Hemolysis Elevated Liver Enzymes Research Articles

#1799 Liver affliction among women with pregnancy-related acute kidney injury and its impact on fetal and maternal outcome

Abstract Background and Aims Pregnancy-related acute kidney injury (PR-AKI) is a worldwide health challenge that is accompanied by an increased risk of morbidity and mortality in both the mother and the fetus. PR-AKI occurs due to several causes including prerenal (hemorrhage, sepsis, hypovolemia, etc), postrenal and intrinsic renal causes (renal cortical necrosis, acute tubular necrosis, thrombotic microangiopathy [TMA], hemolysis elevated liver enzymes, low platelet count (HELLP) syndrome, preeclampsia/eclampsia, acute fatty liver of pregnancy (AFLP), glomerulonephritis [GN], etc). Hepatic affection in the context of PR-AKI may further compromise the detrimental maternal and fetal outcomes, however this seldom has been studied. Thus, this study aimed to explore the incidence of liver affliction in women with PR-AKI and to investigate its effect on the maternal and fetal outcome. Method This three-year retrospective study included women who presented to Mansoura Nephrology and Dialysis Unit with severe PR-AKI. Patients with stage I, II AKI admitted to obstetric departments were not included in the study. Patients with incomplete data were excluded from the study. The routine laboratory data and fetal and maternal outcomes were obtained from the medical records. Results The study included 77 women with PR-AKI, the mean maternal age was 28 with a minimum of 19 and maximum of 43 years. Twelve patients had hypertension while none of them had diabetes. The causes of PR-AKI are displayed in Fig. 1. Thirty-one patients (40.3%) had liver affliction. Six of them were due to HELLP, three due to underlying liver cirrhosis, one due to AFLP, the remaining cases showed abnormally elevated liver enzymes. White blood cells and INR were significantly higher among women with liver affliction than those without (P = 0.023, 0.003, respectively), while platelets were significantly lower in women with liver affliction (P = 0.002). Patients with liver affliction showed significantly higher median alanine transaminase (99 vs 27) and aspartate transaminase (103 vs 23) than those without (P < 0.001 for both). On the other hand, there were no statistically significant differences between patients with and without liver affliction as regard blood hemoglobin, serum creatinine, quantitative proteinuria, bicarbonate, and gestational age at termination of pregnancy. The studied women with liver affliction experienced lower percentage of renal recovery compared to those without but with no statistical significance (54.8%vs72.5%, P = 0.122). Maternal mortality was significantly more among patients with liver affliction compared to those without (32.3% vs 9.8%, P = 0.017). On the other hand, there was no significant difference between patients with and without liver affection regarding fetal outcome (live birth 55.2% vs 55.6%, P = 0.975) (Table 1). Conclusion Liver affliction is not uncommon problem among women with PR-AKI and it is associated with higher maternal mortality and lower rates of renal recovery.

Evaluation of Maternal and Perinatal Outcomes in Pregnancy with Preeclampsia at Aljala Maternity Hospital

Hypertensive disorders of pregnancy (HDP) accounts for 18% of maternal deaths worldwide, with an estimated number of about 62, 000–77, 000 deaths occur each year. The current study aimed to assess maternal and perinatal outcomes of pregnancies complicated by hypertension in Aljala Maternity Hospital. A retrospective, descriptive, case series analysis for four hundred patients was done on the outcome of hypertensive disorder among pregnant women who admitted and were managed at Aljala teaching hospital with preeclampsia during the years 2019 and 2020. Demographic data involving age, parity, gestational week, clinical and laboratory findings were recorded from the medical files. Additionally, delivery route, indications of cesarean section, fetal and maternal complications were determined. The current finding reported high prevalence of perinatal and maternal mortality among pregnant women with preeclampsia. Moreover, other severe maternal and perinatal complications such as Hemolysis Elevated Liver Enzyme Platelet (HELLP) syndrome, placental abruption, eclamptic fits, as well as low birth weight were also commonly reported. The current study showed early onset of preeclampsia was associated with increased risk of developing adverse maternal-fetal/neonatal outcomes compared to late-onset after 36 weeks. Our findings call for special consideration and close surveillance of those women with early-onset diseases.

Labor and delivery: DIC, HELLP, preeclampsia.

Hematologists are often needed to assist with the management of microangiopathic emergencies in pregnancy. A firm understanding of the diagnosis and management of preeclampsia with severe features, hemolysis elevated liver enzyme and low platelet syndrome, and disseminated intravascular coagulation, which are the most common causes of microangiopathic emergencies, is critical. However, being able to consider when other microangiopathic emergencies (acute fatty liver of pregnancy, congenital and acquired thrombotic thrombocytopenic purpura, complement mediated microangiopathy, antiphospholipid syndrome) should be considered is imperative. The hematologist and obstetric team should work together to optimize the care of common as well as rare hematologic emergencies.

