Ethnic, geographical and altitude considerations and maternal mortality associated with HELLP syndrome in Ecuador: a population-based cohort study.

BACKGROUND: Eclampsia and pre-eclampsia rank as the third leading causes of maternal death in Ecuador, following pre-existing chronic diseases and postpartum haemorrhage, as reported by the Ecuadorian National Institute of Statistics and Census (INEC). In contrast, HELLP (Haemolysis, Elevated Liver enzymes, Low Platelet count) syndrome remains underexplored epidemiologically, not only in Latin America but globally. This study marks the first population-based investigation into HELLP syndrome incidence and mortality in Ecuador, examining geographical variations, altitude influences and ethnic backgrounds. METHODS: Conducted as a retrospective population-based cohort study from 2015 to 2017, this research delves into the incidence, risk factors and maternal mortality associated with HELLP syndrome in Ecuador. Utilising data from INEC and the Ecuadorian Ministry of Health, we identified HELLP syndrome cases through ICD-10 (International Classification of Diseases, tenth revision) coding in hospitalised individuals. Logistic regression analysis was employed to explore association, whilst geospatial statistical analysis focused on cantons to identify significant spatial clusters. Primary outcome measures include HELLP syndrome incidence and maternal mortality, supplying crucial insights into the syndrome's impact on maternal health in Ecuador. RESULTS: The incidence of HELLP syndrome is 0.76 (0.69-0.84)/ 1000 deliveries. Afro-Ecuadorian communities have a higher risk (Odds Ratio (OR) = 2.18 (1.03-4.63)) compared to Indigenous Ecuadorian communities. Living at mid-level or high altitude is a significant risk factor OR of 2.79 (2.19-3.55) and an OR 3.61 (2.58-5.03), respectively. Being an older mother was also identified as a risk factor. Women living more than 20 km from the obstetric unit have an OR of 2.55 (2.05-3.18). Moreover, we found that cantons with higher crude HELLP syndrome incidence also have lower numbers of physicians (R = 0.503, p-value < 0.001). The mortality incidence of women with HELLP syndrome is 21.22 (12.05-20.59)/1000 deliveries with HELLP syndrome diagnoses. CONCLUSIONS: High altitude, advanced maternal age and geographical distance between residence and health centres are risk factors for HELLP syndrome. Maternal mortality in women with HELLP syndrome is higher than pre-eclampsia and eclampsia but comparable with previous reports in other countries.

HELLP syndrome and associated factors among pregnant women with preeclampsia/eclampsia at a referral hospital in southwestern Uganda: a cross-sectional study.

BACKGROUND: Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) syndrome, a complication of preeclampsia/eclampsia, is associated with severe maternal morbidity and mortality. In resource-limited settings, such as Uganda, gaps in routine laboratory assessments may lead to underdetection of HELLP syndrome. This study determined the prevalence and factors associated with HELLP syndrome among pregnant women with preeclampsia/eclampsia at Mbarara Regional Referral Hospital (MRRH), southwestern Uganda. METHODS: A cross-sectional study was conducted at the high-risk ward of the MRRH from December 2022 to June 2023. Pregnant women diagnosed with preeclampsia or eclampsia were enrolled consecutively. Participants' sociodemographic and clinical data were collected using an interviewer-administered questionnaire. The diagnosis of complete HELLP syndrome was made based on the Tennessee classification: aspartate aminotransferase enzyme ≥ 70 IU/L, platelet counts < 100,000 cells/µL, and serum lactate dehydrogenase enzyme ≥ 600 IU/L. We used multivariable modified Poisson regression analysis to determine factors associated with HELLP syndrome. RESULTS: A total of 129 participants with a mean age of 28 ± 6.6 years were enrolled in the study. The prevalence of HELLP syndrome was 18.6% (n = 24; 95% CI: 12.7-26.3%). Independent factors associated with HELLP syndrome were maternal age (adjusted prevalence ratio [aPR]: 4.96; 95% CI: 1.57-15.65; for mothers aged < 20 years compared to those aged 20-34 years), the presence of epigastric pain (aPR: 5.89; 95% CI: 1.41-14.63), and referral from other health facilities (aPR: 3.14; 95% CI: 1.27-7.72). CONCLUSION: Approximately 2 of the 10 women who presented with preeclampsia or eclampsia had HELLP syndrome. It is more common among teenage mothers, those with a history of epigastric pain and those referred from lower health facilities. Incorporating routine laboratory testing for HELLP syndrome in the diagnostic protocol for preeclampsia or eclampsia, especially among adolescent mothers, those experiencing epigastric pain, and those referred from lower health facilities, could enhance timely detection and management of mothers with preeclampsia whose pregnancies are complicated by HELLP syndrome.

Evaluation of outcomes and risk factors for recurrent preeclampsia in a subsequent pregnancy.

