An audit of the use of magnesium sulphate in severe pre-eclampsia and eclampsia.

Over the last decade there has been an increase in the use of MgSO4 for the prevention of seizures in women with severe pre-eclampsia or eclampsia. At the Rotunda Hospital it is regularly used for this purpose. The aim of this study was to audit the use of MgSO4 at the hospital, to determine whether the drug was being used according to the hospital's protocol and to observe its effectiveness in the prevention of eclampsia in our population. A retrospective chart review over the two years from 1/1/2000 to 31/12/2001 was undertaken. Outcome measures assessed were; Patient selection, Administration of the drug - whether recommended protocols were adhered, Effectiveness of therapy for seizure prophylaxis, Maternal and neonatal outcomes. There were 12,910 deliveries at the Rotunda hospital over this period of time. Fifty of these women were treated with MgSO4 (0.4%). Patient selection was appropriate in all cases. The correct loading dose of MgSO4 was administered in all cases, however MgSO4 levels were recorded in only 30 (60%) of women. There were no seizures in the treated group. Two women presented with seizures (one was antenatal the other post-natal period), both were treated with MgSO4. There were no maternal or neonatal mortality. Seventy two percent (36) of these women were delivered by lower segment caesarean section. The mean gestation at delivery was 36 weeks (range 28-41 weeks). Thirty eight percent (13) of babies required admission to the neonatal intensive care unit. The mean birth weight at delivery was 2.54 kg (range 1.11-3.68 kg). MgSO4 use in the Rotunda hospital appears to be safe and effective for the prevention of seizures in women with severe pre-eclampsia or eclampsia. Serum MgSO4 levels were only recorded in 60% of patients and the hospital's protocol was not adhered to regarding monitoring of patients on treatment. This needs to be addressed.

Comparison of referral and non-referral hypertensive disorders during pregnancy: an analysis of 271 consecutive cases at a tertiary hospital.

BACKGROUND: This retrospective cohort study analyzed the clinical manifestations in patients with preeclampsia and eclampsia, assessed the risk factors compared to the severity of hypertensive disorders on maternal and perinatal morbidity, and mortality between the referral and non-referral patients. METHODS: 271 pregnant women with preeclampsia and eclampsia were assessed (1993 to 1997). Chi-square analysis was used for the comparison of categorical variables, and the comparison of the two independent variables of proportions in estimation of confidence intervals and calculated odds ratio of the referral and non-referral groups. Multivariate logistic regression was used for adjusting potential confounding risk factors. RESULTS: Of the 271 patients included in this study, 71 (26.2%) patients were referrals from other hospitals. Most of the 62 (87.3%) referral patients were transferred during the period 21 and 37 weeks of gestation. Univariate analysis revealed that referral patients with hypertensive disorder were significantly associated with SBP > or =180, DBP > or =105, severe preclampsia, haemolysis, elevated liver enzymes, low platelets (HELLP), emergency C/S, maternal complications, and low birth weight babies, as well as poor Apgar score. Multivariate logistic regression analyses revealed that the risk factors identified to be significantly associated with increased risk of referral patients included: diastolic blood pressure above 105 mmHg (adjusted odds ratio, 2.09; 95 percent confidence interval, 1.06 to 4.13; P = 0.034), severe preeclampsia (adjusted odds ratio, 3.46; 95 percent confidence interval, 1.76 to 6.81; P < 0.001), eclampsia (adjusted odds ratio, 2.77; 95 percent confidence interval, 0.92 to 8.35; P = 0.071), HELLP syndrome (adjusted odds ratio, 18.81; 95 percent confidence interval, 2.14 to 164.99; P = 0.008). CONCLUSION: The significant factors associated with the referral patients with hypertensive disorders were severe preeclampsia, HELLP, and eclampsia. Lack of prenatal care was the major avoidable factor found in referral and high risk patients. Time constraints relating to referral patients and the appropriateness of patient-centered care for patient safety and better quality of health care need further investigation on national and multi-center clinical trials.

Are we increasing serious maternal morbidity by postponing termination of pregnancy in severe pre-eclampsia/eclampsia?

