Systematic review of postpartum and pregnancy-related cervical artery dissection.

BACKGROUND: Cervical artery dissection (CeAD) is responsible of one fifth of cases of ischemic stroke, but is uncommon during pregnancy or the early postpartum period and evidence is derived from published case reports and case series. OBJECTIVES: This systematic review with a prospectively registered protocol was conducted to study the clinical presentation, management and prognosis of this condition. METHODS: Ovid-Medline, PubMed Central, and CINAHL were searched without language restriction. RESULTS: Fifty-seven articles (50 case reports and seven case series) reporting on 77 patients were included. The mean age was 33.7 years. The main possible risk factors identified were migraine, hyperlipidemia, connective tissue disorders, preeclampsia and eclampsia, HELLP syndrome and prolonged second stage of labor. Headache was the most frequent symptom, followed by neck pain. Acute medical treatments included anticoagulation, antiplatelets, and endovascular therapy. No patients received thrombolysis. The overall prognosis was good with 77.8% of patients making full clinical recovery. CONCLUSIONS: Cervical artery dissection is a rare, but an important complication of pregnancy and puerperium. Diagnosis requires a high index of suspicion. The strong association with hypertensive and connective tissue disorders requires further research.

Hypertension in pregnancy: Prevalence, risk factors and outcomes for women birthing in Ireland.

OBJECTIVES: The purpose of this study was to identify the number of pregnancies affected by hypertension in Ireland and report on possible risk factors and adverse pregnancy outcomes for women and their babies. STUDY DESIGN: Data on maternity hospital discharges for women giving birth in Ireland in 2016 were extracted from the national Hospital In-Patient Enquiry data system. Women with a diagnosis of a hypertensive disorder of pregnancy were identified using relevant ICD codes. Descriptive statistics were used to present prevalence, and Pearson's Chi-square and multivariable regression analyses were conducted to identify risk factors and pregnancy outcomes. Differences between proportions were analysed by Pearson's Chi-squared test of independence. RESULTS: Of 60,188 maternities reported for the year 2016, 5.9% of women (n = 3531) had a hypertensive disorder of pregnancy and 4.6% (n = 2790) had pre-eclampsia. Rates were higher among women with pre-existing diabetes, gestational diabetes, obesity and those aged ≥40 years. After adjusting for maternal age, pre-existing DM, GDM, obesity and tobacco use, obesity (AOR 4.3; 95% CI: 3.2-5.7; p < 0.001), pre-existing diabetes (AOR 3.5; 95% CI: 2.5-4-9; p < 0.001), gestational diabetes (AOR 1.5; 95% CI: 1.3-1.8; p < 0.001) and being aged ≥40 years (AOR 1.5; 95% CI: 1.3-1.7; p < 0.001) remained significantly associated with being diagnosed with a hypertensive disorder of pregnancy in the Republic of Ireland. CONCLUSION: In Ireland where maternal age at childbirth is increasing, the association of hypertension with advancing age will undoubtedly contribute to a greater prevalence of hypertensive disorders of pregnancy and their potential adverse outcomes for pregnant women and their babies. This retrospective study highlights the prevalence rates in Ireland while also identifying possible risk factors and associated adverse pregnancy outcomes. They pinpoint the need for further research to look in more detail at risk factors and adverse outcomes for the 79% (n = 2790) of women presenting with pre-eclampsia among this large nationally representative sample of 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.

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.

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.

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%.

