Perinatal outcome in women with severe chronic hypertension during the second half of pregnancy.

OBJECTIVES: To determine the perinatal outcome associated with severe chronic hypertension (SCH) in pregnancies of > or =20 weeks' gestation. METHODS: A retrospective analysis of data obtained prospectively of patients with SCH (> or =160/110 mmHg) who were hospitalized and delivered during a 5-year period. Each patient received intensive monitoring of the clinical status throughout the hospitalization (mother, fetus and neonates). Antihypertensive drugs were used for blood pressure > or =160/110 mmHg, glucocorticoids for pregnancies of 24-34 weeks and magnesium sulfate for women with superimposed pre-eclampsia (SPE). The main outcome measures were fetal and neonatal deaths, fetal growth restriction (FGR), major neonatal complications and length of stay in the neonatal intensive care unit (NICU). RESULTS: Of 154 women studied, 78% developed SPE and the mean week's gestation at delivery was 34.5+/-4.6. The average birth weight was 2329+/-1011 g. and the FGR was 18.5%. Four patients had a dead fetus at the time of admission, eight during the hospitalization and there were six neonatal deaths resulting in perinatal mortality of 11.4%. Thirty-eight babies were admitted to the NICU, average stay was 14.8 days. The most common contributors to neonatal mortality and morbidity were pulmonary complications and sepsis. CONCLUSIONS: This study found that the neonatal outcomes in pregnancy with SCH are better than the historical experience, but preterm deliveries, cesarean section, SPE, abruptions and total perinatal mortality remains very high.     

Low-Molecular-Weight Heparin for the Prevention of Obstetric Complications in Women with Thrombophilias

Objective. To evaluate the benefit of combined low-molecular-weight (LMW) heparin and aspirin for prophylaxis in women carriers of thrombophilia who had previously suffered from severe obstetric complications.

Methods. The 33 studied women had an earlier pregnancy complicated by severe preeclampsia, abruptio placentae, intrauterine growth retardation, or intrauterine fetal death. All were subsequently diagnosed as carrying inherited thrombophilias. In their subsequent pregnancy, prophylactic therapy consisting of LMW heparin 40 mg/day (Enoxaparin, Rhone-Poulenc-Rorer, France) and aspirin was administered. Patients who were found to be homozygotes for the methylenetetrahydrofolate reductase mutation also received folic acid supplementation throughout their pregnancy.

Results. Low-molecular-weight heparin was well tolerated and none of the women or the newborns developed any hemorrhagic complications. Only three (9.1%) of the women developed pregnancy complications. The mean gestational age and the mean birth weight at delivery in the previously complicated pregnancies were 32.1 ± 5.0 weeks and 1175 ± 590 g, respectively, compared to 37.6 ± 2.3 weeks and 2719 ± 526 g, respectively, in the treated pregnancies (p ≤ 0.001).

Conclusions. This uncontrolled trial suggests that patients with obstetric complications and an inherited thrombophilia may benefit from treatment with combined LMW heparin and aspirin in subsequent pregnancies. However, this needs to be verified by controlled trials before considering clinical application.     

Obstetric implications of fetal inherited thrombophilia in thrombophilic women

ObjectivesThe relationship between fetal thrombophilic polymorphism and adverse pregnancy outcomes is still unclear. The aim of this study is to evaluate if fetal thrombophilia may affect obstetric and perinatal outcomes in thrombophilic women.Study designFrom 2007 to 2011 all patients with a known inherited thrombophilic mutation consecutively admitted to our labor ward at ⩾25 weeks of gestation with a singleton viable pregnancy were considered eligible for the purpose of the study. At the age of 1 year, the infants were tested for inherited thrombophilic mutations. Patients were then divided into two groups according to the presence or absence of any neonatal mutation.Main outcome measuresThe following outcome variables were then compared between the two groups: gestational age at delivery, birth weight, incidence of hypertensive disorders of pregnancy and SGA neonates.ResultsOverall, 67 pregnancies of 49 women were studied. Among them, the G20210A Prothrombin (32/67 or 47.7%) mutation and the Factor V Leiden mutation (31/67 or 46.3%) were the commonest findings, with a single patient presenting both. A thrombophilic mutation was found in 38 mother–infant pairs. The risk of all maternal and perinatal events including the incidence of hypertensive disorders disorders (5/29 or 17.2% vs 6/38 or 15.7% p = 1.00) and of SGA neonates (3/29 or 10.3% vs 7/38 or 18.4%, p = 0.49) was comparable between the two groups irrespective of the associated fetal thrombophilia.ConclusionsOur data suggest that women with inherited thrombophilia carrying a thrombophilic fetus are not at increased risk of adverse pregnancy outcomes.     

