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.

Maternal Serum Angiogenic Factor sFlt-1 to PlGF Ratio in Preeclampsia: A Useful Marker for Differential Diagnosis and Prognosis Evaluation in Chinese Women.

The ratio of soluble fms-like tyrosine kinase-1 to placental growth factor (sFlt-1/PlGF) is elevated and proved to be useful in preeclampsia (PE) diagnosis. Its value in differential diagnosis with other pregnancy complications and prediction of pregnancy duration has yet to be clarified in Chinese population. We retrospectively analyzed 118 singleton pregnancies with suspected or diagnosed PE at the Peking Union Medical College Hospital (PUMCH) in China. Among these, 62 pregnancies were diagnosed as PE (48 early onsets and 14 late onsets, with 39 and 5 severe PE, respectively), 12 gestational hypertension (GH), 15 chronic hypertension (chrHTN), 16 autoimmune diseases, and 13 pregnancies with uncomplicated proteinuria. And 76 normal pregnancies were included as control. The results showed (1) the sFlt-1/PlGF ratio in early onset PE subgroup was significantly higher than that in GH, chrHTN, and control groups; the sFlt-1/PlGF ratio in late onset PE subgroup was significantly higher than that in chrHTN and control groups, but similar as GH group; the sFlt-1/PlGF ratio was similar among GH, chrHTN, and control groups. (2) The sFlt-1/PlGF ratio was significantly increased in the PE group compared with autoimmune disease and uncomplicated proteinuria pregnancies. (3) By ROC curve analysis, the cutoff value of the sFlt-1/PlGF ratio was less than 21.5 to rule out PE and higher than 97.2 to confirm the diagnosis of PE. (4) The sFlt-1/PlGF ratio was higher in PE pregnancies delivering within 7 days than those more than 7 days, either in early onset PE or severe PE. In conclusion, we show that maternal sFlt-1/PlGF ratio is an efficient biomarker in the diagnosis and differential diagnosis of PE. This ratio can be used to predict the timing of delivery for PE pregnancies.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention.

Pre­eclampsia (PE) is a multisystem disorder that typically affects 2%­5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low­resource countries are at a higher risk of developing PE compared with those in high­resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two­stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an "at risk" group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new­onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 µmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia­platelet count <150 000/µL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro­Caribbean and South Asian racial origin; co­morbid medical conditions including hyperglycemia in pregnancy; pre­existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early­onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late­onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early­onset PE is associated with a much higher risk of short­ and long­term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre­eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first­trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high­quality evidence, the document outlines current global standards for the first­trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre­eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive­aged women, particularly in low­resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first­trimester combined test with maternal risk factors and biomarkers as a one­step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy­associated plasma protein A (PAPP­A) is measured for routine first­trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first­trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first­trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11­14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low­dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5­2 g elemental calcium/d) may reduce the burden of both early­ and late­onset PE.

[Preeclampsia: New Classifications]. / Präeklampsie: neue Definitionen.

Preeclampsia: New Classifications Abstract. Preeclampsia is a multisystem disease leading to systemic impairment of the maternal endothelial function. A dysbalance of pro- and antiangiogenic factors appears to be significantly involved. The vascular disease leads to the manifestation of symptoms such as arterial hypertension and involvement of end organs such as kidney, liver and brain. The classical diagnostic criterion for arterial hypertension, 'proteinuria' has been downgraded and is no longer obligatory for diagnosis, if other criteria, as maternal organ dysfunction or intrauterine growth retardation, are present. In addition, white-coat hypertension has been included in the classification of hypertension in pregnancy. To classify preeclampsia as 'mild' is being discouraged in the clinical setting to account for the possibility of rapid worsening with significant danger for mother and foetus.

Prediction of pre-eclampsia and its subtypes in high-risk cohort: hyperglycosylated human chorionic gonadotropin in multivariate models.

