Pregnancy Complications and Long-Term Mortality in a Diverse Cohort.

BACKGROUND: Pregnancy complications are associated with increased risk of development of cardiometabolic diseases and earlier mortality. However, much of the previous research has been limited to White pregnant participants. We aimed to investigate pregnancy complications in association with total and cause-specific mortality in a racially diverse cohort and evaluate whether associations differ between Black and White pregnant participants. METHODS: The Collaborative Perinatal Project was a prospective cohort study of 48 197 pregnant participants at 12 US clinical centers (1959-1966). The Collaborative Perinatal Project Mortality Linkage Study ascertained participants' vital status through 2016 with linkage to the National Death Index and Social Security Death Master File. Adjusted hazard ratios (aHRs) for underlying all-cause and cause-specific mortality were estimated for preterm delivery (PTD), hypertensive disorders of pregnancy, and gestational diabetes/impaired glucose tolerance (GDM/IGT) using Cox models adjusted for age, prepregnancy body mass index, smoking, race and ethnicity, previous pregnancies, marital status, income, education, previous medical conditions, site, and year. RESULTS: Among 46 551 participants, 45% (21 107 of 46 551) were Black, and 46% (21 502 of 46 551) were White. The median time between the index pregnancy and death/censoring was 52 years (interquartile range, 45-54). Mortality was higher among Black (8714 of 21 107 [41%]) compared with White (8019 of 21 502 [37%]) participants. Overall, 15% (6753 of 43 969) of participants had PTD, 5% (2155 of 45 897) had hypertensive disorders of pregnancy, and 1% (540 of 45 890) had GDM/IGT. PTD incidence was higher in Black (4145 of 20 288 [20%]) compared with White (1941 of 19 963 [10%]) participants. The following were associated with all-cause mortality: preterm spontaneous labor (aHR, 1.07 [95% CI, 1.03-1.1]); preterm premature rupture of membranes (aHR, 1.23 [1.05-1.44]); preterm induced labor (aHR, 1.31 [1.03-1.66]); preterm prelabor cesarean delivery (aHR, 2.09 [1.75-2.48]) compared with full-term delivery; gestational hypertension (aHR, 1.09 [0.97-1.22]); preeclampsia or eclampsia (aHR, 1.14 [0.99-1.32]) and superimposed preeclampsia or eclampsia (aHR, 1.32 [1.20-1.46]) compared with normotensive; and GDM/IGT (aHR, 1.14 [1.00-1.30]) compared with normoglycemic. P values for effect modification between Black and White participants for PTD, hypertensive disorders of pregnancy, and GDM/IGT were 0.009, 0.05, and 0.92, respectively. Preterm induced labor was associated with greater mortality risk among Black (aHR, 1.64 [1.10-2.46]) compared with White (aHR, 1.29 [0.97-1.73]) participants, while preterm prelabor cesarean delivery was higher in White (aHR, 2.34 [1.90-2.90]) compared with Black (aHR, 1.40 [1.00-1.96]) participants. CONCLUSIONS: In this large, diverse US cohort, pregnancy complications were associated with higher mortality nearly 50 years later. Higher incidence of some complications in Black individuals and differential associations with mortality risk suggest that disparities in pregnancy health may have life-long implications for earlier mortality.

Fluorescence Sensing of Eclampsia Biomarkers via the Immunosorbent Atom Transfer Radical Polymerization Assay.

Accurate and quantitative detection of pre-eclampsia markers is crucial in reducing pregnancy mortality rates. This study introduces a novel approach utilizing a fluorescent biosensor by the immunosorbent atom transfer radical polymerization (immuno-ATRP) assay to detect the pre-eclampsia protein marker CD81. The critical step used in this sensor is the novel signal amplification strategy of fluorescein polymerization mediated by ferritin-enhanced controlled radical polymerization, which combines with a traditional enzyme-linked immunosorbent assay (ELISA) to further reduce the detection limit of the CD81 protein concentration. The fluorescence intensity was linear versus logarithmic CD81 protein concentration from 0.1 to 10,000 pg mL-1, and the detection limit was 0.067 pg mL-1. Surprisingly, in 30% normal human serum (NHS), the sensor can also detect target protein over 0.1-10,000 pg mL-1, with 0.083 pg mL-1 for the detection limit. Moreover, the proposed biosensor is designed to be cost-effective, making it accessible, particularly in resource-limited settings where expensive detection techniques may not be available. The affordability of this method enables widespread screening and monitoring of preeclampsia, ultimately benefiting many pregnant women by improving their healthcare outcomes. In short, developing of a low-cost and susceptible direct detection method for preeclampsia protein markers, such as CD81, through the use of the immuno-ATRP assay, has significant implications for reducing pregnancy mortality. This method holds promise for early detection, precise treatment, and improved management of preeclampsia, thereby contributing to better maternal and fetal health.

Pregnancy-associated mortality due to cardiovascular disease: Impact of hypertensive disorders of pregnancy.

