Risk Factors for Postpartum Antihypertensive Medication Requirement in Severe Preeclampsia

Objective: To determine antepartum risk factors for postpartum antihypertensive medication use in women with severe preeclampsia. Methods: A case control study was performed on patients who were diagnosed with severe preeclampsia between January 2000 and June 2004 at a single tertiary care center. Women discharged from the hospital on antihypertensive medications were compared to women discharged home on no antihypertensive medications. Demographic data, maternal medical conditions, and delivery data were abstracted from maternal charts. Risk factors were evaluated using multiple logistic regression. Results: 218 patients with severe preeclampsia were identified, of which 112 were discharged on antihypertensives. After adjusting for confounding variables, chronic hypertension was associated with an increased need for post partum antihypertensive medication (OR 7.5 (95% CI 3.0–18.1)). A dose-dependent association was seen with intrapartum hydralazine administration. High-dose hydralazine was associated with increased need for postpartum antihypertensive mediation (OR 5.74 95% CI 2.03–16.2) compared to low-dose hydralazine (OR of 2.51 95% CI 1.26–5.01). Hemolysis/Elevated liver function/low platelet (HELLP) syndrome was associated with a decreased need for antihypertensive medication (OR 0.33, 95% CI 0.13–0.82). Conclusions: Patients with chronic hypertension and patients who required intrapartum hydralazine were more likely to require antihypertensive medications at discharge.     

Health-Related Quality of Life after Induction of Labor versus Expectant Monitoring in Gestational Hypertension or Preeclampsia at Term

Objective. Gestational hypertension (GH) and preeclampsia (PE) are major contributors to maternal and neonatal morbidity and mortality. In GH or PE, labor may be either induced or monitored expectantly. We studied maternal health-related quality of life (HR-QoL) after induction of labor versus expectant monitoring in GH or PE at term. We performed the HR-QoL study alongside a multicenter randomized controlled trial comparing induction of labor to expectant monitoring in women with GH or PE after 36 weeks.?Methods. We used written questionnaires, covering background characteristics, condition-specific issues, and validated measures: the Short-Form (SF-36), European Quality of Life (EuroQoL 6D3L), Hospital Anxiety and Depression Scale (HADS), and Symptom Checklist (SCL-90). Measurements were at the following time points: baseline, 6 weeks postpartum, and 6 months postpartum. A multivariate mixed model with repeated measures was defined to assess the effect of the treatments on the physical component score (PCS) and mental component score (MCS) of the SF-36. Analysis was by intention to treat.?Results. We analyzed the data of 491 randomized and 220 nonrandomized women. We did not find treatment effect on long-term HR-QoL (PCS: p = 0.09; MCS: p = 0.82). The PCS improved over time (p < 0.001) and was better in nonrandomized patients (p = 0.02).?Conclusion. Despite a clinical benefit of induction of labor, long-term HR-QoL is equal after the induction of labor and expectant management in women with GH or PE beyond 36 weeks of gestation.     

L-Arginine Supplementation in Patients with Gestational Hypertension: A Pilot Study

Objective: To evaluate the effects of L-arginine (L-Arg) supplementation on clinical outcomes and blood pressure (BP) changes in patients with gestational hypertension. Methods: Patients with gestational hypertension and proteinuria (n?=?28, >300mg/24 h) and those without proteinuria (n?=?46) were randomized in a double-blind design to receive either L-Arg (20g/500 mL intravenously daily, for 5 days followed by 4g/day orally for 2 weeks) or placebo (PL). The primary outcome variable was time from randomization to delivery (Latency). Automated BP readings were obtained every 2 hours, between 8.00 am and 8.00 pm daily, untill the sixth day after treatment. Results: At inclusion, gestational age and proportions of patients with proteinuria did not differ significantly between the PL and L-Arg group. Latency was significantly longer in the L-Arg group compared with the PL group (19.5 ± 16.9 vs. 31.7 ± 25.2 days; p?=?0.008). Compared with baseline, both systolic and diastolic BP 6 days after treatment were significantly reduced in the L-Arg group but not in the PL group. The subgroup of patients without proteinuria randomized to the group receiving L-Arg showed a trend to prolong pregnancy, to attenuate the evolution to PE, and to reduce the rate of low birth weight. Conclusions: The treatment with L-Arg seems promising in prolonging pregnancy and reducing blood pressure, particularly in patients with gestational hypertension and without proteinuria. This benefit should be confirmed in larger studies with the power to evaluate the effectiveness of L-Arg in preventing the development to preeclampsia.     