PURPOSE: The aim was to evaluate the pregnancy outcomes and identify risk factors for recurrent preeclampsia (PE). METHODS: Retrospective analysis of patients discharged with PE between January 1, 2010, and January 1, 2023, from two tertiary referral hospitals. They were classified into recurrent and non-recurrent groups based on the presence of PE in subsequent pregnancies. RESULTS: Among 519 women who had a subsequent pregnancy after a history of PE, 153 developed recurrent PE while 366 did not. The recurrent cases included 81 preterm PE, of which 41 were early-onset PE (EOPE). Recurrent PE correlated significantly with prior EOPE, HELLP syndrome, placental abruption, and stillbirth, as well as with current chronic hypertension (CH) and type 2 diabetes. The recurrent group showed a 5.8-fold higher risk of preterm birth (PTB) compared to the non-recurrent group (50.7% vs. 8.7%). Notably, 58.1% of the PTBs in the non-recurrent group were spontaneous. Logistic regression identified previous EOPE (aOR: 4.22 [95% CI: 2.50-7.13]) and current CH (aOR: 1.86 [95% CI: 1.09-3.18]) as independent contributors for recurrent PE. Furthermore, recurrent preterm PE shared the same risk factors: previous EOPE (aOR: 5.27 [95% CI: 2.82-9.85]) and current CH (aOR: 2.99 [95% CI: 1.57-5.71]). The morbidity of CH in subsequent pregnancy peaked at 31.9% when women with a history of EOPE delivered within three years. CONCLUSION: Previous EOPE and current CH were sequentially crucial risk factors for the development of PE and preterm PE during the next pregnancy. This may clarify risk stratification in prenatal management for women with a history of PE.

Value of proteinuria in evaluating the severity of HELLP and its maternal and neonatal outcomes.

BACKGROUND: HELLP syndrome refers to a group of clinical syndromes characterized by hemolysis, elevated liver enzymes and low platelet, and the evidence on the association between proteinuria and the severity of HELLP and its maternal and neonatal outcomes is rare. METHODS: 106 pregnant women were assigned to the proteinuric group (24-hUPro ≥ 0.3 g, 79 cases) and the non-proteinuric group (24-hUPro < 0.3 g, 27 cases). The proteinuric group was further divided into three subgroups: mild group (24-hUPro:0.3-2.0 g, 33 cases), moderate group (24-hUPro:2.0-5.0 g, 21 cases) and severe group (24-hUPro: ≥5.0 g, 25 cases). The general clinical data, laboratory indexes, complications and pregnancy outcome and adverse neonatal outcomes of HELLP with or without proteinuric were analyzed. RESULTS: Compared with proteinuric group, the non-albuminuric group or in the three proteinuric subgroups of HELLP pregnant women's, increased proteinuria was associated with earlier onset gestations, higher incidence of abdominal pain, skin jaundice, headache, blurred vision (p < 0.05 respectively), and also the higher levels of ALT, AST, LDH, Fib, APTT, ATII, proportions of tubular urine and lower levels of ALB, PLT (p < 0.05 respectively). In the three subgroups of the proteinuric group, the ratio of fetal growth restriction, cesarean section and postpartum hemorrhage were compared, and the difference was statistically significant (p < 0.05 respectively). Compared with the proteinuric group, the non-proteinuric group had higher birth weight, birth length, and lower SGA, admission rate in NICU (p < 0.05 respectively). In the three subgroups of the proteinuric group, significant differences were identified in the adverse outcomes of newborns (p < 0.05 respectively), and the incidence of adverse outcomes in neonates tended to be higher. Significant differences were identified in birth weight, birth length, and lower SGA and NICU occupancy rate among the three subgroups (p < 0.05 respectively). CONCLUSIONS: HELLP syndrome is a severe complication of pregnancy, involving multiple systems of the whole body. It has posed a great challenge to obstetricians for its acute onset, dangerous condition, rapid progress, and great harm. Thus, insights into HELLP syndrome should be gained, and early diagnosis, early treatment and timely termination of pregnancy should be conducted to reduce the incidence of maternal and fetal adverse outcomes and improve maternal and fetal prognosis.

Risk factors of intracranial haemorrhage in preeclampsia: a case-control study.

Intracranial haemorrhage (ICH) is an uncommon but one of the most devastating and potentially fatal complications of preeclampsia. Most ICHs in pregnancy are reported in the absence of a vascular lesion, and severe systolic hypertension is thought to be an important risk factor even though many reports suggest that ICH can complicate preeclampsia even at lower blood pressure levels. In this case-control study of preeclamptic women, risk factors associated with ICH were compared in women who did and did not develop ICH. During the study period, ICH occurred in 1.8% (42/2167) pregnancies with preeclampsia, with 45.2% (n = 19/42) resulting in maternal mortality. HELLP syndrome (OR = 11.5; 95% CI 3.8-34.8), multiparity (OR 3.2; 95% CI 1.4-7.7), nausea/vomiting (OR = 3.6; 95% CI 1.4-9.3), and lower educational attainment (OR = 38.2; 95% CI 3.5-423.6) were associated with the increased probability of ICH. The incidence of caesarean birth (n = 29, 74.4% vs. n = 161, 34.5%) and neonatal mortality (n = 4, 13.3% vs. n = 17, 4.0%) were higher among preeclamptic who have ICH compared to those who did not have it. Improving awareness as well as early identification of those at risk of preeclampsia and complications can limit the impact of ICH among pregnant women with preeclampsia, especially in low- to middle-income countries.

