Fetal Adverse Events Research Articles

Changes in the Intra-Amniotic Pressure following Transabdominal Amnioinfusion during Pregnancy

Objective: The aim of the article was to investigate the changes in intra-amniotic pressure following transabdominal amnioinfusion during pregnancy. Design: This retrospective study included 19 pregnant women who underwent transabdominal amnioinfusion during pregnancy to relieve umbilical cord compression and improve the intrauterine environment or to increase the accuracy of ultrasonography. Materials and Methods: We measured and analyzed the changes in intra-amniotic pressure, single deepest pocket, and the amniotic fluid index before and after amnioinfusion. We also determined the incidence of maternal or fetal adverse events, such as preterm premature rupture of membranes, preterm delivery, fetal death within 48 h, placental abruption, infection, hemorrhage, and peripheral organ injury. Results: A total of 41 amnioinfusion procedures were performed for 19 patients. The median gestational age during the procedure was 24.3 weeks. The median volume of the injected amniotic fluid was 250 mL. The median single deepest pocket and amniotic fluid index after amnioinfusion were significantly higher than those before amnioinfusion (4.0 cm vs. 2.65 cm; p < 0.001 and 13.4 cm vs. 6.0 cm; p < 0.001). However, the median (range) intra-amniotic pressure after amnioinfusion was not significantly different compared to that before amnioinfusion (11 mm Hg vs. 11 mm Hg; p = 0.134). Maternal or fetal adverse events were not observed following amnioinfusion. Conclusion: Intra-amniotic pressure remained unchanged following amnioinfusion. The complications associated with increased intra-amniotic pressure are not likely to develop if the amniotic fluid index and/or single deepest pocket remains within the normal range after amnioinfusion. Studies of groups with and without complications are warranted to clarify the relationship between the intra-amniotic pressure and incidence of complications.

Female Fertility Clock Closes to Tick around the Age of 43

Objective: To investigate if attempting In Vitro Fertilization (IVF) in women over 40 is of worth. Materials & Methods: Two hundred and thirty nine women over 40 years of age undergoing IVF were enrolled. Long protocol was used for downregulation followed by stimulation and IVF-ET. The primary outcome measure was live-birth rate. Secondary outcomes included rates of miscarriage, cycle cancellation, obstetrical complications, and maternal and fetal adverse events. Results: Clinical pregnancy rates per cycle were 42.85 %, 39.34 %, 34.09 %, 27.27 % and 16.66 % for 40, 41, 42, 43 and 44 years old, respectively. Absolute difference in live birth rate in age 40 - 44 vs control, -15 percentage points; 95 % Confidence Interval (CI) -45 to 15.1, -18.77 percentage points; 95 % CI,(-56.31 to 18.79), -23.77 percentage points; 95 % CI,(-71.31 to 23.81), -25.82 percentage points; 95 % CI, (-77.48 to 25.84) and, - 27.72 percentage points; 95 % CI, (-83.16 to 27.76), respectively. Intra-uterine growth restriction and preterm delivery occurred significantly more frequently in the age group of 42 and above. Only one IVF cycle in patients aged 44 resulted in delivery. Conclusion: It appears that IVF treatment should be limited to patients not older than 43 years, with adequate ovarian response.

Regional tissue oxygen saturation as a predictor of post-spinal anesthesia hypotension for cesarean delivery.

Regional tissue oxygen saturation as a predictor of post-spinal anesthesia hypotension for cesarean delivery.

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

A literature review and best practice advice for second and third trimester risk stratification, monitoring, and management of pre‐eclampsia

Prevalence of Thyroid Dysfunction and Anti–thyroid Peroxidase Antibody in Gestational Diabetes Mellitus