Management of Severe Hypertension in the Postpartum Period with Intravenous Hydralazine or Labetalol: A Randomized Clinical Trial

Objective: To compare the safety and efficacy of intravenous labetalol and intravenous hydralazine for acutely lowering blood pressure in the puerperium. Design: Randomized clinical trial. Setting: Critical care unit of gynecology and obstetrics department in the Complejo hospitalario “Dr. AAM” de la Caja de Seguro Social in Panama. Population: Eighty-two women with severe hypertension during the postpartum period. Methods: Patients were randomized to receive hydralazine (5 mg as a slow bolus dose given intravenously, and repeated every 20 minutes to a maximum of five doses) or labetalol (20 mg in an intravenous bolus dose followed by 40 mg if not effective within 20 minutes, followed by 80 mg every 20 minutes to a maximum dose of 300 mg). The primary endpoint was the successful lowering of blood pressure. Secondary endpoints were maternal complications and side-effects. Results: Forty-two women were enrolled in the hydralazine group and 40 in the labetalol group. Women were similar with respect to characteristics at randomization. No significant differences were observed for persistent severe hypertension or maternal side-effects. There was only one case of persistent severe hypertension in the labetalol group. There were no maternal deaths in any of the women studied. Conclusions: This randomized clinical trial shows that intravenous hydralazine and intravenous labetalol are effective and safe in the management of severe hypertension in the postpartum period.     

Familial Occurrence of Gestational Hypertensive Disorders in a Brazilian Population

Objective: To verify the occurrence of preeclampsia/eclampsia (PE/E) or gestational hypertension (GH) in first-degree relatives of Brazilian pregnant women. Methods: A total of 485 women were enrolled in the study, and 226 were selected (75 with PE/E, 49 with GH, and 102 women with normal pregnancies). Statistical analysis was performed using Fisher's exact test. Results: The frequency of families with mothers and/or sisters with PE/E was higher among the PE/E group compared to the GH and the control groups, and was statistically significant (p < 0.05). Conclusion: Women with PE/E have more female first-degree relatives with PE/E as observed in a Brazilian population.     

Severe Preeclampsia is Associated with a Positive Family History of Hypertension and Hypercholesterolemia

Objective. To investigate an association between a family history of cardiovascular disease and severe preeclampsia and/or HELLP syndrome (Haemolysis, Elevated Liver enzymes, Low Platelets). Methods. One hundred twenty-eight women with a history of severe preeclampsia and/or HELLP syndrome and 123 women with previous uncomplicated pregnancies only were included in the study. All participants completed questionnaires about diagnoses of cardiovascular diseases, hypertension, and hypercholesterolemia among their first-degree relatives, which were subsequently confirmed by the relatives' general practitioners. The main outcome measures were the prevalence of cardiovascular diseases, hypertension, and hypercholesterolemia among first-degree relatives of both groups. Statistical analysis was done using χ²-analysis. Results. The prevalence of familial cardiovascular disease among women with a history of severe preeclampsia and/or HELLP syndrome (23%) compared to controls (19%) was not significantly different (OR 1.3, 95%CI 0.7–2.5). However, women with a history of severe preeclampsia and/or HELLP syndrome more often had one or more first-degree relatives with hypertension and/or hypercholesterolemia before the age of 60 years compared to controls (54% vs. 32%, respectively; OR 2.6, 95%CI 1.5–4.3). The prevalence of hypertension and hypercholesterolemia among first-degree relatives, irrespective of age, also was significantly higher among women with a history of severe preeclampsia and/or HELLP syndrome as compared to controls (60% vs. 42%, respectively; OR 2.0, 95%CI 1.2–3.4). Conclusion. Severe preeclampsia is associated with a positive family history of hypertension and/or hypercholesterolemia.     