Preeclampsia and Severe Maternal Morbidity During the COVID-19 Pandemic: A Population-Based Cohort Study in Ontario, Canada.

OBJECTIVE: Significant changes to the delivery of obstetrical care that occurred with the onset of the COVID-19 pandemic may be associated with higher risks of adverse maternal outcomes. We evaluated preeclampsia/HELLP (hemolysis, elevated liver enzymes and low platelets) syndrome and composite severe maternal morbidity (SMM) among pregnant people who gave birth during the COVID-19 pandemic and compared these data with those of people who gave birth before the pandemic in Ontario, Canada. METHODS: This was a population-based, retrospective cohort study using linked administrative data sets from ICES. Data on pregnant people at ≥20 weeks gestation who gave birth between March 15, 2020, and September 30, 2021, were compared with those of pregnant people who gave birth within the same date range for the years 2015-2019. We used multivariable logistic regression to assess the effect of the pandemic period on the odds of preeclampsia/HELLP syndrome and composite SMM, adjusting for maternal baseline characteristics and comorbidities. RESULTS: There were no differences between the study periods in the adjusted odds ratios (aORs) for preeclampsia/HELLP syndrome among primiparous (aOR 1.00; 95% CI 0.91-1.11) and multiparous (aOR 0.94; 95% CI 0.81-1.09) patients and no differences for composite SMM (primiparous, aOR 1.00; 95% CI 0.95-1.05; multiparous, aOR 1.01; 95% CI 0.95-1.08). CONCLUSION: Adverse maternal outcomes were not higher among pregnant people who gave birth during the first 18 months of the COVID-19 pandemic in Ontario, Canada, when compared with those who gave birth before the pandemic.

Awareness of obstetricians for long-term risks in women with a history of preeclampsia or HELLP syndrome.

PURPOSE: Hypertensive disorders of pregnancy are still a leading cause of maternal and neonatal morbidity and mortality worldwide. Women with a history of preeclampsia have an increased risk for future cardiovascular and cerebrovascular disease, renal disease as well as diabetes mellitus. There is little knowledge on postpartum risk management. The aim of this study was to assess follow-up care for patients after pre-eclampsia or HELLP syndrome. METHODS: This questionnaire-based cross-sectional study aimed to evaluate the current recommendations of obstetricians in Austria regarding follow-up care, long-term risk counselling and risk of recurrence in future pregnancies after preeclampsia or HELLP syndrome. Data were collected using a survey, based on recommendations given by three substantial guidelines on hypertensive disorders of pregnancy, which was distributed via e-mail to 69 public obstetric departments in Austria. Each obstetric department was required to answer one questionnaire per local protocol. RESULTS: Our results revealed that of the 48 participating hospitals most obstetricians are aware of the importance of follow-up care for women after a pregnancy complicated by preeclampsia. Our data show that most physicians counselled patients about the future cardiovascular health risks associated with preeclampsia or HELLP syndrome (79.2%). Most obstetricians recommended lifestyle modification (77.1%) and continued blood pressure measurements (97.9%). All centers stated to counsel about the risk of recurrence (100%). However, counselling regarding follow-up care to exclude kidney damage (37.5%) and underlying diseases like thrombophilia (39.6%) were less prioritized. CONCLUSIONS: We were able to show that counselling concerning the risk of long-term cardiovascular disease and risk of recurrence after a pregnancy complicated by preeclampsia or HELLP syndrome has been established in obstetric departments in public hospitals. Regarding the evaluation of underlying chronic diseases such as thrombophilia or renal disease, as well as counselling on the future risk of renal disease is still improvable according to our data. Further evaluation of follow-up care after hypertensive disorders of pregnancy in the outpatient and private sector and implementation of structured guidelines for follow-up, as well as screening for cardiovascular disease are necessary to ensure adequate risk management and to provide opportunities for prevention.

[Comparison of clinical features in antepartum and postpartum HELLP syndrome].

