Severe Hypertensive Disorders Of Pregnancy Research Articles

Postpartum Readmission for Hypertension After Discharge on Labetalol or Nifedipine.

To assess whether readmission for hypertension by 6 weeks postpartum differed between patients discharged on nifedipine or labetalol. This cohort study included patients with delivery admissions from 2006 to 2017 who were discharged from the hospital on nifedipine or labetalol and were included in a large, national adjudicated claims database. We identified patients' discharge medication based on filled outpatient prescriptions. We compared rates of hospital readmission for hypertension between patients discharged postpartum on labetalol alone, nifedipine alone, or combined nifedipine and labetalol. Patients with chronic hypertension without superimposed preeclampsia were excluded. Comparisons based on medication were performed using logistic regression models with adjustment for prespecified confounders. Comparisons were also stratified by hypertensive disorder of pregnancy severity. Among 1,582,335 patients overall, 14,112 (0.89%) were discharged postpartum on labetalol, 9,001 (0.57%) on nifedipine, and 1,364 (0.09%) on both medications. Postpartum readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine (641 patients vs 185 patients, 4.5% vs 2.1%, adjusted odds ratio [aOR] 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent for patients discharged on labetalol compared with nifedipine for both mild (4.5% vs 2.7%, aOR 1.57, 95% CI 1.29-1.93) and severe hypertensive disorders of pregnancy (261 patients vs 72 patients, 5.7% vs 3.2%, aOR 1.63, 95% CI 1.43-1.85). Readmissions for hypertension were more frequent on combined nifedipine and labetalol compared with nifedipine (3.1% vs 2.1%), but the odds were lower after confounder adjustment (aOR 0.80, 95% CI 0.64-0.99). Postpartum discharge on labetalol was associated with increased risk of readmission for hypertension compared with discharge on nifedipine.

Abstract P346: Cardiac Arrest During Delivery Hospitalization And Severe Hypertensive Disorders Of Pregnancy, United States, 2017-2019

Background: Cardiac arrest is a rare and sometimes fatal maternal complication. Severe hypertensive disorders of pregnancy (HDP) including preeclampsia with severe features, eclampsia, and Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP) syndrome are risk factors for maternal cardiac events. Surveillance on cardiac arrest and severe HDP during delivery is critical to informing evidence-based strategies to reduce pregnancy-related death. Methods: Using pooled data from the National Inpatient Sample from 2017-2019, we identified delivery hospitalizations among women aged 12-55 years. Delivery hospitalizations, cardiac arrest, and maternal medical conditions were identified using ICD-10-CM codes. Survival to hospital discharge was based on patient discharge disposition. Prevalence of cardiac arrest, severe HDP, and survival following cardiac arrest were calculated. We estimated the prevalence of severe HDP among delivery hospitalizations with cardiac arrest, cardiac arrest frequency among delivery hospitalizations with severe HDP, and survival to hospital discharge with co-occurring cardiac arrest and severe HDP. All estimates were weighted to account for complex sampling. Results: During 2017-2019, an estimated 10,921,784 delivery hospitalizations among which 1,465 cardiac arrests were identified. Overall cardiac arrest prevalence was 13.4 per 100,000 delivery hospitalizations (95% CI, 11.9-14.9). Of these, 1,005 (68.6% [95% CI, 63.2-74.0]) survived to hospital discharge. Overall prevalence of severe HDP was 2.7% (95% CI, 2.6-2.7) compared with 15.4% (95% CI 11.2-19.5) of delivery hospitalizations with cardiac arrest. Frequency of cardiac arrest per 100,000 delivery hospitalizations with severe HDP was 76.9 (95% CI, 54.6-99.2). Survival to hospital discharge with co-occurring cardiac arrest and severe HDP was 77.8% (95% CI, 65.6-89.9). Conclusion: Delivery hospitalizations affected by cardiac arrest are rare, and over two thirds survived to hospital discharge. Cardiac arrest disproportionately affected delivery hospitalizations among patients who had severe HDP.

Differences in disease severity and delivery gestational age between black and white patients with hypertensive disorders of pregnancy.

