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OBJECTIVE: To evaluate the proximal effects of hypertensive disorders of pregnancy (HDP) on a validated measure of brain abnormalities in infants born at ≤32 weeks' gestational age (GA) using magnetic resonance imaging at term-equivalent age. STUDY DESIGN: In a multisite prospective cohort study, 395 infants born at ≤32 weeks' GA, underwent 3T magnetic resonance imaging scan between 39 and 44 weeks' postmenstrual age. A single neuroradiologist, blinded to clinical history, evaluated the standardized Kidokoro global brain abnormality score as the primary outcome. We classified infants as HDP-exposed by maternal diagnosis of chronic hypertension, gestational hypertension, pre-eclampsia, or eclampsia. Linear regression analysis identified the independent effects of HDP on infant brain abnormalities, adjusting for histologic chorioamnionitis, maternal smoking, antenatal steroids, magnesium sulfate, and infant sex. Mediation analyses quantified the indirect effect of HDP mediated via impaired intrauterine growth and prematurity and remaining direct effects on brain abnormalities. RESULTS: A total of 170/395 infants (43%) were HDP-exposed. Adjusted multivariable analyses revealed HDP-exposed infants had 27% (95% CI 5%-53%) higher brain abnormality scores than those without HDP exposure (P = .02), primarily driven by increased white matter injury/abnormality scores (P = .01). Mediation analyses showed HDP-induced impaired intrauterine growth significantly (P = .02) contributed to brain abnormality scores (22% of the total effect). CONCLUSIONS: Maternal hypertension independently increased the risk for early brain injury and/or maturational delays in infants born at ≤32 weeks' GA with an indirect effect of 22% resulting from impaired intrauterine growth. Enhanced prevention/treatment of maternal hypertension may mitigate the risk of infant brain abnormalities and potential neurodevelopmental impairments.
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Encéfalo , Edad Gestacional , Hipertensión Inducida en el Embarazo , Imagen por Resonancia Magnética , Humanos , Femenino , Embarazo , Estudios Prospectivos , Recién Nacido , Hipertensión Inducida en el Embarazo/epidemiología , Masculino , Encéfalo/diagnóstico por imagen , Encéfalo/anomalías , Adulto , Factores de Riesgo , Recien Nacido PrematuroRESUMEN
Fetal growth restriction associated with hypertensive disorders of pregnancy (FGR-HDP) is a prevalent pathology with a higher risk of perinatal morbimortality. In this condition, placental insufficiency and endothelial dysfunction serve key roles. The present prospective cohort study monitored 11 patients with an FGR-HDP and 15 with full-term normotensive pregnancies and studied post-natal intracellular calcium concentration ([Ca2+]i) signals in human umbilical vein endothelial cells (HUVECs). Small fetuses with placental insufficiency were identified using fetal biometry with Doppler velocimetry. Mean gestational age and birth weight were 31.8±4.1 weeks and 1,260±646 g for FGR-HDP and 39.2±0.8 weeks and 3,320±336 g for normal births, respectively. Abnormal umbilical artery Doppler waveforms were found in 64% of neonates with FGR-HDP. A significant percentage (86%) of FGR newborns were admitted to the neonatal intensive care unit at Gustavo Fricke hospital, Viña del Mar, Chile, with one case of death after birth. [Ca2+]i signals were measured by microfluorimetry in Fluo-3-loaded HUVECs from primary cultures. Altered [Ca2+]i signals were observed in HUVECs from FGR-HDP, where the sustained phase of ATP-induced [Ca2+]i responses was significantly reduced compared with the normotensive group. Also, the [Ca2+]i signals induced with 10 mM Ca2+ after depletion of internal Ca2+ stores were significantly higher. The present study provides a better comprehension of the role of altered cytosolic Ca2+ dynamics in endothelial dysfunction and an in vitro model to assess novel therapeutic approaches for decreasing or preventing complications in FGR-HDP.
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Resumen OBJETIVO: Describir las características de la población afectada y los retrasos que contribuyeron a la mortalidad materna, secundaria a los trastornos hipertensivos del embarazo. MATERIALES Y MÉTODOS: Estudio descriptivo y retrospectivo efectuado con base en la vigilancia epidemiológica de casos centinela de muertes maternas tempranas de mujeres residentes en Antioquia, Colombia, durante el embarazo, el parto y los 42 días siguientes a éste ocurridas en el periodo 2012-2020. Se creó una base de datos en Microsoft Access 2007 (Microsoft, Redmond, WA, USA) y los datos se analizaron en Microsoft Excel y SPSS versión 22. RESULTADOS: Se registraron 266 muertes maternas, de las que 38 fueron secundarias a trastornos hipertensivos del embarazo. La eclampsia fue causa de 15 fallecimientos; 12 por síndrome HELLP, 9 por hemorragia intracerebral y 2 por desprendimiento prematuro de placenta y coagulación intravascular diseminada. En 13 de los 38 casos no hubo una pauta adecuada del sulfato de magnesio, 19 no recibieron tratamiento antihipertensivo, que estaba indicado y 17 no tuvieron un control antihipertensivo adecuado. CONCLUSIÓN: La atención prenatal es una oportunidad decisiva para la detección, prevención y estratificación del riesgo. Todos los centros de atención obstétrica deben estar preparados para gestionar urgencias asociadas con los trastornos hipertensivos del embarazo. Los desenlaces mejoran con la aplicación de protocolos de emergencia estandarizados, organizados y la participación de equipos multidisciplinarios que garanticen una atención de calidad y un efecto positivo en la morbilidad y mortalidad materna susceptible de prevención.
