Aquatic Exercise Training is Effective in Maintaining Exercise Performance in Trained Heart Failure Patients: A Randomised Crossover Pilot Trial.

BACKGROUND: Providing flexible models and a variety of exercise options are fundamental to supporting long-term exercise participation for patients with heart failure (HF). The aim of this pilot study was to determine the feasibility and efficacy of aquatic exercise training during a maintenance phase for a clinical heart failure population. METHODS: In this 2 x 2 crossover design trial, individuals who had previously completed HF rehabilitation were randomised into either a land-based or aquatic training program once per week for six weeks, after which time they changed to the alternate exercise training protocol for an additional six weeks. Six-minute walk test (6MWT), grip strength, walk speed, and measures of balance were compared for the two training protocols. RESULTS: Fifty-one participants (43 males, mean age 69.2 yrs) contributed data for the analysis. Both groups maintained function during the follow-up period, however improvements in 6MWT were greater in the land-based training group (95% CI: 0.7, 22.5; p=0.038), by a mean difference of 10.8 metres. No significant difference was observed for other parameters when the two training protocols were compared. CONCLUSION: Attending an aquatic exercise program once per week is feasible for patients with stable HF and may provide a suitable option to maintain functional performance in select patients.

A prospective pilot study in assessing the accuracy of ultrasound estimated fetal weight prior to delivery.

BACKGROUND: Perinatal mortality and morbidity related to growth restriction and macrosomia are predicted by birthweight. Estimated fetal weight is a surrogate measure for neonatal weight, and accurate measurement of this is central to providing counselling and managing preterm birth. AIMS: To assess the accuracy of estimated fetal weight (EFW) measured by two sonographers within 1 week of delivery using Hadlock formula. MATERIALS AND METHODS: Two sonographers independently scanned 150 women with singleton pregnancies, who were booked for elective delivery. The sonographers measured four biometric measurements in estimating fetal weight. The accuracy of EFW compared to the birthweight was examined. We also assessed the sensitivity and specificity for diagnosis of small-for-gestational age (SGA) and large-for-gestational age (LGA) according to the EFW. RESULTS: Estimated fetal weight was similar to actual birthweight, with a mean percentage difference (SD) of 1.4(7.0) (P = 0.44). The reliability coefficient of EFW compared to actual birthweight was 0.97 (95% CI (0.96, 0.98)). There was no significant difference between the sonographers for EFWs and among the sonographers from the ultrasound scan to delivery interval. The sensitivity and specificity for detection of SGA and LGA were 93.3% and 99.3%, 60% and 95.6%, respectively. CONCLUSIONS: There is high reproducibility with minimum discrepancy from actual birthweight among sonographers 1 week prior to delivery using Hadlock formula with better prediction of SGA neonates.

A collaborative approach to improve the assessment of physical health in adult consumers with schizophrenia in Queensland mental health services.

OBJECTIVE: The objective of this study was to apply a quality improvement collaborative to increase the number of physical health assessments conducted with consumers diagnosed with schizophrenia in adult community mental health services across Queensland. METHOD: Sixteen adult mental health service organisations voluntarily took part in the statewide collaborative initiative to increase the number of physical health assessments completed on persons with a diagnosis of schizophrenia spectrum disorders managed through the community mental health service. RESULTS: Improvement in the physical health assessment clinical indicator was demonstrated across the state over a 3-year period with an increase in the number of physical health assessments recorded from 12% to 58%. CONCLUSIONS: Significant improvements were made over a 3-year period by all mental health services involved in the collaborative, supporting the application of a quality improvement methodology to drive change across mental health services.

Supportive care needs, anxiety, depression and quality of life amongst newly diagnosed patients with localised invasive cutaneous melanoma in Queensland, Australia.

