Non-proteinuric Hypertension Research Articles

Placental Malarial Infection as a Risk Factor for Hypertensive Disorders During Pregnancy in Africa: A Case-Control Study in an Urban Area of Senegal, West Africa

In tropical countries, malaria and hypertension are common diseases of pregnancy. They have physiopathologic similarities such as placental ischemia, endothelial dysfunction, and production of proinflammatory cytokines. Recent findings suggested their possible link. The authors conducted a case-control study to explore the relation between malaria and hypertension at Guediawaye, a hypoendemic malarial setting in Senegal. Cases were pregnant women admitted to the delivery unit for hypertension. Controls were pregnant women admitted for normal delivery, without any history of hypertension or proteinuria during the present pregnancy. Malarial infection was determined by placental tissue examination. From January to December 2002, 77 cases of gestational hypertension, 113 cases of preeclampsia, 59 cases of eclampsia, and 241 controls were enrolled. Placental malarial infection (PMI) was present in 14 cases (6.3%) and in 15 controls (6.2%). The prevalence of PMI was 4.6% for eclampsia, 4.0% for preeclampsia, and 11.6% for gestational hypertension. In multivariate analysis, PMI appeared to be an independent risk factor for gestational hypertension (adjusted odds ratio = 2.7, 95% confidence interval: 1.0, 7.6). The authors found an association between PMI and nonproteinuric hypertension in women living in a malaria-hypoendemic area. The exact significance of such relation should be clarified in further studies in different settings of malarial endemicity.

Incidence of gestational hypertension in the Calgary Health Region from 1995 to 2004

Hypertension is one of the most common medical conditions complicating pregnancy, and is a major contributor to maternal, fetal and neonatal morbidity and mortality in Canada. To determine the incidence and trends of gestational hypertension among pregnant women in the Calgary Health Region of Alberta. Gestational hypertension was classified according to current published Canadian guidelines: without proteinuria and with proteinuria. Hospital discharge abstracts were used to identify women diagnosed with gestational hypertension in the Calgary Health Region between January 1995 and December 2004. The Birth Registry of Vital Statistics was used to determine the number of live births and stillbirths in the Calgary Health Region during the study period. Incidence was calculated with 95% CIs. Age-standardized gestational hypertension rates were calculated using 2004 live births and stillbirths as the reference. Over the 10-year period, the incidence of nonproteinuric gestational hypertension was relatively stable even after age adjustment, with an average incidence of 6.3% (95% CI 6.1% to 6.4%). When gestational hypertension was stratified by age, women aged 35 years or older had an almost twofold higher incidence of both nonproteinuric and proteinuric gestational hypertension than those younger than 35 years of age. Interventions to prevent and improve the management of gestational hypertension, particularly among women aged 35 years and older, are required.

Inherited Thrombophilia and Preeclampsia Within a Multicenter Cohort: The Montreal Preeclampsia Study

Previous studies have suggested that inherited thrombophilia (hypercoagulability) may be associated with preeclampsia. Most of these studies were retrospective and showed positive associations between preeclampsia and several inherited thrombophilia polymorphisms. This prospective, multicenter case―control study investigated the association between inherited thrombophilia and preeclampsia among a cohort of 5337 pregnant women who were participants in the Montreal Preeclampsia Study, a large multicenter study of causal pathways of preterm birth. Of the 5165 woman followed up to delivery, 113 women (2.2%) developed preeclampsia and became the study group; 443 women who did not develop preeclampsia or nonproteinuric gestational hypertension became the control group. Prenatal blood samples were analyzed for the presence of 3 inherited thrombophilia polymorphisms (factor V Leiden, prothrombin G20210A, and methylenetetrahydrofolate reductase C677T mutations), and homocysteine and folate levels were measured. The frequency of placental underperfusion (infarction, decidual vasculopathy, or syncytial knotting) was determined by pathological examination in all participants. Inherited thrombophilias were not more frequent in the study group than in the control group (14% vs. 21%, respectively); the adjusted odds ratio was 0.6, with a 95% confidence interval, of 0.3 to 1.3. Similar results were found for each individual thrombophilia, and were unchanged when the analysis was restricted to patients with early onset or severe preeclampsia. Homocysteine levels were higher in the control group than the study group. Placental underperfusion was found more frequently in the study group than in control group (63.2% vs. 46.2%, P < 0.0001) and among women with folate levels in the lowest quartile of control values (P = 0.04). There was no association, however, between placental underperfusion and thrombophilia either collectively or by individual mutation. These findings do not indicate an increased risk of preeclampsia among women with any of 3 inherited thrombophilias. The increase in placental underperfusion among women with preeclampsia seems to be associated with low plasma folate levels but not with the 3 thrombophilias examined.

