Predictors, prevalence and outcome of hypertensive disorders in pregnancy in Nigerian tertiary health facilities.

OBJECTIVE: Determine prevalence, risk factors and outcomes of hypertensive disorders in pregnancy (HDP). DESIGN: Cross-sectional analysis of data captured in the Maternal and Perinatal Database for Quality, Equity and Dignity (MPD-4-QED) between September 2019 and August 2020. SETTING: Fifty-four referral level facilities in Nigeria. POPULATION: Women whose pregnancy ended (irrespective of the location or duration of pregnancy) or who were admitted within 42 days of delivery. METHODS: Descriptive statistics and multilevel mixed-effects logistic regression models. MAIN OUTCOME MEASURES: Prevalence of HDP, sociodemographic and clinical factors associated with HDP and perinatal outcomes. RESULTS: Among the 71 758 women 6.4% had HDP and gestational hypertension accounted for 49.8%. Preeclampsia and eclampsia were observed in 9.5% and 7.0% of all pregnancies, respectively. The predictors of HDP were age over 35 years (OR1.96, 95% CI 1.82-2.12; p < 0.001), lack of formal educational (OR 1.18, 95% CI 1.06-1.32; p = 0.002), primary level of education (OR 1.20, 95% CI 1.03-1.4; p < 0.002), nulliparity (OR 1.21, 95% CI 1.12-1.31; p < 0.001), grand-multiparity (OR 1.36, 95%CI 1.21-1.52; p < 0.001), previous caesarean section (OR 1.26, 95%CI 1.15-1.38; p < 0.001) and previous miscarriage (OR 1.22, 95% CI 1.13-1.31; p < 0.001). Overall 3.7% of the patients with HDP died, with eclampsia having the highest case fatality rate of 27.9%. Stillbirth occurred in 11.9% of pregnancies with hypertensive disorders. CONCLUSIONS: Hypertensive disorders in pregnancy are not uncommon in Nigeria. They are associated with adverse outcomes with over one-quarter of women with eclampsia dying. The main predictors include older age, poor education, extremes of parity and previous CS or miscarriage. Maternal and perinatal outcomes are poor with about a quarter developing complications and about 1 in 10 having stillbirths.

Maternal hepatitis C virus infection and three adverse maternal outcomes in the United States.

BACKGROUND: Hepatitis Virus C (HCV) infection rates have trended upwards among pregnant people in the USA since 2009. Existing evidence about HCV infections and maternal outcomes is limited; therefore, we used birth certificate data to investigate the association between HCV infection and maternal health outcomes. METHODS: We used the 2017 US birth certificate dataset (a cross-section of 1.4 million birth records) to assess the association between prevalent HCV infection and gestational diabetes, gestational hypertension, and eclampsia. Potential confounding variables included prenatal care, age, education, smoking, presence of sexually transmitted infections (STIs), body mass index (BMI), and weight gain during pregnancy. We restricted our analysis to only women with a first singleton pregnancy. Odds ratios were estimated by logistic regression models and separate models were tested for white and Black women. RESULTS: Only 0.31% of the women in our sample were infected with HCV (n = 4412). In an unadjusted model, we observed a modest significant protective association between HCV infection and gestational diabetes (Odds ratio [OR]: 0.83; 95% CI: 0.76-0.96); but this was attenuated with adjustment for confounding variables (Adjusted odds ratio [AOR]: 0.88; 95% CI: 0.76, 1.02). There was no association between HCV and gestational hypertension (AOR: 1.03; 95% CI: 0.91, 1.16) or eclampsia (AOR: 1.15; 95% CI: 0.69, 1.93). Results from the race stratified models were similar to the non-stratified summary models. CONCLUSION: We observed no statistically significant associations between maternal HCV infection with maternal health outcomes. Although, our analysis did indicate that HCV may lower the risk of gestational diabetes, this may be attributable to confounding. Studies utilizing more accurately measured HCV infection including those collecting type and timing of testing, and timing of infection are warranted to ensure HCV does not adversely impact maternal and/or fetal health. Particularly in the absence of recommended therapy for HCV during pregnancy.

Prevalence of Preeclampsia in Brazil: An Integrative Review / Prevalência de pré-eclâmpsia no Brasil: Uma revisão integrativa

Abstract Objective To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. Methods We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. Results We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. Conclusion The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

Resumo Objetivo Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. Métodos Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. Resultados Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. Conclusão A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

Associations between residential proximity to oil and gas extraction and hypertensive conditions during pregnancy: a difference-in-differences analysis in Texas, 1996-2009.