Abstract OBJECTIVE: To describe the characteristics of the affected population and the delays that contributed to maternal mortality secondary to hypertensive disorders of pregnancy. MATERIALS AND METHODS: Descriptive and retrospective study based on the epidemiologic surveillance of sentinel cases of early maternal deaths of women residing in Antioquia, Colombia, during pregnancy, delivery and the 42 days after delivery occurring in the period 2012-2020. A database was created in Microsoft Access 2007 (Microsoft, Redmond, WA, USA), and data were analyzed in Microsoft Excel and SPSS version 22. RESULTS: There were 266 maternal deaths, of which 38 were secondary to hypertensive disorders of pregnancy. Eclampsia was the cause of 15 deaths; 12 due to HELLP syndrome, 9 due to intracerebral hemorrhage, and 2 due to placental abruption and disseminated intravascular coagulation. In 13 of the 38 cases, there was no adequate magnesium sulfate regimen, 19 did not receive indicated antihypertensive treatment, and 17 did not have adequate antihypertensive control. CONCLUSION: Antenatal care is a critical opportunity for detection, prevention, and risk stratification. All obstetric care centers should be prepared to manage emergencies associated with hypertensive disorders of pregnancy. Outcomes improve with the use of standardized, organized emergency protocols and the participation of multidisciplinary teams that ensure quality care and a positive impact on preventable maternal morbidity and mortality.
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Resumen OBJETIVO: Describir las complicaciones anestésicas en pacientes con preeclampsia con criterios de severidad. MATERIALES Y MÉTODOS: Estudio observacional, retrospectivo, transversal y descriptivo llevado a cabo en un centro de atención terciaria de la ciudad de Medellín, Colombia, entre enero de 2016 y enero de 2021. La fuente de información fueron las historias clínicas. Criterios de inclusión: pacientes embarazadas, con preeclampsia con criterios de severidad que recibieron anestesia neuroaxial o general. Criterios de exclusión: pacientes con diagnóstico previo de coagulopatías y con otros trastornos hipertensivos del embarazo no relacionados con la preeclampsia con características graves. Se hizo un muestreo no probabilístico de casos consecutivos y un análisis univariado. RESULTADOS: Se incluyeron 508 pacientes; el 69% finalizaron el embarazo mediante cesárea. El 89.4% recibió anestesia neuroaxial y el 10.6% anestesia general. El 29.9% ingresó a cuidados intensivos, 4.7% tuvo hipotensión, 3.9% requirió soporte vasopresor, 3.7% con vía aérea difícil, 0.98% requirió ventilación mecánica. Una paciente resultó con edema pulmonar y otra con accidente cerebrovascular hemorrágico. El 1.5% de quienes recibieron anestesia espinal tuvo retención urinaria. La frecuencia de anestesia neuroaxial fallida fue del 1.4% para parto y 1.3% para cesárea. No se registraron casos de muerte, meningitis, aracnoiditis, paraplejia, punción de la duramadre accidental o reacción alérgica. CONCLUSIONES: La anestesia neuroaxial sigue siendo la técnica anestésica de elección en pacientes con preeclampsia con criterios de severidad. Las complicaciones anestésicas evidenciadas con más frecuencia fueron el ingreso a cuidados intensivos, hipotensión y requerimiento de soporte vasopresor.
Abstract OBJECTIVE: To describe anesthetic complications in patients with pre-eclampsia with severity criteria. MATERIALS AND METHODS: Observational, retrospective, cross-sectional, descriptive study conducted in a tertiary care center in the city of Medellin, Colombia, between January 2016 and January 2021. The source of information was medical records. Inclusion criteria: pregnant patients, with pre-eclampsia with severity criteria, who received neuroaxial or general anesthesia. Exclusion criteria: patients with previous diagnosis of coagulopathies and with other hypertensive disorders of pregnancy unrelated to pre-eclampsia with severe characteristics. Non-probability sampling of consecutive cases and univariate analysis were performed. RESULTS: Fifty-eight patients were included; 69% terminated the pregnancy by cesarean section. Eighty-nine.4% received neuroaxial anesthesia and 10.6% general anesthesia. 29.9% were admitted to intensive care, 4.7% had hypotension, 3.9% required vasopressor support, 3.7% had difficult airway, 0.98% required mechanical ventilation. One patient had pulmonary edema and one patient had hemorrhagic stroke. Urinary retention occurred in 1.5% of patients receiving spinal anesthesia. The incidence of failed neuroaxial anesthesia was 1.4% for labor and 1.3% for cesarean section. There were no cases of death, meningitis, arachnoiditis, paraplegia, accidental dura puncture, or allergic reaction. CONCLUSIONS: Neuroaxial anesthesia remains the anesthetic technique of choice in patients with pre-eclampsia with severity criteria. The most common anesthetic complications were ICU admission, hypotension, and need for vasopressor support.
