only 3 initial weight measurements (bias = -0.74%, precision = 1.54%). CONCLUSIONS: This semimechanistic model characterizes weight changes in healthy breastfed neonates during first week of life. We provide a user-friendly online tool allowing caregivers to forecast and monitor individual weight changes. We plan to validate this model with data from other centers and expand it with data from preterm neonates.
Assuntos
Recém-Nascido/crescimento & desenvolvimento , Modelos Estatísticos , Aumento de Peso , Redução de Peso , Aleitamento Materno , Feminino , Idade Gestacional , Humanos , Estudos Longitudinais , Masculino , Idade Materna , Valor Preditivo dos Testes , Estudos Retrospectivos , Fatores Sexuais , Nascimento a TermoRESUMO
OBJECTIVE: Preoperative assessment of adnexal masses with ultrasound has been shown to be time-, cost-effective, and specific. When used in combination with the menopausal status and the tumor marker CA125, the risk of malignancy index (RMI) can be calculated, allowing appropriate preoperative triage of patients to a gynecologist or a gynecological oncologist. Moreover, it allows for accurate planning of the required surgical procedure (laparoscopy vs laparotomy). METHODS: A large general gynecologic ultrasonic database retrospectively identified 5218 patients for a 14-year period who presented to the outpatient clinic with an adnexal mass. Additional data (menopausal status, histology, CA125 values) were available in 1108 of these patients. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. The results were then compared with previously published data from a large Australian gynecological cancer center (GCC, n = 204). RESULTS: With the use of an RMI cutoff of 200, malignant ovarian tumors were correctly triaged to a gynecologic oncologist in 123 of 172 cases, leading to a sensitivity of 72% and specificity of 92% in our general outpatient clinic population compared with a sensitivity of 84% and a specificity of 77% in the GCC high-risk population. The negative predictive value was 95% compared with only 85% in the GCC cohort. We hypothesize that improvement of the overall detection rate of malignancy could be improved from 72% to 85% using a 2-step model, referring patients with an ultrasonic score of 3 to an experienced sonographer who uses pattern recognition. CONCLUSIONS: The RMI is an easy and reliable tool for the accurate triage of adnexal masses. Its value is higher in an unselected gynecological outpatient setting. Our proposed 2-step model including expert pattern recognition could influence particularly the detection rate in borderline and early-stage ovarian cancers and overcome the limitations of the tumor marker CA125.
Assuntos
Neoplasias Ovarianas/diagnóstico , Triagem/métodos , Antígeno Ca-125/sangue , Feminino , Humanos , Proteínas de Membrana/sangue , Menopausa , Pessoa de Meia-Idade , Pacientes Ambulatoriais , Neoplasias Ovarianas/sangue , Neoplasias Ovarianas/diagnóstico por imagem , Estudos Retrospectivos , Fatores de Risco , UltrassonografiaRESUMO
PURPOSE: Postpartum haemorrhage (PPH) represents a leading cause of maternal morbidity and mortality. Giving oxytocin after birth reduces the risk for PPH. It has never been tested whether different methods of oxytocin administration affect the maternal outcome. This study aims to compare the infusion versus the bolus application of oxytocin after singleton vaginal delivery. METHODS: This retrospective monocentre study compares the incidence of clinically relevant postpartum complications in women receiving 5 IE of oxytocin as a bolus or as a 100 ml-infusion over 5 min, given immediately after birth. Included were women delivering singletons vaginally at term. We used propensity score weighting to compare outcomes between women receiving bolus and infusion and to minimize the selection bias in this retrospective cohort. RESULTS: 1765 patients were included. Patient characteristics were balanced. We found no significant differences for the combined overall postpartum adverse outcome (the incidence of PPH, manual removal of the placenta and/or curettage). For the single outcomes, we observed a significantly higher frequency of manual removal of the placenta (Odds ratio 1.47, 95 % CI 1.02-2.13) and a slightly higher but clinically not relevant estimated blood loss (Relative effect 1.05, 95 % CI 1.01-1.10) in the infusion group. CONCLUSION: The data show a tendency towards more complications in the infusion group. It is related to a more frequent need for manual removal of the placenta.
