Subphenotypes of severe early-onset pre-eclampsia at hospital admission. A Latin American single-center exploratory latent class analysis.

OBJECTIVES: To identify distinct subphenotypes of severe early-onset pre-eclampsia in Latin America and analyze biomarker and hemodynamic trends between subphenotypes after hospital admission. METHODS: A single-center prospective cohort study was conducted in Colombia. The latent class analysis identified subphenotypes using clinical variables, biomarkers, laboratory tests, and maternal hemodynamics. Class-defining variables were restricted to measurements at and 24 h after admission. Primary and secondary outcomes were severe maternal and perinatal complications. RESULTS: Among 49 patients, two subphenotypes were identified: Subphenotype 1 (34.7%) had a higher likelihood of an sFlt-1/PlGF ratio ≤ 38, maternal age > 35, and low probability of TPR > 1400, CO <8, and IUGR; Subphenotype 2 (65.3%) had a low likelihood of an sFlt-1/PlGF ratio < 38, maternal age > 35, and high probability of TPR > 1400, CO <8, and IUGR. At 24 h postadmission, 64.7% of subphenotype 1 patients changed to subphenotype 2, while 25% of subphenotype 2 patients were reclassified as subphenotype 1. Subphenotype 1 displayed significant changes in CO and TPR, while subphenotype 2 did not. Maternal complications were more prevalent in subphenotype 2, with an odds ratio of 5.3 (95% CI: 1.3-22.0; P = 0.02), but no significant differences in severe neonatal complications were observed. CONCLUSIONS: We identified two distinct subphenotypes in a Latin American cohort of patients with severe early-onset pre-eclampsia. Subphenotype 2, characterized by higher TPR, sFlt-1, and serum creatinine and lower CO and PlGF at admission, was associated with worse maternal outcomes and appeared less modifiable after in-hospital treatment.

Ventilatory Parameters in Obstetric Patients With COVID-19 and Impact of Delivery: A Multicenter Prospective Cohort Study.

BACKGROUND: Current evidence on obstetric patients requiring advanced ventilatory support and impact of delivery on ventilatory parameters is retrospective, scarce, and controversial. RESEARCH QUESTION: What are the ventilatory parameters for obstetric patients with COVID-19 and how does delivery impact them? What are the risk factors for invasive mechanical ventilation (IMV) and for maternal, fetal, and neonatal mortality? STUDY DESIGN AND METHODS: Prospective, multicenter, cohort study including pregnant and postpartum patients with COVID-19 requiring advanced ventilatory support in the ICU. RESULTS: Ninety-one patients were admitted to 21 ICUs at 29.2 ± 4.9 weeks; 63 patients (69%) delivered in ICU. Maximal ventilatory support was as follows: IMV, 69 patients (76%); high-flow nasal cannula, 20 patients (22%); and noninvasive mechanical ventilation, 2 patients (2%). Sequential Organ Failure Assessment during the first 24 h (SOFA24) score was the only risk factor for IMV (OR, 1.97; 95% CI, 1.29-2.99; P = .001). Respiratory parameters at IMV onset for pregnant patients were: mean ± SD plateau pressure (PP), 24.3 ± 4.5 cm H2O; mean ± SD driving pressure (DP), 12.5 ± 3.3 cm H2O; median static compliance (SC), 31 mL/cm H2O (interquartile range [IQR], 26-40 mL/cm H2O); and median Pao2 to Fio2 ratio, 142 (IQR, 110-176). Respiratory parameters before (< 2 h) and after (≤ 2 h and 24 h) delivery were, respectively: mean ± SD PP, 25.6 ± 6.6 cm H2O, 24 ± 6.7 cm H2O, and 24.6 ± 5.2 cm H2O (P = .59); mean ± SD DP, 13.6 ± 4.2 cm H2O, 12.9 ± 3.9 cm H2O, and 13 ± 4.4 cm H2O (P = .69); median SC, 28 mL/cm H2O (IQR, 22.5-39 mL/cm H2O), 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O), and 30 mL/cm H2O (IQR, 24.5-44 mL/cm H2O; P = .058); and Pao2 to Fio2 ratio, 134 (IQR, 100-230), 168 (IQR, 136-185), and 192 (IQR, 132-232.5; P = .022). Reasons for induced delivery were as follows: maternal, 43 of 71 patients (60.5%); maternal and fetal, 21 of 71 patients (29.5%); and fetal, 7 of 71 patients (9.9%). Fourteen patients (22.2%) continued pregnancy after ICU discharge. Risk factors for maternal mortality were BMI (OR, 1.10; 95% CI, 1.006-1.204; P = .037) and comorbidities (OR, 4.15; 95% CI, 1.212-14.20; P = .023). Risk factors for fetal or neonatal mortality were gestational age at delivery (OR, 0.67; 95% CI, 0.52-0.86; P = .002) and SOFA24 score (OR, 1.53; 95% CI, 1.13-2.08; P = .006). INTERPRETATION: Contrary to expectations, pregnant patient lung mechanics were similar to those of the general population with COVID-19 in the ICU. Delivery was induced mainly for maternal reasons, but did not change ventilatory parameters other than Pao2 to Fio2 ratio. SOFA24 score was the only risk factor for IMV. Maternal mortality was associated independently with BMI and comorbidities. Risk factors for fetal and neonatal mortality were SOFA24 score and gestational age at delivery.

