THE INAPRES (Indonesia Preeclampsia Study): impact of eclampsia on maternal and perinatal outcomes among women with preeclampsia: findings from a National Multicenter Cohort

The study was undertaken to determine the correlation of serum LDH in pre eclampsia and eclampsia and perinatal outcome. This is a hospital based comparative case control study done in Department of Obstetrics & Gynaecology SMS Medical College, Jaipur between March 2014 to Oct 2015 on 140 subjects including normotensive , mild pre eclamptic , severe pre eclamptic and eclamptic pregnant women after 28 weeks of gestation before termination of pregnancy. Serum LDH levels were recorded and perinatal outcomes observed. The mean value of serum LDH in control group was 391.4 ± 10.9 IU/L, in mild pre eclampsia 531.5 ± 24.5 IU/L, in severe preeclampsia 922.1± 515.5 IU/L and in eclampsia 1497.6 ± 602.1 IU/L. The difference in serum LDH level was highly significant (P<0.001).Higher LDH levels were associated with High Blood Pressure and had significant correlation with poor perinatal outcome. Thus we conclude that High serum LDH levels correlate well with poor maternal and perinatal outcomes in patients of Preeclampsia and Eclampsia.

BackgroundObservational studies have demonstrated various correlations between hypertensive disorders of pregnancy and different weather parameters. We aim to study if a correlation exists between the incidence of eclampsia and pre-eclampsia and various weather parameters in the tropical coastal city of Mumbai which has the distinction of having relatively uniform meteorological variables all throughout the year, except for the monsoon season.MethodsWe retrospectively analysed data from a large maternity centre in Mumbai, India over a period of 36 months from March 1993 to February 1996, recording the incidence of preeclampsia and eclampsia. Meteorological data was acquired from the regional meteorological centre recording the monthly average temperature, humidity, barometric pressure and rainfall during the study period. Study period was then divided into two climate conditions: monsoon season (June to August) and dry season September to May. The incidence of preeclampsia and eclampsia and the meteorological differences between the two seasons were compared.ResultsOver a 36-month period, a total of 29562 deliveries were recorded, of which 1238 patients developed preeclampsia (4.18%) and 34 developed eclampsia (0.11%). The incidence of preeclampsia did not differ between the monsoon and the dry season (4.3% vs. 4.15%, p = 0.5). The incidence of eclampsia was significantly higher in the monsoon (0.2% vs. 0.08%, p = 0.01). The monsoon was significantly cooler (median maximum temperature 30.7°C vs. 32.3°C, p = 0.01), more humid (median relative humidity 85% vs. 70%, p = 0.0008), and received higher rainfall (median 504.9 mm vs. 0.3 mm, p = 0.0002) than the rest of the year. The median barometric pressure (1005 mb) during the monsoon season was significantly lower than the rest of the year (1012 mb, p < 0.0001).ConclusionIn the tropical climate of Mumbai, the incidence of eclampsia is significantly higher in monsoon, when the weather is cooler and humid with a lower barometric pressure than the rest of the year. This effect is not seen with preeclampsia. This strengthens the association of low temperature and high humidity with triggering of eclampsia.

Maternal hemoglobin is very important for maternal and perinatal outcomes. Due to the pathophysiological changes in patients with preeclampsia, the influence of hemoglobin on pregnancy outcomes may differ from that in normal pregnant women. Therefore, this retrospective study aimed to evaluate the relationships between maternal hemoglobin levels and adverse maternal and perinatal outcomes in patients with preeclampsia. All clinical data were retrospectively collected from the medical records of a tertiary obstetrics and gynecology hospital in China. This study evaluated the incidence of adverse maternal and perinatal outcomes in patients with preeclampsia with different hemoglobin levels at admission. The odds ratios and 95% confidence intervals for adverse pregnancy outcomes in patients with preeclampsia with anemia and high hemoglobin levels were estimated, with the normal hemoglobin level serving as the control. A total of 1,715 patients with preeclampsia with singleton pregnancies were included in this retrospective study. Compared with patients with preeclampsia with normal hemoglobin levels, patients with anemia at admission had a greater risk for postpartum hemorrhage (OR: 3.800; 95% CI: 1.677-8.610) and cardiac dysfunction (OR: 2.860; 95% CI: 0.979-8.356). Moreover, patients with high hemoglobin levels at admission had increased risks of HELLP syndrome (OR: 2.503; 95% CI: 1.198-5.229), SGA (OR: 1.343; 95% CI: 0.997-1.808), neonatal asphyxia (OR: 2.046; 95% CI: 1.107-3.784) and NICU admission (OR: 1.359; 95% CI: 1.060-1.742). However, not all abnormal hemoglobin levels were associated with an increased risk of adverse pregnancy outcomes. Patients with preeclampsia with anemia had a lower risk of adverse perinatal outcomes, including SGA (OR: 0.731; 95% CI: 0.517-1.032) and NICU admission (OR: 0.737; 95% CI: 0.567-0.960). This study revealed that both anemia and high hemoglobin levels at admission were related to adverse maternal and perinatal outcomes in patients with preeclampsia. The effects of hemoglobin on adverse maternal and perinatal outcomes in patients with preeclampsia may differ from those in normal pregnant women.

