Application of standardized methods to evaluate the environmental safety of polyvinyl alcohol disposed of down the drain.

The purpose of this research was to use polyvinyl alcohol (PVOH) 18-88 as a case study to evaluate the environmental fate, ecotoxicity, and overall safety profile of water-soluble, nonmodified PVOH polymers used in detergent films. An OECD 303A Wastewater Treatment Plant Simulation Study was conducted with dissolved organic carbon as the analytical endpoint to evaluate the removal of PVOH 18-88 during wastewater treatment. During the plateau phase, high levels of removal due to biodegradation were observed (average 97.4 ± 7.1, range: 88%-116%). The OECD 303A study quantitatively verified that surface water is the dominant receiving compartment for PVOH 18-88 post wastewater treatment. Acute algae, invertebrate, and fish embryo (fish embryo acute toxicity test [FET]) ecotoxicity studies quanitified the 50% lethal/effect concentration (L/EC50) for PVOH 18-88. Due to the potential for the chorion to impact PVOH 18-88 bioavailability, both chorionated and dechorionated FET tests were conducted. L/EC50 > 1000 mg/L for FET (chorionated and dechorionated), invertebrate, and algae were observed. The Sustainable Futures (US) and REACH (EU) frameworks were used to evaluate environmental risk. For the US assessment, the Exposure and Fate Assessment Screening Tool was used to predict the single day lowest flow over a 10-year period (1Q10) surface water concentration and the seven consecutive days of lowest flow over a 10-year period (7Q10) surface water concentration and compared with acute and chronic concentrations of concern. For the EU assessment, the European Union System for the Evaluation of Substances was used to predict local and regional exposure concentrations and compared to the predicted no effect concentration. For both regulatory assessments, the exposure concentrations were >2 orders of magnitude below the effect concentrations. Integr Environ Assess Manag 2024;00:1-13. © 2024 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals LLC on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Multi-laboratory evaluation of the reproducibility of polymer biodegradation assessments applying standardized and modified respirometry methods.

This research evaluated the intra- and interlaboratory variability when applying OECD 301F and OECD 301B Ready Biodegradation respirometric test methods to quantify polymer biodegradation as well as the impact of method modifications including test duration, inoculum level and test substance concentration on results. This assessment synthesizes results of mineralization studies on 5 polymers of varying structural components, molecular weight, charge, and solubility, evaluated at 8 different laboratories in 4 different countries, providing significant geographic variation in inoculum source as well as lab to lab variations in test setup. Across all laboratories, intralaboratory variability was low (≤18 % absolute difference) indicating the reproducibility of results between replicates and uniformity of test setup in each laboratory. Interlaboratory variation was also low for all 5 polymers with extent of mineralization being comparable in all OECD 301F and 301B studies even when test methods were modified. Across all studies mean mineralization was 89 ± 5.5 % for polyethylene glycol 35,000, 85 ± 7.4 % for polyvinyl alcohol 18-88, 44 ± 13 % for carboxymethyl cellulose (DS 0.6), 48 ± 4.1 % for a modified guar gum, and 88 ± 6.2 % for microcrystalline cellulose (MCC) at study completion. Due to the lack of polymeric reference materials, MCC was evaluated and found to be a suitable reference material for polymers that biodegrade rapidly in screening studies. An additional respirometric study was conducted quantifying mineralization of the 5 polymers in river water to evaluate the relationship with OECD 301 results using activated sludge as the inoculum. A similar extent of mineralization was observed for all 5 polymers in the OECD 301 and river water studies but time to reach the maximum extent of mineralization was longer using river water as the inoculum source likely due to the lower microbial counts (106 CFU/L) in the test system.

Water soluble polymer biodegradation evaluation using standard and experimental methods.

