Features Of Severe Preeclampsia Research Articles

Intrapartum trends of NT-proBNP and hs-cTnT in patients with severe features of preeclampsia

BackgroundPreeclampsia with severe features (SPE) is a multisystem syndrome associated with long-term cardiovascular morbidity. Serum concentrations of N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin-T (hs-cTnT) are sensitive markers of cardiac stretch and ischemia, respectively. ObjectiveOur aim was to examine NT-proBNP and hs-cTnT in patients with SPE during labor. We hypothesized that patients with severe preeclampsia would have increased serum concentrations of these analytes as compared with normotensive laboring patients.Study Design.This was a prospective cohort study of intrapartum patients with SPE and normotensive controls. Patients were recruited at the time of SPE diagnosis or admission to the labor unit, and those with medical conditions that could predispose to baseline cardiac dysfunction were excluded. Serum from venous blood was collected for NT-proBNP and hs-cTnT measurement at three time points: 0–2 h, 4 h, and 12 h after admission. A mixed random effects regression model was used to compare analyte levels at each time point and to compare trends over time. The primary outcome was NT-proBNP concentration at each collection time point in patients with severe preeclampsia as compared to normotensive controls. Power analysis yielded a goal sample of 25 patients with a 12 h and at least 1 other sample in each arm. Two-tailed P values less than 0.05 were considered statistically significant. P value adjustment for multiple comparisons was performed. ResultsOf 78 patients analyzed, 36 had severe preeclampsia and 42 were normotensive controls with 25 in each cohort having a 12 h and at least 1 other sample. The NT-proBNP trend was significantly different in the two cohorts (P < 0.001). After adjustment for multiple comparisons, the mean serum concentration of NT-proBNP was elevated in the severe preeclampsia group at 0–2 and 4 h, but not at 12 h. After similar adjustment, detectable serum concentrations of hs-cTnT were more frequent in patients with severe preeclampsia at all three timepoints. ConclusionIntrapartum serum concentrations of NT-proBNP were elevated nearly twofold in patients with SPE when compared with normotensive controls, with the most pronounced differences found during early labor. Detectable but low serum concentrations of hs-cTnT were more common in women with severe preeclampsia as compared with normotensive controls. These findings suggest cardiac dysfunction with SPE may be present at the time of admission and contribute to features of maternal cardiovascular morbidity and mortality.

FETOMATERNAL OUTCOME IN EARLY ONSET SEVERE PRE ECLAMPSIA

Introduction:Preeclampsia is a multisystem disorder occurring exclusively during pregnancy whose exact etiology is yet unknown. It occurs in approximately 5-7% of pregnancies. Early onset preeclampsia (&lt;34 weeks gestational age) occurs in less than 1% of pregnancies and is often associated with maternal morbidity as the riskof progres­sionto severe maternal disease is inversely related with gestational age at onset. Material And Methods:100 pregnant women admitted to labor room in the department of OBG, Govt. medical college,Kota Rajasthan between 1 February 2021 – 31 January 2022who fulfilled the criteria ( Gestational age ≥ 24 weeks &amp;&lt; 34 weeks , diastolic BP ≥ 110 mm Hg, with any features of severe pre eclampsia ) were included in this study . Results:In the present study, Out of 100 patients of early onset severe preeclampsia was more common in Primigravida 59(59%)in the age group of 21-30 years. Mean gestational age at diagnosis was 31weeks 3 days ± 2weeks 3 days. Most underwent termination of pregnancy after 32 weeks. Maternal indication was found to be the most common cause for termination. 31(31%) patients of the total experienced complication like imminent eclampsia, HELLP syndrome ,Acute renal failure and abruption placentae . 65 (65%) delivered by caesarean section. Mean birthweight was 1.59 kg ± 0.5kgand neonatal complication rate was 71(71%). Conclusion:Early onset severe preeclampsia is associated with significant maternal and fetal complications. Decision regarding termination of pregnancy has to be taken based on both maternal and fetal factors.

Intrapartum trends of NT-proBNP and hs-TnT in patients with severe features of preeclampsia

Intrapartum trends of NT-proBNP and hs-TnT in patients with severe features of preeclampsia

Maternal tumour necrosis factor-alpha levels in preeclamptic pregnancies in Lagos, South-West Nigeria.

