Amniotic fluid embolism: A case report of good outcome with timely intensive multidisciplinary team involvement.

OBJECTIVE: Amniotic fluid embolism is one of the most serious pregnancy complications. It can cause sudden maternal collapse with high mortality and morbidity. We present a case report regarding the important of prompt decision making and multidisciplinary team work for management of amniotic fluid embolism to yield favorable maternal and neonatal outcome. CASE REPORT: This is a 35-year-old, gravida 2, para 1, woman underwent labor induction at gestational age of 37 + 6 weeks due to elective induction. She had sudden facial cyanosis and shortness of breath right after artificial rupture of membrane. Prompt decision of urgent cesarean section, aggressive and timely massive blood transfusion and multidisciplinary team work had spared patient from extracorporeal membrane oxygenation placement and prolonged hospitalization. A male infant was born with Apgar score 3' -> 5' with estimate body weight of 2958 gm; he was hospitalized for 10 days and no other complications was found at follow up pediatric outpatient clinic. CONCLUSION: One of the most dreadful, but rare pregnancy complications is amniotic fluid embolism (AFE). It can cause serious maternal and neonatal morbidity and mortality. Rapid recognition and multidisciplinary team management are essential to maternal and neonatal prognosis.

Outcomes of Endocarditis in Pregnancy: A Single-Center Experience.

Background: The incidence of infective endocarditis (IE) in pregnancy is rare (0.006%), with increasing prevalence during the opioid epidemic. IE in pregnancy is associated with high rates of mortality and morbidity, and existing data on outcomes in pregnancy are limited. Our study compares the outcomes of pregnant patients with IE with those of nonpregnant patients. Methods: Patients diagnosed with IE during pregnancy and 30 days postpartum between 2014 and 2021 were identified by International Classification of Diseases, Clinical Modification, Ninth and Tenth Edition codes. Pregnant cases were matched to nonpregnant reproductive-age endocarditis patients in a 1:4 ratio. Data were collected and validated through chart review. Results: One hundred eighty patients with IE were identified; 34 were pregnant or within 30 days postpartum at diagnosis. There were higher rates of hepatitis C and opioid maintenance therapy in the pregnant patients. The etiology of IE in pregnant patients was predominantly S. aureus (methicillin-resistant/sensitive S. aureus), whereas nonpregnant woman had greater microbiological variation. We observed comparable rates of valve replacement (32.4% vs 29%; P = .84) and 2-year mortality (20.6% vs 17.8%; P > .99) in pregnant patients. There were nonsignificantly higher rates of pulmonary emboli (17.6% vs 7.5%; P = .098) and arrhythmia (17.6% vs 9.6%; P = .222) among pregnant patients. There were high rates of intravenous drug use relapse in both groups (>40%). Conclusions: We observed similar rates of mortality in the pregnant IE patients. We observed a microbial predilection for S. aureus in pregnancy, suggesting that the pregnancy physiology may select for this microbiologic etiology. This study, which represents the largest single-center retrospective review of IE in pregnancy, suggests that surgical intervention may be performed safely in the postpartum period.

Best Practices for Managing Postpartum Hypertension.

Purpose of Review: Patients remain at risk for persistent and de novo postpartum hypertension related to pregnancy. This review aims to summarize the current definitions, clinical practices, and novel systems innovations and therapies for postpartum hypertension. Recent Findings: Recent changes to the definitions of hypertension outside of pregnancy have not yet impacted definitions or management of hypertensive disorders of pregnancy (HDP), though research examining the implications of these new definitions on risks of developing HDP and the resultant sequelae is ongoing. The administration of diuretics has been shown to reduce postpartum hypertension among women with HDP. Widespread implementation of telemedicine models and remote assessment of ambulatory blood pressures has increased data available on postpartum blood pressure trajectories, which may impact clinical management. Additionally, policy changes such as postpartum Medicaid extension and an increasing emphasis on building bridges to primary care in the postpartum period may improve long-term outcomes for women with postpartum hypertension. Prediction models utilizing machine learning are an area of ongoing research to assist with risk assessment in the postpartum period. Summary: The clinical management of postpartum hypertension remains focused on blood pressure control and primary care transition for cardiovascular disease risk reduction. In recent years, systemic innovations have improved access through implementation of new care delivery models. However, the implications of changing definitions of hypertension outside of pregnancy, increased data assessing blood pressure trajectories in the postpartum period, and the creation of new risk prediction models utilizing machine learning remain areas of ongoing research.