Damage-control resuscitation in obstetrics.

Severe obstetric hemorrhage is a catastrophic event and represents the main cause of maternal morbidity and mortality worldwide. The elevated mortality rate due to hemorrhage is associated with metabolic complications and organ hypoperfusion that may trigger a state of irreversible coagulopathy. Thus, the use of conventional measures to control bleeding frequently generates a vicious cycle in which the patient continues bleeding (prolonging surgical times). Damage-control surgery has proven to be feasible and effective in the context of obstetric hemorrhage. It combines surgical and resuscitative measures that generate successful results in the control of refractory bleeding, ultimately decreasing mortality in patients being in critical condition.

Overall Maternal Morbidity during Pregnancy Identified with the WHO-WOICE Instrument.

OBJECTIVE: To evaluate the prevalence of nonsevere maternal morbidity (including overall health, domestic and sexual violence, functionality, and mental health) in women during antenatal care and further analyze factors associated with compromised mental functioning and clinical health by administration of the WHO's WOICE 2.0 instrument. METHOD: A cross-sectional study was conducted at a referral center in Brazil with an interview and questionnaire administered to pregnant women at 28 weeks of gestation and beyond. Data collection and management were supported by REDCAP software. A descriptive analysis was performed, and a multiple regression analysis also investigated factors associated with impairment in mental conditions, functionality, and clinical health. RESULTS: 533 women at a mean age of 28.9 years (±6.7) were included, and the majority had a partner (77.1%) and secondary education (67.7%). Exposure to violence occurred in 6.8%, and 12.7% reported substance use. Sexual satisfaction was reported by the vast majority (91.7%), although almost one-fifth were sexually abstinent. Overall, women reported very good and good health (72%), despite being told that they had a medical condition (66%). There was an overall rate of anxiety in 29.9%, depression in 39.5%, and impaired functioning in 20.4%. The perception of an abnormal clinical condition was the only factor independently associated with impaired functioning and mental health in the multiple regression model. Obesity was independently associated with clinical impairment. CONCLUSION: During antenatal care, pregnant women in the study reported having a high rate of anxiety, depression, impaired functioning, and substance use. These issues can affect a woman's health and should be further addressed for specific interventions and improved quality of care.

Immunological Role of the Maternal Uterine Microbiota in Postpartum Hemorrhage.

Recent metagenomics and microbiology studies have identified microorganisms that are typical of the fetoplacental unit. Considering this emerging evidence, the placenta, uterus, and the amniotic cavity are not sterile and not immune privileged. However, there is evidence for a beneficial interaction between active maternal immune system and the presence of commensal pathogens, which lead to an immune-tolerant state, thereby preventing fetal rejection. Multiple conditions associated with the loss of the normal flora are described (dysbiosis), which could result in perinatal and puerperal adverse events, including, directly or indirectly, postpartum hemorrhage. Altered flora when associated with a severe proinflammatory state and combined with patient's genetic and environmental factors confers a high-risk adverse outcome. Better understanding of the adverse role of dysbiosis in pregnancy outcome will improve maternal outcome.

Trauma in Pregnancy.