We sought to quantify racial differences in disease severity and delivery gestational age among Black and White patients with a diagnosis of a hypertensive disorder of pregnancy. This was a retrospective cohort of all Black and White pregnant patients carrying non-anomalous singleton or twin gestations at a single tertiary healthcare system who were diagnosed with a hypertensive disorder of pregnancy, 2014-2020. The primary outcome was delivery<34weeks' gestation. Secondary outcomes were delivery<28weeks', preeclampsia with severe features, acute renal insufficiency, HELLP syndrome, cesarean delivery, classical cesarean delivery, small for gestational age, severe maternal morbidity, and severe composite neonatal morbidity. Outcomes were compared by race. Data were analyzed using chi square, t-test, and logistic regression. 3,522 patients (29.8% Black) met inclusion criteria. Black patients had a higher odds of delivery<34weeks' [adjusted odds ratio (aOR) 2.22, 95% CI 1.7-2.89] and<28weeks' (aOR 2.39, 95% CI 1.43-3.99) and developing preeclampsia with severe features (aOR 1.92, 95% CI 1.62-2.29) than White patients. Black patients also had higher aOR of classical cesarean, severe maternal morbidity, and a small for gestational age neonate. Black patients are more likely to experience severe hypertensive disorders of pregnancy and preterm delivery compared to White patients. These findings suggest that Black-White disparities in preterm birth may be partially attributable to disparities in onset and severity of hypertensive disorders of pregnancy.

Progesterone Attenuates SIRT1-Deficiency-Mediated Pre-Eclampsia.

Pre-eclampsia is a severe hypertensive disorder of pregnancy (HDP), mainly characterized by new-onset hypertension with proteinuria after 20-week gestation. Sirtuin1 (SIRT1), a class III histone deacetylase, is associated with the regulation of various pathophysiological processes, including inflammation, immune response, metabolism, and autophagy. However, the effect of SIRT1 in the pathogenesis of pre-eclampsia remains to be elucidated. In this study, we found that the expression of SIRT1 was relatively lower in the placentas and serum samples of pre-eclampsia patients. Typical pre-eclampsia-like symptoms, such as hypertension, proteinuria, fetal growth restriction, kidney injury, and a narrow placental labyrinth layer, were observed in SIRT1 knockdown (SIRT1+/−) mice. Of note, these performances could be improved after the intraperitoneal injection of SIRT1 agonist SRT2104. More importantly, we found that the efficacy of progesterone on attenuating symptoms of PE was profoundly better than that of metformin in SIRT1+/− mice. In addition, our results suggested that progesterone can promote the invasion and inhibit the apoptosis of trophoblasts. These data suggest that SIRT1 plays an important role in pre-eclampsia and that progesterone alleviates pre-eclampsia-like symptoms mediated by SIRT1 deficiency.

Characteristics of Patients Who Attend the 7- to 10-Day Postpartum Visit for Blood Pressure Evaluation.

This study aimed to assess maternal characteristics that predict attendance of postpartum blood pressure evaluation in patients with hypertensive disorders of pregnancy (HDP). A retrospective case-control study of patients with HDP delivering at a single academic institution (2014-2018). Diagnosis of HDP included gestational hypertension, chronic hypertension, preeclampsia, and superimposed preeclampsia. Univariable and multivariable analyses were used to determine maternal characteristics independently associated with attendance of the 7- to 10-day postpartum blood pressure evaluation. Of the 1,041 patients included in the analysis, 603 (57.9%) attended the 7- to 10-day postpartum blood pressure check. Maternal sociodemographic, clinical, and obstetric factors differed significantly between patients who attended the postpartum blood pressure visit and those who did not. In univariable analyses, nulliparity, non-Hispanic black race and ethnicity, public insurance, HDP with severe features, cesarean birth, gestational age at delivery, receipt of magnesium, mild-range blood pressures on day of discharge, and initiation of antihypertensive medication were associated with attendance of the 7- to 10-day postpartum visit. In multivariable analysis, factors significantly associated with higher odds of attending the blood pressure visit were nulliparity (adjusted odds ratio [aOR]: 1.58; 95% confidence interval: [CI]: 1.14-2.17), severe HDP (aOR: 1.94, 95% CI: 1.44-2.61), and cesarean birth (aOR: 1.92, 95% CI: 1.43-2.59). In contrast, factors associated with lower odds of attendance were non-Hispanic black race and ethnicity compared with non-Hispanic white (aOR: 0.68, 95% CI: 0.47-0.97), and public insurance (aOR: 0.65, 95% CI: 0.45-0.93) compared with private insurance. Clinical factors such as nulliparity, severe HDP, and cesarean birth were associated with higher rates of postpartum blood pressure evaluation attendance, whereas sociodemographic factors such as maternal non-Hispanic black race and ethnicity and public insurance were associated with lower odds of postpartum blood pressure check attendance. · A total of 57.9% of patients with HDP attended in person postpartum blood pressure check.. · Nulliparity, severe features of HDP, and cesarean birth were associated with higher rates of attendance.. · Non-Hispanic black race and ethnicity and public insurance were associated with lower attendance..