BACKGROUND: Reported rates of maternal mortality in the United States have been staggeringly high and increasing, and cardiovascular disease (CVD) is a chief contributor to such deaths. However, the impact of hypertensive disorders of pregnancy (HDP) on the short-term risk of cardiovascular death is not well understood. OBJECTIVES: To evaluate the association between HDP (chronic hypertension, gestational hypertension, preeclampsia, eclampsia, and superimposed preeclampsia) and pregnancy-associated mortality rates (PMR) from all causes, CVD-related causes both at delivery and within 1 year following delivery. METHODS: We used the Nationwide Readmissions Database (2010-2018) to examine PMRs for females 15-54 years old. International Classification of Disease 9 and 10 diagnosis codes were used to identify pregnancy-associated deaths due to HDP and CVD. Discrete-time Cox proportional hazards regression models were used to calculate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for mortality at delivery (0 days) and at <30, <60, <90, <180, and <365 days after delivery in relation to HDP. RESULTS: Of 33,417,736 hospital deliveries, the rate of HDP was 11.0% (n = 3,688,967), and the PMR from CVD was 6.4 per 100,000 delivery hospitalisations (n = 2141). Compared with normotensive patients, HRs for CVD-related PMRs increased with HDP severity, reaching over 58-fold for eclampsia patients. HRs were higher for stroke-related (1.2 to 170.9) than heart disease (HD)-related (0.99 to 39.8) mortality across all HDPs. Except for gestational hypertension, the increased risks of CVD mortality were evident at delivery and persisted 1 year postpartum for all HDPs. CONCLUSIONS: HDPs are strong risk factors for pregnancy-associated mortality due to CVD at delivery and within 1 year postpartum; the risks are stronger for stroke than HD-related PMR. While absolute PMRs are low, this study supports the importance of extending postpartum care beyond the traditional 42-day postpartum visit for people whose pregnancies are complicated by hypertension.

Comparative Analysis of Antihypertensive and Anticonvulsant Regimens in Managing Pre-eclampsia and Eclampsia: Insights from a Sudanese Retrospective Study.

BACKGROUND Preeclampsia presents with gestational proteinuria, usually after 20 weeks of gestation, and can be complicated by generalized tonic-clonic seizures of eclampsia. Particularly in countries with limited healthcare resources, preeclampsia and eclampsia are major causes of maternal morbidity and mortality. This retrospective study aimed to evaluate the presentation, management, and outcomes of 185 women with preeclampsia and eclampsia in 2 maternity hospitals in Omdurman, Sudan, between January and December 2020. MATERIAL AND METHODS An analytical retrospective study was conducted in 2 main maternity hospitals in Omdurman, Sudan, between January and December 2020. The study included 185 pregnant women with preeclampsia or eclampsia. Data on clinical and obstetric characteristics (history of the illness, comorbid diseases, parity, gravida, multifetal pregnancy, and laboratory investigations), medications used, and maternal and neonatal outcomes were obtained for the diagnosis. The data were analyzed using the SPSS version 27. RESULTS Results: The mean age was 27.2±6.3 years, with 42.7% primigravida, 30% had a triple-drug regimen, nifedipine was the most common antihypertensive (60.5%), and 17.3% of patients underwent observation only. The seizure rate was 20%, with 92.73% controlled with magnesium sulfate. The antihypertensive regimen before delivery was significantly associated with the mode of delivery (P=0.001) and maternal outcomes (P=0.047); the regimen used after delivery significantly achieved blood pressure control (P=0.043) and improved maternal outcomes (P=0.007), but not fetal outcomes. CONCLUSIONS Maternal outcomes were markedly affected by the antihypertensive drug regimens used and the patient's seizure control status, and use of anti-convulsants successfully controlled all seizures.

Efficacy and safety of 12-hour versus 24-hour magnesium sulfate in management of patients with pre-eclampsia and eclampsia: a systematic review and meta-analysis.

INTRODUCTION: Magnesium sulfate is the most utilized anticonvulsant for treating patients with eclampsia and pre-eclampsia. The purpose of this study is to determine whether the 12-h regimen of magnesium sulfate outweighs the 24-h regimen in both efficacy and safety in the management of patients with mild or severe pre-eclampsia and eclampsia. METHODS: We searched six electronic databases: PubMed, Scopus, Web of Science, Cochrane Library, Ovid, and Google Scholar. This search was conducted to yield any studies that were published until 15 January 2023. We did the statistical analysis plan by Review Manager Software version 5.4. RESULTS: We included 13 randomized control trials with 2813 patients in this systematic review. Our meta-analysis revealed that there were no statistically significant differences between the 12-h regimen of the magnesium sulfate group and the 24-h regimen of the magnesium sulfate group in our outcome of interest: occurrence of seizure (RD: -0.00, 95% CI [-0.01, 0.00], P = 0.56), diminished deep tendon reflexes (RD: -0.00, 95% CI [-0.01, 0.01], P = 0.80), respiratory depression (RD: -0.00, 95% CI [-0.02, 0.01], P = 0.57), and pulmonary edema (RD: -0.00, 95% CI [-0.01, 0.01], P = 0.85). CONCLUSION: Our study showed no statistically significant difference in effectiveness and toxicity risk between the 12-h and 24-h regimens.