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To analyze the relationship between the level of BP achieved with treatment and the risk for development of preeclampsia/eclampsia (PE), we conducted a historical cohort study on 149 consecutive pregnant women with treated chronic hypertension, evaluated between January 1, 2016, and November 31, 2022. According to office BP readings and ambulatory blood pressure monitoring (ABPM) performed after 20 weeks of gestation, the cohort was classified in controlled hypertension, white-coat uncontrolled hypertension, masked uncontrolled hypertension and sustained hypertension. Risks for the development of PE were estimated using logistic regression. One hundred and twenty-four pregnant women with a control BP evaluation were included in this analysis. The rates of PE were 19.4%, 27.3%, 44.8% and 47.1% for controlled, white-coat uncontrolled, masked uncontrolled and sustained uncontrolled hypertension, respectively. Compared with women with controlled hypertension, the relative risk for PE increased markedly in women with sustained uncontrolled (OR 3.69, 95% CI, 1.19-11.45) and masked uncontrolled (OR 3.38, 95% CI, 1.30-11.45) hypertension, but not in those with white-coat uncontrolled (OR 1.56 95% CI, 0.36-6.70); adjustment for covariates did not modify the results. Each mmHg higher of systolic and diastolic daytime ABPM increased the relative risk for PE ~4% and ~5%, respectively. Each mmHg higher of systolic and diastolic nocturnal BP increased the risk ~5% and ~6%, respectively. When these risks were adjusted for ABPM values in opposite periods of the day, only nocturnal ABPM remained as a significant predictor. In conclusion, masked uncontrolled hypertension implies a substantial risk for the development of PE, comparable to those of sustained uncontrolled. The presence of nocturnal hypertension seems important.
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Eclampsia , Hipertensión , Hipertensión Enmascarada , Preeclampsia , Hipertensión de la Bata Blanca , Humanos , Femenino , Embarazo , Presión Sanguínea/fisiología , Preeclampsia/epidemiología , Monitoreo Ambulatorio de la Presión Arterial , Mujeres Embarazadas , Estudios de Cohortes , Hipertensión de la Bata Blanca/complicaciones , Hipertensión Enmascarada/epidemiologíaRESUMEN
Women with a history of preeclampsia (PE) have a greater risk of pulmonary arterial hypertension (PAH). In turn, pregnancy at high altitude is a risk factor for PE. However, whether women who develop PE during highland pregnancy are at risk of PAH before and after birth has not been investigated. We tested the hypothesis that during highland pregnancy, women who develop PE are at greater risk of PAH compared to women undergoing healthy highland pregnancies. The study was on 140 women in La Paz, Bolivia (3640m). Women undergoing healthy highland pregnancy were controls (C, n = 70; 29 ± 3.3 years old, mean±SD). Women diagnosed with PE were the experimental group (PE, n = 70, 31 ± 2 years old). Conventional (B- and M-mode, PW Doppler) and modern (pulsed wave tissue Doppler imaging) ultrasound were applied for cardiovascular íííassessment. Spirometry determined maternal lung function. Assessments occurred at 35 ± 4 weeks of pregnancy and 6 ± 0.3 weeks after birth. Relative to highland controls, highland PE women had enlarged right ventricular (RV) and right atrial chamber sizes, greater pulmonary artery dimensions and increased estimated RV contractility, pulmonary artery pressure and pulmonary vascular resistance. Highland PE women had lower values for peripheral oxygen saturation, forced expiratory flow and the bronchial permeability index. Differences remained 6 weeks after birth. Therefore, women who develop PE at high altitude are at greater risk of PAH before and long after birth. Hence, women with a history of PE at high altitude have an increased cardiovascular risk that transcends the systemic circulation to include the pulmonary vascular bed.
