Risk Of Adverse Maternal Outcomes Research Articles

Immediate Delivery Versus Expectant Monitoring for Hypertensive Disorders of Pregnancy Between 34 and 37 Weeks of Gestation (HYPITAT-II): An Open-label, Randomized-Controlled Trial

(Lancet. 2015;385(9986):2492–2501) Hypertensive disorders of pregnancy occur in approximately 10% of all pregnancies. Although the first Hypertension and Preeclampsia Intervention Trial At Term (HYPITAT) study demonstrated that immediate delivery reduces the risk of adverse maternal outcomes for women with mild gestational hypertension or preeclampsia past 37 weeks of gestation, little is known about the risks and benefits of immediate delivery versus continuing the pregnancy for women at 34 to 37 weeks of gestation who have hypertensive disorders. This open-label, randomized-controlled trial investigated the effect of immediate delivery versus expectant management on maternal and neonatal outcomes for women with hypertensive disorders at 34 to 37 weeks’ gestation.

HBsAg positivity during pregnancy and adverse maternal outcomes: a retrospective cohort analysis.

Hepatitis B virus infection characterized by HBsAg positivity during pregnancy is a well-recognized issue in developing countries, but the association between HBsAg positivity and adverse maternal outcomes remains uncertain. To examine the association between HBsAg positivity during pregnancy and adverse maternal outcomes, a retrospective cohort study was conducted in Sichuan province, China. Deliveries were recorded from six hospitals between 1 January 2009 and 31 December 2010. Pre-eclampsia, gestational diabetes mellitus (GDM), postpartum haemorrhage (PPH), intrahepatic cholestasis, Caesarean section and placenta previa were prespecified adverse maternal outcomes. We used two multivariate logistic regression models to assess the association between HBsAg positivity and adverse maternal outcomes. In total, 948 (4.2%) pregnant women were HBsAg positive from 22 374 deliveries. Pregnant women with positive HBsAg had higher risk of GDM (aOR1.41, 95%CI 1.15-1.74), PPH (1.44, 1.13-1.83), intrahepatic cholestasis (1.74, 1.40-2.16) and Caesarean section (1.24, 1.06-1.45). No statistical associations were found between HBsAg positivity and pre-eclampsia (1.36, 0.94-1.97), and placenta previa (1.21, 0.87-1.67). HBsAg positivity during pregnancy was associated with higher risk of multiple adverse maternal outcomes. Although the causality has yet to be established, efforts may be warranted in routine care, particularly in those with high risk for adverse maternal outcomes, given the volume population infected with HBsAg. Future studies are needed to establish causality and examine the impact of HBeAg on the adverse outcomes.

756: Fetal hydrops and the risk of adverse maternal outcomes

756: Fetal hydrops and the risk of adverse maternal outcomes

Rotational vaginal delivery with Kielland's forceps: a systematic review and meta-analysis of effectiveness and safety outcomes.

The use of Kielland's forceps has declined significantly in the last three decades. There is a lack of quality evidence on potential benefits and harms associated with using these forceps. We have performed a systematic review of the literature and meta-analysis to assess the safety and efficacy of using Kielland's forceps. We have searched electronic databases for all clinical studies reporting primary data on using Kielland's forceps and assessed their risk of bias using the Newcastle-Ottawa Scale. We have pooled the event rate of adverse outcomes reported following the use of Kielland's forceps including a direct comparison to rotational ventouse. In total we included 23 studies. Direct comparison meta-analysis revealed higher failure rate with rotational ventouse compared with Kielland's. There was no statistically significant difference in the risk of adverse maternal outcomes between the two groups. There was higher risk of neonatal trauma in the ventouse group, but no significant difference in other neonatal outcomes. Kielland's forceps have a high success rate with relatively low adverse outcomes despite their use being controversial. In comparison to rotational ventouse, Kielland's forceps have higher efficacy with less risk of neonatal trauma.

Maternal and neonatal outcomes of pregnancy in women with chronic hypertension: a retrospective analysis of a national register.