Background: Gestational diabetes mellitus (GDM) and thyroid dysfunction are the two common endocrine disorders affecting pregnancy. Some association was hypothesized between GDM and thyroid dysfunction in the literature. The main aim of this study was to unveil this metabolic interplay as better understanding may facilitate early diagnosis and intervention thereby limiting major fetal and maternal adverse events. Here we estimated the prevalence of abnormal thyroid function and anti–thyroid peroxidase (anti-TPO) antibody and also studied the risk factors for thyroid disorders in patients with GDM. Materials and Methods: This cross-sectional study was conducted between February 2014 and January 2015. A total of 100 consecutive pregnant women diagnosed to have GDM as per the American Diabetes Association 2013 recommendations were recruited and thyroid stimulating hormone, free triiodothyronine (T3), free thyroxine (T4), and anti-TPO antibody assays were done. Details regarding pregnancy outcome and any complications if present were also obtained and analyzed. The prevalence is expressed as proportions, and the statistical significance of risk factors was assessed using the chi-square test and independent t-test. Results: Abnormal thyroid function was detected in 31 (31%) patients, which includes 17 cases of subclinical hypothyroidism (54%), 10 hypothyroidism (32%), 2 (6%) subclinical hyperthyroidism, and one case each of isolated low T3 and isolated low T4. Anti-TPO antibody was positive in 35 patients (35%). History of GDM in previous pregnancy, family history of diabetes mellitus, presence of clinically detectable thyroid gland enlargement, and presence of anti-TPO antibody in serum were found to increase the risk of thyroid dysfunction. Majority of the subjects had uneventful delivery, and no significant increase in maternal or fetal complications was reported. Conclusions: This study showed a high prevalence of thyroid dysfunction and anti-TPO antibody in GDM patients. The significant thyroid abnormalities detected were subclinical hypothyroidism and hypothyroidism. The risk of thyroid dysfunction is elevated in patients with the presence of anti-TPO antibody. This scenario provides a strong ground to recommend meticulous assessment of thyroid function in GDM patients.

New insights in diagnostic thresholds for total serum bile acid in intrahepatic cholestasis of pregnancy

Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy specific liver disorder known to be associated with fetal adverse events, in particular stillbirth. At present, an effective treatment to reduce the risk of stillbirth, does not exist. Ursodeoxycholic acid (UDCA) is often given in clinical practice to reduce maternal symptom of pruritus but without strong evidence (Walker KF et al. Pharmacological interventions for treating intrahepatic cholestasis of pregnancy. Cochrane Database Syst Rev. 2020 Jul 27;7(7):CD000493), and iatrogenic preterm birth is induced when the risk of stillbirth is thought to be higher (Ovadia C et al. Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses. Lancet. 2019 Mar 2;393(10174):899-909).

The burden of premature ventricular contractions predicts adverse fetal and neonatal outcomes among pregnant women without structural heart disease: A prospective cohort study.

BackgroundPremature ventricular contractions (PVCs) may increase during pregnancy, however, few studies have evaluated the relationship between PVCs and the pregnant outcomes.HypothesisPVCs may increase the adverse fetal/neonatal outcomes in pregnant women.MethodsSix thousand one hundred and forty‐eight pregnant women were prospectively enrolled in our center between 2017 and 2019 in the study. The average PVC burden was determined by calculating the number of PVCs in total beats. Those who had a PVC burden >0.5% were divided into two groups based on the presence or absence of adverse fetal or neonatal events. The adverse outcomes were compared between the groups to assess the impact of PVCs on pregnancy.ResultsA total of 103 (1.68%) women with a PVC burden >0.5% were recorded. Among them, 17 adverse events (12 cases) were documented, which was significantly higher than that among women without PVCs (11.65% vs. 2.93%, p < .01). The median PVC burden among pregnant women with PVCs was 2.84% (1.02%–6.1%). Furthermore, compared with that of the women without adverse events, the median PVC burden of women with adverse fetal or neonatal outcomes was significantly higher (9.02% vs. 2.30%, p < .01). Multivariate logistic regression analysis demonstrated that not the LVEF, heart rate and bigeminy, but only the PVC burden was associated with adverse fetal or neonatal outcomes among pregnant women with PVCs (OR: 1.34, 95% CI [1.11–1.61], p < .01).ConclusionsFrequent PVCs have adverse effects on pregnancy, and the PVC burden might be an important factor associated with adverse fetal and neonatal outcomes among pregnant women with PVCs.

Maternal, Fetal, and Child Outcomes of Mental Health Treatments in Women: A Meta-Analysis of Pharmacotherapy.