The objective of this study was to evaluate the impact of admission--delivery interval on maternal morbidity in patients with severe pre-eclampsia/eclampsia. This was a retrospective study, which involved review of case sheets of 188 women (admitted to St John's Medical College Hospital during the year 2000--2001 with the above diagnosis). The incidence of severe pre-eclampsia and eclampsia was 5.18% (188/3,627) with 119 primigravida and 69 multigravida. The incidence of serious maternal complications in the post partum period was 17% (11/68) in the category of women who delivered within 12 hours of admission compared with 40.6% (28/69) in the 12--48-h category and 60.8% (31/51) in the>48-h category. The incidence of serious maternal complications in the subset with HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome was 33.4% (7/21) in the12-h. We concluded that termination of pregnancy within 12 hours of admission in severe pre-eclampsia/eclampsia especially in patients with HELLP syndrome helps to prevent avoidable serious maternal morbidity.

Spinal anesthesia-induced hypotension: a risk comparison between patients with severe preeclampsia and healthy women undergoing preterm cesarean delivery.

We previously showed that, in comparison with term healthy parturients, patients with severe preeclampsia had a less frequent incidence of spinal hypotension, which was less severe and required less ephedrine. In the present study, we hypothesized that these findings were attributable to preeclampsia-associated factors rather than to a smaller uterine mass. The incidence and severity of hypotension were compared between severe preeclamptics (n = 65) and parturients with preterm pregnancies (n = 71), undergoing spinal anesthesia for cesarean delivery (0.5% bupivacaine, sufentanil, morphine). Hypotension was defined as the need for ephedrine (systolic blood pressure <100 mm Hg in parturients with preterm fetuses or 30% decrease in mean blood pressure in both groups). Apgar scores and umbilical arterial blood pH were also studied. Neonatal and placental weights were similar between the groups. Hypotension was less frequent in preeclamptic patients than in women with preterm pregnancies (24.6% versus 40.8%, respectively, P = 0.044). Although the magnitude of the decrease in systolic, diastolic, and mean arterial blood pressure was similar between groups, preeclamptic patients required less ephedrine than women in the preterm group to restore blood pressure to baseline levels (9.8 +/- 4.6 mg versus 15.8 +/- 6.2 mg, respectively, P = 0.031). The risk of hypotension in the preeclamptic group was almost 2 times less than that in the preterm group (relative risk = 0.603; 95% confidence interval, 0.362-1.003; P = 0.044). The impact of Apgar scores was minor, and umbilical arterial blood pH was not affected. We conclude that preeclampsia-associated factors, rather than a smaller uterine mass, account for the infrequent incidence of spinal hypotension in preeclamptic patients.

Homocysteine and folic acid: implications for pregnancy.

The role of folic acid and homocysteine in pregnancy is becoming clearer. The efforts of many countries to prevent neural tube defects through public awareness of folic acid have been disappointing, but evidence is now emerging that the food fortification programs in the United States and Canada are effective in reducing the numbers of neural tube defects, and there may be additional benefits in terms of other congenital defects such as oral-facial clefts and congenital heart disease. Homocysteine has a significant association with vascular disease in later life, is elevated in preeclampsia, and has been associated with other pregnancy complications such as early pregnancy loss. The data from cohorts of women with a history of preeclampsia during pregnancy indicate that they are at increased risk for cardiovascular and cerebrovascular disease in later life. Elevated homocysteine concentrations may be a common link that accounts for these associations.

Second pregnancy outcomes following preeclampsia in a first pregnancy.

OBJECTIVES: We compared second pregnancy outcomes among women with and without preeclampsia in their first pregnancies who all had second pregnancies without preeclampsia. METHODS: One hundred thirty women with and 6148 without preeclampsia in their first pregnancies, who all had nonpreeclamptic second pregnancies, were included. Outcomes, including delivery gestational age, birthweight, small-for-gestational-age (SGA), and preterm delivery were compared. RESULTS: Overall, second pregnancy outcomes were not different between women with and without preeclampsia in their first pregnancy. However, when women were stratified by gestational timing of preeclampsia, women with preeclampsia at < 34 weeks (N = 22) had smaller infants and delivered earlier in their second nonpreeclamptic pregnancy compared to women with later preeclampsia (N = 108) or no preeclampsia in the first pregnancy. Women with early preeclampsia also had an increased risk of prematurity (< 37 weeks) in second pregnancies that persisted after controlling for confounding factors [Odds ratio (OR = 3.2)]. DISCUSSION: Second, nonpreeclamptic pregnancy outcomes are different between women with previous early preeclampsia and controls but not between late preeclampsia and controls. These findings support other epidemiological data indicating differences between early and late onset preeclampsia as well as a potential relationship of preeclampsia and spontaneous preterm birth.

