Postpartum preeclampsia or eclampsia: defining its place and management among the hypertensive disorders of pregnancy.

High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.

Hypertensive disorders in pregnancy and child development at 36 months in the All Our Families prospective cohort study.

Hypertensive disorders in pregnancy (HDP) are associated with increased risk of offspring neurodevelopmental disorders, suggesting long-term adverse impacts on fetal brain development. However, the relationship between HDP and deficits in general child development is unclear. Our objective was to assess the association between HDP and motor and cognitive developmental delay in children at 36 months of age. We analyzed data from the All Our Families community-based cohort study (n = 1554). Diagnosis of HDP-gestational or chronic hypertension, preeclampsia, or eclampsia-was measured through medical records. Child development was measured by maternal-report on five domains of the Ages and Stages Questionnaire (ASQ-3). Standardized cut-off scores were used to operationalize binary variables for any delay, motor delay, and cognitive delay. We calculated adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) using logistic regression, sequentially controlling for potential confounders followed by factors suspected to lie on the causal pathway. Overall, 8.0% of women had HDP and hypertension-exposed children had higher prevalence of delay than unexposed children. Hypertension-exposed children had elevated risk for developmental delay, but CIs crossed the null. The aRRs quantifying the fully adjusted effect of HDP on child development were 1.19 (95% CI 0.92, 1.53) for any delay, 1.18 (95% CI 0.86, 1.61) for motor delay, and 1.24 (95% CI 0.83, 1.85) for cognitive delay. We did not find a statistically significant association between HDP and developmental delay. Confidence intervals suggest that children exposed to HDP in utero have either similar or slightly elevated risk of any, motor, and cognitive delay at 36 months after controlling for maternal and obstetric characteristics. The observed direction of association aligns with evidence of biological mechanisms whereby hypertensive pathology can disrupt fetal neurodevelopment; however, more evidence is needed. Findings may have implications for early developmental monitoring and intervention following prenatal hypertension exposure.

Maternal and neonatal outcomes in pregnancies complicated by eclampsia - analysis of cases from 2008-2018.

OBJECTIVE: Evaluation of perinatal results in a set of pregnancies complicated by eclampsia. METHODS: Analysis of 67,304 births performed at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno from 2008-2018. During the given period, eclampsia was dia-gnosed in 16 mothers (0.2). The during the time of eclampsia (week of gestation, prepartum, intrapartum, postpartum) fetal and neonatal status (signs of intrauterine distress, pH of the umbilical artery, Apgar score, intrauterine fetal death, death in the early neonatal period) were evaluated. Symptoms and course of the eclamptic attack, maternal comorbidities, associated obstetric complications (placental abruption, surgical complications, blood loss, hysterectomy) and non-obstetric complications (coagulopathy, renal and hepatic impairment, neurological complications) were monitored. RESULTS: Out of a total of 16 cases of eclampsia, 13 cases (81.3%) were confirmed during pregnancy, one case (6.2%) during childbirth, and two cases (12.5%) within 24 hours after childbirth. The mean gestational week of eclampsia was 33 weeks and 3 days. The typical course of an eclamptic attack characterized by headache and visual disturbances followed by a rapid onset of convulsions was noted in five cases (31%). Fetal hypoxia with a pH of the umbilical artery less than 7.10 occurred in four cases (25%). The dependence of the decrease in pH value on the time interval from the dia-gnosis of eclampsia to the termination of pregnancy was demonstrated. The pH of the umbilical artery decreased on average by 0.054 every 30 minutes from the onset of the eclamptic attack until the end of pregnancy. There were 3 perinatal deaths in the group (19%). Intrauterine fetal death occurred in one case due to partial abruption of the placenta during an eclamptic attack; two newborns died in the early neonatal period. The cause of death was sepsis in one case and perforation of the intestine in necrotizing enterocolitis in the other. The death of the mother was not recorded in the file. The incidence of preeclampsia in subsequent pregnancies reached 18.8%. Non-obstetric and neurological complications (amaurosis, subarachnoid hemorrhage, amnesia) occurred in the group in three cases (18.8%), and renal failure occurred in two cases (12.5%). CONCLUSION: The incidence of eclampsia at the Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital, Brno reached 0.2 and was stable for a long time. Associated serious maternal complications occurred in 37.5% of cases and neonatal complications in 31.3% of cases. Early dia-gnosis of eclampsia and minimization of the time delay until the end of pregnancy is a prerequisite for reducing the risk of associated complications. An interdisciplinary approach is needed.