BACKGROUND: Oil and gas extraction produces air pollutants that are associated with increased risks of hypertension. To date, no study has examined residential proximity to oil and gas extraction and hypertensive conditions during pregnancy. This study quantifies associations between residential proximity to oil and gas development on gestational hypertension and eclampsia. METHODS: We utilized a population-based retrospective birth cohort in Texas (1996-2009), where mothers reside <10 km from an active or future drilling site (n = 2 845 144.) Using full-address data, we linked each maternal residence at delivery to assign exposure and evaluate this exposure with respect to gestational hypertension and eclampsia. In a difference-in-differences framework, we model the interaction between maternal health before (unexposed) or after (exposed) the start of drilling activity (exposed) and residential proximity near (0-1, >1-2 or >2-3 km) or far (≥3-10 km) from an active or future drilling site. RESULTS: Among pregnant women residing 0-1 km from an active oil or gas extraction site, we estimate 5% increased odds of gestational hypertension [95% confidence interval (CI): 1.00, 1.10] and 26% increased odds of eclampsia (95% CI: 1.05, 1.51) in adjusted models. This association dissipates in the 1- to 3-km buffer zones. In restricted models, we find elevated odds ratios among maternal ages ≤35 years at delivery, maternal non-Hispanic White race, ≥30 lbs gained during pregnancy, nulliparous mothers and maternal educational attainment beyond high school. CONCLUSIONS: Living within 1 km of an oil or gas extraction site during pregnancy is associated with increased odds of hypertensive conditions during pregnancy.

Chorionic villus sampling and preeclampsia & eclampsia: coincidence or not?

OBJECTIVES: The purpose of the study is to investigate potential association of chorionic villus sampling (CVS) with subsequent development of preeclampsia (PE) and eclampsia (E). STUDY DESIGN: The development of PE and E was compared between two groups as follows: 1- CVS group: women who underwent CVS (n = 228) and 2- Control group: maternal and gestational age matched women without invasive prenatal diagnostic procedure (n = 456). Main outcome measures were incidence of PE (mild, severe) and E. RESULTS: The incidence of PE and E was not significantly different between CVS and control groups. There was no significant difference regarding mild and severe PE development between the two groups. The incidence of early- and late-onset PE was similar in CVS and control groups. CONCLUSIONS: CVS does not appear to increase the risk of PE and E. The spontaneous elevation of trophoblastic load in the maternal circulation rather than the iatrogenic elevation through CVS may contribute to the development of PE and E.

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.

Association of alcohol and other substance-related diagnoses with severe maternal morbidity.

BACKGROUND: Pregnant women with a substance-related diagnosis, such as an alcohol use disorder, are a vulnerable population that may experience higher rates of severe maternal morbidity, such as hemorrhage and eclampsia, than pregnant women with no substance-related diagnosis. METHODS: This retrospective cross-sectional study reviewed electronic health record data on women (aged 18-44 years) who delivered a single live birth or stillbirth at ≥ 20 weeks of gestation from March 1, 2016, to August 30, 2019. Women with and without a substance-related diagnosis were matched on key demographic characteristics, such as age, at a 1:1 ratio. Adjusting for these covariates, odds ratios and 95% confidence intervals were calculated. RESULTS: A total of 10,125 deliveries met the eligibility criteria for this study. In the matched cohort of 1,346 deliveries, 673 (50.0%) had a substance-related diagnosis, and 94 (7.0%) had severe maternal morbidity. The most common indicators in women with a substance-related diagnosis included hysterectomy (17.7%), eclampsia (15.8%), air and thrombotic embolism (11.1%), and conversion of cardiac rhythm (11.1%). Having a substance-related diagnosis was associated with severe maternal morbidity (adjusted odds ratio = 1.81 [95% CI, 1.14-2.88], p-value = 0.0126). In the independent matched cohorts by substance type, an alcohol-related diagnosis was significantly associated with severe maternal morbidity (adjusted odds ratio = 3.07 [95% CI, 1.58-5.95], p-value = 0.0009), while the patterns for stimulant- and nicotine-related diagnoses were not as well resolved with severe maternal morbidity and opioid- and cannabis-related diagnoses were not associated with severe maternal morbidity. CONCLUSION: We found that an alcohol-related diagnosis, although lowest in prevalence of the substance-related diagnoses, had the highest odds of severe maternal morbidity of any substance-related diagnosis assessed in this study. These findings reinforce the need to identify alcohol-related diagnoses in pregnant women early to minimize potential harm through intervention and treatment.