Multiple polyethylene glycol (PEG) polymers ranging in molecular weight (MW) from 4000 to 500,000 Da, polyvinyl alcohol (PVOH) polymers with degrees of hydrolysis (DH) of 79 % and 88 % and MW 10,000 to 130,000 Da, and carboxy methyl cellulose (CMC) polymers with degrees of substitution (DS) ranging from 0.6 to 1.2 were evaluated in standard screening biodegradation tests to assess method limitations, modification potential, and reproducibility. All PEGs and PVOHs mineralized completely in OECD 301B and 302B studies reaching >80 % biodegradation with negligible dissolved organic carbon remaining at study completion. For high MW PEOs, extension of test duration was needed to reach full extent of mineralization. CMC biodegradation was directly correlated to degree of substitution with CMC 0.6 biodegrading extensively, CMC 0.79 partially biodegrading, and CMC 1.2 not biodegrading significantly in OECD 301B and 302B studies. For all materials tested in both an OECD 301B and 302B, fewer days were necessary to reach 60 % biodegradation in the OECD 302B indicating increased rates of biodegradation with higher inoculum to test chemical ratios. In a series of investigative studies using respirometry as the analytical endpoint, significant variability in the presence of competent degraders in small volume grab samples of river water was observed. Research is needed to overcome this variability and develop a standardized reproducible test method to accurately assess polymer mineralization in river water. At study completion, residual dissolved organic carbon (DOC) data confirmed respirometry data, high levels of mineralization resulted in negligible residual DOC while low levels of mineralization resulted in significant residual DOC, up to dose concentrations. DOC measurements provided confirmation of complete biodegradation when biomass incorporation and test system set up resulted in variable carbon dioxide production or oxygen demand.

Spatial modeling framework for aquatic exposure assessments of chemicals disposed down the drain: Case studies for China and Japan.

A modeling framework was created for the development of spatially explicit aquatic exposure models for any region or country of interest for chemicals disposed of down the drain. The framework relies on globally available data sets for river flow and population, and locally available data sets for wastewater treatment infrastructure and domestic water use, and leverages the iSTREEM® chemical routing algorithm. The framework was applied to China and Japan as case study countries. Spatially explicit population data were obtained from WorldPop. River flows covering the spatial extent of the two countries were derived from a high-resolution surface runoff gridded data set that was based on the Curve Number approach and combined with the hydrology network for catchments and rivers from HydroBASINS and HydroSHEDS data sets. Publicly available data from government sources were used for estimating per capita water use and wastewater treatment infrastructure. To demonstrate the framework, the China model was used to predict the levels of the antifungal agent climbazole in rivers across the country, and the Japan model was used to predict river concentrations of linear alkylbenzene sulfonate. For both chemicals, the comparison of measured to modeled values showed good agreement, using linear regression analysis (R2 ≥ 0.96). The framework presented in this study provides a systematic and robust approach to develop spatially resolved exposure models that can be extrapolated to any country or region, allowing more accurate risk assessment of chemicals disposed down the drain by leveraging concentration distributions generated by the model. Integr Environ Assess Manag 2022;18:722-733. © 2021 SETAC.

Non-human bones in forensic casework: not such a trivial problem.

When bones are submitted to mortuaries significant time and resources from both police and anthropologists are required, even if they are subsequently determined to be non-human. A survey of non-human bone casework was made in order to determine the scope of this problem and the different bone types being assessed. This study used data from nine years of casework at the NSW Department of Forensic Medicine (DOFM), Sydney. It analyzed the number of non-human cases that were assessed, the types of animals represented in these bones, the bone elements found, their condition and their location when found. By 2016, over 70% of skeletal cases handled each year by the Sydney DOFM were non-human. The most common animal remains were sheep and cattle, and the skeletal elements appearing in the greatest number of cases were vertebrae, followed by femora and tibiae. Skull fragments were rare. Slightly more cases were found on the surface rather than buried. Fragmentation might have been expected to contribute to difficulties in identifying bones, but in fact 32% of cases consisted of complete bones only. This study shows a very high proportion of non-human forensic casework in the Sydney region. Data presented in this study may prove useful in designing training workshops in non-human bone identification.

Probabilistic exposure assessment of DEEDMAC using measured effluent and sludge concentrations from 41 wastewater treatment plants across the United States.