Associations of Hypothyroxinemia With Risk of Preeclampsia-Eclampsia and Gestational Hypertension.

Objective: To investigate the association between hypothyroxinemia and the risk of preeclampsia-eclampsia and gestational hypertension. Design: Historical cohort study. Methods: The study included pregnant individuals who delivered live-born singletons and had at least one thyroid function assessment during pregnancy at a tertiary hospital. Hypothyroxinemia was defined as thyroid-stimulating hormone (TSH) levels within the normal reference range and free thyroxine (FT4) levels lower than the tenth percentile. Risk ratios (RRs) with 95% confidence intervals (95% CIs) for preeclampsia-eclampsia and gestational hypertension between women with and without a diagnosis of hypothyroxinemia during pregnancy were estimated using a generalized estimating equation model. Results: A total of 59,463 women with live-born singletons were included in the analysis. Logistic regression models with restricted cubic spline suggested that there was a U-shaped association between FT4 levels and preeclampsia-eclampsia risk. Compared with euthyroid women, those with hypothyroxinemia had an increased risk of preeclampsia-eclampsia (RR = 1.16, 95% CI: 1.02-1.31), and the risk increased with the increasing severity of hypothyroxinemia (p for trend < 0.001). Moreover, persistent hypothyroxinemia from the first to second trimesters was associated with an increased risk of preeclampsia-eclampsia (RR = 1.37, 95% CI: 1.03-1.83), especially for women with severe hypothyroxinemia (RR = 1.70, 95% CI: 1.12-2.58). In contrast, there was no association between hypothyroxinemia and gestational hypertension. Conclusion: Our study suggested that hypothyroxinemia was only associated with an increased risk of preeclampsia-eclampsia, especially in women with persistent hypothyroxinemia in the first half of pregnancy. Analyses of the associated risk of gestational hypertension with hypothyroxinemia were not significant.

Trends and predictors of eclampsia among singleton and multiple gestations in the United States, 1989-2018.

OBJECTIVE: To examine temporal trends of eclampsia by plurality in the US spanning three decades (1989-2018); and to investigate risk factors for eclampsia among singleton and multiple pregnancies in the US during the study period. STUDY DESIGN: We conducted a retrospective cohort study using the Natality data files, including information on all births within the gestational age of 20-42 weeks from 1989 through 2018. We used joinpoint regression analysis to evaluate trends in rates of eclampsia over the study period. We employed logistic regression models to examine the association between plurality and eclampsia after adjusting for socio-demographic and gestational factors. MAIN OUTCOME MEASURES: The primary outcome was eclampsia among singleton and multiple pregnancies. FINDINGS: There was a 2.8% (95% CI: -5.4, -0.1) average annual reduction in eclampsia rates among singletons, whereas among multiples there was a decline of about 3.7% (95% CI: -6.4, -1.0) annually. Mothers with multiple pregnancies had three-fold increased adjusted odds (OR = 95% CI: 2.95-3.21) of experiencing eclampsia when compared to those with singleton gestations. Non-Hispanic (NH) Black mothers with singletons had 37% greater adjusted odds of developing eclampsia than their NH-White peers (95%CI: 1.33-1.42). CONCLUSION: There was an overall decreasing trend in eclampsia incidence in the US from 1989 to 2018, regardless of plurality. The occurrence of eclampsia was associated with plurality, race/ethnicity, maternal age and maternal BMI. Given the heterogeneity in clinical presentations of eclampsia, personalized/standardized risk prediction models are needed to enable consistent diagnosis and timely intervention.

Neurovascular dysfunctions in hypertensive disorders of pregnancy.