Information needs and experiences from pregnancies complicated by hypertensive disorders: a qualitative analysis of narrative responses

BackgroundIncorporation of the patient voice is urgently needed in a broad array of health care settings, but it is particularly lacking in the obstetrical literature. Systematically derived information about patients’ experience with hypertensive disorders of pregnancy (HDP), most notably preeclampsia, is necessary to improve patient-provider communication and ultimately inform patient-centered care and research.We sought to examine the information needs and experiences of individuals with pregnancies complicated by hypertensive disorders.MethodsWe conducted a qualitative content analysis of narrative-responses to an open-ended question from the Preeclampsia Registry (TPR), an online registry hosted by the Preeclampsia Foundation. Individuals were invited to enroll in TPR via social media, web searches, and newsletters. We restricted our analysis to participants who self-reported a history of HDP and responded to the open-ended question, “Is there any information that you could have had at the time of this pregnancy that would have been helpful?”. Available responses from July 2013 to March 2017 were included. Narrative responses were coded, reconciled, and thematically analyzed by multiple coders using an inductive approach. Our main outcome measures included participants’ expressed needs and additional concerns with respect to their HDP pregnancy.ResultsOf 3202 enrolled participants, 1850 completed the survey and self-reported having at least one pregnancy complicated by HDP, of which 895 (48.4%) responded to the open-ended question. Participants delivered in the United States (83%) and 27 other countries. Compared to non-responders, responders reported more severe HDP phenotypes and adverse offspring outcomes. We identified three principal themes from responses: patient-identified needs, management and counseling, and potential action. Responses revealed that participants’ baseline understanding of HDP, including symptoms, management, therapeutic strategies, and postpartum complications, was demonstrably lacking. Responders strongly desired improved counseling so that both they and their providers could collaboratively diagnose, appropriately manage, and robustly and continuously communicate to facilitate a partnership to address any HDP complications.ConclusionsParticipants’ responses regarding their HDP experience provide indispensable insight into the patient’s perspectives. Our study suggests that improved education regarding possible HDP complications and transparency about the consideration of HDP and its associated outcomes during an evaluation are needed, and efforts to implement these strategies should be sought.Trial registrationThe Preeclampsia Registry: NCT02020174

The burden of severe hypertensive disorders of pregnancy on perinatal outcomes: a nationwide case-control study in Suriname

BACKGROUNDLatin America and the Caribbean is the region with the highest prevalence of hypertensive disorders of pregnancy worldwide. In Suriname, where the stillbirth rate is the second highest in the region, it is not yet known which maternal factors contribute most substantially.OBJECTIVEThe aims of this study in Suriname were to (1) study the impact of different types of maternal morbidity on adverse perinatal outcomes and (2) study perinatal birth outcomes among women with severe hypertensive disorders of pregnancy.STUDY DESIGNA case-control study was conducted between March 2017 and February 2018 during which time all hospital births (86% of total) in Suriname were included. We identified babies with adverse perinatal outcomes (perinatal death or neonatal near miss) and women with severe maternal morbidity (according to the World Health Organization Near Miss tool). Stillbirths and early neonatal deaths (<7 days) were considered perinatal death. We defined a neonatal near miss as a birthweight below 1750 g, gestational age <33 weeks, 5-minute Apgar score <7, and preterm intrauterine growth restriction <p3. Descriptive statistics and multivariate binary logistic regression analyses were conducted.RESULTSIn the 1-year study period, adverse perinatal outcomes were reported for 638 singleton births of which 120 (18.8%) involved women with severe maternal morbidity. In most of these cases, the mother suffered severe hypertensive disorders of pregnancy (n=95/120, 79.2%). Severe hypertensive disorders of pregnancy were strongly associated with adverse perinatal outcomes (adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9). The prevalence of severe hypertensive disorders of pregnancy in Suriname was 2.5% (234/9197). Of the 215 singleton pregnancies complicated by severe hypertensive disorders, adverse perinatal outcomes were reported for 44.2% of them (n=95/215; adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9); perinatal death accounted for 18.1% of these cases (n=39/215; adjusted odds ratio, 8.6; 95% confidence interval, 5.8–12.7) and neonatal near miss accounted for another 26.0% (n=56/215). Women with severe hypertensive disorders of pregnancy had a preterm birth (<37 weeks) in 67.1% of the cases (n=143/215; adjusted odds ratio, 14.1; 95% confidence interval, 10.5–19.0), a baby with a low birthweight (<2500 g) in 62.2% of the cases (n=130/215; adjusted odds ratio, 10.8; 95% confidence interval, 8.1–14.5), and a baby with a low 5-minute Apgar score in 20.5% of the cases (n=43/215; adjusted odds ratio, 6.9; 95% confidence interval, 4.8–10.0).CONCLUSIONIn Suriname, severe hypertensive disorders of pregnancy are strongly associated with adverse perinatal outcomes, with an increased risk for preterm birth, low birthweight, low Apgar score, and perinatal mortality. Prevention, early diagnosis, and management of hypertensive disorders of pregnancy are expected to reduce perinatal deaths substantially. Recommendations to reduce perinatal deaths in Suriname include the establishment of a national health plan for the management of severe hypertensive disorders of pregnancy and the introduction of perinatal death and neonatal near miss reviews.