The incidence of severe complications of preeclampsia.

OBJECTIVES: To examine the incidence of life-threatening (near-miss) complications, including hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome occurring in women with preeclampsia in the Grampian region of Scotland between 1981 and 2000. SUBJECTS AND METHODS: All women who were resident in a geographically determined region (the Grampian region of Scotland) and who developed moderate to severe preeclampsia in the time period 1981 to 2000 were identified from the Aberdeen Maternity and Neonatal Databank. All complications occurring antepartum, intrapartum, or postpartum in these pregnancies were listed as International Classification of Diseases (ICD) codes and significant complications were identified from these. The cases of HELLP syndrome were identified by case note review. Data were analyzed using Statistical Package for Social Scientists (SPSS). RESULTS: A total of 4188 cases of preeclampsia were identified over the 20-year period. Six percent (approx. 1 in 16) of preeclamptics developed one or more major systemic complications. The incidence of placental abruption and eclampsia was 2.8% and 1.65%, respectively. Hematological complications were most common, with reduced platelets accounting for about half of these cases; although, a definite diagnosis of HELLP syndrome could only be made in 13 cases over 20 years. After adjusting for gestational age, a woman was 1.14 times more likely to have a caesarean delivery (95% C.I. 1.08, 1.20) if she had complicated preeclampsia. She was also more likely to have a stillbirth [Odds Ratio (O.R.) = 1.45 (95% C.I. (confidence interval) 1.02, 2.29)] or a neonatal death [O.R. = 2.25 (95% C.I. 1.12, 4.260]. CONCLUSIONS: There has been a gradual decline in the rate of preeclampsia in the Grampian region of Scotland over the time period 1986 to 2000; although, the percentage of pre-eclamptics who developed one or more complications has not decreased appreciably. In fact, the incidence of eclampsia and placental abruption has increased in the most recent five years. The presence of complications in preeclampsia is associated with a poor neonatal outcome.

[Massive vulvar edema in severe preeclampsia].

Massive vulvar edema in woman with severe preeclampsia is described.

A randomized trial comparing low-dose combined spinal-epidural anesthesia and conventional epidural anesthesia for cesarean section in severe preeclampsia.

BACKGROUND AND OBJECTIVES: A prospective, randomized study was designed to compare the maternal and neonatal effects of conventional epidural anesthesia and combined spinal epidural anesthesia (CSE) for Cesarean section in severe preeclamptic patients. Additionally, two strategies in the prophylactic management of hypotension in severe preeclamptic patients were evaluated: fluid preloading or prophylactic ephedrine. METHODS: Thirty nonlaboring women with severe preeclampsia (PET), scheduled for an elective Cesarean section, were randomised into three groups: epidural anesthesia with prophylactic fluid loading (EA-F), combined spinal epidural anesthesia with prophylactic fluid loading (CSE-F), or combined spinal epidural anesthesia with prophylactic ephedrine (CSE-V). Hemodynamic data were recorded prior and after induction of regional anesthesia at five-minute intervals. The total amount of intravenous administered fluid and the total dose of vasopressors were recorded. RESULTS: Hemodynamic data were similar between the three groups. The incidence and duration of hypotension was similar in all three groups. Significantly more ephedrine was used in the CSE-V group as compared to the CSE-F group. More lactated Ringer's solution was used in the CSE-F group as compared to the CSE-V group. There were no hypertensive episodes and none of the patients developed pulmonary edema. The time period from induction until the start of surgery and the duration of surgery were significantly shorter in both CSE-groups. Neonatal outcome was comparable between the three groups. CONCLUSION: Our results confirm that combined spinal and epidural anesthesia (CSE) is a safe alternative to conventional epidural anesthesia in severe preeclamptic women and that the prophylactic use of ephedrine is effective and safe to prevent and treat spinal hypotension after combined spinal and epidural anesthesia for Cesarean section in severe preeclamptic women.

Dizygotic twins discordant for early-onset Citrobacter koseri and group B streptococcal sepsis.