The cationic surfactant diethyldialkylester dimethyl ammonium chloride (DEEDMAC) is an active ingredient in liquid fabric softeners and, as such, is disposed of down the drain after consumer use. A monitoring program was conducted across the continental United States to measure the concentration of DEEDMAC in the effluent and sludge from 41 wastewater treatment plants (WWTPs). The concentration in the effluent ranged from 32.4 to 2660ng/L, with a mean and standard deviation of 232±450ng/L. The concentration in the sludge ranged from 0.707 to 314mg/kg dw, with a mean and standard deviation of 29.2±50mg/kg dw. The distribution of measured effluent concentrations was combined with a distribution of mixing zone dilutions factors to predict the distribution of DEEDMAC concentrations in mixing zones and sediments under mean flow and 10-year, 7 consecutive day lowest flow (7Q10 low flow) conditions. Additionally, the distribution of measured sludge concentrations was combined with a distribution of land applied sludge volumes and US tilling practices to obtain a predicted distribution of DEEDMAC concentrations in sludge amended soils. The 90th percentile concentrations of DEEDMAC in mixing zones and sediments under mean flow conditions was 10.3ng/L and 451ng/kg, respectively. The 90th percentile concentration in sludge amended soils was 1.92mg/kg. These predicted exposure concentrations were compared to published eco-toxicity data and showed that DEEDMAC has a wide margin of safety and poses negligible ecologic risk to aquatic, sediment, or terrestrial compartments.

Environmental fate of amine oxide: Using measured and predicted values to determine aquatic exposure.

Amine oxide (AO) surfactants are used widely in North American household detergents resulting in >44,000mtons disposed down the drain annually. Due to AOs substantial down the drain disposal volume, wide dispersive use, and high aquatic toxicity, there is a need to evaluate ecological exposure and corresponding risk. This study refined the current knowledge regarding the fate of AO disposed down the drain through laboratory simulation studies to evaluate biodegradation in the sewer and during activated sludge wastewater treatment. A monitoring program which measured effluent AO concentrations for the dominant carbon chain lengths, C12 and C14, at 44 wastewater treatment plants (WWTP) across the continental US was also conducted. The study results were then used as input into probabilistic exposure models to predict US receiving stream concentrations. In three separate OECD 314A Sewer Water Die-Away studies AO was rapidly biodegraded with >76% mineralized by study completion and the geometric mean of the primary biodegradation rates being 0.184h-1. Two OECD 303A Activated Sludge WWTP Simulation studies showed rapid and complete biodegradation of AO with ≤0.09% of parent AO remaining in the effluent, ≤0.03% of parent AO sorbed to sludge solids, and >97% complete mineralization of AO. Monitoring at US WWPTs confirmed low levels of AO in effluents with mean C12 and C14AO concentrations of 52.8 and 20.1ng/L respectively. Based on the monitoring data, the 90th percentile concentrations of C12 and C14AO for 7Q10 low flow stream conditions were >2 orders of magnitude lower than the predicted no effect concentrations indicating negligible aquatic risk from AO in US receiving streams. This study verifies that AO is safe for the aquatic environment even at the currently high usage volumes due to rapid biodegradation during transit through the sewer and wastewater treatment.

Assessing the biodegradability of microparticles disposed down the drain.

Microparticles made from naturally occurring materials or biodegradable plastics such as poly(3-hydroxy butyrate)-co-(3-hydroxy valerate), PHBV, are being evaluated as alternatives to microplastics in personal care product applications but limited data is available on their ultimate biodegradability (mineralization) in down the drain environmental compartments. An OECD 301B Ready Biodegradation Test was used to quantify ultimate biodegradability of microparticles made of PHBV foam, jojoba wax, beeswax, rice bran wax, stearyl stearate, blueberry seeds and walnut shells. PHBV polymer was ready biodegradable reaching 65.4 ± 4.1% evolved CO2 in 5 d and 90.5 ± 3.1% evolved CO2 in 80 d. PHBV foam microparticles (125-500 µm) were mineralized extensively with >66% CO2 evolution in 28 d and >82% CO2 evolution in 80 d. PHBV foam microparticles were mineralized at a similar rate and extent as microparticles made of jojoba wax, beeswax, rice bran wax, and stearyl stearate which reached 84.8  ± 4.8, 84.9  ± 2.2, 82.7  ± 4.7, and 86.4 ± 3.2% CO2 evolution respectively in 80 d. Blueberry seeds and walnut shells mineralized more slowly only reaching 39.3  ± 6.9 and 5.1 ± 2.8% CO2 evolution in 80 d respectively.