Cardiovascular Risk Reduction in Women Following Hypertensive Disorders of Pregnancy - a Prospective, Randomised, Controlled Interventional Study.

Background Women have a markedly increased lifetime risk for cardiovascular morbidity and mortality following hypertensive disorders of pregnancy. Arterial stiffness is regarded as a target parameter for reducing cardiovascular risk and can be modified by lifestyle changes. Methods In a prospective, randomised, controlled interventional study, starting 6 weeks postpartum, the effect of nutritional intervention combined with an intensive 6-month cardiovascular exercise programme on arterial stiffness was investigated by means of pulse wave velocity (PWV) in 38 women with severe hypertensive disorder of pregnancy (preeclampsia with or without pre-existing hypertension and/or HELLP syndrome). A reference group was formed with postpartum women without pregnancy complications or known cardiovascular risk and the arterial stiffness was studied by means of PWV at the time of delivery. The PWV was measured in the intervention and control groups within a week after delivery and after 32 weeks (6 weeks + 6 months). A feasibility analysis was performed in addition. Results 29 of 38 women with severe hypertensive disorder of pregnancy and 38 postpartum women in the reference group were included in the analysis (intervention group n = 14; control group n = 15; reference group n = 38). Adherence to a) the nutritional counselling and b) the intensive cardiovascular exercise programme was 73% and 79% respectively. A clinically significant difference (d = 0.65) in pulse wave velocity between the intervention and control groups was found after 6 months (6.36 ± 0.76 vs. 7.33 ± 2.25 m/s; group × time: p = 0.632). The PWV of the intervention group corresponded to that of the reference group at the end of the study (6.36 ± 0.76 m/s vs. 6.5 ± 0.70; d = 0.19), while the results in the control group differed markedly from this (7.33 ± 2.25 m/s; d = 0.56). Conclusion The study documents the feasibility of lifestyle intervention with physical exercise after delivery (starting 6 weeks postpartum). The intervention showed a significant clinical effect by reducing arterial stiffness to the level of the reference group. Before this intervention can be included in the standard of care and prevention, follow-up studies must confirm these results and the medium-term effects on cardiovascular risk.

Maternal near-miss attributable to haemorrhagic stroke in patients with hypertensive disorders of pregnancy in Japan: A national cohort study.

To investigate the epidemiologic and clinical characteristics of maternal near-misses attributable to haemorrhagic stroke (HS) occurring in patients with hypertensive disorders of pregnancy (HDP), with a focus on severe neurological morbidity. A national retrospective cohort study was conducted using the national database of health insurance claims for the period 2010 to 2017. The subjects were all insured women with a diagnosis of both HDP and HS. Severe neurological morbidity requiring rehabilitation, types of HDP, types of HS, and magnesium sulphate use were tabulated. The number of women with HDP who were diagnosed with HS was 3.4 per 100,000 deliveries between 2010 and 2017. Forty percent of HDP-related HS cases had neurological morbidities requiring rehabilitation (1.4 per 100,000 deliveries), and 4.4% were in a persistent vegetative state after HS. Of the HDP cases who developed HS, 69.2% were severe HDP, of which 55.6% were without eclampsia. The most common type of HS was intracerebral haemorrhage (2.5 per 100,000 deliveries), followed by subarachnoid haemorrhage due to cerebral aneurysm (1.2 per 100,000 deliveries). The frequency of magnesium sulphate use increased in all patients with HDP-related HS in the second half of the study period (2014-2017) compared with the first half (2010-2013) (p<0.0001). This was more evident in cases of HDP-related HS with eclampsia (31.9% to 83.8%) compared to those without eclampsia (25.0% to 42.9%). Of the maternal near-miss cases due to HDP-related HS, 40.0% were rehabilitated and 69.2% were HDP without either eclampsia or severe hypertension.