Early-onset neonatal sepsis is usually a multisystem fulminant illness with prominent respiratory symptoms, and typically the infant has acquired the organism from the maternal genital tract during the intrapartum period. In this article, we report a rare case of dizygotic twins where each individual suffered early-onset sepsis caused by a different pathogen. Group B streptococcal (GBS) sepsis was diagnosed in twin A 1 day after birth; sepsis and meningitis caused by Citrobacter koseri was diagnosed in twin B at the age of the 4 days. The mother developed pre-eclampsia and fever and the twins were delivered via cesarean section at 35 week's gestation. Twin A received ampicillin treatment for 14 days and recovered fully. Twin B was treated with ceftriaxone for 4 weeks and follow-up brain ultrasound revealed persistent enlargement of the bilateral-lateral ventricles. When empiric antibiotic is considered for the symptomatic twin of a sibling with early-onset GBS infection, samples of blood and cerebrospinal fluid (CSF) should be obtained for culture study before treatment. Adjustment of antibiotic treatment based on the results of cultures and CSF Gram stain and antibiotic susceptibility test is essential.

[Factors associated to maternal mortality among preeclamptic parturients. About 55 cases]. / Facteurs associees a la mortalite maternelle chez les preeclamptiques: a propos de 55 cas.

Retrospective study about 55 preeclamptic parturients. Data was collected from the medical files of the patients hospitalized during two consecutive years. Admittance of preeclamptic women in the intensive care unit was 6,37 % (55/689). Mortality rate was 11% (6 deaths). Complications associated with the maternal death were renal failure, disseminated intravascular coagulopathy and Hemorrhagic shock after subcupsular liver hematoma. Advanced maternal age is a factor associated to maternal mortality. All these risk factors of death may be avoided if adequate management was performed.

Outcomes of severe pre-eclampsia/eclampsia in Yorkshire 1999/2003.

OBJECTIVE: To establish the risk of serious complications from severe pre-eclampsia and eclampsia in a region using a common guideline for the management of these conditions. DESIGN: A five-year prospective study. SETTING: Sixteen maternity units in Yorkshire. POPULATION: All women managed with severe pre-eclampsia and eclampsia. METHODS: A common guideline was developed for the management of women with these conditions. A network of midwives prospectively collected outcome data. MAIN OUTCOME MEASURE: Incidence of the conditions and serious complication rates. RESULTS: A total of 210,631 women delivered in the 16 units between 1 January 1999 and 31 December 2003. One thousand eighty-seven women were diagnosed with severe pre-eclampsia or eclampsia (5.2/1000). One hundred and fifty-one women had serious complications including 82 women (39/10,000) having eclamptic seizures and 49 women (23/10,000) requiring ICU admission. There were no maternal deaths but 54 out of 1145 babies died before discharge, giving a mortality rate of 47.2/1000. Of the 82 cases of eclampsia, 45 occurred antenatally (55%), 18 before admission to the maternity unit. Eleven cases occurred in labour (13%), including 1 during a caesarean section, and 26 cases occurred following delivery (32%). Twenty-five women developed pulmonary oedema (2.3% of cases) and six women required renal dialysis (0.55% of cases). One hundred and sixty-five (15%) required no antihypertensive therapy and 489 (53%) of the remainder required only oral therapy. Two hundred and one (18.5%) required more than one drug. CONCLUSION: A regional guideline for severe pre-eclampsia and eclampsia can be developed and implemented. Its use may contribute to a low rate of serious complications.

[Maternal and foetal prognostic during severe toxemia]. / Pronostic maternel et foetal au cours de la toxemie gravidique severe.

Severe gravidic toxemia gives heavy maternal and foetal morbidity and mortality. The purpose of our study is to loosen the factors of bad maternal and foetal prognostic. It's a retrospective study about 100 cases of severe and complicated gravidic toxemia repertorieted in the maternity of Military Hospital of Tunis. Maternal morbidity is dominated by the complications of hypertension and a blood disorders. We raised 4 cases of eclampsia, 9 cases of retro placental hematome and 5 cases of HELLP syndrome. We don't deplore any maternal death. Perinatal mortality is 28.8%. The rate of delay intra-uterine growth was 43.8% and the prematurity 65.9%. More toxemia appears early during pregnancy more maternal and foetal prognostic is compromised.