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Hipertensión Pulmonar , Preeclampsia , Embarazo , Humanos , Femenino , Adulto , Hipertensión Pulmonar/diagnóstico , Hipertensión Pulmonar/epidemiología , Hipertensión Pulmonar/etiología , Preeclampsia/epidemiología , Preeclampsia/etiología , Altitud , Bolivia/epidemiología , PulmónRESUMEN
The purpose of this study is to compare the levels of maternal serum pregnancy-associated plasma protein-A at the first trimester in pregnancies complicated by impaired placental diseases, such as preeclampsia (PE), intrauterine fetal growth restriction (IUGR), and gestational hypertension (GH), with those in pregnancies without the development of any of these outcomes to expand the knowledge of how this protein behaves in the different impaired placental diseases. This current work is an observational study based on a prospective cohort. Pregnancy-associated plasma protein-A was measured in 422 patients who had completed maternal-perinatal outcomes. Comparisons of pregnancy characteristics and the biomarker between outcome groups (PE, IUGR, gestational hypertension, and not impaired placental outcomes) were analyzed. PAPP-A MoM in the IUGR (0.8 IQR: 0.6-0.9) and GH groups (0.5 IQR: 0.3-1.4) compared to the PE group (1.06 IQR: 0.66-1.52) was significantly lower (p < 0.005). Pregnant women who developed early-onset PE (1.11 IQR 1.08-1.18) presented significant differences with the IUGR group (0.83 IQR: 0.59-0.98; p = 0.002) and those who developed preterm-PE (1.19 IQR: 0.66-1.58; p = 0.045). The results demonstrate that the levels of PAPP-A at first trimester in the sample of women who developed PE, and specially term-PE, were higher than those in women who developed GH or IUGR. The GH group had the lowest PAPP-A values in this sample of pregnant women. Research in a population with a high prevalence of preeclampsia is still lacking and deserves more extended studies to define if these patients could have different rates of PAPP-A.
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Hipertensión Inducida en el Embarazo , Enfermedades Placentarias , Preeclampsia , Recién Nacido , Humanos , Femenino , Embarazo , Hipertensión Inducida en el Embarazo/diagnóstico , Proteína Plasmática A Asociada al Embarazo/metabolismo , Mujeres Embarazadas , Estudios Prospectivos , Placenta/metabolismo , Primer Trimestre del Embarazo , Biomarcadores , Retardo del Crecimiento Fetal/diagnósticoRESUMEN
OBJECTIVES: To analyze soluble fms-like tyrosine kinase 1 (sFlt-1) and placental growth factors (PlGF) concentrations and their ratio in pregnant and postpartum women with suspected COVID-19, and further investigate conditions associated with an increased ratio (sFlt-1/PlGF > 38), including preeclampsia (PE) and severe acute respiratory syndrome (SARS). STUDY DESIGN: The present study is a secondary analysis of a prospective cohort. Blood samples were collected at time of COVID-19 investigation and the serum measurements of sFlt-1 and PlGF were performed. Clinical background, SARS-CoV-2 infection characteristics, maternal and perinatal outcomes were further analyzed. MAIN OUTCOME MEASURES: Serum measurements of sFlt-1 and PlGF; obstetrics and clinical outcomes. RESULTS: A total of 97 SARS-CoV-2 unvaccinated women with suspected infection were considered, 76 were COVID-19 positive cases and 21 COVID-19 negative. Among COVID-19 positive cases, 09 presented with SARS and 11 were diagnosed with PE, of which 6 had SARS-CoV-2 infection in first and second trimester (04 with sFlt-1/PlGF ≥ 38) and 05 with PE and COVID-19 diagnosed at the same time, during third trimester (03 with sFlt-1/PlGF ≥ 38). Five presented with PE with severe features. sFlt-1/PlGF ratio was significantly higher in the COVID-19 positive/PE positive group compared to COVID-19 positive/PE negative group (p-value = 0.005), with no increase in cases complicated by SARS. CONCLUSIONS: sFlt-1/PlGF ratio could be a useful tool for differential diagnosis and adequate counseling among cases of COVID-19 and PE, especially if severe disease. COVID-19 early in pregnancy could potentially be a risk factor for PE later during gestation.
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COVID-19 , Preeclampsia , Embarazo , Femenino , Humanos , Preeclampsia/diagnóstico , Estudios Prospectivos , Placenta , Receptor 1 de Factores de Crecimiento Endotelial Vascular , SARS-CoV-2 , Factor de Crecimiento Placentario , Biomarcadores , Proteínas Tirosina Quinasas Receptoras , Factor A de Crecimiento Endotelial VascularRESUMEN
Abstract Objective To evaluate the fetal and maternal effects of the severe acute respiratory syndrome virus 2 (SARS-CoV-2) infection in women with hypertensive disorders of pregnancy. Methods Patients with hypertensive disorders of pregnancy and SARS-CoV-2 polymerase chain reaction (PCR) positivity (n = 55) were compared with cases with similar characteristics and PCR negativity (n = 53). The study group was further divided into two groups as severe (n = 11) and nonsevere (n = 44) coronavirus disease 2019 (COVID-19). The groups were compared in terms of clinical characteristics and perinatal outcomes. Results The study and control groups were similar in terms of maternal age, parity, gestational age at diagnosis, type of hypertensive disorders, magnesium sulfate administration rate, gestational age at birth, birth weight, Apgar scores, and maternal complications. However, all cases of fetal loss (n = 6) were observed in the SARS-CoV-2 positive group (p = 0.027). From the 6 cases, there were 5 in the nonsevere group and 1 patient in the severe SARS-CoV-2 positive group. Moreover, higher rates of maternal complications, lower oxygen saturation values, and intensive care unit admissions were observed in the severe COVID-19 group. Conclusion Physicians should be cautious about the management of hypertensive disorders of pregnancy cases with SARS-CoV-2 positivity. Fetal loss seems to be more common in cases with SARS-CoV-2 positivity and severe COVID-19 seems to be associated with higher rates of maternal complications. Close follow-up for fetal wellbeing and active management of severe cases in terms of maternal complications seem to be favorable.