Caracterización de las pacientes con síndrome HELLP / Characterization of patients with HELLP syndrome

Introducción: el síndrome HELLP es una complicación de los trastornos hipertensivos del embarazo. Objetivo: identificar las características de las pacientes que padecen este trastorno. Métodos: se realizó un estudio descriptivo de corte transversal y retrospectivo en el Hospital Osio de Cua, Municipio Urdaneta, estado Miranda en la República Bolivariana de Venezuela desde la creación de la Unidad de Cuidados Intensivos (UCI), periodo comprendido desde Septiembre del 2010 hasta Junio del 2012. La muestra la integraron 35 pacientes que ingresaron en la unidad con diagnóstico de Síndrome HELLP o que durante su estadía fueron diagnosticadas con esta patología. La fuente primaria de obtención de datos fue la historia clínica y registro de la Unidad de Cuidados Intensivos. Resultados: encontramos como factores predominantes la edad materna entre 20 y 29 años (57,14 por ciento); la edad gestacional al momento de la interrupción del embarazo entre 28 y 34 semanas (42,87 por ciento). Los motivos del ingreso que más se hallaron fueron la epigastralgia y cifras tensionales elevadas. Por el conteo de plaquetas (48, 58 por ciento) el HELLP tipo II fue el más frecuente, en 80 por ciento de las pacientes, las cifras de hemoglobina fueron inferiores a 100g/l y 88,58 por ciento tuvo los niveles de transaminasas elevadas, también 82,85 por ciento de los valores del perfil renal se comportó por encima de lo normal. Durante el embarazo la enfermedad se presentó en 75 por ciento de las mujeres. Conclusión: el Síndrome HELLP es un proceso patológico que puede presentarse en el embarazo o en el puerperio(AU)

Introduction: HELLP syndrome is a complication of hypertensive disorders in pregnancy. Objective: To identify the characteristics of patients who suffer it. Methods: A retrospective, cross-sectional and descriptive study was carried out in Hospital Osio de Cua, Urdaneta municipality, state of Miranda in the Bolivarian Republic of Venezuela since the creation of the intensive care unit in the period of September 2010 through June 2012. The sample was made up of 35 patients who were admitted to the unit with diagnosis of HELLP syndrome or were so diagnosed during their stay at hospital. The primary data source was the medical history and the intensive care unit records. Results: The predominant factors were found to be maternal age of 20 to 29 years (57.14 percent) and gestational age of 28 to 34 weeks (42.87percent) at the time of pregnancy cessation. The most frequent causes of admission were epigastralgia and high blood pressure figures. According to the platelet count (48.58 percent), the most common type was HELLP II; 80 percent of patients showed hemoglobin values lower than 100g/l and 88.58 percent had high transaminase levels whereas 82.85 percent of the renal profile values were over the normal figures. During pregnancy, the disease affected 75 percent of studied females. Conclusions: HELLP syndrome is a pathological process that may occur in pregnancy or in puerperium(AU)

Prevalencia del síndrome de HELLP en gestantes críticas: Maternidad "Dr. Armando Castillo Plaza", Maracaibo, Venezuela / Prevalence of HELLP syndrome in critical pregnant women: Maternity "Dr. Armando Castillo Plaza", Maracaibo, Venezuela

OBJETIVO: Determinar la prevalencia de síndrome de HELLP (SH) en gestantes críticamente enfermas ingresadas a la Unidad de Cuidados Intensivos Obstétricos (UCIO) de la Maternidad "Dr. Armando Castillo Plaza", de Maracaibo, estado Zulia, Venezuela, periodo 2011 a 2015. MÉTODOS: Investigación descriptiva con diseño retrospectivo, donde se revisaron las historias clínicas de gestantes ingresadas a la UCIO con diagnóstico de SH, analizándo sus características clínicas y epidemiológicas. RESULTADOS: Hubo una prevalencia del 13,60% (111/816), tasa de letalidad de 1,23% (10/8l6) y tasa de mortalidad materna específica de 15,08/100.000 nacidos vivos. Las características clínicas más prevalentes fueron: edad 25,8 ± 6,9 años, estancia en UCIO 4,76 ± 4,46 días, embarazos pretérminos 69,37%, antecedentes de abortos 24,32%, primíparas 42,34%, control prenatal ausente o inadecuado, embarazos simples 95,5%, preeclámpticas 67,57%, antecedentes de condiciones preexistentes 47,75%, sin hábitos como tabaco o alcohol 81,99%, ingresaron embarazadas 89,19% y cesárea 74,77%. Se diagnosticaron mayoritariamente casos de SH incompleto (56,76%), siendo las complicaciones más observadas la disfunción hematológica (98,2%), disfunción hepática (91,9%) y disfunción renal (70,3%). CONCLUSIÓN: La prevalencia de SH resultó más elevada que lo reportada en estudios nacionales e internacionales, presentando características clínicas y epidemiológicas que deben ser consideradas para su prevención y diagnóstico precoz.