This study aimed to assess the association between maternal serum levels of TNF-α and preeclampsia. An analytical cross-sectional study involving 45 women diagnosed with preeclampsia and 45 healthy normotensive pregnant women matched for age, and gestational age at enrolment. Venous samples were collected from each participant after informed consent was obtained. Serum TNF-α level was determined using the human TNF-α competitive enzyme-linked immunosorbent assay (ELISA) technique with ELISA Kit. Hypothesis testing was done using the Chi-square test for categorical variables, the independent samples t-test and the Kruskal-Wallis test for numerical variables. All significances were reported at P<0.05. The median concentrations of TNF-α in women with preeclampsia of varying severity were significantly higher than those with normotensive pregnancies (P=0.001). The median level of TNF-α was also significantly higher in patients with severe features of preeclampsia than in those without. The estimated cut-off levels of serum TNF-α were 15.6ng/mL and 26.4ng/mL respectively for the development and severity of preeclampsia. Maternal serum TNF-α level in preeclamptic patients is strongly correlated with systolic and diastolic BP, serum uric acid and alkaline phosphatase levels, proteinuria, and platelet count (P<0.05). We can infer from this study that increased maternal serum levels of TNF-α may play a significant role in the pathogenesis of preeclampsia. We recommend further validation of these findings with a more robust longitudinal characterization of maternal serum TNF-α profiles in pregnancy through a well-designed prospective cohort study.

The effect of preeclampsia on adverse maternal outcomes in Sidama region, Ethiopia: a prospective open cohort study

Ethiopia has made improvements in the reduction of maternal mortality; the high burden of preeclampsia remains a concern in the Sidama region. This study aimed to measure the effect of preeclampsia on adverse maternal outcomes and identify risk factors among women with preeclampsia in Sidama region. A prospective open cohort study was conducted from August 8, 2019, to October 1, 2020. We enrolled a total of 1015 the pregnant women who had preeclampsia and normotensive women at ≥ 20 weeks of gestation and followed them until 42 days after delivery. A log-binomial logistic regression model was used to estimate the incidence of adverse maternal outcomes and its risk factors. There were 276 adverse maternal outcomes observed in the preeclampsia group compared to 154 adverse maternal outcomes in the normotensive group (P < 0.001). Women with severe features of preeclampsia had a 43% (aRR = 1.43, 95% CI 1.3–1.58) higher risk for adverse maternal outcomes compared to women without severe features of preeclampsia. Women without severe features of preeclampsia had a 39% (aRR = 1.39, 95% CI 1.2–1.76) higher risk for adverse maternal outcomes compared to women in the normotensive group. More adverse maternal outcomes occurred among women with preeclampsia after controlling for confounders.

Incidence of adverse perinatal outcomes and risk factors among women with pre-eclampsia, southern Ethiopia: a prospective open cohort study

BackgroundIn Ethiopia, in 2021, more than 80% of all newborn deaths were caused by preventable and treatable conditions. This study aimed to measure the incidence of adverse perinatal outcomes and...

Hyponatremia among preeclampsia patients- a potential sign of severity.

Although hyponatremia in preeclamptic patients was previously described, its significance remains unknown. We aimed to describe the prevalence and clinical significance of hyponatremia among a cohort of preeclamptic patients. An electronic medical record based retrospective cohort study included all singleton deliveries at Hadassah University Medical Center between 2003 and 2015. Preeclampsia, with and without severe features, was defined using the American College of Obstetrics and Gynecology (ACOG) Hypertension in Pregnancy Guidelines. Hyponatremia was defined as a sodium (Na) level≤130mEq/L, and severe hyponatremia as <125mEq/L. A group of normotensive pregnant women, matched for gestational age, gravdity and parity, served as control. A total of 700 preeclamptic patients were identified during the study period. Hyponatremia was noted in 14.6% compared to 0 of 79 patients in the control group. Hyponatremia was strongly correlated with severe features of preeclampsia, adverse neonatal and obstetrical outcome. Severe hyponatremia was strongly correlated with preeclampsia with severe features. Furthermore, even among subgroup of preeclamptic patients without severe features, hyponatremia correlated with less favorable pregnancy outcomes. Among relatively large cohort of preeclamptic patients, hyponatremia was not a rare finding. We found it more common in patients with preeclampsia and severe features. As women with preeclampsia are at risk for hyponatremia, serum sodium levels should be monitored, especially in those with severe features. In preeclamptic patients without severe features, hyponatremia may indicate a need for closer surveillance. However, larger studies are needed to establish hyponatremia as a marker of severity.