ObjectiveThe authors systematically reviewed evidence on pharmacotherapy for perinatal mental health disorders.MethodsThe authors searched for studies of pregnant, postpartum, or reproductive‐age women with mental health disorders treated with pharmacotherapy in MEDLINE, EMBASE, PsycINFO, the Cochrane Library, and trial registries from database inception through June 5, 2020 and surveilled literature through March 2, 2021. Outcomes included symptoms; functional capacity; quality of life; suicidal events; death; and maternal, fetal, infant, or child adverse events.Results164 studies were included. Regarding benefits, brexanolone for third‐trimester or postpartum depression onset may be associated with improved depressive symptoms at 30 days when compared with placebo. Sertraline for postpartum depression may be associated with improved response, remission, and depressive symptoms when compared with placebo. Discontinuing mood stabilizers during pregnancy may be associated with increased recurrence of mood episodes for bipolar disorder. Regarding adverse events, most studies were observational and unable to fully account for confounding. Evidence on congenital and cardiac anomalies for treatment compared with no treatment was inconclusive. Brexanolone for depression onset in the third trimester or the postpartum period may be associated with risk of sedation or somnolence, leading to dose interruption or reduction when compared with placebo.ConclusionsEvidence from few studies supports the use of pharmacotherapy for perinatal mental health disorders. Although many studies report on adverse events, they could not rule out underlying disease severity as the cause of the association between exposures and adverse events. Patients and clinicians need to make informed, collaborative decisions on treatment choices.

Management of Persistent Cushing’s Disease Despite Prior Pituitary Adenoma Resection in a Pregnant Patient

Introduction: Cushing’s Disease (CD) in pregnancy is a rare, but serious disease that adversely impacts maternal and fetal outcomes. As the sole use of metyrapone in the management of CD has been rarely reported, we describe our experience using it to treat a pregnant patient with pre-existing CD. Clinical Case: The patient is a 29-year-old woman with a history of hypertension (HTN), who was diagnosed with CD a year prior to becoming pregnant based on elevated urinary free cortisol (UFC) 209 ug/24h (Reference Range (RR) 6 - 42), positive 1 mg dexamethasone suppression test, elevated ACTH 61 pg/mL (RR 0-46). and an 8 x 8 x 8 mm pituitary adenoma on magnetic resonance imaging (MRI). She underwent trans-sphenoidal adenoma resection 3 months prior to becoming pregnant; however, was found to have persistent disease based on a repeat MRI showing a residual 8 x 8 x 9 mm adenoma extending into the cavernous sinus and UFC 290 ug/24h. The patient discovered 6 weeks later that she was pregnant. She was referred to endocrinology at 12 weeks’ gestation, where she was experiencing easy bruising and taking labetalol 400 mg twice daily for HTN. UFC was 768 ug/24h and midnight salivary cortisols were 0.175 and 0.625 ug/dL (RR <0.010 - 0.090). Surgery was deemed to be high risk given the proximity of the tumor to the cavernous sinus and likelihood of residual disease. She was started on metyrapone 250 mg twice a day, and was uptitrated to 1000mg three times daily by the time of delivery with a UFC of 120 ug/24h (goal < 150 ug/24h). Her pregnancy was also complicated by diet-controlled gestational diabetes and cervical insufficiency requiring cerclage. Otherwise, her HTN was well controlled on labetolol and she remained normokalemic. The patient was induced at 37 weeks gestation and was given stress dose steroids along with metyrapone. She delivered a healthy baby boy without any complications. Discussion: CD during pregnancy is a rare disease, with the best outcomes in published cases seen with surgical intervention. This case highlights the use of metyrapone, a steroidogenesis inhibitor, as a sole therapy in cases where surgery is deemed to be high risk and unlikely curative due to location of the tumor. While it is effective in reducing cortisol levels, close surveillance of patients is required for worsening HTN, hypokalemia, and potential adrenal insufficiency. Though no fetal adverse events have been reported, the medication does cross the placenta and longterm effects are unknown.