Pregnancies complicated by chronic hypertension are at increased risk of adverse pregnancy outcomes. To assess whether planned early delivery might prevent some of these adverse outcomes, we studied maternal and neonatal outcomes of pregnancy in women with chronic hypertension, including gestational-age-specific outcomes. We performed a retrospective, population-based cohort study, using data from the Netherlands Perinatal Register. We included women with chronic hypertension and normotensive controls who delivered a singleton without congenital anomalies in 2002-2007. We calculated crude and adjusted odds ratios (OR) with 95% CI, compared delivery and ongoing pregnancy using moving averages, and used multiple Cox regression to adjust for differences in baseline characteristics and to examine adverse neonatal outcomes across subgroups of hypertensive disorder. Main outcome measures were composite adverse maternal and neonatal outcomes. We included 3457 (0.3%) women with chronic hypertension and 984 932 normotensive controls. Women with chronic hypertension had adverse maternal outcomes more often (28.7% vs. 6.6%, adjusted OR 5.7, 95% CI 5.3-6.2). Their offspring had an increased rate of neonatal morbidity (17.4% vs. 13.2%, adjusted OR 1.2, 95% CI 1.1-1.4) but not of severe adverse neonatal outcomes (2.5% vs. 2.2%, adjusted OR 0.8, 95% CI 0.6-1.0). The increased risk of adverse maternal outcomes for ongoing pregnancy remained stable around 17% at term. The risk of severe adverse neonatal outcomes for birth was at its lowest between 38 and 40 weeks, mainly in women with iatrogenic onset of delivery. Women with chronic hypertension are at increased risk of adverse maternal and neonatal outcomes compared with controls throughout pregnancy, including at term. Our results suggest that the optimal timing of delivery might be between 38 and 40 weeks of gestation, but prospective randomized studies should confirm this.

Immediate delivery versus expectant monitoring for hypertensive disorders of pregnancy between 34 and 37 weeks of gestation (HYPITAT-II): an open-label, randomised controlled trial

There is little evidence to guide the management of women with hypertensive disorders in late preterm pregnancy. We investigated the effect of immediate delivery versus expectant monitoring on maternal and neonatal outcomes in such women. We did an open-label, randomised controlled trial, in seven academic hospitals and 44 non-academic hospitals in the Netherlands. Women with non-severe hypertensive disorders of pregnancy between 34 and 37 weeks of gestation were randomly allocated to either induction of labour or caesarean section within 24 h (immediate delivery) or a strategy aimed at prolonging pregnancy until 37 weeks of gestation (expectant monitoring). The primary outcomes were a composite of adverse maternal outcomes (thromboembolic disease, pulmonary oedema, eclampsia, HELLP syndrome, placental abruption, or maternal death), and neonatal respiratory distress syndrome, both analysed by intention-to-treat. This study is registered with the Netherlands Trial Register (NTR1792). Between March 1, 2009, and Feb 21, 2013, 897 women were invited to participate, of whom 703 were enrolled and randomly assigned to immediate delivery (n=352) or expectant monitoring (n=351). The composite adverse maternal outcome occurred in four (1·1%) of 352 women allocated to immediate delivery versus 11 (3·1%) of 351 women allocated to expectant monitoring (relative risk [RR] 0·36, 95% CI 0·12-1·11; p=0·069). Respiratory distress syndrome was diagnosed in 20 (5·7%) of 352 neonates in the immediate delivery group versus six (1·7%) of 351 neonates in the expectant monitoring group (RR 3·3, 95% CI 1·4-8·2; p=0·005). No maternal or perinatal deaths occurred. For women with non-severe hypertensive disorders at 34-37 weeks of gestation, immediate delivery might reduce the already small risk of adverse maternal outcomes. However, it significantly increases the risk of neonatal respiratory distress syndrome, therefore, routine immediate delivery does not seem justified and a strategy of expectant monitoring until the clinical situation deteriorates can be considered. ZonMw.