Liver stiffness and steatosis in preeclampsia as shown by transient elastography–a prospective cohort study

Preeclampsia is a multisystem disorder and the leading cause of severe morbidity and death in pregnancy. Liver involvement in preeclampsia ranges from elevated liver enzyme levels to hepatic infarction or rupture. Endothelial dysfunction leads to changes in blood flow and congestion and may be involved in the pathophysiology of preeclampsia. Changes in splanchnic blood flow and portal congestion can lead to altered liver stiffness. Transient elastography is a noninvasive, ultrasound-based technique that measures organ stiffness and steatosis and is therefore widely used in clinical hepatology. Previous studies reported elevated liver stiffness and liver steatosis, as measured by transient elastography, in women with preeclampsia. This study followed changes in liver stiffness and steatosis, as measured by transient elastography, from the antepartum period to 1-week postpartum among women with preeclampsia compared with healthy controls and evaluated the association between preeclampsia severity and transient elastography results. This prospective cohort study was conducted from 2017 through 2021. The study group comprised women with preeclampsia, and the control group comprised healthy pregnant women hospitalized for other reasons. All the participants underwent transient elastography either on diagnosis of preeclampsia (study group) or on hospital admission (control group) and again in the postpartum period. Liver stiffness measurements are expressed in kilopascals (kPa) in the range of 2.5 to 75 kPa, and liver steatosis isexpressed by controlled attenuation parameter in the range of 100 to 400 dB/m. The study group comprised 36 women and the control group 37. Liver stiffness scores were significantly elevated in the study when compared with the control group, both in the antepartum period (P<.001) and the postpartum period (P=.025). Liver stiffness scores decreased significantly after delivery in the study and control groups (P<.001 and P=.002, respectively). Liver steatosis scores were higher in the study group than in the control group both in the antepartum and postpartum periods (P<.001 and P<.02, respectively). In the multivariable analysis, the diagnosis of preeclampsia correlated with higher antepartum liver stiffness scores (P=.005). For the study group, postpartum liver stiffness and liver steatosis scores were increased among those with vs those without severe features of preeclampsia (P=.03 and P=.04, respectively) CONCLUSION: Reductions in liver stiffness and steatosis from the antepartum to the postpartum period were documented in both the preeclampsia and control groups. However, both these measures were higher in the preeclampsia group and correlated with preeclampsia severity. Larger studies may be able to determine whether transient elastography can predict the severity of preeclampsia or other related metabolic conditions that correlate with chronic hypertension.

Impact of Implementation of Maternal Fetal Triage Index on Time-to-Management for Severe Hypertension

Because severe hypertension remains one of the leading preventable causes of maternal mortality in the United States, tracking timeliness to response is a critical quality indicator. We hypothesized that implementation of the Maternal Fetal Triage Index (MFTI) would improve care performance in women with severe hypertension. Our aim was to assess the impact of MFTI on the management of women presenting with severe features of preeclampsia (SPE) as measured by time to provider assessment and administration of magnesium sulfate (MgS04).

Non-inferiority of low-dose compared to standard high-dose calcium supplementation in pregnancy: study protocol for two randomized, parallel group, non-inferiority trials in India and Tanzania