BACKGROUND: The proportion of hyperglycosylated human chorionic gonadotropin (hCG-h) to total human chorionic gonadotropin (%hCG-h) during the first trimester is a promising biomarker for prediction of early-onset pre-eclampsia. We wanted to evaluate the performance of clinical risk factors, mean arterial pressure (MAP), %hCG-h, hCGß, pregnancy-associated plasma protein A (PAPP-A), placental growth factor (PlGF) and mean pulsatility index of the uterine artery (Uta-PI) in the first trimester in predicting pre-eclampsia (PE) and its subtypes early-onset, late-onset, severe and non-severe PE in a high-risk cohort. METHODS: We studied a subcohort of 257 high-risk women in the prospectively collected Prediction and Prevention of Pre-eclampsia and Intrauterine Growth Restriction (PREDO) cohort. Multivariate logistic regression was used to construct the prediction models. The first model included background variables and MAP. Additionally, biomarkers were included in the second model and mean Uta-PI was included in the third model. All variables that improved the model fit were included at each step. The area under the curve (AUC) was determined for all models. RESULTS: We found that lower levels of serum PlGF concentration were associated with early-onset PE, whereas lower %hCG-h was associated with the late-onset PE. Serum PlGF was lower and hCGß higher in severe PE, while %hCG-h and serum PAPP-A were lower in non-severe PE. By using multivariate regression analyses the best prediction for all PE was achieved with the third model: AUC was 0.66, and sensitivity 36% at 90% specificity. Third model also gave the highest prediction accuracy for late-onset, severe and non-severe PE: AUC 0.66 with 32% sensitivity, AUC 0.65, 24% sensitivity and AUC 0.60, 22% sensitivity at 90% specificity, respectively. The best prediction for early-onset PE was achieved using the second model: AUC 0.68 and 20% sensitivity at 90% specificity. CONCLUSIONS: Although the multivariate models did not meet the requirements to be clinically useful screening tools, our results indicate that the biomarker profile in women with risk factors for PE is different according to the subtype of PE. The heterogeneous nature of PE results in difficulty to find new, clinically useful biomarkers for prediction of PE in early pregnancy in high-risk cohorts. TRIAL REGISTRATION: International Standard Randomised Controlled Trial number ISRCTN14030412 , Date of registration 6/09/2007, retrospectively registered.

Prevalencia de preeclampsia en embarazadas en el servicio de ginecología y obstetricia del Hospital Central del Instituto de Previsión Social, 2017 / Prevalence of preeclampsia in pregnant women in the gynecology and obstetrics service of the Central Hospital of the Social Security Institute, 2017

Introducción: Los trastornos hipertensivos son la primera causa de muerte materna en los países desarrollados y la tercera causa de muerte materna en los países en vías de desarrollo. La preeclampsia es una enfermedad de origen desconocido y multifactorial cuyo tratamiento definitivo es el parto, además de ser causal de repercusiones sobre la madre y el recién nacido. Objetivo: El objetivo general del estudio fue determinar la Prevalencia de preeclampsia en embarazadas en el servicio de ginecología y obstetricia del hospital central del instituto de previsión social, 2017. Materiales y métodos: Estudio observacional descriptivo retrospectivo de corte transversal, con muestreo no probabilístico de casos consecutivos. Fueron incluidas todas las embarazadas con preeclampsia que acudieron al Servicio de Ginecología y Obstetricia del Hospital Central de Instituto de Previsión Social en el periodo comprendido entre los meses de enero a diciembre del año 2017. Resultados: Se realizó un estudio observacional descriptivo retrospectivo en 375 pacientes que acudieron al Hospital Central del Instituto de Previsión Social en el año 2017. Los resultados arrojaron que el 38,4% presentó preeclampsia de las cuales 63,2% presentaba en preeclampsia leve y 36,8% presentaba preeclampsia severa Entre los factores de riesgo el que apareció en mayor cantidad fue la Hipertensión Arterial Crónica. En cuanto a las complicaciones maternas se presentan en mayoría Hepáticas, Neurológicas y Renales. Conclusión: Los resultados de este estudio realizado en un centro de referencia nacional y de alta complejidad coinciden con estudio previo, determina datos importantes acerca de la prevalencia de preeclampsia.