Actos cotidianos de resistencia en el embarazo para prevenir la morbimortalidad materna / Everyday acts of resistance in pregnancy to prevent maternal morbidity and mortality

Resumen Objetivo: Analizar acciones de mujeres indígenas respecto a su cuidado durante el embarazo a través de prácticas cotidianas, nombradas como actos cotidianos de resistencia. Material y métodos: Se realizó un estudio cualitativo etnometodológico en Cuetzalan, Sierra Norte de Puebla, México; se aplicaron 93 cuestionarios a mujeres indígenas embarazadas; a 67 de ellas se les aplicaron entrevistas semiestructuradas. Se realizó análisis crítico del discurso. Resultados: Se identificaron tres actos cotidianos de resistencia para el cuidado del embarazo: 1) Convivencia comunitaria; 2) Movilidad para la atención prenatal, y 3) Saberes del cuidado del embarazo. En conjunto, los actos describen acciones preventivas de morbilidad partiendo de la percepción cultural de riesgo en mujeres embarazadas de un contexto sociocultural y económicamente vulnerable. Conclusiones: El conjunto de prácticas cotidianas para el cuidado del embarazo por las mujeres debe ser reconocido como acciones inmediatas de prevención en pro de la salud materna.

Abstract Objective: To analyze actions of indigenous women regarding their care during pregnancy through daily practices that we name as everyday acts of resistance. Materials and methods: A qualitative ethnomethodological study was carried out in Cuetzalan, Sierra Norte de Puebla, México; 93 questionnaires were applied to pregnant indigenous women, 67 of them were semi-structured interviews. Also, a critical discourse analysis was performed. Results: Three everyday acts of resistance were identified for pregnancy care: 1) Community coexistence; 2) Mobility for prenatal care, and 3) Beliefs in pregnancy care. Altogether the acts describe preventive morbidity actions based on the cultural perception of risk in pregnant women within a context sociocultural and economically vulnerability. Conclusions: The set of daily practices in prenatal care by women, must be recognized as immediate preventive actions in favor of maternal health.

Placental Findings in Preterm and Term Preeclampsia: An Integrative Review of the Literature / Achados placentários na pré-eclâmpsia pré-termo e a termo: Uma revisão integrativa da literatura

Abstract Introduction Preeclampsia (PE) is a pregnancy complication associated with increased maternal and perinatal morbidity and mortality. The disease presents with recent onset hypertension (after 20 weeks of gestation) and proteinuria, and can progress to multiple organ dysfunction, with worse outcomes among early onset preeclampsia (EOP) cases (<34 weeks). The placenta is considered the root cause of PE; it represents the interface between the mother and the fetus, and acts as a macromembrane between the two circulations, due to its villous and vascular structures. Therefore, in pathological conditions, macroscopic and microscopic evaluation can provide clinically useful information that can confirm diagnosis and enlighten about outcomes and future therapeutic benefit. Objective To perform an integrative review of the literature on pathological placental findings associated to preeclampsia (comparing EOP and late onset preeclampsia [LOP]) and its impacts on clinical manifestations. Results: Cases of EOP presented worse maternal and perinatal outcomes, and pathophysiological and anatomopathological findings were different between EOP and LOP placentas, with less placental perfusion, greater placental pathological changes with less villous volume (villous hypoplasia), greater amount of trophoblastic debris, syncytial nodules, microcalcification, villous infarcts, decidual arteriolopathy in EOP placentas when compared with LOP placentas. Clinically, the use of low doses of aspirin has been shown to be effective in preventing PE, as well asmagnesium sulfate in preventing seizures in cases of severe features. Conclusion The anatomopathological characteristics between EOP and LOP are significantly different, with large morphological changes in cases of EOP, such as