OBJECTIVE: The aim of this paper is to determine levels of supportive care needs, anxiety, depression and symptoms amongst patients newly diagnosed with localised invasive primary melanoma and if these varied amongst patients who had a sentinel lymph node biopsy (SLNB). We also considered quality of life compared with general population norms. METHODS: Patients newly diagnosed with clinical stage IB-II invasive melanoma were ascertained through Queensland hospitals, specialist clinics and pathology laboratories. Validated surveys measured 46 need items (Supportive Care Needs Survey-Short Form + melanoma subscale), anxiety and depression (Hospital Anxiety and Depression Scale) and quality of life and symptoms (Functional Assessment of Cancer Therapy-Melanoma). Regression models compared outcomes according to whether or not participants had a SLNB. RESULTS: We surveyed 386 patients, 155 before and 231 after wide local excision, of whom 46% reported ≥1 moderate-level or high-level unmet need. The three highest needs were for help with fears about cancer spreading (17%), information about risk of recurrence (17%) and outcomes when spread occurred (16%). Those who had a SLNB were more likely to report a moderate or high unmet need for help with uncertainty about the future or with lymphoedema (p < 0.05). Overall, 32% of participants had anxiety and 15% had depression regardless of performance of SLNB. Melanoma-specific symptoms were worse in SLNB patients (p = 0.03). Compared with the general population, emotional well-being was lower amongst melanoma patients. CONCLUSIONS: A substantial proportion of newly diagnosed patients with localised invasive melanoma need further melanoma-specific information and support with psychological concerns. Patients who have a SLNB clear of disease may need help with symptoms after surgery.

The development and evaluation of an oncological palliative care deprescribing guideline: the 'OncPal deprescribing guideline'.

PURPOSE: Current data suggests that potentially inappropriate medicines (PIMs) are common in palliative cancer patients; however, there is a lack of criteria to assist clinicians in identifying PIMs in these patients. The aims of this study were to design and validate a deprescribing guideline for palliative cancer patients and to undertake a descriptive analysis of the identified PIMs. METHODS: This prospective, non-interventional cohort study consisted of four major stages: developing an 'OncPal Deprescribing Guideline' from current evidence, the prospective recruitment of consecutive palliative cancer inpatients with an estimated <6-month prognosis, the assessment of all medications to identify PIMs using both a panel of medical experts without access to the guideline as well as a Clinical Pharmacist independently using the OncPal Deprescribing Guideline and the evaluation of the guideline by testing concordance. Descriptive data on the incidence of PIMs identified were also assessed. RESULTS: A total of 61 patients were recruited. The OncPal Deprescribing Guideline matched 94% of 617 medicines to the expert panel with a Kappa value of 0.83 [95% CI (0.76, 0.89)] demonstrating an 'outstanding' concordance. Forty-three (70%) patients were taking at least one PIM, with 21.4% of the total medicines assessed identified as PIMs. The medication-associated cost per patient/month was AUD$26.71. CONCLUSION: A guideline to assist in the de-escalation of inappropriate medications in palliative cancer patients was developed from current literature. The OncPal Deprescribing Guideline was successfully validated, demonstrating statistically significant concordance with an expert panel. We found that the incidence of PIMs was high in our patient group, demonstrating the potential benefits for the OncPal Deprescribing Guideline in clinical practice.

Does depression experienced by mothers leads to a decline in marital quality: a 21-year longitudinal study.

PURPOSE: Marital conflict and/or marital breakdown are known pathways to the onset of depression. Few studies however have examined the possibility that depression can lead to a decrease in marital quality and an increase in marital breakdown. Depression may be an important pathway to a decline in martial quality. METHODS: A birth cohort study with women (mothers) recruited early in pregnancy and followed for 21 years. Using repeated measures analysis for four waves of data collection we use GEE to examine the extent to which symptoms of depression predict subsequent poor martial quality in women and poor marital quality predicts subsequent depression. RESULTS: A bidirectional association between poor marital quality and depression is observed. After removing those who had pre-existing poor marital quality we note that depression predicts subsequent poor martial quality. Similarly, we note that poor marital quality predicts subsequent depression. These associations are all statistically significant and of a similar magnitude. CONCLUSION: Over the maternal reproductive life course there is a long-term trajectory of reduced marital quality and increased depression. Maternal depression is as likely to lead to a decline in marital quality as poor martial quality is likely to lead to increased levels of depression. There may be a need to develop intervention programmes to reduce this long-term pattern of change.

Use of standardised assessment forms in referrals to hepatology outpatient services: implications for accurate triaging of patients with chronic hepatitis C.