BackgroundMaternal hemoglobin is very important for maternal and perinatal outcomes. Due to the pathophysiological changes in patients with preeclampsia, the influence of hemoglobin on pregnancy outcomes may differ from that in normal pregnant women. Therefore, this retrospective study aimed to evaluate the relationships between maternal hemoglobin levels and adverse maternal and perinatal outcomes in patients with preeclampsia.MethodsAll clinical data were retrospectively collected from the medical records of a tertiary obstetrics and gynecology hospital in China. This study evaluated the incidence of adverse maternal and perinatal outcomes in patients with preeclampsia with different hemoglobin levels at admission. The odds ratios and 95% confidence intervals for adverse pregnancy outcomes in patients with preeclampsia with anemia and high hemoglobin levels were estimated, with the normal hemoglobin level serving as the control.ResultsA total of 1,715 patients with preeclampsia with singleton pregnancies were included in this retrospective study. Compared with patients with preeclampsia with normal hemoglobin levels, patients with anemia at admission had a greater risk for postpartum hemorrhage (OR: 3.800; 95% CI: 1.677–8.610) and cardiac dysfunction (OR: 2.860; 95% CI: 0.979–8.356). Moreover, patients with high hemoglobin levels at admission had increased risks of HELLP syndrome (OR: 2.503; 95% CI: 1.198–5.229), SGA (OR: 1.343; 95% CI: 0.997–1.808), neonatal asphyxia (OR: 2.046; 95% CI: 1.107–3.784) and NICU admission (OR: 1.359; 95% CI: 1.060–1.742). However, not all abnormal hemoglobin levels were associated with an increased risk of adverse pregnancy outcomes. Patients with preeclampsia with anemia had a lower risk of adverse perinatal outcomes, including SGA (OR: 0.731; 95% CI: 0.517–1.032) and NICU admission (OR: 0.737; 95% CI: 0.567–0.960).ConclusionThis study revealed that both anemia and high hemoglobin levels at admission were related to adverse maternal and perinatal outcomes in patients with preeclampsia. The effects of hemoglobin on adverse maternal and perinatal outcomes in patients with preeclampsia may differ from those in normal pregnant women.

The aim of this study was to evaluate the relationship between serum beta-human chorionic gonadotropin (β-hCG) and preeclampsia (PE) and the effects of βhCG on maternal and perinatal outcomes. This case-control study included 125 pregnant women who were admitted to the labor ward of the Maternity Teaching Hospital, Erbil City, Kurdistan, Iraq between January and December 2016. Participants included 50 women with severe PE, 25 with mild PE, and 50 who were normotensive. Serum β-hCG concentrations during labor were compared between groups and maternal and perinatal outcomes were recorded. There were no significant differences in maternal age or parity distribution between the three groups. Gestational age was less than 37weeks in 34% of the women with severe PE and in 12% of women in the mild PE and normotensive groups (p = 0.012). Mean β-hCG concentration was 37,520.56 mIU/mL in women with severe PE, 16,487 mIU/mL in those with mild PE, and 11,699.82 mIU/mL in those who were normotensive (p < 0.001). There were no significant differences in perinatal outcomes between groups; however, those with β-hCG concentrations ≥ 40,000 mIU/mL had worse neonatal outcomes (lower Apgar scores, higher rate of NICU admission, and lower survival rate) and unfavorable maternal outcomes (seizures, abruption, post-partum hemorrhage, and deep vein thrombosis). There was a significant difference in β-hCG concentrations between women with PE and normotensive women. There were no significant differences in perinatal or maternal outcomes between groups, except in patients with β-hCG ≥ 40,000 mIU/mL.

