Severe maternal morbidity and maternal near miss in a tertiary hospital of Delhi.

Background: In addition to maternal mortality, information on maternal near miss and severe maternal morbidity are important in maternal healthcare. We aimed to determine the incidence, causes and outcome of severe maternal morbidity and near miss, and the sociodemographic and obstetric factors associated with these at a tertiary care teaching hospital in Delhi. Methods: Women admitted with severe maternal morbidity and near miss, as defined by the WHO study group, were included in the study. The incidence ratio of near miss and severe morbidity in the hospital was determined, and a case-control study was conducted to study the factors associated with the occurrence of near miss. Information was obtained from hospital records and interviews, using a semi-structured open-ended questionnaire. Results: The incidence ratio of near miss was 6.85/ 1000, and severe morbidity was 11.38/1000 live births. Hypertensive disorders and haemorrhage were the common causes of cases of near miss and severe morbidity. Coagulation dysfunction (62%) was the most common organ dysfunction, followed by uterine dysfunction (22%). Older age (odds ratio [OR] 2.01, confidence interval [CI] 1.02-3.93), the absence of formal education (OR 2.05, CI 1.11-3.75), <18 years of age at marriage (OR 2.01, CI 1.21-3.32), lower income (OR 3.8, CI 1.88-7.64), gravida of four or more (OR 2.25, CI 1.21-4.17) and residence outside Delhi (OR 9.31, CI 4.36-19.90) were significant predictors of near miss. Sepsis, hypertensive disorders and haemorrhage were the most common underlying conditions in women who died. The foetal outcome was a live birth in 64% of near-miss cases and 62% among severe morbidity. Conclusions: The burden of severe maternal morbidity and near miss is high. These need to be identified and managed at the earliest.

Risk of Stroke After the International Classification of Diseases-Ninth Revision Discharge Code Diagnosis of Hypertensive Encephalopathy.

BACKGROUND AND PURPOSE: Although chronic hypertension is a well-established risk factor for stroke, little is known about stroke risk after hypertensive encephalopathy (HE), when neurologic sequelae of hypertension become evident. Therefore, we evaluated the risk of stroke after a diagnosis of HE. METHODS: We identified all patients discharged from California, New York, and Florida emergency departments and acute care hospitals between 2005 and 2012 with a primary International Classification of Diseases, Ninth Edition, Clinical Modification discharge diagnosis of HE (437.2). Patients discharged with a primary diagnosis of seizure (345.x) served as negative controls, whereas patients with a primary diagnosis of transient ischemic attack (435.x) were positive controls. Our primary outcome was the composite of subsequent ischemic stroke or intracerebral hemorrhage. Kaplan-Meier survival statistics were used to calculate cumulative outcome rates, and Cox proportional hazard analysis was used to examine the association between index disease types and outcomes while adjusting for vascular risk factors. RESULTS: We identified 8233 patients with HE, 191 091 with seizure, and 308 680 with transient ischemic attack. The 1-year cumulative rate of ischemic stroke or intracerebral hemorrhage after HE was 4.90% (95% confidence interval [CI], 4.45-5.40) when compared with 0.92% (95% CI, 0.88-0.97) after seizure and 4.49% (95% CI, 4.42-4.57) after transient ischemic attack. The risk of intracerebral hemorrhage was significantly elevated in those with HE (hazard ratio, 2.0; 95% CI, 1.7-2.5) but not in those with transient ischemic attack (hazard ratio, 1.0; 95% CI, 0.9-1.1), when compared with seizure patients. CONCLUSIONS: Patients discharged with a diagnosis of HE face a high risk of future cerebrovascular events, particularly intracerebral hemorrhage.

Increasing trend in admissions for malignant hypertension and hypertensive encephalopathy in the United States.

Malignant hypertension and hypertensive encephalopathy are life-threating manifestations of hypertension. These syndromes primarily occur in patients with a history of poorly controlled hypertension. The purpose of this study was to investigate national trends in hospital admissions for malignant hypertension, hypertensive encephalopathy, and essential hypertension. This was a retrospective cohort study that used the Nationwide Inpatient Sample. We identified all hospitalizations between 2000 and 2011, during which a primary diagnosis of malignant hypertension (ICD 9 code: 401.0), hypertensive encephalopathy (ICD 9 code: 437.2), or essential hypertension (ICD 9 code: 401.9) was recorded. Time series models were estimated for malignant hypertension, hypertensive encephalopathy, essential hypertension and also for the combined series. A piecewise linear regression analyses was performed to investigate whether there were changes in the trends of these series. In addition, we also compared the characteristics of patients with these diagnoses. The estimated number of admissions for both malignant hypertension and hypertensive encephalopathy increased dramatically after 2007, whereas discharges for essential hypertension fell, and there was no change in trend for the combined series. Costs rose substantially for patients with these diagnoses after 2007, but mortality significantly fell for malignant hypertension and mortality for hypertensive encephalopathy did not change. The dramatic increase in the number of hospital admissions for hypertensive encephalopathy and malignant hypertension should have resulted in dramatic increases in morbidity, but it did not. The change is most likely related to changes in coding related to diagnostic-related groups that occurred in 2007.