Increased risk of severe maternal morbidity among infertile women: analysis of US claims data.

BACKGROUND: Severe maternal morbidity continues to be an issue of national and global concern and is increasing in incidence. The incidence of infertility is also on the rise, and infertile women experience a higher risk of incident chronic medical disease and cancer, suggesting that fertility may serve as a window to a woman's overall health. OBJECTIVE: To investigate the risk of severe maternal morbidity by maternal fertility status. MATERIALS AND METHODS: This was a retrospective cohort analysis using Optum's de-identifed Clinformatics Data Mart Database between 2003 and 2015. Infertile women stratified by infertility diagnosis, testing, or treatment were compared to fertile women seeking routine gynecologic care. In both groups, only women who underwent pregnancy and delivery of a singleton during the follow-up period were included. Main outcomes were severe maternal morbidity indicators, defined by the Centers for Disease Control and Prevention and identified by International Classification of Diseases 10th Revision and Common Procedural Technology codes within 6 weeks of each delivery. Results were adjusted for maternal age, race, education, nulliparity, smoking, obesity, delivery mode, preterm birth, number of prenatal visits, and year of delivery. RESULTS: A total of 19,658 women comprised the infertile group and 525,695 women comprised the fertile group. The overall incidence of any severe maternal morbidity indicator was 7.0% among women receiving fertility treatment, 6.4% among women receiving a fertility diagnosis, 5.5% among women receiving fertility testing, and 4.3% among fertile women. Overall, infertile women had a significantly higher risk of developing any severe maternal morbidity indicator (adjusted odds ratio, 1.22; confidence interval, 1.14-1.31, P < .01) as well as a significantly higher risk of disseminated intravascular coagulation (adjusted odds ratio, 1.48; confidence interval, 1.26-1.73, P < .01), eclampsia (adjusted odds ratio, 1.37; confidence interval, 1.05-1.79, P < .01), heart failure during procedure or surgery (adjusted odds ratio, 1.54; confidence interval, 1.21-1.97, P < .01), internal injuries of the thorax, abdomen, or pelvis (adjusted odds ratio, 1.59; confidence interval, 1.12-2.26, P < .01), intracranial injuries (adjusted odds ratio, 1.77; confidence interval, 1.20-2.61, P < .01), pulmonary edema (adjusted odds ratio, 2.18; confidence interval, 1.54-3.10, P < .01), thrombotic embolism (adjusted odds ratio, 1.58; confidence interval, 1.14-2.17, P < .01), and blood transfusion (adjusted odds ratio, 1.50; confidence interval, 1.30-1.72, P < .01) compared to fertile women. Fertile women did not face a significantly higher risk of any maternal morbidity indicator compared to infertile women. In subgroup analysis by maternal race/ethnicity, the likelihood of severe morbidity was significantly higher among fertile black women compared to fertile white women. There was no difference between infertile black women and infertile white women after multivariable adjustment. CONCLUSION: Using an insurance claims database, we report that women diagnosed with infertility and women receiving fertility treatment experience a significantly higher risk of multiple indicators of severe maternal morbidity compared to fertile women. The increased risk of severe maternal morbidity noted among fertile black women compared to fertile white women is attenuated among infertile black women, who face risks similar to those of infertile white women.

Desenlaces materno-fetales de los embarazos con trastornos hipertensivos: un estudio transversal / Maternal and fetal outcomes of pregnancies with hypertensive disorders: a cross-sectional study

INTRODUCCIÓN Y OBJETIVO: Los trastornos hipertensivos asociados al embarazo son considerados un problema de salud pública. Se busca describir las características clínicas y desenlaces materno-fetales de las pacientes con esta patología, atendidas en el Hospital Universitario de Santander (HUS) durante el primer semestre de 2017. MÉTODOS: Estudio observacional retrospectivo de corte transversal. Se incluyeron las pacientes en estado de embarazo o puerperio con diagnóstico o sospecha de trastorno hipertensivo; se excluyeron aquellas que no pudieron ser clasificadas o no correspondían a éstos. RESULTADOS: Se analizaron 181 historias clínicas; la edad de las pacientes osciló entre 14 y 44 años; el 43,7% eran primigestantes; el 40,3% tuvo un control prenatal inadecuado y el 27,5% tenía antecedente de trastorno hipertensivo en gestaciones previas. El 75,1% de las pacientes fueron clasificadas como preeclampsia, 18,2% con hipertensión gestacional, 4,4% con hipertensión más preeclampsia sobreagregada y 2,2% con hipertensión crónica. El 16,9% de las pacientes con preeclampsia debutaron antes de la semana 34, de las cuales el 91,3% tenían criterios de severidad; mientras que entre las demás, el 84% presentaron criterios de severidad. CONCLUSIONES: La preeclampsia fue el trastorno hipertensivo más frecuente, predominó la presentación tardía y severa con importantes tasas de complicación maternas y fetales. Mediante la implementación de estrategias de detección temprana y adecuada atención de los trastornos hipertensivos asociados al embarazo podrían mejorarse los desenlaces materno-fetales.