OBJECTIVES: To determine the spectrum of disease among non-urgent referrals to a tertiary hospital hepatology outpatient clinic, assess the adequacy of referral information in terms of risk stratification and determine whether a specifically designed referral template altered urgency for specialist assessment. METHODS: A snapshot of the waiting list of a hepatology clinic at a tertiary hospital was taken from the scheduling database. Information was retrieved from referrals and attached investigations. Updated information was requested from subjects and their current general practitioner. RESULTS: Hepatitis C virus accounted for 68.7% of the 1223 reviewed referrals. Clinical information provided by referring clinicians was often incomplete. Provision of updated information identified the presence of comorbidities (obesity, 'heavy' alcohol consumption, mental health issues) and altered the need or urgency for specialist assessment in 22% of cases. CONCLUSIONS: Hepatitis C virus accounts for the majority of non-urgent referrals waiting to access hepatology outpatient consultations. Using a standardised assessment form as part of the referral process provides more information on comorbidities and risk factors and facilitates more accurate triaging of clinical urgency. Wider adoption of this strategy may increase appropriate access to hepatology services and reduce the future burden of cirrhosis and hepatocellular cancer. WHAT IS KNOWN ABOUT THE TOPIC? Little published data are available that describe the content and standard of hepatology referrals, or the urgency with which these patients need to be reviewed. Inadequate clinical information impairs the ability to accurately triage referrals and may lead to delays in access. WHAT DOES THE PAPER ADD? Almost 70% of reviewed referrals were for management of patients with hepatitis C virus infection, confirming this condition remains a major priority area in liver disease. Clinical information provided by referring clinicians was often incomplete, impairing the ability to accurately triage referrals. Only a minority of referrals provided information about relevant comorbidities (alcohol intake, injecting drug use, mental health issues and obesity) that negatively impact on the progression of liver disease or the response to antiviral treatment. WHAT ARE THE IMPLICATIONS FOR PRACTITIONERS? Hepatitis C virus remains a major health priority area in liver disease, increasing the future burden of cirrhosis and hepatocellular cancer. Many referred patients have comorbidities that increase their risk of progressive liver disease and related complications. Strategies to increase recognition and management of liver disease and its comorbidities in the community are required. The use of a standardised assessment form in referrals to hepatology outpatient services may assist with triaging of patients and improve access to appropriate care.

A longitudinal study of child mental health and problem behaviours at 14 years of age following unplanned pregnancy.

A substantial minority of children are born as a consequence of an unplanned pregnancy. Yet little is known about the impact of unplanned/unwanted pregnancy (UP) on long-term health outcomes for children. This study aimed to examine the association between UP and child mental health and behavioural problems at 14 years, and whether this association is confounded or mediated by other variables. Data were from a pre-birth prospective study that included 4765 mothers and their children (48.4% female and 51.6% male) followed up from pregnancy to 14 years of the child's age in Brisbane, Australia. Child anxiety/depression, aggression, delinquency, attention problems, withdrawal problems, somatic complaints, social problems, thought problems, internalizing, externalizing and total problems were measured using the Achenbach's Youth Self Report at 14 years. Child smoking and alcohol consumption were self-reported at 14 years. UP was prospectively assessed at the first antenatal visit of pregnancy. UP as reported by mothers at first antenatal visit predicted elevated levels of problem behaviours and increased substance use in children at 14 years. The impact of UP on child mental health and problem behaviours is partly due to the confounding effect of other variables, such as maternal socio-demographic status, mental health and substance use during pregnancy. Further research is needed to investigate the mechanism of association between UP and child aggression and early alcohol consumption at 14 years.

Use of medical emergency call data as a marker of quality of emergency department care in the post-National Emergency Access Target era.