844 Characteristics of patients that attend 7-10 days postpartum visit for blood pressure check

To assess maternal characteristics that predict attendance of postpartum blood pressure visit in patients with hypertensive disorders of pregnancy (HDP). A retrospective case-control study of patients with HDP delivering at a single academic institution (2014-2018). Diagnosis of HDP included gestational hypertension, chronic hypertension, preeclampsia and superimposed preeclampsia. Univariable and multivariable analyses were used to determine maternal characteristics independently associated with attendance of 7-10 days postpartum blood pressure check. Of the 1,042 patients included in analysis, 603 (57.9%) attended the 7-10 days postpartum blood pressure check. Maternal sociodemographic, clinical and obstetric factors differed significantly between patients that attended the postpartum blood pressure visit and those that did not (Table). In univariable analyses, nulliparity, non-Hispanic black race and ethnicity, public insurance, HDP with severe features, cesarean birth, gestational age at delivery, receipt of magnesium, mild range blood pressures on day of discharge and initiation of antihypertensive medication were associated with attendance of the 7-10 days postpartum visit (Table). In multivariable analysis, factors significantly associated with higher odds of attending the blood pressure visit were nulliparity (aOR 1.58; 95% CI 1.14-2.17), severe HDP (aOR 1.94, 95% CI 1.44-2.61) and cesarean birth (aOR 1.92, 95%CI 1.43 – 2.59). In contrast, factors associated with lower odds of attendance were non-Hispanic black race and ethnicity compared with non-Hispanic white (aOR 0.68, 95% CI 0.47 – 0.97), and public insurance (aOR 0.65, 95% CI 0.45 – 0.93) compared with private insurance (Table). Clinical factors such as nulliparity, severe HDP and cesarean birth were associated with higher rates of postpartum blood pressure check attendance, whereas sociodemographic factors such as maternal non-Hispanic black race and ethnicity and public insurance were associated with lower odds of postpartum blood pressure check attendance.

Circulating Total Cell-Free DNA Levels Are Increased in Hypertensive Disorders of Pregnancy and Associated with Prohypertensive Factors and Adverse Clinical Outcomes.

Previous studies have described increased circulating cell-free DNA (cfDNA) in hypertensive disorders of pregnancy (HDP). Here, we aimed first to confirm this information using a simple, but sensible fluorescent assay, and second to investigate whether total cfDNA is associated with circulating factors known to be linked to the pathophysiology of HDP as well as with poor maternal-fetal outcomes. We studied 98 women with healthy pregnancies (HP), 88 with gestational hypertension (GH), and 91 with preeclampsia (PE). Total DNA was extracted from plasma using the QIAamp DNA blood mini kit and quantified using Quant-iT™ PicoGreen® dsDNA fluorescent detection kit. We found higher total cfDNA levels in GH and PE (197.0 and 174.2 ng/mL, respectively) than in HP (140.5 ng/mL; both p < 0.0001). Interestingly, total cfDNA levels were elevated in both male and female-bearing pregnancies diagnosed with either HDP, and in more severe versus less severe HDP cases, as classified according to responsiveness to antihypertensive therapy. In addition, total cfDNA was independently associated with HDP, and a cutoff concentration of 160 ng/mL provided appropriate sensitivity and specificity values for diagnosing GH and PE compared to HP (70–85%, both p < 0.0001). Moreover, high total cfDNA was associated with adverse clinical outcomes (high blood pressure, low platelet count, preterm delivery, fetal growth restriction) and high prohypertensive factors (sFLT-1, sEndoglin, MMP-2). These findings represent a step towards to the establishment of cfDNA as a diagnostic tool and the need to understand its role in HDP.