BackgroundHypertensive disorders of pregnancy are important causes of maternal morbidity and mortality, as well as preterm birth, the leading cause of death for children under 5 years globally. The World Health Organization currently recommends that pregnant women receive high-dose calcium supplementation (1500–2000 mg elemental calcium) for prevention of preeclampsia in populations with low dietary calcium intake. Trials of low-dose calcium supplementation (< 1000 mg elemental calcium/day) during pregnancy have also shown similar reductions in the risk of preeclampsia; however, no trials to date have directly compared low-dose to the standard high-dose calcium supplementation. Our objective is to assess the non-inferiority of low-dose as compared to standard high-dose calcium supplementation in pregnancy.Methods/designWe will conduct two independent trials in Bangalore, India (n = 11,000 pregnancies), and Dar es Salaam, Tanzania (n = 11,000 pregnancies). The trial designs are individually randomized, parallel group, quadruple-blind, non-inferiority trials of low-dose calcium supplementation (500 mg elemental calcium/day) as compared to standard high-dose calcium supplementation (1500 mg elemental calcium/day) among nulliparous pregnant women. Pregnant women will be enrolled in the trial before 20 weeks of gestation and will receive the randomized calcium regimen from randomization until the time of delivery. The co-primary outcomes are (i) preeclampsia and (ii) preterm birth; we will test non-inferiority of the primary outcomes for low-dose as compared to the standard high-dose supplementation regimen in each trial. The trials’ secondary outcomes include gestational hypertension, severe features of preeclampsia, pregnancy-related death, third trimester severe anemia, fetal death, stillbirth, low birthweight, small-for-gestational age birth, and infant death.DiscussionThe trials will provide causal evidence on the non-inferiority of low-dose as compared to the standard high-dose supplementation in India and Tanzania. A single tablet, low-dose calcium supplementation regimen may improve individual-level adherence, reduce programmatic costs, and ultimately expand implementation of routine calcium supplementation in pregnancy in populations with low dietary calcium intake.Trial registrationClinicalTrials.gov identifier: NCT03350516; registered on 22 November 2018. Clinical Trials Registry—India identifier: CTRI/2018/02/012119; registered on 23 February 2018.Tanzania Medicines and Medical Devices Authority Trials Registry identifier: TFDA0018/CTR/0010/5; registered on 20 December 2018.

The Different Outcomes in Pregnant Women with Severe Features of Preeclampsia between New Onset Hypertension Group and Pre-Existing Hypertension Group

Background: There are extensive evidence that preeclampsia is the reason for many maternal and perinatal morbidities. However, there are no previous study on the different outcomes in severe preeclamptic women between new onset hypertension and chronic hypertension. Objective: To compare the rate of low Apgar score at 5 minutes and other adverse pregnancy outcomes of preeclamptic women with severe features between those who had new onset hypertension in pregnancy and those with chronic hypertension before pregnancy. Materials and Methods: A retrospective cohort study was conducted. The medical records of pregnant women diagnosed with preeclampsia with severe features and delivered at Chonburi Hospital between January 2017 and June 2020 were reviewed. The authors categorized these pregnant women into two groups, new onset hypertension and chronic hypertension. Descriptive statistics were used for the data analyses. Results: Of the 526 women diagnosed with preeclampsia with severe features, 290 met the inclusion and exclusion criteria. Eighty-nine had superimposed preeclampsia on chronic hypertension and 201 patients had new onset hypertension. The rate of low Apgar score at 5 minutes was not statistically different between the two groups (p=0.258). The incidence of impaired liver function and HELLP syndrome were increased in the new onset hypertension group at 18.9% versus 6.7% (p=0.008) and 9.5% versus 1.1% (p=0.010), respectively. Conclusion: There was no significant difference in the rate of low Apgar score between the two groups. Regarding the severity of maternal outcomes, new onset preeclampsia with severe features seems to be more severe than superimposed preeclampsia on chronic hypertension. Keywords: Low Apgar score; Preeclampsia with severe features; Chronic hypertension; Superimposed preeclampsia; Pregnancy outcomes

Mild thrombocytopenia indicating maternal organ damage in pre\u2010eclampsia: a cross\u2010sectional study

BackgroundCurrently, there is a disagreement between guidelines regarding platelet count cut-off values as a sign of maternal organ damage in pre-eclampsia; the American College of Obstetricians and Gynecologists guidelines state a cut-off value of < 100 × 109/L; however, the International Society for the Study of Hypertension in Pregnancy guidelines specify a cut-off of < 150 × 109/L. We evaluated the effect of mild thrombocytopenia: platelet count < 150 × 109/L and ≥ 100 × 109/L on clinical features of pre-eclampsia to examine whether mild thrombocytopenia reflects maternal organ damage in pre-eclampsia.MethodsA total of 264 women were enrolled in this study. Participants were divided into three groups based on platelet count levels at delivery: normal, ≥ 150 × 109/L; mild thrombocytopenia, < 150 × 109/L and ≥ 100 × 109/L; and severe thrombocytopenia, < 100 × 109/L. Risk of severe hypertension, utero-placental dysfunction, maternal organ damage, preterm delivery, and neonatal intensive care unit admission were analyzed based on platelet count levels. Estimated relative risk was calculated with a Poisson regression analysis with a robust error.ResultsPlatelet counts indicated normal levels in 189 patients, mild thrombocytopenia in 51 patients, and severe thrombocytopenia in 24 patients. The estimated relative risks of severe thrombocytopenia were 4.46 [95 % confidence interval, 2.59–7.68] for maternal organ damage except for thrombocytopenia, 1.61 [1.06–2.45] for preterm delivery < 34 gestational weeks, and 1.35 [1.06–1.73] for neonatal intensive care unit admission. On the other hand, the estimated relative risks of mild thrombocytopenia were 0.97 [0.41–2.26] for maternal organ damage except for thrombocytopenia, 0.91 [0.62–1.35] for preterm delivery < 34 gestational weeks, and 0.97 [0.76–1.24] for neonatal intensive care unit admission.ConclusionsMild thrombocytopenia was not associated with severe features of pre-eclampsia and would not be suitable as a sign of maternal organ damage.