Incidence of eclampsia with HELLP syndrome and associated mortality in Latin America.

OBJECTIVE: To describe the maternal outcome among women with eclampsia with and without HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). METHODS: A cross-sectional study of women with eclampsia was undertaken in 14 maternity units in Latin America between January 1 and December 31, 2012. Outcomes were compared between women with and without concomitant HELLP syndrome. Logistic regression analysis was performed to identify independent risk factors of maternal mortality. RESULTS: There were 196 eclampsia cases among 115 038 deliveries; 142 (72.4%) women had eclampsia alone and 54 (27.6%) women had concomitant HELLP syndrome. Severe systolic hypertension (≥160 mm Hg), severe diastolic hypertension (≥110 mm Hg), and hypertensive encephalopathy were significantly more common among women with HELLP than among those with eclampsia alone (P=0.01 for all). There were 8 (4.1%) maternal deaths, all in the group with HELLP syndrome, and 18 (9.1%) perinatal deaths. In a multivariate regression model, maternal mortality was significantly associated with low platelet count and severe systolic hypertension (P<0.05). CONCLUSION: Eclampsia with HELLP syndrome is a dangerous complication associated with pregnancy. Low platelet count secondary to HELLP syndrome and severe systolic hypertension were independently associated with maternal mortality from eclampsia.

Risk of subsequent dementia in patients with hypertensive encephalopathy: a nationwide population-based study in Taiwan.

BACKGROUND/AIMS: We investigated the association of hypertensive encephalopathy (HE) with subsequent dementia. METHODS: Using universal insurance claims data, we identified a study cohort of 5,504 participants with HE newly diagnosed between 1997 and 2010 and a comparison cohort of 22,016 healthy participants. Incidence and risks of dementia were estimated for both cohorts until the end of 2010. RESULTS: The dementia incidence was 1.45-fold [95% confidence interval (CI) = 1.27-1.66] higher in the study cohort than in the comparison cohort, with an adjusted hazard ratio (HR) of 1.38 (95% CI = 1.19-1.59) for the study cohort. The risk was higher for males than for females and elderly patients. With an incidence of 13.4 per 1,000 person-years, the HR of dementia increased to 2.09 (95% CI = 1.18-3.71) for the HE patients with the comorbidities of head injury and diabetes compared to those without HE and comorbidities. The risk of developing dementia declined with the follow-up time. CONCLUSION: Hypertensive patients with HE displayed a significantly higher risk for dementia than those without HE. The risk increased further in those with the comorbidities of head injury and diabetes. Physicians should be aware of the link between HE and dementia when assessing patients with HE.

Hypertension and hypertensive encephalopathy.

The definition of hypertension has continuously evolved over the last 50 years. Hypertension is currently defined as a blood pressure greater than 140/90mmHg. One in every four people in the US has been diagnosed with hypertension. The prevalence of hypertension increases further with age, affecting 75% of people over the age of 70. Hypertension is by far the most common risk factor identified in stroke patients. Hypertension causes pathologic changes in the walls of small (diameter<300 microns) arteries and arterioles usually at short branches of major arteries, which may result in either ischemic stroke or intracerebral hemorrhage. Reduction of blood pressure with diuretics, ß-blockers, calcium channel blockers, and angiotensin-converting enzyme (ACE) inhibitors have all been shown to markedly reduce the incidence of stroke. Hypertensive emergency is defined as a blood pressure greater than 180/120mmHg with end organ dysfunction, such as chest pain, shortness of breath, encephalopathy, or focal neurologic deficits. Hypertensive encephalopathy is believed to be caused by acute failure of cerebrovascular autoregulation. Hypertensive emergency is treated with intravenous antihypertensive agents to reduce blood pressure by 25% within the first hour. Selective inhibition of cerebrovascular blood vessel permeability for the treatment of hypertensive emergency is beginning early clinical trials.