One of the most common causes of obstetric morbidity and mortality is trauma in pregnancy. Several maternal physiological changes during pregnancy have a significant impact on the mechanism, presentation, and management of trauma in this population. It is crucial for health providers dealing with trauma to know and understand these differences between pregnant and nonpregnant patients. The obstetric trauma patient requires a multidisciplinary approach, including obstetrics, maternal fetal medicine, anesthesiology, surgery, and intensive care teams. The aim of this article is to review the most updated information on trauma during pregnancy.

Postpartum hemorrhage care bundles to improve adherence to guidelines: A WHO technical consultation.

OBJECTIVE: To systematically develop evidence-based bundles for care of postpartum hemorrhage (PPH). METHODS: An international technical consultation was conducted in 2017 to develop draft bundles of clinical interventions for PPH taken from the WHO's 2012 and 2017 PPH recommendations and based on the validated "GRADE Evidence-to-Decision" framework. Twenty-three global maternal-health experts participated in the development process, which was informed by a systematic literature search on bundle definitions, designs, and implementation experiences. Over a 6-month period, the expert panel met online and via teleconferences, culminating in a 2-day in-person meeting. RESULTS: The consultation led to the definition of two care bundles for facility implementation. The "first response to PPH bundle" comprises uterotonics, isotonic crystalloids, tranexamic acid, and uterine massage. The "response to refractory PPH bundle" comprises compressive measures (aortic or bimanual uterine compression), the non-pneumatic antishock garment, and intrauterine balloon tamponade (IBT). Advocacy, training, teamwork, communication, and use of best clinical practices were defined as PPH bundle supporting elements. CONCLUSION: For the first response bundle, further research should assess its feasibility, acceptability, and effectiveness; and identify optimal implementation strategies. For the response to refractory bundle, further research should address pending controversies, including the operational definition of refractory PPH and effectiveness of IBT devices.

Experience of combined use of a Bakri uterine balloon and a non-pneumatic anti-shock garment in a university hospital in Colombia.

OBJECTIVE: To compare the outcomes of women with postpartum hemorrhage (PPH) refractory to initial management and in a state of hypoperfusion between management with a non-pneumatic anti-shock garment (NASG) and Bakri balloon and management with other surgical interventions. METHODS: A retrospective observational descriptive study of women with PPH and hemorrhagic shock who were treated at a high complexity obstetric unit in Columbia between 2011 and 2017. Clinical records were reviewed and women were divided in two groups by clinical management. Group 1 women were managed with surgical interventions; group 2 women were managed with NASG plus a Bakri balloon. RESULTS: Overall, 142 women were treated for PPH, with 69 in group 1 and 73 in group 2). There were differences between group 1 and group 2 in the degree of hypovolemic shock (shock index: 1.1 vs 0.9, P=0.02), indicators associated with hypoperfusion (lactic acid, 2.9 vs 1.9 mmol/L, P=0.001), and frequency of transfusion of blood components (68% vs 44%, P<0.05). CONCLUSIONS: The joint use of NASG and Bakri balloon in PPH management seemed to improve hypoperfusion-related markers such as lactic acid and shock index, and reduce the frequency of additional blood transfusion.

Characterization of obstetric patients with sepsis identified by two diagnostic scales at a fourth-level clinic in Colombia.

OBJECTIVE: To compare the characterization of an obstetric population diagnosed with sepsis using systemic inflammatory response syndrome (SIRS) criteria and sepsis-related organ failure assessment (SOFA). METHODS: The present retrospective observational descriptive study was conducted at a fourth-level clinic in Colombia among pregnant women who met the inclusion criteria (two SIRS criteria plus infection) between January 1, 2015, and December 31, 2016. Patients with systemic compromise were admitted to the high-complexity obstetric unit (HCOU), whereas those with multiorgan dysfunction were admitted to the intensive care unit (ICU). The SIRS scale was deemed positive if all four criteria were met. A SOFA score of at least 2 was considered a positive result. RESULTS: The study included 688 patients. The SIRS test at admission was positive among 431 patients (62.6%); 279 (64.7%) in the HCOU group and 152 (35.2%) in the ICU group. The SOFA test at admission was positive in 69 (38.5%) of 179 patients with complete data. The concordance-measured using the κ statistic-between SIRS and SOFA was low (0.016). CONCLUSION: Using the SIRS scale could promote early sepsis management by identifying patients who require admission to the HCOU or ICU; however, low concordance between the SIRS and SOFA results suggested a need to create diagnostic scales specifically for the obstetric population.

