Assessing the incremental value of blood oxygen saturation (SpO(2)) in the miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) Risk Prediction Model.

OBJECTIVE: To assess the incremental value of blood oxygen saturation (SpO(2)) as a predictor in the miniPIERS model, a risk prediction model for adverse outcomes among women with a diagnosis of hypertensive disorder of pregnancy (HDP) in low-resourced settings. METHODS: Using data from a prospective cohort including 852 women admitted to hospital for a HDP, the association between SpO(2) and adverse maternal outcome was assessed using logistic regression. The miniPIERS model was recalibrated and extended to include SpO(2). The incremental value of adding SpO(2) to the model was measured using a net reclassification index (NRI), sensitivity, specificity, positive and negative predictive values, and likelihood ratios. RESULTS: SpO(2) of < 93% was associated with a 30-fold increase in risk (95% CI 14 to 68) of adverse maternal outcome compared to women with SpO(2) > 97%. After recalibration and extension, the miniPIERS model including SpO(2) (vs. not including SpO(2)) had improved sensitivity (32.8% vs. 49.6%) at the cost of minimally decreased specificity (91.5% vs. 96.2%) with a NRI of 0.122. CONCLUSION: SpO(2) is a significant independent predictor of risk in women with a HDP. Adding SpO(2) to the miniPIERS model improved the model's ability to correctly identify high-risk patients who would benefit most from interventions.

Objectif : Évaluer la valeur cumulative de la saturation en oxygène (SaO2) à titre de facteur prédictif dans le cadre du modèle miniPIERS, soit un modèle de prévision des risques en ce qui concerne les issues indésirables chez les femmes ayant obtenu un diagnostic de trouble hypertensif de la grossesse (THG) dans des milieux qui ne disposent que de faibles ressources. Méthodes : Grâce à des données issues d'une cohorte prospective ayant porté sur 852 femmes hospitalisées en raison d'un THG, l'association entre la SaO2 et les issues indésirables maternelles a été évaluée au moyen d'une régression logistique. Le modèle miniPIERS a été recalibré et élargi de façon à inclure la SaO2. La valeur cumulative de l'ajout de la SaO2 à ce modèle a été mesurée en ayant recours à l'indice NRI (net reclassification index), à la sensibilité, à la spécificité, aux coefficients de prévision d'un test positif et d'un test négatif et aux rapports de vraisemblance. Résultats : La SaO2 < 93 % a été associée à un risque 30 fois plus élevé (IC à 95 %, 14 - 68) de constater une issue maternelle indésirable, par comparaison avec une SaO2 > 97 %. Après avoir été recalibré et élargi, le modèle miniPIERS comprenant la SaO2 (par comparaison avec le modèle ne comprenant pas la SaO2) présentait une sensibilité améliorée (32,8 % vs 49,6 %); cela a toutefois mené à une baisse minime de la spécificité (91,5 % vs 96,2 %) en présence d'un indice NRI de 0,122. Conclusion : La SaO2 constitue un facteur prédictif indépendant significatif pour ce qui est du risque auquel sont exposées les femmes qui présentent un THG. L'ajout de la SaO2 au modèle miniPIERS a mené à l'amélioration de la capacité de ce dernier à identifier correctement les patientes exposées à des risques élevés qui tireraient le plus avantage de la tenue d'interventions.

Pre-eclampsia challenges and care in low and middle-income countries: Understanding diagnosis, management, and health impacts in remote and developing regions.

As an example of a low- and middle-income country (LMIC), India ranks pre-eclampsia among the top three causes of maternal mortality, following haemorrhage and infections. It is one of the primary concerns for maternal and perinatal health in LMICs. Many LMICs lack clear consensus and guidelines for the prevention, diagnosis, and management of hypertensive disorders in pregnancy, including pre-eclampsia. The International Society for the Study of Hypertension in Pregnancy 2021 guidelines address LMIC applications, offering customisable solutions. Atypical presentations of pre-eclampsia contribute to diagnostic delays, resulting in additional adverse maternal and perinatal outcomes. Implementing management strategies faces challenges in both urban and rural settings. Adapting global research involving local populations is imperative, with the potential for cost-effective adoption of international guidelines. Prevention, early diagnosis, and education dissemination are essential, involving healthcare providers and advocacy initiatives. Encouraging government investment in pre-eclampsia management as a public health initiative is important. This article explores socio-economic, cultural, and legislative factors influencing the management of pre-eclampsia in LMICs, addressing emerging challenges and potential partnerships for healthcare provision.

sFlt1/PlGF among patients with suspected preeclampsia when considering hypertensive status.