Development and validation of a prediction model on severe maternal outcomes among pregnant women with pre-eclampsia: a 10-year cohort study

Pre-eclampsia is a severe hypertensive disorder of pregnancy and could lead to severe maternal morbidities and death. Our study aimed to develop and validate a prognostic prediction model for severe maternal outcomes among Chinese population with pre-eclampsia. We conducted a 10-year cohort study in a referral center by collecting all pregnant women who diagnosed as pre-eclampsia and delivered from 2005 to 2014. A composite of severe maternal outcomes, including maternal near-miss defined by World Health Organization, cortical blindness/retinal detachment, temporary facial paralysis and maternal death, were adopted. We used logistic regression model to develop Model 1 by retaining the predictors of p < 0.05, and further conducted Model 2 by adding quadratic terms and interaction terms to Model 1. We undertook a bootstrapping validation and estimated the model performance. A total of 397 pregnant women suffered from severe maternal outcomes among 2,793 eligible participants, with an incidence of 14.21% (95% confidence interval (CI) 12.91%–15.51%). Of 13 predictors were finally selected in Model 1. Combined with quadratic and interactive terms, the Model 2 showed higher area under the ROC curve (82.2%, 95% CI 79.6%–84.7%) and good calibration. By the bootstrapping validation, similar model performances were present.

Neuro-imaging in severe hypertensive disorders of pregnancy and correlation with laboratory data: A study from North Indian tertiary health care institution

Neuro-imaging in severe hypertensive disorders of pregnancy and correlation with laboratory data: A study from North Indian tertiary health care institution

Hypertensive Disorders of Pregnancy and Future Cardiovascular Health

Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations. These women are known to have higher cardiovascular morbidity and mortality later in life in comparison with parous controls who had normotensive pregnancies. Several studies have demonstrated that women with preeclampsia present in a state of segmental impaired myocardial function, biventricular chamber dysfunction, adverse biventricular remodeling, and hypertrophy, a compromised hemodynamic state and indirect echocardiographic signs of localized myocardial ischemia and fibrosis. These cardiac functional and geometric changes are known to have strong predictive value for cardiovascular disease in non-pregnant subjects. A “dose effect” response seems to regulate this relationship with severe HDP, early-onset HDP, coexistence of fetal growth disorders, and recurrence of HDP resulting in poorer cardiovascular measures. The mechanism underlying the relationship between HDP in younger women and cardiovascular disease later in life is unclear but could be explained by sharing of pre-pregnancy cardiovascular risk factors or due to a direct impact of HDP on the maternal cardiovascular system conferring a state of increased susceptibility to future metabolic or hemodynamic insults. If so, the prevention of HDP itself would become all the more urgent. Shortly after delivery, women who experienced HDP express an increased risk of classic cardiovascular risk factors such as essential hypertension, renal disease, abnormal lipid profile, and diabetes with higher frequency than controls. Within one or two decades after delivery, this group of women are more likely to experience premature cardiovascular events, such as symptomatic heart failure, myocardial ischemia, and cerebral vascular disease. Although there is general agreement that women who suffered from HDP should undertake early screening for cardiovascular risk factors in order to allow for appropriate prevention, the exact timing and modality of screening has not been standardized yet. Our findings suggest that prevention should start as early as possible after delivery by making the women aware of their increased cardiovascular risk and encouraging weight control, stop smoking, healthy diet, and daily exercise which are well-established and cost-effective prevention strategies.

Severe Hypertensive Disorders of Pregnancy in Eastern Ethiopia: Comparing the Original WHO and Adapted sub-Saharan African Maternal Near-Miss Criteria.

ObjectivesTo assess life-threatening complications among women admitted with severe hypertensive disorders of pregnancy and compare applicability of World Health Organization (WHO) maternal near-miss (MNM) criteria and the recently adapted sub-Saharan African (SSA) MNM criteria in eastern Ethiopia.MethodsOf 1,054 women admitted with potentially life-threatening conditions between January 2016 and April 2017, 562 (53.3%) had severe preeclampsia/eclampsia. We applied the definition of MNM according to the WHO MNM criteria and the SSA MNM criteria. Logistic regression was performed to identify factors associated with severe maternal outcomes (MNMs and maternal deaths).ResultsThe SSA MNM criteria identified 285 cases of severe maternal outcomes: 271 MNMs and 14 maternal deaths (mortality index 4.9%). The WHO criteria identified 50 cases of severe maternal outcomes: 36 MNMs and 14 maternal deaths (mortality index 28%). The MNM ratio was 36.6 per 1,000 livebirths according to the SSA MNM criteria and 4.9 according to the WHO criteria. More than 80% of women in both groups had MNM events on arrival or within 12 hours after admission. Women without antenatal care, from rural areas, referred from other facilities, and with concomitant hemorrhage more often developed severe maternal outcomes.ConclusionRegarding hypertensive disorders of pregnancy, the SSA tool is more inclusive than the WHO tool, while still maintaining a considerably high mortality index indicating severity of included cases. This may enable more robust audits. Strengthening the referral system and improving prevention and management of obstetric hemorrhage in women with hypertensive disorders of pregnancy are required to avert severe maternal outcomes.