Association Between Insulin Resistance, Glucose Intolerance, and Hypertension in Pregnancy

There is an association between insulin resistance, glucose intolerance, and essential hypertension, but the relation between insulin resistance, glucose intolerance, and hypertension diagnosed during pregnancy is not well understood. Transient hypertension of pregnancy, the new-onset nonproteinuric hypertension of late pregnancy, is associated with a high risk of later essential hypertension and glucose intolerance; thus, these conditions may have a similar pathophysiology. To assess the association between insulin resistance, glucose intolerance, essential hypertension, and subsequent development of proteinuric and nonproteinuric hypertension in pregnancy in women without underlying essential hypertension, we performed a prospective study comparing glucose (fasting, 1 and 2 hours postglucose load), insulin, glycosylated hemoglobin (HbA1c), high-density lipoprotein cholesterol (HDL-C), and triglycerides levels on routine screening for gestational diabetes mellitus. Women who developed hypertension in pregnancy (n = 37) had higher glycemic levels (fasting, 1 and 2 hours postglucose load) on a 100-gram oral glucose loading test, although only the fasting values showed a statistical significance (p < 0.05), and a significantly higher frequency of abnormal glucose loading tests, two hours after glucose load (>or=140 mg/dL) (p < 0.05) than women who remained normotensive (n = 180). Glucose intolerance was common in women who developed both subtypes of hypertension, particularly preeclampsia. Women who developed hypertension had greater prepregnancy body mass index (p < 0.0001), higher frequency and intensity of acanthosis nigricans (p < 0.0001), and higher baseline systolic and diastolic blood pressures (p <or= 0.0001 for both), although all subjects were normotensive at baseline by study design; they also presented lower levels of HDL-C (p < 0.05). However, after adjustment for these and other potential confounders, an abnormal glucose loading test remained a significant predictor of development of hypertension (p < 0.05) and, specifically, preeclampsia (p < 0.01). There was a trend toward higher insulin and homeostasis model assessment-insulin resistance (HOMA-IR) levels in women developing any type of hypertension. When comparing women that remained normotensive to term with those with transient hypertension and preeclampsia, the preeclamptic women were born with lower weight (p < 0.05) and shorter length (p < 0.005); at screening they were older (p < 0.005), showed higher frequency and intensity of acanthosis nigricans (p < 0.0001), had higher prepregnancy BMI (p < 0.0005), as well as higher baseline systolic and diastolic blood pressures (p <or= 0.0001 for both). They also showed higher HOMA-IR levels that did not show a statistical significance. When glucose tolerance status was taken in account, an association was found between increasing indexes of hypertension (p < 0.05) and of HOMA-IR (p < 0.05) with the worsening of glucose tolerance. These results suggest that insulin resistance and relative glucose intolerance are associated with an increased risk of new-onset hypertension in pregnancy, particularly preeclampsia, and support the hypothesis that insulin resistance may play a role in the pathogenesis of this disorder.

Valores de proteinuria y daño vascular en gestantes sanas, preeclámpticas y con hipertensión no proteinúrica, evaluados por ultrasonografía vascular