Objective: The present study aimed to investigate perinatal outcomes and to describe antenatal factors for development of preeclampsia (PE) in patients with isolated proteinuria in pregnancy. Methods: This retrospective case control study consisted of patients with isolated proteinuria between 2009 and 2014. The patients were considered as gestational proteinuria (GP) (group 1, n: 35) if they remain normotensive. Patients who develop PE after onset of proteinuria were allocated into group 2 (n: 19). Perinatal outcomes of patients in each group were compared. Logistic regression analysis was performed to detect antenatal risk factors for PE. Results: The rate of small for gestational age (SGA) fetuses was higher in patients with isolated proteinuria than control group. In the logistic regression model, maternal age and completed gestational weeks at onset of proteinuria decreased the risk of PE in multivariate analysis (OR: 0.849 (95% CI: 0.731–0.986), OR: 0.732 (95% CI: 0.594–0.902) respectively). Systolic BP at onset of proteinuria, however, was associated with an independently increased risk of PE (OR: 1.181 (95% CI: 1.046–1.333)). Conclusion: Maternal clinical characteristics, but not laboratory features may help to predict development of PE.

To determine the rate of placental apoptosis and adverse perinatal outcome in patients with late-onset pre-eclampsia (PE) and abnormal uterine artery (UtA) Doppler at diagnosis. This was a prospective cohort study of women with singleton pregnancy diagnosed with late PE, performed between August 2011 and January 2014 at the Maternal-Fetal Medicine Unit of Hospital Carlos Van Buren. Patients were stratified according to UtA Doppler status at diagnosis (pulsatility index (PI) ≤ or > 95th percentile). Logistic regression analysis was performed to identify associations between abnormal UtA Doppler and adverse maternal and perinatal outcomes. In a subset of this cohort for whom placental samples were available, immunohistochemical analysis of the placenta was performed to identify the rate of apoptosis and its association with UtA Doppler by comparing samples from those with normal and those with abnormal UtA Doppler and normotensive controls. Non-parametric linear trend analysis was performed for assessment of the apoptotic index. Eighty-six patients were included in the final analysis. Of these, UtA-PI was above the 95th percentile in 33 (38.4%) patients. Gestational age at diagnosis and delivery were significantly lower in this group compared with patients with normal UtA Doppler. Abnormal UtA Doppler was associated with increased risk of severe PE (odds ratio (OR) = 7.5; 95% CI, 2.76-20.46; P < 0.001), late preterm delivery (OR = 13.7; 95% CI, 4.53-41.46; P < 0.001), small-for-gestational age at birth (OR = 12.3; 95% CI, 3.17-47.57; P < 0.001) and admission to the neonatal intensive care unit (OR = 12.8; 95% CI, 2.61-62.36; P = 0.002). Moreover, UtA Z-score demonstrated a significant inverse correlation with birth-weight Z-score (r = -0.34; P = 0.0013). Mean placental apoptotic index demonstrated an ascending linear trend according to UtA Doppler status (P = 0.04). In patients with late PE, UtA Doppler was useful for clinical classification and as an indicator of placental histological findings. Correlation between UtA Doppler and the apoptotic index provides new evidence of a subgroup of late PE with a placental origin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

To determine the association between soluble FMS-like tyrosine kinase-1 (sFlt-1) and high-sensitivity C-reactive protein (hs-CRP) with maternal and perinatal outcomes in patients with preeclampsia (PE) with severe features.A cohort study was conducted on 100 patients, 60 with PE with severe features, and 40 healthy women in the third trimester of pregnancy. Admission serum levels of sFlt-1 and hs-CRP and clinical and epidemiological parameters were evaluated to quantify the predictive ability of adverse maternal and perinatal outcomes using hierarchical multiple regression and receiver operating characteristic curves.Compared to controls, patients with PE and severe features had significantly higher levels of sFlt-1 but not hs-CRP. sFlt-1 and hs-CRP proved to be reasonable parameters for the prediction of composite adverse maternal outcomes. However, we found no correlation between these 2 biomarkers. PE integrated estimate of risk scores were correlated only with sFlt-1 levels. Regarding fetal outcomes, unlike hs-CRP, sFlt-1 was strongly associated with birth weight and Apgar score < 7 at 5 minutes. Following multivariate analysis, maternal age, previous hypertension, sFlt-1, and hs-CRP levels remained independently associated with composite adverse maternal outcomes.sFlt-1 levels were elevated in patients with PE and severe features. Both sFlt-1 and hs-CRP may predict composite adverse maternal outcomes but do not correlate with each other and differ in perinatal morbidity patterns. These data support the hypothesis that the varied outcomes in PE may result from different pathogenic pathways.