Prevalence of Hypertensive Disorder of Pregnancy in North India

Aims and Objective: Hypertensive disorders of pregnancy (HDP) are among the commonest medical disorders during pregnancy constituting one of the greatest causes of maternal and perinatal morbidity and mortality worldwide . This study aimed to analyze the prevalence of hypertensive disorder of pregnancy in North India&#x0D; Material and Method: The study group consisted of a total of 150 pregnant women attending Maharaja Agrasen hospital OPD/IPD during their second trimester (14-20 weeks) of pregnancy from Dec 2016 to Nov 2017.&#x0D; Results: Out of 146 cases studied , 129 cases remained normotensive and 17 cases developed HDP. Out of 17 cases ,8 cases had mild HDPs and 9 cases had severe HDPs. The prevalence of HDP was 11.7% in present study.&#x0D; Conclusion: The study concluded that the incidence of hypertensive disorders in pregnancy was higher than worldwide average and hence early diagnosis and intervention through regular antenatal checkup is pivotal to prevent hypertensive disorders of pregnancy and its complications.

A Protocol for Nurse-Practitioner Led Cardiovascular Follow-Up After Pregnancy Complications in a Socioeconomically Disadvantaged Population.

Background: Women who experience pregnancy complications have an increased risk of future cardiovascular disease when compared to their healthy counterparts. Despite recommendations, there is no standardized cardiovascular follow-up in the postpartum period for these women, and the Australian follow-up protocols that have been previously described are research-based. This study proposes a new model of care for a nurse practitioner-led postpartum intervention clinic for women who experience severe hypertensive disorders of pregnancy, gestational diabetes mellitus requiring medication, severe intrauterine growth restriction, idiopathic preterm delivery, or placental abruption, in a socioeconomically disadvantaged population.Methods: All women receiving antenatal care or who deliver at the Lyell McEwin Hospital, a tertiary acute care facility located in the northern Adelaide metropolitan area, following a severe complication of pregnancy are referred to the intervention clinic for review at 6 months postpartum. A comprehensive assessment is conducted from demographics, medical history, diet and exercise habits, psychosocial information, health literacy, pathology results, and physical measurements. Subsequently, patient-specific education and clinical counseling are provided by a specialized nurse practitioner. Clinic appointments are repeated at 18 months and 5 years postpartum. All data is also collated into a registry, which aims to assess the efficacy of the intervention at improving modifiable cardiovascular risk factors and reducing cardiovascular risk.Discussion: There is limited information on the efficacy of postpartum intervention clinics in reducing cardiovascular risk in women who have experienced pregnancy complications. Analyses of the data collected in the registry will provide essential information about how best to reduce cardiovascular risk in women in socioeconomically disadvantaged and disease-burdened populations.

Adenomyosis as a Potential Risk Factor for Adverse Pregnancy Outcomes: A Multicenter Case-Control Study.

As the number of women who postpone their first pregnancy until their late 30s or early 40s is increasing, adenomyosis is more frequently encountered by obstetricians. Some studies have reported on the relationship between adenomyosis and pregnancy complications. We aimed to investigate the effect of adenomyosis on pregnancy complications and outcomes and associations between adenomyosis type and pregnancy outcomes. This multicenter retrospective 1:4 case-control study included 61 women with singleton pregnancies diagnosed with adenomyosis. The control group included women with singleton pregnancies without adenomyosis; these women were matched to those with adenomyosis using propensity scores. The incidence of obstetric complications, delivery, and neonatal outcomes were compared. The adenomyosis group (n = 61) had significantly higher incidence of preterm delivery (21.3% vs. 9.4%), hypertensive disorders of pregnancy (13.1% vs. 5.3%), cesarean delivery (46.0% vs. 20.9%), and postpartum hemorrhage (57.3% vs. 36.8%) than the control group (n = 244). Subgroup analysis by the adenomyosis type revealed that the diffuse adenomyosis group (n = 41) was significantly more likely to experience preterm labor (29.3% vs. 7.3%), hypertensive disorders of pregnancy (17.0% vs. 5.5%), severe hypertensive disorders of pregnancy (12.2% vs. 1.8%), preterm premature rupture of membranes (12.2% vs. 2.4%), cesarean delivery (61.3% vs. 18.9%), and postpartum hemorrhage (70.7% vs. 44.5%) than the control group (n = 164). The focal adenomyosis (n = 20) group was not statistically different from the control group (n = 80) with respect to obstetric complications. Women with diffuse adenomyosis require more careful perinatal management than previously thought.