Assuntos
Ocitocina/administração & dosagem , Período Pós-Parto , Resultado da Gravidez , Adulto , Parto Obstétrico , Feminino , Humanos , Terceira Fase do Trabalho de Parto , Complicações do Trabalho de Parto/epidemiologia , Ocitócicos/administração & dosagem , Placenta Retida/epidemiologia , Placenta Retida/terapia , Hemorragia Pós-Parto/epidemiologia , Gravidez , Estudos RetrospectivosRESUMO
INTRODUCTION: The analysis of cell-free DNA from maternal blood samples has facilitated the noninvasive detection of fetal aneuploidies or hereditary Mendelian disorders. In this context, previous studies have indicated that the pool of cell-free DNA is greater in maternal serum than in plasma samples, necessitating optimized collection and storage protocols. As the source of this increased amount of cell-free DNA is not clear, we have now examined whether neutrophil extracellular traps (NETs) contribute to this material. MATERIAL AND METHODS: Serum samples were collected in all three trimesters of normal healthy pregnant women, and at term from cases with manifest preeclampsia. The presence of NET-derived material was demonstrated by the detection of cell-free DNA fragments complexed to neutrophil granular proteins (i.e. myeloperoxidase). RESULTS: Our data indicate that NET-derived cell-free DNA/myeloperoxidase complexes were greater in serum from normal pregnant women than in normal matching nonpregnant controls. This neutrophil chromosomal material increased incrementally throughout gestation and was most pronounced in cases with preeclampsia. DISCUSSION: By detecting increased levels of cell-free DNA/myeloperoxidase complexes in maternal serum samples, our data indicate that a significant proportion of this material is derived from the generation of NETs.
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DNA/sangue , Armadilhas Extracelulares , Neutrófilos , Adulto , Feminino , Idade Gestacional , Humanos , Pré-Eclâmpsia/diagnóstico , Gravidez , Soro/citologia , Fatores de TempoRESUMO
Ovarian cancer is the most aggressive gynecologic malignancy, with a 5-year survival rate ranging around 40%. A crucial factor influencing the prognosis is early detection of a suspicious mass and referral to a gynecologic oncology center for further diagnosis, staging and debulking surgery. Here, we present the different imaging methods ultrasound (US), magnetic resonance imaging, computer tomography (CT) and 18F-fluoro-deoxyglucose positron emission tomography (PET)/CT that are used for the characterization, diagnosis, staging and surveillance of ovarian cancer. In this review, we focus on US and discuss in detail the advantages and the limitations, as well as the appropriate indications for each of the individual imaging techniques.
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Neoplasias Ovarianas/diagnóstico por imagem , Meios de Contraste , Feminino , Humanos , Imageamento por Ressonância Magnética , Programas de Rastreamento , Estadiamento de Neoplasias , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/patologia , Tomografia por Emissão de Pósitrons , Compostos Radiofarmacêuticos , Tomografia Computadorizada por Raios X , UltrassonografiaRESUMO
INTRODUCTION: To investigate the ability of cardiovascular plasma biomarkers to identify imminent preeclampsia (PE) among pregnant women at triage. MATERIAL AND METHODS: C-terminal pro-arginine vasopressin (copeptin), C-terminal pro-endothelin-1 (CT-proET-1), mid-regional pro-adrenomedullin (MR-proADM), and mid-regional pro-atrial natriuretic peptide (MR-proANP) were prospectively measured in pregnant women presenting at the obstetrical triage units of the University Hospitals of Basel and Zurich, Switzerland. Logistic regression and receiver operating characteristics (ROC) analysis was used to assess and quantify the predictive ability of cardiovascular biomarkers. RESULTS: Of the 147 included women, 27 (18.4%) were diagnosed at admission with PE. All biomarker levels were significantly higher in participants with PE as compared to controls. However, only MR-proANP, MR-proADM and CT-proET-1 were significant and independent predictors of PE, after taking into account the effect of various clinical confounders. The area under the ROC curve (AUC) was 0.62 (95% confidence interval 0.50-0.73) for copeptin, 0.64 (0.52-0.76) for MR-proADM, 0.71 (0.61-0.82) for CT-proET-1, and 0.83 (0.73-0.92) for MR-proANP. The combination of MR-proANP and MR-proADM resulted in the highest diagnostic performance (AUC 0.88; 0.79-0.96). DISCUSSION: Assessment of the cardiovascular plasma biomarkers MR-proANP and MR-proADM holds promise to support diagnosis of PE at triage.