Biodegradation of nonionic and anionic surfactants in domestic wastewater under simulated sewer conditions.

The ultimate disposition of chemicals discarded down the drain can be substantially impacted by their fate in the sewer, but to date limited data have been published on the biodegradability of chemicals in sewer systems. The recently established OECD 314 guideline (Simulation tests to assess the biodegradability of chemicals discharged in wastewater, 2008) contains a simulation method (314A) for evaluating the biodegradation of chemicals in sewage under simulated sewer conditions. This research used the OECD 314A method to evaluate the rates and pathways of primary and ultimate biodegradation of a suite of 14C-labeled homologues representing four classes of high volume surfactants including nonionic alkyl ethoxylates (AE), and anionic alkyl ethoxysulfates (AES), alkyl sulfate (AS) and linear alkyl benzene sulfonate (LAS). All the tested homologues exhibited >97 % loss of parent, formation of metabolites, and some level (16-94 %) of CO2 production after being incubated 96-100 h in raw domestic wastewater. Comparison of C12E3, C14E3, and C16E3 showed that the first order biodegradation rate was affected by alkyl chain length with rates ranging from 6.8 h-1 for C12E3 to 0.49 h-1 for C16E3. Conversely, comparison of C14E1, C14E3, and C14E9 showed that the number of ethoxy units did not impact the biodegradation rate. AES and AS degraded quickly with first order kinetic rates of 1.9-3.7 and 41 h-1 respectively. LAS did not exhibit first order decay kinetics and primary degradation was slow. Biodegradation pathways were also determined. This work shows that biodegradation in the sewer has a substantial impact on levels of surfactants and surfactant metabolites that ultimately reach wastewater treatment plants.

The CHIPS Randomized Controlled Trial (Control of Hypertension in Pregnancy Study): Is Severe Hypertension Just an Elevated Blood Pressure?

To determine whether clinical outcomes differed by occurrence of severe hypertension in the international CHIPS trial (Control of Hypertension in Pregnancy Study), adjusting for the interventions of "less tight" (target diastolic blood pressure [dBP] 100 mm Hg) versus "tight" control (target dBP 85 mm Hg). In this post-hoc analysis of CHIPS data from 987 women with nonsevere nonproteinuric preexisting or gestational hypertension, mixed effects logistic regression was used to compare the following outcomes according to occurrence of severe hypertension, adjusting for allocated group and the influence of baseline factors: CHIPS primary (perinatal loss or high-level neonatal care for >48 hours) and secondary outcomes (serious maternal complications), birth weight <10th percentile, preeclampsia, delivery at <34 or <37 weeks, platelets <100×109/L, elevated liver enzymes with symptoms, maternal length of stay ≥10 days, and maternal readmission before 6 weeks postpartum. Three hundred and thirty-four (34.1%) women in CHIPS developed severe hypertension that was associated with all outcomes examined except for maternal readmission (P=0.20): CHIPS primary outcome, birth weight <10th percentile, preeclampsia, preterm delivery, elevated liver enzymes (all P<0.001), platelets <100×109/L (P=0.006), and prolonged hospital stay (P=0.03). The association between severe hypertension and serious maternal complications was seen only in less tight control (P=0.02). Adjustment for preeclampsia (464, 47.3%) did not negate the relationship between severe hypertension and the CHIPS primary outcome (P<0.001), birth weight <10th percentile (P=0.005), delivery at <37 (P<0.001) or <34 weeks (P<0.001), or elevated liver enzymes with symptoms (P=0.02). Severe hypertension is a risk marker for adverse maternal and perinatal outcomes, independent of BP control or preeclampsia co-occurrence. CLINICAL TRIAL REGISTRATION: URL: http://pre-empt.cfri.ca/. Unique identifier: ISRCTN 71416914. URL: https://www.clinicaltrials.gov/. Unique identifier: NCT01192412.

Women's views and postpartum follow-up in the CHIPS Trial (Control of Hypertension in Pregnancy Study).