AIMS: To determinate the prevalence of HELLP syndrome (HS) in critical pregnant women admitted to the Obstetrics Intensive Care Unit (OICU) of the "Maternidad Dr. Armando Castillo Plaza", in Maracaibo, Zulia state, Venezuela, during 2011 to 2015. METHODS: A descriptive research with retrospective design was due, in which were reviewed the clinical files of all pregnant admit into the OICU complicated with HS, was analyzed establish the clinical and epidemiological features. RESULTS: We found a prevalence of 13.60% (111/816), fatality rate of 1.23% (10/816) and specific maternal mortality rate of 15.08/100,000 live births. The most prevalent clinical characteristics were: age 25.8 ± 6.9 years, stay in UCIO 4.76 ± 4.46 days, pre-terms pregnancies (69.37%), history of abortions (24.32%), primiparous (42.34%), absent or inadequate prenatal care, singleton pregnancies (95.50%), preeclampsia (67.57%), history of pre-existing conditions (47.75%), without habits such as tobacco or alcohol (81.99%), admitted pregnant (89.19%) and cesarean section (74.77%). Also, were mainly diagnosed cases of incomplete HS (56.76%); the most observed com-plications were hematologic dysfunction (98.2%), liver dysfunction (91.9%) and renal dysfunction (70.3%). CONCLUSION: The prevalence of HELLP syndrome was higher than reported in national and international studies, presenting clinical and epidemiological characteristics that should be considered for prevention and early diagnosis.

Near miss materno em unidade de terapia intensiva: aspectos clínicos e epidemiológicos / Maternal near miss in the intensive care unit: clinical and epidemiological aspects

RESUMOObjetivos:Analisar o perfil clínico epidemiológico de mulheres com near miss materno segundo os novos critérios da Organização Mundial da Saúde.Métodos:Foi realizado um estudo descritivo, tipo corte transversal, analisando- se os prontuários das pacientes admitidas na unidade de terapia intensiva obstétrica de um hospital terciário do Recife (Brasil), em um período de quatro anos. Foram incluídas as mulheres que apresentavam pelo menos um dos critérios de near miss. As variáveis estudadas foram: idade, raça/cor, estado civil, escolaridade, procedência, número de gestações e consultas de pré-natal, complicações e procedimentos realizados, via de parto, idade gestacional no parto e critérios de near miss materno. A análise descritiva foi executada utilizando-se o programa Epi-Info 3.5.1.Resultados:Foram identificados 255 casos de near miss materno, totalizando uma razão de near miss materno de 12,8/1.000 nascidos vivos. Dentre esses casos, 43,2% das mulheres apresentavam ensino fundamental incompleto; 44,7% eram primigestas e 20,5% tinham realizado cesariana prévia. Quanto aos diagnósticos específicos, houve predominância dos distúrbios hipertensivos (62,7%), sendo que muitos deles foram complicados pela síndrome HELLP (41,2%). Os critérios laboratoriais de near miss foram os mais observados (59,6%), em função, principalmente, da elevada frequência de plaquetopenia aguda (32,5%).Conclusões:Evidenciou-se uma frequência elevada de mulheres com baixa escolaridade e primigestas. Com os novos critérios propostos pela Organização Mundial da Saúde, os distúrbios hipertensivos da gestação continuam sendo os mais comuns entre os casos de near miss materno. Destaca-se ainda a elevada frequência da síndrome HELLP, o que contribuiu para que a trombocitopenia aguda fosse o critério mais frequente de near miss.