Objective: To analyze the clinical features and pregnancy outcomes in antepartum and postpartum hemolysis, elevated live enzymes, and low platelet count syndrome(HELLP syndrome). Methods: A retrospective study was conducted to collect maternal and neonatal information of pre-eclampsia complicated with HELLP syndrome in Peking University First Hospital during the ten years from April 2009 to March 2019. A total of 83 pregnant women were included according to the Tennessee Classification System. They were then allocated into two groups based on the onset time of HELLP syndrome: antepartum HELLP syndrome group (n=70) and postpartum HELLP syndrome group (n=13). The clinical features, symptoms, laboratory biomarkers, and pregnancy outcomes were compared between the two groups. Results: Among the 83 pregnant women with HELLP syndrome, 70 occurred prenatally (84%, 70/83) and 13 occurred postpartum (16%, 13/83). The twin or triplet pregnancy rate in the postpartum HELLP syndrome group was significantly higher than that in the antepartum HELLP syndrome group [6/13 vs 6% (4/70), P=0.001]. The gestational weeks for HELLP onset and delivery in the postpartum HELLP syndrome group were significantly later than those in the antepartum HELLP syndrome group [(35.8±3.0) vs (31.5±5.2) weeks, P=0.025; (36.7±2.3) vs (32.2±5.0) weeks, P=0.002]. The incidence of early-onset pre-eclampsia in the antepartum HELLP syndrome group was significant higher than that in the postpartum HELLP syndrome group [64% (45/70) vs 2/13, P=0.002]. The quantitative of 24-hour proteinuria was significant higher in the antepartum HELLP syndrome group than that in the postpartum HELLP syndrome group [(4.8±5.1) vs (1.8±1.6) g, P=0.002]. But there were no statistical significances in the comparison of other laboratory test indexes (all P>0.05). There were no significant differences between the two groups in clinical symptoms, severe maternal complications, transfusion or adverse maternal outcomes (all P>0.05). Conclusions: Antepartum and postpartum HELLP syndrome have similar clinical symptoms and laboratory characteristics. Both antepartum and postpartum HELLP syndrome could lead to severe maternal complications, which should be paid special attention in clinical practice, especially to the postpartum HELLP syndrome.

Perinatal outcomes in women with elevated blood pressure and stage 1 hypertension.

BACKGROUND: Hypertension was redefined in 2017 with lower diagnostic thresholds; elevated blood pressure is defined as systolic blood pressure of 120 to 129 mm Hg with diastolic blood pressure of <80 mm Hg and stage 1 hypertension as systolic blood pressure of 130 to 139 mm Hg or diastolic blood pressure of 80 to 89 mm Hg. These guidelines did not include pregnant women. There is limited information on stage 1 hypertension and pregnancy outcomes. OBJECTIVE: This study aimed to determine whether elevated blood pressure and stage 1 hypertension as newly defined by the 2017 American College of Cardiology and the American Heart Association guidelines are associated with an increased risk of hypertensive disorders of pregnancy and other adverse maternal and neonatal outcomes. STUDY DESIGN: In this retrospective cohort study, 18,801 women with singletons from 2013 to 2019 were categorized as normotensive, prehypertensive (elevated blood pressure), stage 1 hypertensive, or chronic hypertensive. Women with ≥2 systolic blood pressures of 120 to 129 mm Hg before 20 weeks' gestation were classified into the elevated blood pressure group. Women with ≥2 systolic blood pressures of 130 to 139 mm Hg or ≥2 diastolic blood pressures of 80 to 89 mm Hg before 20 weeks' gestation were assigned to the stage 1 hypertension group. Women were classified as chronic hypertensives if they had any of the following: ≥2 systolic blood pressure of ≥140 mm Hg or ≥2 diastolic blood pressure of ≥90 mm Hg before 20 weeks' gestation, a history of chronic hypertension, or antihypertensive medication use before 20 weeks' gestation. Women with pregestational diabetes, lupus, or <2 blood pressures before 20 weeks' gestation were excluded. The association of stage 1 hypertension with the risk of developing hypertensive disorders of pregnancy was estimated using multivariate logistic regression controlling for maternal sociodemographic characteristics, gestational weight gain by prepregnancy body mass index, parity, and aspirin use. Secondary outcomes included subgroups of hypertensive disorders (gestational hypertension, preeclampsia, eclampsia, and hemolysis, elevated liver enzymes, and low platelet count syndrome), gestational diabetes, placental abruption, intrauterine growth restriction, preterm birth, neonatal intensive care unit admission, stillbirth and neonatal death, and maternal intensive care unit admission. All outcomes were adjusted for potential confounders. RESULTS: Of the 18,801 women, 13,478 (71.7%) were normotensive, 2659 (14.1%) had elevated blood pressure, 1384 (7.4%) were stage 1 hypertensive, and 1280 (6.8%) were chronic hypertensive. A dose-response relationship was observed: the risk of hypertensive disorders of pregnancy increased from 4.2% in normotensive women to 6.7% (adjusted odds ratio, 1.50; 95% confidence interval, 1.26-1.79) in women with elevated blood pressure, to 10.9% (adjusted odds ratio, 2.54; 95% confidence interval, 2.09-3.08) in women with stage 1 hypertension, and 28.4% (adjusted odds ratio, 7.14; 95% confidence interval, 6.06-8.40) in women with chronic hypertension. Compared with normotensive women, women with stage 1 hypertension had an increased risk of neonatal intensive care unit admissions (15.8% vs 13.0%; adjusted odds ratio, 1.21; 95% confidence interval, 1.03-1.42), preterm birth at <37 weeks' gestation (7.2% vs 5.2%; adjusted odds ratio, 1.45; 95% confidence interval, 1.16-1.81), and gestational diabetes (14.8% vs 6.8%; adjusted odds ratio, 2.68; 95% confidence interval, 2.27-3.17). CONCLUSION: Our study demonstrates that elevated blood pressure and stage 1 hypertension, using the 2017 American College of Cardiology and the American Heart Association guideline definition, are associated with increased maternal and neonatal risk. This group of women warrants further investigation to determine whether pregnancy management can be altered to reduce maternal and neonatal morbidity.

