Racial differences in healthcare utilization among patients with suspected or diagnosed preeclampsia: A retrospective cohort study.

OBJECTIVES: To analyze healthcare resource utilization and severe maternal morbidity (SMM) in Black and White patients with preeclampsia diagnosis versus signs/symptoms. STUDY DESIGN: This was a retrospective cohort study analyzing data from the IBM® Explorys Database between 7/31/2012-12/31/2020. Demographic, clinical, and laboratory data were extracted. Healthcare utilization and SMM were analyzed during the antepartum period (20 weeks of gestation until delivery) among Black and White patients with signs/symptoms of preeclampsia, with a diagnosis of preeclampsia, or neither (control). MAIN OUTCOME MEASURES: Healthcare utilization and SMM in those with a preeclampsia diagnosis or signs/symptoms of preeclampsia only were compared with a control group (White patients with no preeclampsia diagnosis or signs/symptoms). RESULTS: Data from 38,190 Black and 248,568 White patients were analyzed. Patients with preeclampsia diagnosis or signs/symptoms were more likely to visit the emergency room compared to those without diagnosis or signs/symptoms. Black patients with signs/symptoms of preeclampsia had the highest elevated risk (odds ratio [OR] = 3.4), followed by Black patients with a preeclampsia diagnosis (OR = 3.2), White patients with signs/symptoms (OR = 2.2), and White patients with a preeclampsia diagnosis (OR = 1.8). More Black patients experienced SMM (SMM rate 6.1% [Black with preeclampsia diagnosis] and 2.6% [Black with signs/symptoms]) than White patients (5.0% [White with preeclampsia diagnosis] and 2.0% [White with signs/symptoms]). SMM rates were higher for Black preeclampsia patients with severe features than for White preeclampsia patients with severe features (8.9% vs 7.3%). CONCLUSIONS: Compared with White patients, Black patients had higher rates of antepartum emergency care and antepartum SMM.

Accidental acetaminophen overdose results in liver transplant during second trimester of pregnancy: a case report.

Acetaminophen overdose is the most rapidly growing cause of fulminant hepatic failure in Western countries. Pregnant women are counseled that acetaminophen is safe during pregnancy and an alternative to nonsteroidal anti-inflammatory medications. This report describes a case of acetaminophen overdose during the second trimester of pregnancy with resultant fulminant hepatic failure requiring liver transplantation. The fetus was previable at the time of liver transplantation, and methods to preserve viability during and after transplantation are discussed. Despite the best attempts of the team, the fetus expired. The challenges and outcomes of fulminant hepatic failure in pregnancy are discussed in detail.

PP143. Relationship between mid-pregnancy placenta growth factor and hemodynamics in the mother, fetus, and uterus.

INTRODUCTION: Placental Growth Factor (PlGF) is an angiogenic and vasoregulatory peptide member of the vascular endothelial growth factor family. Reduction of free, circulating PlGF is associated with preeclampsia and fetal growth restriction, and precedes the clinical manifestations of disease by several weeks. It is not known whether aberrant PlGF is related for alterations in endothelial vascular function that cause or exacerbate the placental syndromes of pregnancy. OBJECTIVES: We sought to determine if mid-pregnancy PlGF was related to, and possibly mediating, measures of maternal, fetal, or uterine hemodynamic function in women at risk for placenta-mediated complications of pregnancy. METHODS: We measured free plasma PlGF (Triage PlGF Assay, Alere, Inc.) between 22 and 25 weeks in high risk subjects referred for assessment of fetal growth and uterine artery Dopplers due to abnormalities of serum screening analytes or other risk factors for preeclampsia. Maternal hemodynamic parameters including mean arterial pressure (MAP), cardiac index (CI), systemic vascular resistance (SVR) and index of contractility (ICON) were measured in recumbent position with noninvasive electrical cardiography (Aesculon EC System, Cardiotronics, Inc.). Doppler measurements of blood flow in the uterine arteries (pulsatility index, PI) and umbilical artery (systolic:diastolic ratio, S/D) were obtained by ultrasound (Voluson E8, GE Healthcare, Inc.), along with the estimated fetal weight (EFW). PlGF was expressed as the log concentration, plotted against the hemodynamic measurements, and analyzed with Spearman's correlation coefficient, R. Statistical significance was set to p=0.05. RESULTS: Data from seventeen fully studied patients were analyzed. The median gestational age was 24.3 weeks. PlGF concentration ranged from 25 to 1180 with a median of 235pg/ml. PlGF was positively related to maternal cardiac index (R=0.56, p=0.02) and ICON (R=0.51, p=0.04) and negatively related to SVR (R=-0.48, p=0.05). There was a non-significant negative correlation with MAP (R=-0.41, p=0.10). PlGF showed a positive correlation to EFW (R=0.52, p=0.03) and a negative relationship to umbilical artery S/D ratio (R=-0.42,p=0.06). There was no correlation between maternal PlGF and uterine artery Doppler PI (R=-0.19, p=0.46). CONCLUSION: The concentration of circulating free PlGF at mid-pregnancy is related to both maternal systemic hemodynamic function and fetal umbilical artery resistance (and growth) in high risk pregnancies prior to the onset of preeclampsia. It is not, however, related to vascular resistance in the uterine artery. PlGF may play a role in modulating the general vascular function of the fetus and mother after establishment of the uteroplacental circulation.