BACKGROUND AND OBJECTIVE: Hypertensive disorders of pregnancy are considered a public health issue. The aim is to describe the clinical features, maternal - fetal outcomes of patients with this disease, who were admitted at the University Hospital of Santander (Bucaramanga, Colombia) during the first half of 2017. METHOD: Cross-sectional retrospective observational study. Patients in pregnancy or puerperium with diagnosis of hypertensive disorder were included; those who could not be classified or did not correspond were excluded. RESULTS: 181 clinical charts were analyzed, the age of the patients ranged between 14 and 44 years, 43.7% were nulliparous, 40.3% had an inadequate prenatal control and 27.5% had history of hypertensive disorder in previous pregnancies. 75.1% were classified as preeclampsia, 18.2% as gestational hypertension, 4.4% as hypertension and superimposed preeclampsia and 2.2% with chronic hypertension; 16.9% of the patients were of an early-onset preeclampsia before week 34, of which 91.3% had criteria of severity; among the others, 84% presented criteria of severity. CONCLUSION: Preeclampsia was the most frequent hypertensive disorder, late and severe presentation prevailed with important maternal and fetal complication rates. Through the implementation of early detection strategies and adequate care of hypertensive disorders associated with pregnancy maternal and fetal outcomes could be improved.

Risks of cause-specific mortality in offspring of pregnancies complicated by hypertensive disease of pregnancy.

BACKGROUND: Fetal environment has a substantial influence on an individual's health throughout their life course. Animal models of hypertensive disease of pregnancy have demonstrated adverse health outcomes among offspring exposed to hypertensive disease of pregnancy in utero. Although there are numerous descriptions of the neonatal, infant, and pediatric outcomes of human offspring affected by hypertensive disease of pregnancy, there are few data in US populations on later life outcomes, including mortality. OBJECTIVE: To assess risk for early mortality among offspring of pregnancies complicated by hypertensive disease of pregnancy. STUDY DESIGN: This is a retrospective cohort study of offspring born to women with singleton or twin pregnancies between 1947 and 1967 with birth certificate information in the Utah Population Database. We identified offspring from delivery diagnoses of gestational hypertension, preeclampsia, or eclampsia. Offspring from these pregnancies (exposed) were matched to offspring of pregnancies without hypertensive disease of pregnancy (unexposed) by maternal age at delivery, birth year, sex, and multiple gestation. We also identified unexposed siblings of exposed offspring for a separate sibling analysis. Mortality follow-up of all offspring continued through 2016, at which time they would have been 49-69 years old. Adjusted hazard ratios for cause-specific mortality comparing exposed with unexposed offspring were estimated using Cox proportional hazard models. RESULTS: We compared mortality risks for 4050 exposed offspring and 6989 matched unexposed offspring from the general population and 7496 unexposed siblings. Mortality risks due to metabolic, respiratory, digestive, nervous, and external causes of death did not differ between exposed and unexposed groups. Mortality risks from cardiovascular disease were greater in exposed offspring compared with unexposed offspring (adjusted hazard ratio, 1.57; 95% confidence interval, 1.16-2.12). In sex-specific models among the general population, cardiovascular disease mortality was significantly associated with exposure among male patients (adjusted hazard ratio, 1.92; 95% confidence interval, 1.27-2.88) but not among female patients (adjusted hazard ratio, 0.97; 95% confidence interval, 0.81-1.94). An interaction between hypertensive disease of pregnancy exposure and birth order on cardiovascular disease mortality was significant (P=.047), suggesting that the effect of hypertensive disease of pregnancy on cardiovascular disease mortality increased with higher birth order. Among siblings, the association between hypertensive disease of pregnancy exposure and cardiovascular disease mortality was not significant (adjusted hazard ratio, 1.39; 95% confidence interval, 0.99-1.95), and this was also true for sex-specific analyses of males (adjusted hazard ratio, 1.26; 95% confidence interval, 0.81-1.94) and females (adjusted hazard ratio, 1.71; 95% confidence interval, 0.96-3.04). As in the general population, there was a significant interaction between hypertensive disease of pregnancy exposure and birth order on cardiovascular disease mortality (P=.011). CONCLUSION: In a US population, overall mortality risks are greater for offspring of pregnancies complicated by hypertensive disease of pregnancy compared with unexposed offspring. Among siblings, there was not a significant association between hypertensive disease of pregnancy exposure and cardiovascular disease mortality.