Effect of High-Dose Intravenous Vitamin C on Postpartum Oxidative Stress in Severe Preeclampsia

Purpose: To determine whether high-dose intravenous vitamin C reduces oxidative stress in patients with severe preeclampsia in the first days postpartum. Methods: Biomarkers of oxidative stress were assessed as secondary outcomes of a single-center, randomized, placebo-controlled trial. Thirty-four patients with singleton pregnancies complicated by severe features of preeclampsia were randomized into two groups: intravenous vitamin C (1.5 g/6 h) (n = 17) or placebo (n = 17). Urinary concentrations of dityrosine, 8-hydroxy-2-deoxyguanosine (8-OHdg), 8-isoprostane, and N epsilon-(hexanoyl) lysine (HEL) were measured at days one and three after delivery and normalized for urinary creatinine in 22 of patients included (12 in vitamin C and 10 in placebo group). The Mann–Whitney U-test was used to compare values of oxidative stress biomarkers at days one and three after delivery in vitamin C vs. placebo groups (p ≤ 0.05 significant). Results: Dityrosine and 8-OHdg values did not differ significantly between the two study groups at day one after delivery (p = 0.23 and p = 0.77, respectively), but were significantly lower in the vitamin C group compared to the placebo group at day three after delivery (p = 0.04 and p = 0.03, respectively). Values of 8-isoprostane and HEL did not differ significantly between the two study groups at day one (p = 0.41 and p = 0.42, respectively), as well as at day three, after delivery (p = 0.25 and p = 0.24, respectively). Conclusion: High-dose intravenous vitamin C treatments in patients with severe preeclampsia reduced urinary levels of dityrosine and 8-OHdg (markers of protein and DNA oxidative damage, respectively) on day three after delivery. Vitamin C treatment had no significant effect on lipid peroxidation biomarkers, i.e., 8-isoprostane and HEL.

Marijuana use and pregnancy outcomes among women with hypertension in pregnancy

Background Marijuana has vasoconstrictive properties and its use has been associated with increased blood pressure in the general population. Yet, there are limited data on marijuana use and adverse outcomes among women with hypertension in pregnancy, even though these disorders are associated with severe maternal and fetal morbidity and mortality. Since marijuana is currently the most commonly used illicit drug in pregnancy, there is an urgent need to better understand the potential association between marijuana use and hypertension in pregnancy. Objective To determine the adverse prenatal effects of marijuana use in women with hypertension in pregnancy. Study design We conducted a retrospective cohort study among individuals with hypertension in pregnancy that delivered ≥23 weeks’ gestation at Oregon Health & Science University (October 2013–September 2018). The primary exposure assessed was marijuana use, identified by chart review of documented patient self-report or positive urine toxicology screen. Individuals were stratified into two groups by marijuana use: use during pregnancy versus never used. Primary outcomes included composite adverse maternal and neonatal outcomes. Secondary outcomes included individual maternal outcomes, rarer neonatal outcomes and severe features of preeclampsia. Differences were analyzed by Fisher’s exact, t-test, and logistic regression. Significance was determined by alpha = 0.05 for primary outcomes and alpha = 0.01 for secondary outcomes. Results From 11,825 deliveries, 1,613 (13.6%) were classified with hypertension in pregnancy. A total of 117 individuals (7.3%) used marijuana during pregnancy, 1,110 (68.2%) had never used marijuana and 396 (24.6%) had unknown marijuana use and were excluded, leaving 1,217 individuals in this analysis. Women using marijuana in pregnancy were more likely to be younger, non-Hispanic White, publicly insured and using other substances compared to women who did not use marijuana. There were no differences in the overall distribution of hypertensive disorders, including preeclampsia with severe features, in women who used marijuana versus those who did not (p = .80). In multivariable analyses, after adjusting for maternal factors and other substance use, marijuana use was not associated with adverse maternal (aOR 1.23, 95% CI 0.43–3.50, p = .69) or neonatal (aOR 0.90, 95% CI 0.28–2.89, p = .86) outcomes. Conclusions Marijuana use in pregnancy was not associated with maternal or neonatal outcomes or worsened hypertensive disease among women with hypertension in pregnancy after adjusting for maternal characteristics, including use of other substances. Our data highlight the need to consider use of other substances when evaluating the association between marijuana use in pregnancy and adverse pregnancy outcomes.