ABSTRACTObjective:To analyze the epidemiological clinical profile of women with maternal near miss according to the new World Health Organization criteria.Methods:A descriptive crosssectional study was conducted, in which the records of patients admitted to the obstetric intensive care unit of a tertiary hospital in Recife (Brazil) over a period of four years were analyzed. Women who presented at least one near miss criterion were included. The variables studied were age, race/color, civil status, education, place of origin, number of pregnancies and prenatal consultations, complications and procedures performed, mode of delivery, gestational age at delivery, and maternal near miss criteria. The descriptive analysis was performed using the program Epi-Info 3.5.1.Results:Two hundred fifty-five cases of maternal near miss were identified, with an overall ratio of maternal near miss of 12.8/1,000 live births. Among these cases, 43.2% of the women had incomplete primary education, 44.7% were primiparous, and 20.5% had undergone a previous cesarean section. Regarding specific diagnoses, there was a predominance of hypertensive disorders (62.7%), many of which were complicated by HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (41.2%). The laboratory near miss criteria were the most often observed (59.6%), due mainly to the high frequency of acute thrombocytopenia (32.5%).Conclusions:A high frequency of women who had a low level of education and who were primiparous was observed. According to the new criteria proposed by the World Health Organization, hypertensive pregnancy disorders are still the most common among maternal near miss cases. The high frequency of HELLP syndrome was also striking, which contributed to acute thrombocytopenia being the most frequent near miss criterion.

Prediction of obstetrical risk using maternal serum markers and clinical risk factors.

OBJECTIVE: Abnormal maternal serum analytes (pregnancy associated plasma protein A, total human chorionic gonadotropin, alpha fetoprotein, Inhibin A, and unconjugated estriol) measured as part of aneuploidy screening programs have been associated with adverse obstetrical outcomes in euploid pregnancies. This study aimed to determine if their predictive ability could be enhanced with additional information on obstetrical history. METHOD: Forty-five thousand two hundred eighty-seven women participated in the screening program and delivered euploid singleton infants between 2010 and 2012 in British Columbia, Canada. A split-sample design was used to develop and validate prognostic models for serious perinatal events (stillbirth, preterm birth <32 weeks, or HELLP syndrome) and severe pre-eclampsia [pre-eclampsia with preterm birth <34 weeks or small for gestational age <10th percentile] using logistic regression. RESULTS: Three thousand five hundred four women (7.7%) had at least one abnormal marker using standard cut-off values. The combination of serum markers and clinical risk factors improved the ability of statistical models to predict a serious perinatal event [area under the curve (AUC) = 0.62] and severe pre-eclampsia (AUC = 0.78) compared with serum markers or clinical risk factors alone. CONCLUSIONS: While detection rates are low, the combination of maternal serum markers and obstetrical history helps to identify a small subset of women at higher risk for serious perinatal events and severe pre-eclampsia.

Spectrum of kidney diseases in patients with preeclampsia-eclampsia.

AIM: The aim of this study was to analyse the clinical spectrum of renal manifestation of preeclampsia in pregnant women. METHOD: Diagnosis of preeclampsia was made using two cardinal feature of the disease after 20th weeks of gestation in previously normotensive and nonproteinuric women: (1) Blood pressure > 140/90 mm Hg and (2) urinary protein excretion of > 300 mg/24 hour. The patients with renal manifestations were followed up to 12 weeks postpartum or till death whichever was earlier. RESULT: Of 1805 pregnant women, preeclampsia was diagnosed in 106 (5.87%) patients. Primiparity constitutes 53.77% of total patients. Hypertension and proteinuria were observed in all patients. Hyperuricemia was observed in 93.65% of cases. Acute renal failure occurred in 22 patients. Dialysis support was needed in only four cases of ARF with complete recovery of renal function in 82% of cases. HELLP syndrome was seen in 16 (preeclampsia 5; eclampsia 11) patients. Sixty six patients (Death 13 and lost to follow up 27) were followed for 12 weeks. The renal parameters (Hypertension, Proteinuria and renal function) returned to normal in all except in two patients. Renal biopsy in these two cases revealed FSGS and MPGN in one each. CONCLUSION: The incidence of preeclampsia was 5.87%. Nephrotic syndrome was observed in 11.32% of patients. Acute renal failure occurred in 20.8% of patients. Hypertension, proteinuria and renal function resolved to normal over a average period of 35.8 days in all survivors. The overall mortality was 12%. Neurological complication, pulmonary edema and multiple organ failure were the causes of death.