Hipertensión arterial, crisis hipertensiva y emergenciahipertensiva: actitud en urgencias / Hypertension, hypertensive crisis, and hypertensive emergency: approaches to emergency department care

La elevación de las cifras de presión arterial (PA) constituye un motivo de consulta frecuente en los servicios de urgencias. Es importante tener en cuenta que esta elevación por si sola no define si se trata de una urgencia o de una emergencia, sino el cuadro que acompaña a dicha elevación, por lo que es primordial diferenciar, de entrada, ambas situaciones. La emergencia hipertensiva se caracteriza por la existencia de una lesión aguda evidente de órgano diana, y que se presenta en forma de la encefalopatía hipertensiva, hemorragia intracraneal, síndrome coronario agudo, insuficiencia cardiaca con edema agudo de pulmón, disección de aorta, eclampsia-preeclampsia o hipertensión acelerada. Requiere una reducción inmediata aunque no brusca de las cifras de PA por vía parenteral. En contraposición, la urgencia hipertensiva es aquel cuadro caracterizado por un aumento severo de las cifras de PA sin evidencia de lesión aguda o progresiva de órgano diana y que require una reducción progresiva de dichas cifras en el plazo de 24 horas a varios días con fármacos administrados por vía oral. Existe un gran número de fármacos para el manejo de esta patología, y no se ha demostrado de forma fehaciente que un fármaco, ya sea parenteral o no, sea mejor que otro para reducirlas cifras de PA. Sin embargo, en función del cuadro acompañante y de las características individuales de cada paciente, se pueden hacer recomendaciones particulares, como se muestra en la presente revisión (AU)

Elevated arterial blood pressure is a frequent reason for seeking emergency care. It is important to remember that pressure elevation alone does not define whether the situation should be considered a life-threatening emergency or denotes only a need for urgent attention. Rather, it is the signs and symptoms accompanying the elevation that will reveal which patients are in need of emergency treatment. A hypertensive emergency is characterized by clear signs of acute injury to a target organ, presenting as hypertensive encephalopathy, intracranial bleeding, acute coronary syndrome, heart failure with acute pulmonary edema, aortic dissection, eclampsia or preeclampsia, or accelerated hypertension. These situations require the immediate but not abrupt reduction of arterial pressures by means of parenteral administration of drugs. Ahypertensive patient in need of urgent care, but not in an emergency situation, on the other hand, has seriously elevated pressures but no signs of acute or progressive target organ injury. Such a patient requires gradual reduction of pressures over a period of 24 hours to several days and can receive oral treatment. A large number of drugs are available for managing hypertension. No single drug has been reliably shown to be better than others at reducing pressures, whether administered parent rally or not. However, recommendations can be made based on the accompanying clinical pictureand individual patient characteristics. This review will outline such recommendations (AU)

Value of retinal examination in hypertensive encephalopathy.

The presence of grade III or IV hypertensive retinopathy (HRP) is considered to distinguish hypertensive urgencies from emergencies. However, case-reports suggest that these retinal changes may be lacking in patients with hypertensive encephalopathy. To assess the frequency of grade III and IV retinopathy in this hypertensive emergency, we conducted a retrospective cohort study. We retrieved 162 patients with malignant hypertension and 34 patients (17%) fulfilled the predefined criteria for hypertensive encephalopathy. Data on retinal examination were incomplete for 6 patients (18%), thus leaving 28 patients who were analysed for the presence or absence of grade III and IV HRP. In 9 (32%) patients with hypertensive encephalopathy, grade III or IV HRP was absent, 11 (39%) patients presented with grade III and 8 (29%) patients with grade IV retinopathy. Patients without retinal abnormalities were on average 13 years younger (P=0.05), more often black (P=0.02) and displayed lower blood pressure (BP) values (P=0.04 for systolic and diastolic BP). A substantial proportion of patients with hypertensive encephalopathy lack grade III or IV HRP. This suggests that the decision to admit these patients should not only rely on the presence of grade III and IV retinopathy alone, but should also include a careful neurological examination.

Epidemiology and clinical features of glomerulonephritis in Calabar, Nigeria.

A retrospective study of children with acute glomerulonephritis (AGN) over a 10-year period (January 1997-December 2006) was carried out with the aim to establish the prevalence, the population at risk, and the predisposing factors. Out of a total of 6,026 admissions during the study period, 76 (1.3%) had acute glomerulonephritis. Forty of the 76 were males while 28 were females with a male to female ratio of 1.4:1. The mean age for males was 7.2+/-4.3 years and that of females was 6.5+/-3.2 years. The overall age range was 3-13 years with a modal age of 5 years for both sexes. The annual prevalence showed two peaks, May-July and October-January. Eighty two percent of patients were of the low while 11.8% were of the middle socio-economic classes. Haematuria, oedema, proteinuria and hypertension were the major presenting features. Hypertensive encephalopathy and acute renal failure were the complications recorded and also emerged as the causes of death. Childhood AGN is common in Calabar compared to other centres in Nigeria, afflicting largely those of low socio-economic status and displays a peak in the middle of both dry and rainy seasons of the year. The outcome is good but could be better if facilities are provided for dialysis.