Resumo Introdução A pré-eclâmpsia (PE) é uma complicação da gravidez associada ao aumento da morbidade e mortalidade materna e perinatal. A doença se apresenta com hipertensão de início recente (após 20 semanas de gestação) e proteinúria, que pode progredir para disfunção de múltiplos órgãos, com resultados piores entre os casos de início precoce (<34 semanas). A placenta é considerada a principal causa da PE, representando a interface entre a mãe e o feto, e atuando como uma macromembrana entre as duas circulações, devido às suas estruturas vilosas e vasculares, demodo que, em condições patológicas, avaliações macroscópicas e microscópicas podem fornecer informações clinicamente úteis, que podem fornecer diagnóstico, prognóstico e benefício terapêutico. Objetivo Realizar uma revisão integrativa da literatura para compreender e descrever os achados placentários patológicos associados à pré-eclâmpsia e seus impactos nas manifestações clínicas. Resultados Os casos de início precoce apresentaram piores desfechos maternos e perinatais, e os achados fisiopatológicos e anatomopatológicos foram diferentes entre as placentas de início precoce e início tardio, commenor perfusão placentária, maiores alterações patológicas placentárias commenor volume viloso (hipoplasia vilosa), maior quantidade de debris trofoblásticos, nódulos sinciciais, microcalcificação, infartos vilosos, arteriolopatia decidual em placentas de início precoce quando comparadas com placentas de início tardio. Clinicamente, o uso de baixas doses de aspirina tem se mostrado significativo na prevenção da PE, assim como o sulfato de magnésio na prevenção de convulsões na doença com manifestações de gravidade. Conclusão As características anatomopatológicas entre a pré-eclâmpsia precoce e tardia são significativamente diferentes, com grandes alterações morfológicas nos casos de início precoce, como hipóxia, infartos vilosos e hipoplasia, entre outros, na tentativa de estabilizar o fluxo sanguíneo para o feto. Portanto, um entendimento comum do exame macroscópico básico e dos padrões histológicos da lesão é importante para maximizar o benefício diagnóstico, prognóstico e terapêutico do exame da placenta e, consequentemente, reduzir os riscos para a mãe e o feto.

Are we listening? Obstetric anesthesiology and the national call for birth justice and accountability: a perspective from the United States.

Despite declining rates of pregnancy-related deaths worldwide, the United States (US) has seen an increase in maternal mortality. It is widely known that this increased risk of mortality impacts unevenly Black people, who are three-fold more likely to die from pregnancy-related causes than white people. This disparity in maternal mortality and morbidity is not unique to the US; countries like Brazil, the Netherlands, South Africa, and the United Kingdom (UK) report similar racial disparities in peripartum health outcomes. It is thought that many factors contribute to this tragic health inequity, including, but not limited to, structural racism, provider implicit bias, and lack of access to high quality, culturally humble reproductive health care. On July 25, 2020, activists for reproductive justice and birth justice published an open call in the New York Times entitled "How many Black, Brown, and Indigenous people have to die giving birth? National call for birth justice and accountability." It is a powerful statement that uses an intersectional framework to understand reproductive inequities, while making demands for positive healthcare reforms and radically dreaming of a reality where the struggle for reproductive justice has been actualized. Using personal narrative, this paper reflects on the field of obstetric anesthesiology and how clinicians can make meaningful change to address and eventually help solve this health care inequity.

Incidence, causes, and maternofetal outcomes of obstructed labor in Ethiopia: systematic review and meta-analysis.