Hypertensive disorders in pregnancy pose a huge challenge to the socioeconomic stability of a community; being a major cause of maternal and neonatal morbidity and mortality during delivery. Although there have been recent improvements in management strategies, still, the diversified nature of the underlying pathogenesis undermines their effectiveness. Generally, these disorders are categorized into two; hypertensive disorders of pregnancy with proteinuria (pre-eclampsia and eclampsia) and hypertensive disorders of pregnancy without proteinuria (gestational and chronic hypertension). Each of these conditions may present with unique characteristics that have interwoven symptoms. However, the tendency of occurrence heightens in the presence of any pre-existing life-threatening condition(s), environmental, and/or other genetic factors. Investigations into the cerebrovascular system demonstrate changes in the histoarchitectural organization of neurons, the proliferation of glial cells with an associated increase in inflammatory cytokines. These are oxidative stress indicators which impose a deteriorating impact on the structures that form the neurovascular unit and the blood-brain barrier (BBB). Such a pathologic state distorts the homeostatic supply of blood into the brain, and enhances the permeability of toxins/pathogens through a process called hyperperfusion at the BBB. Furthermore, a notable aspect of the pathogenesis of hypertensive disorders of pregnancy is endothelial dysfunction aggravated when signaling of the vasoprotective molecule, nitric oxide, amongst other neurotransmitter regulatory activities are impaired. This review aims to discuss the alterations in cerebrovascular regulation that determine the incidence of hypertension in pregnancy.

Assessment of Incidence and Factors Associated With Severe Maternal Morbidity After Delivery Discharge Among Women in the US.

Importance: Previous efforts to examine severe maternal morbidity (SMM) in the US have focused on delivery hospitalizations. Little is known about de novo SMM that occurs after delivery discharge. Objective: To investigate the incidence, timing, factors, and maternal characteristics associated with de novo SMM after delivery discharge among women in the US. Design, Setting, and Participants: In this retrospective cohort study, data from the IBM MarketScan Multi-State Medicaid database and the IBM MarketScan Commercial Claims and Encounters database were used to construct a sample of women aged 15 to 44 years who delivered between January 1, 2010, and September 30, 2014. Severe maternal morbidity was reported by the timing of diagnosis, and the associated maternal characteristics were examined. Women in the Medicaid and commercial insurance sample were classified into 3 distinct outcome groups: (1) those without any SMM during the delivery hospitalization and the postdelivery period (reference group), (2) those who exhibited at least 1 factor associated with SMM during the delivery hospitalization, and (3) those who exhibited any factor associated with de novo SMM after delivery discharge (defined as SMM that was first diagnosed in the inpatient setting during the 6 weeks [or 42 days] after discharge from the delivery hospitalization, conditional on no factor associated with SMM being identified during delivery). Data were analyzed from February to July 2020. Exposures: Timing of SMM diagnosis. Main Outcomes and Measures: Women with SMM were identified using diagnosis and procedure codes from the International Classification of Diseases, Ninth Revision, Clinical Modification for the 21 factors associated with SMM that were developed by the Centers for Disease Control and Prevention. Results: A total of 2 667 325 women in the US with delivery hospitalizations between 2010 and 2014 were identified; of those, 809 377 women (30.3%) had Medicaid insurance (30.3%; mean [SD] age, 25.6 [5.5] years; 51.1% White), and 1 857 948 women (69.7%; mean [SD] age, 30.6 [5.4] years; 36.4% from the southern region of the US) had commercial insurance. Among those with Medicaid insurance, 17 584 women (2.2%) experienced SMM during the delivery hospitalization, and 3265 women (0.4%) experienced de novo SMM after delivery discharge. Among those with commercial insurance, 32 079 women (1.7%) experienced SMM during the delivery hospitalization, and 5275 women (0.3%) experienced de novo SMM after hospital discharge. A total of 5275 SMM cases (14.1%) and 3265 SMM cases (15.7%) among women with commercial and Medicaid insurance, respectively, developed de novo within 6 weeks after hospital discharge; of those, 3993 cases (75.7%) in the commercial insurance cohort and 2399 cases (73.5%) in the Medicaid cohort were identified in the first 2 weeks after discharge. The most common factors associated with SMM varied based on the timing of diagnosis. In the Medicaid population, non-Hispanic Black women (adjusted odds ratio [aOR], 1.53; 95% CI, 1.48-1.58), Hispanic women (aOR, 1.46; 95% CI, 1.37-1.57), and women of other races or ethnicities (aOR, 1.40; 95% CI, 1.33-1.47) had higher rates of SMM during delivery hospitalization than non-Hispanic White women; however, only the disparity between Black and White women (aOR, 1.69; 95% CI, 1.57-1.81) persisted into the postdischarge period. Conclusions and Relevance: In this study, 15.7% of SMM cases in the Medicaid cohort and 14.1% of SMM cases in the commercial insurance cohort first occurred after the delivery hospitalization, with notable disparities in factors and maternal characteristics associated with the development of SMM. These findings suggest a need to expand the focus of SMM assessment to the postdelivery discharge period.

