Acute pulmonary edema in pregnancy

OBJECTIVE: To describe the incidence, predisposing conditions, and inciting factors culminating in pulmonary edema in the pregnant patient. METHODS: A review of 62,917 consecutive pregnancies delivered at our institution from January 1, 1989 to June 1, 1999 was undertaken for the diagnosis of pulmonary edema. Each chart was reviewed for maternal demographics, admission diagnoses, medication use, gestational age at diagnosis, fluid balance, coexisting maternal illness, tocolytic use, evidence of preeclampsia, and diagnostic criteria. After careful review of the records, the most likely cause of pulmonary edema was assigned. RESULTS: Fifty-one women (0.08%) were diagnosed with acute pulmonary edema during pregnancy or in the postpartum period. The mean patient age at the time of diagnosis was 27.6 +/- 6.4 years. The mean gestational age at the time of diagnosis was 31.5 +/- 6.8 weeks. The diagnosis of pulmonary edema was made during the antepartum period in 24 patients (47%), the intrapartum period in seven (14%), and the postpartum period in 20 (39%). The most common attributable causes were tocolytic use (13 patients [25.5%]), cardiac disease (13 patients [25.5%]), fluid overload (11 patients [21.5%]), and preeclampsia (nine patients [18%]). Those with fluid overload identified as the likely etiology had a significantly greater mean positive fluid balance (6022 +/- 3340 mL). All patients whose pulmonary edema was secondary to tocolytic use received multiple simultaneous tocolytic agents; the most common combination was intravenous magnesium sulfate and subcutaneous terbutaline. Six of the 13 women with cardiac disease were found to have previously undiagnosed structural heart disease. CONCLUSION: The most common causes of pulmonary edema are the use of tocolytic agents, underlying cardiac disease, fluid overload, and preeclampsia.     

Breast-feeding in women with hypertensive disorders in pregnancy

AIMS: Breast feeding is particularly important and difficult in children born prematurely, especially after hypertensive diseases in pregnancies (HDP). Therefore, we aimed to investigate breast feeding in women who developed HDP. METHODS: Data on breast-feeding was collected within a nationwide research project on psychosocial factors in HDP. A self-administered questionnaire was given to 2600 women with a suspected history of HDP and 1233 controls. After matching and confirming diagnosis according to ISSHP criteria, 877 women with HDP and 623 controls were included into the study. RESULTS: Control women initiated (48.9/39.2%; P<0.001) and continued (42.2/37.2%; P<0.005) breast-feeding significantly more often than women with HDP. This holds particularly for women who developed HELLP syndrome (48.9/34.7%; P<0.0001, 42.2/33.5%; P<0.0001). A delivery before the 32(nd) gestational week (19.5/81.8%; P<0.0001) and a birth weight of less than 1500 g (18.8/75%; P<0.0001) were associated with the decision not to breast-feed. CONCLUSIONS: Women affected by HDP breast fed significantly less often than control women. This effect is at least partly caused by the increased rate of prematurity. Encouraging and supporting these women in breast-feeding is important to improve neonatal physical and mental development.     

Laparoscopic management of tubal ectopic pregnancy in obese women

OBJECTIVE: To study the surgical morbidity associated with the laparoscopic management of tubal ectopic pregnancy in an overweight population compared with a lean population. DESIGN: Retrospective study. SETTING: An academic tertiary referral obstetrics and gynecology center. PATIENT(S): One hundred seventeen patients in two groups, lean (n = 90; body mass index 30) who had pathology-confirmed tubal ectopic pregnancies that were managed laparoscopically. Each group was subdivided into a laparoscopically managed group and a group in which laparoscopy was converted to laparotomy. INTERVENTION(S): None.Operative time, blood loss, and complications of laparoscopic surgery as well as causes of conversion from laparoscopy to laparotomy, in obese compared with lean women, with ectopic pregnancy. RESULT(S): There was no significant difference in gestational age; beta-hCG level; or history of previous surgeries, ectopic pregnancy, pelvic inflammatory disease, or endometriosis or in any of the studied outcomes (conversion rate, blood loss, and operative time) between the lean and obese groups or their respective subgroups except for operative time between obese women who underwent laparotomy, which was significantly longer when compared with the case of lean women who underwent laparotomy. Intraoperative and postoperative complications were comparable between the lean and obese groups, and all complications occurred in the completed-laparoscopy group. CONCLUSION(S): Laparoscopic management of tubal ectopic pregnancy does not appear to significantly increase surgical morbidity in obese patients.     

