Hemolysis, Elevated Liver Enzymes, Low Platelets Research Articles

First-trimester uterine artery Doppler and hypertensive disorders in twin pregnancies: Use of twin versus singleton references.

To determine the association of first-trimester uterine artery Doppler with hypertensive disorders of pregnancy in twin pregnancies. This was a retrospective cohort study of twin pregnancies followed at the University Hospital Center of Central Lisbon, Portugal, between January 2010 and December 2022. First-trimester uterine artery pulsatility index (UtA-PI) was determined and compared between twin pregnancies (n = 454) and singleton pregnancies (n = 908), matched to maternal and pregnancy characteristics. Maternal characteristics and mean UtA-PI were analyzed for gestational age, birth weight, gestational hypertension, early- and late-onset pre-eclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, and preterm birth. Univariable and multivariable logistic regression models were used. The mean first-trimester UtA-PI was significantly lower in dichorionic twins than in singletons (P < 0.001). To study hypertensive disorders of pregnancy in twins, 390 pregnancies were included: 311 (79.7%) dichorionic and 79 (20.3%) monochorionic twins. The observed rates of early- and late-onset pre-eclampsia, gestational hypertension, and HELLP syndrome were 1.0%, 4.4%, 7.4%, and 1.5%, respectively. We achieved a 100% detection rate for early-onset pre-eclampsia using the UtA-PI 90th centile for twins. However, when singleton references were considered, the detection rate decreased to 50%. UtA-PI at or above the 95th centile was associated with increased odds for preterm birth before 32 weeks (adjusted odds ratio 4.1, 95% confidence interval 1.0-16.7, P = 0.043). Unless other major risk factors for hypertensive disorders are present, women with low UtA-PI will probably not benefit from aspirin prophylaxis. Close monitoring of all twin pregnancies for hypertensive disorders is still recommended.

Factors associated with refractory severe hypertension in patients with preeclampsia.

To identify factors associated with refractory severe hypertension that does not resolve after an initial dose of antihypertensive medication in patients with preeclampsia. This was a retrospective study of all pregnant and postpartum individuals with a diagnosis of preeclampsia, superimposed preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelet) syndrome, or eclampsia who delivered at 22 weeks or greater at a single academic institution from 2010 to 2020. Inclusion criteria were patients with preeclampsia who developed severe hypertension (systolic pressure 160 mmHg or more or diastolic pressure 110 mmHg or more) and received antihypertensive medications for acute severe hypertension. We defined refractory severe hypertension as a systolic blood pressure of 160 mmHg or greater or a diastolic blood pressure of 110 mmHg or greater that did not improve after receiving the initial treatment. To evaluate for factors associated with refractory severe hypertension, we developed multivariable modified Poisson regression using all variables with p-value < 0.1 on bivariable analysis and calculated adjusted relative risks (aRRs) with 95% confidence intervals (95%CI). Of 850, 386 (45.4%) had refractory severe hypertension and 464 (54.6%) responded to the initial antihypertensive medications. Factors associated with refractory severe hypertension included higher body mass index (BMI), chronic hypertension, and higher systolic pressure. Every 5 kg/m2 increase in BMI was associated with a 7% increased risk of refractory severe hypertension (aRR 1.07; 95%CI 1.02-1.12). Every 10 mmHg increase in systolic blood pressure was associated with a 10% increased risk of refractory severe hypertension (aRR 1.10; 95%CI 1.04-1.17). Chronic hypertension was associated with a 25% increased risk of refractory severe hypertension (aRR 1.25; 95%CI 1.01-1.56) in the diastolic pressure model. Refractory severe hypertension was associated with elevated BMI, chronic hypertension, and higher systolic blood pressure.

Acute liver failure in pregnancy.

Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseasessuch as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.

Unique presentation of previable HELLP syndrome

Introduction: Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a serious complication of pregnancy characterized by hemolysis, elevated liver enzymes, and low platelets. This condition typically affects pregnant women in the third trimester or postpartum states, with only a handful of reported cases in previable pregnancies. The symptoms of HELLP syndrome can mimic those of other critical conditions during pregnancy, such as acute fatty liver of pregnancy (AFLP), thrombotic thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), systemic lupus erythematosus (SLE), and antiphospholipid syndrome (APS), making early diagnosis crucial to prevent maternal and fetal harm. Case Report: We report the case of a 23-year-old nulliparous woman who developed HELLP syndrome at 21 weeks gestation. We highlight the importance of recognizing early onset HELLP syndrome and differentiating it from other potential diagnoses to ensure prompt and appropriate treatment. Conclusion: This case of previable HELLP syndrome in a nulliparous patient without other risk factors highlights the importance of early detection and intervention as life saving measures. By understanding the clinical and laboratory findings specific to HELLP syndrome, healthcare providers can improve maternal and fetal outcomes in cases of this rare and serious complication of pregnancy.