Screening for gestational diabetes in the Lombardy region: A population-based study

AimAs the treatment of hyperglycaemia during pregnancy with diet or insulin reduces the risk of adverse maternal outcomes and perinatal complications, screening for gestational diabetes mellitus (GDM) is included, albeit to variable extents, in all guidelines of care for pregnant women. The aim of the present investigation was to estimate the proportion of pregnancies screened for GDM in Lombardy between 2007 and 2010, and to identify predictors of screening. MethodsA retrospective cross-sectional study using regional healthcare utilization databases of Lombardy was conducted. The study included all residents of Lombardy without pregestational diabetes who delivered between 1 January 2007 and 31 December 2010. The proportion of pregnancies with at least one screening test for GDM was calculated, along with the odds ratios and 95% confidence intervals associated with selected covariates for GDM screening. ResultsOf the 362,818 pregnancies included in the sample, 30% were screened for GDM. The proportion of pregnancies screened increased slightly from 2007 (27%) to 2010 (33%) and with maternal age (from 28% among women<25 years to 32% among those ≥35years), and varied widely across local health management organizations (HMOs) of residence (range: 20% to 68%). Socioeconomic indicators (education, immigrant status), obstetric history and prepregnancy hypertension were independent predictors of GDM screening. ConclusionThe study finding of a low rate of pregnant women screened for GDM among residents of Lombardy supports the need for programmes to improve training of healthcare professionals, to raise women's awareness of GDM and to eliminate barriers to GDM screening.

Hydatidiform mole and subsequent pregnancy outcome: a population-based cohort study

The objective of the study was to investigate whether a history of hydatidiform mole (HM) is associated with an increased risk of adverse outcomes in subsequent pregnancies. This was a nationwide cohort study with data from population-based registers. The study population consisted of all children registered in the Swedish Medical Birth Register 1973-2009 (n = 3,730,825). Odds ratios (ORs) with 95% confidence intervals (CIs) were estimated for adverse maternal and offspring pregnancy outcomes by maternal history of HM prior to the delivery, with children to women with no maternal history of HM as the reference. Risk estimates were adjusted for maternal age at delivery and maternal country of birth. A history of HM was not associated with an increased risk of adverse maternal outcomes in subsequent pregnancies (n = 5186). Women exposed to a molar pregnancy prior to the index birth were at an almost 25% increased risk of preterm birth (OR, 1.23; 95% CI, 1.06-1.43), whereas women with at least 1 birth between the HM and the index birth were at an increased risk of a large-for-gestational-age birth and stillbirth (OR, 1.35; 95% CI, 1.10-1.67 and OR, 1.81; 95% CI, 1.11-2.96, respectively). The risk of repeat mole was 0.4%. Women with a history of HM are at no increased risk of adverse maternal outcomes in subsequent pregnancies but have an increased risk of large-for-gestational-age birth, stillbirth, and preterm birth. However, in absolute terms, the risk of subsequent adverse offspring outcomes is very low.

A Risk Prediction Model for the Assessment and Triage of Women with Hypertensive Disorders of Pregnancy in Low-Resourced Settings: The miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) Multi-country Prospective Cohort Study

Pre-eclampsia/eclampsia are leading causes of maternal mortality and morbidity, particularly in low- and middle- income countries (LMICs). We developed the miniPIERS risk prediction model to provide a simple, evidence-based tool to identify pregnant women in LMICs at increased risk of death or major hypertensive-related complications. From 1 July 2008 to 31 March 2012, in five LMICs, data were collected prospectively on 2,081 women with any hypertensive disorder of pregnancy admitted to a participating centre. Candidate predictors collected within 24 hours of admission were entered into a step-wise backward elimination logistic regression model to predict a composite adverse maternal outcome within 48 hours of admission. Model internal validation was accomplished by bootstrapping and external validation was completed using data from 1,300 women in the Pre-eclampsia Integrated Estimate of RiSk (fullPIERS) dataset. Predictive performance was assessed for calibration, discrimination, and stratification capacity. The final miniPIERS model included: parity (nulliparous versus multiparous); gestational age on admission; headache/visual disturbances; chest pain/dyspnoea; vaginal bleeding with abdominal pain; systolic blood pressure; and dipstick proteinuria. The miniPIERS model was well-calibrated and had an area under the receiver operating characteristic curve (AUC ROC) of 0.768 (95% CI 0.735-0.801) with an average optimism of 0.037. External validation AUC ROC was 0.713 (95% CI 0.658-0.768). A predicted probability ≥25% to define a positive test classified women with 85.5% accuracy. Limitations of this study include the composite outcome and the broad inclusion criteria of any hypertensive disorder of pregnancy. This broad approach was used to optimize model generalizability. The miniPIERS model shows reasonable ability to identify women at increased risk of adverse maternal outcomes associated with the hypertensive disorders of pregnancy. It could be used in LMICs to identify women who would benefit most from interventions such as magnesium sulphate, antihypertensives, or transportation to a higher level of care.