BACKGROUND: Obstructed labor is a preventable obstetric complication. However, it is an important cause of maternal mortality and morbidity and of adverse outcomes for newborns in resource-limited countries in which undernutrition is common resulting in a small pelvis in which there is no easy access to functioning health facilities with a capacity to carry out operative deliveries. Therefore, this systematic review and meta-analysis aimed to estimate the incidence, causes, and maternofetal outcomes of obstructed labor among mothers who gave birth in Ethiopia. METHOD: for this review, we used the standard PRISMA checklist guideline. Different online databases were used for the review: PubMed, Google Scholar, EMBASE, Cochrane Library, HINARI, AFRO Library Databases, and African Online Journals. Based on the adapted PICO principles, different search terms were applied to achieve and access the essential articles. The search included all published and unpublished observational studies written only in the English language and conducted in Ethiopia. Microsoft Excel 16 was used for data entrance, and Stata version 11.0 (Stata Corporation, College Station, Texas, USA) was used for data analysis. RESULTS: I included sixteen (16) primary studies with twenty-eight thousand five hundred ninety-one (28,591) mothers who gave birth in Ethiopia. The pooled incidence of obstructed labor in Ethiopia was 12.93% (95% CI: 10.44-15.42, I2 = 98.0%, p < 0.001). Out of these, 67.3% (95% CI: 33.32-101.28) did not have antenatal care follow-up, 77.86% (95% CI: 63.07-92.66) were from the rural area, and 58.52% (95% CI: 35.73- 82.31) were referred from health centers and visited hospitals after 12 h of labor. The major causes of obstructed labor were cephalo-pelvic disproportion 64.65% (95% CI: 57.15- 72.14), and malpresentation and malposition in 27.24% (95% CI: 22.05-32.42) of the cases. The commonest complications were sepsis in 38.59% (95% CI: 25.49-51.68), stillbirth in 38.08% (95% CI: 29.55-46.61), postpartum hemorrhage in 33.54% (95% CI:12.06- 55.02), uterine rupture in 29.84% (95% CI: 21.09-38.58), and maternal death in 17.27% (95% CI: 13.47-48.02) of mothers who gave birth in Ethiopia. CONCLUSION: This systematic review and meta-analysis showed that the incidence of obstructed labor was high in Ethiopia. Not having antenatal care follow-up, rural residency, and visiting hospitals after 12 h of labor increased the incidence of obstructed labor. The major causes of obstructed labor were cephalo-pelvic disproportion, and malpresentation and malpresentation. Additionally, the commonest complications were sepsis, stillbirth, postpartum hemorrhage, uterine rupture, and maternal death. Thus, promoting antenatal care service utilization, a good referral system, and availing comprehensive obstetric care in nearby health institutions are recommended to prevent the incidence of obstructed labor and its complications.

Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter?

Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.

Clinical Outcomes in High-Risk Pregnancies Due to Advanced Maternal Age.

Although the influence of advanced maternal age (AMA) and delayed childbearing on adverse maternal and perinatal outcomes has been studied extensively, no universal consensus on the definition of AMA exists. This terminology currently refers to the later years of a woman's reproductive life span and generally applies to women age ≥35 years. AMA increases the risk of pregnancy complications, including ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, placenta previa and abruption, gestational diabetes, preeclampsia, and cesarean delivery. Such complications could be the cause of preterm birth and increase the risk of perinatal mortality. For women who have a chronic illness, pregnancy may lead to additional risk that demands increased monitoring or surveillance. The management of pregnant women of AMA requires understanding the relationship between age and preexisting comorbidities. The outcomes from pregnancy in AMA may have a negative impact on women's health as they age because of both the changes from the pregnancy itself and the increased risk of pregnancy-related complications. Postpartum depression affects women of AMA at higher rates. Links between preeclampsia and the risk of future development of cardiovascular disease require follow-up surveillance. The association between hypertensive pregnancy disorders and cognitive and brain functions needs further investigation of sex-specific risk factors across the life span. Educating providers and women of AMA is crucial to facilitate clinical decision making and such education should consider cultural influences, risk perception, and women's health literacy, as well as providers' biases and system issues.