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Humanos , Femenino , Embarazo , Preeclampsia , Atención Perinatal , COVID-19/complicaciones , HipertensiónRESUMEN
BACKGROUND: Latin 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. OBJECTIVE: The 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 DESIGN: A 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
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OBJECTIVES: To validate the use of fullPIERS to predict maternal and perinatal adverse outcomes in a referral center. METHODS: Cross-sectional study including all pregnant women with preeclampsia (PE) at a referral center in southeast Brazil. The prevalence of PE and adverse outcomes were assessed. The fullPIERS score was tested on three composites of adverse outcomes: maternal adverse outcome; fetal adverse outcomes; and the combination of these two. Furthermore, the fullPIERS risk calculator, was considered to define the cutoff that better estimates adverse outcomes. RESULTS: 2839 women were screened in a one year period, with 208 (7.3%) cases of PE; most were preterm (56.7%); with severe features (74.5%). HELLP syndrome (6.7%), eclampsia (3.8%) and placental abruption (2.4%) were the most frequent complications. FullPIERS assessement had a median of 1.2% (0.45 - 2.3%) and the score had an excelent performance to predict adverse maternal outcome (AUC = 0.845, confidence interval 0.776 - 0.914, p-value < 0.01). For perinatal adverse outcomes (AUC = 0.699, confidence interval 0.581 - 0.816, p-value < 0.01) and the composite of maternal and perinatal adverse outcome (AUC = 0.804, confidence interval 0.736 - 0.872, p-vale < 0.01), fullPIERS score had a suboptimal performance. The cutoff value that best performed for the assessment of maternal adverse outcome was 2.15% (sensitivity of 75% and specificity of 83%). CONCLUSION: Preeclampsia was a significant complication during pregnancy. The fullPIERS model was an excellent tool to predict maternal adverse outcomes; with a cutoff value of 2.15% in the tested population.
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Síndrome HELLP/diagnóstico , Maternidades/estadística & datos numéricos , Preeclampsia/diagnóstico , Adulto , Brasil/epidemiología , Cesárea/estadística & datos numéricos , Estudios Transversales , Femenino , Síndrome HELLP/epidemiología , Humanos , Preeclampsia/epidemiología , Embarazo , Nacimiento Prematuro/epidemiología , Prevalencia , Medición de Riesgo/métodos , Sensibilidad y EspecificidadRESUMEN
Hypertensive disorders of pregnancy account for approximately 22% of all maternal deaths in Latin America and the Caribbean. Pharmacotherapies play an important role in preventing and reducing the occurrence of adverse outcomes. However, the patterns of medications used for treating women with hypertensive disorders of pregnancy (HDP) living in this country is unclear. A population-based birth cohort study including 4262 women was conducted to describe the pattern of use of cardiovascular agents and acetylsalicylic acid between women with and without HDP in the 2015 Pelotas (Brazil) Birth Cohort. The prevalence of maternal and perinatal outcomes in this population was also assessed. HDP were classified according to Ministry of Health recommendations. Medications were defined using the Anatomical Therapeutic Chemical Classification System and the substance name. In this cohort, 1336 (31.3%) of women had HDP. Gestational hypertension was present in 636 (47.6%) women, 409 (30.6%) had chronic hypertension, 191 (14.3%) pre-eclampsia, and 89 (6.7%) pre-eclampsia superimposed on chronic hypertension. Approximately 70% of women with HDP reported not using any cardiovascular medications. Methyldopa in monotherapy was the most frequent treatment (16%), regardless of the type of HDP. Omega-3 was the medication most frequently reported by women without HDP. Preterm delivery, caesarean section, low birth weight, and neonatal intensive care admissions were more prevalent in women with HDP. Patterns of use of methyldopa were in-line with the Brazilian guidelines as the first-line therapy for HDP. However, the large number of women with HDP not using medications to manage HDP requires further investigation.