Methodological issues in the development of a prediction model for pre-eclampsia complications

PREP (Prediction of risks in early onset pre-eclampsia) is a multicentre prospective cohort study aiming to develop and validate a prediction model in women admitted with early-onset pre-eclampsia for risk of adverse maternal outcome at 48 hours and until discharge. The primary outcome was a composite of adverse maternal outcomes and the secondary outcome a composite of adverse fetal outcomes. The planned model includes multiple predictor variables in combination to predict the risk of adverse outcomes in individual patients. We highlight the methodological challenges encountered in model development. The predictor variables were pre-selected based on symptoms, signs and results of investigations routinely taken during management of pre-eclampsia. Challenges included accounting for correlation between variables, choosing the most abnormal variable within a time period or from a pre-determined time point, inconsistency in ascertainment of the data points ie blood results available later than the signs and symptoms, modelling a combination of binary, ordinal and continuous variables and the approach in prioritisation of these variables. Clinician management such as anti-hypertensives and magnesium sulphate will affect the relationship between the predictor and outcome. We will include clinical management as a covariate and assess consistency in model performance across different treatment groups to account for this. Selecting the optimum type of prediction model posed a further challenge. Logistic regression focuses on the relationship between predictor variables and adverse outcomes whereas survival analysis takes into account the time to develop the outcome. The former may be statistically more suitable but the latter clinically more useful.

Maternal and neonatal health outcomes following the implementation of an innovative model of nurse practitioner‐led care for diabetes in pregnancy

AbstractAimTo investigate maternal and neonatal outcomes following implementation of a nurse practitioner‐led model of care for diabetes in pregnancy.BackgroundDiabetes in pregnancy increases the risk of adverse health outcomes in mothers and infants. The management of diabetes in pregnancy is crucial to reduce poor outcomes.DesignUncontrolled before‐after intervention study.MethodsInternational Classification of Diseases codes were used to identify pregnancies suspected of being complicated by diabetes. Demographic, health, diabetes and maternity data were extracted from hospital records. Adverse maternal and neonatal outcomes were compared pre‐ (2003–2006) and postintervention (2010–2011). Adjusted relative risks (aRR) were calculated using the glm command in Stata.ResultsA total of 261 pregnancies were included: 112 pre‐intervention and 149 managed under the nurse practitioner‐led model. There were 37 women with pre‐existing diabetes (26 T1DM, 11 T2DM) and 195 with gestational diabetes. Referrals to dieticians and diabetes educators increased, while referrals to physicians decreased. There was no decrease in the risk of adverse maternal outcomes for all women with DIP or women with GDM. However, there was a 24% decrease in adverse neonatal outcomes overall and a 40% decrease among infants of women with gestational diabetes.ConclusionThe study demonstrated that nurse practitioner‐led models of care for diabetes in pregnancy are feasible. The findings suggest that the model reduced adverse neonatal outcomes. By improving information provision, support and care coordination, the model is particularly valuable in rural areas, where access to medical specialists is often restricted.