Hydroxychloroquine prophylaxis for preeclampsia, hypertension and prematurity in pregnant patients with systemic lupus erythematosus: A meta-analysis.

OBJECTIVES: This meta-analysis aimed to evaluate the effectiveness of HCQ in improving the maternal and fetal outcomes in pregnancies with SLE. METHODS: A literature search was conducted using PubMed, MEDLINE, EMBASE, and the Cochrane database for relevant English language articles, and Wanfang, CNKI and VIP for Chinese articles, from the databases' inception to April 30, 2020. These studies compared the maternal and/or fetal outcomes between pregnant patients with SLE who were administered HCQ during pregnancy (HCQ+ group) and those who were not administered HCQ (HCQ- group). Two investigators extracted the data and assessed the quality using the Newcastle-Ottawa Scale (NOS) and GRADE criteria independently. Odds ratio (OR) and 95% confidence intervals (CIs) were calculated. All statistical analyses were conducted using the Stata 12.0 software. RESULTS: Nine studies involving 1132 pregnancies were included in the study (3 case controls, 2 prospective cohorts, 4 retrospective cohorts). Preeclampsia, gestational hypertension, and prematurity were significantly lower in the HCQ+ group than in the HCQ- group (OR 0.35, 95% CI 0.21-0.59), (OR 0.41, 95% CI 0.19-0.89) and (OR 0.55, 95% CI 0.36-0.86), respectively. There were no significant differences in the rates of HELLP Syndrome (OR 0.88, 95% CI 0.19-3.96), gestational diabetes (OR 2.3, 95% CI 0.44-12.12), thrombotic events (OR 0.26, 95% CI 0.05-1.51), spontaneous abortion (OR 1.77, 95% CI 0.96-3.26), premature rupture of membranes (OR 0.58, 95% CI 0.24-1.39), oligohydramnios (OR 0.90, 95% CI 0.38-2.14), live birth (OR 1.22, 95% CI 0.60-2.47), stillbirth (OR 1.00, 95% CI 0.50-2.00), congenital malformation (OR 0.53, 95% CI 0.14-2.04), low birth weight (OR 0.77, 95% CI 0.43-1.39), intrauterine distress (OR 1.07, 95% CI 0.41-2.76,), intrauterine growth restriction (OR 0.57, 95% CI 0.06-5.43), or five-minute APGAR score <7 (OR 0.72, 95% CI 0.20-2.58) between the two groups. CONCLUSIONS: HCQ treatment during pregnancy could reduce the risk of preeclampsia, pregnancy hypertension and prematurity in SLE patients. The certainty of evidence is high but majority of the studies included are retrospective studies and not randomized controlled trials. Therefore, the multidisciplinary management of pregnant patients with SLE should promote HCQ use, irrespective of disease activity or severity.

The natural course of pregnancies in women with primary atypical haemolytic uraemic syndrome and asymptomatic relatives.

Pregnancy has been linked to various microangiopathies, including primary atypical haemolytic uraemic syndrome (aHUS). Complement dysregulation, often linked to rare variants in complement genes, is key for primary aHUS to manifest and may play a role in pregnancy complications of the mother and fetus. The burden of such complications is unknown, making counselling of women with primary aHUS and asymptomatic relatives difficult. We analyzed the maternal and fetal outcomes of 39 pregnancies from 17 women with primary aHUS and two asymptomatic relatives. Seven out of 39 pregnancies were complicated by pregnancy-associated aHUS. Five out of 32 pregnancies not linked to pregnancy-associated aHUS were complicated by pre-eclampsia or HELLP. Rare genetic variants were identified in 10 women (asymptomatic relatives, n = 2) who had a total of 14 pregnancies, including 10 uncomplicated pregnancies. Thirty-five out of 39 pregnancies resulted in live birth. Eight out of 19 women had progressed to end-stage kidney disease, with an incidence of 2·95 (95% confidence interval, 1·37-5·61) per 100 person-years after the first pregnancy. Thus, we emphasized the frequency of successful pregnancies in women with primary aHUS and asymptomatic relatives. Pregnancies should be monitored closely. Rare genetic variants cannot predict the risk of a given pregnancy.

Feto-maternal outcomes of hypertensive disorders of pregnancy in Yekatit-12 Teaching Hospital, Addis Ababa: a retrospective study.