Association of ATP2B1 gene polymorphism with incidence of eclampsia.

OBJECTIVE: The aim of this study was to analyze the association of ATPase plasma membrane Ca2+ transporting 1 (ATP2B1) gene polymorphism with the incidence of eclampsia, and to investigate the possible underlying mechanism. PATIENTS AND METHODS: ATP2B1 genotype and allele distributions in umbilical venous blood cells were analyzed in 50 control subjects and 117 eclampsia patients via Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and TaqMan genotyping technique. Meanwhile, the differences in the single nucleotide polymorphisms at rs2681472 and rs17249754 in the case group and control group were analyzed using the χ2-test. The risk factors for eclampsia were analyzed via univariate, multivariate, and Logistic regression analyses. Furthermore, the associations of rs2681472 gene polymorphism with risk factors for eclampsia (hypertension and lower extremity edema) were verified via χ2-test. RESULTS: The statistically significant differences were observed in the gestational week, body mass index, blood pressure, and incidence rates of proteinuria and lower extremity edema of pregnant women between the case group and the control group (p<0.05). Meanwhile, the genotype and allele distributions at rs2681472 in the case group were remarkably different from those of the control group (p<0.05). However, no evident differences were observed at rs17249754 between the two groups (p>0.05). According to univariate, multivariate, and logistic regression analyses, hypertension, and lower extremity edema were significantly associated with the incidence of eclampsia (p<0.05). In addition, the gene polymorphism at rs2681472 showed significant differences among subjects with and without hypertension and lower extremity edema (p<0.05). CONCLUSIONS: ATP2B1 gene polymorphism at rs2681472 shows significant differences between eclampsia patients and normal controls. Moreover, its gene polymorphism is closely related to the occurrence of hypertension and lower extremity edema.

Acute kidney injury in patients with HELLP syndrome.

PURPOSE: To evaluate the risk factors and renal prognosis of acute kidney injury (AKI) in patients with hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome. METHODS: Women with HELLP syndrome over a 15-year period at Peking Union Medical College Hospital, China, were retrospectively studied. RESULTS: A total of 108 patients with HELLP syndrome were included. Fifty-two (48.1%) patients were diagnosed with AKI (median serum creatinine, 139.72 µmol/L; range, 89.00-866.00); 11 (21.2%) required hemodialysis. The AKI group had significantly more multiparity (p = 0.034), hemorrhage > 400 mL (p = 0.027), severe systolic hypertension ≥ 160 mmHg (p = 0.005), infection (p < 0.001), and low hemoglobin (p = 0.002) than non-AKI patients. Multivariate logistic regression showed that infection (OR 36.441, 95% CI 3.819-347.732, p = 0.002), severe systolic hypertension (OR 5.295, 95% CI 1.795-15.620, p = 0.003), and low hemoglobin (OR 0.960, 95% CI 0.932-0.988, p = 0.006) were independent risk factors for AKI. Six patients with AKI died (mortality rate: 11.5%); no death occurred among patients without AKI. In addition to infection (OR 16.268, CI 1.334-198.385, p = 0.029) and eclampsia (OR 69.895, CI 2.834-1723.910, p = 0.009), elevated serum creatinine (OR 1.006, CI 1.001-1.011, p = 0.031) was an independent predictor of maternal mortality. Renal function in 43 (82.7%) patients completely recovered. Two (3.8%) patients developed chronic renal dysfunction after 1 to 2 years of follow-up. CONCLUSIONS: Elevated creatinine was an independent predictor of maternal mortality in HELLP syndrome. AKI severely affects renal prognosis and mortality in pregnant women. The occurrence of AKI was related to infection, severe hypertension, and renal ischemia.

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.

Pregnancy outcomes following nonobstetric surgery during gestation: a nationwide population-based case-control study in Taiwan.