OBJECTIVE: To compare women's views about blood pressure (BP) control in CHIPS (Control of Hypertension In Pregnancy Study) (NCT01192412). DESIGN: Quantitative and qualitative analysis of questionnaire responses. SETTING: International randomised trial (94 sites, 15 countries). POPULATION/SAMPLE: 911 (92.9%) women randomised to 'tight' (target diastolic blood pressure, 85mmHg) or 'less tight' (target diastolic blood pressure, 100mmHg) who completed questionnaires. METHODS: A questionnaire was administered at ∼6-12 weeks postpartum regarding post-discharge morbidity and views about trial participation. Questionnaires were administered by the site co-ordinator, and contact was made by phone, home or clinic visit; rarely, data was collected from medical records. Quantitative analyses were Chi-square or Fisher's exact test for categorical variables, mixed effects multinomial logistic regression to adjust for confounders, and p<0.001 for statistical significance. NVivo software was used for thematic analysis of women's views. MAIN OUTCOME MEASURES: Satisfaction, measured as willingness to have the same treatment in another pregnancy or recommend that treatment to a friend. RESULTS: Among the 533 women in 'tight' (N=265) vs. 'less tight' (N=268) control who provided comments for qualitative analysis, women in 'tight' (vs. 'less tight') control made fewer positive comments about the amount of medication taken (5 vs. 28 women, respectively) and intensity of BP monitoring (7 vs. 17, respectively). However, this did not translate into less willingness to either have the same treatment in another pregnancy (434, 95.8% vs. 423, 92.4%, respectively; p=0.14) or recommend that treatment to a friend (435, 96.0% and 428, 93.4%, respectively; p=0.17). Importantly, although satisfaction remained high among women with an adverse outcome, those in 'tight' control who suffered an adverse outcome (vs. those who did not) were not consistently less satisfied, whereas this was not the case among women in 'less tight' control among whom satisfaction was consistently lower for the CHIPS primary outcome (p<0.001), severe hypertension (p≤0.01), and pre-eclampsia (p<0.001). CONCLUSIONS: Women in 'tight' (vs. 'less tight') control were equally satisfied with their care, and more so in the face of adverse perinatal or maternal outcomes.

The Cost Implications of Less Tight Versus Tight Control of Hypertension in Pregnancy (CHIPS Trial).

UNLABELLED: The CHIPS randomized controlled trial (Control of Hypertension in Pregnancy Study) found no difference in the primary perinatal or secondary maternal outcomes between planned "less tight" (target diastolic 100 mm Hg) and "tight" (target diastolic 85 mm Hg) blood pressure management strategies among women with chronic or gestational hypertension. This study examined which of these management strategies is more or less costly from a third-party payer perspective. A total of 981 women with singleton pregnancies and nonsevere, nonproteinuric chronic or gestational hypertension were randomized at 14 to 33 weeks to less tight or tight control. Resources used were collected from 94 centers in 15 countries and costed as if the trial took place in each of 3 Canadian provinces as a cost-sensitivity analysis. Eleven hospital ward and 24 health service costs were obtained from a similar trial and provincial government health insurance schedules of medical benefits. The mean total cost per woman-infant dyad was higher in less tight versus tight control, but the difference in mean total cost (DM) was not statistically significant in any province: Ontario ($30 191.62 versus $24 469.06; DM $5723, 95% confidence interval, -$296 to $12 272; P=0.0725); British Columbia ($30 593.69 versus $24 776.51; DM $5817; 95% confidence interval, -$385 to $12 349; P=0.0725); or Alberta ($31 510.72 versus $25 510.49; DM $6000.23; 95% confidence interval, -$154 to $12 781; P=0.0637). Tight control may benefit women without increasing risk to neonates (as shown in the main CHIPS trial), without additional (and possibly lower) cost to the healthcare system. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT01192412.

Evaluation of anionic surfactant concentrations in US effluents and probabilistic determination of their combined ecological risk in mixing zones.