Maternal and Perinatal Outcomes of Pregnancies Complicated by Chronic Hypertension Followed at a Referral Hospital.

To assess maternal and perinatal outcomes of pregnancies in women with chronic hypertension (CH). Retrospective cohort of women with CH followed at a referral center for a 5 year period (2012-2017). Data were obtained from medical charts review and described as means and frequencies, and a Poisson regression was performed to identify factors independently associated to the occurrence of superimposed pre-eclampsia (sPE). A total of 385 women were included in the present study; the majority were > than 30 years old, multiparous, mostly white and obese before pregnancy. One third had pre-eclampsia (PE) in a previous pregnancy and 17% of them had organ damage associated with hypertension, mainly kidney dysfunction. A total of 85% of the patients used aspirin and calcium carbonate for pre-eclampsia prophylaxis and our frequency of sPE was 40%, with an early onset (32.98 ± 6.14 weeks). Of those, 40% had severe features of PE, including 5 cases of HELLP syndrome; however, no cases of eclampsia or maternal death were reported. C-section incidence was high, gestational age at birth was 36 weeks, and nearly a third (115 cases) of newborns had complications at birth One third of the women remained using antihypertensive drugs after pregnancy. Chronic hypertension is related with the high occurrence of PE, C-sections, prematurity and neonatal complications. Close surveillance and multidisciplinary care are important for early diagnosis of complications.

Soluble angiotensin IV receptor levels in preeclampsia: is there a variation?

Objective To measure the concentration of plasma soluble angiotensin IV receptor (sAT-4), a component of the renin-angiotensin system in healthy normotensive pregnancies and preeclampsia. Study design Stored maternal plasma samples obtained at the time of diagnosis from pregnant women of African ancestry were stratified into normotensive and preeclampsia groups. Preeclampsia was subdivided into early-onset, late-onset, and into and severe preeclampsia. Plasma concentrations of sAT-4 were measured at 450 nm using the ELISA technique (LNPEP KIT). Results The systolic and diastolic blood pressure (BP) levels of the normotensive group were statistically lower compared to preeclampsia groups (p < .05) and the mean gestational age in early-onset preeclampsia was lower compared to late-onset preeclampsia and the normotensive group (p < .05). Plasma sAT-4 levels were significantly elevated (p < .0001) in the normotensive group (median 1.95, range 1.89–2.02 ng/ml) compared to the preeclampsia group (median 1.55, range 1.42–1.74 ng/ml), regardless of gestational age. Soluble AT-4 was decreased in relation to the severity of preeclampsia (p < .001), the level in preeclampsia without severe features (median 1.57, range 1.42–1.74 ng/ml) was significantly higher than in preeclampsia with severe features (median 1.51, range 1.42–1.55 ng/ml). There was no significant difference in the sAT-4 level between early-onset preeclampsia (1.60 ± 0.13 ng/ml) and late-onset preeclampsia (1.65 ± 0.29 ng/ml) groups (p = .59). Conclusion Plasma circulating levels of sAT-4 in women with severe features of preeclampsia had lower levels than normotensives and those with preeclampsia without severe features.