Estudio comparativo de la morbimortalidad del producto gestacional en mujeres embarazadas con preeclampsia modera o severa / Comparative study of morbimortality of gestational product in pregnant women with mild or severe preeclampsia

INTRODUCCION: La preeclampsia es una enfermedad exclusiva de la gestación humana, que afecta a la embarazada produciendo una disfunción vascular. OBJETIVO: Comparar la morbimortalidad del producto gestacional en mujeres embarazadas con preeclampsia (PE) moderada o severa. PACIENTES Y METODO: Estudio de tipo no experimental, descriptivo, por causa-efecto, de carácter retrospectivo. La población estudiada correspondió a toda paciente que sufrió PE, subclasificada en dos grupos; pacientes con PE moderada y pacientes con PE severa. El estudio se realizó en la Clínica Hospital del Profesor en el período comprendido entre junio del año 2007 y junio del año 2008. Se analizaron variables clínicas del recién nacido y de la embarazada. Los resultados obtenidos fueron analizados por medio de las pruebas de comparación de medias poblacionales y comparación de proporciones poblacionales. RESULTADOS: De un total de 1680 embarazos registrados en la Clínica Hospital del Profesor, 42 fueron diagnosticados con síndrome hipertensivo del embarazo (SHE), correspondiendo a un 2,5 por ciento. 28 (66 por ciento) correspondieron a PE moderada, 13 (32 por ciento) correspondieron a PE severa. El retardo del crecimiento intrauterino (RCIU) presentó diferencia significativa con un p< 0,05. El sufrimiento fetal agudo (SFA) y la mortalidad fetal, no presentaron diferencia significativa con un p> 0,05. CONCLUSION: Si bien las diferencias clínicas para el diagnóstico de preeclampsia moderada y severa son claras, las complicaciones que pueden traer al producto de la gestación no presentan diferencia, salvo al analizar el RCIU.

INTRODUCTION: Preeclampsia is an exclusive disease of human gestation, that affects pregnant women producing vascular dysfunction. AIM: Compare the morbid-mortality of the gestational product in pregnant women with mild or severe preeclampsia (PE). PATIENT AND METHODS: Retrospective, descriptive, non experimental, cause-effect study. The studied subjects were women that suffered with PE, sub-classified in two groups, mild PE patients and severe PE patients. The study was made in the “Clínica Hospital del Profesor” from June 2007 to June 2008. Different clinical parameters from the newborn and the pregnant were analyzed. The results were analyzed by the comparison of population and population ratio tests. RESULTS: From a total of 1680 pregnant women registred in the “Clínica Hospital del Profesor”, 42 were diagnosed pregnancy-induced hypertension / gestational hypertension, which represents 2.5 percent of all pregnancies. 28 (66 percent) represents to a moderate PE, 13(32 percent) represents to a severe PE. Intrauterine growth restriction presented a significant difference with an p< 0,05. The acute fetal suffering and fetal mortality didn’t have a significant difference with an p> 0,05. CONCLUSION: Although the clinical differences for the diagnose of mild and severe PE are clear, the complications that may ocurre to the product of the pregnancy don’t present a significant difference, except for the intrauterine growth restriction, that presented a significant difference with an alpha = 0,05.

Association between tumor necrosis factor (TNF)-alpha G-308A gene polymorphism and preeclampsia complicated by severe fetal growth restriction.