Plasma Uric Acid Remains a Marker of Poor Outcome in Hypertensive Pregnancy

Please cite this paper as: Hawkins T, Roberts J, Mangos G, Davis G, Roberts L, Brown M. Plasma uric acid remains a marker of poor outcome in hypertensive pregnancy: a retrospective cohort study. BJOG 2012 2012;119:484–492. Objective To examine the relationship between hyperuricaemia, haemoconcentration and maternal and fetal outcomes in hypertensive pregnancies. Design Retrospective analysis of a database of hypertensive pregnancies. Setting St George Hospital, a major obstetric unit in Australia. Population A cohort of 1880 pregnant women without underlying hypertension or renal disease, referred for management of pre-eclampsia or gestational hypertension. Methods Demographic, clinical and biochemical data at time of referral and delivery were collected for each pregnancy. Women were grouped according to diagnosis (pre-eclampsia or gestational hypertension) and logistic regression analysis was used to determine the relationship between uric acid, haemoglobin, haematocrit and adverse outcomes; an α level of P < 0.01 was used for statistical significance. Main outcome measures Composites of adverse maternal and fetal outcomes. Results In women with ‘benign’ GH (without proteinuria or any other maternal clinical feature of pre-eclampsia) gestation-corrected hyperuricaemia was associated with increased risk of a small-for-gestational-age infant (OR 2.5; 95% CI 1.3–4.8) and prematurity (OR 3.2; 95% CI 1.4–7.2), but not with adverse maternal outcome. In the whole cohort of hypertensive pregnant women (those with pre-eclampsia or gestational hypertension) the risk of adverse maternal outcome (OR 2.0; 95% CI 1.6–2.4) and adverse fetal outcome (OR 1.8; 95% CI 1.5–2.1) increased with increasing concentration of uric acid. Hyperuricaemia corrected for gestation provided additional strength to these associations. Haemoglobin and haematocrit were not associated with adverse pregnancy outcome. Conclusions Hyperuricaemia in hypertensive pregnancy remains an important finding because it identifies women at increased risk of adverse maternal and particularly fetal outcome; the latter, even in women with gestational hypertension without any other feature of pre-eclampsia.

Comparison between emergent and elective delivery in women with placenta accreta

Objective: To identify possible predictive factors associated with emergent delivery of antenatally diagnosed placenta accreta and to estimate association between emergent delivery and adverse maternal outcomes in comparison to elective delivery.Methods: A retrospective study of all patients with placenta accreta diagnosed antenatally and confirmed pathologically, who were delivered between 2000 and 2010. Baseline characteristics and outcomes of emergent deliveries were compared with elective deliveries.Results: A total of 48 women met inclusion criteria, of which 24 (50%) were delivered emergently. 79.2% of emergent deliveries were preceded by antenatal bleeding (p = 0.0005), and 62.5% were preceded by recurrent bleeding (p = 0.001). Comparison of elective and emergent deliveries revealed no clinical significant difference in maternal outcome.Conclusions: Antenatal bleeding is associated with an increased risk of emergent delivery. Emergent delivery in a tertiary care facility with immediate access to blood bank and ICU capabilities does not appear to be associated with an increased risk of adverse maternal outcomes. Consequently, some patients may be candidates for delivery later than 34 weeks of gestation.

Gestational diabetes mellitus and pregnancy outcomes among Chinese and South Asian women in Canada

Objective: To determine the association between Chinese or South Asian ethnicity and adverse neonatal and maternal outcomes for women with gestational diabetes compared to the general population. Methods: A cohort study was conducted using population-based health care databases in Ontario, Canada. All 35,577 women aged 15–49 with gestational diabetes who had live births between April 2002 and March 2011 were identified. Their delivery hospitalization records and the birth records of their neonates were examined to identify adverse neonatal outcomes and adverse maternal outcomes. Results: Compared to infants of mothers from the general population (55.5%), infants of Chinese mothers had a lower risk of an adverse outcome at delivery (42.9%, adjusted odds ratio 0.63, 95% confidence interval 0.58–0.68), whereas infants of South Asian mothers had a higher risk (58.9%, adjusted odds ratio 1.15, 95% confidence interval 1.07–1.23). Chinese women also had a lower risk of adverse maternal outcomes (32.4%, adjusted odds ratio 0.58, 95% confidence interval 0.54–0.63) compared to general population women (41.2%), whereas the risk for South Asian women was not different (39.4%, adjusted odds ratio 0.94, 95% confidence interval 0.88–1.02) from that of general population women. Conclusions: The risk of complications of gestational diabetes differs significantly between Chinese and South Asian patients and the general population in Ontario. Tailored interventions for gestational diabetes management may be required to improve pregnancy outcomes in high-risk ethnic groups.