Maternal Serum Chlamydia Pneumoniae Antibodies and CRP Levels in Women with Preeclampsia and Gestational Hypertension

Objective. To determine whether Chlamydia pneumoniae antibodies and highly sensitive C-reactive protein (hsCRP) levels in maternal sera are associated with preeclampsia or gestational hypertension. Methods. C. pneumoniae antibodies and hsCRP levels were measured in maternal serum during first trimester (mean, 10.4 weeks of gestation) using the microimmunofluorescence (MIF) test and a highly sensitive immunoenzymometric assay, respectively. Results. No differences in the IgG antibody levels against C. pneumoniae or hsCRP levels were seen between the women with preeclampsia or gestational hypertension and those in the reference group. However, the women with preeclampsia and preterm delivery had serum IgG antibodies to C. pneumoniae (IgG titre ≥32) significantly more often in their first trimester sera compared with women having preeclampsia and full-term deliveries (p = 0.03). In addition, the proportion of subjects with C. pneumoniae IgG antibodies (IgG titre ≥32) and/or elevated CRP levels (≥3.8 mg/L, upper quartile) was double among the women with preeclampsia and elective preterm delivery compared with the women with preeclampsia who delivered at term (p = 0.01). Conclusion. Our results suggest that chronic C. pneumoniae infection and systemic low-grade inflammation may be associated with preeclampsia requiring elective delivery before 37 weeks gestation.     

Continuous Non-Invasive Blood Pressure Monitoring,a Validation Study of Nexfin in a Pregnant Population

Objective: To assess the accuracy of a non-invasive beat-to-beat continuous blood pressure monitoring device (Nexfin) in pregnancy according to the International Protocol of the European Society of Hypertension.?Methods: The validation was performed according to the International Protocol of the European Society of Hypertension. The test device (Nexfin, BMEYE, Amsterdam, the Netherlands) calculates beat to beat blood pressure from finger pulse wave analysis. Measurements of systolic and diastolic BP in 33 volunteers were obtained using the mercury sphygmomanometer and the Nexfin alternatingly.?Results: The device passed phase 1 as 30 systolic and 32 diastolic readings fell within 5 mmHg (25 required). In addition, the device also passed phase 2.1 as 68 systolic and 67 diastolic readings fell within 5 mmHg (65 required). Finally, it failed to pass phase 2.2 as 24 subjects for systolic and 23 for diastolic had at least 2/3 of their comparisons falling within 5 mmHg (22 required) but 6 subjects for systolic and 8 for diastolic had all three comparisons more than 5 mmHg different from the mercury readings (three allowed). The mean differences were 2.3 mmHg (SD 6.8) for SBP and 0.8 mmHg (SD 6.3) for DBP.?Conclusion: The Nexfin device passed phase 1 and phase 2.1 but failed to pass phase 2.2. However, adaptation of the data to the more permissive AAMI (mean difference <5 ± 8 mmHg) and BHS (systolic grade B, diastolic grade A) protocols indicated adequate accuracy for application in research settings or for longitudinal within-patient tracking of blood pressure, given the possibility for continuous monitoring.     

妊娠期糖尿病与妊娠高血压综合征相关因素的探讨

目的 :探讨妊娠糖尿病 (GDM)与妊娠高血压综合征 (妊高征 ,PIH)的相关因素。方法 :将 16 1例 GDM分为三组 ,GDM合并 PIH的 39例中 ,2 3例合并轻度 PIH分为 组 ;16例 GDM合并中、重度妊高征者为 组 ;12 2例单纯GDM为 组。结果 :1 组孕期体重增加值大于其余两组 (P=0 .0 2 8,P=0 .0 33)。 组有高血压家族史者明显高于 组(P=0 .0 0 7)。 2 组肾功能改变、眼底改变、血粘度、外周血管阻力异常发生率高于 组 (P=0 .0 0 4 ,0 .0 0 6 ,0 .0 0 5 ,0 .0 0 3)。孕 2 4～ 2 8周的平均动脉压 (MAP) 组比 、 组均高 (P=0 .0 0 9,P=0 .0 0 5 )。 3孕期血糖控制满意率 组远低于其他两组 (P=0 .0 0 1,P=0 .0 0 2 )。结论 :高血压家族史及孕期体重异常增加、孕中期 MAP升高、血粘度增加和外周血管阻力增高及孕期血糖控制不满意均为 GDM合并 PIH的高危因素     