BACKGROUND: Preeclampsia and HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome are multifactorial disorders with genetic and environmental components. Given that the tumor necrosis factor (TNF)-alpha G-308A single nucleotide polymorphism (SNP) affects TNF-alpha gene transcription and that preeclampsia and HELLP syndrome are characterized by a shift towards a Th1-type maternal immune response with increased TNF-alpha production, the aim of the current study was to investigate whether this SNP is associated with preeclampsia and HELLP syndrome in a Caucasian population from Hungary. Additionally, we aimed to examine whether TNF-alpha G-308A polymorphism can influence the risk for fetal growth restriction in preeclamptic patients, which issue none of the earlier studies dealt with. METHODS: In a case-control study, we analyzed blood samples from 140 preeclamptic patients, 69 patients with HELLP syndrome and 144 normotensive, healthy pregnant women using the polymerase chain reaction (PCR)-restriction fragment length polymorphism (RFLP) method. We performed also a meta-analysis with our results and those of 8 previously published studies. RESULTS: There were no significant differences in the genotype and allele frequencies of the TNF-alpha G-308A polymorphism between preeclamptic patients and normotensive, healthy pregnant women. However, the mutant (TNF2 or A) allele occurred significantly more frequently in preeclamptic patients with IUGR than in those without IUGR (18.5% versus 7.1%, p=0.003). In addition, the frequency of the mutant allele carriers was significantly higher among preeclamptic patients with IUGR compared to those without IUGR (30.6% versus 12.8%, p=0.010). The mutant allele carriers were found to have an increased risk of severe IUGR-complicated preeclampsia, which was independent of maternal age, prepregnancy BMI and primiparity (odds ratio (OR): 2.89, 95% confidence interval (CI): 1.16-7.22, p=0.023; adjusted OR: 2.78, 95% CI: 1.04-7.45, p=0.042). Nevertheless, no significant differences were detected in the genotype and allele frequencies of the TNF-alpha G-308A polymorphism between patients with HELLP syndrome and control subjects. In the meta-analysis, no association was observed between this SNP and preeclampsia (summary OR: 0.956, 95% CI: 0.693-1.319). CONCLUSIONS: Although the meta-analysis demonstrated a lack of an overall association between TNF-alpha G-308A polymorphism and preeclampsia, our results suggest a role of this SNP in the risk of severe IUGR-complicated preeclampsia. However, further studies are required with a larger sample size to confirm our findings.

Síndrome HELLP: diagnóstico e conduta / HELLP Syndrome: diagnosis and management

A síndrome HELLP é definida pela presença de hemólise, elevação de enzimas hepáticas e trombocitopenia em gestante com toxemia. Sua incidência é estimada em aproximadamente 20 porcento dos casos de pré-eclampsia grave e está associada a grande morbidade materna e perinatal. O diagnóstico laboratorial da síndrome HELLP constitui temática controversa, não havendo consenso tanto quanto aos testes como aos valores a serem utilizados. A conduta das gestantes com síndrome HELLP deve levar em consideração a idade gestacional, a presença de complicações maternas, a vitalidade fetal e as condições do colo uterino. O tratamento ideal, assim como em qualquer caso de toxemia, é o parto. Recentemente, tem-se aventado que a utilização de altas doses de corticóides pode melhorar o desfecho materno, além do já comprovado benefício fetal.

Síndrome HELLP: experiencia del Hospital Regional de Puerto Montt, 2000-2006 / HELLP syndrome: Hospital Regional of Puerto Montt experience, 2000-2006

Objetivos: Caracterizar el síndrome HELLP en una población obstétrica de la décima Región de Chile. Método: Análisis de 33 pacientes con síndrome HELLP asistidas en el hospital de Puerto Montt, en el período 2000-2006. Resultados: La incidencia fue 1,3 casos por mil partos. La edad gestacional promedio de presentación fue de 33 semanas. En 84,8% de las pacientes el diagnóstico fue anteparto. El 27% de las pacientes recibió dexametasona. La principal complicación materna fue la insuficiencia renal aguda. El 91% de las pacientes presentó hipertensión arterial. No hubo muertes maternas. El peso promedio de los recién nacidos fue 2.048 gramos; 42% con edad gestacional menor a 34 semanas; 34,4% pesó menos de 1500 gramos; 9,4% presentó depresión neonatal severa a los 5 minutos; 12,1% falleció en el período neonatal. Conclusiones: El síndrome HELLP es una patología de baja incidencia y con elevada morbimortalidad neonatal.

