Stage 1 Hypertension in Nulliparous Pregnant Patients and Risk of Unplanned Cesarean Delivery.

OBJECTIVE: The aim of the study is to determine whether stage 1 hypertension is a risk factor for cesarean at ≥390/7 weeks. STUDY DESIGN: This is a retrospective cohort study of nulliparas delivering at ≥390/7weeks. Exposure was defined as stage 1 hypertension and compared with normotension. The primary outcome was unplanned cesarean. Statistical analysis was performed using SPSS 27. RESULTS: Two hundred and fifty patients had stage 1 hypertension and 250 had normotension. Thirty-eight percent of the patients with stage 1 hypertension required cesarean as did 22% of controls (risk ratio [RR]=1.55, 95% confidence interval [CI]: 1.23-1.96, p <0.001). This remained significant after controlling for confounders in a logistic regression (odds ratio [OR]=1.61, 95% confidence interval [CI]: 1.02-2.55, p <0.040). Upon secondary analysis, these results were statistically significant for gestational age ≥395/7 weeks (adjusted odds ratio [AOR]=1.89, 95% CI: 1.05-3.39, p=0.033) but not from 390/7 to 394/7weeks (AOR=0.68, 95% CI: 0.31-1.50, p=0.34). CONCLUSION: In nulliparas, stage 1 hypertension is an independent risk factor for unplanned cesarean. KEY POINTS: · Stage 1 hypertension correlates with more cesareans.. · Unplanned cesarean for nonreassuring fetal status correlates with impaired placental function.. · Stages 1 and 2 hypertension carry similar risks..

Diminished trophoblast differentiation in early onset preeclampsia.

The mechanism by which human cytotrophoblast cells (CTB) differentiate into extravillous trophoblast cells (EVT) is an epithelial-mesenchymal transition (EMT). Polarized CTB, anchored in an epithelial layer, are transformed into motile, non-polar EVT which invade the uterus. Our previous research has shown that over gestation, invasive first trimester EVT are converted to a non-invasive phenotype showing a reduced degree of EMT. We hypothesized that in an under-invasion pathology, such as early onset preeclampsia, third trimester EVT would display a less advanced EMT profile than controls. The goal of this study was to determine whether expression of EMT-associated genes in the EVT of early onset preeclamptics shows a less mesenchymal, more epithelial phenotype compared to control pregnancies. Measures of preeclamptic CTB and EVT gene expression, using highly purified cells from third trimester, early onset preeclamptics and gestational-age matched controls, showed clear evidence of a phenotypic pattern characteristic of an EMT. Comparison of preeclamptic EVT to gestational-age matched, control EVT demonstrated multiple changes in gene expression, including changes in well-known EMT gene markers, indicative of a more limited EMT. These changes are not explained by differences in the preeclamptic CTB precursors. In this first study of purified third trimester EVT, we show that the pattern of gene expression corresponding to EMT-associated differentiation is diminished in early onset preeclampsia. This provides a mechanistic framework for many of the molecular changes observed in preeclampsia and presents an opportunity for detailed studies of the pathways regulating the aberrant EMT and for potential biomarkers of the process.

Risk factors for needing postpartum antihypertensive medications with hypertensive disorders: Timing of diagnosis, presence of proteinuria, and severity of disease.

OBJECTIVES: Evaluate the association between the need for post-partum antihypertensive medications in patients with hypertensive disorders of pregnancy (HDP) and the following: timing of disease onset (antepartum vs. intrapartum), presence of proteinuria, and severity of disease. STUDY DESIGN: This was a retrospective cohort study. We reviewed the charts of 204 patients diagnosed with HDP: 106 were diagnosed antepartum and 98 diagnosed intrapartum. Patients withchronichypertensionwereexcluded. MAIN OUTCOME MEASURES: The need for outpatient antihypertensive medications at time of hospital discharge was the primary outcome. We performed logistic regression of covariates and a stratified analysis for each specific HDP (gestational hypertension (GHTN), preeclampsia and preeclampsia with severe features). RESULTS: While the diagnosis of HDP in the antepartum period was a statistically significant risk factor for needing postpartum anti-hypertensive medications at discharge in bivariate analysis RR 2.07 (1.27-3.37), p = 0.001, it did not remain significant after correction for the covariates RR 1.41 (0.45-4.49), P = 0.55. However, the presence of proteinuria was an independent risk factor after logistic regression. Compared to GHTN, there was a significant difference in the need for postpartum anti-hypertensive medications in patients with preeclampsia OR 10.70 (1.54-74.42), p = 0.017 and in preeclampsia with severe features OR 112.14 (20.05-627.22), p < 0.001. CONCLUSION: Timing of onset of HDP (antepartum vs. intrapartum) was not an independent risk factor for needing antihypertensive medications postpartum. However, proteinuria and the presence of severe features were. Patients with proteinuria and those with severe disease may warrant closer surveillance in the post-partum period than those without proteinuria.

