Pre-eclampsia Steegers, Eric AP, Prof; von Dadelszen, Peter, MBChB; Duvekot, Johannes J, MD ...
The Lancet (British edition),
08/2010, Letnik:
376, Številka:
9741
Journal Article
Recenzirano
Summary Pre-eclampsia remains a leading cause of maternal and perinatal mortality and morbidity. It is a pregnancy-specific disease characterised by de-novo development of concurrent hypertension and ...proteinuria, sometimes progressing into a multiorgan cluster of varying clinical features. Poor early placentation is especially associated with early onset disease. Predisposing cardiovascular or metabolic risks for endothelial dysfunction, as part of an exaggerated systemic inflammatory response, might dominate in the origins of late onset pre-eclampsia. Because the multifactorial pathogenesis of different pre-eclampsia phenotypes has not been fully elucidated, prevention and prediction are still not possible, and symptomatic clinical management should be mainly directed to prevent maternal morbidity (eg, eclampsia) and mortality. Expectant management of women with early onset disease to improve perinatal outcome should not preclude timely delivery—the only definitive cure. Pre-eclampsia foretells raised rates of cardiovascular and metabolic disease in later life, which could be reason for subsequent lifestyle education and intervention.
The worldwide incidence of abnormally invasive placenta is rapidly rising, following the trend of increasing cesarean delivery. It is a heterogeneous condition and has a high maternal morbidity and ...mortality rate, presenting specific intrapartum challenges. Its rarity makes developing individual expertise difficult for the majority of clinicians. The International Society for Abnormally Invasive Placenta aims to improve clinicians’ understanding and skills in managing this difficult condition. By pooling knowledge, experience, and expertise gained within a variety of different healthcare systems, the Society seeks to improve the outcomes for women with abnormally invasive placenta globally.
The recommendations presented herewith were reached using a modified Delphi technique and are based on the best available evidence. The evidence base for each is presented using a formal grading system. The topics chosen address the most pertinent questions regarding intrapartum management of abnormally invasive placenta with respect to clinically relevant outcomes, including the following: definition of a center of excellence; requirement for antenatal hospitalization; antenatal optimization of hemoglobin; gestational age for delivery; antenatal corticosteroid administration; use of preoperative cystoscopy, ureteric stents, and prophylactic pelvic arterial balloon catheters; maternal position for surgery; type of skin incision; position of the uterine incision; use of interoperative ultrasound; prophylactic administration of oxytocin; optimal method for intraoperative diagnosis; use of expectant management; adjuvant therapies for expectant management; use of local surgical resection; type of hysterectomy; use of delayed hysterectomy; intraoperative measures to treat life-threatening hemorrhage; and fertility after conservative management.
To provide evidence to support updated guidelines for the management of pregnant women with hereditary thrombophilia in order to reduce the risk of a first venous thromboembolism (VTE) in pregnancy.
... Systematic review and bayesian meta-analysis.
Embase, Medline, Web of Science, Cochrane Library, and Google Scholar from inception through 14 November 2016.
Observational studies that reported on pregnancies without the use of anticoagulants and the outcome of first VTE for women with thrombophilia were eligible for inclusion. VTE was considered established if it was confirmed by objective means, or when the patient had received a full course of a full dose anticoagulant treatment without objective testing.
36 studies were included in the meta-analysis. All thrombophilias increased the risk for pregnancy associated VTE (probabilities ≥91%). Regarding absolute risks of pregnancy associated VTE, high risk thrombophilias were antithrombin deficiency (antepartum: 7.3%, 95% credible interval 1.8% to 15.6%; post partum: 11.1%, 3.7% to 21.0%), protein C deficiency (antepartum: 3.2%, 0.6% to 8.2%; post partum: 5.4%, 0.9% to 13.8%), protein S deficiency (antepartum: 0.9%, 0.0% to 3.7%; post partum: 4.2%; 0.7% to 9.4%), and homozygous factor V Leiden (antepartum: 2.8%, 0.0% to 8.6%; post partum: 2.8%, 0.0% to 8.8%). Absolute combined antepartum and postpartum risks for women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutations, or compound heterozygous factor V Leiden and prothrombin G20210A mutations were all below 3%.
Women with antithrombin, protein C, or protein S deficiency or with homozygous factor V Leiden should be considered for antepartum or postpartum thrombosis prophylaxis, or both. Women with heterozygous factor V Leiden, heterozygous prothrombin G20210A mutation, or compound heterozygous factor V Leiden and prothrombin G20210A mutation should generally not be prescribed thrombosis prophylaxis on the basis of thrombophilia and family history alone. These data should be considered in future guidelines on pregnancy associated VTE risk.