Assuntos
Adrenomedulina/sangue , Fator Natriurético Atrial/sangue , Endotelina-1/sangue , Glicopeptídeos/sangue , Fragmentos de Peptídeos/sangue , Pré-Eclâmpsia/sangue , Precursores de Proteínas/sangue , Adulto , Biomarcadores/sangue , Doenças Cardiovasculares/sangue , Estudos Epidemiológicos , Feminino , Humanos , Gravidez , TriagemRESUMO
OBJECTIVES: Pertussis and influenza are endemic infections and associated with relevant morbidity and mortality in newborns and young infants. The Swiss Federal Office of Public Health has recommended influenza vaccination since 2011 and pertussis vaccination in pregnancy (ViP) since 2013 and expanded to repetition in each pregnancy since 2017. ViP is safe and effective in preventing severe diseases, but implementation is a challenge. We hypothesized that the proportion of women receiving ViP is persistently low despite existing national recommendations. Our primary objective was to compare the proportion of pertussis and influenza vaccine recommendations for and its acceptance by pregnant women before and after an information campaign tailored to obstetricians. Secondly, we aimed to identify reasons for missing or declining ViP. STUDY DESIGN: We conducted a prospective, single-center, single-arm implementation study in the maternity ward at the University Women's Hospital Basel. We performed standardized interviews with women hospitalized for postpartum care before (October to December 2019, Phase 1, n = 262) and after an information campaign (October to December 2020, Phase 2, n = 233) and compared categorical variables using chi-squared or Fisher's exact test and continuous variables using Whitney Mann U test. RESULTS: We found no significant differences in the proportion of recommendation for pertussis ViP (80 % vs. 84 %, p = 0.25) and implementation (76 % vs. 78 %, p = 0.63) between Phase 1 and 2. Main reasons for missing or declining vaccinations were lack of recommendation (62.8 %) and safety concerns regarding the unborn child (17.7 %). In contrast, the proportion of recommendation for influenza ViP (45 % vs. 63 %, p < 0.001) and implementation (29 % vs. 43 %, p < 0.001) increased significantly. CONCLUSION: Proactive recommendations by obstetricians play a key role in the implementation of ViP but is still insufficient in our setting. We believe that future efforts should aim to explore possible hurdles that impede recommendations by obstetricians for ViP. The focus should be on the needs and experiences of obstetricians in private practice, but also other health care professionals involved in care of pregnant women. Local campaigns do not seem effective enough, therefore national campaigns with new strategies are desirable.
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Vacinas contra Influenza , Influenza Humana , Complicações Infecciosas na Gravidez , Coqueluche , Recém-Nascido , Lactente , Feminino , Gravidez , Humanos , Gestantes , Coqueluche/prevenção & controle , Influenza Humana/prevenção & controle , Estudos Prospectivos , Vacina contra Coqueluche , Aceitação pelo Paciente de Cuidados de Saúde , Inquéritos e Questionários , Vacinação , Vacinas contra Influenza/uso terapêutico , Complicações Infecciosas na Gravidez/prevenção & controleRESUMO
Postpartum hypertension (PPHT) is hypertension that persists or develops after delivery and is a frequent cause of readmission, affecting 10% of pregnancies. This interim analysis aims to describe the cohort and to determine the feasibility and acceptance of a home-based telemonitoring management strategy (HBTMS) in PPHT patients. Enrollment at the University Hospital Basel began during the 2020 SARS-CoV-2 pandemic. Maternity-ward patients were screened for preexisting hypertension, hypertensive disorders of pregnancy, and de novo PPHT. In this pragmatic non-randomized prospective trial, the participants chose the HBTMS or standard of care (SOC), which consisted of outpatient hypertension clinic appointments. The HBTMS was a smartphone application or a programmed spreadsheet to report blood pressure (BP), followed by telephone consultations. Three months postpartum, the participants underwent a 24 h BP measurement and a blood, biomarker, and urine analysis. A total of 311 participants were enrolled between 06/20 and 08/23. The mean age was 34 (±5.3) years. The current pregnancy history demonstrated the following (≥1 diagnosis possible): 10% had preexisting hypertension, 27.3% gestational hypertension, 53% preeclampsia (PE), 0.3% eclampsia, 6% HELLP (hemolysis, elevated liver enzymes, and low platelets), and 18.3% de novo PPHT. A family history of cardiovascular disease and PE was reported in 49.5% and 7.5%, respectively. In total, 23.3% were high-risk for PE. A total of 68.5% delivered via c-section, the mean hospitalization was 6.3 days (±3.9), and newborn intrauterine growth restriction occurred in 21%. A total of 99% of the participants chose the HBTMS. This analysis demonstrated that the HBTMS was accepted. This is vital in the immediate postpartum period and pertinent when the exposure of hospital visits should be avoided.