Swansea criteria evaluation in acute fatty liver of pregnancy, hemolysis elevated liver enzyme and low platelet syndrome, pre-eclampsia, and viral acute liver failure in pregnancy.

SynopsisNot only AFLP but also HELLP and acute liver failure due to viruses in pregnancy meet the Swansea criteria, meriting a reappraisal and a reevaluation of the criteria.

The Role of Pancreatic Stone Protein (PSP) as a Biomarker of Pregnancy-Related Diseases.

Background: Pancreatic stone protein (PSP) is a biochemical serum marker that contains levels that are elevated in various inflammatory and infectious diseases. The role of PSP in the diagnosis of these diseases seems to be more important compared to clinically established biochemical serum markers in discriminating the severity of the same diseases. Standard values for PSP in pregnant women in relation to gestational age have been reported recently. Additionally, increased PSP levels have been observed to be associated with renal dysfunction in pregnant women. The aim of this study is to evaluate the diagnostic role of PSP in pregnancy-related diseases, such as pre-eclampsia (PE), hemolysis-elevated liver enzymes, and low platelet (HELLP) syndrome. In addition, the study aims to assess its diagnostic role in inflammation-triggered diseases as preterm premature rupture of membranes (PPROM) or COVID-19-positive pregnant women. Materials and Methods: In this single-centred prospective study performed at a tertiary university hospital between 2013 and 2021, we included 152 pregnant women who were diagnosed with either PE, HELLP syndrome, or PPROM. In December 2020, in the context of the COVID-19 pandemic, the Independent Ethics Committee (IEC) approved an amendment to the study protocol. Depending on the underlying disease, single or serial-serum PSP measurements were assessed. These PSP values were compared to PSP levels of women with normal pregnancies. Results: Pregnant women diagnosed with pre-eclampsia or HELLP syndrome had significantly increased PSP values (mean 9.8 ng/mL, SD 2.6) compared to healthy singleton pregnant women (mean 7.9 ng/mL, SD 2.6, p ≤ 0.001). There was no difference in serum PSP in pregnant women with PPROM compared to women with uncomplicated singleton pregnancies (mean in PPROM: 7.9 ng/mL; SD 2.9 versus mean in healthy pregnancies: 7.9 ng/mL; SD 2.6, p = 0.98). Furthermore, no difference in the PSP values in women with or without intra-amniotic infection was observed (infection: mean 7.9 ng/mL; SD 2.8 versus no infection: mean 7.8 ng/mL; SD 3, p = 0.85). The mean value of PSP in COVID-19-infected women during pregnancy (8.5 ng/mL, SD 2.3) was comparable to healthy singleton pregnancies (mean 7.9 ng/mL, SD 2.6), p = 0.24. Conclusions: The novel serum biomarker PSP is significantly upregulated in pregnant women with pre-eclampsia and HELLP syndrome. Our observations call for the further evaluation of PSP in randomized controlled clinical trials to demonstrate the actual role of PSP in pregnancy-related diseases and whether it may provide new approaches for the management and discrimination of the severity of these gestational conditions.

Serum LDH Levels in Normotensive and Preeclamptic-Eclamptic Pregnant Women and Its Correlation With Fetomaternal Outcome.