Obesity and the Hypertensive Disorders of Pregnancy

Overweight and obesity have a strong association with the development of hypertensive disorders of pregnancy. However, the mechanisms underpinning this relationship are not clear. Obesity is associated with insulin resistance, endothelial dysfunction, hypertension dyslipidaemia, inflammatory upregulation, alteration in immune function and prothrombotic changes. These changes may contribute to the development of hypertensive disorders of pregnancy, by influencing placentation, endothelial function, and inflammation. The genetic predisposition for hypertensive disorders of pregnancy needs to be examined in the context of obesity. Common antecedents such as dietary factors and inadequate physical activity might also explain the relationship between hypertensive disorders of pregnancy and obesity. This review is concluded with a synopsis and recommendations for further research.     

High Uric Acid Level During the First 20 Weeks of Pregnancy is Associated with Higher Risk for Gestational Diabetes Mellitus and Mild Preeclampsia

Objective. To examine the association between uric acid (UA) level during the first 20 weeks of pregnancy and the development of gestational diabetes mellitus (GDM) and preeclampsia in the second half of pregnancy. Methods. The study population included registered births (n = 5507) between 2001 and 2007 in a tertiary medical center. The UA levels during the first 20 weeks of pregnancy were sorted by UA ≤ 2.4 mEq/L; UA = 2.5–4.0 mEq/L, UA = 4.1–5.5 mEq/L, and UA > 5.5 mEq/L. The linear-by-linear chi-square test and ROC curves were used to determine the association between UA level during the first 20 weeks and pregnancy complications. Multivariate analyses were performed to demonstrate whether UA level is an independent factor for the prevalence of preeclampsia and GDM. Results. Significant linear association was documented between UA level in the first 20 weeks and the prevalence of GDM and mild preeclampsia. The lowest and the highest prevalence of GDM were found in the UA ≤ 2.4 mEq/L group (6.3%) and in the UA > 5.5 mEq/L group (10.5%) (p < 0.001), respectively. Mild preeclampsia was diagnosed in 2.1% of the patients from the UA ≤ 2.4 mEq/L group, 3.3% from the UA = 2.5–4.0 mEq/L group, 5.3% from the UA = 4.1–5.5 mEq/L group, and 4.5% from the UA > 5.5 mEq/L group (p < 0.001). Three multiple logistic regression models controlling for maternal age showed that UA level is an independent risk factor for both GDM and mild preeclampsia. Conclusions. UA levels in the highest quartile of the normal range during the first 20 weeks of pregnancy are associated with higher risk for the development of GDM and mild preeclampsia.     

Homocysteine and Cellular Fibronectin are Increased in Preeclampsia,not Transient Hypertension of Pregnancy

Objective. The objective of this study was to confirm that endothelial dysfunction is present in preeclampsia and absent in transient hypertension of pregnancy, and to determine whether the cardiovascular risk factor homocysteine is associated with the degree of endothelial dysfunction.

Methods. We measured cellular fibronectin (as a marker of endothelial injury) and total plasma homocysteine in samples collected at the time of admittance to labor and delivery in 17 women with preeclampsia (increased blood pressure, proteinuria, and hyperuricemia), 16 women with transient hypertension of pregnancy (only increased blood pressure), and 34 normal pregnant women. Each subject with preeclampsia was matched by prepregnancy body mass index, race, and gestational age at delivery to one subject with transient hypertension of pregnancy and two controls.

Results. Cellular fibronectin was found to be significantly increased in women with preeclampsia compared to subjects with transient hypertension of pregnancy or normal pregnant women (22.9±14.1 μg/mL versus 10.9±5.4 and 10.1±6.2 μg/mL, respectively, p<0.0001). Similarly, total plasma homocysteine was also significantly increased in the women with preeclampsia compared to subjects with transient hypertension of pregnancy or normal pregnant women (8.3±2.5 μM versus 5.5±2.2 and 5.4±3.4 μM respectively, p<0.01). However, contrary to our hypothesis, there was no apparent association between cellular fibronectin and homocysteine.