Cesarean Section in a Patient with Severe Preeclampsia and Vertebral Artery Aneurysm, Secondary to Neurofibromatosis—A Rare Case

Neurofibromatosis (NF1) is a relatively common multi-system genetic disorder. NF1 increases the risk of hypertension, and vasculopathy is a common finding. Extracranial vertebral artery aneurysm, though rare, can rupture and cause fatal hemorrhage. Pregnancy in NF1 is known to be associated with hypertension, preeclampsia, Hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. We report anesthesia management of a primigravida with 30 weeks of gestation with neurofibromatosis presenting with severe preeclampsia and acute onset vertebral artery aneurysm, who underwent urgent cesarean section. We opted for general anesthesia over regional due to the risk of aneurysm rupture and technical difficulty with vigilant hemodynamic control. Postoperative course was complicated with HELLP and sepsis but was successfully managed. Knowledge, careful preoperative evaluation, appropriate technique, and management of anesthesia, and close postoperative monitoring are of utmost importance.

Waitlist and posttransplant outcomes of pregnancy-related acute liver failure in the United States.

Data on the liver transplant (LT) outcomes of women with acute liver failure (ALF) due to liver diseases unique to pregnancy (P-ALF) are limited. Using United Network of Organ Sharing (UNOS) data (1987-2021), we analyzed waitlist and post-LT outcomes of ALF in women of childbearing age comparing P-ALF versus ALF due to liver diseases not unique to pregnancy. Baseline characteristics were compared between groups at the time of listing for LT. Of 3542 females aged 16-43 years and listed for LT for ALF, 84 (2%) listed for P-ALF were less likely to be Black (11 vs. 21%, p =0.033), have lower international normalized ratio (2.74 vs. 4.53 p <0.002), but more likely to have respiratory failure (56% vs. 41%, p <0.005), be on pressors (58% vs. 43%, p <0.005), and require dialysis (23% vs. 10%, p <0.001). The cumulative 90-day waitlist mortality (WLM) was lower in P-ALF vs. ALF due to liver diseases not unique to pregnancy (7.4 vs. 16.6%, p <0.001). Posttransplant survival rates at 5 years were similar (82% vs. 79%, p =0.89). In a Fine and Gray regression model controlled for listing year and Model for End-Stage Liver Disease score, 90-day WLM was lower in P-ALF with a sub-HR of 0.42 (95% CI: 0.19-0.94, p =0.035). Of 84 women with P-ALF and listed for LT, 45 listed for hemolysis-elevated liver enzymes-low platelets (HELLP) versus 39 for acute fatty liver of pregnancy had higher 90-day WLM (19.3% vs. 5.7% p <0.005). The 90-day WLM was about 10-fold higher in HELLP versus acute fatty liver of pregnancy with a sub-HR of 9.97 (95% CI: 1.64-60.55, p =0.013). In this UNOS database analysis of ALF among women of childbearing age, the waitlist outcome is better in women with P-ALF compared to women with ALF due to liver diseases not unique to pregnancy. Among women with P-ALF, the 90-day WLM is worse for HELLP versus acute fatty liver of pregnancy. Further studies are needed to improve the management of HELLP and prevent the development of ALF in this subgroup population.

Blinding lights: Acute persistent vision loss in pregnancy

Acute persistent vision loss in pregnancy is an emergent presentation with a broad differential and should prompt rapid assessment and treatment of the underlying etiology. In pregnancy, causes can include preeclampsia, severe gestational hypertension, and hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome. Nonobstetrically related etiologies that can exacerbate in pregnancy include optic neuritis, giant cell arteritis, central retinal artery occlusion, or retinal detachment. In this case report, we describe a case of acute vision loss due to Purtscher's-like retinopathy, a rare but serious complication of pancreatitis in pregnancy. To our knowledge, this is the first published case of Purtscher's-like retinopathy in pregnancy unrelated to preeclampsia. Given the impact of permanent visual loss associated with Purtscher's-like retinopathy, more research is needed to determine treatments to substantively improve outcomes.