Background One of the most prevalent medical issues observed during pregnancy is hypertension. Hypertensive disorders of pregnancy (HDP) and their consequences affect around 5-10% of all pregnancies globally. Preeclampsia is caused by endothelial dysfunction, which causes widespread endothelial leakage and contributes to potentially fatal consequences, such as eclampsia, placental abruption, disseminated intravascular coagulation (DIC), severe renal failure, pulmonary edema, and hepatocellular necrosis. As a result, looking for predictive markers for at-risk pregnancies that can suggest poor maternal or fetal outcomes is critical. Elevated levels of lactate dehydrogenase (LDH), as a sign of cellular damage and dysfunction, can be utilized as a biochemical marker in pregnancy-induced hypertension (PIH) as it represents the severity of the disease, and the occurrence of problems, and has also been demonstrated to co-relate with fetomaternal outcomes. Methodology A total of 230 singleton pregnant women of 28-40 weeks of gestational age were enrolled in this study. All women were divided into two groups - normotensive and preeclamptic-eclamptic groups; the second group was further divided intomild preeclampsia, severe preeclampsia, and eclampsia, based on blood pressure and the presence of proteinuria. Serum lactate dehydrogenase levels were measured in both groups and correlated with their fetomaternal outcome. Results Mean serum lactate dehydrogenase (LDH) levelin eclamptic women was 1515.86 ± 754, in severely preeclamptic women was 932.2 ± 448, mild preeclamptic women were 580.5±213, while in normotensive women mean LDH level was 378.6 ± 124. The difference between normotensive and preeclamptic-eclamptic women was statistically significant (p < 0.001). The complications in the preeclamptic-eclamptic group were increased significantly in women with LDH > 800 IU/L, 600-800 IU/L compared to those who had < 600 IU/L LDH levels. Conclusions Serum LDH levels were significantly higher in women of preeclamptic-eclamptic group compared to the normotensive pregnant women. Higher LDH levels were positively correlated with disease severity and maternal complications like placental abruption, hemolysis elevated liver enzymes low platelet count (HELLP), disseminated intravascular coagulation (DIC), acute renal failure, intracranial hemorrhage, pulmonary edema, and maternal death and for fetal complications like preterm, intrauterine growth restriction (IUGR), APGAR at 1 minute < 7, APGAR at 5 minutes < 7, low birth weight (LBW), neonatal intensive care unit (NICU) admission and intrauterine fetal death (IUFD).

Acute Fatty Liver of PregnancyA Case Series from a Tertiary Hospital of Kolkata, India: A Case Series

Acute Fatty Liver of Pregnancy (AFLP) is a rare, life-threatening complication of pregnancy that affects women in the third trimester or immediate postpartum period. Although the exact pathogenesis is poorly understood, it has been linked to a deficiency in Long Chain 3-hydroxyacyl-CoA Dehydrogenase (LCHAD) in foetal fatty acid metabolism. The early diagnosis of AFLP can sometimes be challenging due to overlapping features with severe preeclampsia, Haemolysis Elevated Liver Enzymes, Low Platelet (HELLP) syndrome, viral hepatitis, and cholestasis of pregnancy. It is a diagnosis of exclusion when no other known liver diseases are present in the mother. Herein, the authors presented a case series of four cases of AFLP, including their chief complaints, clinicopathological findings, management, and outcomes. Early diagnosis, termination of pregnancy, and multidisciplinary management in the postdelivery period are crucial for improving foetomaternal prognosis.

Assessment of Clinical Characteristics and Outcomes of Liver Diseases Unique to Pregnancy at a Tertiary Hospital in Ethiopia: A Retrospective Cohort Study.

Liver disease is a rare complication of pregnancy that can lead to several consequences and require specific intervention with implications for both the mother and fetus. This study is aimed at assessing the clinical profile and associated complications of liver diseases unique to pregnancy at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Methodology. This study is a retrospective cohort study of all identified cases admitted to the obstetrics ward and intensive care unit (ICU) from January 2018 to December 2020 at St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia. Medical records were reviewed for clinical features, biochemical profiles, and fetomaternal complications. Data were analyzed using SPSS version 26. A chi-square test was done to look for an association with a p value less than 0.05 considered statistically significant, and an odds ratio was determined to assess the effect size. From 95 cases identified, preeclampsia/eclampsia with liver dysfunction accounted for 43 (45%), followed by hemolysis elevated liver enzyme and low platelet (HELLP syndrome) 35 (36.8%), hyperemesis gravidarum with liver dysfunction 9 (9.5%), acute fatty liver of pregnancy (AFLP) 7 (7.4%), and intrahepatic cholestasis of pregnancy 1 (1.1%). When compared to HELLP syndrome, AFLP showed significantly higher median (IQR) values (p < 0.05) for total bilirubin 13.3 (7.3-16.3), direct bilirubin 9.73 (6.87-11.9) mg/dL, prothrombin time 23 (20.4-25.7) seconds, international normalization ratio 2.2 (1.9-2.4), white blood count 23.8 (17.8-26.6)∗103/μL, creatinine 3.5 (2.44-5.6) mg/dL, and lower hemoglobin level of 7.9 (6.2-10) g/dL. There were 4 (4.2%) maternal hospital deaths, with a case fatality rate of HELLP syndrome being 8.6% and 14.3% in AFLP. The overall hospital fetal mortality was 33 (34.7%). In this study, 42 patients with HELLP syndrome and AFLP had an increased risk of maternal ICU admission (OR = 25.5, 95% CI: 5.48-118.6, p value = 0.001), acute kidney injury requiring dialysis (OR = 12.2, 95% CI: 1.46-102.2, p value = 0.009), placental abruption (OR = 14.2, 95% CI: 1.72-117.1, p value = 0.004), and stillbirth (OR = 7.2, 95% CI: 2.38-21.7, p value = 0.001). Preeclampsia with liver dysfunction and HELLP syndrome accounted for the majority of cases. It also demonstrated key biochemical characteristics that can be used to distinguish between HELLP syndrome and AFLP. Emphasis has to be given to the risk of requiring maternal ICU admission, dialysis, abruption of the placenta, and stillbirths while managing patients diagnosed with HELLP syndrome and AFLP.