Dengue in pregnancy: Review article

Dengue is the most common viral mosquito- borne disease. It is a major public health problem, especially in tropical and sub-tropical areas worldwide. According to the World Health Organization (WHO), approximately 40% of the world’s population (over 2.5 billion people) live in areas with high risk of contracting dengue infection. Adults of childbearing age and pregnant women are travelling more frequently to tropical areas. Therefore exposing themselves to specific arboviral infections such as dengue, which may impact ongoing and future pregnancies. Clinical manifestations of dengue are wide ranging from asymptomatic to needing intensive care in cases of hemorrhagic dengue fever. The effects of dengue during and on pregnancy are unclear, moreover there is a lack of a cohesive reference to inform women of reproductive age who live in or travel to endemic areas and are at risk of contracting dengue. Here we present review of literature specifically looking at etiology, pathogenesis, clinical manifestations, management of dengue in pregnancy as well as its effect on maternal health and fetal outcomes. There is clear evidence to suggest adverse maternal outcomes in women with symptomatic dengue in low resource countries. A high index of clinical suspicion and early referral to tertiary center will prevent maternal –fetal serious adverse events in endemic areas.This review will help Clinicians in advising as well as managing women who travel during pregnancy to endemic areas as well as clinicians based in endemic areas who are managing women with dengue in pregnancy.

Maternal and fetal outcomes of patients with liver cirrhosis: a case-control study

BackgroundWe aimed to describe the characteristics and outcomes in pregnant women with liver cirrhosis, and identify the predictors of adverse events of mother and fetus.MethodsRetrospectively collected mothers with liver cirrhosis in our center from 6/2010 to 6/2019. Women without liver cirrhosis were selected as a control in a 1:2 ratio. The primary assessment was the frequency of maternal and fetal adverse events. The secondary assessment was the adverse events in patients continuing pregnancy or not and the factors to predict the severe adverse events.ResultsOf 126 pregnancies enrolled, 29 pregnancies were terminated for worrying disease progression and 97 pregnancies continued. One hundred ninety-four pregnancies without liver cirrhosis were selected as control. At baseline, patients with liver cirrhosis have a lower level of platelet, hemoglobin, prothrombin activity, and a higher level of ALT, total Bilirubin, creatinine. Compared to control, patients with liver cirrhosis had a higher frequency of adverse events, including bleeding gums (7.2%vs. 1.0%), TBA elevation (18.6%vs.3.1%), infection (10.3%vs.0.5%), cesarean section (73.6%vs.49.5%), postpartum hemorrhage (13.8% vs 2.1%), blood transfusion (28.9% vs 2.1%), new ascites or aggravating ascites (6.2% vs.0%), MODS (7.2% vs.0.5%) and intensive care unit admissions (24.1% vs 1.1%). The incidence of severe maternal adverse events was also higher (32.0% vs 1.5%). Women who chose to terminated the pregnancy had less severe adverse events (3.4% vs.32.0%).A higher frequency of fetal/infants’ complications was observed in liver cirrhosis population than control, including newborn asphyxia (10.2% vs1.1%), low birth weight infant (13.6% vs. 2.6%). In patients who progressed into the third trimester, multivariable regression analysis demonstrated that severe adverse events were associated with a higher CTP score (OR 2.128, 95% CI [1.002, 4.521], p = 0.049). Wilson’s disease related liver cirrhosis has a better prognosis (OR = 0.009, 95% CI [0, 0.763], p = 0.038).ConclusionsThe incidence of the adverse events was significantly increased in pregnancies complicated by cirrhosis. The predictor of severe adverse events is higher CTP score. Wilson’s disease induced liver cirrhosis have a better prognosis. Timely termination of pregnancy during the first trimester may avoid the incidence of severe adverse events.

SELF-MONITORING OF BLOOD PRESSURE IN WOMEN WITH PREGNANCY HYPERTENSION: THE BUMP2 MULTICENTRE RANDOMISED CONTROLLED TRIAL