Conceptualising the prevention of adverse obstetric outcomes among immigrants using the ‘three delays’ framework in a high-income context

Women from high-mortality settings in sub-Saharan Africa can remain at risk for adverse maternal outcomes even after migrating to low-mortality settings. To conceptualise underlying socio-cultural factors, we assume a ‘maternal migration effect’ as pre-migration influences on pregnant women’s post-migration care-seeking and consistent utilisation of available care. We apply the ‘three delays’ framework, developed for low-income African contexts, to a high-income western scenario, and aim to identify delay-causing influences on the pathway to optimal facility treatment. We also compare factors influencing the expectations of women and maternal health providers during care encounters. In 2005–2006, we interviewed 54 immigrant African women and 62 maternal providers in greater London, United Kingdom. Participants were recruited by snowball and purposive sampling. We used a hermeneutic, naturalistic study design to create a qualitative proxy for medical anthropology. Data were triangulated to the framework and to the national health system maternity care guidelines. This maintained the original three phases of (1) care-seeking, (2) facility accessibility, and (3) receipt of optimal care, but modified the framework for a migration context. Delays to reciprocal care encounters in Phase 3 result from Phase 1 factors of ‘broken trust, which can be mutually held between women and providers. An additional factor is women’s ‘negative responses to future care’, which include rationalisations made during non-emergency situations about future late-booking, low-adherence or refusal of treatment. The greatest potential for delay was found during the care encounter, suggesting that perceived Phase 1 factors have stronger influence on Phase 3 than in the original framework. Phase 2 ‘language discordance’ can lead to a ‘reliance on interpreter service’, which can cause delays in Phase 3, when ‘reciprocal incongruent language ability’ is worsened by suboptimal interpreter systems. ‘Non-reciprocating care conceptualisations’, ‘limited system-level care guidelines’, and ‘low staff levels’ can additionally delay timely care in Phase 3.

Plasma uric acid remains a marker of poor outcome in hypertensive pregnancy: a retrospective cohort study

To examine the relationship between hyperuricaemia, haemoconcentration and maternal and fetal outcomes in hypertensive pregnancies. Retrospective analysis of a database of hypertensive pregnancies. St George Hospital, a major obstetric unit in Australia. A cohort of 1880 pregnant women without underlying hypertension or renal disease, referred for management of pre-eclampsia or gestational hypertension. Demographic, clinical and biochemical data at time of referral and delivery were collected for each pregnancy. Women were grouped according to diagnosis (pre-eclampsia or gestational hypertension) and logistic regression analysis was used to determine the relationship between uric acid, haemoglobin, haematocrit and adverse outcomes; an α level of P < 0.01 was used for statistical significance. Composites of adverse maternal and fetal outcomes. In women with 'benign' GH (without proteinuria or any other maternal clinical feature of pre-eclampsia) gestation-corrected hyperuricaemia was associated with increased risk of a small-for-gestational-age infant (OR 2.5; 95% CI 1.3-4.8) and prematurity (OR 3.2; 95% CI 1.4-7.2), but not with adverse maternal outcome. In the whole cohort of hypertensive pregnant women (those with pre-eclampsia or gestational hypertension) the risk of adverse maternal outcome (OR 2.0; 95% CI 1.6-2.4) and adverse fetal outcome (OR 1.8; 95% CI 1.5-2.1) increased with increasing concentration of uric acid. Hyperuricaemia corrected for gestation provided additional strength to these associations. Haemoglobin and haematocrit were not associated with adverse pregnancy outcome. Hyperuricaemia in hypertensive pregnancy remains an important finding because it identifies women at increased risk of adverse maternal and particularly fetal outcome; the latter, even in women with gestational hypertension without any other feature of pre-eclampsia.