Critical Care Problem in a Case of Intracerebral Hemorrhage Due to Eclampsia and Its Ethics and Medicolegal Consideration

BACKGROUND: Eclampsia accompanied by hemolysis elevated liver enzymes low platelet (HELLP) syndrome is an emergency condition during late trimester pregnancy characterized by hypertension, seizures, and coma. Obstetric history is known that the patient does not conducted antenatal care regularly to the doctor so that the patient does not know she has eclampsia. One of which complications due to eclampsia is intracerebral hemorrhage which is a major cause of death and morbidity in pregnant woman. This case report discusses how ethical and medicolegal decision-making for procedures to withholding or withdrawing life support for the critical care problem. The ethical dilemma faced by neuroanesthesia and critical care (NACC) consultants is whether to continue to treat patients in the intensive care unit (ICU) even though the results will be in vain or to restrict critical care because they concluded that the condition of the patient has a terminal stage. CASE REPORT: A reported case of a 23-year-old woman, pregnant, and had a caesarian section for the indication of eclampsia accompanied by HELLP syndrome in rural hospital. Because the patient’s condition worsened, she was referred to Zainoel Abidin hospital due to decrease in consciousness and a computed tomography scan of the head showed extensive bleeding. The results of the neuroanesthesia and neurosurgery team’s assessment stated that there was no indication of surgery on the patient because extensive bleeding had occurred accompanied by brain edema. The patient then undergoes treatment in the ICU to improve the patient’s critical condition. In an effort to overcome this problem, the NACC consultant consults with an ethics and medicolegal consultant as a representation of the medical committee and ethical committee to determine the withholding or withdrawing of life support therapy to the patient. CONCLUSION: Life support therapies that can be withhold or withdraw are simply an extraordinary treatment that provides no benefit. The basic principles of ethics in making decisions to do withholding and withdrawing life support in these patients are beneficence and non-maleficence, while the medicolegal principle in these patients lies in the patient’s condition being medically incurable (terminal state) and medical treatment is useless (futile treatment).

Serum Lactate Dehydrogenase Level in Pregnancy Induced Hypertension and Fetomaternal Outcome

Hypertensive disorders complicate 5-10% of all pregnancies and associated with potentially dangerous maternal and fetal complications. Studies have shown that pre-eclamptic patients with higher levels of lactate dehydrogenase (LDH) are at high risk of developing subsequent complications with poor maternal and fetal outcome. So with the aim to correlate serum LDH level in pregnancy induced hypertension (PIH) with fetomaternal outcome this hospital based observational descriptive study was done at Tribhuvan University Teaching Hospital (TUTH) for the duration of 1 year from 15th May, 2018 to 14th May, 2019. Women with PIH fulfilling inclusion criteria were enrolled in the study. Serum LDH level was measured and severity of PIH, maternal and perinatal outcome were studied according to the levels of LDH. Results were analyzed using SPSS 18. The incidence of hypertensive disorder in pregnancy was 4.74% in this study and total 180 cases were enrolled. The mean serum LDH level increased with increase in severity of PIH. Thirty two (17.7%) cases had maternal complications and hemolysis elevated liver enzymes and low platelet (HELLP) syndrome was most common complication. More than 2/3rd (62.5%) of cases with LDH level &gt;800 IU/L had complications. The most common perinatal complication was intrauterine growth restriction (IUGR). The perinatal morbidity and mortality were significantly high in patients with PIH with LDH level &gt;800 IU/l. As with the increase in serum LDH level increase in maternal and fetal complications was observed, LDH can be a useful biochemical marker that reflects the severity of PIH.

The Impact of Preeclampsia on Work-Related Psychosocial Aspects and Need for Recovery

Women with a history of preeclampsia and/or Hemolysis Elevated Liver enzymes Low Platelets (HELLP) syndrome report impaired cognitive functioning, such as concentration problems and decreased memory function. The presence of subjective cognitive impairment, depressive symptoms and cognitive deficits may affect working abilities.

Leptospirosis in pregnancy: A systematic review.