Objective: Self-monitoring of blood pressure (BP), in conjunction with co-interventions, is associated with clinically significant BP reduction in the general adult population. No adequately powered trials have been conducted in women with pregnancy hypertension. The BUMP2 trial aimed to evaluate whether BP self-monitoring in women with pregnancy hypertension improved BP control. Design and method: This multicentre, non-masked, randomised controlled trial recruited pregnant women with chronic or gestational hypertension up to 37 weeks’ gestation. Participating women were randomised to either BP self-monitoring with telemonitoring and usual care or usual care alone. An app provided real time feedback advising women of appropriate actions to take at each blood pressure threshold. The primary outcome was mean systolic BP between baseline and delivery recorded by a healthcare professional. Secondary outcomes included maternal and perinatal outcomes, quality of life, and adverse maternal and fetal events. A sample size of 512 (256/group) at 90% power was required to detect a 5 mm Hg difference in systolic BP between groups (SD 16 mmHg), assuming 15% attrition, subsequently inflated to allow for analysis by hypertension type. Trial Registration: NCT03334149 Results: 850 women (454 with chronic hypertension (CH) and 396 with gestational hypertension (GH)) were randomised to either BP self-monitoring (CH n = 233; GH n = 197) or usual care (CH n = 221; GH n = 199). Primary outcome data were available from 821 (97%) women. Baseline characteristics were similar. Mean systolic BP between randomisation and delivery was not significantly different in women with chronic hypertension between self-monitoring (mean 133.8 (SD 10.3) mmHg) and usual care (133.6 (11.1) mmHg) groups; mean difference 0.03 (-1.73 to 1.79), p = 0.97 or in women with gestational hypertension (137.6 (12.1) mmHg vs. 137.2 (10.8) mmHg; mean difference -0.03 (-2.29 to 2.24), p = 0.98. There were no differences in other maternal and fetal outcomes or in Serious Adverse Events. Conclusions: BP self-monitoring in women with pregnancy hypertension does not improve BP control, but appears to be safe when used alongside usual care. Further work will elucidate whether empowering some women with BP self-monitoring may alter behaviour of clinicians or women in initiating or titrating antihypertensive medications.

548 Use of ketamine infusion in post cesarean pain management in patients with opioid use disorder

Low dose post-operative IV ketamine infusions successfully improve pain and decrease opioid usage in non-obstetric populations. In this study, we have examined the effect of low dose IV ketamine in post-cesarean section women with opioid use disorder (OUD). We performed a single center retrospective cohort study of women >18 years old receiving medication assisted treatment (MAT) for OUD who underwent cesarean delivery between June 1, 2019-September 1, 2020. Women were stratified based on whether or not they received ketamine infusion for pain control and outcomes were assessed over the first 48 hours postpartum. The primary outcome was opioid consumption in the first 24 hours postpartum; the secondary outcome was pain scores during this period. Outcomes were compared between subgroups using chi square or the Fisher exact test, and t tests or Mann Whitney U tests, as appropriate. Significance was accepted at P<.05 44 subjects met inclusion criteria, with 22 receiving and 22 not receiving ketamine infusion. Overall, 43/44 (97.7%) were white; 33/44 (75%) were taking buprenorphine, and 11/44 (25%) were taking methadone. All characteristics were similar between subgroups, except for a higher rate of tobacco use among those not receiving ketamine [12 (54.5%) vs 8 (36.4%), P=0.03]. The mean (SD) duration of ketamine infusion was 23.8 (12.4) hours. Opioid consumption in the first 24 hours post-op was decreased in the ketamine group compared to the non-ketamine group (median [interquartile range], 30 [7.6-46.2] vs. 45.5 [18.7-60] morphine milli-equivalents, p=0.08), but did not reach statistical significance. Mean pain scores, measured on a numerical rating scale, did not differ between groups 5.4 (1.8) and 5.0 (1.6), respectively. No major maternal or fetal adverse events were recorded. Low dose ketamine infusion shows promise for use in women receiving MAT for OUD to reduce the dose of opioid analgesia required in the first 24 hours following cesarean delivery. Larger, prospective studies are needed.

Therapeutic strategy of pregnancy associated with renal transplant and SARS-CoV-2 infection – case report

Pregnancy in women with renal transplant is associated with both maternal and fetal adverse events. The rates of preeclampsia, still birth or caesarean section are significantly higher than those in the general population. In these cases, the SARS-CoV-2 infection leads to an increased mortality rate. The management of pregnancy-associated renal transplant requires a multidisciplinary approach.