Autosomal dominant polycystic kidney disease in pregnancy complicated by twin gestation and severe preeclampsia: a case report.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD), an autosomal dominant genetic disorder with a reported prevalence of 1 in 1,000, may be associated with hypertensive disease in pregnancy. The evaluation of a pregnant woman with an adult-onset genetic disorder is complex and involves counseling about inheritance, prenatal diagnosis and management of the current pregnancy. CASE: A 33-year-old woman presented for obstetric care with a history of hypertension and ADPKD for 6 years. The patient had secondary infertility, which was treated by in vitro fertilization. The case was complicated by twin gestation and superimposed severe preeclampsia, leading to preterm cesarean delivery at 26 weeks' estimated gestational age. CONCLUSION: Because of the heritable nature of ADPKD and the long-term risk of end-stage renal disease requiring dialysis and/or renal transplantation, the evaluation and counseling of women with ADPKD who are pregnant or considering pregnancy should include a discussion of the modes of inheritance, natural history, available prenatal diagnostic options, and pregnancy risks and management options. Specific counseling issues in this case include the genetic concepts of variable expression and penetrance and the medical management of chronic hypertension and preeclampsia.

Early occurrence of metabolic syndrome after hypertension in pregnancy.

OBJECTIVE: The objective of the present study was to evaluate the cardiovascular risk profile and the prevalence of metabolic syndrome among women with a history of pregnancy-induced hypertension (PIH). METHODS: From a cohort of 3,799 nulliparous women prospectively recruited between 1989 and 1997, we performed an observational study on 168 case-control pairs 7.8 years after delivery. Participants were scheduled for a visit with a research nurse to evaluate their cardiovascular risk profile using a questionnaire, anthropometric measurements and blood specimen analysis. RESULTS: One hundred sixty-eight women with prior PIH (105 with gestational hypertension and 63 with preeclampsia) and 168 controls matched for age and year of index delivery were evaluated. The women with PIH (34.6 +/- 4.4 years) were more obese and had higher systolic (115 mm Hg versus 108 mm Hg) and diastolic (75 mm Hg versus 70 mm Hg) blood pressures (P < .001) than the 168 controls (35.1 +/- 4.5 years). They had lower high-density lipoprotein cholesterol level (1.30 mmol/L versus 1.42 mmol/L; P < .001), increased fasting blood glucose concentration (5.2 mmol/L versus 5.0 mmol/L; P = .002), and higher insulin levels (119 versus 91 pmol/L; P < .001). The prevalence of the metabolic syndrome was higher in the PIH group (unadjusted odds ratio = 4.9; 95% confidence interval 2.1-10.9) compared with controls, even after adjustment for confounders (adjusted odds ratio = 3.6; 95% confidence interval 1.4 -9.0). CONCLUSION: In white women in their mid-30s, the prevalence of the metabolic syndrome is 3- to 5-fold increased in those with a history of PIH in their first pregnancy. This emphasizes the importance of long-term follow-up assessment for cardiovascular risk factors in these women.

Spontaneous acute thoracic epidural hematoma causing paraplegia in a patient with severe preeclampsia in early labor.

This is a case of acute spontaneous thoracic epidural hematoma in a laboring patient at term who presented with severe preeclampsia and acute spinal cord compression, paraplegia, and sensory loss below T8. In early labor, at home, the patient experienced sudden lumbar back pain that progressed to mid-scapular pain leading to paraplegia and T8 sensory loss within one hour of onset of pain. Her symptoms were caused by a spontaneous thoracic epidural hematoma. Upon arrival at the first hospital, the correct presumptive diagnosis was made in the emergency room, magnesium sulfate was administered, and the patient was transferred to our medical center. Her hypertension was not treated despite severe preeclampsia in order to maintain spinal cord perfusion pressure. Following cesarean section under general anesthesia, thoracic laminectomy was performed and an epidural hematoma compressing the spinal cord to 2-3 mm was evacuated 13 h after the onset of symptoms. After approximately three months of paraplegia, five months with quad-walker and cane use, the patient can now walk with a cane or other minimal support but has remaining bowel and bladder problems. The conflicting anesthetic management objectives of severe preeclampsia and acute paraplegia secondary to spinal epidural hematoma required compromise in the management of her preeclampsia in order to preserve spinal cord perfusion.