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Antihipertensivos , Hipertensión Inducida en el Embarazo , Preeclampsia , Antihipertensivos/uso terapéutico , Brasil/epidemiología , Cesárea/estadística & datos numéricos , Estudios de Cohortes , Ácidos Grasos Omega-3/uso terapéutico , Femenino , Humanos , Hipertensión Inducida en el Embarazo/tratamiento farmacológico , Hipertensión Inducida en el Embarazo/epidemiología , Recién Nacido , Metildopa/uso terapéutico , Preeclampsia/tratamiento farmacológico , Preeclampsia/epidemiología , EmbarazoRESUMEN
OBJECTIVES: Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator 'magnesium sulfate (MgSO4) coverage'. STUDY DESIGN: A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility. MAIN OUTCOME MEASURES: We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed. RESULTS: Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was <24 h, i.e. guideline adherence existed in only 43%. MgSO4 was ceased during CS in all women (n = 40). Stable BP was achieved before CS in 46%. The median seizure-to-delivery interval was 27 h, and ranged from four to 36 h. CONCLUSION: Solely 'MgSO4 coverage' is not a reliable quality-of-care indicator, as it conceals inadequate MgSO4 dosage and timing, discontinuation during CS, stabilization before delivery, and seizure-to-delivery interval. These other quality-of-care indicators need attention from the international community in order to reduce the prevalence of eclampsia.
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Anticonvulsivantes/administración & dosificación , Eclampsia/tratamiento farmacológico , Sulfato de Magnesio/administración & dosificación , Adulto , Estudios de Casos y Controles , Eclampsia/epidemiología , Femenino , Humanos , Embarazo , Prevalencia , Estudios Prospectivos , Factores de Riesgo , Suriname/epidemiologíaRESUMEN
RESUMEN Los desórdenes hipertensivos del embarazo se encuentran dentro de las tres primeras causas de morbimortalidad materna y perinatal a nivel mundial, hasta el año 2016. Diferentes estudios realizados en los últimos 5 años e importantes organizaciones científicas han abordado este tema en el que existen discrepancias en cuanto a su etiopatogenia. Sin embargo, los avances logrados en la misma, la profundización en sus manifestaciones clínicas, los modos de presentación y los elementos diagnósticos han permitido el reconocimiento precoz y la efectividad del tratamiento. Esto ha ocasionado, principalmente en lo referente a los desórdenes hipertensivos tipo I, cambios que afectan desde la definición hasta el tratamiento. De esta manera, el presente documento pone al alcance de la comunidad médica una amplia revisión científica que facilita un mejor diagnóstico de la preeclampsia y de otras formas de hipertensión arterial en la etapa grávido-puerperal. Asimismo, contribuirá a reducir el error diagnóstico y logrará una intervención temprana para la obtención de mejores resultados maternos y perinatales (AU).
SUMMARY Hypertensive disorders of pregnancy are among the first three causes of maternal and perinatal Morbimortality in the world until 2016. Important scientific organizations and several studies carried out in the last five years have approached the theme, but there are still discrepancies with respect to etiopathogeny. Nevertheless, advances in it and deepening in its clinical manifestations, presentation ways and diagnostic elements have allowed its precocious recognition and diagnostic elements, causing changes from its definition up to its treatment, mainly in the case of the hypertensive disorders type I. In the current article, the authors put at reach of the medical community a wide scientific review facilitating a better diagnosis of preeclampsia and other forms of arterial hypertension in the pregnancy-puerperal stage that will contribute to reducing diagnosis error and making an early intervention, leading to better maternal and perinatal results (AU).
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Humanos , Femenino , Embarazo , Preeclampsia , Hipertensión Inducida en el Embarazo/clasificación , Eclampsia , Hipertensión Inducida en el Embarazo/diagnóstico , Hipertensión Inducida en el Embarazo/etiología , Hipertensión Inducida en el Embarazo/patologíaRESUMEN
BACKGROUND: Obstetric guidelines are useful to improve the quality of care. Availability of international guidelines has rapidly increased, however the contextualization to enhance feasibility of implementation in health facilities in low and middle-income settings has only been described in literature in a few instances. This study describes the approach and lessons learned from the 'bottom-up' development process of context-tailored national obstetric guidelines in middle-income country Suriname. METHODS: Local obstetric health care providers initiated the guideline development process in Suriname in August 2016 for two common obstetric conditions: hypertensive disorders of pregnancy (HDP) and post partum haemorrhage (PPH). RESULTS: The process consisted of six steps: (1) determination of how and why women died, (2) interviews and observations of local clinical practice, (3) review of international guidelines, (4) development of a primary set of guidelines, (5) initiation of a national discussion on the guidelines content and (6) establishment of the final guidelines based on consensus. Maternal enquiry of HDP- and PPH-related maternal deaths revealed substandard care in 90 and 95% of cases, respectively. An assessment of the management through interviews and labour observations identified gaps in quality of the provided care and large discrepancies in the management of HDP and PPH between the hospitals. International recommendations were considered unfeasible and were inconsistent when compared to each other. Local health care providers and stakeholders convened to create national context-tailored guidelines based on adapted international recommendations. The guidelines were developed within four months and locally implemented. CONCLUSION: Development of national context-tailored guidelines is achievable in a middle-income country when using a 'bottom-up' approach that involves all obstetric health care providers and stakeholders in the earliest phase. We hope the descriptive process of guideline development is helpful for other countries in need of nationwide guidelines.