ObjectiveTo compare the effectiveness of vascular ultrasonography and proteinuria in diagnosing systemic vascular damage. Subjects and methodsForty healthy pregnant women, 35 with preeclampsia, and 35 with non-proteinuric hypertension in the Yanahuara and Nacional del Sur hospitals in Arequipa (Peru) underwent measurement of blood pressure, proteinuria, and ultrasonographic studies in the humeral artery to obtain their flow-mediated dilation (FMD). Comparisons between the three groups were made using ANOVA or Kruskal-Wallis tests, depending on whether the distribution was normal or non-normal, respectively. Values of P<0.05 were considered statistically significant. ResultsProteinuria values were 0.05 g/24 h, 2.57 g/24 h and 0.21 g/24 h while FMD values showed mean values of 0.66mm, 0.25mm, and 0.45mm for healthy pregnant women, women with preeclampsia and women with non-proteinuric hypertension, respectively. Comparison of FMD among groups showed significant differences among the groups (P<.01). However, proteinuria values in the group with non-proteinuric hypertension were within the normal range (< 0.03 g/24 h). No relation was found between FMD and proteinuria. ConclusionsUltrasonographic evaluation of FMD detected vascular damage even in the group of pregnant women with pregnancy-induced hypertension without proteinuria.

Inherited thrombophilia and preeclampsia within a multicenter cohort: the Montreal Preeclampsia Study

We sought to evaluate the association between inherited thrombophilia and preeclampsia. From a multicenter cohort of 5337 pregnant women, we prospectively identified 113 women who developed preeclampsia and selected 443 control subjects who did not have preeclampsia or nonproteinuric gestational hypertension. Blood samples were tested for DNA polymorphisms affecting thrombophilia (factor V Leiden mutation, prothrombin G20210A mutation, methylenetetrahydrofolate reductase C677T polymorphism), homocysteine, and folate levels, and placentae underwent pathological evaluation. Thrombophilia was present in 14% of patients and 21% of control subjects (adjusted logistic regression odds ratio, 0.6; 95% confidence interval, 0.3-1.3). Placental underperfusion was present in 63% of patients vs 46% of control subjects (P < .001) and was more frequent in women with folate levels in the lowest quartile (P = .04), but was not associated with thrombophilia. We did not find evidence to support an association between inherited thrombophilia and increased risk of preeclampsia. Placental underperfusion is associated with preeclampsia, but this does not appear to be consequent to thrombophilia.

Antepartum Percutaneous Renal Biopsy

Percutaneous needle biopsy of the kidney has long been the definitive means of determining the cause of hypertension in pregnant women, even though its safety remains controversial. Diagnosing underlying renal disease might appropriately postpone delivery, whereas preeclampsia (PE) might indicate for immediate delivery. This study evaluated ultrasound-guided thin-needle renal biopsy in 36 women with hypertensive disease (but a diastolic blood pressure no higher than 105 mm Hg and a blood platelet count of no less than 100 × 109/liter) and 18 healthy pregnant women. The former group included 28 women with PE and 8 with nonproteinuric hypertension. PE was rated as severe in 13 women at the time of biopsy. The same highly experienced physician did all biopsies following a standardized procedure. Glomerular endotheliosis—a structural condition typical of PE—was found in all hypertensive women but was more marked in those with PE. Similar changes were observed in 11 of the 18 nonhypertensive women. Discomfort from the biopsy procedure was most often minor; 3 women described loin pain. One woman had a rim of blood about the lower kidney but recovered fully within 2 days. The patient with the most marked glomerular changes had severe pain and was found to have a retroperitoneal hematoma and 2 small bleeding arteries. She recovered well following arterial embolization with metal coils and emergency cesarean delivery. Few complications of note followed thin-needle renal biopsy in this study, but complications can occur and glomerular endotheliosis is not pathognomonic for PE. It probably is best not to do an antepartum renal biopsy when renal function is deteriorating rapidly and the kidneys are swollen. If biopsy is mandatory, an ultrasonographically guided procedure should be performed by a skilled and experienced practitioner.

A randomized trial of tight vs. less tight control of mild essential and gestational hypertension in pregnancy

To assess the effects of applying a tight vs. a less tight control of mild chronic essential or gestational non-proteinuric hypertension in pregnancy. A randomized trial was conducted in 2006-2007 in the University of Ain Shams, Egypt. Eligible participants (n=125) were randomly assigned to either tight or less tight control of mild chronic (essential) or gestational (non-proteinuric) hypertension. The primary outcome measure was the development of severe hypertension during follow-up. Analysis was by intention-to-treat. In the tight target group, adjustment of the dose with an increment of 191 mg yielded a mean dose of methyldopa of 1267+/-406 mg. Both systolic and diastolic BP levels were significantly less than in the tight target group. More women in the less tight group had severe hypertension during follow up (RR 3.167 and 95% CI 1.36-7.37). The rate of antenatal hospitalization was significantly higher in the less tight target group with a relative risk of 2.57 and 95% CI 1.16-5.70. The gestational age at delivery was significantly better in the tight target group. Preterm delivery and birth weight were not significantly different between the study groups. Tight control of blood pressure reduces the rate of antenatal hospitalization and does not adversely affect perinatal outcomes in women with mild essential or gestational hypertension.