BACKGROUND: Whether nonobstetric surgery during gestation is associated with a higher risk of spontaneous abortion or adverse delivery outcomes is still unclear. METHODS: We performed a retrospective case-control study using a Longitudinal Health Insurance Database (LHID 2000) containing claim-data of 1 million randomly selected beneficiaries. We compared the incidences and estimated the adjusted odds ratios (aOR) with 95% confidence interval (95% CI) for spontaneous abortion, adverse delivery outcomes, cesarean delivery, and prolonged hospital stay to determine the risk of adverse outcomes in women who had nonobstetric surgery during gestation as compared to those who did not have any surgery during gestation. RESULTS: After exclusion, we were left with 114,852 delivery and 3999 abortion cases in our study; and 462 (0.39%) of them had nonobstetric surgery under general or regional anesthesia during pregnancy. The leading surgeries were repair of cervical os (33.12%), appendectomy (17.32%), ovarian surgeries (13.64%), and fixation of fractured bone (8.01%).The risk of spontaneous abortion (4.23% vs. 2.43%, aOR:1.53; 95% CI: 1.01-2.31), antepartum hemorrhage (7.14% vs. 2.83%, aOR: 2.51; 95% CI: 1.74-3.61), pre-eclampsia/eclampsia (2.60% vs. 1.01%, aOR: 2.35; 95% CI: 1.30-4.23), gestational diabetes (2.38% vs. 0.69%, aOR: 3.12; 95% CI: 1.69-5.78), prematurity (9.06 vs. 4.90%, aOR: 3.31; 95% CI: 2.54-4.31), cesarean section (43.55% vs. 33.76%, aOR: 1.41; 95% CI: 1.17-1.71), and prolonged hospital stay (1.82% vs. 5.91%, aOR: 3.23; 95% CI: 2.16-4.83) were higher in those women who had nonobstetric surgery after adjusting for age and comorbidities. CONCLUSIONS: Nonobstetric surgery during gestation were associated with a higher risk of spontaneous abortion, adverse delivery outcomes, cesarean section, and prolonged hospital stay.

Complicaciones neurológicas en la materna crítica / Neurological complications in critically ill pregnant women

Introducción: Las pacientes obstétricas pueden presentar numerosas complicaciones que ponen en peligro sus vidas con necesidad de ingreso en unidades de cuidados intensivos. Objetivo: Caracterizar clínicamente las maternas críticas con complicaciones neurológicas. Métodos: Se realizó un estudio observacional, descriptivo, retrospectivo en el Hospital Clínico Quirúrgico Hermanos Ameijeiras durante el período de enero de 2007 a diciembre de 2016. Para el análisis de los datos se efectuó el cálculo de frecuencias absolutas y relativas, se aplicaron medidas de tendencia central (media) y dispersión (rango) y para conocer la posible asociación entre las variables cualitativas se aplicó el Test de chi-cuadrado con una significación de p<0,05. Resultados: Las complicaciones neurológicas se presentaron en 33,3 por ciento de las pacientes, las más frecuentes fueron: eclampsia (65,7 por ciento), infarto cerebral (9,0 por ciento) y la trombosis venosa cerebral (8,6 por ciento). Las nulíparas (51,4 por ciento) y la edad mayor de 35 años (42,8 por ciento) fueron los factores de riesgo más observados. La hipertensión arterial fue el antecedente patológico personal principal y se evidenció asociación entre las complicaciones neurológicas y la causa directa de la muerte (p=0,00043). Conclusiones: Las complicaciones neurológicas fueron frecuentes en las maternas críticas y constituyen causa directa de muerte. Como complicación más frecuente se presentó la eclampsia(AU)

Introduction: Obstetric patients can present numerous complications that put in danger their lives, and they need of admission in intensive care units. Objective: To characterize in a clinical way the critically ill pregnant women with neurological complications. Methods: An observational, descriptive, retrospective study was conducted in Hermanos Ameijeiras. Clinical-Surgical Hospital during the period from January, 2007 to December, 2016. There was carried out the calculation of absolute and relative frequencies for the analysis of the data; there were applied measures of central (average) trends and dispersion (range), and to know the possible association between the qualitative variables the Chi-square´s Test was performed with a significance of p < 0.05. Results: The neurological complications appeared in 33,3 percent of the patients and the most frequent were: eclampsia (65,7 percent), cerebral infarction (9,0 percent) and cerebral venous thrombosis (8,6 percent). Being a nulliparous women (51,4 percent) and age of more than 35 years (42,8 percent) were the most common risk factors. Arterial hypertension was the main pathological background and the association between the neurological complications and the direct cause of the death (p=0.00043) was demonstrated. Conclusions: The neurological complications were frequent in critically ill pregnant women and they constitute a direct cause of death. The most frequent complication was eclampsia(AU)