Hématome rétroplacentaire. Diagnostic,prise en charge et pronostic maternofœtal : étude rétrospective de 100 cas

ObjectivesTo update knowledge on placental abruption because there are few recent series published although the perinatal care has progressed.Patients and methodsA retrospective observational study has been conducted on 100 consecutive cases of abruptio placentae, occurring from January 2008 to June 2011, in the two maternity units of the University Hospital of Strasbourg (France).ResultsOne hundred and five births among which five twin pregnancies were included. Clinical context was evident in 91% of cases, but the classic clinical triad was present in only 4% of cases. Clots were found at immediate placenta examination in 77% of cases. Pathological diagnosis was directly in accordance with clinical diagnosis in half the cases. Mean date of childbirth was 33 weeks of amenorrhea and 6 days. Sixty-seven patients gave birth prematurely. Among them, 50 patients delivered before 34 weeks. Sixty caesareans were performed in emergency before labor, including 47 with general anesthesia. Twelve patients had post-partum haemorrhage and ten coagulation disorders. There was no maternal death. Perinatal mortality was 19% with 13 fetal deaths in utero (12.4%), four children born in an apparent death state with resuscitation failure (3.8%) and three neonatal deaths (2.8%).Discussion and conclusionPlacental abruption is a serious and unpredictable situation. Joint medical care of obstetricians and intensivists is often required. Perinatal mortality mainly occurs in utero.     

Cesarean versus vaginal delivery in abruptio placentae associated with live fetuses

In order to test the relative effectiveness of cesarean section and vaginal delivery in mild abruptio placentae associated with live fetuses, 23 consecutive patients were delivered vaginally and 18 by cesarean section over an 18-month period at the University of Ife Hospital in Nigeria. The perinatal mortality of the vaginal delivery group (52.2%) was significantly greater than that of those delivered by cesarean section (16.7%) (P greater than 0.02; less than 0.05; chi 2 test). The 1-min Apgar score test was also significantly greater than that of those delivered by cesarean section (P greater than 0.001). These differences have been attributed to the admission-to-delivery interval, which was significantly longer in the vaginal delivery group (12 h vs. 2 h). It is concluded that cesarean section is clearly superior to vaginal delivery in the management of abruptio placentae associated with live fetuses.     

Expectant Management of Severe Preeclampsia Remote from Term: A Structured Systematic Review

Objective: To compare outcomes associated with expectant vs. interventionist care of severe preeclampsia in observational studies. Data Sources: Medline (01/1980–07/2007), bibliographies of retrieved papers, personal files, Cochrane Database of Systematic Reviews. Study Selection: Expectant or interventionist care of preeclampsia at <34 wk. Tabulation, Integration, Results: Data abstraction independently by two reviewers. Median [IQR] of clinical maternal/perinatal outcomes presented. Results: 72 publications, primarily from tertiary care centres in Dutch and developed world sites. Expectant care of severe preeclampsia <34 wk (39 cohorts, 4,650 women), for which 40% of women are eligible, is associated with pregnancy prolongation of 7–14 d, and few serious maternal complications (median <5%), similar to interventionist care (2 studies, 42 women). Complication rates are higher with HELLP <34wk (12 cohorts, 438 women) and severe preeclampsia <28wk (6 cohorts, 305 women), similar to interventionist care (6 cohorts, 467 women and 2 cohorts, 70 women, respectively). Expectant care of HELLP <34 wk (12 cohorts, 438 women) is associated with fewer days gained (median 5), but more serious maternal morbidity (e.g., eclampsia, median 15%). More than half of women have at least temporary improvement of HELLP. In the developed world, expectant (vs. interventionist) care of severe preeclampsia or HELLP <34 wk is associated with reduced neonatal death and complications. Stillbirth is higher in Dutch and developing world sites where viability thresholds are higher. For preeclampsia <24wk (4 cohorts), perinatal mortality is >80%. No predictors of adverse maternal/perinatal outcomes were identified (13 studies). Conclusions: Future research should establish the best maternal/fetal monito regimen and indications for delivery with expectant care. A definitive RCT is needed.     

Association between placental pathology and neonatal outcome in preeclampsia: a large cohort study

Objective: To study associations between placental histopathology and neonatal outcome in preeclampsia (PE). Study design: The cohort consisted of 544 singleton pregnancies complicated by PE and managed at Karolinska University Hospital, Stockholm, Sweden during 2000–2009. Evaluation of placental histopathology was made by one senior perinatal pathologist, blinded to outcome. Clinical outcome was obtained from prospectively collected medical registry data and medical records. Main outcome measures were intrauterine fetal death, smallness for gestational age, admission to neonatal unit, major neonatal morbidity (defined as presence of intraventricular hemorrhage ≥grade 3, retinopathy of prematurity ≥grade 3, necrotizing enterocolitis, cystic periventricular leucomalacia and/or severe bronchopulmonary dysplasia) and neonatal mortality. Logistic regression analyses including gestational age were performed. Results: Abnormal placental weight, both low (adjusted odds ratio (OR) [95% confidence interval] 5.2 [1.1–24], p?=?0.03) and high (adjusted OR 1048 [21–51?663], p?p?=?0.02). Decidual arteriopathy increased the odds for admission to neonatal care (adjusted OR 2.7 [1.1–6.5], p?=?0.03). Infarction involving ≥5% of the placenta was associated with intrauterine fetal death and small for gestational age infants (adjusted OR’s 75 [5.5–1011], p?=?0.001 and 3.2 [1.7–5.9], p?Conclusion: Placental pathology in PE reflects adverse perinatal events and deviant placental weight predicts adverse neonatal outcome in preeclamptic women delivering preterm. Placental investigation without delay can contribute to neonatal risk assessment.     