Upper airway obstruction as a cause of pulmonary edema during late pregnancy

We describe a 35-year-old woman who developed pulmonary edema at 38 weeks of pregnancy as a result of upper airway obstruction caused by a progressively enlarging euthyroid goiter.     

The lifestyle modification project: limiting pregnancy weight gain in obese women

Objective: To assess the impact of a group lifestyle intervention on gestational weight gain in a cohort of obese pregnant women.

Methods: A cohort study comparing 60 pregnant women enrolled in an educational intervention with controls from the same institution who receive routine prenatal care. Subjects were matched with controls by pre-pregnancy body mass index, parity and ethnicity. Subjects participated in group and individual counseling sessions focused on diet, exercise and weight goals. The primary outcome was gestational weight gain.

Results: A greater number of patients in the intervention group met the Institute of Medicine weight gain recommendations (35 versus 24, p?=?0.0446). Mean gestational weight gain of participants was lower than the control group, but this was not statistically significant. Number of sessions attended was associated with a decrease in total weight gained.

Conclusion: Educational interventions targeting obese pregnant women may be an effective way to limit gestational weight gain. Participation in educational sessions likely influences total weight gain.     

Thoracic-fluid conductivity in peripartum women with pulmonary edema.

OBJECTIVE: To measure the level of thoracic-fluid conductivity associated with pulmonary edema in peripartum women by noninvasive thoracic electrical bioimpedance. METHODS: Between March 1994 and August 1996, 134 women were selected for thoracic electrical bioimpedance monitoring. Among them, 12 had pulmonary edema, 33 had severe preeclampsia, 17 had mild preeclampsia, and 72 were in uncomplicated early labor. Each subject's highest thoracic-fluid conductivity measurement was related to her clinical presentation. The Kruskal-Wallis one-way analysis of variance was used to compare groups' means. A receiver operating characteristic curve was used to identify thoracic-fluid conductivity values associated with pulmonary edema. RESULTS: Pulmonary edema was associated with severe preeclampsia in ten cases, urosepsis in one case, and postoperative volume overload in one case. Other than gestational age, there were no significant differences in maternal demographics between groups. Thoracic-fluid conductivity values in women with pulmonary edema (80.6+/-18.3 kohm(-1)) were significantly higher than those in women with severe preeclampsia (62.8+/-16.3 kohm(-1)), mild preeclampsia (53.3+/-11.2 kohm(-1)), or early labor (41.3+/-6.7 kohm(-1)). Thoracic-fluid conductivity of at least 65 kohm(-1) best identified pulmonary edema (sensitivity 83.3%; specificity 86.9%; positive predictive value 38.5%; negative predictive value 98.1%). CONCLUSION: Preeclampsia was associated with increased thoracic-fluid conductivity stratified between mild and severe disease. Thoracic-fluid conductivity of at least 65 kohm(-1) was strongly associated with peripartum pulmonary edema. Women with values above 65 kohm(-1) might be candidates for medical intervention even without overt clinical symptoms.     

Excessive weight gain and hypertensive disorders of pregnancy in the obese patient

Objective: To evaluate the association between excessive weight gain and pregnancy-related hypertension (PRH) among obese women (body mass index (BMI) ≥30?kg/m²).

Methods: We performed a case control study among women with (n?=?440) and without (n?=?600) PRH from 2005 to 2007. Height and weight were recorded at initial and final prenatal visits. 695 women had BMI recorded at ≤18 weeks of gestation, of which 257 (36.9%) were obese. Obese women were divided into three categories based on 2009 Institute of Medicine (IOM) guidelines: (1) below recommended amount (under weight gain – UWG); (2) more than recommended (excessive weight gain – EWG) or (3) within recommended amount (normal weight gain – NWG). PRH was defined as gestational hypertension, mild or severe preeclampsia. Patients with and without PRH were prospectively identified. The association between weight gain category and development of PRH was analyzed.

Results: We noticed a 1.5-fold higher odds of having PRH with an initial BMI ≥30?kg/m² compared to BMI <30?kg/m² (OR 1.64, 95% CI 1.2–2.2, p?=?0.002). Among obese women, we noted a 2-fold higher odds of having PRH with EWG compared to NWG (OR 2.52, 95% CI 1.2–3.9, p?=?0.012). The increased odds persisted after adjusting for race, chronic hypertension and diabetes, and length of gestation (AOR 2.61, 95% CI 1.4–4.9, p?=?0.003). Among obese women with PRH, those with EWG had a 76% decreased odds of having severe disease compared to NWG (OR?=?0.242 [0.07–0.79], p?=?0.019).