Prevalencia de Síndrome de Hellp en el servicio de ginecología y obstetricia del Hospital Central del Instituto de Previsión Social. 2017 / Prevalence of Hellp Syndrome in the gynecology and obstetrics service of the Central Hospital of the Instituto de Previsión Social

Introducción: En la actualidad, la mortalidad materna va aumentando, debido a ciertas complicaciones producidas durante la gestación, una de ellas es el Síndrome de HELLP que es considerada una de las complicaciones más severas de las enfermedades hipertensivas del embarazo que mayoritariamente se presenta en embarazadas que cursan con preeclampsia. Objetivo: Determinar la prevalencia de Síndrome de HELLP en el Servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social durante el año 2017. Materiales y método: Estudio observacional descriptivo de corte transversal, muestreo probabilístico aleatorio simple. Fueron incluidas las fichas clínicas de las embarazadas que acudieron al servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social desde enero a diciembre del 2017. Resultados: Fueron incluidas en el estudio 177 embarazadas; de las cuales el 14,2% presentó Síndrome de HELLP. La mediana de edad fue de 28 años; el estado civil predominante fue unión libre en un 49,15%; el 62,71% de las gestantes procedieron de áreas urbanas, mayoritariamente del departamento Central y el 33,90% de ellas son ama de casa. La edad gestacional estuvo comprendida predominantemente entre las 33,2 a 37,6 semanas; la mediana del número de controles prenatales fue de 5. Con respecto a las enfermedades hipertensivas del embarazo la mayor parte de las gestantes presentaron preeclampsia. Conclusión: La prevalencia de Síndrome de HELLP en las embarazadas que acudieron al servicio de Ginecología y Obstetricia en el Hospital Central del Instituto de Previsión Social durante el año 2017 fue del 14,2%; dato similar a otros estudios realizados.

Long-term Risk of a Seizure Disorder After Eclampsia.

OBJECTIVE: To evaluate the incidence rate and relative risk of a seizure disorder after eclampsia. METHODS: We evaluated 1,565,733 births in a retrospective data linkage cohort study in Ontario, Canada, from April 1, 2002, to March 31, 2014. We included females aged 15-50 years and excluded patients with epilepsy, conditions predisposing to seizure, and those who died within 30 days of the delivery discharge date. The exposure was defined as a hypertensive disorder of pregnancy, namely 1) eclampsia, 2) preeclampsia, or 3) gestational hypertension. The referent was an unaffected pregnancy. The primary outcome was the risk of seizure disorder starting 31 days after a hospital birth discharge. Risk was expressed as an incidence rate and a hazard ratio (HR) with 95% CI. The predefined study hypothesis was that women with eclampsia would have an increased risk of future seizure disorder. RESULTS: There were 1,615 (0.10%) pregnancies exclusively affected by eclampsia, 17,264 (1.1%) with preeclampsia, 60,863 (3.9%) with gestational hypertension, and 1,485,991 (94.9%) unaffected. A future seizure disorder was significantly more likely after a pregnancy with eclampsia (4.58/10,000 person-years) than a pregnancy without a hypertensive disorder of pregnancy (0.72/10,000 person-years; crude HR 6.09, 95% CI 2.73-13.60). The adjusted HR was minimally attenuated from 6.09 to 5.42 (95% CI 2.42-12.12) after multivariable adjustment for confounders at the index birth as well as adjusting for traumatic brain injury, stroke, cerebral tumor, aneurysm or hemorrhage, and multiple sclerosis. The risk of seizure disorder was doubled in pregnancies affected by preeclampsia (adjusted HR 1.96, 95% CI 1.21-3.17), but not by gestational hypertension (adjusted HR 1.01, 95% CI 0.71-1.43). CONCLUSION: Women with eclampsia should be reassured that, although the relative risk of a seizure disorder is higher than unaffected women, the absolute risk is extremely low (approximately one seizure/2,200 person-years).

First-trimester smoking cessation in pregnancy did not increase the risk of preeclampsia/eclampsia: A Murmansk County Birth Registry study.