The association between dyslipidaemia in the first trimester and adverse pregnancy outcomes in pregnant women with subclinical hypothyroidism: a cohort study.

BACKGROUND: Subclinical hypothyroidism (SCH) is linked to dyslipidaemia and adverse pregnancy outcomes. However, the impact of dyslipidaemia on the outcome of pregnancy in SCH is unclear. METHODS: We enrolled 36,256 pregnant women and evaluated their pregnancy outcomes. The following data was gathered during the first trimester (≤ 13+ 6 weeks of gestation): total cholesterol (TC), low-density lipoprotein (LDL-C), triglyceride (TG), high-density lipoprotein (HDL-C), free thyroxine (FT4) and thyroid-stimulating hormone (TSH) concentrations. The reference ranges for lipids were estimated to range from the 5th to the 95th percentile. Logistic regression assessed the relationships between dyslipidaemia and adverse pregnancy outcomes, including abortion, preeclampsia/eclampsia, low birth weight, foetal growth restriction, premature rupture of foetal membranes, gestational hypertension, preterm birth, macrosomia and gestational diabetes mellitus (GDM). Additionally, the best thresholds for predicting adverse pregnancy outcomes based on TSH, FT4, and lipid levels were determined using receiver operating characteristic curves. RESULTS: In the first trimester, LDL-C > 3.24 mmol/L, TG > 1.92 mmol/L, HDL-C < 1.06 mmol/L, and TC > 5.39 mmol/L were used to define dyslipidaemia. In this cohort, 952 (3.56%) patients were diagnosed with SCH, and those who had dyslipidaemia in the first trimester had higher incidences of gestational hypertension (6.59% vs. 3.25%), preeclampsia/eclampsia (7.14% vs. 3.12%), GDM (22.53% vs. 13.77%), and low birth weight (4.95% vs. 2.08%) than did those without dyslipidaemia. However, after adjusting for prepregnancy body mass index (pre-BMI), dyslipidaemia was no longer related to these risks. Furthermore, elevated TG dyslipidaemia in SCH patients was connected to an enhanced potential of gestational hypertension (odds ratio [OR]: 2.687, 95% confidence interval [CI]: 1.074 ~ 6.722), and elevated LDL-C dyslipidaemia correlated with increased preeclampsia/eclampsia risk (OR: 3.172, 95% CI: 1.204 ~ 8.355) after accounting for age, smoking status, alcohol use, pre-BMI, and levothyroxine use. Additionally, the combination of TC, TG, LDL-C, pre-BMI, and TSH exhibited enhanced predictive capabilities for gestational hypertension, preeclampsia/eclampsia, and GDM. Values of 0.767, 0.704, and 0.706 were obtained from the area under the curve. CONCLUSIONS: Among pregnant women with SCH, dyslipidaemia in early pregnancy was related to elevated risks of adverse pregnancy consequences. The combined consideration of age, pre-BMI, TSH, and lipid levels in the first trimester could be beneficial for monitoring patients and implementing interventions to reduce adverse pregnancy outcomes.

Causal relationship between iron status and preeclampsia-eclampsia: a Mendelian randomization analysis.

BACKGROUND: Preeclampsia/eclampsia is a severe pregnancy-related disorder associated with hypertension and organ damage. While observational studies have suggested a link between maternal iron status and preeclampsia/eclampsia, the causal relationship remains unclear. The aim of this study was to investigate the genetic causality between iron status and preeclampsia/eclampsia using large-scale genome-wide association study (GWAS) summary data and Mendelian randomization (MR) analysis. METHODS: Summary data for the GWAS on preeclampsia/eclampsia and genetic markers related to iron status were obtained from the FinnGen Consortium and the IEU genetic databases. The "TwoSampleMR" software package in R was employed to test the genetic causality between these markers and preeclampsia/eclampsia. The inverse variance weighted (IVW) method was primarily used for MR analysis. Heterogeneity, horizontal pleiotropy, and potential outliers were evaluated for the MR analysis results. RESULTS: The random-effects IVW results showed that ferritin (OR = 1.11, 95% CI: .89-1.38, p = .341), serum iron (OR = .90, 95% CI: .75-1.09, p = .275), TIBC (OR = .98, 95% CI: .89-1.07, p = .613), and TSAT (OR = .94, 95% CI: .83-1.07, p = .354) have no genetic causal relationship with preeclampsia/eclampsia. There was no evidence of heterogeneity, horizontal pleiotropy, or possible outliers in our MR analysis (p > .05). CONCLUSIONS: Our study did not detect a genetic causal relationship between iron status and preeclampsia/eclampsia. Nonetheless, this does not rule out a relationship between the two at other mechanistic levels.

Determinants of prematurity in urban Indonesia: a meta-analysis.