Leptospirosis is a leading zoonotic disease worldwide with more than 1 million cases in the general population per year. With leptospirosis being an emerging infectious disease and as the world's environment changes with more floods and environmental disasters, the burden of leptospirosis is expected to increase. The objectives of the systematic review were to explore how leptospirosis affects pregnancy, its burden in this population, its effects on maternal and fetal outcomes and the evidence base surrounding treatment options. We performed a systematic review of published and unpublished literature using automated and manual methods to screen nine electronic databases since inception, with no language restriction. Two reviewers independently screened articles, completed the data extraction and assessment of risk of bias. Due to significant heterogeneity and paucity of data, we were unable to carry out a meta-analysis, but we conducted a pooled analysis of individual patient data from the case reports and case series to examine the patient and disease characteristics, diagnostic methods, differential diagnoses, antibiotic treatments, and outcomes of leptospirosis in pregnancy. The protocol for this review was registered on the International Prospective Register of Systematic Reviews, PROSPERO: CRD42020151501. We identified 419 records, of which we included eight observational studies, 21 case reports, three case series and identified four relevant ongoing studies. Overall the studies were with moderate bias and of 'fair' quality. We estimated the incidence of leptospirosis in pregnancy to be 1.3 per 10,000 in women presenting with fever or with jaundice, but this is likely to be higher in endemic areas. Adverse fetal outcomes were found to be more common in pregnant patients who presented in the second trimester compared with patients who presented in the third trimester. There is overlap between how leptospirosis presents in pregnancy and in the general population. There is also overlap between the signs, symptoms and biochemical disturbances associated with leptospirosis in pregnancy and the presentation of pregnancy associated conditions, such as Pre-Eclampsia (PET), Acute Fatty Liver of Pregnancy (AFLP) and HELLP Syndrome (Haemolysis Elevated Liver enzymes Low Platelets). In 94% of identified cases with available data, there was an indicator in the patient history regarding exposure that could have helped include leptospirosis in the clinician's differential diagnosis. We also identified a range of suitable antibiotic therapies for treating leptospirosis in pregnancy, most commonly used were penicillins. This is the first systematic review of leptospirosis in pregnancy and it clearly shows the need to improve early diagnosis and treatment by asking early, treating early, and reporting well. Ask early-broaden differential diagnoses and ask early for potential leptospirosis exposures and risk factors. Treat early-increase index of suspicion in pregnant patients with fever in endemic areas and combine with rapid field diagnosis and early treatment. Report well-need for more good quality epidemiological studies on leptospirosis in pregnancy and better quality reporting of cases in literature.

Accurate Prediction of Total PlGF (Placental Growth Factor) From Free PlGF and sFlt-1 (Soluble Fms-Like Tyrosine Kinase-1): Evidence for Markedly Elevated PlGF Levels in Women With Acute Fatty Liver of Pregnancy.

Acute fatty liver of pregnancy (AFLP) is characterized by elevated circulating sFlt-1 (soluble Fms-like tyrosine kinase-1), although the free circulating levels of its ligand, PlGF (placental growth factor) are not decreased. Here, we hypothesized that women with AFLP exhibit elevated PlGF production in comparison to women with preeclampsia or hemolysis elevated liver enzymes and low platelet count syndrome. Making use of the well-known mathematical formulas describing drug-receptor interactions, we established that serum total PlGF could be accurately predicted from sFlt-1 and free PlGF levels (n=42; mean calculated KD of 50 pmol/L), yielding similar values as the previously published method of thermal dissociation of the sFlt-1-PlGF complexes (r=0.94, P<0.0001). We found that median levels of free PlGF were significantly lower in women with preeclampsia (n=13; 117pg/mL) or hemolysis elevated liver enzymes and low platelet count syndrome (n=12; 59 pg/mL) compared with women without preeclampsia (n=11; 349pg/mL, P<0.0001). In contrast, median total PlGF did not differ between women with no preeclampsia, preeclampsia, and hemolysis elevated liver enzymes and low platelet count syndrome (354 versus 435 versus 344pg/mL), whereas it was markedly elevated in AFLP compared with all groups (2054 pg/mL, P<0.0001). Furthermore, in AFLP, both sFlt-1 and total PlGF declined rapidly postdelivery, with significantly higher predelivery total PlGF (n=12; median, 2054 pg/mL) than postpartum levels (n=14; median, 163pg/mL, P<0.0001), suggesting that in AFLP, PlGF is largely placenta-derived. Collectively, our findings indicate that like sFlt-1, PlGF production is significantly upregulated in AFLP, mainly originating from the placenta. Importantly, total PlGF can now be easily calculated from already available free PlGF and sFlt-1 levels, allowing subsequent evaluation of other groups in whom PlGF is altered.

Is There a Role for Indoxyl Sulfate in Contributing to Impaired Cognition and Anxiety Following a Hypertensive Pregnancy?