BACKGROUND: In resource poor countries, hypertensive disorders of pregnancy are common and form one of the deadly triads, along with hemorrhage and infection, which contribute greatly to maternal and fetal jeopardy. METHODS: The aim of this study was to assess the prevalence of hypertensive disorders of pregnancy, and determine the effects of hypertensive disorders of pregnancy on the feto-maternal outcomes. It was a descriptive, cross-sectional, retrospective study on randomly selected 615 women who attended delivery at Yekatit-12 Teaching Hospital from 1st of July 2017 -1st of Jan 2018. Data was analyzed using SPSS version 20 software. Descriptive statistics were used to calculate rates. Chi-square statistics were used to estimate the associations among selected predictor variables. A p-value < 0.05 was taken as statistically significant. RESULTS: Out of the 615 study population, the prevalence of hypertensive disorders of pregnancy was found to be 25.4%, of which the majority (52.5%) was severe pre-eclampsia. Eclampsia accounted for 2.6%, and superimposed pre-eclampsia was 2.6%. The rate of severe pre-eclampsia with HELLP syndrome was 7.1% of all mothers with the hypertensive disorders. The majority of mothers with hypertensive disorders (59.6%) had age range of 25-34 years. About 46% of mothers required interventions to terminate the pregnancy either by cesarean section (42.3%) or instrumental deliveries (3.7%) due to conditions related to Hypertensive disorders. The rate of preterm, low birth weight, and low Apgar at 1st and 5thminutes accounted for 29.5, 24.4, 22.4 and 16.7% of neonates born to mothers with hypertensive disorders, respectively. Over 10.9% of neonates required resuscitation and 11.5% NICU referral. The rate of still birth was 3.8%. CONCLUSION: The prevalence of hypertensive disorders of pregnancy is high in the study area and complicates maternal and fetal outcomes of the pregnancy. To deter its detrimental effects both on fetal and maternal outcomes of pregnancy, antenatal surveillance should be expanded to enable early detection, stringent follow-up and timely intervention in severely affected pregnancies.

Effect of HELLP syndrome on acute kidney injury in pregnancy and pregnancy outcomes: a systematic review and meta-analysis.

BACKGROUND: HELLP syndrome may increase adverse pregnancy outcomes, though the incidence of it is not high. At present, the impact of HELLP syndrome on P-AKI (acute kidney injury during pregnancy) and maternal and infant outcomes is controversial. Thus, we conducted a meta-analysis to find out more about the relationship between HELLP syndrome and P-AKI and pregnancy outcomes. METHODS: We systematically searched PubMed, Embassy and Cochrane Databases for cohort studies and RCT to assess the effect of HELLP syndrome on P-AKI and maternal and infant outcomes. Study-specific risk estimates were combined by using fixed-effect or random-effect models. RESULTS: This meta-analysis included 11 cohort studies with a total of 6333 Participants, including 355 cases of pregnant women with HELLP syndrome and 5979 cases that without. HELLP syndrome was associated with relatively higher risk of P-AKI (OR4.87 95% CI 3.31 ~ 7.17, P<0.001), fetal mortality (OR1.56 95% CI 1.45 ~ 2.11, P<0.001) and Maternal death (OR3.70 95% CI 1.72 ~ 7.99, P<0.001). CONCLUSIONS: HELLP syndrome is associated with relatively higher risk of P-AKI, fetal mortality and maternal death.

Probability and outcomes of second pregnancy after HELLP syndrome in the first: A population-based registry study.

INTRODUCTION: Some studies have suggested that women may avoid further pregnancies after experiencing a pregnancy affected by a hypertensive disorder. Large population-based studies are needed to better understand the outcomes of later pregnancies among women who have a history of hypertensive disorders of pregnancy. The aims of the study were to assess outcomes of the second pregnancy and second delivery rate among women experiencing Hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome in their first pregnancy. MATERIAL AND METHODS: This population-based registry study included all women with a first delivery registered in the Medical Birth Registry of Norway from 1999 to 2014 (n = 418 897). Logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for adverse outcomes of the second delivery and the probability of no second delivery among women with HELLP syndrome in first pregnancy compared with women without HELLP syndrome. We also compared outcomes in the first and second pregnancies among women with HELLP syndrome in first. RESULTS: HELLP syndrome occurred in 0.24% of first pregnancies (n = 1006). Among women with HELLP syndrome in their first pregnancy, adverse outcomes were substantially less frequent in the second pregnancy: preterm deliveries declined from 56.0% to 14.2%, and small for gestational age from 6.6% to 2.8%. More than 75% had no hypertensive disorder in their second pregnancy. Still, compared with women without a history of HELLP syndrome, ORs for adverse outcomes in second pregnancies were increased: preterm birth (OR 3.7, 95% CI 2.8-4.8), small for gestational age (OR 2.7, 95% CI 1.6-4.8), perinatal death (OR 3.1, 95% CI 1.4-7.0), placental abruption (OR 4.2, 95% CI 1.8-9.4) and hypertensive complication (OR 8.3, 95% CI 6.7-10.3). HELLP syndrome did not influence the probability of a second delivery. CONCLUSIONS: Among women with HELLP syndrome in their first pregnancy, the occurrence of adverse pregnancy outcomes was substantially reduced in the second pregnancy. However, compared with unaffected women, they were still at greater risk of pregnancy complications.

