Committee Opinion no. 514: emergent therapy for acute-onset, severe hypertension with preeclampsia or eclampsia

Acute-onset, persistent (lasting 15 minutes or more), severe systolic (greater than or equal to 160 mm Hg) or severe diastolic hypertension (greater than or equal to 110 mm Hg) or both in pregnant or postpartum women with preeclampsia or eclampsia constitutes a hypertensive emergency. Severe systolic hypertension may be the most important predictor of cerebral hemorrhage and infarction in these patients and if not treated expeditiously can result in maternal death. Intravenous labetalol and hydralazine are both considered first-line drugs for the management of acute, severe hypertension in this clinical setting. Close maternal and fetal monitoring by the physician and nursing staff are advised. Order sets for the use of labetalol and hydralazine for the initial management of acute, severe hypertension in pregnant or postpartum women with preeclampsia or eclampsia have been developed.     

The Importance of Interdepartmental Collaboration and Safe Triage for Pregnant Women in the Emergency Department

Pregnant women who present to the emergency department can present challenges that range from the diagnoses of unsuspected pregnancies to the determination of where evaluations should occur. In this review we identify literature associated with the triage of pregnant women in the emergency department and propose a model for triage and evaluation of pregnant women in the emergency department. Strategies are described to facilitate interdepartmental communication to optimize safe maternal/fetal care.     

Aneurysmal subarachnoid haemorrhage in pregnancy

Although uncommon, aneurysmal subarachnoid haemorrhage (SAH) in pregnancy can be devastating for both mother and baby. It is the leading cause of other indirect maternal death in England and Wales accounting for 60 deaths in the decade 1988-1999. No single obstetric or neurosurgical unit has sufficiently large database or experience in managing this condition in pregnancy. With significant improvements in antenatal care and management of deliveries, non-obstetric causes of maternal death such as aneurysmal subarachnoid haemorrhage are likely to become increasingly significant. The clinical features of aneurysmal subarachnoid haemorrhage closely resemble those of other commoner conditions seen in pregnancy. It is therefore imperative that awareness by obstetricians and other frontline staff is increased so that a high index of suspicion is maintained when pregnant women present with unique headaches. Prompt neurosurgical referral is vital and early involvement of an experienced neuroradiologist essential. It is only when an early diagnosis is made and an aggressive treatment instituted that the bleak case-fatality figure associated with aneurysmal subarachnoid haemorrhage in pregnancy can be improved. This review, by a multidisciplinary and multicenter team, provides a comprehensive update on the epidemiology, aetiology, clinical presentation, diagnosis and the complexities of the multidisciplinary management of this serious and potentially fatal condition when it occurs in pregnancy.     

高龄孕产妇慢性代谢性疾病的长期管理

目前高龄孕产妇的比例逐渐增加。随着年龄的增长,糖尿病、高血压、高脂血症、肥胖等代谢性疾病患病风险增加,而年龄往往是这些疾病的独立危险因素。因此,高龄孕产妇较年轻者将面临更大的风险,对高龄孕产妇的管理要求也更高。但目前对于高龄孕产妇代谢性疾病的关注点主要在于孕期,对于产后的管理与远期康复的关注度较为缺乏,孕期保健及治疗上仍存在不足及局限。为使孕产妇健康生活质量得到保障,现对高龄孕产妇产后常见慢性代谢性疾病的管理进行综述,增强产科医生对年龄因素的关注与重视。建议采用全局随访理念,加强对高龄孕产妇产后的规范管理,注意定期监测血糖、血脂、血压、体质量和腰围等,从而降低远期代谢性疾病的发病风险。     

Automobile trauma in pregnancy: Prevention and treatment

Trauma remains a significant problem for pregnant women. This article discusses the physiology, emergency management, and prevention of injury in pregnant automobile accident victims. The following are the most important messages:

• 1.1) The mere presence of pregnancy should not alter initial emergency trauma resuscitation and subsequent management.
• 2.2) Similarly, pregnancy should not discourage obtaining x-rays necessary for appropriate diagnosis of trauma victims.
• 3.3) Following trauma, the sympathetic responses of the mother divert blood flow away from the pregnant uterus and other “nonvital” organs. Under such circumstances, the fetus may become hypoxic and die, even while the maternal vital signs remain within normal limits.
• 4.4) An experienced labor nurse should be assigned to the trauma victim as soon as possible, and the electronic fetal monitor should be applied by and observed by this nurse until stabilization of the victim has occurred and the patient is admitted to the hospital.
• 5.5) The patient's obstetrician should be brought into the emergency care management as soon as possible—one of his/her assignments is to be the physician/advocate for the fetus.
• 6.6) Placental separation occurs frequently in trauma victims, and in some situations maternal clinical signs may not be evident. Under such circumstances, there is usually some evidence of fetal compromise.
• 7.7) Pregnant women and all children should use automobile restraint systems.