Pregnancy-Related Mortality and Severe Maternal Morbidity in Rural Appalachia: Established Risks and the Need to Know More.

PURPOSE: The Centers for Disease Control and Prevention (CDC) and the American College of Obstetrics and Gynecology have called for researchers to further elucidate medical and social determinants of pregnancy-related death and severe maternal morbidity. This report begins to answer this call in the context of rural Appalachia. METHODS: This report identifies risk factors exposing women in rural Appalachia to pregnancy-related death and severe maternal morbidity. We also use CDC WONDER data to illustrate rural-urban differences in pregnancy-related death. FINDINGS: Rural women nationally die of pregnancy-related causes at a greater rate than urban women. It is unknown how rurality specifically influences pregnancy-related death, but rural women more often embody multiple risk factors associated with negative maternal outcomes. Established risk factors, including high rates of chronic illness and substance abuse, place rural women at risk for severe maternal morbidity and pregnancy-related mortality. These women may also lack the resources to mitigate these risks, including access to high-risk obstetric care. NEXT STEPS: To address these issues and the concerning lack of data, we propose 4 directions for future study: (1) a determination of the prevalence of pregnancy-related death and severe maternal morbidity in this population; (2) an examination of how rural women utilize existing pre- and perinatal resources; (3) better validation concerning surveillance methods of pregnancy-related death and severe maternal morbidity in rural areas; and (4) an exploratory qualitative study of rural women and health care providers.

Staffing needs for unscheduled activity in obstetrics and gynecology.

INTRODUCTION: To determine a minimum threshold of medical staffing needs (obstetricians-gynecologists, anesthesiologists-resuscitation specialists, nurse-anesthetists, pediatricians, and midwives) to ensure the safety and quality of care for unscheduled obstetrics-gynecology activity. MATERIALS AND METHODS: Face to face meetings of French healthcare professionals involved in perinatal care in different types of practices (academic hospital, community hospital or private practice) who belong to French perinatal societies: French National College of Gynecologists-Obstetricians (CNGOF), the French Society of Anesthesia and Resuscitation Specialists (SFAR), the French Society of Neonatology (SFN), the French Society of Perinatal Medicine (SFMP), the National College of French Midwives (CNSF), and the French Federation of Perinatal Care Networks (FFRSP). RESULTS: Different minimum thresholds for each category of care provider were proposed according to the number of births/year in the facility. These minimum thresholds can be modulated upwards as a function of the level of care (Level 1, 2 or 3 for perinatal centers), existence of an emergency department, and responsibilities as a referral center for maternal-fetal and/or surgical care. For example, an obstetrics-gynecology department handling 3000-4500 births per year without serving as a referral center must have an obstetrician-gynecologist, an anesthesiologist-resuscitation specialist, a nurse-anesthetist, and a pediatrician onsite specifically to provide care for unscheduled obstetrics-gynecology needs and a second obstetrician-gynecologist available within a time compatible with security requirements 24/7; the number of midwives always present (24/7) onsite and dedicated to unscheduled care is 5.1 for 3000 births and 7.2 for 4500 births. A maternity unit's occupancy rate must not exceed 85 %. CONCLUSION: The minimum thresholds proposed here are intended to improve the safety and quality of care of women who require unscheduled care in obstetrics-gynecology or during the perinatal period.

Litigating to ensure access to quality maternal health care for women and girls in Kenya.