607: Severe blood pressure elevation and adverse outcomes in hypertensive disorders of pregnancy

Severe blood pressure (BP) elevations in pregnancy predispose to adverse outcomes and require urgent treatment. Yet, when pregnant women present with a severe BP, treatment is often clouded by the underlying hypertensive diagnosis. We sought to evaluate the association between severe BP [systolic (SBP), diastolic (DBP), or both] and adverse outcomes, regardless of actual clinical diagnosis. Retrospective cohort study of deliveries ≥23 weeks’ gestation at a single institution (Oct ‘13 – Sept ‘18) with a hypertensive disorder of pregnancy. ICD discharge codes were used to identify subjects, followed by chart review. Subjects were categorized into four groups based on BP values before delivery: i) no severe BP; ii) severe SBP only (≥160 mmHg); iii) severe DBP only (≥110 mmHg); iv) both severe SBP and DBP. We assessed adverse neonatal and maternal outcomes in each group and performed multivariable logistic regression. Data were analyzed by ANOVA and chi-square test, with α=0.05. Among 11,825 deliveries, 1,630 (13.8%) had a hypertensive disorder of pregnancy. 698 (43.0%) subjects had a severe BP recording before delivery, with 346 (50.0%) having only severe SBP recordings, 88 (12.6%) having only severe DBP recordings, and 264 (39.0%) having both. Race, nulliparity, diabetes, and insurance were significantly different among BP groups. Adverse maternal and neonatal outcomes were greatest in those with both severe SBP and DBP, compared to other groups (Table 1). After adjusting for confounders, including other severe features of preeclampsia, the association between severe BP and adverse maternal outcomes was attenuated. However, the adverse neonatal outcomes remained significant for severe SBP and both severe SBP and DBP (aOR: 1.58, p=0.004 and aOR: 2.22, p< 0.001, respectively) (Table 2). In women with a hypertensive disorder of pregnancy, severe BPs are associated with adverse neonatal outcomes, independent of other severe features. Our data supports that severe BP elevation in pregnancy is a critical driver of adverse outcomes, regardless of the clinical diagnosis.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

562: Hyponatremia among preeclampsia patients - feature of severity

Hyponatremia occurring in the preeclamptic patient was previously described in several case reports and in one cohort study. The significance of this, presumably rare, complication is yet unknown. The aim of our study was to describe its prevalence and the correlation between hyponatremia and other preeclampsia complications. An Electronic Medical Record based retrospective cohort study included all singleton deliveries at Hadassah Medical Center between 2003-2015. Preeclampsia with and without severe features was defined using the criteria outlined in the current ACOG Hypertension in Pregnancy Guidelines. Sodium levels during pregnancy have been shown to be approximately 5 mEq/L lower than in non-pregnancy, therefore, hyponatremia was defined as a sodium level ≤ 130 mEq/L, and severe hyponatremia as < 125 mEq/L. A control group of 79 women admitted to the high risk antepartum unit at our facility for other pregnancy complications. We identified 700 pregnancies complicated by preeclampsia during the study period. Hyponatremia was noted in 102 (14.6%) patients compared with 0 of 79 women in the control group. Hyponatremia was strongly correlated with severe features of preeclampsia: HELLP syndrome, abnormal kidney function, severe hypertension as well as early delivery, low birth weight, unplanned CS, and NICU admission of the newborn (Table 1). Severe hyponatremia was strongly correlated with preeclampsia with severe features. Surprisingly, in a group of preeclamptic patients without severe features, hyponatremia was correlated with several adverse pregnancy outcomes (Table 2). Hyponatremia is not a rare complication of preeclampsia, and is even more common in patients with preeclampsia and severe features. As women with preeclampsia are at risk for hyponatremia, serum sodium should be monitored, especially in those women with severe features. In preeclamptic patients without severe features, hyponatremia may, by it self, be a sign of severity. However, the current study was too small to point toward hyponatremia as a sign of severity and further research is needed.