Etiology of intracerebral hemorrhage during pregnancy or puerperium: A nationwide study.

Intracerebral hemorrhage during pregnancy or puerperium (pICH) is one of the leading causes of maternal death worldwide. However, limited epidemiological data exist on the etiology and outcomes of pICH, which is required to guide prevention and treatment. A retrospective nationwide cohort study and a nested case-control study was performed in Finland 1987-2016. We identified women with incident pICH by linking the Medical Birth Register (MBR) and the Hospital Discharge Register (HDR). The clinical details were collected from patient records. Three matched controls with a pregnancy without ICH were selected for each case from the MBR. In total, 49 pICH cases were identified. Half of these cases occurred during pregnancy, and the other half during peripartum and puerperium. Based on the SMASH-U (structural vascular lesion, medication, amyloid angiopathy, systemic disease, hypertension, undetermined) classification, 35.4% of the patients had a systemic disease, most commonly preeclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome; 31.3% had a structural vascular lesion; 31.3% had an undetermined etiology; and one patient (2.1%) had hypertension. The most important risk factor was hypertensive disorders of pregnancy (HDP; odds ratio = 3.83, 95% confidence interval = 1.60-9.15), occurring in 31% of the cases. Maternal mortality was 12.5%, and 20.9% of the surviving women had significant disability (modified Rankin Scale = 3-5) 3 months after the pICH. Women with systemic disease had the worst outcomes. Even in a country with a comprehensive pregnancy surveillance system, the maternal mortality rate for pICH is high, and the sequelae are severe. Early recognition and treatment of the key risk factor, HDP, is crucial to help prevent this serious pregnancy complication.

Risk factors for severe postpartum hemorrhage requiring blood transfusion after cesarean delivery for twin pregnancy: a nationwide cohort study.

Postpartum hemorrhage (PPH) is a leading cause of maternal morbidity and mortality. Twin pregnancy and cesarean delivery are well-known risk factors for PPH. However, few studies have investigated PPH risk factors in mothers who have undergone cesarean delivery for twin pregnancies. Therefore, this study investigated the risk factors associated with severe PPH after cesarean delivery for twin pregnancies. We searched and reviewed the Korean Health Insurance Review and Assessment Service's claims data from July 2008 to June 2021 using the code corresponding to cesarean delivery for twin pregnancy. Severe PPH was defined as hemorrhage requiring red blood cell (RBC) transfusion during the peripartum period. The risk factors associated with severe PPH were identified among the procedure and diagnosis code variables and analyzed using univariate and multivariate logistic regressions. We analyzed 31,074 cesarean deliveries for twin pregnancies, and 4,892 patients who underwent cesarean deliveries for twin pregnancies and received RBC transfusions for severe PPH were included. According to the multivariate analysis, placental disorders (odds ratio, 4.50; 95% confidence interval, 4.09-4.95; P < 0.001), general anesthesia (2.33, 2.18-2.49; P < 0.001), preeclampsia (2.20, 1.99-2.43; P < 0.001), hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome (2.12, 1.22-3.68; P = 0.008), induction failure (1.37, 1.07-1.76; P = 0.014), and hypertension (1.31, 1.18-1.44; P < 0.001) predicted severe PPH. Placental disorders, hypertensive disorders such as preeclampsia and HELLP syndrome, and induction failure increased the risk of severe PPH after cesarean delivery for twin pregnancy.

Association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy: prospective, population based cohort study

ObjectiveTo study the association between SARS-CoV-2 infection and newly diagnosed hypertension during pregnancy.DesignProspective, population based cohort study.SettingAll singleton pregnancies after 22 completed gestational weeks registered in the Swedish Pregnancy Register...

Maternal and perinatal outcome of women with early-onset severe pre-eclampsia before 28 weeks: Is expectant management beneficial in a low-resource country? A prospective observational study.