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Servicios de Salud Materna/estadística & datos numéricos , Mortalidad Materna/tendencias , Complicaciones del Trabajo de Parto/mortalidad , Complicaciones del Embarazo/mortalidad , Femenino , Encuestas de Atención de la Salud , Humanos , Guías de Práctica Clínica como Asunto , Embarazo , Suriname/epidemiologíaRESUMEN
Non-communicable diseases (NCDs) are important contributors to maternal morbidity and mortality worldwide. Yet, data on their prevalence and related outcomes in low-income countries are currently lacking. Additionally, screening and treatment protocols adapted for resource-limited settings are urgently required. This collaborative research initiative on the screening and management of hypertensive disorders of pregnancy and gestational diabetes was conducted in Saint-Nicolas Hospital in Saint-Marc, Haiti. The report discusses methods used to overcome several local challenges to implementation of care for NCDs. It also describes how collaborative research initiatives are efficient strategies to innovate and build research capacity for NCD care delivery during pregnancy in low-income countries.
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Creación de Capacidad , Diabetes Gestacional/terapia , Salud Global , Investigación sobre Servicios de Salud , Hipertensión Inducida en el Embarazo/terapia , Salud Materna , Enfermedades no Transmisibles/terapia , Evaluación de Resultado en la Atención de Salud , Investigación Biomédica , Atención a la Salud , Países en Desarrollo , Diabetes Gestacional/diagnóstico , Manejo de la Enfermedad , Femenino , Haití , Humanos , Hipertensión Inducida en el Embarazo/diagnóstico , Ciencia de la Implementación , Innovación Organizacional , Embarazo , Diagnóstico Prenatal , Mejoramiento de la Calidad , InvestigaciónRESUMEN
OBJECTIVE: To identify possible relationships between postpartum depression and hypertensive disorders of pregnancy (HDP), as well as the associated risk factors for developing postpartum depression. METHODS: The present prospective descriptive cross-sectional study was conducted among postpartum women who attended a public maternity hospital in Brazil between January 15, 2015, and January 15, 2017. The diagnosis and severity of HDP were based on blood pressure measurements (systolic ≥140 mm Hg or diastolic ≥90 mm Hg), proteinuria, clinical findings, and laboratory findings. A group of normotensive women was also included. The Edinburgh Postnatal Depression Scale was used to assess the risk of postpartum depression. RESULTS: Of 168 participants (42 with HDP and 126 normotensive), 40 (23.8%) women displayed depressive symptoms (25 normotensive and 15 with HDP). The probability of postpartum depression correlated with a diagnosis of HDP (Spearman correlation coefficient [rS ] 0.219; P=0.004); premonitory signs of eclampsia (rS 0.171; P=0.027); magnesium sulfate therapy (rS 0.199; P=0.010); diastolic blood pressure (rS 0.165; P=0.033); and use of milk formula during hospitalization (rS 0.152; P=0.048). CONCLUSION: Women diagnosed with HDP were more likely to have depressive symptoms than their normotensive counterparts.
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Depresión Posparto/epidemiología , Hipertensión Inducida en el Embarazo/epidemiología , Adulto , Presión Sanguínea , Brasil/epidemiología , Estudios de Casos y Controles , Estudios Transversales , Diástole , Femenino , Humanos , Hipertensión Inducida en el Embarazo/fisiopatología , Fórmulas Infantiles , Sulfato de Magnesio/uso terapéutico , Embarazo , Estudios Prospectivos , Escalas de Valoración Psiquiátrica , Factores de Riesgo , Tocolíticos/uso terapéutico , Adulto JovenRESUMEN
BACKGROUND AND AIMS: Pre-eclampsia constitutes a leading cause of maternal and perinatal morbidity and mortality. Pre-eclampsia susceptibility is believed to be associated with altered lipid profiles and abnormal lipid metabolism via lipid peroxidation that leads to endothelial dysfunction. The goal of this study was to evaluate the association of maternal blood lipid and apolipoprotein levels with pre-eclampsia in a large-scale study. METHODS: Using data from a large case-control study (1366 cases of pre-eclampsia and 1741 normotensive controls), the association between the distributions of eight lipid fractions and pre-eclampsia risk was evaluated using adjusted logistic regression models. Pre-eclampsia was defined as blood pressure ≥140/90 mmHg and proteinuria ≥300 mg/24 h (>1 + dipstick). Sub-group analyses were conducted for early (<34 weeks) and late (≥37 weeks) pre-eclampsia, estimating the effect of 1 standard deviation increase in log-transformed lipid fraction levels in adjusted multinomial regression models. RESULTS: After adjustment for potential confounders, concentrations of triglycerides, apolipoprotein E (ApoE) and the relationship between apolipoprotein B and A1 (ApoB/ApoA1) showed the strongest associations with pre-eclampsia, particularly for those cases with an early onset. CONCLUSIONS: Higher levels of triglycerides, ApoE and the ApoB/ApoA1 ratio are associated with an increased risk of pre-eclampsia. Further studies that allow for a causal inference are needed to confirm or refute the aetiological role of blood lipids in pre-eclampsia.