RESUMO
Objective: To predict birth weight at various potential gestational ages of delivery based on data routinely available at the first antenatal visit. Design: Individual participant data meta-analysis. Data sources: Individual participant data of four cohorts (237 228 pregnancies) from the International Prediction of Pregnancy Complications (IPPIC) network dataset. Eligibility criteria for selecting studies: Studies in the IPPIC network were identified by searching major databases for studies reporting risk factors for adverse pregnancy outcomes, such as pre-eclampsia, fetal growth restriction, and stillbirth, from database inception to August 2019. Data of four IPPIC cohorts (237 228 pregnancies) from the US (National Institute of Child Health and Human Development, 2018; 233 483 pregnancies), UK (Allen et al, 2017; 1045 pregnancies), Norway (STORK Groruddalen research programme, 2010; 823 pregnancies), and Australia (Rumbold et al, 2006; 1877 pregnancies) were included in the development of the model. Results: The IPPIC birth weight model was developed with random intercept regression models with backward elimination for variable selection. Internal-external cross validation was performed to assess the study specific and pooled performance of the model, reported as calibration slope, calibration-in-the-large, and observed versus expected average birth weight ratio. Meta-analysis showed that the apparent performance of the model had good calibration (calibration slope 0.99, 95% confidence interval (CI) 0.88 to 1.10; calibration-in-the-large 44.5 g, -18.4 to 107.3) with an observed versus expected average birth weight ratio of 1.02 (95% CI 0.97 to 1.07). The proportion of variation in birth weight explained by the model (R2) was 46.9% (range 32.7-56.1% in each cohort). On internal-external cross validation, the model showed good calibration and predictive performance when validated in three cohorts with a calibration slope of 0.90 (Allen cohort), 1.04 (STORK Groruddalen cohort), and 1.07 (Rumbold cohort), calibration-in-the-large of -22.3 g (Allen cohort), -33.42 (Rumbold cohort), and 86.4 g (STORK Groruddalen cohort), and observed versus expected ratio of 0.99 (Rumbold cohort), 1.00 (Allen cohort), and 1.03 (STORK Groruddalen cohort); respective pooled estimates were 1.00 (95% CI 0.78 to 1.23; calibration slope), 9.7 g (-154.3 to 173.8; calibration-in-the-large), and 1.00 (0.94 to 1.07; observed v expected ratio). The model predictions were more accurate (smaller mean square error) in the lower end of predicted birth weight, which is important in informing clinical decision making. Conclusions: The IPPIC birth weight model allowed birth weight predictions for a range of possible gestational ages. The model explained about 50% of individual variation in birth weights, was well calibrated (especially in babies at high risk of fetal growth restriction and its complications), and showed promising performance in four different populations included in the individual participant data meta-analysis. Further research to examine the generalisability of performance in other countries, settings, and subgroups is required. Trial registration: PROSPERO CRD42019135045.
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A current major obstacle is that no reliable screening markers exist to detect pregnancies at risk for preeclampsia. Quantitative proteomic analysis employing isobaric labelling (iTRAQ) has been suggested to be suitable for the detection of potential plasma biomarkers, a feature we recently verified in analysis of pregnancies with Down syndrome foetuses. We have now examined whether this approach could yield biomarkers to screen pregnancies at risk for preeclampsia. In our study, we used maternal plasma samples obtained at 12 weeks of gestation, six from women who subsequently developed preeclampsia and six with uncomplicated deliveries. In our analysis, we observed elevations in 10 proteins out of 64 proteins in the preeclampsia study group when compared to the healthy control group. These proteins included clusterin, fibrinogen, fibronectin, and angiotensinogen, increased levels of which are known to be associated with preeclampsia. An elevation in the immune-modulatory molecule, galectin 3 binding protein, was also noted. Our pilot study, therefore, indicates that quantitative proteomic iTRAQ analysis could be a useful tool for the detection of new preeclampsia screening markers.