To study the maternal and perinatal outcomes in women with severe pre-eclampsia before 28 weeks of pregnancy. A descriptive study from a tertiary care center. All consecutive women with severe pre-eclampsia withonset before 28 weeks of pregnancy were included. The details were collected in a predesigned structured proforma prospectively. The study cohort included 145 women with a mean maternal age of 26.97 ± 5.36 years (range 19-47 years). The mean duration of prolongation of pregnancy was 13.04 ± 10.57 days (range 1-51 days). A total of 29.7% (n = 43) of women had at least one major adverse maternal outcome, and the most common was HELLP (hemolysis, elevated liver enzymes, low platelet count) syndrome (n = 24,16.6%), followed by eclampsia (n = 12,8.3%). The stillbirth rate was high (n = 103,68.7%), and most occurred in the antepartum period. Of 47 (31.3%) neonates born alive, only eight (17.02%;8/47) survived up to 28 days of life. Fetal growth restriction with Doppler abnormalities and neonatal sepsis were the most common reasons for perinatal mortality. Expectant management should not be considered routinely when the onset of severe pre-eclampsia is before 25+6 weeks of pregnancy. Between 26 and 27+6 weeks it can be offered under close monitoring and the perinatal survival depends on the neonatal services available in their facility.

1277: USE OF MOLECULAR ADSORBENT RECIRCULATING SYSTEM LEADING TO IMPROVED TRANSPLANT-FREE SURVIVAL

Introduction: Acute liver failure (ALF) has many different etiologies and carries significant morbidity and mortality. Hepatic encephalopathy (HE) is a main cause of mortality in these patients and is associated with cerebral edema and risk for progression to brainstem herniation. Albumin dialysis, mainly utilizing the Molecular Adsorbent Recirculating System (MARS) has been demonstrated in the past to improve HE, although data on mortality benefit has been inconsistent. The Children’s Hospital at Montefiore is a children’s hospital within a larger adult healthcare system. We report our single center experience utilizing extracorporeal liver support via the MARS device on pediatric and adult patients over our inaugural year. Methods: This is a retrospective report of all patients who underwent MARS therapy during the first year of our program. As per our institutional guidelines, all patients were eligible for MARS due to having grade 3+ HE or grade 2 HE with an additional failing organ system. All patients, despite their age, were treated by the pediatric MARS team. Results: Four pediatric and two adult patients underwent MARS therapy. The underlying etiologies of the acute liver failure were: acetaminophen overdose in one, indeterminate in three, disseminated varicella in one, and acute fatty liver of pregnancy with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome and atypical hemolytic uremic syndrome in one. Survival was 100%. Of the two adults, one had severe Grade 4 HE with loss of multiple brainstem reflexes upon initiation of MARS support. Her neurologic exam demonstrated improvement during her first MARS treatment cycle, and she was successfully transplanted later that night. The second adult, as well as all four pediatric patients were able to achieve full recovery of their native liver function without need for transplantation. Conclusions: The use of MARS therapy appears in this cohort to allow for liver recovery and improved transplant free survival.

A Prospective Study of Maternal and Perinatal Outcomes in Eclampsia in a Tertiary Care Centre

Background: The term eclampsia is derived from a Greek word, meaning like a flash of lightening. The onset of convulsions in a woman with pre-eclampsia that cannot be attributed to other causes is termed eclampsia. It is a major cause of maternal and fetal mortality and morbidity in our country. The management of eclampsia is still challenging to the obstetrician, requiring the greatest skill, judgement, and patience. Methods and Materials: Our study is an observational and prospective study of 58 cases admitted with eclampsia in Mahatma Gandhi Institute of Medical Sciences (MGIMS), Sewagram. The study was extended from January 2020 to December 2021. The inclusion criteria were all the cases of eclampsia (antepartum and postpartum), primigravida and multigravida, duration of gestation&gt;20 weeks. Patients with convulsion during pregnancy or in puerperal period attributed to epilepsy or other causes were excluded from the study. Results: In our study majority of cases (58.6 %) belong to the younger age group /= 37 weeks). 55.2% had antepartum eclampsia, 36.2% postpartum and 8.6% had intrapartum eclampsia. Most common complication observed was need of blood or blood products transfusion (35 %), Hemolysis, Elevated Liver Enzymes Low Platelets (HELLP) syndrome (21%), prolonged Intensive Care Unit (ICU) admission (19%) followed by abruption, Disseminated Intravascular Coagulation (DIC), Acute Kidney Injury (AKI), Posterior Reversible Encephalopathy Syndrome (PRES), hypertensive retinopathy, pulmonary edema. Majority of patients (57%) underwent cesarean section, most common indication being poor bishop’s score with deteriorating maternal condition (54.5%). Out of 58 cases, 84.4% were live births and 15.6% were still born. 63.2% of all live births were small for gestational age, 44.8% had Neonatal Intensive Care Unit (NICU), and 8% had early neonatal death. Conclusion: Early pregnancy registration, good antenatal care and counselling about warning symptoms, early identification of pre-eclampsia and its complications, and timely intervention can reduce the incidence of eclampsia. Early identification of high-risk cases at primary healthcare facilities including severe pre-eclampsia, impending eclampsia and eclampsia and immediate referral to tertiary care centre equipped with multidisciplinary team, ICU and NICU facilities, might reduce fetal morbidities like prematurity, neonatal intensive care unit admission etc. and maternal morbidities like prolonged hospitalisation, AKI, DIC , pulmonary edema, multi organ dysfunction syndrome etc. and mortality.