Posterior reversible encephalopathy syndrome: an emerging clinical entity in adult, pediatric, and obstetric critical care.

PURPOSE: To describe the signs, symptoms, causative factors, and treatment for posterior reversible encephalopathy syndrome (PRES), an emerging clinical neuroradiologic entity which may be encountered by nurse practitioners in almost any clinical setting. DATA SOURCES: Extensive review of worldwide literature, including peer-reviewed medical specialty journals, supplemented by an actual case study. Currently, a paucity of information exists in the nursing literature. CONCLUSIONS: PRES occurs as a result of disordered cerebral circulatory autoregulation and/or endothelial dysfunction, usually as a result of acute, intermittent hypertension. Clinical manifestations include mental status change, headache, visual disturbance, and seizures. Characteristic abnormalities in the posterior cerebral white matter, seen best on diffusion-weighted magnetic resonance imaging, confirm the presence of the syndrome. PRES has been documented worldwide among a diverse patient population, yet many clinicians are still unfamiliar with this diagnosis. IMPLICATIONS FOR PRACTICE: PRES is a clinical-radiographic diagnosis that requires close collaboration between the clinician and interpreting radiologist. Rapid identification and appropriate diagnostics are essential, as prompt treatment usually results in reversal of symptoms; permanent neurologic injury or death can occur with treatment delay.

[Topical electrophysiological correlates of emotional states (on the evidence of incipient hypertension encephalopathology)].

Comprehensive investigations of 97 patients with incipient hypertension encephalopathologies were performed with the use of standard psychodiagnostic questionnaires and EEG. Topographic analysis of spectral power showed stable constellation of altered alpha- and beta-zones in the EEG parietal, temporal and occipital leads. Given the clinical implications of this finding, we can view it as a potential neurophysiological background for depression, and a "functional" phase in disease development.

Vascular risk and low serum B12 predict white matter lesions in patients with major depression.

BACKGROUND: While patients with depression have been shown to have a greater incidence of vascular risk factors and structural brain changes, any association with dietary co-factors is unclear. METHODS: Forty-seven patients with major depression (mean age = 52.8 years, SD = 12.6) and 21 healthy volunteers (mean age = 54.7 years, SD = 9.1) underwent high-resolution magnetic resonance imaging scanning. T2-weighted films were scored for deep white matter (DWM), periventricular (PV), and subcortical (SC) hyperintensities. RESULTS: There was no difference in lesion severity between patients and control subjects. After controlling for age, vitamin B12 levels were predictive of DWM lesions in patients. DWM and SC lesions were associated with histories of hypertension and diabetes. LIMITATIONS: A relatively small sample of patients were recruited from specialist services and the findings may not represent those observed in larger or community-based cohorts. CONCLUSIONS: In patients with major depression, vitamin B12 levels and histories of hypertension and/or diabetes are predictive of white matter lesions.

[Arterial hypertension in the medical-surgical emergency service. Apropos of 139 cases observed in national reference general hospital of N'Djamena]. / Hypertension artérielle dans le service des urgences médico-chirurgicales. A propos de 139 cas observés à l'hôpital général de référence nationale de N'Djamena.

The authors achieved a prospective study on 139 hypertensive patients admitted at the emergency service of the Hôpital général de référence nationale during the period from March to October 1998. The aim of the study was to define the epidemiological and the clinical aspects of high blood pressure. The results were as following: Epidemiologic aspects: The inward prevalence was 2.7%. There was clear male prevalence: 59.7% vs 40.7% with a sex-ratio M/F of 1.5%. The average age was 53 (18-88) of which an average of 54 for men and 50 for women. The most concerned age backets were between 40 and 60 years. For clinical aspects: Forty nine of our patients reported in their medical history the high blood pressure notion known and followed up. From the main examination, diagnoses held, were the following in descending order: high blood pressure, 41.7%: hypertensive encephalopathy, 15.1% and cerebral stroke, 10.1%. Regarding the degree of high blood pressure, most of patients (74 patients over 139 i.e. 53.23%) showed a severe and cunning high blood pressure and men were more concerned than women: 68.9% vs 31.20%. From complications point of view, the renal attack held the first place and the neurological slowing down was a factor of bad prognosis. The global hospital mortality was 15.8% (22 death cases over 139) of which 15 men and 7 women. Neurological complications were the most numerous with 31.8% of cases. The old age and the lack of patients follow-up were the factors of bad prognosis.