Dexmedetomidine versus fentanyl as adjunct to ropivacaine-dexamethasone for labor analgesia: a randomized control study

Background and aims Although intrathecal analgesia is an effective option during labor, there is a need to establish sustainable and assured analgesia during the entire labor process. We aimed to compare the effect of dexmedetomidine versus fentanyl as an adjuvant to low-dose ropivacaine-dexamethasone for intrathecal labor analgesia in primigravida women.Patients and methods The study was conducted after approval of ethical committee of Al Azhar University Hospital. A total of 60 primiparous women classified in American Society of Anesthesiologists classes II with a singleton pregnancy in active labor were given combined spinal epidural analgesia. This was a double-blind randomized controlled trial that allocated them in two groups of 30 patients each. Group I received intrathecal 2.5 mg of 0.1% ropivacaine (diluted to 2.5 ml with normal saline)+5 μg dexmedetomidine+4 mg dexamethasone. Occurrence of any adverse reaction was observed for ten min. Group II received 25 μg of fentanyl instead of 5 μg dexmedetomidine. For both groups, epidural top-ups of 10 ml of 1% ropivacaine were given when parturients complained of two painful contractions (visual analog scale ≥4), after epidural test dose of 3 ml of 0.5% ropivacaine was slowly injected via epidural catheter and no occurrence of adverse reaction was observed 10 min later. Data collected were demographic profile of the patients, intrathecal block characteristics, needs for epidural activation before delivery, and maternal and fetal adverse effects. The primary study goal was to prove the analgesic efficacy and safety of intrathecal selective sensory block on both mother and fetus, whereas the study secondary goal was to prove that intrathecal single dose injection could be used as an effective alternative option in labor analgesia as well as epidural analgesia. Catecholamine level (epinephrine and norepinephrine) was measured using enzyme-linked immunosorbent assay technique.Results The mean age (years), weight (kg), height (cm), and BMI (kg/m2) in group I were 24.3±3.30, 65.4±16.2, 161.3±4.6, and 22.3±3.4, respectively, whereas in group II were 25.23±4.44, 66.3±15.6, 160.4±4.3, and 22.2±3.1, respectively, with insignificant difference (P>0.05). Mean visual analog scale score before onset of analgesia in group I and group II was 8.59±1.22 and 8.7±1.14, respectively. The time to full cervical dilatation was 120.14±10.2 in group I and 120.0±10.6 in group II, and the mean duration of second stage of labor was 12.02±1.37 min in group I and 11.83±0.93 min in group II. The mean duration of analgesia was statistically significant (lower) in group II (221.83±22.26) as compared with group I (296.33±44.83) (P<0.001). The mean analgesia in group I (12.3±1.8) and group II (12.1±1.7) was statistically insignificant (P>0.05). The mean highest sensory levels in group I and group II were statistically insignificant, that is, T5 (T4–T8) versus T6 (T4–T7) (P>0.05). The sensory region time in group II was greater (241.83±22.26 min) as compared with group I (329.83±44.10), with P value less than 0.001. Neither maternal nor fetal adverse events were statistically significant different between both groups (P>0.05). The mean basal norepinephrine level in pg/ml in group I was 130.30±27.6 and in group II was 103.50±20.6, with P value more than 0.05. At 2 h, norepinephrine level in pg/ml was 119.90±24.1 in group I and 90.50±13.6 in group II, with P value more than 0.05. At baseline, the epinephrine level in pg/ml in group I and group II was 59.20±11.3 and 53.20±10.3, respectively, whereas at 2 h, the epinephrine level in pg/ml was 57.90±9.1 in group I and 49.20±8.6 in group II, with P value more than 0.05.Conclusion Ropivacaine-dexamethasone combined with dexmedetomidine for intrathecal block achieved a potent selective sensory block with prolonged duration of analgesia, delayed S1 regression time, and limited maternal and fetal adverse effects than intrathecal ropivacaine-dexamethasone combined with fentanyl. However, dexmedetomidine or fentanyl provides a safe and efficacious adjuvant to intrathecal ropivacaine-dexamethasone in primigravida women with rapid onset, profound analgesia, and hemodynamic stability throughout the labor.