Assuntos
Pré-Eclâmpsia/sangue , Primeiro Trimestre da Gravidez/sangue , Diagnóstico Pré-Natal/métodos , Bases de Dados de Proteínas , Feminino , Humanos , Fragmentos de Peptídeos/sangue , Pré-Eclâmpsia/metabolismo , Gravidez , Proteoma/metabolismo , Proteômica/métodos , Estudos Retrospectivos , Espectrometria de Massas em TandemRESUMO
OBJECTIVE: The soluble fms-like tyrosine kinase (sFlt-1)/placental growth factor (PlGF) ratio is a reliable tool in the assessment of preeclampsia. We tested the hypothesis that the sFlt-1/PlGF ratio is able to identify women at risk for imminent delivery. We characterized the sFlt-1/PlGF ratio in different types of hypertensive pregnancy disorders. STUDY DESIGN: We investigated 388 singleton pregnancies with normal pregnancy outcome, 164 with PE, 36 with gestational hypertension, and 42 with chronic hypertension. sFlt-1 and PlGF were measured in serum samples. RESULTS: Patients with preeclampsia had a significantly increased sFlt-1/PlGF ratio as compared with controls and with patients with chronic and gestational hypertension in <34 weeks and ≥34 weeks (P < .001). Time to delivery was significantly reduced in women with preeclampsia in the highest quartile of the sFlt-1/PlGF ratio (P < .001). CONCLUSION: The sFlt-1/PlGF ratio allows the identification of women at risk for imminent delivery and is a reliable tool to discriminate between different types of pregnancy-related hypertensive disorders.
Assuntos
Proteínas de Membrana/sangue , Pré-Eclâmpsia/diagnóstico , Receptor 1 de Fatores de Crescimento do Endotélio Vascular/sangue , Adulto , Biomarcadores/sangue , Doença Crônica , Feminino , Humanos , Pré-Eclâmpsia/sangue , Gravidez , Resultado da Gravidez , PrognósticoRESUMO
INTRODUCTION: Adrenomedullin (ADM) is one of the strongest endogenous vasodilating hormones. Its stable by-product midregional-proADM (MR-proADM) is an established indicator of systemic infection and cardiovascular compromise in adult patients. METHODS: A prospective cross-sectional study was performed to investigate the perinatal factors affecting MR-proADM plasma concentrations in 328 newborn infants with a gestational age (GA) between 24 and 41 wk. RESULTS: Blood samples were obtained in 270 infants from umbilical veins (with additional 108 paired samples from umbilical arteries), and at 2-3 d of life in 183 infants. Paired venous and arterial umbilical cord MR-proADM concentrations were closely related (Spearman's rank order correlation coefficient (R(s)) = 0.825, P < 0.001). MR-proADM concentrations at birth and at 2-3 d were inversely related to GA (R(s) = -0.403 and R(s) = -0.541, respectively) and birth weight (BW; R(s) = -0.421 and R(s) = -0.530, respectively; all P < 0.001). On stepwise regression analysis, clinical chorioamnionitis and umbilical arterial blood base excess retained a significant impact on MR-proADM cord venous blood concentrations. At 2-3 d of life, histologic chorioamnionitis and GA at delivery were significantly associated with MR-proADM levels. DISCUSSION: As compared with adults, MR-proADM concentrations are elevated in neonates, especially those born very preterm. Immaturity and infection, which both feature low systemic vascular resistance, are related to increased MR-proADM concentrations.
Assuntos
Adrenomedulina/sangue , Recém-Nascido Prematuro/sangue , Infecções/sangue , Precursores de Proteínas/sangue , Peso ao Nascer , Estudos Transversais , Feminino , Idade Gestacional , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Análise de RegressãoRESUMO
OBJECTIVE: Accurate identification of preeclampsia (PE) at triage is essential to reduce maternal and fetal morbidity and mortality. The use of maternal blood based biomarkers may facilitate the clinician's ability to assess high risk pregnancies at triage. METHODS: A prospective cross-sectional study was performed to investigate the value of soluble fms-like tyrosine kinase-1 (sFlt-1), soluble endoglin (sEng), placental growth factor (PlGF), sP-selectin, cell-free fetal DNA and total cell-free DNA in patients with late-onset PE versus gestational age-matched controls. RESULTS: The diagnosis of late-onset PE (n = 21) at triage was significantly improved by altered levels of sFlt-1, sEng, PlGF and cffDNA as compared with controls (n = 42). Areas under the receiver operating characteristic curves [AUC, Standard error (SE)] for predicting PE were for marker measurements prior to the first stage of labor as follows: sFlt-1 0.97 (SE 0.02), sEng 0.91 (SE 0.04), PlGF 0.95 (SE 0.04), cell-free fetal DNA (DYS 14) 0.84 (SE 0.06), total cell-free DNA (glyceraldehyde 3-phosphate dehydrogenase) 0.61 (SE 0.07), sP-selectin 0.51 (SE 0.07). The discrimination could be slightly improved by using the slt1-PlGF ratio: 0.98 (SE 0.02). CONCLUSION: The sFlt-1 is a useful tool for the detection of late-onset PE at triage. This can be slightly improved using a sFlt-1/PIGF ratio. The addition of other biomarkers did not improve screening performance for late-onset PE.