Pre-eclampsia (PE) complicates 2%-8% of all pregnancies and is an important cause of perinatal morbidity and mortality worldwide. In order to reduce these complications and to develop possible ...treatment modalities, it is important to identify women at risk of developing PE. The use of biomarkers in early pregnancy would allow appropriate stratification into high and low risk pregnancies for the purpose of defining surveillance in pregnancy and to administer interventions. We used formal methods for a systematic review and meta-analyses to assess the accuracy of all biomarkers that have been evaluated so far during the first and early second trimester of pregnancy to predict PE. We found low predictive values using individual biomarkers which included a disintegrin and metalloprotease 12 (ADAM-12), inhibin-A, pregnancy associated plasma protein A (PAPP-A), placental growth factor (PlGF) and placental protein 13 (PP-13). The pooled sensitivity of all single biomarkers was 0.40 (95% CI 0.39-0.41) at a false positive rate of 10%. The area under the Summary of Receiver Operating Characteristics Curve (SROC) was 0.786 (SE 0.02). When a combination model was used, the predictive value improved to an area under the SROC of 0.893 (SE 0.03). In conclusion, although there are multiple potential biomarkers for PE their efficacy has been inconsistent and comparisons are difficult because of heterogeneity between different studies. Therefore, there is an urgent need for high quality, large-scale multicentre research in biomarkers for PE so that the best predictive marker(s) can be identified in order to improve the management of women destined to develop PE.
ABSTRACT
Introduction
Early‐onset fetal growth restriction is a pregnancy complication often coinciding with abnormal Doppler flow in the umbilical artery. Absent or reversed end‐diastolic flow in ...the umbilical artery is associated with adverse perinatal outcome. As the optimal management of this condition is unclear, the objective of this study was to analyze the time interval from admission to delivery of pregnancies with early‐onset fetal growth restriction, while pursuing a policy of postponing delivery unless active management of labor would be required because of fetal distress or maternal condition. We also assessed short‐ and long‐term perinatal outcome.
Material and methods
In this historical cohort study, all pregnant women with singleton pregnancies, admitted during 2004–2015 with early‐onset fetal growth restriction were included. Pregnancies with absent or reversed end‐diastolic flow (AREDF) were compared with pregnancies with a positive end‐diastolic Doppler flow (PEDF). Time until delivery was determined and perinatal outcome was assessed for both groups.
Results
In our study, 111 women were allocated to the PEDF group and 109 to the AREDF group. In the AREDF group, fetal distress was more often an indication for delivery, in comparison with the PEDF group (p = .004). Median time until delivery in patients admitted between 26 and 28 weeks’ gestation was 6+5 weeks in the PEDF group and 1+4 weeks in the AREDF group (p = .001). No statistically significant difference was found between the Doppler groups in the composite adverse neonatal outcome, which includes at least one of the following outcomes: infant respiratory distress syndrome, sepsis, bronchopulmonary dysplasia, necrotizing enterocolitis, intraventricular hemorrhage >grade 2, periventricular leukomalacia and perinatal death (p = .63).
Conclusions
In this study, comprising pregnancies with early‐onset fetal growth restriction, fetal distress was observed more frequently in the AREDF group with the consequence of delivery at an earlier stage of gestation, compared with the PEDF group. AREDF was not associated with increased perinatal morbidity and mortality compared with PEDF.
•Implementation of the new ISSHP/ACOG definitions for preeclampsia increases cases of preeclampsia with 10/2%.•This increase is due to inclusion of non-proteinuric preeclampsia cases.•Severe ...preeclampsia cases increase with 4.6% (ACOG 2013).•Proteinuric and non-proteinuric preeclampsia cases had similar short-term complications rates.•Introduction of the new guidelines will lead to more admissions and inductions of labor.
In 2018/2013 both ISSHP and ACOG revised their original statements and postulated new criteria for preeclampsia with and without severe features. Most importantly, preeclampsia can now also be established in the absence of proteinuria when other specific symptoms are present.
What is the clinical impact of the use of three different new definitions for the diagnosis of preeclampsia?
Retrospective cohort study of all pregnant women who gave birth in the Erasmus MC between 01 and 01-2014 and 01-01-2016. Hypertensive disorders of pregnancy (HDP) were defined when blood pressure was elevated at least during two occasions. All HDP cases were classified according to the ISSHP 2001, ISSHP 2018 and ACOG 2013 definitions.
In our cohort (N = 4395) 878 patients had HDP (20,0%). The ISSHP 2018/ACOG 2013 definition cause a significant increase in patients with (superimposed) preeclampsia versus the ISSHP 2001 definition, from 272 patients (6,2%) to respectively 360 (8,2%)/290 (6,6%) (p < 0,001/p < 0,001). This increase is due to non-proteinuric preeclampsia cases. According to the ACOG 2013 definition there were 154 (53,1%) cases of preeclampsia with severe features. Neonatal NICU admission rates were almost doubled in the proteinuric preeclampsia group compared to the non-proteinuric preeclampsia group.