Clinical and pathogenetic features of early- and late-onset pre-eclampsia.

BACKGROUND: PE is present in ∼2-8% of all pregnant women worldwide. Placental bed disorders at early and late PE have been not carried out yet. However, these studies help to explore details of the pathogenesis of PE, and to optimize the prognosis and obstetric management. OBJECTIVE: To identify clinical and morphological differences between early- and late-onset PE based on a comprehensive observation of pregnant women with regard to morphological and immunohistochemical characteristics of the placental bed. MATERIALS AND METHODS: One hundred fifty patients aged 18-43 years old delivered by cesarean section due to severe PE. The samples of placental bed tissue were studied by morphological and immunohistochemical methods. RESULTS: The violation of invasion trophoblast, remodeling of spiral arteries were expressed in early onset PE; the degree of compensation of chronic hypoxia tissue in the area of the placental site was typical for late PE and was absent of an early onset PE. CONCLUSION: Our studies confirm the need for separation of early- and late-onset PE, being justified in terms of different pathogenetic mechanisms of formation, and therefore the possibility of therapeutic effects, duration of pregnancy prolongation, forecasting, search early diagnostic markers of the disease, and personalized approaches.

Hacia la detección temprana de la preeclampsia: parte 2 / By the early detection of preeclampsia: part 2

En esta parte del artículo se presenta un metanálisis en el que participaron 32.217 mujeres, en su mayoría con riesgo bajo o moderado de desarrollar PE, que reveló una reducción moderada (10%) pero sistemática del riesgo de parto pretérmino por PE antes de las 34 semanas de gestación, así como del número de embarazos con resultados adversos graves. Este metanálisis concluyó además que las mujeres multíparas con antecedentes de trastornos de hipertensión durante el embarazo pueden obtener beneficios incluso superiores. También se presenta una revisión de estudios relacionados con otros tratamientos

Hacia la detección temprana de la preeclampsia: Parte 1 / By the early detection of preeclampsia: part 1

La preeclampsia (PE) es una afección propia de las mujeres gestantes. Se define como un incremento de la presión sanguínea (hipertensión) inducido por el embarazo y la presencia de proteínas en la orina (proteinuria) que puede provocar eclampsia o convulsiones. Se estima que la PE afecta a 8.370.000 mujeres en todo el mundo cada año y es la principal causa de morbimortalidad materna, fetal y neonatal. En esta primer parte se describen directrices internacionales para su predicción y prevención...

Abnormal analyte preeclampsia: do the second-trimester maternal serum analytes help differentiate preeclampsia subtypes?

OBJECTIVE: To determine if serum screen analytes identify preeclamptic patients at risk for small-for-gestational age newborns, maternal laboratory abnormalities and preterm delivery (<37 weeks gestation). STUDY DESIGN: Using a retrospective cohort of 102 preeclamptic patients, associations between serum screen analytes and newborn birth-weight percentile, gestational age (GA) at delivery and maternal pre-delivery laboratory abnormalities were evaluated using correlation coefficients and local polynomial regression. RESULT: Inhibin-A and maternal serum alpha fetoprotein were inversely correlated with newborn birth-weight percentile (-0.27, P=0.006; -0.35, P=0.00004) and delivery GA (r=-0.42, P<0.0001; r=-0.26, P=0.008) and positively correlated with pre-delivery aspartate aminotransferase (r=0.22, P=0.03; r=0.21, P=0.04) and lactate dehydrogenase (r=0.33, P=0.0007; r=0.29, P=0.004). A positive correlation was noted between both second-trimester beta human chorionic gonadotropin and estriol and maternal pre-delivery creatinine (0.28, P=0.004; 0.4, P<0.0001, respectively). Hundred percent of patients with ≥ 2 abnormal analytes delivered before 37 weeks gestation. CONCLUSION: Preeclamptic patients with abnormal serum screen analytes are more likely to have small-for-gestational age newborns, deliver preterm and have pre-delivery laboratory abnormalities.