Antepartum percutaneous renal biopsy

Objective To assess the value and adverse effects of an ultrasound-guided renal biopsy technique in women with normal and pathologic pregnancies. Method Biopsy samples were taken from 36 women with hypertensive disease (28 with pre-eclampsia) and 18 healthy pregnant women using a thin needle and an ultrasound-guided biopsy device. Results Glomerular endotheliosis, a structural change typical of pre-eclampsia, was found in all hypertensive women, but it was more pronounced in the 28 pre-eclamptic women than in the 8 women with nonproteinuric hypertension. A similar change, however, was seen in 11 of the 18 controls. One serious adverse event occurred, retroperitoneal hematoma, in the woman with the most severe pre-eclampsia. Conclusion Glomerular endotheliosis is not to be considered pathognomonic for pre-eclampsia. Few complications followed renal biopsy in this study, but complications arose in the sickest patient. It is probably not advisable to perform antepartum renal biopsies in pregnant women with a rapidly deteriorating renal function and swollen kidneys. In these women, the biopsy does not facilitate diagnosis and is hazardous.

The psychosocial outcomes of antenatal day care for three medical complications of pregnancy: A randomised controlled trial of 395 women

Although antenatal day care is becoming increasingly common, there is little evidence as to the psychosocial efficacy of this model of care. We aimed to assess the broader psychosocial impact of antenatal day care compared with admission to hospital. We carried out a randomised trial of 395 women, randomly assigned in a 2 : 1 ratio between day care and antenatal ward, stratified for major diagnostic categories (proteinuric hypertension, non-proteinuric hypertension and preterm premature rupture of membranes). Main outcome measures--self-report questionnaires (response rates ranging from 80 to 90%) were sent to women's homes four days after randomisation and seven weeks after delivery. Overall, there were statistically significant differences favouring day care in 12 of 28 items at four days post-randomisation, with no differences in the two groups for the other 16 items. At seven weeks postdelivery, we found differences in eight of 28 items favouring day care, with no differences in the two groups for the other 20 items. The types of items indicating a sustained difference covered a range of aspects of care and included satisfaction with staff, continuity of carer, information transfer, and social support. There were no differences in relation to infant feeding and relationship with the baby. Day care has an effect on women's satisfaction with care but does not produce broader psychosocial outcomes.

Total and free tissue factor pathway inhibitor in pregnancy hypertension

To clarify the role played by tissue factor pathway inhibitor (TFPI) in pregnancy hypertension. Using enzyme-linked immunosorbent assays, hemostatic measurements were obtained for women with pre-eclampsia (n=51), nonproteinuric hypertension of pregnancy (n=62), postpartum pre-eclampsia 24 h after childbirth (n=31), and no hypertension (healthy pregnant controls, n=100). There was a significant increase in circulating free TFPI levels in women with pre-eclampsia (9.7+/-6.2 ng/mL) or nonproteinuric hypertension of pregnancy (8.3+/-5.3 ng/mL) compared with healthy controls (5.3+/-2.1 ng/mL). In women with pre-eclampsia the levels remained elevated after placental delivery (10.6+/-4.0 ng/mL). Free protein S levels were significantly higher in women with pre-eclampsia (40.0%+/-10.7%), nonproteinuric hypertension of pregnancy (37.1%+/-12.5%), or postpartum pre-eclampsia (39.3%+/-9.1%) than in healthy pregnant controls (32.2%+/-8.5%). Increased levels of the physiologically active free forms of TFPI and free protein S, 2 coagulation inhibitors, may protect women with pregnancy-induced hypertension from the risks of hemostatic activation.