OBJECTIVES: Indonesia is the fifth country with the highest number of preterm births worldwide. More than a third of neonatal deaths in Indonesia were attributed to preterm birth. Residential areas affected the occurrence of preterm birth due to differing socioeconomic and environmental conditions. Many studies have investigated the determinants of prematurity in Indonesia, however, most of them were performed in rural areas. This study is the first meta-analysis describing the determinants of preterm birth in urban Indonesia, which aimed to become the foundation upon implementing the most suitable preventative measure and policy to reduce the rate of preterm birth. METHODS: We collected all published papers investigating the determinants of preterm birth in urban Indonesia from PubMed MEDLINE and EMBASE, using keywords developed from the following key concepts: "preterm birth", "determinants", "risk factors", "Indonesia" and the risk factors, such as "high-risk pregnancy", "anemia", "pre-eclampsia", and "infections". Exclusion criteria were multicenter studies that did not perform a specific analysis on the Indonesian population or did not separate urban and rural populations in their analysis, and articles not available in English or Indonesian. The Newcastle Ottawa Scale was used to assess the risk of bias. This systematic review was registered in PROSPERO. RESULTS: Sixteen articles were included in the analysis and classified into five categories: genetic factors, nutrition, smoking, pregnancy characteristics or complications, and disease-related characteristics. CONCLUSIONS: Our meta-analysis revealed adolescent pregnancy, smoking, eclampsia, bacterial vaginosis, LC-PUFA, placental vitamin D, and several minerals as the significant determinants of preterm birth in urban Indonesia.

Posterior Reversible Encephalopathy Syndrome in Eclamptic Patients: The Relationship between Blood Pressure, Cranial Involvement, and Seizure Recurrence.

OBJECTIVES: Posterior reversible encephalopathy syndrome (PRES) is a clinic radiological disorder characterized by headache, epileptic seizure, encephalopathy, visual impairment, and focal neurological deficits. Gestational hypertension, which is a significant risk factor for PRES, may cause significant morbidity and mortality among pregnant women. DESIGN: Twenty-four patients with PRES caused by eclampsia who were admitted to our hospital in the last 5 years were included in this study. PARTICIPANTS/MATERIALS, SETTING, METHODS: Blood pressure at admission, the number of regions with vasogenic edema in the brain, and recurrent seizures were noted. Patients were divided into three groups: mild, moderate, and severe. RESULTS: Using Kruskal-Wallis and Pearson χ2 tests, there was no statistical significance between the groups in terms of cranial involvement (p = 0.471). However, binary logistic regression analysis showed that seizure recurrence increased in correlation with blood pressure (p = 0.04). LIMITATIONS: PRES is a rare syndrome associated with several etiologies. In our study, only patients with PRES due to eclampsia were included. Therefore, the number of included patients was limited (24 participants). CONCLUSION: PRES may occur in eclamptic patients with mild, moderate, or severe blood pressure values. Evaluation by magnetic resonance imaging is needed to confirm the diagnosis. Early and rapid treatment is essential for reducing morbidity and mortality among pregnant women.

The Effect of Body Mass Index on Post-Bolus Magnesium Levels in the Obstetric Patient.

OBJECTIVE: In the setting of a growing obese obstetric population, we sought to determine whether differences in body mass index (BMI) and obesity class influenced both serum magnesium levels and the likelihood of achieving therapeutic levels for eclampsia prophylaxis after standard boluses of magnesium sulfate. STUDY DESIGN: This is a retrospective cohort study of patients treated with magnesium sulfate in the setting of either preeclampsia with severe features or preterm labor between 2010 and 2016. Subjects were categorized by BMI: Normal (BMI < 30 kg/m2), Class 1 (BMI 30-34.9 kg/m2), Class 2 (BMI 35-39.9 kg/m2), and Class 3 (BMI ≥ 40 kg/m2). Study participants' demographics, intrapartum characteristics, and adverse reactions were compared among the groups. Logistic regression models were used to calculate unadjusted and adjusted odds ratios comparing the likelihood of each BMI class reaching therapeutic eclamptic prophylactic levels. Linear regression models were also evaluated to determine the relationship between BMI and post-bolus serum magnesium levels. RESULTS: Of the 760 people who met the inclusion criteria, 313 (41.1%) had normal BMI, 190 (25.0%) had Class 1 obesity, 135 (17.8%) had Class 2 obesity, and 122 (16.1%) had Class 3 obesity. When adjusted for confounders, those with Class 1 obesity were 54% less likely to achieve serum levels deemed therapeutic for seizure prophylaxis compared with normal BMI counterparts. Meanwhile, those with Class 2 or 3 obesity were 90% less likely. Linear regression models also demonstrated an inverse association between BMI and post-bolus serum magnesium levels. CONCLUSION: Increasing BMI has a significant effect on post-bolus serum magnesium levels regardless of standard loading dose used. Immediately after bolus administration, obese gravidas are significantly less likely to reach levels effective for eclamptic seizure prophylaxis. When considering which bolus to administer in an obese gravida, it may be more beneficial to choose a 6 g load. KEY POINTS: · BMI has an inverse relationship with post-bolus serum magnesium levels.. · Obese gravidas were less likely to reach eclampsia prophylaxis levels regardless of bolus type.. · Obesity class, not just the presence or absence of obesity, plays a role in serum magnesium levels..