Is female genital mutilation associated with eclampsia? Evidence from a nationally representative survey data.

BACKGROUND: Studies have shown the impact of female genital mutilation (FGM), especially infibulation (WHO type III), on reproductive health, and adverse obstetric outcomes like postpartum haemorrhage and obstructed labour. However, whether an association exists with maternal hypertensive complication is not known. The present study sought to investigate the role of the different types of FGM on the occurrence of eclampsia. METHODS: The study used data from the 2006 Demographic and health survey of Mali. The proportion of eclampsia in women with each type of FGM and the unadjusted and adjusted odds ratios (OR) were calculated, using women without FGM as reference group. Unadjusted and adjusted OR were also calculated for women who underwent infibulation compared to the rest of the population under study (women without FGM and women with FGM type I, II, and IV). RESULTS: In the 3997 women included, the prevalence of infibulation was 10.2% (n = 407) while 331 women did not report FGM (8.3%). The proportion of women reporting signs and symptoms suggestive of eclampsia was 5.9% (n = 234). Compared with the absence of female genital mutilation and adjusted for covariates, infibulation was associated with eclampsia (aOR 2.5; 95% CI:1.4-4.6), while the association was not significant in women with other categories of FGM. A similar aOR was found when comparing women with infibulation with the pooled sample of women without FGM and women with the other forms of FGM. CONCLUSION: The present study suggests a possible association between infibulation and eclampsia. Future studies could investigate this association in other settings. If these findings are confirmed, the possible biological mechanisms and preventive strategies should be investigated.

Association of ATP2B1 gene polymorphism with incidence of eclampsia.

OBJECTIVE: The aim of this study was to analyze the association of ATPase plasma membrane Ca2+ transporting 1 (ATP2B1) gene polymorphism with the incidence of eclampsia, and to investigate the possible underlying mechanism. PATIENTS AND METHODS: ATP2B1 genotype and allele distributions in umbilical venous blood cells were analyzed in 50 control subjects and 117 eclampsia patients via Reverse Transcription-Polymerase Chain Reaction (RT-PCR) and TaqMan genotyping technique. Meanwhile, the differences in the single nucleotide polymorphisms at rs2681472 and rs17249754 in the case group and control group were analyzed using the χ2-test. The risk factors for eclampsia were analyzed via univariate, multivariate, and Logistic regression analyses. Furthermore, the associations of rs2681472 gene polymorphism with risk factors for eclampsia (hypertension and lower extremity edema) were verified via χ2-test. RESULTS: The statistically significant differences were observed in the gestational week, body mass index, blood pressure, and incidence rates of proteinuria and lower extremity edema of pregnant women between the case group and the control group (p<0.05). Meanwhile, the genotype and allele distributions at rs2681472 in the case group were remarkably different from those of the control group (p<0.05). However, no evident differences were observed at rs17249754 between the two groups (p>0.05). According to univariate, multivariate, and logistic regression analyses, hypertension, and lower extremity edema were significantly associated with the incidence of eclampsia (p<0.05). In addition, the gene polymorphism at rs2681472 showed significant differences among subjects with and without hypertension and lower extremity edema (p<0.05). CONCLUSIONS: ATP2B1 gene polymorphism at rs2681472 shows significant differences between eclampsia patients and normal controls. Moreover, its gene polymorphism is closely related to the occurrence of hypertension and lower extremity edema.

Neuropathological complications associated with hypertensive disorders of pregnancy.

Objective: Hypertensive disorders in pregnancy particularly severe preeclampsia and eclampsia result in significant maternal and neonatal morbidity and mortality. Many of these misfunctions can aggravate some of the neuropathological complications of hypertensive disorders during pregnancy. Method: In this review article, we described some of the neuropathological complications associated with hypertensive disorders of pregnancy. Results and conclusion: It is explained how the possible mechanism of neuropathological events triggers some of the complications associated with hypertensive disorders of pregnancy. Conclusion: A strong plea is made for the early detection of high blood pressure, its immediate control with rapid acting anti-hypertensive agents if necessary and timeous delivery of fetus as the exact pathogenesis of preeclampsia remains unknown.

Maternal and perinatal outcomes after caesarean delivery in early and late onset preeclampsia with HIV positive and HIV negative South African Women.