Doppler velocimetry of uterine arteries predicts perinatal outcome in patients with non-proteinuric hypertension in pregnancy

Doppler velocimetry of uterine arteries predicts perinatal outcome in patients with non-proteinuric hypertension in pregnancy

Bed rest with or without hospitalisation for hypertension during pregnancy

Bed rest or restriction of activity, with or without hospitalisation, have been advocated for women with hypertension during pregnancy to improve pregnancy outcome. However, benefits need to be demonstrated before such interventions can be recommended since restricted activity may be disruptive to women's lives, expensive, and increase the risk of thromboembolism. To assess the effects on the mother and the baby of different degrees of bed rest, compared with each other, and with routine activity, in hospital or at home, for primary treatment of hypertension during pregnancy. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2005), and EMBASE (January 2002 to December 2004). Randomised trials evaluating bed rest for women with hypertension in pregnancy were selected. Two review authors assessed trials for inclusion independently, and extracted data. Data were entered into RevMan software and double-checked. Four small trials (449 women) were included. Three were of good quality. Two trials (145 women) compared strict bed rest with some rest, in hospital, for women with proteinuric hypertension. There was insufficient evidence to demonstrate any differences between the groups for reported outcomes. Two trials (304 women) compared some bed rest in hospital with routine activity at home for non-proteinuric hypertension. There was reduced risk of severe hypertension (1 trial, 218 women; RR 0.58, 95% CI 0.38 to 0.89) and a borderline reduction in risk of preterm birth (1 trial, 218 women; RR 0.53, CI 0.29 to 0.99) with some rest compared to normal activity. More women in the bed rest group opted not to have the same management in future pregnancies, if the choice were given (1 trial, 86 women; RR 3.00, 95% CI 1.43 to 6.31). There were no significant differences for any other outcomes. Few randomised trials have evaluated rest for women with hypertension during pregnancy, and important information on side-effects and cost implication is missing from available trials. Although one small trial suggests that some bed rest may be associated with reduced risk of severe hypertension and preterm birth, these findings need to be confirmed in larger trials. At present, there is insufficient evidence to provide clear guidance for clinical practice. Therefore, bed rest should not be recommended routinely for hypertension in pregnancy, especially since more women appear to prefer unrestricted activity, if the choice were given.

An accurate automated blood pressure device for use in pregnancy and pre‐eclampsia: the Microlife 3BTO‐A

To assess the accuracy of an automated blood pressure device (Microlife 3BTO-A) in pregnancy and pre-eclampsia according to the British Hypertension Society (BHS) protocol. Prospective observational study. Antenatal ward and clinics at Guy's and St Thomas' Hospital, London, UK. One hundred and five pregnant women including 35 women with non-proteinuric hypertension and 35 with pre-eclampsia. Two trained observers took nine sequential same-arm measurements from each woman. Measurements alternated between a mercury sphygmomanometer and the device. Grading criteria of the BHS protocol (A/B grade = pass; C/D grade = fail). The device passed the BHS protocol by achieving an A/B grade. It also achieved criteria of the Association for the Advancement of Medical Instrumentation for systolic and diastolic pressures respectively, in normotensive [-0.5 (5.7) mmHg; -0.07 (7.7) mmHg], non-proteinuric hypertensive [-3.3 (6.9) mmHg; -2.4 (6.6) mmHg] and pre-eclamptic pregnancy [-4.1 (6.4) mmHg; -1.3 (7.9) mmHg]. The Microlife 3BTO-A can be recommended for use in a pregnant population, including pre-eclampsia, according to the BHS protocol.

First Trimester Sex Hormone-Binding Globulin and Subsequent Development of Preeclampsia or Other Adverse Pregnancy Outcomes