Abnormal Liver Function Tests as Predictors of Adverse Maternal Outcomes in Women With Preeclampsia

ObjectivesTo evaluate whether (1) the absolute magnitude of liver function test values, (2) the percentage change in liver function test values over time, or (3) the rate of change in liver function test values over time predicts adverse maternal outcomes in women with preeclampsia. MethodsWe used data from the PIERS (Pre-eclampsia Integrated Estimate of RiSk) study, a prospective multicentre cohort study assessing predictors of adverse maternal outcomes in women with preeclampsia. Women with at least one liver function test performed at the time of hospital admission were included. Liver functions were tested by serum concentrations of aspartate amino transferase (AST), alanine amino transferase (ALT), lactate dehydrogenase (LDH), albumin, total bilirubin, and the international normalized prothrombin time ratio. Parameters investigated were absolute levels, change within 48 hours of hospital admission, change from admission to delivery or outcome, and rate of change from admission to delivery or outcome of each liver function test. The ability of these parameters to predict adverse outcomes was assessed using logistic regression analyses and by calculating the receiver operating characteristic (ROC) area under the curve (AUC). ResultsOf the 2008 women, 1056 (53%) had at least one abnormal liver function test result. The odds of having an adverse maternal outcome were higher in women with any abnormal liver function test than in women with normal results. When test results were stratified into quartiles, women with results in the highest quartile (lowest quartile for albumin) were at higher risk of adverse outcomes than women in the lowest quartile for all parameters (highest for albumin). The absolute magnitude of AST, ALT, and LDH predicted adverse maternal outcomes (AST: ROC AUC 0.73 [95% CI 0.67 to 0.97]; ALT: ROC AUC 0.73 [95% CI 0.67 to 0.79]; LDH: ROC AUC 0.74 [95% CI 0.68 to 0.81]). Neither change of liver function test results, within 48 hours of admission or from admission to delivery or outcome, nor rate of change were predictive. ConclusionWe found abnormal liver function test results to be associated with an increased risk for adverse maternal outcomes. Levels of AST, ALT, and LDH were found to be modestly predictive of these outcomes.

Prediction of Adverse Maternal Outcomes in Preeclampsia: Development and Validation of the FullPIERS Model

ABSTRACT Maternal deaths from preeclampsia primarily result in cases with eclampsia, uncontrolled hypertension, or progressing HELLP syndrome. Delivery is the only cure for preeclampsia. Management strategies involve determination of risk factors to predict which pregnancies are at high risk for adverse maternal outcomes. Previous attempts to develop risk assessment models that could identify potential predictive risk factors for adverse outcomes occurring at any time after admission with preeclampsia have been unsuccessful. The aim of this prospective multicenter study was to develop and internally validate a preeclampsia outcome prediction model—the fullPIERS (Preeclampsia Integrated Estimate of RiSk) model that could identify serious or fatal complications in women with preeclampsia or who developed the disorder within 48 hours of hospital admission. Between 2003 and 2010, data for 2023 women from 8 international sites were entered into the fullPIERS database. The primary study outcome was maternal mortality or other serious complications of preeclampsia. A stepwise backward elimination logistic regression model incorporating routinely reported and informative variables was used to predict adverse maternal outcome. Standard methods were used to calculate the area under the curve (AUC) of the receiver operating characteristic (ROC). Of the 2023 women with preeclampsia, 261 (13%) had adverse outcomes at any time after hospital admission and 106 (5%) had adverse outcomes within 48 hours of admission. Predictors in the fullPIERS model associated with adverse maternal outcome included gestational age at eligibility, chest pain or dyspnea, oxygen saturation, creatinine, platelet counts, and aspartate transaminase. Analysis of the fullPIERS model showed that the model predicted adverse maternal outcomes within the first 48 hours of eligibility; the AUC ROC was 0.88, with a 95% confidence interval, 0.84–0.92. Additionally, fullPIERS was also predictive of adverse maternal outcomes up to 7 days after eligibility (AUC ROC >0.7). Identification of women at high risk of preeclampsia complications at 48 hours to 7 days after admission may help guide clinical care and management of these women. Over time this may lead to development of new treatments and interventions that may reduce the risk of life-altering or life-ending complications such as stroke or end-organ damage.