Performance of Low-Dose Perfusion Scintigraphy and CT Pulmonary Angiography for Pulmonary Embolism in Pregnancy.

BACKGROUND: The symptoms of normal pregnancy overlap those of pulmonary embolism (PE). Limited literature suggests that low-dose perfusion scanning (LDQ), which yields lower maternal-fetal radiation exposure than CT pulmonary angiography (CTPA), performs well in excluding PE in pregnant patients. METHODS: We performed a retrospective cohort study of sequential pregnant women who underwent imaging for PE with LDQ or CTPA between 2008 and 2013 at Montefiore Medical Center. Our practice recommends LDQ for patients with negative results on chest radiographs. Patients were categorized according to initial imaging modality, and a subgroup analysis was performed in patients with asthma. The primary outcome was the negative predictive value (NPV) of imaging determined by VTE diagnosis within 90 days. RESULTS: Of 322 pregnant women (mean age, 27.3 ± 6.3 years), initial imaging was positive for PE in 2.7% (6 of 225) of LDQs and 4.1% (4 of 97) of CTPAs, negative in 88.0% (198 of 225) of LDQs and 86.6% (84 of 97) of CTPAs, and indeterminate/nondiagnostic in 9.3% (21 of 225) of LDQs and 9.3% (9 of 97) of CTPAs (P = .79). Ten patients (3.1%) were treated for PE. The NPV was 100% for LDQ and 97.5% for CTPA. Subgroup analysis of patients with asthma (23.9% of this population) revealed a high likelihood of a negative study in the LDQ and CTPA groups (74.1% and 87.0%, respectively) and 100% NPV for both modalities. CONCLUSIONS: PE is an uncommon diagnosis in pregnancy. LDQ and CTPA perform well, with less maternal-fetal radiation exposure with LDQ. Therefore, when available, LDQ is a reasonable first-choice modality for suspected PE in pregnant women with a negative result on chest radiograph.

Postoperative intra-abdominal collections using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier at the time of laparotomy for ovarian, fallopian tube, or primary peritoneal cancers.

OBJECTIVES: To determine whether HA-CMC was associated with the development of postoperative intra-abdominal collections in patients undergoing laparotomy for ovarian, fallopian tube, or primary peritoneal malignancies. METHODS: We retrospectively identified all laparotomies performed for these malignancies from March 1, 2005 to December 31, 2007. The use of HA-CMC was identified. Laparotomies for malignant bowel obstruction or repair of fistulae were excluded. Intra-abdominal collections, non-infected and infected, were defined as localized intraperitoneal fluid accumulations in the absence of re-accumulating ascites. All other complications were also captured. Appropriate statistical tests were applied using SPSS 15.0. RESULTS: We identified 219 laparotomies with HA-CMC and 204 without HA-CMC. Upper abdominal resections were performed in 65/219 (30%) HA-CMC cases compared to 39/204 (19%) cases without HA-CMC (P=0.01). The rates of large bowel and/or rectal resections were similar in both cohorts. Intra-abdominal collections were seen in 18/219 (8.2%) HA-CMC cases compared to 5/204 (2.5%) cases without HA-CMC (P=0.009). HA-CMC was independently associated with the diagnosis of a postoperative intra-abdominal collection (P=0.01). All but 2 collections developed in patients undergoing debulking procedures. CONCLUSIONS: HA-CMC appears to be associated with a higher rate of postoperative intra-abdominal collections. This seems to be greatest in patients who are undergoing a debulking procedure.