Objective. To investigate whether first trimester maternal serum sex hormone-binding globulin (SHBG) concentrations are altered in women who subsequently develop preeclampsia or other pregnancy complications. Population. Women undergoing first trimester combined ultrasound and biochemical screening for chromosomal anomalies. We searched the database and identified 32 pregnancies resulting in miscarriage, 64 pregnancies with preexisting or gestational diabetes mellitus, 107 with fetal growth restriction, 103 with preeclampsia, 64 with pregnancy-induced hypertension, and 26 with spontaneous preterm delivery. We also selected 400 controls from among the population of pregnancies that had a delivery of a normal baby with no pregnancy complications. Methods. Maternal serum SHBG concentrations were measured retrospectively using a competitive chemiluminescent immunoassay. The levels between those with normal outcome and those resulting in adverse outcome were compared. Results. The median maternal serum SHBG concentration was not significantly different from controls, in those that subsequently developed preeclampsia (median MoM 1.05), nonproteinuric hypertension (median MoM 0.94) or preterm delivery (median MoM 1.15). The levels were significantly lower in those with diabetes (median MoM, 0.81 p = 0.0005) and those pregnancies resulting in miscarriage (median MoM 0.80, p = 0.008). Conclusion. First trimester maternal serum SHBG concentrations are no different from controls in women who subsequently develop preeclampsia, pregnancy-induced hypertension, fetal growth restriction, or preterm delivery. Levels are reduced in those who subsequently miscarry or in those presenting with diabetes.

Editor's Choice

Britain has the highest teenage pregnancy rate in the European Union. While the social burden of this is considerable, it may be that pregnancy itself poses little health risk to teenagers or their babies. Now, from Sweden, comes evidence that teenage mothers face a higher risk of premature death in later life (Olausson et al., pages 793–799). These women's lifestyles and their continued exposure to a hostile social environment contribute to their early demise. In an accompanying commentary, Drife (pages 763–764) suggests a dual approach of preventing unwanted teenage pregnancies whilst supporting those who wish to have their babies. Ultrasound has been the cornerstone for fetal imaging for a number of years but in-utero Magnetic Resonance Imaging (MRI) may be better at visualising some aspects of fetal anatomy. On pages 784–792, Whitby et al. compare ultrasound and MRI imaging in pregnancies with suspected fetal brain abnormalities and suggest that where ultrasound is equivocal, MRI provides information which can potentially change clinical management. The authors do not report a direct comparison of MRI versus ultrasound so while MRI may have a role in clarifying ultrasound suspected abnormalities it should not become the screening method of choice in all pregnancies. As women live longer, the limitations of traditional methods of prolapse surgery become more apparent. Dwyer and O' Reilly, from Australia (pages 831–836) describe a promising new approach to the use of synthetic mesh in vaginal surgery. Meanwhile, the debate about the place of tension free vaginal tape (TVT) in the treatment of urinary incontinence continues. Trial evidence supports TVT as an effective and less morbid alternative to Burch colposuspension but a group from St George's Hospital (Karantanis et al., pages 837–841) report that in women over sixty five it is associated with lower satisfaction rates. Developing new surgical techniques should not distract us from subjecting routine aspects of postoperative care to rigorous evaluation. Results of a randomised comparison of short and long term post-operative bladder catheterisation following vaginal surgery for prolapse are reported on pages 828–830. Women in the long-term catheterisation group were less likely to undergo repeat catheterisation, but experienced a higher incidence of urinary tract infection and a longer hospital stay. The authors conclude that the disadvantages of short-term catheterisation outweigh the advantages, but crucially omit to present any data on women's perceptions of the quality of their care. The last few years have seen the publication of many clinical guidelines. On pages 874–876, Zaki and colleagues deplore the wide variation in standards of intra-partum and post-partum bladder care across England and Wales and blame a lack of guidelines. However Foy and colleagues, (pages 765–770) suggest that guidelines may not always be the answer. They examined the impact of a Scottish national guideline on the management of mild non-proteinuric hypertension. Despite steps to ensure guideline implementation by a national clinical effectiveness programme, pregnant women continued to receive inconsistent clinical care. Guidelines aim to improve standards of practice but even clear consistent guidelines, supported by a national implementation programme, do not guarantee success. The global impact of the Severe Acute Respiratory Syndrome (SARS) epidemic last year cannot be overstated. Despite the plethora of publications on this topic, few papers have directly addressed the issue of SARS in pregnancy. A paper from Hong Kong (Lam et al., pages 771–774) shows that pregnant women face a higher rate of complications and require more aggressive management than non-pregnant controls. The authors provide a much needed insight into the obstetric aspects of this life threatening infection and highlight the uncertainty surrounding its treatment in pregnant women.

Clinical, psychosocial, and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women

Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward. 395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81.0% or higher) and via the hospital's financial system. Analysis was by intention to treat. All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5-9] vs 57 [35-123] h; p=0.001). Overall stay was also significantly shorter in the day-care group (mean 7.22 [SE 0.31] vs 8.53 [0.44]; p=0.014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0.01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care. Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate.