     

Anticoagulants

Pregnancy is a period of heightened coagulability and enhanced risk for thrombotic complications. Thromboembolism is the leading cause of maternal mortality. Anticoagulants are very useful during pregnancy for the acute treatment of venous thromboembolism and for the prevention of recurrent venous thromboembolism. They may also be beneficial in patients with thrombophilias, particularly among women who have experienced adverse pregnancy outcomes such as recurrent pregnancy loss. Anticoagulation is essential but problematic in the management of pregnant women with mechanical heart valve prostheses. When utilizing these medications among pregnant women the potential benefits must be balanced against the possibility of maternal haemorrhagic complications, adverse effects on the pregnancy or toxic effects on the fetus. This chapter summarizes current knowledge about the anticoagulant agents, their potential toxicities and their therapeutic role in pregnant women with various indications for anticoagulant therapy.     

Drugs in pregnancy. Anticoagulants.

Pregnancy is a period of heightened coagulability and enhanced risk for thrombotic complications. Thromboembolism is the leading cause of maternal mortality. Anticoagulants are very useful during pregnancy for the acute treatment of venous thromboembolism and for the prevention of recurrent venous thromboembolism. They may also be beneficial in patients with thrombophilias, particularly among women who have experienced adverse pregnancy outcomes such as recurrent pregnancy loss. Anticoagulation is essential but problematic in the management of pregnant women with mechanical heart valve prostheses. When utilizing these medications among pregnant women the potential benefits must be balanced against the possibility of maternal haemorrhagic complications, adverse effects on the pregnancy or toxic effects on the fetus. This chapter summarizes current knowledge about the anticoagulant agents, their potential toxicities and their therapeutic role in pregnant women with various indications for anticoagulant therapy.     

Studies of diet management and insulin resistance in obese pregnant women]

In an attempt to determine the principles of diet management in obese pregnant women, the association between maternal weight gain during pregnancy (Group I; weight reduction, Group II; +0-4 kg, Group III; +5-9 kg, Group IV; +10 kg-) and the incidence of the complications was investigated in 151 obese pregnant women. Studies on glucose tolerance and insulin binding to erythrocytes were also undertaken. 1) In Group I, the incidences of C/S, forceps delivery, prolonged labor and complication of PIH were lower than those of other groups. There were no heavy-for-dates and light-for-dates babies in Group I, differing from the other three groups. 2) Plasma levels of glucose and insulin were high in obese pregnant women on 75 g OGTT in the second trimester. The binding sites of insulin to erythrocytes were significantly decreased in obese pregnant women. In conclusion, the risks of pregnancy complicated by obesity were high. Insulin resistance was a characteristic of obese pregnant women. The results of this study suggested that the nutritional requirements for very obese pregnant women should be restricted to maintaining the same weight or losing weight during the course of pregnancy to minimize maternal and perinatal risks.     

Hypertension in pregnancy.

Pregnancies complicated by hypertension require a well-formulated management plan. Women with chronic hypertension should be evaluated prior to pregnancy. At onset of pregnancy, they should be classified into low-risk and high-risk groups. The majority of pregnant women identified as low-risk hypertensives will have good perinatal outcome without the use of antihypertensive drugs. In general, antihypertensive medications should be reserved for those considered as having high-risk hypertension. In either case, all these women should have close follow-up of maternal and fetal conditions throughout pregnancy. All women with diagnosed preeclampsia should be hospitalized at the time of diagnosis for evaluation of maternal and fetal well-being. Subsequent management will then depend on gestational age and the severity of the disease process. An individualized management plan and a referral to a tertiary care center will improve maternal and perinatal outcome in those women who are remote from term and in those with the HELLP syndrome.     

Endovascular treatment of acutely ruptured intracranial aneurysms in pregnancy.

Intracranial aneurysm rupture is responsible for important morbidity and mortality during pregnancy. We report 2 cases of subarachnoid hemorrhage in pregnant women resulting from ruptured aneurysms. Both patients were treated by endovascular approach. Successful maternal and fetal outcome were achieved in both cases without craniotomy and aneurysmal surgical exposure.     