Objective Women with hypertensive conditions of pregnancy are at an increased risk of developing Acute Kidney Injury (AKI) which can lead to the progression of chronic kidney disease (CKD). Patients with CKD have impairments in cognition and increases in anxiety and depression. Indoxyl Sulfate (I.S.), a uremic toxin associated with CKD progression, has been reported to contribute to spatial memory impairment. We hypothesized that impairments in learning and memory and anxiety among rats with a previous hypertensive pregnancy (Hemolysis elevated liver enzyme low platelet – HELLP Syndrome) and AKI are accompanied by increased levels of I.S. Study Design On gestational day (GD) 12, sFlt-1 and sEng were infused via mini-osmotic pumps into the abdomen of timed-pregnant Sprague Dawley rats to induce HELLP. A subset of rats underwent either bilateral renal ischemia-reperfusion surgery for 45 minutes on GD18 to induce AKI or a SHAM surgery. Rats were either euthanized on GD19 to assess I.S. levels during pregnancy or at post-partum week (PPW) 15. Between PPW 11-13 rats underwent Barnes Maze and anxiety testing. I.S. concentrations were measured in the circulation and brainstem of rats. Tissue concentrations were normalized to total protein and group comparisons analyzed via statistical analysis where p<0.05 was considered significant. N=9-14 rats/group. Results HELLP and AKI rats displayed hypertension (p<0.05) and kidney injury (p<0.05) relative to NP rats at both time periods. There was a significant group (p=0.04) effect in Barnes maze with NP rats finishing the test significantly faster relative to all other groups by the 5th day of testing (p<0.03). There was a significant difference between groups in anxiety where HELLP+AKI rats spent significantly less time in the open area of the zero maze compared to NP+AKI rats (p=0.02). When the groups were compared there were no changes in circulating I.S. at GD19 (p=0.06) or at PPW15 (p=0.78). Brainstem levels of I.S. during pregnancy were increased in response to AKI and were significantly increased in NP+AKI vs. HELLP rats (p=0.02). However, by PPW15 brainstem levels of I.S. were trending towards an increase among HELLP+AKI rats vs. NP+AKI rats (p=0.06). Conclusion The results from this study suggest that AKI during pregnancy contributes to behavioral deficits, hypertension and imbalances in brainstem I.S. concentrations. We are currently examining other regions of the brain and increasing the N in the I.S. studies (currently n=3-5/group). As I.S. could possibly be one the mechanisms causing impairments in learning and memory after a hypertensive pregnancy complicated by AKI, additional studies to determine if blockade of I.S. results in improvements in cognition and anxiety are planned.

Preconceptional maternal weight loss and hypertensive disorders in pregnancy: a systematic review and meta-analysis.

Hypertensive disorders of pregnancy (HDP), including pregnancy-induced hypertension (PIH), Preeclampsia (PE), Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) and chronic hypertension, are leading causes of maternal and perinatal morbidity and mortality. Although the pathophysiology of HDP is complex, preconceptional weight reduction in obese women might reduce these complications. We conducted a systematic review and meta-analysis to investigate the effectiveness of preconceptional weight loss by lifestyle intervention or bariatric surgery in overweight and obese women and the reduction of the risk of HDP. Databases are searched until September 2019 resulting in 2547 articles: 110 full-text analysis and 29 detailed analysis. Reduced risks were shown for HDP in seven articles (n = 4381) of weight loss after lifestyle intervention or bariatric surgery (OR range 0.10-0.64), for PIH in four articles (n = 46,976) (OR range 0.14-0.79), and for PE in seven articles (n = 169,734) (OR range 0.14-0.84). The stratified analysis of weight loss after lifestyle intervention and bariatric surgery shows comparable results. The meta-analysis of 20 studies of the effectiveness of lifestyle intervention and bariatric surgery revealed reduced risks of HDP (OR 0.45 (95% CI 0.32-0.63)), PIH (OR 0.61 (95%CI 0.44-0.85)) and PE (OR 0.67 (95%CI 0.51-0.88)). Preconceptional weight loss after lifestyle intervention or bariatric surgery is effective in reducing risks of HDP, PIH and PE, and emphasizes the need to optimize weight in overweight and obese women with a child wish. More research is recommended to investigate short-term and long-term beneficial and harmful side-effects of these interventions on maternal and offspring health.

Prediction of Preeclampsia-Related Adverse Outcomes With the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor)-Ratio in the Clinical Routine: A Real-World Study.