Objectives Any new model of care should always be accompanied by rigorous monitoring to ensure that there are no negative consequences, especially any that impact upon patient safety. In 2013, 'THERMoSTAT' (Two- Hour Evaluation and Referral Model for Shorter Turnaround Times), an emergency department model of care developed by Royal Brisbane and Women's Hospital staff was launched to gain efficiencies and improve hospital National Emergency Access Target (NEAT) compliance. The aim of this study was to trial the use of medical emergency call data as a novel marker of the quality of care delivered by our emergency department. Methods Incidence of medical emergency calls for hospital emergency admission patients for the 2 years pre- and 1 year post-THERMoSTAT were compared after standardising for overall hospital activity. Results During the study period, hospital activity increased 10%, and the emergency department experienced a total of 222645 presentations, 68000 (30.5%) of which converted into an admission. THERMoSTAT improved NEAT compliance by 17% (from 57.7% to 74.9%) with no change in any patient-safety indicators. A total of 8432 medical emergency calls were made on 5930 patients, 2831 of whom were emergency admissions. After adjusting for hospital activity, there was no change in the average number of patients per week who triggered a medical emergency call after the introduction of THERMoSTAT. These results were reproduced when data was analysed for: total number of inpatients triggering calls; emergency admission patients; and emergency admission patients within the first 24h or first 4h of admission. Conclusions This is the first report to investigate the correlation between inpatient medical emergency call incidence and emergency department model of care. Medical emergency call data showed significant promise as a measure of morbidity and as a more direct, objective, simple, quantitative and meaningful measure of patient safety. What is known about the topic? It is well established that extended emergency department lengths of stay are associated with poorer patient outcomes. The corollary of this is not always true however; shorter emergency department length of stay does not automatically translate into better care. Although the underlying philosophy of NEAT is to enhance patient care, there is a risk of negative consequences if NEAT is seen as an end in itself. Many of the commonly used emergency department key performance indicators focus on the timeliness of care and there is a scarcity of easily quantifiable markers that reliably reflect the quality of that care. What does this paper add? This study builds on the concept of medical emergency call incidence as a marker of safety and quality. It explores the utility of using the number of medical emergency calls made in the first few hours of an emergency admission as an indicator of the quality of care delivered by the emergency department. This is significant because it introduces a measure that has a focus that embraces more than the timeliness of care only. What are the implications for practitioners? If medical emergency call incidence in early emergency admissions can be proven to accurately reflect emergency department quality of care then it would provide an easily monitored, objective, quantitative and prompt measure that evaluates dimensions other than timeliness.

Do children born to teenage parents have lower adult intelligence? A prospective birth cohort study.

Teenage motherhood has been associated with a wide variety of negative offspring outcomes including poorer cognitive development. In the context of limitations of previous research, this paper assesses the contemporary relevance of this finding. In this study we investigate the long-term cognitive status (IQ) among 21 year adult offspring born to teenage parents using the Mater University Study of Pregnancy- a prospective birth cohort study, which recruited all pregnant mothers attending a large obstetrical hospital in Brisbane, Australia, from 1981 to 1983. The analyses were restricted to a sub-sample of 2643 mother-offspring pair. Offspring IQ was measured using the Peabody Picture Vocabulary Test at 21 year. Parental age was reported at first clinic visit. Offspring born to teenage mothers (<20 years) have -3.0 (95% Confidence Interval (CI): -4.3, -1.8) points lower IQ compared to children born to mothers ≥20 years and were more likely to have a low IQ (Odds Ratio (OR) 1.7; 95% CI: 1.3, 2.3). Adjustment for a range of confounding and mediating factors including parental socioeconomic status, maternal IQ, maternal smoking and binge drinking in pregnancy, birthweight, breastfeeding and parenting style attenuates the association, though the effect remains statistically significant (-1.4 IQ points; 95% CI: -2.8,-0.1). Similarly the risk of offspring having low IQ remained marginally significantly higher in those born to teenage mothers (OR 1.3; 95% CI: 1.0, 1.9). In contrast, teenage fatherhood is not associated with adult offspring IQ, when adjusted for maternal age. Although the reduction in IQ is quantitatively small, it is indicative of neurodevelopmental disadvantage experienced by the young adult offspring of teenage mothers. Our results suggest that public policy initiatives should be targeted not only at delaying childbearing in the population but also at supporting early life condition of children born to teenage mothers to minimize the risk for disadvantageous outcomes of the next generation.

Hyperbaric oxygen therapy in the treatment of sudden sensorineural hearing loss: a retrospective analysis of outcomes.