Objectives: To characterize HELLP syndrome. Method: Analysis of 33 patients with HELLP syndrome assistedat the Puerto Montt hospital, in the period 2000-2006. Results: The incidence was 1.3 cases per thousand births. The average gestational age at presentation was 33 weeks; 84.4% of patient had prepartum diagnosis; 27% of patients received dexamethasone. The main complication was maternal acute renal failure. 91% of patients had hypertension syndrome. There were no maternal deaths. The average weight of newborns was 2,048 grams; 42% with gestational age less than 34 weeks; 34.4% weighed less than 1,500 grams; 9.4% had severe 5 minutes newborn depression; 12.1% died in the neonatal period. Conclusions: The HELLP syndrome is a disease of low incidence, with a high neonatal morbimortality.

Síndrome HELLP: considerações acerca de diagnóstico e conduta / Hellp syndrome: considerations about diagnosis and management

A síndrome HELLP é uma grave complicação da pré-eclampsia, cursando com elevada morbimortalidade materna e perinatal. Controvérsias ocorrem com relação à incidência, critérios de diagnóstico e conduta nesta síndrome. As mortes perinatais estão relacionadas com o descolamento prematuro da placenta, asfixia intra-útero e prematuridade. A utilização de altas doses de corticóide no tratamento parece proporcionar melhores resultados maternos e perinatais, no entanto, são necessários estudos randomizados para sua completa e segura utilização na síndrome HELLP. O maior desafio diante desta síndrome é o diagnóstico precoce, intervenção oportuna e a prevenção das complicações. Sendo assim, as pacientes com suspeita de síndrome HELLP deverão ser encaminhadas para um serviço de assistência terciária para que sejam assistidas por uma equipe especializada, e tão logo possível, promova-se a interrupção da gestação.

HELLP syndrome - a multisystemic disorder.

HELLP syndrome is a multisystemic disorder with an incidence of 0.17-0.85% of all pregnancies. Its etiopathogenesis is not completely understood. The most widely accepted hypotheses are: a change in the immune feto-maternal balance, platelet aggregation, endothelial dysfunction, arterial hypertension and an inborn error of the fatty acid oxidative metabolism. Hepatic involvement occurs by intravascular fibrin deposition and hypovolemia. Materno-fetal complications cause a 6.7-70% perinatal mortality rate and a 1-24% maternal mortality rate. The recognition of HELLP syndrome and the rapid initiation of therapy are required for the improvement of materno-fetal prognosis.

Espectro clínico de la preeclampsia: estudio comparativo de sus diversos grados de severidad / Clinical spectrum of preeclampsia: comparative study of different grades of severity

Objetivo: Comparar los resultados maternos y perinatales en embarazadas que cursaron con preeclampsia (PE) en sus diversas presentaciones en el período 2001 -2005. Material y Método: Estudio retrospectivo de 7.205 partos asistidos en la maternidad del Hospital Clínico de la Universidad de Chile. 204 mujeres presentaron PE/eclampsia, dividiéndose en 3 grupos: PE modera, severa y síndrome de HELLP. Se analizaron las variables clínicas y de laboratorio de la embarazada y del recién nacido. Se compararon estos resultados en los 3 grupos de estudio. Para variables continuas de distribución normal se empleó el análisis de varianza (ANOVA). Para variables categóricas se empleó la tabla de contingencia de Chi2 o la prueba exacta de Fisher. Resultados: 80 mujeres presentaron PE moderada (39,2 por ciento), 114 PE severa (55,8 por ciento) y 10 HELLP (4,9 por ciento). Se observaron diferencias significativas en la vía de parto, edad gestacional, peso del recién nacido, percentil, morbi-mortalidad neonatal, complicaciones maternas médico-quirúrgicas en los grupos de PE severa y HELLP comparados con las PE moderadas. La PE severa tuvo una mayor proteinuria que los otros dos grupos. Así mismo, se observaron también diferencias significativas en el grupo de síndrome de HELLP en los niveles de enzimas hepáticas, LDH y recuento plaquetario en comparación con el grupo de las PE moderadas y severas. Conclusión: La PE es una entidad clínica que puede presentarse en diversos grados de severidad, por lo que su correcta clasificación de acuerdo a criterios clínicos y de laboratorio, es clave para el tratamiento y pronóstico de las pacientes.