Access to comprehensive reproductive health care for women and girls, including access to quality maternal health services remains a challenge in Kenya. A recent government enquiry assessing close to 500 maternal deaths that occurred in 2014 revealed gaps in the quality of maternal care, concluding that more than 90% of the women who had died had received "suboptimal" maternal care. In Kenya, the Center for Reproductive Rights (the Center) has undertaken public interest litigation among other strategies to challenge human rights violations and systematic failures within the health sector. In 2014, before the High Court of Bungoma in Western Kenya, the Center filed a case on behalf of Josephine Majani who had been neglected and abused by the staff of the Bungoma County Referral Hospital, a public health facility where she had gone to deliver in 2013. This commentary addresses the situation of maternal health care in Kenya and the actions leading to litigation that was specifically aimed at enabling access to quality maternal health care. It provides an analysis of some of the outcomes of the litigation and highlights the implications thereof on implementation of maternal health care in Kenya and beyond.

Homocysteine as Predictive Marker for Pregnancy-Induced Hypertension-A Comparative Study of Homocysteine Levels in Normal Versus Patients of PIH and Its Complications.

OBJECTIVE: To find the correlation between serum homocysteine levels, relevant laboratory investigations and complications associated with PIH. METHODS: This was a prospective study conducted over 2 years. Two hundred and fourteen cases were studied. They were divided into mild preeclampsia (64), severe preeclampsia (50), eclampsia (32) and control groups (68). Parameters evaluated for statistical analysis were blood pressure, platelet counts, SGOT, SGPT and serum homocysteine levels. RESULTS: A definite statistical correlation was found between the homocysteine levels and severity of hypertension (8 mmol/l, p = .759). A higher level of homocysteine was also associated with many maternal complications like abruption, retinopathy, MODS, maternal mortality and eclampsia. Sixty-nine out of 87 patients with elevated homocysteine levels were complicated with some or the other condition, making a high percentage of 79.31 %. Patients with normal level of homocysteine delivered healthy babies (88.1 %). There were 6 maternal mortalities and 20 stillbirths in the hyperhomocysteinemia group. CONCLUSION: Homocysteine levels have a direct statistical correlation with the severity of hypertension and complication with preeclampsia and eclampsia. It can be considered as a reliable predictive marker for PIH and its wide syndrome.

National Initiatives to Improve Systems for Postpartum Care.

Purpose To showcase several current national initiatives that focus on reducing maternal mortality and severe maternal morbidity and promote postpartum health and wellness for all women. Description Maternal injuries and deaths are a serious public health concern with tremendous impact on families, communities, and healthcare providers. Over the past two decades, it has become apparent that the timing of serious maternal complications has shifted, with more than half of deaths occurring in the immediate postpartum period up to 1 year following birth. Many of these reported deaths could have been prevented, and the number of "near misses" of maternal morbidity cases continues to grow exponentially. In addition, postpartum women experience substantial unmet health needs, compromising their wellbeing. Assessment The American College of Obstetricians and Gynecologists and the Association of Women's Health, Obstetric, and Neonatal Nurses have thoroughly assessed the significance of the rising trends in maternal morbidity/mortality and are leading efforts to reduce these rates and improve overall health and wellbeing for all women during the postpartum period. Conclusion Developing national initiatives to improve postpartum health are vital to increasing the effectiveness of postpartum discharge education, and improving the participation in and the quality of postpartum care. Hopefully, evidence-based practice and widespread dissemination of these efforts will lead to a reduction in preventable post-birth maternal morbidity and mortality.

What is the impact of multi-professional emergency obstetric and neonatal care training?

This paper reviews evidence regarding change in health-care provider behaviour and maternal and neonatal outcomes as a result of emergency obstetric and neonatal care (EmONC) training. A refined version of the Kirkpatrick classification for programme evaluation was used to focus on change in efficiency and impact of training (levels 3 and 4). Twenty-three studies were reviewed - five randomised controlled trials, two quasi-experimental studies and 16 before-and-after observational studies. Training programmes had all been developed in high-income countries and adapted for use in low- and middle-income countries. Nine studies reported on behaviour change and 13 on process and patient outcomes. Most showed positive results. Every maternity unit should provide EmONC teamwork training, mandatory for all health-care providers. The challenges are as follows: scaling up such training to all institutions, sustaining regular in-service training, integrating training into institutional and health-system patient safety initiatives and 'thinking out of the box' in evaluation research.