Hypertensive disorders of pregnancy and cardiovascular disease risk: A Mendelian Randomisation study.

Objective: Observational studies show that hypertensive disorders of pregnancy (HDPs) are related to unfavourable maternal cardiovascular disease (CVD) risk profiles later in life. We investigated whether genetic liability to pre-eclampsia/eclampsia and gestational hypertension is associated with CVD risk factors and occurrence of CVD events. Methods: We obtained genetic associations with HDPs from a genome-wide association study and used individual-participant-data from the UK Biobank to obtain genetic associations with CVD risk factors and CVD events (defined as myocardial infarction or stroke). In our primary analysis, we applied Mendelian Randomisation using inverse-variance weighted regression analysis in ever pregnant women. In sensitivity analyses, we studied men and nulligravidae to investigate genetic liability to HDPs and CVD risk without the ability to experience the underlying phenotype. Results: Our primary analysis included 221,155 ever pregnant women (mean age 56.8 [SD 7.9]) with available genetic data. Odds ratios for CVD were 1.20 (1.02-1.41) and 1.24 (1.12-1.38) per unit increase in the log odds of genetic liability to pre-eclampsia/eclampsia and gestational hypertension, respectively. Furthermore, genetic liability to HDPs was associated with higher levels of systolic and diastolic blood pressure and younger age at hypertension diagnosis. Sensitivity analyses revealed no statistically significant differences when comparing the findings to those of nulligravidae and men. Conclusions: Genetic liability to HDPs is associated with higher CVD risk, lower blood pressure levels, and earlier hypertension diagnosis. Our study suggests similar findings in ever pregnant women, nulligravidae and men, implying biological mechanisms relating to HDPs are causally related to CVD risk.

Sympathetic Neurofunction Testing in Gestational Hypertension and Relationship with Developing Preeclampsia and Eclampsia: Real-world Evidences from Clinical Pharmacology Clinics.

BACKGROUND: Gestational hypertension carries a high-risk for adverse maternal and fetal outcomes, and it can also develop into preeclampsia. A relative decrease in parasympathetic and increase in sympathetic activity has been seen in normal pregnancy which returns to baseline after delivery. The present study aimed to detect any abnormality in sympathetic neurofunction in gestational hypertension and to identify its possible association with the development of preeclampsia/eclampsia. METHODS: A prospective, observational study was carried out among gestational hypertensive patients between 24 and 26 weeks of gestation, who were sent to clinical pharmacology clinics for autonomic neurofunction testing, along with their 24-hour urinary protein testing reports. Preisometric handgrip (IHG) and post-IHG differences in diastolic blood pressure (DBP) were noted. The association between Δ DBP and the development of eclampsia/preeclampsia was probed. RESULTS: A total of 52 pregnancy-induced hypertension (PIH) participants, both multigravida (n = 15) and primigravida (n = 37) were included in one arm (PIH arm), and 52 matched (age and gravida) pregnant women, those do not have PIH included in another arm for comparative analysis. On comparing the PIH arm and normal arm, prehand grip DBP (p ≤ 0.0001), posthand grip DBP, and Δ DBP were significantly higher in the PIH arm. Correlation between Δ DBP and 24 hours' proteinuria was observed in the PIH arm, with a significant positive correlation. CONCLUSION: A high-rise in DBP post-IHG exercise is associated with gestational hypertensive mothers and this rise is strongly correlated with the development of preeclampsia and eclampsia, which suggests that addressing sympathetic hyperactivity could be a potential area to target therapeutics while managing gestational hypertension.

Risk factors of posterior reversible encephalopathy syndrome in patients with preeclampsia or eclampsia: A retrospective review.

Background and purpose:

Posterior reversible encephalopathy syndrome (PRES) is characterized by vasogenic edema, usually reversible, with the prominent involvement of the parietal and occipital lobes. The exact etiopathogenesis leading to PRES is unknown. Because signs of eclampsia and preeclampsia in neuroimaging often overlap and manifest as PRES, we aimed to evaluate whether demographic, clinical, and laboratory parameters predict PRES in patients with preeclampsia or eclampsia.

213 pre-eclampsia or eclampsia patients with cranial imaging were retrospectively examined. We recorded the patients’ demographic information, systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), hemogram, biochemical indicators, clinical symptoms, and imaging features.

Of all patients, 69% (n = 147) had preeclampsia while 31% (n = 66) had eclampsia, and 24.4% (n = 53) were diagnosed with PRES. The mean age of patients who developed PRES was 25.81 ± 6.07 years and thus significantly less than that of patients who did not develop PRES (p = .000). Patients with PRES had significantly higher mean SBP (p = .015), DBP (p = .009), and MAP (p = .003) than patients without PRES, along with significantly higher aspartate aminotransferase (ASAT; p = .001), alanine aminotransferase (ALAT; p = .001) blood urea nitrogen (BUN; p = .001), white blood cell (WBC; p = .003), neutrophil (p = .001), and hemoglobin (Hb; p = .027) levels, but significantly lower albumin (p = .000) levels.