This retrospective real-world study investigated the clinical use of the sFlt-1 (soluble fms-like tyrosine kinase 1)/PlGF (placental growth factor) ratio alone or in combination with other clinical tests to predict an adverse maternal (maternal death, kidney failure, hemolysis elevated liver enzymes low platelets-syndrome, pulmonary edema, disseminated intravascular coagulation, cerebral hemorrhage, or eclampsia) or fetal (delivery before 34 weeks because of preeclampsia and/or intrauterine growth restriction, respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, placental abruption or intrauterine fetal death or neonatal death within 7 days post natum) pregnancy outcome in patients with signs and symptoms of preeclampsia. We evaluated the sFlt-1/PlGF-ratio cutoff values of 38 and 85 and evaluated its integration into a multimarker model. Of 1117 subjects, 322 (28.8%) developed an adverse fetal or maternal outcome. Patients with an adverse versus no adverse outcome had a median sFlt-1/PlGF-ratio of 177 (interquartile range, 54-362) versus 14 (4-64). Risk-stratification with the sFlt-1/PlGF cutoff values into high- (>85), intermediate- (38-85), and low-risk (<38) showed a significantly shorter time to delivery in high- and intermediate- versus low-risk patients (4 versus 8 versus 29 days). When integrating all available clinical information into a multimarker model, an area under the curve of 88.7% corresponding to a sensitivity, specificity, positive and negative predictive value of 80.0%, 87.3%, 75.0%, and 90.2% was reached. The sFlt-1/PlGF-ratio alone was inferior to the full model with an area under the curve of 85.7%. As expected, blood pressure and proteinuria were significantly less accurate with an area under the curve of 69.0%. Combining biomarker measurements with all available information in a multimarker modeling approach increased detection of adverse outcomes in women with suspected disease.

Clinical presentation and outcomes of pre-eclampsia and eclampsia at a national hospital, Kenya: A retrospective cohort study.

Hypertensive disorders in pregnancy including pre-eclampsia are associated with maternal and newborn mortality and morbidity. Early detection is vital for effective treatment and management of pre-eclampsia. This study examines and compares the clinical presentation and outcomes between early- and late-onset pre-eclampsia over a two year period. A retrospective cohort study design which examines socio-demographic characteristics, treatment, outcomes, and fetal and maternal complications among women with early onset of pre-eclampsia (EO-PE) and late onset of pre-eclampsia (LO-PE). De-identified records of women who attended antenatal, intrapartum and postnatal care services and experienced pre-eclampsia at Kenyatta National teaching and referral hospital were reviewed. We used chi square, t-test, and calculated odds ratio to determine any significant differences between the EO-PE and LO-PE cohorts. Out of 620 pre-eclamptic and eclamptic patients' records analyzed; 44 percent (n = 273) exhibited EO-PE, while 56 percent had late onset. Women with EO-PE compared to LO-PE had greater odds of adverse maternal and perinatal outcomes including hemolysis elevated liver enzymes and low platelets (HELLP) syndrome (OR: 4.3; CI 2.0-10.2; p<0.001), renal dysfunction (OR; 1.7; CI 0.7-4.1; p = 0.192), stillbirth (OR = 4.9; CI 3.1-8.1; p<0.001), and neonatal death (OR: 8.5; CI 3.8-21.3; p<0.001). EO-PE was also associated with higher odds of prolonged maternal hospitalization, beyond seven days (OR = 5.8; CI 3.9-8.4; p<0.001), and antepartum hemorrhage (OR = 5.8; CI 1.1-56.4; p<0.001). Neonates born after early onset of pre-eclampsia had increased odds of respiratory distress (OR = 17.0; CI 9.0-32.3, p<0.001) and birth asphyxia (OR: 1.9; CI 0.7-4.8; p = 0.142). The profiles and outcomes of women with EO-PE (compared to late onset) suggest that seriousness of morbidity increases with earlier onset. To reduce adverse neonatal and maternal outcomes, it is critical to identify, manage, referral and closely follow-up pregnant women with pre-eclampsia throughout the pregnancy continuum. This study protocol was approved by Population Council's research ethics Institutional Review Board, Protocol 813, and KNH-UoN Ethics and Research Committee, Protocol 293/06/2017.