Metalloprotease (ADAM12-S) as a Predictor of Preeclampsia: Correlation with Severity,Maternal Complications,Fetal Outcome,and Doppler Parameters

Objectives. To compare the first trimesteric serum level of ADAM12-S in women who developed mild and severe preeclampsia and in healthy gravidas and to correlate these changes with the severity of the disease, maternal complications, fetal outcome, and Doppler cerebroplacental ratio (CPR). Design. Comparative prospective observational study. Setting: University hospital. Methods: Serum samples were obtained from 414 women in their first trimester, of which 259 women completed their pregnancy without complications and 155 women developed preeclampsia later in their pregnancies. All were subjected to history taking, examination, laboratory investigations, obstetric ultrasound, and Doppler CPR. Results. ADAM12-S was significantly decreased in patients with severe and in mild preeclampsia compared with the controls. Moreover, there was strong negative correlation with disseminated intravascular coagulopathy (DIC) and HELLP syndrome, cesarean delivery, postpartum hemorrhage, and neonatal intensive care unit admission. ADAM12-S had medium negative correlation with systolic blood pressure and diastolic blood pressure, accidental hemorrhage, cesarean hysterectomy, prematurity, and low birth weight. In addition, it had a weak negative correlation with intracranial hemorrhage, residual hypertension, and intrauterine fetal death. ADAM12-S had strong positive correlation with CPR. There were no correlation with eclampsia, intrauterine growth retardation, acute pulmonary edema, and acute renal failure. Conclusion. ADAM12-S is significantly decreased in severe and mild preeclampsia and is correlated with CPR, severity of preeclampsia, maternal complications, and fetal outcome. It is recommended to measure ADAM12-S in the first trimester to predict maternal complications and fetal outcome in pregnancies complicated by preeclampsia.     

REDUCED RED BLOOD CELL DEFORMABILITY,AN INDICATOR FOR HIGH FETAL OR MATERNAL RISK,IS FOUND IN PREECLAMPSIA AND IUGR

Objective: Red blood cell (RBC) deformability is one of the factors determining microcirculation. In preeclampsia (PE) and some cases of intrauterine growth restriction (IUGR), microcirculation appears to be reduced. The aim of the study is to examine whether there are differences in RBC deformability in uncomplicated pregnancy when compared to pregnancies complicated by PE and/or IUGR. Material and methods: RBC deformability of 87 pregnant women with initially normal pregnancies was evaluated with the laser diffractoscope. RBC deformability was measured beginning in week 16 of gestation up to 5 days after delivery. Thirty-seven women had an uncomplicated pregnancy. In addition, RBC deformability of 10 nonpregnant women was measured on days 5 and 22 of their menstrual cycle. RBC deformability of women with preeclampsia (PE, N=15), intrauterine growth restriction (IUGR, N=17), or PE plus IUGR (N=17) was measured weekly, beginning with the onset of clinical symptoms, up to 5 days after delivery. Results: In early uncomplicated pregnancies, RBC deformability does not differ from the nonpregnant state. At week 30 of gestation, there is a slight decrease in RBC deformability followed by a return back to the values of nonpregnant women after delivery. Women with PE and/or IUGR show reduced RBC deformability. This is most pronounced in cases with severe fetal or maternal complications. After delivery, RBC deformability also returns to nonpregnancy values within 5 days. Conclusion: Reduced RBC deformability may contribute to a reduced microcirculation in PE and IUGR. Increasing RBC deformability therapeutically in these cases could offer new options for the treatment of decreased uterine and fetal perfusion and their sequelae.     

子宫内膜异位症与晚期不良妊娠结局的研究进展

子宫内膜异位症（endometriosis,EMs）常见于生育年龄女性,主要临床表现是疼痛和不孕等。近年研究认为,EMs增加晚期不良妊娠结局的相关因素包括EMs局部免疫和炎性反应对妊娠过程的持续影响,以及在位子宫内膜孕酮抵抗、子宫异常收缩和子宫结合带增厚对胚胎着床的影响。研究发现与非EMs孕妇相比,EMs孕妇的前置胎盘风险增加,可能与EMs的子宫异常收缩有关;另外EMs孕妇的剖宫产风险增加,可能与EMs孕妇的年龄较大、盆腔粘连及妊娠晚期并发症增加有关;对于EMs是否增加孕妇的胎盘早剥、子痫前期、早产、胎儿生长受限及产后出血的风险还存在争议;EMs孕妇要警惕妊娠期急性并发症自发性腹腔出血。目前未发现使用预防性手术可以降低不良妊娠结局风险,但对EMs的人类辅助生殖技术妊娠者可适当增加额外的产前管理项目。