Age, high blood pressure, and BUN, neutrophil, and WBC levels were predictors of the development of PRES in patients with preeclampsia and eclampsia. Early neuroimaging considering those predictors should be performed to diagnose PRES in patients with preeclampsia and eclampsia.

Prediction of Cardiovascular Diseases in Women With Rheumatoid Arthritis.

AIM: To develop prognostic models for arterial hypertension (AH) and atherosclerosis based on studying the totality and significance of traditional and disease-mediated risk factors (RFs) in women with rheumatoid arthritis (RA). MATERIAL AND METHODS: 223 female patients with RA aged 54.9±2.1 years were evaluated at the premises of the polyclinic of the Gulla Municipal Hospital #4 (Barnaul), the "Health Center", the City Rheumatology Department of the polyclinic, and the Hospital Department in 2016-2019. Statistical analysis was performed using Excel Microsoft Office 2007, Statistica 6.0 and 10.0, and SigmaPlot 12.5 software packages. Multivariate regression analysis was used for studying the attributes influencing the development of AH and atherosclerosis in RA and for constructing predictive models. ROC analysis was used to determine the quality of the developed models. Differences were considered statistically significant at p<0.05. RESULTS: The following RFs predominating in the onset of disease were identified: traditional (hyperglycemia, obesity, increased diastolic BP (DBP), tachycardia, dyslipidemia); disease-mediated (ESR, fibrinogen, C-reactive protein (CRP), rheumatoid factor, cyclic citrullinated peptide antibodies, moderate and high DAS-28 activity), and psychosocial (stress, anxiety, depression, sleep disorders). The highest RF incidence and their combinations were determined with a RA duration of more than a year: traditional (obesity, hyperglycemia, increased systolic BP (SBP)), and decreased glomerular filtration rate; and disease-mediated (prednisolone treatment). A highly sensitive model for AH screening was developed that included a combination of RFs: disease-mediated (RA duration, CRP); traditional (improper diet, low physical activity, history of early cardiovascular diseases, increased SBP and DBP, preeclampsia and/or eclampsia, early menopause, older age, dyslipidemia); psychosocial (anxiety, depression), and a high salt-taste threshold. A highly sensitive model was developed for probable prediction of multifocal atherosclerosis in RA in women. The model includes a complex of risk factors: disease-mediated (RA activity by DAS-28, CRP, fibrinogen, ESR, dose-dependent prednisolone treatment); traditional (AH, SBP, waist circumference, heart rate, early menopause, preeclampsia and/or eclampsia, age 55 years and older, dyslipidemia); and psychosocial (sleep disorders, depression). CONCLUSION: Algorithms for early prevention of AH and atherosclerosis were developed with consideration of identified predictors and proposed prediction models for women with RA.

Neurological manifestations of COVID-19 in pregnancy: a cross-sectional study.

The occurrence of neurological manifestations and complications in pregnant women compared to non-pregnant women with COVID-19 is unclear. This cross-sectional study included women aged over 18 years hospitalized with SARS-CoV-2 infection confirmed by RT-PCR from March to June 2020 in Recife, Brazil. We evaluated 360 women, including 82 pregnant patients who were significantly younger (27.5 vs. 53.6 years; p < 0.01) and less frequently obese (2.4% vs. 15.1%; p < 0.01) than the non-pregnant group. All pregnancies were confirmed using ultrasound imaging. Abdominal pain was the only more frequent COVID-19 manifestation during pregnancy (23.2% vs. 6.8%; p < 0.01), but was not associated with the outcomes. Almost half the pregnant women presented neurological manifestations, including anosmia (31.7%), headache (25.6%), ageusia (17.1%), and fatigue (12.2%). However, neurological manifestations occurred similarly in pregnant and non-pregnant women. Four (4.9%) pregnant women and 64 non-pregnant women (23%) presented delirium, but the frequency with age-adjustment was similar in the non-pregnant group. Pregnant women with COVID and preeclampsia (19.5%) or eclampsia (3.7%) were older (31.8 vs. 26.5 years; p < 0.01), and epileptic seizures occurred more often in association with eclampsia (18.8% vs. 1.5%; p < 0.01) regardless of previous epilepsy. There were three maternal deaths (3.7%), one dead fetus, and one miscarriage. The overall prognosis was good. There was no difference in prolonged hospital stay, the need for ICU and mechanical ventilation, or death when comparing pregnant and non-pregnant women.

The genetic risk factors for pregnancy-induced hypertension: Evidence from genetic polymorphisms.