Differences in Post-Delivery Blood Pressures Between Women Who Will Develop Postpartum Preeclampsia and Controls [12M

INTRODUCTION: Postpartum preeclampsia (with first clinical manifestation after delivery) is poorly understood but has the potential for catastrophic consequences for patients. Predictive variables in the postpartum period may improve outcomes. The purpose of this study was to determine if there is a difference in blood pressure in the immediate postpartum period (delivery to discharge) in women readmitted with postpartum preeclampsia and controls. METHODS: Deliveries in a 5-year interval (2014-2019) at a university hospital were included in this retrospective cohort study (n=3,621 unique patients). IRB committee waiver was obtained for the study. Exclusion criteria were diagnosis of preeclampsia, eclampsia, or Hemolysis Elevated Liver Enzymes Low Platelets (HELLP) prior to delivery. Cases included readmissions for preeclampsia, eclampsia, or HELLP diagnosed after delivery (n=26). Controls were randomized from remaining patients (3:1 controls to cases, inflated by 10% to account for prevalence of exclusion criteria) (n=78). Each subject’s highest systolic (SBP) and diastolic blood pressure (DBP) from delivery until discharge was recorded. Two sample t-tests were used, significance set at 0.05. RESULTS: The mean peak SBP for cases was significantly higher than controls at 147.4 mmHg (SD 13.4 mmHg) compared to 133.3 mmHg (SD 12.0 mmHg) (P&lt;.001). Mean peak DBP for cases was also higher than controls at 91.6 mmHg (SD 8.7 mmHg) compared to 82.9 mmHg (SD 8.0) (P&lt;.001). CONCLUSION: Blood pressure in the immediate postpartum period was higher in women readmitted for postpartum preeclampsia compared to controls. This information may be a first step in developing a predictive model to better understand and predict postpartum preeclampsia.

Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): rationale and design of a multicenter randomized controlled trial

BackgroundHypertensive disorders of pregnancy (HDP), such as preeclampsia (PE) or the Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) syndrome are associated with elevated cardiovascular disease (CVD) risks, but standardized prevention guidelines after such pregnancies are lacking. Hypertension is the first emerging risk factor after PE/HELLP pregnancies and is a major risk factor for CVD. Hypertension before the age of 55 years may lead to various manifestations of end-organ damage at relatively young age. Therefore, timely treatment of elevated blood pressure is mandatory, but many of these high-risk women have long-term undetected and untreated hypertension before adequate treatment is initiated.AimThe aim of our study is to assess whether home blood pressure monitoring (HBPM) in women with a previous PE/HELLP pregnancy is a valuable tool for the early detection of hypertension.MethodsWomen with a history of both early and late PE/HELLP syndrome aged 40–60 years are invited to participate. Patients with a history of CVD, known hypertension and/or use of antihypertensive medication are excluded. Women are randomized between HPBM or ‘usual care’. The primary outcome is feasibility and usability of HBPM after 1 year of follow-up.Secondary outcomes will be the effectiveness of HPBM to detect hypertension, the efficacy of BP treatment, quality of life, health-related symptoms, work ability, and life-style behaviour.The results of this study will provide better strategies for timely detection and prevention of hypertension in women after PE/HELLP.Trial registrationClinicalTrials.gov, NCT03228082. Registered June 15, 2017.

Analytical study to determine the impact of jaundice in pregnancy on maternal and perinatal outcome

Background: Jaundice in pregnancy carries a grave prognosis for both the foetus and the mother, and is responsible for 12% of maternal deaths. Liver disease is a rare complication of pregnancy, but when it occurs it may do so in a dramatic and tragic fashion for both the mother and infant. Materials and Methods: Data were collected as prospective Hospital based observational study at tertiary care centre. After the preliminary assessment with regard to the inclusion and exclusion criteria, informed consent was obtained from all patients. Thorough history was taken and physical examination was done. Demographic details of each patient were obtained. Relative investigations were done. Results: Out of 300 patients, 287 were healthy and alive and 13 patients died. The maternal mortality was 4.33%. Out of the total 13 maternal deaths, 4 cases died due to hepatic encephalopathy, 3 due to disseminated-intravascular coagulation and 3 due to sepsis with multiorgan failure. Mortality was due to HELLP- Hemolysis Elevated Liver enzymes and Platelet count in two cases and due to acute fatty liver in one case. In 126 (42%) cases, the mode of delivery was lower segment caesarean section, 138 (46%) cases had normal vaginal delivery, while 36 (12%) cases had undergone abortion. A total of 114 (38%) cases delivered full-term live baby and 78 (26%) cases delivered preterm live baby. Full-term intrauterine foetal death (IUFD) was seen in 15 (5%) cases and preterm IUFD was seen in 69 cases (23%). There was neodeath in 24 (8%) babies. The total perinatal mortality was 36.0%. Conclusion: The present study shows that although liver dysfunction is infrequently seen in pregnancy, it can result in severe maternal and foetal compromise. Jaundice in pregnancy should be managed as a team with the collaboration of the department of obstetrics, internal medicine, gastroenterology, anaesthesia and critical care so that early diagnosis and aggressive management can prevent and reduce foeto–maternal morbidity and mortality.