Delivery or expectant management for prevention of adverse maternal and neonatal outcomes in hypertensive disorders of pregnancy: an individual participant data meta-analysis.

OBJECTIVE: Hypertensive disorders affect 3-10% of pregnancies. Delayed delivery carries maternal risks, while early delivery increases fetal risk, so appropriate timing is important. The aim of this study was to compare immediate delivery with expectant management for prevention of adverse maternal and neonatal outcomes in women with hypertensive disease in pregnancy. METHODS: CENTRAL, PubMed, MEDLINE and ClinicalTrials.gov were searched for randomized controlled trials comparing immediate delivery to expectant management in women presenting with gestational hypertension or pre-eclampsia without severe features from 34 weeks of gestation. The primary neonatal outcome was respiratory distress syndrome (RDS) and the primary maternal outcome was a composite of HELLP syndrome and eclampsia. The PRISMA-IPD guideline was followed and a two-stage meta-analysis approach was used. Relative risks (RR) and numbers needed to treat or harm (NNT/NNH) with 95% CI were calculated to evaluate the effect of the intervention. RESULTS: Main outcomes were available for 1724 eligible women. Compared with expectant management, immediate delivery reduced the composite risk of HELLP syndrome and eclampsia in all women (0.8% vs 2.8%; RR, 0.33 (95% CI, 0.15-0.73); I2  = 0%; NNT, 51 (95% CI, 31.1-139.3)) as well as in the pre-eclampsia subgroup (1.1% vs 3.5%; RR, 0.39 (95% CI, 0.15-0.98); I2  = 0%). Immediate delivery increased RDS risk (3.4% vs 1.6%; RR, 1.94 (95% CI 1.05-3.6); I2  = 24%; NNH, 58 (95% CI, 31.1-363.1)), but depended upon gestational age. Immediate delivery in the 35th week of gestation increased RDS risk (5.1% vs 0.6%; RR, 5.5 (95% CI, 1.0-29.6); I2  = 0%), but immediate delivery in the 36th week did not (1.5% vs 0.4%; RR, 3.4 (95% CI, 0.4-30.3); I2 not applicable). CONCLUSION: In women with hypertension in pregnancy, immediate delivery reduces the risk of maternal complications, whilst the effect on the neonate depends on gestational age. Specifically, women with a-priori higher risk of progression to HELLP, such as those already presenting with pre-eclampsia instead of gestational hypertension, were shown to benefit from earlier delivery. © 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.

Liver disease in pregnancy: Medical aspects and their implications for mother and child.

Liver disease during pregnancy is more common than expected and may require specialized intervention. It is important to determine if changes in liver physiology may develop into liver disease, to assure early diagnosis. For adequate surveillance of mother-fetus health outcome, liver disease during pregnancy might require intervention from a hepatologist. Liver diseases have a prevalence of at least 3% of all pregnancies in developed countries, and they are classified into two main categories: related to pregnancy; and those non- related that are present de novo or are preexisting chronic liver diseases. In this review we describe and discuss the main characteristics of those liver diseases associated with pregnancy and only some frequent pre-existing and co-incidental in pregnancy are considered. In addition to the literature review, we compiled the data of liver disease occurring during pregnancies attended at the National Institute of Perinatology in Mexico City in a three-year period. In our tertiary referral women hospital, liver disease was present in 11.24 % of all pregnancies. Associated liver disease was found in 10.8% of all pregnancies, mainly those related to pre-eclampsia (9.9% of pregnancies). Only 0.56% was due to liver disease that was co-incidental or preexisting; the acute or chronic hepatitis C virus was the most frequent in this group (0.12%). When managing pregnancy in referral hospitals in Latin America, it is important to discard liver alterations early for adequate follow up of the disease and to prevent adverse consequences for the mother and child.

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.

Severe maternal morbidity and maternal near miss in a tertiary hospital of Delhi.

Background: In addition to maternal mortality, information on maternal near miss and severe maternal morbidity are important in maternal healthcare. We aimed to determine the incidence, causes and outcome of severe maternal morbidity and near miss, and the sociodemographic and obstetric factors associated with these at a tertiary care teaching hospital in Delhi. Methods: Women admitted with severe maternal morbidity and near miss, as defined by the WHO study group, were included in the study. The incidence ratio of near miss and severe morbidity in the hospital was determined, and a case-control study was conducted to study the factors associated with the occurrence of near miss. Information was obtained from hospital records and interviews, using a semi-structured open-ended questionnaire. Results: The incidence ratio of near miss was 6.85/ 1000, and severe morbidity was 11.38/1000 live births. Hypertensive disorders and haemorrhage were the common causes of cases of near miss and severe morbidity. Coagulation dysfunction (62%) was the most common organ dysfunction, followed by uterine dysfunction (22%). Older age (odds ratio [OR] 2.01, confidence interval [CI] 1.02-3.93), the absence of formal education (OR 2.05, CI 1.11-3.75), <18 years of age at marriage (OR 2.01, CI 1.21-3.32), lower income (OR 3.8, CI 1.88-7.64), gravida of four or more (OR 2.25, CI 1.21-4.17) and residence outside Delhi (OR 9.31, CI 4.36-19.90) were significant predictors of near miss. Sepsis, hypertensive disorders and haemorrhage were the most common underlying conditions in women who died. The foetal outcome was a live birth in 64% of near-miss cases and 62% among severe morbidity. Conclusions: The burden of severe maternal morbidity and near miss is high. These need to be identified and managed at the earliest.