Evaluation and management of severe preeclampsia before 34 weeks' gestation

BackgroundOne of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each female having eclampsia and to evaluate the factors that govern the outcomes in females with eclampsia.AimTo decode the fetal and maternal outcomes in subjects having eclampsia and to evaluate various factors that govern the outcomes.MethodsThis retrospective cohort and epidemiological study commenced at the Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, in January 2016 till April 2017, and included females that either developed eclampsia in hospital stay duration or presented with pre-existing eclampsia. In included females, various fetal and maternal parameters were assessed along with the outcome of pregnancy. The institutional data records and the database were also used to determine the prevalence and incidence of eclampsia. Baseline maternal parameters were recorded from the already-existing institute data. These included the gestational age (in years), socioeconomic status, educational attainment, parity, gravidity, and the number of weeks of gestation present at the time of delivery. Antenatal care data assessed were blood pressure recordings, any proteinuria documented in the data, and the number of antenatal visits by the subjects. Statistical analysis was performed to assess both parameters.Results In the current investigation, there were 0.34% eclampsia cases among females visiting the institution for deliveries. Incidences of stillbirth were seen in 19.04% and 8% of study participants, respectively. We found 9.52% (n=4) of female infants to have perished from eclampsia. Preterm births, a delayed start to the treatment, and insufficient care were all linked to poor foetal and mother outcomes. The longer the period between the beginning of a fit and delivery, the greater the likelihood of unfavourable results. Seizure onset before or after birth, parity, or subject age had no impact on mother or foetal health. The p-value for statistical significance was kept at 0.05.ConclusionMost of the research participant women, had intrapartum eclampsia, postpartum eclampsia, and antepartum eclampsia, based on the time of the convulsions in relation to the labor. It was highlighted that there was no conclusive evidence linking the date of the fit's beginning to unfavourable results or an elevated risk of complications. Neonatal mortality and stillbirth were observed with vaginal delivery in eclampsia cases. Outcomes in eclampsia can be improved by early treatment initiation, timely and appropriate referral, early disease recognition, and appropriate antenatal care.

Background: Preeclampsia is a condition characterized by new-onset hypertension during pregnancy, which can lead to various complications for both the mother and baby. It is categorized into early-onset preeclampsia (EO-PE) and late-onset preeclampsia (LO-PE) based on the timing of onset, each having distinct pathophysiologies and complications. Objective: This study aims to evaluate maternal and perinatal outcomes in patients with early and late-onset severe preeclampsia. Methods: An analytic observational study with a cross-sectional design was conducted at a secondary healthcare facility. The study included 554 women with severe preeclampsia who delivered at the facility, categorized into EO-PE and LO-PE groups. Maternal characteristics and outcomes, as well as perinatal outcomes, were analyzed. Results: Out of the total cases, 40 (7.22%) were EO-PE and 514 (92.78%) were LO-PE. Maternal outcomes such as HELLP syndrome, visual impairment, placental abruption, oliguria, ICU admission, and eclampsia were significantly higher in the EO-PE group. Additionally, perinatal outcomes including birth weight and APGAR scores were notably worse in the EO-PE group. Conclusion: Adverse maternal and perinatal outcomes were significantly more prevalent in early-onset preeclampsia compared to late-onset preeclampsia.

Objective: Pre-eclampsia (PE) complicated by fetal growth restriction (FGR) increases both perinatal mortality and the incidence of preterm birth and neonatal asphyxia. Because ultrasound measurements are bone markers, soft tissues, such as fetal fat and muscle, are ignored, and the selection of section surface and the influence of fetal position can lead to estimation errors. The early detection of FGR is not easy, resulting in a relative delay in intervention. It is assumed that FGR complicated with PE can be predicted by laboratory and clinical indicators. The present study adopts an artificial neural network (ANN) to assess the effect and predictive value of changes in maternal peripheral blood parameters and clinical indicators on the perinatal outcomes in patients with PE complicated by FGR.Methods: This study used a retrospective case-control approach. The correlation between maternal peripheral blood parameters and perinatal outcomes in pregnant patients with PE complicated by FGR was retrospectively analyzed, and an ANN was constructed to assess the value of the changes in maternal blood parameters in predicting the occurrence of PE complicated by FGR and adverse perinatal outcomes.Results: A total of 15 factors—maternal age, pre-pregnancy body mass index, inflammatory markers (neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio), coagulation parameters (prothrombin time and thrombin time), lipid parameters (high-density lipoprotein, low-density lipoprotein, and triglyceride counts), platelet parameters (mean platelet volume and plateletcrit), uric acid, lactate dehydrogenase, and total bile acids—were correlated with PE complicated by FGR. A total of six ANNs were constructed with the adoption of these parameters. The accuracy, sensitivity, and specificity of predicting the occurrence of the following diseases and adverse outcomes were respectively as follows: 84.3%, 97.7%, and 78% for PE complicated by FGR; 76.3%, 97.3%, and 68% for provider-initiated preterm births,; 81.9%, 97.2%, and 51% for predicting the severity of FGR; 80.3%, 92.9%, and 79% for premature rupture of membranes; 80.1%, 92.3%, and 79% for postpartum hemorrhage; and 77.6%, 92.3%, and 76% for fetal distress.Conclusion: An ANN model based on maternal peripheral blood parameters has a good predictive value for the occurrence of PE complicated by FGR and its adverse perinatal outcomes, such as the severity of FGR and preterm births in these patients.