Conclusion: We have demonstrated that EWG among obese patients increases overall risk of PRH.     

The clinical outcomes of unplanned pregnancy in severely obese women

Objective: The objective of this study was to compare the clinical outcomes of unplanned pregnancies among severely obese women with those of planned pregnancies.

Methods: This prospective cohort study included severely obese women (Body Mass Index [BMI] ≥40.0?kg/m²) who delivered a baby weighing ≥500?g over 5 years 2009–2013 in a large university hospital. Maternal weight and height were measured and BMI was calculated at the first prenatal visit.

Results: Of the 650 women, the mean BMI was 43.8?kg/m², mean age was 31.6 years, and 30.0% (n?=?195) were nulliparous. Prenatal complications including gestational diabetes mellitus (GDM), hypertensive and thromboembolic disorders occurred in 56.6% (n?=?368). Compared with planned pregnancies (58.2%, n?=?378), those that were unplanned (41.8%, n?=?272) were associated with increased prepregnancy risk factors including essential hypertension (4.0% versus 1.6%, p?=?0.03) and depression (6.6% versus 3.2%, p?=?0.03). Unplanned pregnancy was associated with a higher macrosomia rate (birthweight?>?4.5?kg) compared with planned pregnancies (p?=?0.03). This was not explained by a higher GDM rate in unplanned pregnancies. Compared with planned pregnancies, unplanned pregnancies were not associated with increased adverse fetomaternal outcomes.

Conclusion: Despite increased prepregnancy risk factors, in severely obese women, unplanned pregnancies were not associated with increased prenatal complications or adverse pregnancy outcomes compared with planned pregnancies.     

Autophagy in the placenta of women with hypertensive disorders in pregnancy

IntroductionAutophagy has not been studied extensively in the human placenta. This study was performed to determine whether autophagy is increased in the placentas of women with hypertensive disorders in pregnancy compared to normotensive pregnancies.MethodsLC3-II and p62 protein expression were examined by quantitative Western blotting analysis in 40 placentas from women not experiencing labor pains. The 40 placentas were from 13, 8, and 19 women with preeclampsia, gestational hypertension, and normal pregnancy, respectively. Hypertensive disorders in pregnancy included preeclampsia and gestational hypertension.ResultsLC3-II expression was significantly increased, while that of p62 was significantly reduced in 21 placentas of women with hypertensive disorders compared to those with normal blood pressure irrespective of the presence or absence of fetal growth restriction (FGR). LC3-II expression was also significantly increased in 13 placentas of women with preeclampsia irrespective of the presence or absence of FGR.DiscussionThe results of this study suggested that autophagy is active in the placenta of hypertensive disorders even in the absence of FGR.     

Measuring physical activity in pregnancy: a comparison of accelerometry and self-completion questionnaires in overweight and obese women

Objectives

Increased physical activity in pregnancy may reduce the risk of gestational diabetes and pre-eclampsia, which occur more commonly in overweight and obese women. There is limited assessment of physical activity questionnaires in pregnancy. This study compares self-reported physical activity using two questionnaire methods with objectively recorded physical activity using accelerometry in overweight and obese pregnant women.

Study design

59 women with booking BMI ≥ 25 kg/m² completed the Recent Physical Activity Questionnaire (RPAQ) and Australian Women's Activity Survey (AWAS) or recorded at least 3 days of accelerometry at median 12 weeks’ gestation. Accelerometer thresholds of 100 counts/min and 1952 counts/min were used to define light and moderate or vigorous physical activity (MVPA) respectively.

Results

48% of women were in their first pregnancy and 41% were obese. Median daily self-reported MVPA was significantly higher for both AWAS (127 min, p < 0.001) and RPAQ (81 min, p < 0.001) than that recorded by accelerometer (35 min). There was low or moderate correlation between questionnaire and accelerometer estimates of total active time (AWAS ρ = 0.36, p = 0.008; RPAQ ρ = 0.53, p < 0.001) but no significant correlation between estimates of time spent in MVPA.