2237 Double Trouble: Coxsackie A and B Induced Hepatitis in an Adult

INTRODUCTION: Coxsackie virus which was first isolated in 1948 is a relatively common virus predominantly effecting children. There are 23 serotypes of Coxsackie A and 6 serotypes of the Coxsackie B viral strains. Clinical manifestations are generally mild in nature. We present a rare case of a 41yo female with Coxsackie A and B virus induced hepatitis. CASE DESCRIPTION/METHODS: 41yo F PMH DM, presented 36 weeks pregnant c/o 4 days of severe SOB and b/l LE edema. Home medications included metformin, insulin and pre-natals. No recent travel or use of herbal supplements. VS were T-98.3F, BP 130/92, HR 130, RR-22. PE showed LE edema and crackles on auscultation. Pt had severe features of preeclampsia and echo showed Global Cardiomyopathy (EF 21-25%). Labs showed Ph-7.21, CO2-33, HCO3-13, Cr-0.8, LDH-252, Alb-2.7, Bili-0.9/0.3, AST-40, ALT-23, ALP-184, WBC-11.8, Plt-172, INR-1.1, high urine protein. She was intubated for airway protection and taken for C-section. Over the next 3 days pt became febrile, hypotensive, tachycardic and worsening of her labs was noted, Cr-1.5, LDH-1528, Alb-2.1, Bili-0.9/0.5, AST-767, ALT-597, ALP-127, WBC-25.9, Plt-219, INR-1.3 before they started to improve. Pt was managed with aggressive diuresis, broad spectrum abx, and IV pressors for presumed septic/cardiogenic shock. Work up was positive for Coxsackie A and B virus. Pts bilirubin never increased beyond its current values. The rest of liver disease work up was unremarkable. Pt was discharged after stabilization and optimization of her medical condition. DISCUSSION: Coxsackie belongs to the Enterovirus genus, a member of the Picornaviridaefamily. It spreads via the fecal oral route, direct contact with bodily secretions or inhalation. Diagnosis is established with a positive viral culture or an increase in IgM titers. Coxsackie virus infection presents with nonspecific febrile illness, but may include pericarditis, myocarditis, hepatitis and encephalitis. Coxsackie A causes Hand foot and mouth disease, while Coxsackie B is the culprit of hepatitis. Hepatitis as a result of Coxsackie A strain is a very rare clinical phenomenon especially in the adult population. As seen in this case, the pts hepatitis and severe cardiomyopathy were likely secondary to Coxsackie virus. Treatment of Coxsackie virus infection is mainly supportive. Although commonly viral hepatitis is a results of Hepatitis A, B, C, D, E virus, HSV, EBV, and HIV, the possibility of Coxsackie virus induced hepatitis should always be considered.

EP01.05: Adjusting the risk of pre‐eclampsia throughout pregnancy in a high‐risk population under aspirin prophylaxis

We aimed to analyse the risk for Pre-eclampsia(PE) in high risk women under Aspirin, by analysing the blood pressure and uterine arteries at 20-236 weeks(w), 28-316w and 36-386w of pregnancy. This is a preliminary analysis of a cohort study that included 125 women at high risk for PE. We selected singleton pregnancies with an increased risk for PE before 37w above 1:100 at first trimester scan based on the Fetal Medicine Foundation algorithm. At enrolment maternal characteristics, biochemical and biophysical parameters were evaluated. All women initiated ≥ 100mg of aspirin (ASA) before 16 weeks and stopped at 36w. Systolic (SBP), diastolic (DBP), mean arterial blood pressure (MAP) and Z-score of the median pulsatility index of the uterine arteries were evaluated at 20-236, 28-316 and 36-386w. A ROC curve was used to evaluate the respective cutoffs and its correlation with PE development in patients who consistently screened positive for PE. Among the 125 patients under ASA, 12% (15) developed PE of which 1.6% (5) developed PE < 37w. At 20-236w by using a PAS = 119.5mmHg, PAD = 73.5mmHg, MAP = 89.17mmHg and Z-score UtArt = 1.282, 88 (70.4%) patients would be considered as screen positive and 14/15 would develop PE. At 28-316w by using a PAS = 133.5mmHg, PAD = 84.5mmHg, MAP = 90.17mmHg and Z-score UtArt = 0.653, 50/88 (56.8%) patients would be considered as screen positive and 12/14 would develop PE. At 36-386w by using a PAS = 133.5, PAD = 85.5, MAP = 98.17 and Z-score UtArt = 1.461, 25/50 (50%) patients would be considered as screen positive and 9/10 would develop PE. All the PE that were missed were term PE not associated to small for gestational age and no had no severe features of pre-eclampsia. By reassessing the risk of PE throughout pregnancy it's possible to identify patients whose ASA will be effective in prevention of PE and in those cases reduce the medical surveillance. Patients in whom ASA won't be enough can be correctly identified and benefit from a more personalised medical care. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.