MATERNAL AND FOETAL OUTCOMES IN PREGNANCY WITH GESTATIONAL THROMBOCYTOPENIA: A PROSPECTIVE OBSERVATIONAL STUDY

Thrombocytopeniaissecond to anaemia as the most common hematological abnormality during pregnancy. Accurate etiological diagnosis is essential for optimal therapeutic management and thus can prevent maternal and fetal morbidity and mortality. Aim &amp;Objective:To study the clinical profile, maternal and perinatal outcomes in thrombocytopenic antenatal patients. Design:This Prospective observational study design was carried out in the department of obstetrics and gynecology at Chalmeda Anand Rao Institute of Medical sciences Karimnagar, over a period of 18 months from October 2020 to April 2022. Materials And Methods:All the pregnant women who attended antenatal OPD at Chalmeda Anand Rao Institute of Medical Sciences were tested for thrombocytopenia. 70 pregnant women with thrombocytopenia, platelet count lessthan 150x 109 /L and 70 pregnant women with normal platelet count were recruited into the study and the maternal &amp; Fetal outcomes of both groups were studied and compared. Results: Gestational thrombocytopenia is the most common etiology (57.1%). Incidence of thrombocytopenia due to severe preeclampsia and Hemolysis, Elevated Liver enzymes, Low Platelet (HELLP) syndrome in the study group was 28.5% and 8.5% of them had medical cause like malarial or dengue fever. Major causes were gestational thrombocytopenia (GT), Idiopathic Thrombocytopenic Purpura (ITP), Preeclampsia, HELLP syndrome, Malaria, and Dengue. Maternal complications due to bleeding tendencies like placental abruption, Postpartumhemorrhage were evident in the study population. Fetal complications were significantly higher in the study group. Early neonatal thrombocytopenia depended on etiology rather than severity of maternal thrombocytopenia. Conclusions:Outcome of pregnancy with moderate to severe thrombocytopenia dependsmainly on the etiology of thrombocytopenia. Adverse outcomes are especially seen with pregnancy complicated by preeclampsia and HELLP syndrome. Fetomaternal outcome is favorable in gestational thrombocytopenia. Thus, accurate etiological diagnosis is essential for optimal therapeutic management.

An Unusual Cause of Acute Kidney Injury in Pregnancy: Beware of HELLP Look-Alikes

The differential diagnosis between new occurrence or revelation of chronic kidney diseases in pregnancy and hypertensive disorders of pregnancy is not easy, and the presence of a hypertensive disorder superimposed on a glomerular disease is even more challenging, as this case exemplifies. A 29-year-old woman was referred with HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome at the end of her pregnancy. Immediately after cesarean delivery, she developed anuria, unexplained by blood loss or hypotension, and in the absence of known nephrotoxic drugs. While the laboratory features of HELLP rapidly resolved, AKI persisted, and the finding of high-level proteinuria was the hint leading to diagnosis of a glomerular disease (focal segmental glomerulosclerosis, FSGS), later proven by kidney biopsy. This case, reporting on the rare association between HELLP and FSGS, offers the opportunity to discuss the role of proteinuria, hypertension, and in the differential diagnosis of pregnancy-related acute kidney injury (pAKI).