Trends in the incidence of pre-eclampsia and eclampsia in Taiwan between 1998 and 2010

Background: To determine the perinatal outcome in patients attending Joint obstetric and diabetic clinic who had diabetes and one previous caesarean section.Methods: A prospective service evaluation was conducted in a secondary care hospital having approximately 5100 deliveries per year. The combined cesarean section rate during the study period for all pregnant women and for all diabetic patients were 31% and 60%, respectively. Patients attending joint obstetric diabetic clinic from July 2015 to July 2016 were considered for the study. Fifty five (55) patients with both pregestational diabetes and gestational diabetes requiring pharmacotherapy and one previous caesarean, out of 358 patients who attended the clinic, were identified. The perinatal care, including timing, mode of delivery and indication for Cesarean section, maternal and neonatal outcomes were studied.Results: Out of 55 women, 8 (15%) had type 2 diabetes mellitus and 47 (85%) had gestational diabetes mellitus requiring pharmacotherapy. Initially, during antenatal follow up, 23 women (41%) were planned for vaginal birth after caesarean and 32(59%) were planned for elective cesarean section. Seven (7) women (13%) had a successful vaginal birth after cesarean section. These women had no additional risk factors and delivery was uneventful. Forty eight (48) women (87%) had cesarean section (elective, 60% and emergency, 27%). Eleven (75%) out of these 15 emergency cesarean section patients had additional risk factors that contributed to the decision for cesarean section. Most of the maternal complications 13/55 (23%) were in the cesarean section group and the majority were from emergency cesarean section group. Fifteen out of the fifty five cases (27%) were due to intra-uterine growth restriction, preeclampsia, eclampsia, abruption and postpartum hemorrhage. Similarly in all neonatal complications 14/55 (25%) were from the Cesarean section group (2 cases of small for gestational age, 6 cases of respiratory distress syndrome, 6 cases of Large for date). Among the 8 type 2 diabetes mellitus patients, 7 delivered by Cesarean section (4 emergencies and 3 elective) and only one had a successful vaginal birth after cesarean section. All 4 of the emergency Cesarean cases had additional risk factors.Conclusion: We found an exceptionally high caesarean section rate of 87% in our study which is almost twice as high as was found in the general diabetic pregnant population from other studies. Our study is the first of its kind to determine the cesarean section rate and perinatal outcome in combined pregestational and gestational diabetic patients requiring medical treatment and with one prior cesarean section. This study highlights the need for multi-centered studies to determine the optimal cesarean section rate that affords the lowest perinatal and maternal morbidity and mortality and also on how to modify these confounding factors so as to decrease the high caesarean section rate amongst this high risk group of patients.

To examine the association between pre-pregnancy BMI and severe maternal morbidity (SMM), perinatal death and severe neonatal morbidity in twin pregnancies. All twin births at ≥ 20 weeks gestation in British Columbia, Canada, from 2000 to 2017 were included. We estimated rates of SMM, a perinatal composite of death and severe morbidity, and its components per 10,000 pregnancies. Confounder-adjusted rate ratios (aRR) between pre-pregnancy BMI and outcomes were estimated using robust Poisson regression. Overall, 7770 (368 underweight, 1704 overweight, and 1016 obese) women with twin pregnancy were included. The rates of SMM were: 271.1, 320.4, 270.0, and 225.9 in underweight, normal BMI, overweight and obese women, respectively. There was little association between obesity and any of the primary outcomes (e.g., aRR = 1.09, 95% CI = 0.85, 1.38 for composite perinatal outcome). Underweight women had higher rates of the composite perinatal adverse outcome (aRR = 1.79, 95% CI = 1.32-2.43), driven by increased rates of severe respiratory distress syndrome, and neonatal death. There was no evidence of elevated risk of adverse outcomes among twin pregnancies of women who were overweight or obese. Risk was higher in underweight women, who may require specific care when carrying twins.