Avaliação do status de magnésio e da sua associação com o estresse oxidativo e as citocinas inflamatórias na pré-eclâmpsia / Assessment of the magnesium status and its association with oxidative stress and inflammatory cytokines in preeclampsia

O objetivo deste trabalho foi avaliar o status de magnésio (Mg) e a sua relação com o estresse oxidativo e as citocinas inflamatórias na pré-eclâmpsia (PE). Participaram do estudo, 18 gestantes saudáveis (controle - CT) e 18 gestantes com PE, diagnosticadas com pressão arterial >= 140/90 mmHg, proteinúria >= 0,3 g/24 h e sem doenças associadas. Sangue e urina de 24 horas foram coletados para análise de status de Mg, estresse oxidativo [malondialdeído (MDA), 8-isoprostano urinário e a atividade antioxidante das enzimas catalase (CAT) e glutationa peroxidase (GSH-Px)], a concentração de óxido nítrico (NO), e das citocinas inflamatórias [proteína C reativa, interleucina 6 (IL-6) e fator de necrose tumoral (TNF-α)]; Foi aplicado um questionário quantitativo de frequência alimentar para gestantes. As comparações entre os grupos foram feitas pelos testes Qui-quadrado, t-Student ou Mann Whitney. O coeficiente de correlação de Spearman foi usado para verificar associação entre as variáveis. A análise do Receiver Operating Characteristic (ROC) foi realizada para identificar as variáveis que melhor discriminassem os grupos (α=5%). As concentrações de Mg plasmático e eritrocitário, bem como a concentração de NO, a atividade da CAT e as concentrações de TNF-α e IL-6 foram maiores na PE do que no CT. Associações positivas entre o Mg plasmático e a proteinúria (p=0,04), o TNFα (p=0,03) e a IL-6 (p=0,02) foram verificadas; associações negativas foram encontradas entre a atividade da CAT e a concentração de 8-isoprostano urinário (p=0,02) e entre a atividade da GSH-Px e os níveis de pressão arterial diastólica (p=0,01). A análise ROC mostrou que o Mg plasmático e o TNF-α foram as variáveis que mellhor discriminaram as gestantes com PE das CT. Os resultados mostraram que o estresse oxidativo não foi evidente na fisiopatologia da PE, possivelmente devido aos mecanismos antioxidantes compensatórios do organismo. A inflamação e os eventos inerentes à PE, como vasoconstrição, podem ter promovido as alterações no status de Mg

The aim of this study was to assess the magnesium (Mg) status and its relationship with oxidative stress and inflammatory cytokines in preeclampsia (PE). Were included 18 healthy pregnant women (CT- control) and 18 PE, diagnosed with blood pressure >= 140/90 mmHg, proteinuria >= 0,3 g/24 h, and without other diseases. Blood and 24h urine were collected for analyses of the Mg status, oxidative stress [malondialdehyde (MDA), 8-isoprostane urinary and activities of the antioxidant enzymes: catalase (CAT) and glutathione peroxidase (GSH-Px)], nitric oxide (NO) and inflammatory cytokines concentrations [protein C reactive, interleukin 6 (IL-6), tumor necrosis factor-α (TNF-α); Furthermore, a quantitative food frequency questionnaire was applied to pregnant women. The comparisons between groups were done by Chi-square, t-Student or Mann Whitney tests. Spearman correlation coefficient was used to verify association among variables and the Receiver Operating Characteristic (ROC) analysis was performed to identify variables that better discriminated the groups (α = 5 %). The Mg concentration, in plasma and in erythrocyte, as well as NO concentration, CAT activity and TNF-α and IL-6 concentrations were higher in PE than CT group. Positive associations between plasma Mg and proteinuria (p=0,04), TNF-α (p=0,03) and IL-6 (p=0,02) were verified; Negative associations were found between CAT activity and 8-isoprostane urinary concentration (p=0,02) and between GSH-Px activity and diastolic blood pressure levels (p=0,01). ROC analyses showed that plasma Mg and TNF-α were the variables which better discriminate pregnant women with PE from CT. The results showed that oxidative stress was not evident in physiopathology of PE, possibly due to compensatory antioxidant mechanisms present in the body. The inflammatory and the events inherent to PE, such as vasoconstriction, possibly have promoted changes in Mg status