Comparing hands-on and video training for postpartum hemorrhage management.

The objective was to compare two teaching methods for postpartum hemorrhage management: interactive hands-on training and non-interactive video training. In a controlled intervention study at a secondary health care center in Kenya, the two training methods, based on the Advanced Life Support in Obstetrics curriculum, were evaluated utilizing structured observation of a standardized scenario before and after training. Both intervention groups significantly increased in performance scores after receiving hands-on training: 40% (95% CI 29.5-47.0) and video training: 34.5% (95% CI 25.0-42.0); likewise, pass rates improved significantly. No significant differences in performance score or pass rates were found between the two methods. The findings indicate that postpartum hemorrhage management training by mobile media might be just as effective as conventional hands-on training and a feasible way to overcome the outreach gap in sub-Saharan Africa's rural areas, where peripheral health facilities are generally difficult to reach with conventional training programs.

Intrahepatic cholestasis of pregnancy is common among patients' first-degree relatives.

Intrahepatic cholestasis of pregnancy has been shown to have a genetic predisposition. We studied whether Finnish women who had suffered from the disorder reported their first-degree relatives to have had liver dysfunction during their pregnancies. Questionnaires were sent in autumn 2010 to a total of 544 former intrahepatic cholestasis of pregnancy patients and 1235 controls, all having delivered during 1969-1988. The response rate was 66.2%. The incidence of intrahepatic cholestasis is 0.5-1.5% of pregnancies in Finland. In our survey, altogether 12.8% of mothers (odds ratio 9.2), 15.9% of sisters (odds ratio 5.3) and 10.3% of daughters (odds ratio 4.8) of women who had suffered from intrahepatic cholestasis of pregnancy had had liver dysfunction during pregnancy. Our findings strengthen the earlier knowledge of the genetic component in intrahepatic cholestasis of pregnancy. We suggest that all pregnant women are asked about their family history regarding liver dysfunction during pregnancy.

Augmentation index and pulse wave velocity in normotensive and pre-eclamptic pregnancies.

OBJECTIVE: Hypertensive disorders during pregnancy remain a major health burden. Normal pregnancy is associated with systemic cardiovascular adaptation. The augmentation index and pulse wave velocity measures may serve as surrogate markers of cardiovascular pathology, including pre-eclampsia. We evaluated these parameters during and after normotensive and pre-eclamptic pregnancies. DESIGN: Longitudinal cohort trial involving a case-control analysis of healthy women and women with pre-eclampsia. SETTING: University hospital. POPULATION: Fifty-three healthy pregnant women between 11(+6) and 13(+6) gestational weeks, as well as 21 patients with pre-eclampsia. METHODS: The augmentation index and pulse wave velocity were measured seven times during pregnancy and postpartum. MAIN OUTCOME MEASURES: Changes in augmentation index and pulse wave velocity during and after healthy pregnancies were measured. The influence of early-onset and late-onset pre-eclampsia on these measurements both during and after pregnancy was evaluated. RESULTS: The normotensive pregnancies exhibited a significant decrease in the augmentation index from the first trimester to the end of the second trimester; however, the normotensive pregnancies showed an increase in the augmentation index during the third trimester as term approached. The patients with early-onset and late-onset pre-eclampsia displayed a significantly elevated augmentation index during pregnancy. The postpartum augmentation index and pulse wave velocity were significantly elevated in the early-onset pre-eclampsia group. CONCLUSION: After pregnancy, early-onset and late-onset pre-eclamptic patients exhibit differences in vascular function. This result indicates the presence of a higher cardiovascular risk in patients after early-onset pre-eclampsia.