Pregnancy-induced hypertension (PIH) is a multifactorial and severe pregnancy complication including preeclampsia/eclampsia, gestational hypertension, chronic (pre-existing) hypertension, and preeclampsia/eclampsia variants superimposed on chronic hypertension. PIH-induced maternal mortality accounts for approximately 9% of all maternal deaths over the world. A large number of case-control studies have established the importance of various genetic factors in the occurrence and development of PIH. In this narrative review, we summarized the genetic risk factors involved in the renin-angiotensin system, endothelin system, inflammatory factors, oxidative stress, and other functional networks, with the aim of sorting out the genetic factors that may play a potential role in PIH and providing new ideas to elucidate the pathogenesis of PIH.

Is magnesium sulfate therapy warranted in all cases of late postpartum severe hypertension? A suggested approach to a clinical conundrum.

Magnesium sulfate reduces the risk for eclamptic seizures antepartum, intrapartum, and in the immediate postpartum period, however, there are no studies that have evaluated the benefits and risks of magnesium sulfate among women with late postpartum severe hypertension only. Juxtaposed on this clinical uncertainty is the increased incidence of severe hypertension owing to a rise in pregnancies complicated by advanced maternal age, obesity, chronic hypertension, diabetes, and recent protocols for intensive monitoring of blood pressure in the postpartum period. These factors have led to a significant increase in postpartum presentations for the evaluation and management of severe hypertension, in some cases leading to postpartum readmissions for administration of antihypertensive therapy and magnesium sulfate without data demonstrating clear clinical benefit. Postpartum readmissions can have several negative consequences, including interfering with early bonding with a newborn, breastfeeding, and use of scarce healthcare resources. In addition, magnesium sulfate is associated with risks for serious cardiorespiratory depression and bothersome side effects and can delay determining the optimal antihypertensive regimen, which is typically the most pressing clinical need during postpartum presentations of late-postpartum severe hypertension. Eclampsia that occurs more than 48 hours after delivery is rare (constitutes 16% of all cases of eclampsia) and is most commonly preceded by headaches or other cerebral symptoms. In this commentary, we propose an approach to evaluating and managing patients with late postpartum severe hypertension aimed at identifying those women at highest risk for end-organ injury. We recommend that the short- and long-term focus for all patients with severe hypertension should be the optimal management of blood pressures with a goal of close outpatient monitoring when logistically feasible and clinically appropriate. We suggest reserving magnesium sulfate therapy for the subset of patients with neurologic symptoms who may be at highest risk for an eclamptic seizure.

Eclampsia with hypothyroidism complicated with posterior reversible encephalopathy syndrome-a case report.

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is a rare neurological disorder with complex physiopathological mechanisms that have not been fully understood. Early identification is of great prognostic significance, of which the symptoms and radiological abnormalities can be completely reversed. If the diagnosis and treatment are delayed, ischemia and massive infarction may be developed in some patients. Posterior reversible encephalopathy syndrome (PRES) has been reported mainly in association with postpartum eclampsia, which have been rarely reported, while the association with hypothyroidism has not been reported at home or abroad. CASE PRESENTATION: Here we report on a pregnant 29-year-old with multipara and a chief complication of hypothyroidism. She presented in the emergency department with frequent attacks of severe headache symptoms resulting from reversible cerebral vasoconstriction syndrome (RCVS), accompanied with prenatal eclampsia. PRES was determined by radiological examination. CONCLUSION: To the best of our knowledge, this is the first case of PRES complicated by hypothyroidism and prepartum eclampsia.Clinicians should be alert for the co-occurence of eclampsia, PRES, and RCVS when patients have convulsions after a typical throbbing headache. Moreover, regular monitoring of thyroid function during pregnancy should also occupy certain special attention.

Temporal and Spatial Trends of Adverse Pregnancy and Birth Outcomes in a Sample of Births from a Public Hospital in Chile.

Understanding temporal and spatial trends in pregnancy and birth outcomes within an urban area is important for the monitoring of health indicators of a population. We conducted a retrospective cohort study of all births in the public hospital of Temuco, a medium-sized city in Southern Chile between 2009 and 2016 (n = 17,237). Information on adverse pregnancy and birth outcomes, as well as spatial and maternal characteristics (insurance type, employment, smoking, age, and overweight/obesity), was collected from medical charts. Home addresses were geocoded and assigned to neighborhood. We tested whether births and prevalence of adverse pregnancy outcomes changed over time, whether birth events were spatially clustered (Moran's I statistic), and whether neighborhood deprivation was correlated to outcomes (Spearman's rho). We observed decreases in eclampsia, hypertensive disorders of pregnancy, and small for gestational age, while gestational diabetes, preterm birth, and low birth weight increased over the study period (all p < 0.01 for trend), with little changes after adjusting for maternal characteristics. We observed neighborhood clusters for birth rate, preterm birth, and low birth weight. Neighborhood deprivation was negatively correlated with low birth weight and preterm birth, but not correlated with eclampsia, preeclampsia, hypertensive disorders of pregnancy, small for gestational age, gestational diabetes, nor stillbirth. Several encouraging downward trends and some increases in adverse pregnancy and birth outcomes, which, overall, were not explained by changes in maternal characteristics were observed. Identified clusters of higher adverse birth outcomes may be used to evaluate preventive health coverage in this setting.