Conclusions. The increased concentrations of homocysteine observed in preeclampsia are not a general feature of all hypertensive complications of pregnancy. Furthermore, endothelial dysfunction is present in preeclampsia and is not evident in transient hypertension of pregnancy. However, the apparent endothelial dysfunction in preeclampsia is not explained by the increase in homocysteine concentrations observed.     

Preeclampsia and Risk of Developing Subsequent Diabetes

Objective: Determine whether preeclampsia is associated with developing diabetes. Methods: Subsequent diabetes was ascertained using ICD-9 codes, pharmacy and glucose data in a retrospective cohort study of 2,032 women with preeclampsia and 29,431 without preeclampsia. Results: During a median follow-up of 8.2 years, 342 women developed diabetes. Preeclampsia was associated with a higher risk of diabetes adjusting for age, primigravidity, and gestational diabetes (hazard ratio, HR 1.82, 95%CI 1.26, 2.62) and in women without gestational diabetes (n = 30,109; HR 1.86, 95%CI 1.22, 2.84). Conclusion: Women with preeclampsia have greater risk of developing diabetes, even in the absence of gestational diabetes.     

Motivators and Barriers to a Healthy Postpartum Lifestyle in Women at Increased Cardiovascular and Metabolic Risk: A Focus-Group Study

Objective. To describe the motivators and barriers to the adoption of a healthy postpartum lifestyle after a pregnancy complicated by preeclampsia, intrauterine growth restriction, and/or gestational diabetes. Methods. Thirty-six women with complicated pregnancies participated in six focus-group interviews that aimed to explore the perceptions of modifiable determinants of postpartum lifestyle. Results. Although women expressed that they intended to live a healthy postpartum lifestyle, it was generally not achieved. The motivators included improving their own current health condition as well as modeling a healthy lifestyle for their children. Important barriers were reported to be lack of knowledge, poor recovery, and lack of professional support after delivery. Conclusions. The reported motivators and barriers can be used to develop a postpartum lifestyle intervention.     

Preeclampsia knowledge among women in Utah

Background: Despite the benefits of preeclampsia (PE) education in improving health outcomes, little is known about how often healthcare providers in Utah include PE in prenatal education or how much information women retain. As such, the purpose of this study was to explore PE awareness among mothers in Utah and inquire how often PE is included in prenatal education. Factors associated with PE knowledge were also investigated. Methods: A cross-sectional survey was conducted. Questions were created from two Preeclampsia Awareness Surveys developed by the Preeclampsia Foundation. PE knowledge was measured with 29 items from the 2014 Preeclampsia Awareness Survey, and a knowledge score was calculated. Results: A total of 340 women completed the survey. Over half (56.7%) of women reported their healthcare provider described the signs and symptoms of PE to them. The mean PE knowledge score was 17.07. Hearing of PE from a healthcare provider, having the signs and symptoms of PE described by a healthcare provider and having a history of PE were significantly associated with a higher PE knowledge score. Conclusions: Patient awareness is essential to the successful management of PE. The need for improved PE education in Utah was evident in this survey. As not all healthcare providers are diligent in instructing patients regarding PE, more research is needed to fully assess the knowledge of mothers and examine the practices of providers. An explanation of PE signs and symptoms should be given to all women at prenatal care visits to improve health outcomes.     

妊娠期糖尿病产后管理策略

妊娠期糖尿病的发病率逐年增加,并且是妇女日后发展为糖尿病、代谢综合征以及心血管疾病的高危因素.因此,妊娠期糖尿病妇女产后管理是降低产后并发症的重要手段.妊娠期糖尿病妇女的产后管理包括:产后血糖筛查、糖尿病相关知识的教育、改变生活方式的措施以及产后避孕等多方面.目前,妊娠期糖尿病的产后管理工作仍十分欠缺,需要多个学科密切...     

Maternal pregnancy-induced hypertension increases the subsequent risk of neonatal candidiasis: A nationwide population-based cohort study

Objective

Neonatal candidiasis is a leading infectious cause of significant morbidity and mortality in premature birth mainly due to impaired physical barriers and immature immune system of fetus. Maternal pregnancy-induced hypertension (PIH) has been reported to be able to disturb the neonatal immune system, which could cause the increased possibility of neonatal infection. Therefore, we hypothesized that maternal PIH may increase the risk of neonatal candidiasis. The aim of this study was to evaluate whether PIH increased the risk of neonatal candidiasis and identify the predictive risk factors.