Conclusions

These self-report questionnaires over-estimated MVPA and showed poor ability to discriminate women on the basis of MVPA. Accelerometry measurement was feasible and acceptable. Objective methods should be used where possible in studies measuring physical activity in pregnancy. Questionnaires remain valuable to define types of activity.     

Accelerated starvation in late pregnancy: a comparison between obese women with and without gestational diabetes mellitus

We compared the glucose, insulin, free fatty acid, and 3-hydroxybutyrate responses to a briefly extended overnight fast during the third trimester of pregnancy between two groups: obese women with normal glucose tolerance (n = 10) and age- and weight-matched women with gestational diabetes mellitus (n = 10). After a 12-hour overnight fast, plasma glucose (95 +/- 4 vs. 78 +/- 2 mg/dl; p less than 0.01), insulin (32 +/- 5 vs. 17 +/- 2 microU/ml; p less than 0.02), and free fatty acid (860 +/- 63 vs. 639 +/- 79 mmol/L; p less than 0.05) levels were higher in the patients with gestational diabetes mellitus. 3-Hydroxybutyrate levels were similar in the two groups at that time (0.23 +/- 0.04 vs. 0.18 +/- 0.03 mmol/L; p greater than 0.3). When the fast was extended to 18 hours by having the patients skip breakfast, glucose levels fell more rapidly in the group with gestational diabetes mellitus but remained elevated compared with the nondiabetic women. Insulin levels declined at a similar rate in the two groups. Free fatty acid levels did not increase significantly in the group with gestational diabetes mellitus during the extended fast. In contrast, free fatty acid levels increased by 44% in the normal pregnant women, reaching the level observed in the group with gestational diabetes mellitus after 18 hours. 3-Hydroxybutyrate levels remained virtually identical in the two groups throughout the brief fast. Thus, compared with that of normal pregnant women, the response of obese women with gestational diabetes mellitus to brief caloric deprivation during late pregnancy was characterized by a greater fall in plasma glucose values without a greater propensity to ketosis. Our findings may have important implications for the dietary management of obese patients with gestational diabetes mellitus.     

One-year infant outcome in women with early-onset hypertensive disorders of pregnancy

Objectives  To evaluate the role of plasma volume expansion on 1-year infant outcome after severe hypertensive disorders of pregnancy and to determine prognostic factors for adverse neurodevelopmental infant outcome.
Design  Randomised controlled trial, observational prognostic study.
Setting  Two university hospitals in Amsterdam, The Netherlands.
Population  One hundred and seventy-two infants alive of 216 mothers with severe hypertensive disorders of pregnancy who were randomised for a temporising management strategy with or without plasma volume expansion.
Methods  At 1 year of corrected age, a neurological examination according to Bayley (mental development index [MDI] and psychomotor development index [PDI]) and Touwen was performed.
Main outcome measures  Adverse neurodevelopmental infant outcome was defined as a MDI/PDI score below 70 and/or an abnormal Touwen. Risk factors for adverse neurodevelopmental outcome were explored by univariate and multivariate analyses.
Results  Adverse neurodevelopmental infant outcome was observed in 31 infants (18%). There were no differences between the randomisation groups. In multivariate analysis, an association with abnormal umbilical artery/middle cerebral artery Doppler ratio higher than the median, major neonatal morbidity, higher education of the parents, multiparity and Caucasian ethnicity was observed.
Conclusion  Nearly 70% of the infants were alive at 1 year without adverse neurodevelopmental outcome. Maternal plasma volume expansion during pregnancy has no effect on 1-year infant outcome. The prediction of adverse outcome at 1 year by perinatal parameters is limited.     

Physical activity during pregnancy in normal-weight and obese women: compliance using pedometer assessment

The objectives of this prospective study were to compare physical activity in 70 normal-weight women with a body mass index (BMI) 20-25 kg/m(2), and 70 obese with a BMI ≥ 30 kg/m(2), before and during pregnancy, and to compare compliance using the pedometer. Physical activity before pregnancy was assessed by questionnaires and during pregnancy by a pedometer worn on 7 consecutive days every 4th week. Obese women were less physically active than normal-weight women both before (p <0.05) and during pregnancy (p <0.0012). Both the compliance and the physical activity gradually declined during gestation. The change in physical activity could be described by a significant interaction between BMI group, gestational age (p <0.007) and the day of the week (p <0.001) when using ANOVA and interaction analysis. Maternal weight gain was larger in the normal-weight than in the obese women, but lower in the non-compliant obese women compared with the compliant (p <0.05).     