Alternative magnesium sulphate regimens for women with pre-eclampsia and eclampsia.

BACKGROUND: Magnesium sulphate is the drug of choice for the prevention and treatment of women with eclampsia. Regimens for administration of this drug have evolved over the years, but there is no clarity on the comparative benefits or harm of alternative regimens. This is an update of a review first published in 2010. OBJECTIVES: To assess if one magnesium sulphate regimen is better than another when used for the care of women with pre-eclampsia or eclampsia, or both, to reduce the risk of severe morbidity and mortality for the woman and her baby. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (29 April 2022), and reference lists of retrieved studies. SELECTION CRITERIA: We included randomised trials and cluster-randomised trials comparing different regimens for administration of magnesium sulphate used in women with pre-eclampsia or eclampsia, or both. Comparisons included different dose regimens, intramuscular versus intravenous route for maintenance therapy, and different durations of therapy. We excluded studies with quasi-random or cross-over designs. We included abstracts of conference proceedings if compliant with the trustworthiness assessment. DATA COLLECTION AND ANALYSIS: For this update, two review authors assessed trials for inclusion, performed risk of bias assessment, and extracted data. We checked data for accuracy. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS: For this update, a total of 16 trials (3020 women) met our inclusion criteria: four trials (409 women) compared regimens for women with eclampsia, and 12 trials (2611 women) compared regimens for women with pre-eclampsia. Most of the included trials had small sample sizes and were conducted in low- and middle-income countries. Eleven trials reported adequate randomisation and allocation concealment. Blinding of participants and clinicians was not possible in most trials. The included studies were for the most part at low risk of attrition and reporting bias. Treatment of women with eclampsia (four comparisons) One trial compared a loading dose-alone regimen with a loading dose plus maintenance dose regimen (80 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsions or maternal death (very low-certainty evidence). One trial compared a lower-dose regimen with standard-dose regimen over 24 hours (72 women). It is uncertain whether either regimen has an effect on the risk of recurrence of convulsion, severe morbidity, perinatal death, or maternal death (very low-certainty evidence). One trial (137 women) compared intravenous (IV) versus standard intramuscular (IM) maintenance regimen. It is uncertain whether either route has an effect on recurrence of convulsions, death of the baby before discharge (stillbirth and neonatal death), or maternal death (very low-certainty evidence). One trial (120 women) compared a short maintenance regimen with a standard (24 hours after birth) maintenance regimen. It is uncertain whether the duration of the maintenance regimen has an effect on recurrence of convulsions, severe morbidity, or side effects such as nausea and respiratory failure. A short maintenance regimen may reduce the risk of flushing when compared to a standard 24 hours maintenance regimen (risk ratio (RR) 0.27, 95% confidence interval (CI) 0.08 to 0.93; 1 trial, 120 women; low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials. Prevention of eclampsia for women with pre-eclampsia (five comparisons) Two trials (462 women) compared loading dose alone with loading dose plus maintenance therapy. Low-certainty evidence suggests an uncertain effect with either regimen on the risk of eclampsia (RR 2.00, 95% CI 0.61 to 6.54; 2 trials, 462 women) or perinatal death (RR 0.50, 95% CI 0.19 to 1.36; 2 trials, 462 women). One small trial (17 women) compared an IV versus IM maintenance regimen for 24 hours. It is uncertain whether IV or IM maintenance regimen has an effect on eclampsia or stillbirth (very low-certainty evidence). Four trials (1713 women) compared short postpartum maintenance regimens with continuing for 24 hours after birth. Low-certainty evidence suggests there may be a wide range of benefit or harm between groups regarding eclampsia (RR 1.99, 95% CI 0.18 to 21.87; 4 trials, 1713 women). Low-certainty evidence suggests there may be little or no effect on severe morbidity (RR 0.96, 95% CI 0.71 to 1.29; 2 trials, 1233 women) or side effects such as respiratory depression (RR 0.80, 95% CI 0.25 to 2.61; 2 trials, 1424 women). Three trials (185 women) compared a higher-dose maintenance regimen versus a lower-dose maintenance regimen. It is uncertain whether either regimen has an effect on eclampsia (very low-certainty evidence). Low-certainty evidence suggests that a higher-dose maintenance regimen has little or no effect on side effects when compared to a lower-dose regimen (RR 0.79, 95% CI 0.61 to 1.01; 1 trial 62 women). One trial (200 women) compared a maintenance regimen by continuous infusion versus a serial IV bolus regimen. It is uncertain whether the duration of the maintenance regimen has an effect on eclampsia, side effects, perinatal death, maternal death, or other neonatal morbidity (very low-certainty evidence). Many of our prespecified critical outcomes were not reported in the included trials. AUTHORS' CONCLUSIONS: Despite the number of trials evaluating various magnesium sulphate regimens for eclampsia prophylaxis and treatment, there is still no compelling evidence that one particular regimen is more effective than another. Well-designed randomised controlled trials are needed to answer this question.