OBJECTIVE: To analyse predictive factors affecting outcome after treatment with hyperbaric oxygen (HBOT) in patients with idiopathic sudden sensorineural hearing loss (ISSHL). METHODS: This is a retrospective audit of outcome in 77 consecutive patients referred for consideration of HBOT for ISSHL for either adjunctive treatment or after failure of steroid therapy. The hearing measured from the pre- and post-HBOT pure-tone audiogram (PTA4) at four frequencies; 500 Hz, 1 kHz, 2 kHz and 4 kHz, was averaged and compared. The PTA4 score was classified into three groups: complete improvement (≤ 25 dB residual hearing loss); moderate improvement (11-50 dB gain) and no improvement (≤ 11dB gain). Data were also analysed using mean residual loss on completion as the outcome measure. RESULTS: Seventy-six patients underwent 1,029 HBOT sessions. Twenty five of 78 ears (33%) had complete resolution of deafness after HBOT. A further 31 (40%) had a significant improvement in PTA4. Delay (〉 28 days) and older age were associated with worse outcomes in PTA4 improvement. Those with less severe hearing loss and short delay (〈 15 days) had the best outcome (mean residual loss 28 dB). Eight of nine patients who were delayed 〉 28 days had no improvement in PTA4. CONCLUSIONS: Fifty-six of 76 (74%) patients had complete (25) or moderate (31) improvement in hearing loss after HBOT. Short delay to HBOT, a severer degree of hearing loss and younger age were the best predictive factors of improved PTA4. Outcome was poor if treatment was delayed over 28 days. Well-designed randomised controlled trials are needed to clarify the role of HBOT and steroids.

Household and personal factors are sources of heterogenity in intestinal parasite clearance among Mexican children 6-15 months of age supplemented with vitamin A and zinc.

A randomised, double-blind, placebo-controlled trial was carried out among Mexico children aged 6-15 months to determine how household characteristics modify vitamin A and zinc supplementation efficacy on Ascaris lumbricoides, Giardia intestinalis and Entamoeba histolytica/E. dispar infection durations. Children assigned to receive vitamin A every 2 months, a daily zinc supplement, a combined vitamin A-zinc supplement or a placebo were followed for 1 year. Parametric hazard models were fit to infection durations stratified by personal and household factors. Children supplemented with vitamin A and zinc combined from households lacking piped water and children in all three treatment arms from households with dirt floors had longer G. intestinalis and A. lumbricoides infection durations than their counterparts, respectively. Shorter E. histolytica/E.dispar durations were found among zinc-supplemented children of mothers who had <6 years of education and no indoor bathrooms. Heterogeneity in supplementation efficacy among children may reflect differences in exposure risk and baseline immune responses.

Marital disruption: determinants and consequences on the lives of women in a rural area of Bangladesh.

This study, carried out during the second half of 1995, investigated the predisposing factors leading to marital disruption and its consequences on the lives of women in Matlab, a rural area of Bangladesh. Both qualitative and quantitative methods were used. Data were generated from detailed case studies and quantitative surveys of a small number of maritally-disrupted women. Additional data were used from the ongoing demographic surveillance system of ICDDR,B: Centre for Health and Population Research. The findings revealed that divorced and abandoned women and their children were extremely vulnerable, both socially and economically. Various factors that influence marital disruption were identified, the most important ones being: aspects determining the process of marriage, various family problems due to non-fulfillment of demand for dowry, mutual distrust, extramarital relationships, quality of sexual life, education of women, and other behavioural characteristics of individuals. Level of education of the wife showed an inverse relationship with the risk of divorce. Women who did not have livebirths from their first pregnancy had a higher risk of divorce. The effect of pregnancy outcome was dependent on the level of education of women. Illiterate women with unsuccessful pregnancy outcomes were at the highest risk of being divorced, with the lowest risk for women with some education and a livebirth. The findings clearly indicate the need for broad-based social development programmes for women, especially to enhance their education to reduce their vulnerability to marital instability and its consequences.

Prescribing databases can be used to monitor trends in opioid analgesic prescribing in Australia.

OBJECTIVE: There has been increased use of prescription opioid analgesics in Australia in the past 20 years with increasing evidence of related problems. A number of data sources collect information about the dispensed prescribing for opioid medications, but little is known about the extent to which these data sources agree on levels of opioid prescribing. METHODS: In Queensland, all opioid prescriptions (S8 prescriptions) dispensed by community pharmacies must be submitted to the Drugs of Dependence Unit (DDU). This potentially comprises a 'gold standard' against which other data sources may be judged. There are two national data sources: the Pharmaceutical Benefits Schedule (PBS) for all medications subsidised by government; and an annual national survey of representative pharmacies, which assesses non-subsidised opioid prescribing. We examined the agreement between these data sources. RESULTS: The three data sources provided consistent estimates of use over time. The correlations between different data sources were high for most opioid analgesics. There was a substantial (60%) increase in the dispensed use of opioid analgesics and a 180% increase in the dispensed use of oxycodone over the period 2002-2009. Tramadol was the most used opioid-like medication. CONCLUSIONS: Since 2002 different data sources reveal similar trends, namely a substantial increase in the prescribing of opioid medications. With few exceptions, the conclusions derived from using any of these data sources were similar. IMPLICATIONS: Improved access to PBS data for relevant stakeholders could provide an efficient and cost-effective way to monitor use of prescription opioid analgesics.