Exercise in obese pregnant women: The role of social factors, lifestyle and pregnancy symptoms

BackgroundPhysical activity may reduce the risk of adverse maternal outcomes, yet there are very few studies that have examined the correlates of exercise amongst obese women during pregnancy. We examined which relevant sociodemographic, obstetric, and health behaviour variables and pregnancy symptoms were associated with exercise in a small sample of obese pregnant women.MethodsThis was a secondary analysis using data from an exercise intervention for the prevention of gestational diabetes in obese pregnant women. Using the Pregnancy Physical Activity Questionnaire (PPAQ), 50 obese pregnant women were classified as "Exercisers" if they achieved ≥900 kcal/wk of exercise and "Non-Exercisers" if they did not meet this criterion. Analyses examined which relevant variables were associated with exercise status at 12, 20, 28 and 36 weeks gestation.ResultsObese pregnant women with a history of miscarriage; who had children living at home; who had a lower pre-pregnancy weight; reported no nausea and vomiting; and who had no lower back pain, were those women who were most likely to have exercised in early pregnancy. Exercise in late pregnancy was most common among tertiary educated women.ConclusionsOffering greater support to women from disadvantaged backgrounds and closely monitoring women who report persistent nausea and vomiting or lower back pain in early pregnancy may be important. The findings may be particularly useful for other interventions aimed at reducing or controlling weight gain in obese pregnant women.

General anesthesia for endoscopic laser for severe TTTS is associated with increased risk of adverse maternal outcome

WITH INCREASED RISK OF ADVERSE MATERNAL OUTCOME GREG RYAN, CRAIG PENNELL, FAWAZ ALKAZALEH, GARETH SEAWARD, JENNY PORTER, SHARON DAVIES, RORY WINDRIM, University of Toronto, Obstetrics & Gynaecology, Toronto, Ontario, Canada, University of Western Australia, Women’s and Infants’ Health, Perth, Western Australia, Australia, Mount Sinai Hospital, Toronto, Ontario, Canada, Fetal Medicine Unit, Mount Sinai Hospital, Toronto, Ontario, Canada, Mount Sinai Hospital, Obstetrics and Gynecology, Toronto, Ontario, Canada OBJECTIVE: To evaluate 3 anaesthesia techniques general (GA), epidural (ED) and conscious sedation (CS) employed for the first 80 cases of laser for severe TTTS. STUDY DESIGN: Data were abstracted from clinical records: major and minor maternal complications and fetal outcomes were compared for all techniques. Univariate comparisons were made using one-way ANOVA and Fisher’s exact tests. Multivariate logistic regression was used to identify independent associations with major maternal adverse outcomes. RESULTS: 18 cases were done under GA, 4 under ED and 58 under CS. There was no difference in maternal demographic data between groups. The GA group recorded lower systolic pressures, increased requirements for pressure therapy (p!0.01) and increased intra-operative intravenous fluids (all p!0.02). Major maternal complications (n=13) were more common with GA as compared to the other groups (p!0.01). GA remained independently associated with major maternal complications in multivariate analysis (adjusted OR 36; p=0.03) after controlling for covariates. Pulmonary edema within 24 hrs of the procedure occurred in 8 women, total IV fluid volume was the only factor independently associated with the development of pulmonary edema (adjusted OR 4.5 for each 1000 mL increase in IV fluid). CONCLUSION: GA was associated with increased risk of major maternal complications, particularly pulmonary edema, when compared to ED and CS.