OBJECTIVE: We analyzed the maternal and perinatal outcomes in early onset preeclampsia (EOPE) and late onset preeclampsia (LOPE) pregnant women who had scheduled caesarean deliveries. We sub-analyzed the two categories into HIV positive and HIV negative. PATIENTS AND METHODS: This prospective study was conducted at a regional hospital in Durban, South Africa during 14 months. A total of 14304 deliveries were registered. Out of the 1759 preeclampsia, 351 (19.9%) were EOPE and 1408 (80.1%) were LOPE. Hundred and twenty preeclamptics (n = 120) scheduled for caesarean delivery were selected and divided into two categories namely EOPE (n = 60) and LOPE (n = 60). Each preeclampsia category was then further stratified into HIV positive (n = 30) and HIV negative (n = 30) groups. Maternal demographic, clinical details for preeclampsia, blood laboratory tests, maternal, and perinatal outcomes were recorded. RESULTS: Women with EOPE were older compared to those with LOPE (P = 0.0001). Also the HIV positive women were older compared to the HIV negative groups in both EOPE and LOPE categories (P = 0.03). However, multiparous and primiparous were predominant in EOPE and LOPE categories, respectively (P = 0.00 and P = 0.00). The severity of hypertension and the HIV status did not differentiate the 2 groups. Overall, maternal complications (eclampsia, persistent postpartum hypertension, HELLP syndrome, maternal death) and poor fetal outcomes occurred predominately in EOPE. CONCLUSION: This study confirms the heterogeneity of preeclampsia and shows that the timing of onset of this pregnancy disorder is important to disease severity. Further HIV status influences maternal and neonatal outcome.

Dietary patterns before and during pregnancy and maternal outcomes: a systematic review.

BACKGROUND: Hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) are common maternal complications during pregnancy, with short- and long-term sequelae for both mothers and children. OBJECTIVE: Two systematic review questions were used to examine the relation between 1) dietary patterns before and during pregnancy, 2) HDP, and 3) GDM. METHODS: A search was conducted from January 1980 to January 2017 in 9 databases including PubMed, Embase, and Cochrane. Two analysts independently screened articles using a priori inclusion and exclusion criteria; data were extracted from included articles, and risk of bias was assessed. After qualitative synthesis, a conclusion statement was drafted for each question and the evidence supporting the conclusion was graded. RESULTS: Of the 9103 studies identified, 8 [representing 4 cohorts and 1 randomized controlled trial (RCT)] were included for HDP and 11 (representing 6 cohorts and 1 RCT) for GDM. Limited evidence in healthy Caucasian women with access to health care suggests dietary patterns before and during pregnancy that are higher in vegetables, fruits, whole grains, nuts, legumes, fish, and vegetable oils and lower in meat and refined grains are associated with reduced risk of HDP, including preeclampsia and gestational hypertension. Limited but consistent evidence suggests certain dietary patterns before pregnancy are associated with reduced risk of GDM. These protective dietary patterns are higher in vegetables, fruits, whole grains, nuts, legumes, and fish and lower in red and processed meats. Most of the research was conducted in healthy, Caucasian women with access to health care. Insufficient evidence exists on the associations between dietary patterns before and during pregnancy and risk of HDP in minority women and those of lower socioeconomic status, and dietary patterns during pregnancy and risk of GDM. CONCLUSIONS: Although some conclusions were drawn from these systematic reviews, more research is needed to address gaps and limitations in the evidence.

Increased proteinuria and uric acid levels are associated with eclamptic crisis.

OBJECTIVES: Eclampsia results in high morbidity and mortality, so it is important to identify clinical and laboratorial aspects that may be useful as potential markers to differentiate women at higher risk. Thus, we aim to identify, among women with preeclampsia, aspects that may increase the risk to develop eclampsia. STUDY DESIGN: Retrospective cohort study. The records of patients delivered at Hospital São Lucas/PUCRS were reviewed retrospectively; 733 pregnant women with hypertension were analyzed; 329 had preeclampsia, and 45 eclampsia. MAIN OUTCOME MEASURES: Serum uric acid levels and protein excretion in women that develop eclampsia. RESULTS: Patients with eclampsia had higher serum uric acid levels and protein excretion, systolic and diastolic blood pressure; were more likely to have cesarean section and had worst perinatal outcomes. The combination of uric acid above 5.9 mg/dL and protein/creatinine ratio over 4.9 had a striking association with eclampsia (p ≤ 0.001). The occurrence of HELLP syndrome was significantly different between groups, with a higher incidence among women who developed eclampsia (OR 6.5; 95%CI, 3.2-13.2; p < 0.001). CONCLUSION: Our data suggest that the combination of high levels of maternal serum uric acid and proteinuria are strongly associated with the development of eclamptic crises.