Abstract 13924: Impact of a Pandemic on Women Diagnosed With Peripartum Cardiomyopathy

Background: Peripartum cardiomyopathy (PPCM) is a dilated form of cardiomyopathy that occurs during the last month of pregnancy or up to five months postpartum. Approximately 1,100 women develop PPCM in the United States each year. The aim of our study is to compare the incidence of PPCM prior to the start of the Coronavirus Disease 2019 (COVID) pandemic to afterwards and to determine the impact of COVID on hospitalized patients with PPCM. Methods: This was a retrospective study of 2,286 patients with a diagnosis of PPCM who were admitted to a private hospital system across the United States between the year 2017 and year 2021. There was 1,790 patients in the pre-COVID cohort, and 496 patients in the COVID era cohort. Demographics of patients were collected, with t-test and chi square p-values utilization for statistical description. Results: The mean age of women was 32.13 years. In the COVID era cohort, the percentage of Hispanic patients was significantly higher than the pre-COVID era (16.84% vs. 12.34%, p=0.012). In the COVID era, patients were more likely to have preeclampsia (20.16% vs. 13.52%, p&lt;0.001), HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome (2.62% vs. 0.61%, p&lt;0.001), respiratory failure (19.56% vs. 10.57%, p&lt;0.001), and myocardial infarction (3.63% vs. 1.90%, p=0.022). There was no significant difference in troponin and d-dimer values between the two era cohorts. The average length of stay, percentage of patients admitted to the intensive care unit (ICU), and death did not significantly differ between the pre-COVID and COVID era cohorts. Conclusion: In our study, although there was no significant difference in length of stay, ICU admission, or death in the COVID era cohort, myocardial infarction, preeclampsia, HELLP syndrome, and respiratory failure were each more prevalent in women with PPCM during the COVID era. These findings might indicate suboptimal access to outpatient and inpatient medical care during the COVID pandemic, which could have led to these more serious diagnoses.

Predictors of ICU admission in patients with peripartum cardiomyopathy

Abstract Background Peripartum cardiomyopathy (PPCM) is a dilated cardiomyopathy that affects women in the peripartum period. The incidence of PPCM in the United States is 1,100 women per year. We studied the admission of women diagnosed with PPCM to the intensive care unit (ICU) with the goal of identifying factors that increase risk for adverse outcomes. Methods This was a retrospective study of 2,286 patients with a diagnosis of PPCM admitted to a private hospital system across the United States between the years 2017 and 2021. Logistical regression analysis was utilized to identify specific patient characteristics and risk factors that were associated with admission to the ICU. Results The average age of patients was 32.13 years. The patient cohort was 39.76% black, 39.15% white, and 13.12% Hispanic. The average length of stay was 3.35 days. Preeclampsia was present in 342 (14.96%) patients, cerebral infarction in 31 (1.36%) patients, eclampsia in 48 (2.10%) patients, myocardial infarction (MI) in 52 (2.27%) patients, and HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in 24 (1.05%) patients. There was a total of 504 (22.05%) patients admitted to the ICU. Preeclampsia (adjusted odds ratio [adj. OR] 1.588, 95% confidence interval [CI] 1.215–2.074, p&amp;lt;0.001), eclampsia (adj. OR 3.131, 95% CI 1.718–5.708, p&amp;lt;0.001), cerebral infarction (adj. OR 4.381, 95% CI 2.028–9.463, p&amp;lt;0.001), age (adj. OR 0.967, 95% CI 0.953–0.982, p&amp;lt;0.001), MI (adj. OR 2.961, 95% CI 1.608–5.455, p&amp;lt;0.001), and HELLP syndrome (adj. OR 4.655, 95% CI 1.926–11.256, p&amp;lt;0.001) were all associated with increased odds of requiring ICU level of care. However, hypertension, d-dimer level, troponin level, active tobacco smoking, alcohol use, and diabetes mellitus were not associated with increased likelihood of admission to the ICU. Conclusion In our study of 2,286 women with PPCM, we found statistically significant predictors of ICU admission included age, HELLP syndrome, eclampsia, preeclampsia, MI, and cerebral infarction. This data may be useful for the early identification and triaging of patients with PPCM that require higher level of care. These results can be utilized in developing a risk score to assist in this goal. Funding Acknowledgement Type of funding sources: Private hospital(s). Main funding source(s): HCA-Riverside Community Hospital

Ambient temperature during pregnancy and risk of maternal hypertensive disorders: A time-to-event study in Johannesburg, South Africa