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Apolipoproteínas/sangre , Preeclampsia/sangre , Preeclampsia/etiología , Triglicéridos/sangre , Adolescente , Adulto , Apolipoproteína A-I/sangre , Apolipoproteína B-100/sangre , Apolipoproteínas E/sangre , Biomarcadores/sangre , Presión Sanguínea , Estudios de Casos y Controles , Colombia , Femenino , Humanos , Preeclampsia/diagnóstico , Preeclampsia/fisiopatología , Embarazo , Factores de Riesgo , Adulto JovenRESUMEN
Introducción: Los trastornos hipertensivos del embarazo siguen siendo una preocupación central de la salud pública en todo el mundo debido a que son una de las principales causas de mortalidad materna. Su tratamiento adecuado depende en gran medida del diagnóstico oportuno e intervención temprana. Objetivo: Identificar los principales biomarcadores para el diagnóstico temprano de los trastornos hipertensivos inducidos por el embarazo. Método: Se revisaron artículos científicos en MedLine, Pubmed, Cochrane, Scielo, entre otras bases de datos. Resultados y discusión: Niveles elevados de kinasa de tirosina símil FMS (sFtl-1), niveles bajos de factor de crecimiento placentario (PIGF) o factor de crecimiento endotetelial vascular (VEGF) libre y niveles altos de (PlGF/sFtl-1) tienen un alto valor predictivo positivo para el diagnóstico de preeclampsia. También parace demostrar resultados efectivos la combinación de ultrasonido doppler y niveles alterados de biomarcadores como proteína placentaria 13 (PP13) y endoglina soluble (sEng). Conclusiones: El uso de biomarcadores abre una nueva era en el diagnóstico y tratamiento de trastornos hipertensivos del embarazo.
Background: Hypertensive disorders of pregnancy constitute a public health concern throughout the world, mainly because they are one of the main causes of maternal mortality. Their adequate treatment depends on a great extent on an early diagnosis and oportune intervention. Objective: To identify the most important biomarkers for the early diagnosis of hypertensive disorders induced by pregnancy. Methodology: Review of academic articles available in MedLine, Pubmed, Cochrane, Scielo, among others. Results and discusión: Elevated levels of Fms-like tyrosine kinase 1 (sFtl-1), low levels of placental growth factor (PlGF) or free vascular endotelial growth factor (VEGF), and elevated levels of (PlGF/sFtl-1) have a high positive predictive value for the diagnosis of preeclampsia. Similarly, it seems equally efective the combination of doppler ultrasound and altered levels of biomarkers including placental protein 13 (PP13) and soluble endolgin (sEng). Conclusions: The use of biobarkers opens a new era for the early diagnosis and treatment hypertensive disorders of pregnancy.
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Humanos , Femenino , Embarazo , Preeclampsia , Biomarcadores , Hipertensión Inducida en el Embarazo , Tirosina Quinasa 3 Similar a fms , Factor de Crecimiento PlacentarioRESUMEN
PURPOSE: Pre-eclampsia is a multisystem disorder characterized by new-onset hypertension and proteinuria during pregnancy. Pre-eclampsia remains a major cause of maternal death in low-income countries. Vitamin D has a very diverse biological role in cardiovascular diseases. This study will evaluate the association of vitamin D levels and relevance to pre-eclampsia. METHODS: We conducted a case-control study of women recruited from the GenPE (Genetics and Pre-eclampsia) Colombian registry. This is a multicenter case-control study conducted in eight Colombian cities. 25-Hydroxyvitamin D (25(OH)D) concentration was measured using liquid-chromatography-tandem mass spectrometry from 1013 women with pre-eclampsia and 1015 mothers without pre-eclampsia (controls). RESULTS: Fifty-two percent of women with pre-eclampsia were vitamin D deficient. The 25(OH)D concentrations were significantly lower in the pre-eclampsia (mean 29.99â¯ng/mL; 95% CI: 29.40-30.58â¯ng/mL) group compared to controls (mean 33.7â¯ng/mL; 95% CI: 33.20-34.30â¯ng/mL). In the unadjusted model, maternal vitamin D deficiency, defined by maternal 25(OH)D concentration <30â¯ng/mL, was associated with an increased probability of suffering from pre-eclampsia (OR 2.10; 95% CI, 1.75-2.51). After adjusting for covariates, a similarly increased probability of having pre-eclampsia was observed (OR 2.18; 95% CI, 1.80-2.64) among women with vitamin D deficiency, relative to controls. CONCLUSION: Although the results suggest that low maternal concentrations of 25(OH)D increase pre-eclampsia risk, this evidence may not be indicative of a causal association. Future studies are needed to confirm a definite causal relationship between concentrations of vitamin D and the risk of pre-eclampsia, by means of powered clinical trials.