Alcohol sulfates (AS), alcohol ethoxysulfates (AES), linear alkyl benzenesulfonates (LAS) and methyl ester sulfonates (MES) are anionic surfactants that are widely used in household detergents and consumer products resulting in over 1 million tons being disposed of down the drain annually in the US. A monitoring campaign was conducted which collected grab effluent samples from 44 wastewater treatment plants (WWTPs) across the US to generate statistical distributions of effluent concentrations for anionic surfactants. The mean concentrations for AS, AES, LAS and MES were 5.03±4.5, 1.95±0.7, 15.3±19, and 0.35±0.13µg/L respectively. Since each of these surfactants consist of multiple homologues that differ in their toxicity, the concentration of each homologue measured in an effluent sample was converted into a toxic unit (TU) by normalizing to the predicted no effect concentration (PNEC) derived from high tier effects data (mesocosm studies). The statistical distributions of the combined TUs in the effluents were used in combination with distributions of dilution factors for WWTP mixing zones to conduct a US-wide probabilistic risk assessment for the aquatic environment for each of the surfactants. The 90th percentile level of TUs for AS, AES, LAS and MES in mixing zones were 1.89×10-2, 2.73×10-3, 2.72×10-2, and 3.65×10-5 under 7Q10 (lowest river flow occurring over a 7day period every 10years) low flow conditions. Because these surfactants have the same toxicological mode of action, the TUs were summed and the aquatic safety for anionic surfactants as a whole was assessed. At the 90th percentile level under the conservative 7Q10 low flow conditions the forecasted TUs were 4.21×10-2 which indicates that there is a significant margin of safety for the class of anionic surfactants in US aquatic environments.

Can adverse maternal and perinatal outcomes be predicted when blood pressure becomes elevated? Secondary analyses from the CHIPS (Control of Hypertension In Pregnancy Study) randomized controlled trial.

INTRODUCTION: For women with chronic or gestational hypertension in CHIPS (Control of Hypertension In Pregnancy Study, NCT01192412), we aimed to examine whether clinical predictors collected at randomization could predict adverse outcomes. MATERIAL AND METHODS: This was a planned, secondary analysis of data from the 987 women in the CHIPS Trial. Logistic regression was used to examine the impact of 19 candidate predictors on the probability of adverse perinatal (pregnancy loss or high level neonatal care for >48 h, or birthweight <10th percentile) or maternal outcomes (severe hypertension, preeclampsia, or delivery at <34 or <37 weeks). A model containing all candidate predictors was used to start the stepwise regression process based on goodness of fit as measured by the Akaike information criterion. For face validity, these variables were forced into the model: treatment group ("less tight" or "tight" control), antihypertensive type at randomization, and blood pressure within 1 week before randomization. Continuous variables were represented continuously or dichotomized based on the smaller p-value in univariate analyses. An area-under-the-receiver-operating-curve (AUC ROC) of ≥0.70 was taken to reflect a potentially useful model. RESULTS: Point estimates for AUC ROC were <0.70 for all but severe hypertension (0.70, 95% CI 0.67-0.74) and delivery at <34 weeks (0.71, 95% CI 0.66-0.75). Therefore, no model warranted further assessment of performance. CONCLUSIONS: CHIPS data suggest that when women with chronic hypertension develop an elevated blood pressure in pregnancy, or formerly normotensive women develop new gestational hypertension, maternal and current pregnancy clinical characteristics cannot predict adverse outcomes in the index pregnancy.

Widespread Microbial Adaptation to l-Glutamate-N,N-diacetate (L-GLDA) Following Its Market Introduction in a Consumer Cleaning Product.

l-Glutamate-N,N-diacetate (L-GLDA) was recently introduced in the United States (U.S.) market as a phosphate replacement in automatic dishwashing detergents (ADW). Prior to introduction, L-GLDA exhibited poor biodegradation in OECD 301B Ready Biodegradation Tests inoculated with sludge from U.S. wastewater treatment plants (WWTPs). However, OECD 303A Activated Sludge WWTP Simulation studies showed that with a lag period to allow for growth (40-50 days) and a solids retention time (SRT) that allows establishment of L-GLDA degraders (>15 days), significant biodegradation (>80% dissolved organic carbon removal) would occur. Corresponding to the ADW market launch, a study was undertaken to monitor changes in the ready biodegradability of L-GLDA using activated sludge samples from various U.S. WWTPs. Initially all sludge inocula showed limited biodegradation ability, but as market introduction progressed, both the rate and extent of degradation increased significantly. Within 22 months, L-GLDA was ready biodegradable using inocula from 12 WWTPs. In an OECD 303A study repeated 18 months post launch, significant and sustained carbon removal (>94%) was observed after a 29-day acclimation period. This study systematically documented field adaptation of a new consumer product chemical across a large geographic region and confirmed the ability of laboratory simulation studies to predict field adaptation.