Epilepsy and pregnancy: an obstetric perspective

ObjectiveThe purpose of this study was to determine the obstetric and neonatal outcomes of women with prepregnancy diagnoses of epilepsy. Study designThis was a cohort study of women with epilepsy (n=414 women) who were delivered in a tertiary referral center (1978-2000). Outcomes were compared with women who did not have epilepsy (n=81,759 women) who were delivered during the same period, with the use of t tests or contingency table analyses. ResultsComparison showed increased rates of nonproteinuric hypertension (P<.05), induction of labor (P<.001), and fetal cardiovascular malformations (P<.001) among women with epilepsy. Rates of other antenatal, intrapartum, and neonatal complications and congenital malformations were similar to those of control subjects. There were fewer instrumental vaginal deliveries. There were no live births with neural tube defects. The occurrence of major antepartum seizures did not increase the rate of adverse outcomes significantly. Major congenital malformations increased in proportion to the number of anticonvulsants that were prescribed. ConclusionWomen with epilepsy are not at increased risk for obstetric complications, provided that appropriate care is available during preconception, pregnancy, labor, delivery, and after delivery.

Cardiovascular responses to the change from the left lateral to the upright position in pregnant hypertensives

Objective: To evaluate by non-invasive means, the autonomically mediated changes in heart rate and blood pressure in response to postural change in pregnancy. Method: Ninety-one patients were studied, of whom 17 were non-pregnant controls, 21 were normotensive parturients, 22 had non-proteinuric hypertension, and 31 were pre-eclamptics. In all patients the heart rate and blood pressure response to the change from the left lateral to the erect position was measured non-invasively, during the third trimester in the pregnant groups. Results: The change from the left lateral to the erect position induced significantly greater mean changes (increases) in systolic blood pressure in the normotensive pregnant (PC) women than all other groups ( P<0.05). Pre-eclamptic patients (PE) exhibited significantly less of an increase in systolic blood pressure than the non-proteinuric hypertensive (H) group. Both the H and PC groups showed significantly greater increases in diastolic pressure than the non-pregnant (NP) group. PE patients had a significantly smaller increase in diastolic pressure than the H group. There were no significant differences between heart rate changes when comparing the PC, NP and H groups. The PE group exhibited a significantly greater increase in heart rate on adopting the erect position than all other groups. Conclusions: Pre-eclamptics exhibit smaller changes in blood pressure than normotensive pregnant patients and non-proteinuric hypertensives on standing, while producing an exaggerated heart rate response, indicating altered autonomic compensatory mechanisms in these patients.

Glomerular endotheliosis in normal pregnancy and pre-eclampsia

Objective To investigate the proportion of women with findings characteristic for pre-eclampsia, as opposed to renal disease, in a controlled study of hypertensive pregnant women undergoing antepartum renal biopsy. Design An observational prospective controlled study. Setting University Hospital of Lund, Sweden. Sample Thirty-six previously healthy women with hypertensive disease in pregnancy, consecutively admitted to the antenatal ward at onset of disease during a 20 month period and giving informed consent, as well as 12 voluntary healthy pregnant controls. Methods Renal biopsy samples were obtained from all participants and evaluated by light microscopy, electron microscopy and immunofluorescence techniques. Main outcome measures Presence and degree of glomerular endotheliosis. Results Glomerular endotheliosis was present in all women with pre-eclampsia and gestational hypertension, and in 5 of the 12 controls, although significant differences in the degree of endotheliosis were found between the groups. Clinically undetected renal disease was not diagnosed in any of the women. Conclusion Glomerular endotheliosis was found in women with normal pregnancy as well as in both non-proteinuric and proteinuric hypertension and is consequently not, as earlier believed, pathognomonic for pre-eclampsia. The transition between normal term pregnancy, gestational hypertension and pre-eclampsia appears to be a continuous process, perhaps of increasing adaptation to pregnancy. Pre-eclampsia may be the extreme of the adaptational process, rather than a separate abnormal condition. Clinically undetected renal disease could be a rare cause of hypertension in pregnancy.