Assessment of risk factors and pregnancy outcomes in women with thrombotic microangiopathy in Ain Shams University Maternity Hospital over a 5-year period

Thrombotic microangiopathy in pregnancy can lead to maternal and fetal life-threatening adverse events. Objective. To study the demographic characteristics (age, parity), risk factors, treatment modalities, and pregnancy outcomes in women with thrombotic microangiopathy in Ain Shams University Maternity Hospital over a 5-year period. Patients and methods. This study was retrospectively conducted at Ain Shams University Maternity Hospital and included 419 patients; the study population were pregnant women admitted to the hospital from January 2014 to December 2018, with pregnancy-associated thrombotic microangiopathy. The study was performed through revising the medical records in the archive and the ICU and contacting the patients to assess demographic data, risk factors, presentation of the patient, type of the syndrome, and the maternal and fetal outcome. Results. HELLP syndrome was the most common pregnancy complication. In most of cases, women delivered by cesarean section (72.1%). Complications included chronic hypertension (CHTN), acute kidney injury (AKI), chronic kidney injury (CKI). Maternal mortality was significantly more frequent in hemolytic uremic syndrome (HUS). Maternal mortality was 8.8 %, and neonatal mortality was 26.7%. Most of women were admitted to the ICU (87.1%). Conclusion. Thrombotic microangiopathy in pregnancy continues to pose a large challenge to obstetricians, immunologists, and nephrologists due to potential risks and complications. Pregnancy outcome is more optimistic when termination of pregnancy occurs early in the disease with the possible use of corticosteroids with or without plasma exchange transfusion under the control of a multidisciplinary approach team. Key words: risk factors, outcome, pregnant women, thrombotic microangiopathy

EFFECTIVENESS OF LOWER LEG COMPRESSION MANEUVER IN REDUCING SPINAL ANESTHESIA INDUCED HYPOTENSION FOR WOMEN UNDERGOING CESAREAN SECTION

Background: Hypotension during spinal anesthesia for caesarean delivery remains a common clinical problem. It has a risk factor for adverse maternal and fetal events. This study aimed to evaluate the effectiveness of lower leg compression maneuver in reducing spinal anathesia induced hypotension for women undergoing cesarean Section. A Quasi-experimental designwas utilized in the current study.Setting: The study was conducted at cesarean delivery unit in Mansoura University Hospital during the period from October 2016 to March 2017.Asystematic random sample was calculated to be 220 of women underwent elective cesarean delivery with spinal anesthesia to be recruited in both study group and control group. Pre-hydration and anesthetic technique standardized protocol was followed. Hypotension defined as a decrease in any mean arterial pressure (MAP) measurement by more than 20% of the baseline. Tools:Three tools were used in the current study to collect the necessary data, Structured interviewing questionnaire sheet, maternal hemodynamic and signs of hypotension record, and neonatal assessment sheet. Results: A highly statistical significant difference was found between study group and control group regarding mean arterial pressure and neonatal acidosis .Conclusion: lower leg compression for women under elective cesarean with spinal anesthesia is more effective measure to reduce spinal anathesia induced hypotension during cesarean delivery. Recommendations: lower leg compression during cesarean delivery should be included in maternal hospitals protocol for reducing spinal induced hypotension during cesarean delivery.

Abstract 17390: Maternal and Fetal Cardiovascular Adaptations to Pregnancy and Outcomes in Mothers With Cardiac Disease - A Magnetic Resonance Imaging Study