Management and midterm outcomes of post-infarction ventricular septal defect.

We assessed midterm outcomes, predictors of mortality, and residual defects after repair of post-infarction ventricular septal defect in 10 patients (mean age, 65.3 years; range, 50-78 years) who were operated on between 2000 and 2008. Mean time from onset of symptoms of myocardial infarction to diagnosis of ventricular septal defect was 3.5 days. Time from diagnosis to surgery ranged from 6 h to 84 days. The defects were located anteriorly in 4 patients and posteriorly in 6. Patch reconstruction of the septum was used in 6 patients and the infarct exclusion technique in 4. Hospital mortality was 60%. The only predictor of mortality was tricuspid valve competence (p = 0.048). There was no correlation between location of the defect or type of repair and operative mortality. Residual or recurrent ventricular septal defect was noted in 6 patients. Location of the defect and type of repair were not predictors of residual or recurrent defects. Residual ventricular septal defect was not associated with increased short-term mortality or reduction of functional status. Early mortality associated with post-infarction ventricular septal defect repair is significant. Discharged patients continue to have good functional capacity and quality of life, as well as favorable midterm survival.

Common symptoms during pregnancy to predict depression and health status 14 years post partum.

OBJECTIVE: To examine the prospective association between symptoms commonly experienced during pregnancy and the mental and general health status of women 14 years post partum. METHODS: Data used were from the Mater-University of Queensland Study of Pregnancy, a community-based prospective birth cohort study begun in Brisbane, Australia, in 1981. Logistic regression analyses were conducted. RESULTS: Data were available for 5118 women. Women who experienced a higher burden of symptoms during pregnancy were at greater risk of becoming depressed and reporting poorer health status 14 years post partum. Women who experienced major problems during pregnancy were 4 times more likely to be depressed and nearly 8 times more likely to report poorer health status 14 years after the index pregnancy compared with women who experienced few problems. CONCLUSIONS: Findings suggest that pregnant women who experience common symptoms during pregnancy are likely to experience poorer mental and self-reported general health 14 years after the pregnancy.

Maternal health during pregnancy and perinatal mortality in Bangladesh: evidence from a large-scale community-based clinical trial.

Perinatal mortality is very high in Bangladesh. In this setting, few community-level studies have assessed the influence of underlying maternal health factors on perinatal outcomes. We used the data from a community-based clinical controlled trial conducted between 1994 and 1997 in the catchment areas of a large MCH/FP hospital located in Mirpur, a suburban area of Dhaka in Bangladesh, to investigate the levels of perinatal mortality and its associated maternal health factors during pregnancy. A total of 2007 women were followed after recruitment up to delivery, maternal death, or until they dropped out of the study. Of these, 1584 who gave birth formed our study subjects. The stillbirth rate was 39.1 per 1000 births [95% confidence interval (CI) 39.0, 39.3] and the perinatal mortality rate (up to 3 days) was 54.3 per 1000 births [95% CI 54.0, 54.6] among the study population. In the fully adjusted logistic regression model, the risk of perinatal mortality was as high as 2.7 times [95% CI 1.5, 4.9] more likely for women with hypertensive disorders, 5.0 times [95% CI 2.3, 10.8] as high for women who had antepartum haemorrhage and 2.6 times [95% CI 1.2, 5.8] as high for women who had higher haemoglobin levels in pregnancy when compared with their counterparts. The inclusion of potential confounding variables such as poor obstetric history, sociodemographic characteristics and preterm delivery influenced only marginally the net effect of important maternal health factors associated with perinatal mortality. Perinatal mortality in the study setting was significantly associated with poor maternal health conditions during pregnancy. The results of this study point towards the urgent need for monitoring complications in high-risk pregnancies, calling for the specific components of the safe motherhood programme interventions that are designed to manage these complications of pregnancy.