PP153. Noninvasive assessment of maternal hemodynamic function by electrical impedance cardiography (EIC) and correlation with uterine and umbilical vascular resistance in mid-pregnancy.

INTRODUCTION: Maternal vascular adaptation to pregnancy involves the coordinated augmentation of both systemic and uteroplacental circulations, with the concomitant development of a new fetoplacental circuit. Disturbances of maternal hemodynamic adaptation in early pregnancy are often associated with compromise in the other circulations, although the assessment of maternal vascular function by conventional means is cumbersome and expensive. OBJECTIVES: We sought to assess maternal hemodynamic function with a noninvasive cardiographic monitor, and to correlate the findings to both uteroplacental and fetoplacental vascular resistance. METHODS: We measured cardiac output and index (CO,CI), systemic vascular resistance (SVR), mean arterial pressure (MAP) and an index of contractility (ICON) with a novel electrical impedance cardiograph (Aesculon EIC System, Cardiotronic, USA) that provides a volume independent estimate of cyclical blood flow velocity. We enrolled high-risk subjects between 22 and 25weeks who were referred for assessment of fetal growth and uterine artery Dopplers due to abnormalities of serum screening analytes or other risk factors for preeclampsia. Doppler measurements of blood flow in the uterine arteries (pulsatility index, PI) and umbilical artery (systolic: diastolic ratio, S/D) were obtained by ultrasound (Voluson E8, GE Healthcare, Inc.), along with the fetal weight percentile (FW%). Data were expressed as medians (+/- range), and analyzed with Spearman's correlation coefficient, R. Statistical significance was set to p=0.05. RESULTS: Electrical impedance cardiography (EIC) data was collected from seventeen subjects. There were no measurement failures. The median gestational age was 24.3weeks and the BMI was 26.4 (21-47). The median PI, S/D and FW% were 0.96 (0.47-2.1), 3.3 (2.6-7.1), and 53% (6-82%). EIC results and their relationship to uterine and umbilical Dopplers and fetal growth are shown in Table 1. There were no significant correlations between maternal systemic hemodynamic parameters and uterine artery PI. On the other hand, maternal cardiac function was strongly related to the umbilical artery S/D ratio, and SVR was uniquely related to the FW%. CONCLUSION: Maternal systemic hemodynamics can be conveniently acquired by EIC at the same time as routine obstetrical imaging. Our data suggest that maternal cardiovascular adaptation more closely reflects the fetoplacental circulation than the uteroplacental circulation in women at moderate risk of preeclampsia. EIC may be a useful adjunct in assessing risk of fetal compromise.

Changes in the pharmacokinetics of the low-molecular-weight heparin enoxaparin sodium during pregnancy.

OBJECTIVE: We sought to evaluate the pharmacokinetics of subcutaneously administered enoxaparin sodium during and after pregnancy. STUDY DESIGN: Daily subcutaneous injections of enoxaparin sodium (40 mg) were administered to 13 pregnant women. On 3 separate occasions, once early in pregnancy (12-15 weeks), once late in pregnancy (30-33 weeks), and once in the nonpregnant state (6-8 weeks post partum), serial blood samples were collected, and plasma was analyzed for antifactor Xa activity. Analysis of variance was used for statistical analysis. P <.05 was significant. RESULTS: The time to maximum concentration and the mean residence time in pregnancy compared with the postpartum state were not significantly different. During early and late pregnancy, maximum concentration and the last measurable anti-factor Xa activity level were lower than in the nonpregnant state (P <.05). The area under the plasma activity-versus-time curve was significantly lower in pregnancy than in the postpartum state (P <.05). CONCLUSION: The pharmacokinetics of enoxaparin sodium are significantly different during pregnancy than in the same women when nonpregnant. The observed difference is likely because of increased renal clearance of enoxaparin during pregnancy. This finding has significant implications for appropriate dosing of enoxaparin in pregnancy.