Model of obstetric attention based on critical care in Latin America.

PURPOSE: Report the results obtained following the implementation of an OCC (Obstetric Critical Care) model. MATERIALS AND METHODS: This is an observational prospective study in obstetric population with high complexity illness attended in a safety and quality model of attention in a specific unit supporting the concept of obstetric critical care. Records were used as the primary source for collecting information, using the standards of the Center for Clinical Research. RESULTS: In a 5-year period, 10,956 patients were admitted. About 51% had diseases that were not exclusive to pregnancy, 91% were admitted while pregnant and, from all births, 46% were by vaginal delivery. 1685 (19%) patients met the criteria for Near Miss Maternal Mortality (NMMM). Forty-three patients died, which represented a mortality rate of 0.49% of the total of hospitalized patients. CONCLUSIONS: The implementation of an OOC model, security models, and an institutional support system improve the quality of care in the obstetric services of reference hospitals in developing countries.

Detección de Helicobacter pylori en tejido aórtico humano mediante la amplificación del gen del 16S rDNA / Detection of Helicobacter pylori in human aortic tissue through amplification of the 16S rDNA gen

Helicobacter pylori es un patógeno humano reportado de manera frecuente como responsable de afecciones gastrointestinales. En los últimos años, se ha sugerido una asociación causal entre infecciones crónicas por varios patógenos, entre ellos Helicobacter pylori, y la génesis y/o progresión de la aterosclerosis. Aunque se han realizado varios estudios, no hay evidencia contundente de que esta asociación sea verdadera. El propósito de este estudio fue investigar la presencia de Helicobacter pylori en muestras de tejido aórtico de pacientes con diagnóstico clínico de ectasia anulo-aórtica, mediante la amplificación por técnicas de reacción en cadena de la polimerasa (PCR) de un fragmento del gen del 16S rDNA de este microorganismo. Se analizaron muestras de ADN de tejido aórtico obtenido de 20 pacientes. Se procesó un fragmento de aorta con lesión aterosclerótica aparente y otro de una región aparentemente sana en cada uno de los pacientes. No se detectaron ácidos nucleicos de Helicobacter pylori en ninguno de los especímenes analizados. Los resultados del estudio sugieren baja o nula asociación entre Helicobacter pylori y enfermedad coronaria en nuestro medio.

Intrafetal alcohol chemosclerosis of acardiac twins: a multicenter experience.

OBJECTIVE: To report a multicenter experience with intrafetal alcohol chemosclerosis in the treatment of pregnancies complicated with the twin reversed arterial perfusion sequence. METHODS: Percutaneous injection of 1- 2 ml of absolute alcohol into the intra-abdominal segment of the single umbilical artery was performed in 8 acardiac twins. Cases were collected from 5 centers following a standardized protocol. The procedure was performed under continuous ultrasound control, using color Doppler ultrasound to identify the main arterial vessel entering the abdomen of the acardiac twin and passing a 20-gauge spinal needle into the targeted vessel. Intraoperative and short-term complications were noted. Information on pregnancy outcome was obtained by reviewing the medical records or contacting the referring obstetrician. RESULT: At the time of the procedure, the acardiac twin was severely hydropic and the size exceeded 70% of the size of the pump twin in all cases. In addition, there were associated complications in all the pump twins including polyhydramnios in 8 cases (100%), cardiac insufficiency in 5 (63%), and fetal growth restriction in 1 (13%). The procedure was performed at a mean gestational age of 24.7 weeks (range 20-32), and it was technically successful in all cases. However, it was complicated with thrombosis of the umbilical vessels of the pump twin in 1 case, and transient bradycardia in 2 others. These 3 pump twins died in utero as a result of the procedure. The other 5 procedures were technically and clinically successful, resulting in an overall survival rate of 63%. In 4 pregnancies, the pump twin was delivered after 35 weeks and had no neonatal complications. CONCLUSIONS: Intrafetal alcohol chemosclerosis is a simple procedure that can be performed in any fetal medicine center around the world to stop the vascular supply to acardiac twins. However, the main concern with this technique is intravascular transfer of the ablative material to the circulation of the pump twin. The use of this technique should therefore be restricted to those pregnancies with poor prognostic factors and in countries where more sophisticated methods for the treatment of this condition are not available.