Increased Risk of Pregnancy Complications After Stroke: The FUTURE Study (Follow-Up of Transient Ischemic Attack and Stroke Patients and Unelucidated Risk Factor Evaluation).

BACKGROUND AND PURPOSE: The study goal was to investigate the prevalence of pregnancy complications and pregnancy loss in women before, during, and after young ischemic stroke/transient ischemic attack. METHODS: In the FUTURE study (Follow-Up of Transient Ischemic Attack and Stroke Patients and Unelucidated Risk Factor Evaluation), a prospective young stroke study, we assessed the occurrence of pregnancy, miscarriages, and pregnancy complications in 223 women aged 18 to 50 years with a first-ever ischemic stroke/transient ischemic attack. Pregnancy complications (gestational hypertension, diabetes mellitus, preeclampsia, and hemolysis, elevated liver enzymes, low platelet count syndrome) were assessed before, during, and after stroke using standardized questionnaires. Primary outcome was occurrence of pregnancy complications and the rate of pregnancy loss compared with the Dutch population. Secondary outcome was the risk of recurrent vascular events after stroke, stratified by a history of hypertensive disorder in pregnancy. RESULTS: Data were available for 213 patients. Mean age at event was 39.6 years (SD=7.8) and mean follow-up 9.5 years (SD=8.5). Miscarriages occurred in 35.2% and fetal death in 6.2% versus 13.5% and 0.9% in the Dutch population, respectively (P<0.05). In nulliparous women after stroke (n=22), in comparison with Dutch population, there was a high prevalence of hypertensive disorders in pregnancy (33.3 versus 12.2%; P<0.05), hemolysis, elevated liver enzymes, low platelet count syndrome (9.5 versus 0.5%; P<0.05), and early preterm delivery <32 weeks (9.0 versus 1.4%; P<0.05). In primi/multiparous women (n=141) after stroke, 29 events occurred (20-year cumulative risk 35.2%; 95% confidence interval, 21.3-49.0), none during subsequent pregnancies, and a history of a hypertensive disorder in pregnancy did not modify this risk (log-rank P=0.62). CONCLUSIONS: When compared with the general population, women with young stroke show higher rates of pregnancy loss throughout their lives. Also, after stroke, nulliparous women more frequently experienced serious pregnancy complications.

Long-term mortality risk and life expectancy following recurrent hypertensive disease of pregnancy.

BACKGROUND: Women with a history of hypertensive disease of pregnancy have increased risks for early mortality from multiple causes. The effect of recurrent hypertensive disease of pregnancy on mortality risk and life expectancy is unknown. OBJECTIVE: We sought to determine whether recurrent hypertensive disease of pregnancy is associated with increased mortality risks. STUDY DESIGN: In this retrospective cohort study, we used birth certificate data to determine the number of pregnancies affected by hypertensive disease of pregnancy for each woman delivering in Utah from 1939 through 2012. We assigned women to 1 of 3 groups based on number of affected pregnancies: 0, 1, or ≥2. Exposed women had ≥1 affected singleton pregnancy and lived in Utah for ≥1 year postpartum. Exposed women were matched 1:2 to unexposed women by age, year of childbirth, and parity. Underlying cause of death was determined from death certificates. Mortality risks by underlying cause of death were compared between exposed and unexposed women as a function of number of affected pregnancies. Cox regressions controlled for infant sex, gestational age, parental education, ethnicity, and marital status. RESULTS: We identified 57,384 women with ≥1 affected pregnancy (49,598 women with 1 affected pregnancy and 7786 women with ≥2 affected pregnancies). These women were matched to 114,768 unexposed women. As of 2016, 11,894 women were deceased: 4722 (8.2%) exposed and 7172 (6.3%) unexposed. Women with ≥2 affected pregnancies had increased mortality from all causes (adjusted hazard ratio, 2.04; 95% confidence interval, 1.76-2.36), diabetes (adjusted hazard ratio, 4.33; 95% confidence interval, 2.21-8.47), ischemic heart disease (adjusted hazard ratio, 3.30; 95% confidence interval, 2.02-5.40), and stroke (adjusted hazard ratio, 5.10; 95% confidence interval, 2.62-9.92). For women whose index pregnancy delivered from 1939 through 1959 (n = 10,488), those with ≥2 affected pregnancies had shorter additional life expectancies than mothers who had only 1 or 0 hypertensive pregnancies (48.92 vs 51.91 vs 55.48 years, respectively). CONCLUSION: Hypertensive diseases of pregnancy are associated with excess risks for early all-cause mortality and some cause-specific mortality, and these risks increase further with recurrent disease.