Preterm Premature Rupture of Membranes – Inpatient Versus Outpatient Management: an Evidence-Based Review

According to current guidelines, inpatient management until birth is considered standard in pregnant women with preterm premature rupture of membranes (PPROM). With the increasing burden on obstetric departments and the growing importance of satisfaction and right to self-determination in pregnant women, outpatient management in PPROM is a possible alternative to inpatient monitoring. The most important criterion for this approach is to ensure the safety of both the mother and the child. Due to the small number of cases (n = 116), two randomised controlled trials (RCTs) comparing inpatient and outpatient management were unable to draw any conclusions. By 2020, eight retrospective comparative studies (cohort/observational studies) yielded the following outcomes: no significant differences in the rate of maternal complications (e.g., chorioamnionitis, premature placental abruption, umbilical cord prolapse) and in neonatal morbidity, significantly prolonged latency period with higher gestational age at birth, higher birth weight of neonates, and significantly shorter length of stay of preterm infants in neonatal intensive care, shorter hospital stay of pregnant women, and lower treatment costs with outpatient management. Concerns regarding this approach are mainly related to unpredictable complications with the need for rapid obstetric interventions, which cannot be performed in time in an outpatient setting. Prerequisites for outpatient management are the compliance of the expectant mother, the adherence to strict selection criteria and the assurance of adequate monitoring at home. Future research should aim at more accurate risk assessment of obstetric complications through studies with higher case numbers and standardisation of outpatient management under evidence-based criteria.Key words: preterm premature rupture of membranes, inpatient versus outpatient management, latency period, maternal complications, perinatal/neonatal morbidity     

Sexually transmitted diseases in pregnancy

STDs can be one of the most common antepartum complications in high-risk gravidas. Screening for gonorrhea, syphilis, HPV, and possibly hepatitis B and chlamydial infection, should be considered in most, if not all, pregnant women. Familiarity with the common clinical presentations and treatment of bacterial STDs will prevent untoward maternal and neonatal outcome. Recognition of viral STDs, followed by appropriate counseling and management, will avoid most neonatal viral infection.     

Ruptured tuboovarian abscess in late pregnancy. A case report.

BACKGROUND: Tuboovarian abscess is an unusual obstetric complication that causes maternal and fetal morbidity and mortality. CASE: A woman, G1, P0, with a 32-week pregnancy presented with abdominal pain. Physical examination on admission revealed fever and unremarkable abdominal signs. Eleven hours after admission, signs of peritonitis became prominent, necessitating emergency laparotomy. Surgical findings included an 8-cm, right, ruptured tuboovarian abscess with massive purulent contamination of the abdominal cavity. Cesarean hysterectomy with bilateral salpingo-oophorectomy was performed. Neither the newborn nor the mother had postoperative complications. CONCLUSION: Since there are discrepancies in the incidences of tuboovarian abscess in pregnant and nonpregnant groups, the pathogenesis of tuboovarian abscess may be different in the two populations. In pregnancy, diagnosis and management are also more difficult than in the nonpregnant state. Clinical data may not reveal the diagnosis until surgery is mandatory. Because most pregnant women with tuboovarian abscesses are young, conservative surgery should be attempted if the pathology is limited to only one side of the adnexa and further reproduction is desired.     

Maternal arrhythmia: a case report and review of the literature

Pregnant patients with maternal arrhythmias can be challenging and difficult to treat. Medication choices may be limited in patients who are pregnant. Pregnancy carries with it a unique and complex physiology, coupled with fetal concerns. We describe a pregnant patient with an arrhythmia to illustrate treatment thought process and options. We also present a comprehensive review of the literature in regard to treatment of maternal arrhythmias and their potential adverse fetal and maternal outcomes. These treatments include antiarrhythmic medications, electrical cardioversion, and radiofrequency ablation. Antepartum and intrapartum monitoring will also be addressed along with delivery planning and postpartum considerations. The most important aspect in treating these patients is the use of a multidisciplinary approach. The decision of what therapy to use must be addressed on a case-by-case basis with special attention to the patient's individual issues and concerns. TARGET AUDIENCE: Obstetricians and gynecologists, family physicians, emergency room physicians LEARNING OBJECTIVES: After completion of this educational activity, the obstetrician/gynecologist should be better able to assess and council patients on the risks and complications of maternal arrhythmias in pregnancy. Evaluate the current treatment options available for health care providers caring for pregnant patients with maternal arrhythmia, and manage the antepartum course, labor, and delivery in these patients.     