Embarazo complicado con hipertensión arterial en el Hospital Roatán, Honduras / Pregnancy-induced hypertension at Hospital Roatán, Honduras

La hipertensión arterial en el embarazo amenaza la salud y la vida del binomio madre-hijo; su diagnóstico oportuno es una prioridad. El objetivo de este estudio fue determinar la frecuencia del embarazo complicado con hipertensión arterial y factores de riesgo asociados en un grupo de mujeres de Roatón, Islas de la Bahia, Honduras, realizado entre diciembre de 2009 y marzo de 2010. Pacientes y Métodos: Descriptivo transversal cuyo universo poblacional fueron todas las mujeres embarazadas con 20 semanas de gestación que acudieron a la consulta externa y la emergencia del Hospital Roatón, realizado entre diciembre de 2009 y marzo de 2010, obteniendo una muestra de 28 mujeres embarazadas. Previo consentimiento informado, se utilizó una encuesta estructurada para recolectar la información. Resultados: Se encontró un 10.7% de embarazos complicados con hipertensión arterial de los cuales un 66.7% presentó hipertensión gestacional y 33.6% preeclampsia. Todas las embarazadas tenían acceso a la red de servicios de salud, de las cuales el 89% recibia el controlde embarazo por médico general en los centros de atención primaria del estado y las embarazadas complicadas eran referidas al servicio de Gineco-obstetricia del Hospital. El 32.1% eran primigestas, el 3.6% consumia alcohol y ninguna tabaco ni drogas ilícitas. Dentro de los antecedentes familiares el 32.1% tenían alguién familiar consanguíneo con hipertensión arterial, 21.4% diabetes mellitus y ninguna con preeclampsia,eclampsia u obesidad. Además de la hipertensión arterial, no se encontraron complicaciones maternas ni fetales relacionadas. Conclusión: En Roatón la frecuencia de embarazo complicado con hipertensión arterial es similar a lo reportado en la literatura, pero reflejan la necesidad de utilizar adecuadamente la hoja de atención prenatal, ya que es un documento ampliamente estructurado que permite identificar los factoresde riesgo tempranamente para prevenir las posibles complicaciones...

Pré-eclâmpsia precoce e tardia: uma classificação mais adequada para o prognóstico materno e perinatal? / Early-onset preeclampsia: is it a better classification for maternal and perinatal outcomes?