Introduction: Insufficient maternal cardiac output (CO) has been implicated in poor pregnancy outcomes in mothers with heart disease (HD). Simultaneous delineation of vascular flows in the mother and her fetus have not been reported but could contribute to our understanding of the mechanisms of adverse events in this susceptible population. Methods: Pregnant women with moderate or severe HD (n=22; age 32±5 years) were studied using magnetic resonance imaging (MRI) and were compared with healthy controls (n=21; 34±3 years). Each MRI study included maternal and fetal components during the third trimester of pregnancy (corresponding to peak CO) and six months postpartum (surrogate for baseline hemodynamics). Phase contrast (PC) imaging was used to quantify maternal and fetal vascular flows. Fetal vessel T1 and T2 oximetry was used for derivation of fetal oxygen delivery and consumption. Maternal cardiac index (CI) was calculated using CO and pre-pregnancy body surface area. In the HD group, an “adapter” to pregnancy was defined as a woman with peak pregnancy CI measurement which met or exceeded the mean CI in the control population. Maternal and fetal outcomes were recorded. Results: There was no antepartum differences in absolute CO or CI in HD versus controls (CO 7.2±1.5 versus 7.3±1.6 L/min, p=0.79; CI 4.0±0.7 versus 4.3±0.7 L/min/m 2 , p=0.28). The percent increase in CO and CI (antepartum minus postpartum) was greater in women with HD versus controls (CO 46±24% versus 27±16%, p=0.02; CI 51±28% versus 28±17%, p&lt;0.01). Fetal growth and oxygen delivery/consumption were similar between groups. Six adverse maternal cardiovascular events occurred in the HD group (heart failure n=2 and arrhythmia n=4) and there were none in the control group. There were no adverse fetal events in either group. There were 6 HD adapters (30%) and the adverse event rate was lower as compared with non-adapters (0% versus 38%, p=0.03). Conclusions: Maternal and fetal vascular flows can be characterized in pregnancy using MRI. Impaired adaptation to pregnancy in women with HD, as determined by magnitude of change in CO/CI, appears to be associated with adverse outcomes of pregnancy in the mother.

Aortic coarctation in pregnancy: outcomes and predictors for cardiovascular and hypertensive complications. Data from the ESC Registry of Pregnancy and Cardiac disease (ROPAC)

Abstract Background Pregnancy in women with repaired aortic coarctation (CoA) has a moderately increased risk (mWHO II-III) of an adverse cardiovascular, obstetric or fetal event, but prospective data to validate this estimated risk is scarce. Purpose We examined maternal and fetal outcomes in pregnant women with unrepaired and repaired CoA to identify predictors of adverse outcomes. Methods Pregnancies in women with CoA were selected from the worldwide prospective Registry of Pregnancy and Cardiac Disease (ROPAC, n=5739). The frequency and predictors of major adverse cardiac events (MACE, defined as maternal cardiac death, heart failure, atrial fibrillation/flutter, ventricular tachyarrhythmia, endocarditis, thromboembolic events, aortic dissection and acute coronary syndrome), and hypertensive complications (defined as pregnancy-induced hypertension, (pre)eclampsia or HELLP syndrome) were analyzed. Results Of 303 pregnancies in women with CoA (median age 30 years, median pregnancy duration 39 weeks), 10% were in women with unrepaired CoA and 27% in women with pre-existing hypertension. There were no maternal deaths. There were 4 neonatal deaths of which 3 occurred after a spontaneous extreme preterm birth. MACE occurred in 4.3% of pregnancies, predominantly involving heart failure (3.3%). MACE rate was similar in unrepaired vs repaired CoA (3.4% vs 4.4%, p=0.814). Predictors of MACE included pre-pregnancy clinical signs of heart failure (OR 31.8, 95% CI 6.8–147.7), LVEF &amp;lt;40% (OR 10.4, 95% CI 1.8–59.5), NYHA class &amp;gt;1 (OR 11.4, 95% CI 3.6–36.3), cardiac medication use (OR 4.9, 95% CI 1.3–18.3) and living in an emerging country (OR 4.88, 95% CI 1.58–15.07). Hypertensive complications occurred in 6.3%, more often in the subgroup with pre-existing hypertension (11% vs 5%, p=0.040). Pre-existing hypertension was the only predictor (OR 2.6, 95% CI 1.01–6.6). Caesarean section was performed in 50% of the total cohort. Conclusions Pregnancies in women with CoA are safe, well tolerated and MACE and hypertensive complication rates are low. These findings support mWHO risk score reevaluation to mWHO II for women with CoA without cardiac impairment. Funding Acknowledgement Type of funding source: Foundation. Main funding source(s): ESC EURObservational Research Programme (EORP)

Pregnancy outcomes in women with aortic coarctation

ObjectivePregnancy in women with aortic coarctation (CoA) has an estimated moderately increased risk (mWHO II–III) of adverse cardiovascular, obstetric or fetal events, but prospective data to validate this risk classification...