BACKGROUND: In high-resource settings, biomarkers of angiogenic balance, such as the soluble fms-like tyrosine kinase-1 (sFlt1)/placental growth factor (PlGF) ratio, have been studied extensively to aid in evaluation of patients with suspected preeclampsia (PE), and have been incorporated into the 2021 International Society for the Study of Hypertension in Pregnancy definition of PE. The utility in under-resourced settings has not been as well characterized. OBJECTIVE: This analysis sought to identify the role of the sFlt1/PlGF ratio in the evaluation of patients with or without hypertension who are suspected of having PE without other diagnostic information. STUDY DESIGN: This is a secondary analysis of a prior prospective study of patients who were presented with suspected PE at ≥20+0 weeks' gestation at a single academic tertiary care center. Patients were recruited in the parent study from July 2009 to June 2012. In the original study, clinicians were masked to biomarker results, and patients were followed by chart review. In this analysis, the performance of the sFlt1/PlGF ratio (≤38, >38, or >85) was assessed alone in identifying both hypertensive and non-hypertensive patients at risk of evolving into PE with severe features (PE-SF; American College of Obstetricians and Gynecologists' definition) within two weeks of the triage visit (PE-SF2). Hypertension was defined as a blood pressure (BP)≥140/90 mmHg. RESULTS: There were 1043 patients included in the analysis; of whom, 579 (55.5%) and 464 (44.5%) presented with or without hypertension, respectively. In triage, 332 (75.4%) of hypertensive patients presented due to BP concerns, and the remainder were evaluated due to other features (new-onset headache, proteinuria, or edema). On triage evaluation, 66.8% of all patients had a normal sFlt1/PlGF ratio ≤38, and 17.0% had an elevated ratio >85. Among hypertensive patients, a sFlt1/PlGF ratio ≤38 was a good rule-out test for PE-SF2 (negative likelihood ratio [LR-] of 0.15), and a ratio >85 was a good rule-in test (positive likelihood ratio [LR+] of 5.75). Among normotensive patients, sFlt1/PlGF was useful as a rule-in test for ratio >38 (LR+ 5.13) and >85 (LR+ 12.80). Stratified by gestational age, sFlt1/PlGF continued to be a good rule in and good rule out test at <35 weeks among those with hypertension but did not have good test performance ≥35 weeks. sFlt1/PlGF had a good test performance as a rule in test for >85 regardless of gestational age. In triage, 4.3% (30/693) of patients with sFlt1/PlGF ratio <38 had concurrent laboratory evidence of PE, compared with 15.9% (28/176) patients with ratio >85. CONCLUSION: These findings support the potential for the use of sFlt1/PlGF and BP measurement alone in resource-limited settings where other laboratory tests or clinical expertise are unavailable for risk stratification. Performance of the biomarker varied by the presence of hypertension and gestational age.

Women's experiences of maternity care in the United Kingdom during the COVID-19 pandemic: A follow-up systematic review and qualitative evidence synthesis.

BACKGROUND: Maternity care services in the United Kingdom have undergone drastic changes due to pandemic-related restrictions. Prior research has shown maternity care during the pandemic was negatively experienced by women and led to poor physical and mental health outcomes in pregnancy. A synthesis is required of published research on women's experiences of maternity care during the latter half of the COVID-19 pandemic. AIM: To update a previous systematic review of maternity care experiences during the pandemic to June 2021, exploring experiences of maternity care specifically within the United Kingdom and how they may have changed, in order to inform future maternity services. METHODS: A systematic review of qualitative literature was conducted using comprehensive searches of five electronic databases and the Cochrane COVID Study Register, published between 1 June 2021 and 13 October 2022, and further updated to 30 September 2023. Thematic Synthesis was utilised for data synthesis. FINDINGS: Of 21,860 records identified, 27 studies were identified for inclusion. Findings included 14 descriptive themes across the five core concepts: (1)Care-seeking and experience; (2)Virtual care; (3)Self-monitoring; (4)COVID-19 vaccination; (5)Ethical future of maternity care. DISCUSSION: Our findings in the UK are consistent with those globally, and extend those of the previous systematic review, particularly about women's perceptions of the COVID-19 vaccine during pregnancy. CONCLUSION: Our findings suggest the following are important to women for future maternity care: personalisation and inclusiveness; clear and evidence-based communication to facilitate informed decision-making; and achieving balance between social commitments and time spent settling into motherhood.

Global changes in maternity care provision during the COVID-19 pandemic: A systematic review and meta-analysis.

BACKGROUND: The COVID-19 pandemic has had a profound impact on healthcare systems globally, with a worrying increase in adverse maternal and foetal outcomes. We aimed to assess the changes in maternity healthcare provision and healthcare-seeking by pregnant women during the COVID-19 pandemic. METHODS: We performed a systematic review and meta-analysis of studies of the effects of the pandemic on provision of, access to and attendance at maternity services (CRD42020211753). We searched MEDLINE and Embase in accordance with PRISMA guidelines from January 1st, 2020 to April 17th 2021 for controlled observational studies and research letters reporting primary data comparing maternity healthcare-seeking and healthcare delivery during compared to before the COVID-19 pandemic. Case reports and series, systematic literature reviews, and pre-print studies were excluded. Meta-analysis was performed on comparable outcomes that were reported in two or more studies. Data were combined using random-effects meta-analysis, using risk ratios (RR) or incidence rate ratios (IRR) with 95% confidence intervals (CI). FINDINGS: Of 4743 citations identified, 56 were included in the systematic review, and 21 in the meta-analysis. We identified a significant decrease in the number of antenatal clinic visits (IRR 0614, 95% CI 0486-0776, P<00001, I2=54.6%) and unscheduled care visits (IRR 0741, 95% CI 0602-0911, P = 00046, I2=00%) per week, and an increase in virtual or remote antenatal care (IRR 4656 95% CI 7762-2794, P<00001, I2=90.6%) and hospitalisation of unscheduled attendees (RR 1214, 95% CI 1118-1319, P<00001, I2=00%). There was a decrease in the use of GA for category 1 Caesarean sections (CS) (RR 0529, 95% CI 0407-0690, P<00001, I2=00%). There was no significant change in intrapartum epidural use (P = 00896) or the use of GA for elective CS (P = 079). INTERPRETATION: Reduced maternity healthcare-seeking and healthcare provision during the COVID-19 pandemic has been global, and must be considered as potentially contributing to worsening of pregnancy outcomes observed during the pandemic.