OBJETIVO: avaliar as diferenças entre o resultado materno e perinatal de gestações complicadas pela pré-eclâmpsia, segundo classificação em sua forma grave/leve e de início precoce/tardio. MÉTODOS: estudo retrospectivo envolvendo 211 gestações complicadas pela pré-eclâmpsia, avaliadas em centro universitário de referência, no período de 2000 a 2010. O diagnóstico e a gravidade da doença foram baseados nos valores da pressão arterial, proteinúria e nos achados clínicos e laboratoriais. A idade da gestante, cor da pele, paridade, pressão arterial, valores de proteinúria semiquantitativa, presença de incisura bilateral em artérias uterinas à doplervelocimetria e as condições de nascimento foram comparados entre os casos de forma leve/grave, assim como entre aqueles de surgimento precoce/tardio. A doença foi considerada precoce quando diagnosticada antes da 34ª semana. RESULTADOS: a maioria das gestantes apresentava a forma grave da pré-eclâmpsia (82,8 por cento) e 50,7 por cento, de início precoce. Os valores da pressão arterial (133,6±14,8 versus 115,4 mmHg, p=0,0004, e 132,2±16,5 versus 125,7 mmHg, p=0,0004) e proteinúria semiquantitativa (p=0,0003 e p=0,0005) foram mais elevados nas formas grave e precoce em relação às formas leve e tardia. O peso ao nascimento (1.435,4±521,6 versus 2.710±605,0 g, 1.923,7±807,9 versus 2.415,0±925,0 g, p<0,0001 para ambos) e o índice de Apgar (p=0,01 para ambos) foram menores nas formas grave e precoce da pré-eclâmpsia, em relação às formas leve e tardia. Por outro lado, a presença de incisura bilateral em artérias uterinas se associou às formas de início precoce (69,2 versus 47,9 por cento, p=0,02), enquanto a restrição de crescimento fetal foi mais frequente nas formas graves da pré-eclâmpsia (30 versus 4,4 por cento, p=0,008). CONCLUSÃO: a classificação da pré-eclâmpsia baseada em parâmetros clínicos maternos refletiu melhor as condições de nutrição fetal, enquanto o seu surgimento precoce se associou melhor à vasculopatia placentária detectada à doplervelocimetria.

PURPOSE: to evaluate the differences between the maternal and perinatal outcomes of pregnancies complicated by preeclampsia, according to the classification as the severe/mild form, and the early/late onset form. METHODS: a retrospective study with 211 pregnancies complicated by preeclampsia, assessed at a university reference center from 2000 to 2010. The diagnosis and disease severity were based on the values of blood pressure, proteinuria, and clinical and laboratory findings. The pregnant's age, skin color, parity, blood pressure, urine protein semiquantitative values, presence of bilateral notch in the uterine artery dopplervelocimetry and birth conditions were compared between patients with mild and severe disease, as well as between those of early/late onset. The disease was considered to be of early onset when diagnosed at less than 34 weeks of gestational age. RESULTS: most patients had the severe form of preeclampsia (82.8 percent), and the onset of the condition was early in 50.7 percent. Blood pressure values (133.6±14.8 versus 115.4 mmHg, p=0.0004 and 132.2±16.5 versus 125.7 mmHg, p=0.0004) and semiquantitative proteinuria (p=0.0003 and p=0.0005) were higher in the early and severe forms compared to mild and late forms. Infant birth weight (1,435.4±521.6 versus 2,710±605.0 g, 1,923.7±807.9 versus 2,415.0±925.0 g, p<0.0001 for both) and Apgar score (p=0.01 for both) were smaller for severe and early preeclampsia compared to mild and late preeclampsia. On the other hand, the presence of a bilateral notch in the uterine arteries was linked to the forms of early onset (69.2 versus 47.9 percent, p=0.02), whereas fetal growth restriction was more frequent in the severe forms of preeclampsia (30 versus 4.4 percent, p=0.008). CONCLUSION: the preeclampsia classification based on maternal clinical parameters better reflected the conditions of fetal nutrition, while the early onset of the condition was associated with placental vasculopathy detected by dopplervelocimetry.

Evidence for distinct preterm and term phenotypes of preeclampsia.

OBJECTIVE: To determine differences in maternal and fetal characteristics in pregnancies complicated by preterm versus term preeclampsia. METHODS: Using our electronic database we identified 143 women who met the American College of Obstetricians and Gynecologists criteria for preeclampsia between January 1995 and August 2003. We collected data on age, smoking status, maternal serum markers, and newborns. We compared the group delivering preterm (<37 weeks) with those delivering at term (> or =37 weeks). Analyses were based on ANOVA, Wilcoxon Rank Sum test, and chi-square test. Statistical significance was determined based on alpha = 0.05. Data are expressed as mean +/- SD unless otherwise indicated. RESULTS: Eighty women delivered preterm and 63 delivered at term. Women who delivered preterm with preeclampsia were younger, lighter, and were more likely to smoke cigarettes than those delivering at term with preeclampsia. Maternal liver enzyme concentrations were significantly greater in the preterm group. Newborn birthweight percentile (gestational age specific) was significantly lower for preterm preeclampsia. We found no significant differences in maternal platelet count, uric acid concentration, or newborn gender between groups. CONCLUSIONS: Differences exist in maternal and fetal characteristics between women who develop preterm preeclampsia and those who develop preeclampsia at term. These data support the hypothesis that multiple preeclamptic phenotypes exist.