Maternal and perinatal outcomes in pregnant women with BMI >50: An international collaborative study.

OBJECTIVE: To examine the association between maternal BMI>50kg/m2 during pregnancy and maternal and perinatal outcomes. MATERIALS AND METHODS: An international cohort study was conducted using data from separate national studies in the UK and Australia. Outcomes of pregnant women with BMI>50 were compared to those of pregnant women with BMI<50. Multivariable logistic regression estimated the association between BMI>50 and perinatal and maternal outcomes. RESULTS: 932 pregnant women with BMI>50 were compared with 1232 pregnant women with BMI<50. Pregnant women with BMI>50 were slightly older, more likely to be multiparous, and have pre-existing comorbidities. There were no maternal deaths, however, extremely obese women had a nine-fold increase in the odds of thrombotic events compared to those with a BMI<50 (uOR: 9.39 (95%CI:1.15-76.43)). After adjustment, a BMI>50 during pregnancy had significantly raised odds of preeclampsia/eclampsia (aOR:4.88(95%CI: 3.11-7.65)), caesarean delivery (aOR: 2.77 (95%CI: 2.31-3.32)), induction of labour (aOR: 2.45(95% CI:2.00-2.99)) post caesarean wound infection (aOR:7.25(95%CI: 3.28-16.07)), macrosomia (aOR: 8.05(95%CI: 4.70-13.78)) compared a BMI<50. Twelve of the infants born to women in the extremely obese cohort died in the early neonatal period or were stillborn. CONCLUSIONS: Pregnant women with BMI>50 have a high risk of inferior maternal and perinatal outcomes.

Risk of eclampsia or HELLP-syndrome by institution availability and place of delivery - A population-based cohort study.

OBJECTIVE: To examine the association between availability of obstetric institutions and risk of eclampsia, HELLP-syndrome, or delivery before 35 gestational weeks in preeclamptic pregnancies. STUDY DESIGN: National population-based retrospective cohort study of deliveries in Norway, 1999-2009 (n = 636738) using data from The Medical Birth Registry of Norway and Statistics Norway. Main exposures were institution availability, measured by travel time to the nearest obstetric institution, and place of delivery. We computed relative risks (RR) with 95% confidence intervals (CI) using travel time ≤1 h as reference. We stratified analyses by parity and preeclampsia, and adjusted for socio-demographic and medical risk factors. Successive deliveries were linked using the national identification number. RESULTS: We identified 1387 eclampsia/HELLP cases (0.2%) and 3004 (0.5%) deliveries before 35 weeks in preeclamptic pregnancies. Nulliparous women living >1 h from any obstetric institution had 50% increased risk of eclampsia/HELLP (0.50 versus 0.35%, adjusted RR 1.5; 95 %CI 1.1-1.9). Parous women living >1 h from emergency institutions had a doubled risk of eclampsia (0.6‰ versus 0.3‰, adjusted RR 2.0; 1.2-3.3). Women without preeclampsia in the present pregnancy or history of preeclampsia constituted all eclampsia/HELLP cases in midwife-led institutions, 39-50% of cases in emergency institutions, and 78% of cases (135/173) in subsequent deliveries. Women with risk factors delivered in the emergency institutions, indicating well-implemented selective referral. CONCLUSION: The study shows the importance of available obstetric institutions. Policymakers and clinicians should consider the distribution of potential benefits and burdens when planning and evaluating the obstetric health service structure.

Hypertensive Disorders in Pregnancy.

Hypertensive disorders of pregnancy are a heterogeneous group of conditions that include chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. These disorders account for a significant proportion of perinatal morbidity and mortality nearly 10% of all maternal deaths in the United States. Given the substantial health burden of hypertensive disorders in pregnancy, there is increasing interest in optimizing management of these conditions. This article summarizes the diagnosis and management of each of the disorders in the spectrum of hypertension in pregnancy and highlights recent updates in the field.

[HYPERTENSION OF PREGNANCY ASSOCIATED WITH HYPERGOMOCYSTEINEMIA OF THE FIRST TRIMESTER OF PREGNANCY].