Emergency obstetric care in developing countries: impact of guidelines implementation in a community hospital in Senegal

OBJECTIVE: To evaluate, with volunteer professionals in a resource-poor setting, an approach of audit and feedback to promote local implementation of emergency obstetric guidelines. DESIGN: Triple cohort observational time series study. SETTING: A 46-bed obstetric unit in an academic-affiliated community hospital in Senegal. POPULATION: All pregnant women with haemorrhagic and hypertensive complications who were admitted to the maternity unit during the study periods. METHODS: To assess the benefits of guidelines implementation, maternal outcomes during the intervention period were compared with those occurring in two one-year periods when staff daily supervision was the main potentially effective action on clinical management. MAIN OUTCOME MEASURES: The intervention strategy was criteria-based audits with regular feedback over a one-year period. The clinical focus was haemorrhage and hypertension the most frequent causes of maternal death in the study population. Hospital charts were audited by external reviewers. The primary outcome was the case fatality rate (CFR) among patients with haemorrhage and hypertension. RESULTS: There was an increase in morbidity diagnoses during the intervention period. In addition, there was a marked increase in obstetric interventions, especially for transfusions and caesarean deliveries. Patients characteristic-adjusted case fatality decreased by 53% between baselines I and II and during the intervention period by 33% and 24%, compared with baseline periods I and II, respectively. Outcome improvements were different for haemorrhage and hypertension. CONCLUSION: While staff daily supervision may have improved maternal outcome before the intervention period, audit and feedback produced marked effects on emergency obstetric care, specially for complications requiring highly trained management (e.g. pre-eclampsia). Audit and feedback are one of the potentially effective guidelines implementation strategies that should be considered for further studies in resource-poor health facilities.     

心脏病史女性孕前保健和管理

心脏病女性在妊娠期易发生心血管并发症,是孕产妇非产科因素死亡的重要原因,应加强孕前保健和管理。结合患者病史和检查进行孕前风险评估,能够手术矫正者建议其孕前手术治疗,不宜妊娠者应建议其避孕,允许继续妊娠者孕期应联合多学科管理,提高妊娠分娩安全性。     

Leiomiomatosis múltiple y gestación. Cesárea e histerectomía programadas

The prevalence of leiomyomas in pregnant women ranges from 0.3 to 2.6% while that of multiple uterine leiomyomatosis is even lower. These myomas provoke obstetric and systemic complications in pregnant women. Planned cesarean hysterectomy does not increase maternal morbidity and mortality rates and reduces puerperal complications. We present two cases of pregnant women at term with an obstetric indication for cesarean section and a gynecological indication for hysterectomy. Both procedures were performed in the same intervention. There were no postoperative complications and hospital stay was reduced by 50%.     

235例妊娠合并心脏病围产期的处理

分析了１９７８年至１９９１年妊娠合并心脏病２３５例的临床资料，结果表明患病率为１％，产妇病死率１７‰，心脏病孕产妇病死率占非产科原因死亡的第一位。围产儿病死率为５９．６‰。本组剖宫产率为３６．１％，其中心功能Ⅲ、Ⅳ级者１５例，占６．４％。认为改善母婴预后的关键在于良好的孕产妇系统管理及高危妊娠的临护，积极防治贫血、妊高征、产程延长及各种并发症，适时终止妊娠可获良好的妊娠结局。     

妊娠合并急性脑出血的临床分析

目的研究妊娠合并急性脑出血的临床特点及其对母婴的影响,探讨合并急性脑出血的孕妇的妊娠结局。方法对1990年1月至2012年9月,12例妊娠合并急性脑出血患者的临床资料进行回顾性分析。结果 12例妊娠急性脑出血的孕产妇死亡7例,存活5例;新生儿存活7例。结论妊娠期脑出血多发生在晚期妊娠及分娩过程,妊娠合并急性脑出血应先行终止妊娠,依患者情况适时行开颅手术,分娩以剖宫产为宜,尽量同时行绝育术。不宜采取母乳喂养。妊娠合并急性脑出血以全麻下剖宫产为宜,并同时做好新生儿抢救的准备,母婴多可获得较好的结局。     

Clinical management of paroxysmal nocturnal hemoglobinuria in pregnancy: a case report and updated review

Because women with paroxysmal nocturnal hemoglobinuria (PNH) are especially vulnerable to thromboembolic phenomena, pregnancy is a time of increased risk for both mother and fetus. However, pregnancies in affected women are rare; only case reports and small studies have been reported so far. We present the case of a 20-year-old woman with PNH who, while undergoing medical tests in preparation for a bone marrow transplant, was discovered to be pregnant. We also review the obstetric literature on pregnancy complicated by PNH, which indicates that both maternal and fetal mortality is exceptionally high (11.6% and 7.2%) with the major cause of maternal mortality being thromboembolism. Major maternal complications are more frequent postpartum (30.2%) than antepartum or intrapartum (16.3%). TARGET AUDIENCE: Obstetricians & Gynecologists, Family Physicians. LEARNING OBJECTIVES: After completion of this article, the reader should be able to recall that paroxysmal nocturnal hemoglobinuria (PNH) during pregnancy increases adverse events for both the mother and the fetus, state that maternal and fetal mortality are both high, and explain that the major complications occur in the postpartum period.