Dilatação mediada por fluxo no diagnóstico diferencial da síndrome de pré-eclâmpsia / Dilatación mediada por flujo en el diagnóstico diferencial del síndrome de preeclampsia / Flow-mediated dilatation in the differential diagnosis of preeclampsia syndrome

FUNDAMENTO: A síndrome de pré-eclâmpsia se associa com a disfunção endotelial e o diagnóstico diferencial entre pré-eclâmpsia pura (PE) e sobreposta (PES) só pode ser feito após 12 semanas do parto. OBJETIVO: Comparar a avaliação da função endotelial através de dilatação mediada por fluxo de gestantes com pré-eclâmpsia pura e sobreposta. MÉTODOS: A dilatação mediada por fluxo da artéria braquial foi realizada utilizando as recomendações da International Brachial Artery Reactivity Task Force em gestantes com a Síndrome de Pré-eclâmpsia. Pré-eclâmpsia (n = 14) e pré-eclâmpsia sobreposta (n = 13) foram diagnosticadas no pós-parto segundo as definições do National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTADOS: A mediana da dilatação mediada por fluxo (DMF) na PES (6,0 por cento; 1,9-10,3) foi reduzida em comparação com PE (13,6 por cento; 4,4-17,1), uma disparidade aparentemente relevante, mas sem diferença estatisticamente significativa (p = 0,08). A DMF inferior a 10 por cento foi detectada em 30,8 por cento das PE e em 69,2 por cento das PES (p = 0,057). Diferenças significativas não ocorreram na comparação entre a morfologia das artérias uterinas de PE e PES através do espectro do Doppler. CONCLUSÃO: A DMF da artéria braquial de pacientes com Síndrome de Pré-eclâmpsia não se mostrou ser um método capaz de diferenciar PE de PES. Entretanto, os dados sugerem que PES se associa com pior função endotelial em comparação a PE.

BACKGROUND: The preeclampsia syndrome is associated with endothelial dysfunction and the differential diagnosis between pure preeclampsia (PE) and superimposed preeclampsia (SPE) can be only be attained 12 weeks after delivery. OBJECTIVE: To compare the assessment of endothelial function through flow-mediated dilatation in pregnant women with pure preeclampsia and superimposed preeclampsia. METHODS: The flow-mediated dilatation of the brachial artery was carried out according to the recommendations of the International Brachial Artery Reactivity Task Force in pregnant women with preeclampsia syndrome. PE (n=14) and SPE (n=13) were diagnosed in the postpartum period according to the definitions of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTS: The median of the flow-mediated dilatation (FMD) in SPE (6.0 percent; 1.9-10.3) was decreased in comparison with the PE (13.6 percent;4.4-17.1), an apparently relevant difference , but not statistically significant (p = 0.08). The FMD < 10 percent was detected in 30.8 percent of the PE cases and in 69.2 percent of the SPE cases (p = 0.057). Significant differences could not be detected in the morphology of the uterine arteries between the PE and SPE cases through the Doppler spectrum. CONCLUSION: The FMD of the brachial artery of patients with preeclampsia syndrome was not capable of differentiating between PE and SPE. However, the data suggest that SPE is associated with worse endothelial function I comparison to PE.