In this study, the association of high homocysteine concentrations (>10 µmol/L) of pregnant women with hypertensive disorders during pregnancy was studied, as well as other complications of pregnancy, such as loss of pregnancy in the first half, premature birth, intrauterine growth retardation, congenital malformations development of the fetus. A single-center prospective cohort study was conducted. Depending on the concentration of homocysteine detected by the immunoenzyme assay with monoclonal antibodies Homocysteine EIA ELISA (Axis-Shield Diagnostics Ltd, Scotland), for a period of up to 14 weeks, the subjects were divided into 2 groups: with high concentrations (>10 µmol/L) and normal levels (<10 µmol/L). We controlled complications of pregnancy: loss of pregnancy in the first half, premature birth, delayed fetal growth, congenital malformations of the fetus, gestational hypertension, mild and severe preeclampsia, eclampsia and HELLP syndrome. The results of the study showed that at a level of homocysteine I trimester >10 µmol/l spontaneous abortion, premature birth, gestational hypertension, mild preeclampsia develop more often. There were no differences in the groups for delaying intrauterine growth of the fetus, congenital malformations, severe preeclampsia.

Predictors of oedema type in reversible posterior leukoencephalopathy syndrome with preeclampsia or eclampsia.

OBJECTIVE: To explore the predictive factors of oedema types in reversible posterior leukoencephalopathy syndrome (RPLS) with preeclampsia (PE) and eclampsia, which is closely related to reversible lesions and clinical recovery. METHOD: We collected data from 44 consecutive patients diagnosed with RPLS in PE or eclampsia between 2013 and 2017. All patients were classified into vasogenic oedema (n = 31) or cytotoxic oedema (n = 13) groups according to magnetic resonance imaging (MRI) results. General information, clinical data, biochemical indicators and imaging features were collected retrospectively to explore the differences between the groups. Furthermore, we analysed potential predictive factors by logistic regression. RESULTS: The occurrence rates of immune disease and stillbirth, hospitalization time and the levels of serum albumin (ALB), lactate dehydrogenase (LDH), aspartate transaminase (AST) and alanine aminotransferase (ALT) were higher, while the values of systolic blood pressure (SBP), mean arterial pressure (MAP) and 24-h urine protein were lower in the cytotoxic oedema patients than those in the vasogenic oedema patients (p < .05). The ALB concentration was closely correlated with vasogenic oedema, while AST and ALT were closely correlated with cytotoxic oedema by logistic regression (p < .05). CONCLUSION: The levels of ALB, AST and ALT are potential predictors for the development of oedema in RPLS. ALB is related to vasogenic oedema by a possible mechanism of decreased colloid osmotic pressure, while AST and ALT are related to cytotoxic oedema by a possible mechanism of endothelial dysfunction.

Peripapillary retinal nerve fiber layer thickness in preeclampsia and eclampsia.

PURPOSE: To evaluate peripapillary retinal nerve fiber layer (RNFL) thickness during and after pregnancy in pregnant women with preeclampsia or eclampsia and compare it with normotensive pregnant women as controls. METHODS: In a prospective comparative case-control study 35 women (70 eyes) with mild to moderate preeclampsia, 70 women (140 eyes) with severe preeclampsia and eclampsia, and 44 (88 eyes) healthy pregnant women were enrolled in three groups. Peripapillary RNFL thickness in three groups was measured after 28 weeks of pregnancy and 2 months postpartum by using optical coherence tomography. Mean and quadratic RNFL thickness changes were compared within and among the groups. RESULTS: Mean peripapillary RNFL thickness decreased significantly from 104 ± 10, 104 ± 23, and 106 ± 9 µm during pregnancy to 101 ± 10, 96 ± 10, and 103 ± 9 µm 2 months after pregnancy in the mild to moderate preeclampsia, severe preeclampsia and eclampsia, and healthy pregnant women groups, respectively (P < 0.001 for all). While the difference among the groups was insignificant during pregnancy, it reached to a significant level after delivery (P = 0.006). The highest reduction in mean RNFL thickness (6 ± 10 µm) occurred in the severe preeclampsia and eclampsia groups. CONCLUSIONS: In relation to the time of pregnancy, peripapillary RNFL reduced in preeclamptic and eclamptic cases as well as in normotensive pregnant women at 2 months postpartum. This reduction was more in the severe forms of pregnancy-induced hypertension.