Increased Risk of Hypertension,Proteinuria and Preeclampsia in Pregnant Saudi Females with IgA Nephropathy

Background. IgA nephropathy is fairly prevalent in Saudi Arabia. In this paper we examine the natural history of pregnancies and their impact on renal function in Saudi females affected by this condition. Methods. We followed a series of 12 patients, documented to have IgA nephritis by kidney biopsy, during their gestation. We monitored their blood pressure, serum creatinine, creatinine clearance, 24-hour protein before conception and at the third trimester of pregnancy. We also documented any maternal or fetal complications. Results. All patients had well-controlled blood pressure, normal renal function, and proteinuria of less than one gram per day prior to conception. During pregnancy, all patients (100%) developed hypertension-requiring treatment and three of them (25%) developed preeclampsia. One patient (8.3%) had hemolysis, elevated liver enzymes, and, low platelets syndrome. All patients had worsening of their proteinuria during pregnancy from 535.2 (101.4) to 2179.2 (636.6) mg/24 h (p < 0.01) with a decrease in creatinine clearance from 88.6 (7.6) mls/min to 77.4 (5.9) mls/min (p < 0.05). No fetal complications were observed. Conclusion. We conclude that pregnancies in patients, even with mild IgA nephritis, require close observation as there is an increased incidence of worsening hypertension and preeclampsia.     

Predicting Transformation from Gestational Hypertension to Preeclampsia in Clinical Practice: A Possible Role for 24 Hour Ambulatory Blood Pressure Monitoring

Objective: To identify parameters that may assist clinicians in predicting which women will develop preeclampsia (PE) after initially presenting with gestational hypertension (GH). Methods: 118 women were recruited to the study with GH or PE. They were divided into three groups based on their diagnosis at delivery- (1) GH, (2) PE from the time of presentation, (3) those with an initial diagnosis of GH who progressed to PE. Women underwent 24 hour ambulatory blood pressure monitoring (ABPM) and had serum estrogen, progesterone, β-HCG, leptin and adiponectin measured as possible predictors of transformation of GH to PE. Results: Women who presented with GH, and progressed to PE, presented four weeks earlier (33 vs 37 weeks, p < 0.001) than those who did not progress. Women with PE, either as their initial diagnosis or after progression from GH, were delivered earlier (p < 0.001) and had more small for gestational age (SGA) babies than women with GH at delivery (p < 0.05). Those who developed PE after presenting with GH generally had higher blood pressures than those who remained as GH, significant for awake and 24 hour systolic blood pressures (p < 0.05). β-HCG, estrogen, progesterone or leptin values were similar across the groups. Adiponectin was higher in women with established PE at presentation compared to women with GH (p = 0.02) but adiponectin failed to discriminate those women with an initial diagnosis of GH who progressed to PE. Conclusion: 24 hr ABPM may provide a non-invasive method of identifying this ‘at risk’ GH population, particularly in the case of early presentation.     

硝苯地平对妊娠高血压综合征患者产后出血的影响

目的　观察产时使用硝苯地平对妊娠高血压综合征 (妊高征 )患者产后出血的影响。方法　 6 4例妊高征患者分为硝苯地平组和对照组各 32例 ,两组患者均口服硝苯地平 10～ 2 0mg ,每日 3次。对照组在出现规律宫缩后停止使用 ;硝苯地平组继续以每 6h 1次服用硝苯地平 10～ 2 0mg ,直至第二产程末 ,观察两组患者产后 2h内出血量。结果　 (1)产后 2h内出血量 ,硝苯地平组为 (35 9.1±136 .6 )ml,对照组为 (2 6 8.5± 110 .7)ml,两组比较 ,差异有极显著性 (P <0 .0 1)。 (2 )两组妇女产后出血百分比显示 ,硝苯地平组为 43.75 % (14/ 32 ) ,对照组为 18.75 % (6 / 32 ) ,两组比较 ,差异有显著性 (P <0 .0 5 )。结论　妊高征患者产时应用硝苯地平会增加产后出血量 ,易引起产后出血。