FUNDAMENTO: El síndrome de preeclampsia se asocia con la disfunción endotelial y el diagnóstico diferencial entre preeclampsia pura (PE) y sobreagregada (PES) sólo puede realizarse 12 semanas después del parto. OBJETIVO: Comparar la evaluación de la función endotelial a través de dilatación mediada por flujo en gestantes con preeclampsia pura y sobreagregada. MÉTODOS: La dilatación mediada por flujo de la arteria braquial se realizó utilizando las recomendaciones de la International Brachial Artery Reactivity Task Force en gestantes con Síndrome de Preeclampsia. La Preeclampsia (n = 14) y preeclampsia sobreagregada (n = 13) fueron diagnosticadas en el posparto según las definiciones del National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy. RESULTADOS: El promedio de la dilatación mediada por flujo (DMF) en la PES (6,0 por ciento; 1,9-10,3) fue reducido en comparación con la PE (13,6 por ciento; 4,4-17,1), una disparidad aparentemente relevante, pero sin diferencia estadísticamente significativa (p = 0,08). Una DMF inferior al 10 por ciento se detectó en el 30,8 por ciento de las PE y en el 69,2 por ciento de las PES (p = 0,057). No aparecieron diferencias significativas en la comparación entre la morfología de las arterias uterinas de PE y PES a través del espectro del Doppler. CONCLUSIÓN: La DMF de la arteria braquial de pacientes con Síndrome de Preeclampsia no demostró ser un método capaz de diferenciar PE de PES. No obstante, los datos sugieren que la PES se asocia a una peor función endotelial en comparación con la PE.

Morte materna por hipertensão no Estado de Santa Catarina / Maternal death rate related to hypertension in Santa Catarina State

Objetivo: Esse trabalho tem por objetivo avaliar o coeficiente de Morte Materna por hipertensão nos anos de 1996 a 2005 no estado de Santa Catarina. Métodos: Foi realizado um estudo descritivo retrospectivo. A fonte oficial relativa aos óbitos maternos estudados é o Sistema de Informações sobre Mortalidade, tendo sido utilizada as bases de óbitos de residentes em Santa Catarina no período de 1996 a 2005. O número de nascidos vivos foi obtido a partir da base de dados do Sistema de Informações sobre Nascidos Vivos. Calculou-se o Coeficiente de Mortalidade Materna geral e o relacionado a distúrbios hipertensivos e a porcentagem de óbitos relacionados aos distúrbios hipertensivos no total geral. Resultados: No período do estudo ocorreram 79 óbitos maternos relacionados à hipertensão. Esse número corresponde a 20 % do total de óbitos maternos ocorridos. O coeficiente de mortalidade materna geral no período do estudo foi de 43,3 por 100000 nascidos vivos e o de mortalidade materna relacionada à hipertensão foi de 8,6 por 100000 nascidos vivos. Conclusões: As mortes maternas por hipertensão ainda representam 20% das mortes maternas no estado. Sabe-se que as complicações da hipertensão gestacional são passíveis de prevenção com a ampliação da cobertura pré-natal, preparação do pessoal de assistência (incluindo atenção primária), diagnóstico precoce de pacientes de alto risco e um sistema de referência eficaz e rápido para centros de atenção terciária.

Objective: To evaluate the maternal death rate related to hypertension from 1996 to 2005 in Santa Catarina State. Methods: A retrospective descriptive study was made. The official source of maternal death is the Information System about Mortality. The database of deaths in Santa Catarina state from 1996 to 2005 was used. The number of born alive was gathered from the Information System about Born Alive databases. The general and hypertension maternal death rates are calculated along with the general death rate related to hypertension. Results: During the studied time 79 maternal deaths related to hypertension occurred. This number represents 20% of maternal deaths in the period. The general maternal death rate in the period was 43.3 by 100,000 born alive and the one related to hypertension was 8.6 by 100,000 born alive. Conclusions: Maternal deaths related to hypertension still represent 20% of maternal death in the state. It is known that the complications of gestational hypertension may be prevented by the broadening of prenatal coverage, training of personnel, early diagnosis of high risk patients and a quick and efficient reference system on the third health-attention level.