Less-tight versus tight control of hypertension in pregnancy.

BACKGROUND: The effects of less-tight versus tight control of hypertension on pregnancy complications are unclear. METHODS: We performed an open, international, multicenter trial involving women at 14 weeks 0 days to 33 weeks 6 days of gestation who had nonproteinuric preexisting or gestational hypertension, office diastolic blood pressure of 90 to 105 mm Hg (or 85 to 105 mm Hg if the woman was taking antihypertensive medications), and a live fetus. Women were randomly assigned to less-tight control (target diastolic blood pressure, 100 mm Hg) or tight control (target diastolic blood pressure, 85 mm Hg). The composite primary outcome was pregnancy loss or high-level neonatal care for more than 48 hours during the first 28 postnatal days. The secondary outcome was serious maternal complications occurring up to 6 weeks post partum or until hospital discharge, whichever was later. RESULTS: Included in the analysis were 987 women; 74.6% had preexisting hypertension. The primary-outcome rates were similar among 493 women assigned to less-tight control and 488 women assigned to tight control (31.4% and 30.7%, respectively; adjusted odds ratio, 1.02; 95% confidence interval [CI], 0.77 to 1.35), as were the rates of serious maternal complications (3.7% and 2.0%, respectively; adjusted odds ratio, 1.74; 95% CI, 0.79 to 3.84), despite a mean diastolic blood pressure that was higher in the less-tight-control group by 4.6 mm Hg (95% CI, 3.7 to 5.4). Severe hypertension (≥160/110 mm Hg) developed in 40.6% of the women in the less-tight-control group and 27.5% of the women in the tight-control group (P<0.001). CONCLUSIONS: We found no significant between-group differences in the risk of pregnancy loss, high-level neonatal care, or overall maternal complications, although less-tight control was associated with a significantly higher frequency of severe maternal hypertension. (Funded by the Canadian Institutes of Health Research; CHIPS Current Controlled Trials number, ISRCTN71416914; ClinicalTrials.gov number, NCT01192412.).

PIERS proteinuria: relationship with adverse maternal and perinatal outcome.

OBJECTIVE: To examine the ability of three different proteinuria assessment methods (urinary dipstick, spot urine protein:creatinine ratio [Pr/Cr], and 24-hour urine collection) to predict adverse pregnancy outcomes. METHODS: We performed a prospective multicentre cohort study, PIERS (Preeclampsia Integrated Estimate of RiSk), in seven academic tertiary maternity centres practising expectant management of preeclampsia remote from term in Canada, New Zealand, and Australia. Eligible women were those admitted with preeclampsia who had at least one antenatal proteinuria assessment by urinary dipstick, spot urine Pr/Cr ratio, and/or 24-hour urine collection. Proteinuria assessment was done either visually at the bedside (by dipstick) or by hospital clinical laboratories for spot urine Pr/Cr and 24-hour urine collection. We calculated receiver operating characteristic area under the curve (95% CI) for each proteinuria method and each of the combined adverse maternal outcomes (within 48 hours) or adverse perinatal outcomes (at any time). Models with AUC ≥ 0.70 were considered of interest. Analyses were run for all women who had each type of proteinuria assessment and for a cohort of women ("ALL measures") who had all three proteinuria assessments. RESULTS: More women were proteinuric by urinary dipstick (≥ 2+, 61.4%) than by spot urine Pr/Cr (≥ 30 g/mol, 50.4%) or 24-hour urine collection (≥ 0.3g/d, 34.7%). Each proteinuria measure evaluated had some discriminative power, and dipstick proteinuria (categorical) performed as well as other methods. No single method was predictive of adverse perinatal outcome. CONCLUSION: The measured amount of proteinuria should not be used in isolation for decision-making in women with preeclampsia. Dipstick proteinuria performs as well as other methods of assessing proteinuria for prediction of adverse events.

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model.

BACKGROUND: Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder. METHODS: We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting. FINDINGS: 261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility. INTERPRETATION: The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia. FUNDING: Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.