BACKGROUND: Although prior studies have shown that smoking reduces preeclampsia/eclampsia risk, the consequence of giving up this habit during pregnancy should be assessed. The aims of the current study were threefold: (i) describe maternal characteristics of women with preeclampsia/eclampsia; (ii) examine a possible association between the number of cigarettes smoked daily during pregnancy and the development of this affliction; and (iii) determine if first-trimester discontinuation of smoking during pregnancy influences the risk. METHODS: A registry-based study was conducted using data from the Murmansk County Birth Registry (MCBR). It included women without pre-existing hypertension, who delivered a singleton infant during 2006-2011 and had attended the first antenatal visit before 12 week of gestation. We adjusted for potential confounders using logistic regression. RESULTS: The prevalence of preeclampsia/eclampsia was 8.3% (95%CI: 8.0-8.6). Preeclampsia/eclampsia associated with maternal age, education, marital status, parity, excessive weight gain and body mass index at the first antenatal visit. There was a dose-response relationship between the number of smoked cigarettes per day during pregnancy and the risk of preeclampsia/eclampsia (adjusted OR1-5 cig/day = 0.69 with 95%CI: 0.56-0.87; OR6-10 cig/day = 0.65 with 95%CI: 0.51-0.82; and OR≥11 cig/day = 0.49 with 95%CI: 0.30-0.81). There was no difference in this risk among women who smoked before and during pregnancy and those who did so before but not during pregnancy (adjusted OR = 1.10 with 95%CI: 0.91-1.32). CONCLUSIONS: Preeclampsia/eclampsia was associated with maternal age, education, marital status, parity, excessive weight gain, and body mass index at the first antenatal visit. There was a negative dose-response relationship between the number of smoked cigarettes per day during pregnancy and the odds of preeclampsia/eclampsia. However, women who gave up smoking during the first trimester of gestation had the same risk of preeclampsia/eclampsia as those who smoked while pregnant. Consequently, antenatal clinic specialists are advised to take these various observations into account when counselling women on smoking cessation during pregnancy.

Ingresos a Unidad de Cuidados Intensivos de mujeres durante el embarazo y periodo puerperal / Admission of women to an intensive care unit during pregnancy or the postpartum period

Introducción: las complicaciones del embarazo y parto constituyen las principales causas de muerte entre las mujeres en edad reproductiva. Las embarazadas o puérperas que ingresan a Unidad de Cuidados Intensivos (UCI) son en su mayoría casos agudos críticos con riesgo de muerte, que necesitan tratamiento especializa do y complejo. Constituyen un grupo significativo de la práctica obstétrica. Objetivo: determinar las características clínicas y demográficas de las pacientes gestantes o puérperas que ingresaron a UCI del Hospital Nacional de Itauguá durante 5 años (2011-2015) Materiales y métodos: diseño observacional descriptivo de corte trasverso. Fueron incluidas gestantes y puérperas que requirieron ingreso a UCI por complicaciones obstétricas y no obstétricas, descompensación materna, con y sin morbilidad previa. Resultados: necesitaron ingreso a UCI 135 pacientes (0,48%). La edad media fue 27 ± 6,7 años. La muestra estuvo conformada por 21 gestantes (15,5%), 85 puérperas (63%), 27 mujeres con post aborto (20%) y 2 con embarazo ectópico (1,5 %). La complicación obstétrica más frecuente que motivó el ingreso a UCI fue la sepsis y entre las no obstétricas la cardiopatía descompensada. El tiempo medio de internación en la UCI fue 6,47 ± 8,5 días y 50 pacientes (37,03%) necesitaron asistencia respiratoria mecánica. Hubo 19 óbitos (14%) Conclusiones: el ingreso a UCI se observó en 0,48%. La mortalidad en UCI fue 14%.

Introduction: complications of pregnancy and childbirth are the main causes of death among women of childbearing age. Pregnant women or postpartum women entering the Intensive Care Unit (ICU) are mostly acute cases with a high risk of death, which require specialized and complex treatment. They constitute a significant group of obstetric practice. Objective: to determine the clinical and demographic characteristics of the pregnant or puerperal patients who entered the ICU of the National Hospital of Itauguá for 5 years (2011-2015) Materials and methods: descriptive observational cross-sectional design. Pregnant women and postpartum women who required admission to the ICU due to obstetric and non-obstetric complications, maternal decompensation, with and without prior morbidity were included. Results: 135 patients required admission to the ICU. The mean age was 27 ± 6.7 years. The sample consisted of 21 pregnant women (15.5%), 85 postpartum women (63%), 27 women with post abortion (20%) and 2 with ectopic pregnancy (1.5%). The most frequent obstetric complication that led to ICU admission was sepsis and non-obstetric heart disease was decompensated. The mean ICU admission time was 6.47 ± 8.5 days and 50 patients (37.03%) required mechanical ventilation. There were 19 deaths (14%) Conclusions: ICU admission was observed at 0.48%. Mortality in ICU was 14%.