Hypertensive disorders in pregnancy are a leading cause of maternal and perinatal mortality and morbidity. We evaluate the effects of ambient temperature on risk of maternal hypertensive disorders throughout pregnancy. We used birth register data for all singleton births (22–43 weeks' gestation) recorded at a tertiary-level hospital in Johannesburg, South Africa, between July 2017–June 2018. Time-to-event analysis was combined with distributed lag non-linear models to examine the effects of mean weekly temperature, from conception to birth, on risk of (i) high blood pressure, hypertension, or gestational hypertension, and (ii) pre-eclampsia, eclampsia, or HELLP (hemolysis, elevated liver enzymes, low platelets). Low and high temperatures were defined as the 5th and 95th percentiles of daily mean temperature, respectively. Of 7986 women included, 844 (10.6%) had a hypertensive disorder of which 432 (51.2%) had high blood pressure/hypertension/gestational hypertension and 412 (48.8%) had pre-eclampsia/eclampsia/HELLP. High temperature in early pregnancy was associated with an increased risk of pre-eclampsia/eclampsia/HELLP. High temperature (23 °C vs 18 °C) in the third and fourth weeks of pregnancy posed the greatest risk, with hazard ratios of 1.76 (95% CI 1.12–2.78) and 1.79 (95% CI 1.19–2.71), respectively. Whereas, high temperatures in mid-late pregnancy tended to protect against pre-eclampsia/eclampsia/HELLP. Low temperature (11°) during the third trimester (from 29 weeks’ gestation) was associated with an increased risk of high blood pressure/hypertension/gestational hypertension, however the strength and statistical significance of low temperature effects were reduced with model adjustments. Our findings support the hypothesis that high temperatures in early pregnancy increase risk of severe hypertensive disorders, likely through an effect on placental development. This highlights the need for greater awareness around the impacts of moderately high temperatures in early pregnancy through targeted advice, and for increased monitoring of pregnant women who conceive during periods of hot weather.

Diagnosis and management of thrombocytopenia in pregnancy.

Thrombocytopenia, defined as platelet count <150×109/L, is frequently observed by physicians during pregnancy, with an incidence of approximately 10% of all pregnancies. Most of the cases of thrombocytopenia in pregnancy are due to gestational thrombocytopenia, which does not confer an increased risk of maternal bleeding. However, because other causes can be associated with life-threatening events, such as severe bleeding, that can affect to maternal and fetal outcomes, differentiating other cause of thrombocytopenia, which includes preeclampsia, HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome, acute fatty liver of pregnancy, immune thrombocytopenia, hereditary thrombocytopenia, antiphospholipid syndrome, thrombotic thrombocytopenic purpura, and atypical hemolytic uremic syndrome, is important. Understanding the mechanisms and recognition of symptoms and signs are important to decide an adequate line of investigation. In this review, the approach to diagnosis and the management of the thrombocytopenia commonly observed in pregnancy are presented.

Evidence of Anxiety, Depression and Learning Impairments following Prenatal Hypertension.

Background: Hypertensive disorders of pregnancy, such as Preeclampsia (PreE) and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome, affects approximately 5–10% of pregnancies and increases the risk of women developing disorders, such as anxiety or depression, in the postpartum period. Using preclinical rodent models, we set out to determine whether rats with a history of PreE or HELLP had evidence of anxiety, depression or cognitive impairment and whether immune suppression during pregnancy prevented these changes in mood and/or cognition. Methods: Timed-pregnant rats were infused with sFlt-1 and/or sEng to induce PreE or HELLP beginning on gestational day 12. After delivery, a battery of validated behavioral assays was used to assess post-partum depression, anxiety and learning. Results: There was no negative effect on maternal pup interaction due to PreE or HELLP; however, hypertensive dams spent more time immobile in the forced swim test (p < 0.0001). Hypertensive dams also spent less time in the open area of the open field (p = 0.001). There were no significant changes in recognition memory (p = 0.08); however, spatial learning was impaired in hypertensive dams (p = 0.003). Immobility time in the forced swim test was positively correlated with increased circulating S100B (p = 0.04), while increased time spent in the outer zones of the open field was negatively correlated with BDNF levels (p < 0.0001). Conclusion: The results from this study suggest that hypertensive pregnancy disorders are associated with depression, anxiety and learning impairments in the post-partum period.