Cardiac abnormalities in pulmonary oedema associated with hypertensive crises in pregnancy

Objective To describe the cardiac abnormalities by two-dimensional and Doppler echo-cardiography (echo-Doppler) in hypertensive crises in pregnancy (HCP) complicated by pulmonary oedema and identify pathogenic factors.
Design A prospective observational study.
Setting King Edward VIII Hospital, Durban, South Africa.
Participants Sixteen patients with HCP complicated by pulmonary oedema over a six-month period. Two control groups, 55 patients with HCP alone and 16 with normotensive pregnancies, were also studied.
Results Echocardiography diagnosed impaired left ventricular systolic function in 4 of 16 (25 %) patients with HCP and pulmonary oedema. In the remaining 12 patients with preserved systolic function, left ventricular diastolic filling abnormalities were demonstrated in a significant proportion compared to control hypertensive and normotensive groups. Fifteen of 16 (94%) study patients presented with pulmonary oedema antepartum; in seven of these patients, the use of dexamethasone to enhance fetal lung maturity appeared to be a contributing factor in precipitating pulmonary oedema.
Conclusion This study demonstrates the value of echo-Doppler to diagnose structural and functional cardiac abnormalities in HCP complicated by pulmonary oedema. The potential role of left ventricular diastolic filling abnormalities in the pathogenesis of pulmonary oedema complicating HCP is discussed.     

Risk perception of future cardiovascular disease in women diagnosed with a hypertensive disorder of pregnancy

Objective: The objective of this study is to evaluate a woman’s risk perception for future cardiovascular disease (CVD) after being diagnosed with a hypertensive disorder of pregnancy.

Methods: A prospective cohort of women diagnosed with a hypertensive disorder of pregnancy (HDP) was studied. Each woman completed two surveys, one prior to hospital discharge and one 2 weeks later, designed to assess knowledge of and risk perception for future CVD based on their recent diagnosis of a HDP. Rates of postpartum depression were also assessed.

Results: Of the 146 subjects included, 28% were diagnosed with preeclampsia with severe features, 52.1% with preeclampsia with mild features, and 19.9% had chronic hypertension. Women with severe features and those delivering preterm were more likely to report a perception of increased risk of both recurrent HDP in a future pregnancy (p?=?0.004 and 0.005, respectively) and hypertension later in life (p?=?0.01 and 0.03, respectively). Women delivering preterm were more likely to report an accurate perception of increased risk of myocardial infarction and stroke compared to those delivering at term (p?=?0.006 and 0.002, respectively).

Conclusions: Disease severity and preterm delivery were associated with a higher likelihood of the perception of an increased risk for both recurrent HDP and hypertension in the future. Only preterm delivery was associated with a higher risk perception for stroke and myocardial infarction. Interventions targeted at improved health awareness in women diagnosed with HDP are warranted.     

Leg static pressure values in pregnant women with iatrogenic pulmonary edema

In two pregnant women with iatrogenic pulmonary edema, impedance plythsmographic measurements indicated low values for maternal cardiac output and venous resistance (or static pressure). Decreased venous tone could account for the pulmonary edema.     

Bariatric surgery and associated adverse pregnancy outcomes among obese women

Objective: To evaluate whether bariatric surgery is associated with intrauterine growth restriction (IUGR).

Methods: We performed a population-based retrospective cohort study to estimate the relationship between prior bariatric surgery and adverse pregnancy outcomes. The data were collected from the 2012 Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP-NIS). Pregnancies in obese women with a prior bariatric surgery were compared to those of obese women without. Outcomes of interest were pre-eclampsia, IUGR, intrauterine fetal demise, large for gestational age, postpartum hemorrhage, failed induction of labor, cesarean delivery and operative vaginal delivery. Multivariable logistic regression analysis was used to adjust for potential confounders.

Results: 186?605 obese women with singleton gestations were identified. Among these, 1585 (0.8%) women had a prior bariatric surgery. Prior bariatric surgery was associated with an increased risk of IUGR (5.7% versus 2.2%, adjusted odds ratio 2.89, 99% CI 1.55–5.39, p?<?0.0001) even after adjusting for confounding factors. No differences were seen in our other outcomes of interest.

Conclusion: Singleton gestations in obese women with a prior bariatric surgery have an increased risk of IUGR. It may be reasonable screen these pregnancies for the development of growth restriction.