Implementation of the ISSHP 2018/ACOG 2013 definitions cause a shift from gestational hypertension and chronic hypertension towards (superimposed) preeclampsia (relative increase 10%/2%). These increases are caused by inclusion of non-proteinuric cases. More research is necessary into the course and prognosis of especially non-proteinuric preeclampsia cases.
Summary Background No consensus exists for the best way to monitor and when to trigger delivery in mothers of babies with fetal growth restriction. We aimed to assess whether changes in the fetal ...ductus venosus Doppler waveform (DV) could be used as indications for delivery instead of cardiotocography short-term variation (STV). Methods In this prospective, European multicentre, unblinded, randomised study, we included women with singleton fetuses at 26–32 weeks of gestation who had very preterm fetal growth restriction (ie, low abdominal circumference <10th percentile and a high umbilical artery Doppler pulsatility index >95th percentile). We randomly allocated women 1:1:1, with randomly sized blocks and stratified by participating centre and gestational age (<29 weeks vs ≥29 weeks), to three timing of delivery plans, which differed according to antenatal monitoring strategies: reduced cardiotocograph fetal heart rate STV (CTG STV), early DV changes (pulsatility index >95th percentile; DV p95), or late DV changes (A wave the deflection within the venous waveform signifying atrial contraction at or below baseline; DV no A). The primary outcome was survival without cerebral palsy or neurosensory impairment, or a Bayley III developmental score of less than 85, at 2 years of age. We assessed outcomes in surviving infants with known outcomes at 2 years. We did an intention to treat study for all participants for whom we had data. Safety outcomes were deaths in utero and neonatal deaths and were assessed in all randomly allocated women. This study is registered with ISRCTN, number 56204499. Findings Between Jan 1, 2005 and Oct 1, 2010, 503 of 542 eligible women were randomly allocated to monitoring groups (166 to CTG STV, 167 to DV p95, and 170 to DV no A). The median gestational age at delivery was 30·7 weeks (IQR 29·1–32·1) and mean birthweight was 1019 g (SD 322). The proportion of infants surviving without neuroimpairment did not differ between the CTG STV (111 77% of 144 infants with known outcome), DV p95 (119 84% of 142), and DV no A (133 85% of 157) groups (ptrend =0·09). 12 fetuses (2%) died in utero and 27 (6%) neonatal deaths occurred. Of survivors, more infants where women were randomly assigned to delivery according to late ductus changes (133 95% of 140, 95%, 95% CI 90–98) were free of neuroimpairment when compared with those randomly assigned to CTG (111 85% of 131, 95% CI 78–90; p=0.005), but this was accompanied by a non-significant increase in perinatal and infant mortality. Interpretation Although the difference in the proportion of infants surviving without neuroimpairment was non-significant at the primary endpoint, timing of delivery based on the study protocol using late changes in the DV waveform might produce an improvement in developmental outcomes at 2 years of age. Funding ZonMw, The Netherlands and Dr Hans Ludwig Geisenhofer Foundation, Germany.
To assess incidence and possible risk factors of severe maternal morbidity and mortality from cardiovascular disease in The Netherlands.
A prospective population based cohort study.
All 98 maternity ...units in The Netherlands.
All women delivering in The Netherlands between August 2004 and August 2006 (n = 371,021).
Cases of severe maternal morbidity and mortality from cardiovascular disease were prospectively collected during a two-year period in The Netherlands. Women with cardiovascular complications during pregnancy or postpartum who were admitted to the ward, intensive care or coronary care unit were included. Cardiovascular morbidity was defined as cardiomyopathy, valvular disease, ischaemic heart disease, arrhythmias or aortic dissection. All women delivering in the same period served as a reference cohort.
Incidence, case fatality rates and possible risk factors.
Incidence of severe maternal morbidity due to cardiovascular disease was 2.3 per 10,000 deliveries (84/358,874). Maternal mortality rate from cardiovascular disease was 3.0 per 100,000 deliveries (11/358,874). Case fatality rate in women with severe maternal morbidity due to cardiovascular disease was 13% (11/84). Case fatality rate was highest in aortic dissection (83%). Pre-existing acquired or congenital heart disease was identified in 34% of women. Thirty-one percent of women were of advanced maternal age (>35 years of age) and 5 percent above 40 years of age. Possible risk factors for cardiovascular morbidity were caesarean section (either resulting in or as a result of cardiovascular disease), multiple pregnancy, prior caesarean section, non-Western ethnicity and obesity.
In The Netherlands cardiovascular disease is a rare cause of severe maternal morbidity with an incidence of 2.3 per 10,000 deliveries and a high case fatality rate of 13%. Cardiovascular complications develop mostly in women not known with cardiac disease pre-pregnancy.
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