Smoking and the risk of developing hypertensive diseases in pregnancy: what is the effect on HELLP syndrome?

BACKGROUND: The aim of our study was to investigate the role of smoking in the development of HELLP syndrome, pre-eclampsia and gestational hypertension. METHODS: A self-administered questionnaire was sent to 2,600 women who had contacted the German Pre-eclampsia Self-help Group previously for information on hypertensive disorders in pregnancy and to 1,233 controls. Diagnoses were verified by reviewing medical records and classified according to ISSHP criteria. Student's t-test, Wilcoxon test, Chi-square test, and multiple logistic regressions were used for statistical analysis. RESULTS: After matching age, parity, nationality, and education a total of 905 women with a hypertensive disease in pregnancy and 945 controls were evaluated for the present study. In comparison to the patients, controls smoked significantly more often during their pregnancies (8.5%/18%, p<0.0001). Smoking during pregnancy was associated with a decreased risk of developing hypertensive disorders in pregnancy by 56%. The most prominent effect of smoking was on the risk of developing HELLP syndrome (OR 0.19, 95% CI 0.08-0.43) followed by HELLP syndrome + pre-eclampsia (OR 0.33, 95% CI 0.17-0.63), pre-eclampsia only (OR 0.46, 95% CI 0.26-0.8), and gestational hypertension (OR 0.66, 95% CI 0.41-1.08). CONCLUSIONS: Smoking is associated with an 80% reduction of the risk developing HELLP syndrome. However, pregnant women should be advised to quit smoking. Understanding the different effects of smoking in the etiology of each subtype of hypertensive diseases in pregnancy will improve the knowledge of underlying pathophysiological mechanisms and may help in designing more effective prevention and treatment strategies.

Outcomes of subsequent pregnancy after first pregnancy with early-onset preeclampsia.

OBJECTIVE: The aim of this study was to report outcome of subsequent pregnancy after early-onset preeclampsia in first pregnancy, and to evaluate potential risk factors for recurrence of preeclampsia and preterm delivery. STUDY DESIGN: Reproductive follow-up data were obtained for women with a history of early-onset preeclampsia, resulting in delivery before 34 weeks of gestation at the University Medical Center Utrecht, The Netherlands, between July 1993 and September 2002. The relative contributions of demographic data, outcome variables of first pregnancy, and common thrombophilias to the recurrence risk of preeclampsia and preterm delivery in subsequent pregnancy, were estimated by Cox proportional hazard models. RESULTS: Subsequent pregnancy outcome data were available for 120 women. Overall, preeclampsia reoccurred in the second pregnancy in 30 women (25%). However, 6 women delivered before 34 weeks of gestation (5%), 20 women between 34 and 37 weeks of gestation (17%), and 94 women after 37 weeks of gestation (78%). Forty-one women (34%) had an uneventful pregnancy. Recurrence rates for preeclampsia or preterm delivery were not related to severity of first pregnancy complications, including delivery before 28 weeks of gestation, occurrence of hemolysis, elevated liver enzymes, and low platelet count syndrome, small-for-gestational age infants, and to hereditary or acquired thrombophilias. Chronic hypertension was related to a higher recurrence risk of preeclampsia in the second pregnancy (hazard ratio 2.1, 95% CI 1.0-4.4), and smoking was related to a higher recurrence risk of preterm birth (hazard ratio 2.4, 95% CI 1.1-5.6). CONCLUSION: Outcomes of subsequent pregnancy after first pregnancy with early-onset preeclampsia is generally favorable.