Efficacy of nifedipine versus hydralazine in the management of severe hypertension in pregnancy: A randomised controlled trial.

Despite the availability of effective antihypertensive drugs, the quality of evidence regarding the best antihypertensive agent for the treatment of hypertensive emergencies in pregnancy is still poor. The aim of this study was to compare the efficacy and side effects of oral nifedipine and intravenous hydralazine for control of blood pressure (BP) in severe hypertension in pregnancy. An open-label, parallel, randomised, controlled trial of 78 pregnant women (≥28 weeks' gestation) with severe hypertension was conducted. Severe hypertension was defined as systolic BP of 160 mmHg or above and/or diastolic BP of 110 mmHg or above. They were randomly (1:1 ratio) administered oral nifedipine 20 mg or intravenous hydralazine 10 mg every 30 min up to 5 doses or until the target BP of 140-150 mmHg systolic and 90-100 mmHg diastolic was achieved. Intravenous labetalol was given if the primary treatment failed. The primary outcome measure was the number of doses needed to achieve targeted BP. The secondary outcome measures were the time needed to achieve desired BP, maternal adverse effects and perinatal outcome. The sociodemographic characteristics did not differ between the two study groups. The average number of dosages (nifedipine; 1.4 ± 0.6 vs. hydralazine; 1.7 ± 0.5, P = 0.008) needed to control the BP was lower in the nifedipine arm. Time (min) taken to control the BP was similar between the groups (hydralazine; 43.7 ± 19.7 vs. nifedipine; 51.2 ± 18.9, P = 0.113). Adverse maternal and perinatal effects did not differ in the study groups. Oral nifedipine and intravenous hydralazine showed comparable efficacy in the BP control in the severe hypertensive disorders of pregnancy without significant difference in adverse maternal and perinatal outcomes. However, further studies are required to explore the role of these drugs in BP control during hypertensive emergencies in pregnancy. (Identification number: NCT04435210).

Association between legal status, prenatal care utilization, severe perinatal and maternal morbidity

Abstract Background Some groups of migrant women have a higher risk of inadequate prenatal care utilization (PCU), severe maternal morbidity (SMM) and severe perinatal morbidity (SPM). To better understand this association, our aim was to assess the association between the legal status and PCU, SMM and SPM during pregnancy. Methods The analysis was performed in the database of the multicenter prospective PreCARE cohort. All pregnant women registered for delivery in 4 university hospital maternity units in Paris north area from October 2010 to May 2012 were included (N = 10 419). Women whose pregnancies ended before 22 weeks of gestation or who delivered in another maternity unit were excluded (N = 820). Women were distributed according to legal status in 4 groups: non-migrants, migrants with French or European nationality, legal migrants and undocumented migrants. The associations between the legal status and the composite variables of prenatal care utilization, SMM and SPM were tested through multivariate logistic regressions also adjusted for maternal characteristics. Results The illegal status was associated with increased risk of inadequate prenatal care utilization [adjusted odds ratio (aOR) 2,52 (2,10 - 3,01)]. Overall, the prevalence of SMM was 3,2 % and SPM 7,0 %. The illegal status was associated with higher risk of SMM [aOR 1,84 (1,21 - 2,79)], especially severe hypertensive disorder of pregnancy [aOR 2,29 (1,19 - 4,40)]. However, no significant association with SPM was found [aOR 1,29 (0,95 - 1,74)]. The sensitivity analysis demonstrates that results do not change after exclusion of women who arrived less than 12 months before delivery and those who started their follow-up after 14 weeks of gestation. Conclusions The illegal status was associated with an inadequate prenatal care utilization and a higher risk of SMM, especially severe hypertensive disorder of pregnancy. Key messages The illegal status was associated with increased risk of inadequate prenatal care utilization. The illegal status was associated with higher risk of severe maternal morbidity during pregnancy.