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American Journal of Obstetrics and... Feb 2022High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time... (Review)
Review
High blood pressure in the postpartum period is most commonly seen in women with antenatal hypertensive disorders, but it can develop de novo in the postpartum time frame. Whether postpartum preeclampsia or eclampsia represents a separate entity from preeclampsia or eclampsia with antepartum onset is unclear. Although definitions vary, the diagnosis of postpartum preeclampsia should be considered in women with new-onset hypertension 48 hours to 6 weeks after delivery. New-onset postpartum preeclampsia is an understudied disease entity with few evidence-based guidelines to guide diagnosis and management. We propose that new-onset hypertension with the presence of any severe features (including severely elevated blood pressure in women with no history of hypertension) be referred to as postpartum preeclampsia after exclusion of other etiologies to facilitate recognition and timely management. Older maternal age, black race, maternal obesity, and cesarean delivery are all associated with a higher risk of postpartum preeclampsia. Most women with delayed-onset postpartum preeclampsia present within the first 7 to 10 days after delivery, most frequently with neurologic symptoms, typically headache. The cornerstones of treatment include the use of antihypertensive agents, magnesium, and diuresis. Postpartum preeclampsia may be associated with a higher risk of maternal morbidity than preeclampsia with antepartum onset, yet it remains an understudied disease process. Future research should focus on the pathophysiology and specific risk factors. A better understanding is imperative for patient care and counseling and anticipatory guidance before hospital discharge and is important for the reduction of maternal morbidity and mortality in the postpartum period.
Topics: Anticonvulsants; Antihypertensive Agents; Blood Pressure Monitoring, Ambulatory; Diuresis; Eclampsia; Female; Humans; Magnesium Sulfate; Pre-Eclampsia; Pregnancy; Puerperal Disorders; Risk Factors
PubMed: 35177218
DOI: 10.1016/j.ajog.2020.10.027 -
Obstetrics and Gynecology Jun 2021The goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques based on assessment of fetal heart rate (FHR)...
The goal of antepartum fetal surveillance is to reduce the risk of stillbirth. Antepartum fetal surveillance techniques based on assessment of fetal heart rate (FHR) patterns have been in clinical use for almost four decades and are used along with real-time ultrasonography and umbilical artery Doppler velocimetry to evaluate fetal well-being. Antepartum fetal surveillance techniques are routinely used to assess the risk of fetal death in pregnancies complicated by preexisting maternal conditions (eg, diabetes mellitus) as well as those in which complications have developed (eg, fetal growth restriction). The purpose of this document is to provide a review of the current indications for and techniques of antepartum fetal surveillance and outline management guidelines for antepartum fetal surveillance that are consistent with the best scientific evidence.
Topics: Blood Flow Velocity; Female; Fetal Death; Fetal Distress; Fetal Movement; Heart Rate, Fetal; Humans; Oligohydramnios; Pregnancy; Pregnancy Complications; Prenatal Diagnosis; Stillbirth; Ultrasonography, Doppler; Ultrasonography, Prenatal; Umbilical Arteries; Uterine Contraction
PubMed: 34011889
DOI: 10.1097/AOG.0000000000004410 -
Obstetrics and Gynecology Jan 2023To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions...
OBJECTIVE
To analyze temporal trends in and risk factors for postpartum hemorrhage and to analyze the association of risk factors with postpartum hemorrhage-related interventions such as blood transfusion and peripartum hysterectomy.
METHODS
This repeated cross-sectional study analyzed delivery hospitalizations from 2000 to 2019 in the National (Nationwide) Inpatient Sample. Trends analyses were conducted using joinpoint regression to estimate the average annual percent change (AAPC) with 95% CIs. Unadjusted and adjusted survey-weighted logistic regression models were performed to evaluate the relationship between postpartum hemorrhage risk factors and likelihood of 1) postpartum hemorrhage, 2) postpartum hemorrhage that requires blood transfusion, and 3) peripartum hysterectomy in the setting of postpartum hemorrhage, with unadjusted odds ratios and adjusted odds ratios with 95% CIs as measures of association.
RESULTS
Of an estimated 76.7 million delivery hospitalizations, 2.3 million (3.0%) were complicated by postpartum hemorrhage. From 2000 to 2019, the rate of postpartum hemorrhage increased from 2.7% to 4.3% (AAPC 2.6%, 94% CI 1.7-3.5%). Over the study period, the proportion of deliveries to individuals with at least one postpartum hemorrhage risk factor increased from 18.6% to 26.9% (AAPC 1.9%, 95% CI 1.7-2.0%). Among deliveries complicated by postpartum hemorrhage, blood transfusions increased from 5.4% to 16.7% from 2000 to 2011 and then decreased from 16.7% to 12.6% from 2011 to 2019. Peripartum hysterectomy among hospitalized individuals with postpartum hemorrhage increased from 1.4% to 2.4% from 2000 to 2009, did not change significantly from 2009 to 2016, and then decreased significantly from 2.1% to 0.9% from 2016 to 2019 (AAPC -27.0%, 95% CI -35.2% to -17.6%). Risk factors associated with postpartum hemorrhage and transfusion and hysterectomy in the setting of postpartum hemorrhage included prior cesarean delivery with previa or placenta accreta, placenta previa without prior cesarean delivery, and antepartum hemorrhage or placental abruption.
CONCLUSION
Postpartum hemorrhage and related risk factors increased over a 20-year period. Despite the increased postpartum hemorrhage rates, blood transfusions, and hysterectomy rates decreased in recent years.
Topics: Pregnancy; Female; United States; Humans; Postpartum Hemorrhage; Cross-Sectional Studies; Placenta; Cesarean Section; Abruptio Placentae; Risk Factors; Placenta Previa; Placenta Accreta; Hysterectomy; Retrospective Studies
PubMed: 36701615
DOI: 10.1097/AOG.0000000000004972 -
Journal of Obstetrics and Gynaecology... Jul 2020To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.
OBJECTIVES
To summarize the current evidence and to make recommendations for diagnosis and classification of placenta previa and for managing the care of women with this diagnosis.
OPTIONS
To manage in hospital or as an outpatient and to perform a cesarean delivery preterm or at term or to allow a trial of labour when a diagnosis of placenta previa or a low-lying placenta is suspected or confirmed.
OUTCOMES
Prolonged hospitalization, preterm birth, rate of cesarean delivery, maternal morbidity and mortality, and postnatal morbidity and mortality.
INTENDED USERS
Family physicians, obstetricians, midwives, and other maternal care providers.
TARGET POPULATION
Pregnant women with placenta previa or low-lying placenta.
EVIDENCE
Medline, PubMed, Embase, and the Cochrane Library were searched from inception to October 2018. Medical Subject Heading (MeSH) terms and key words related to pregnancy, placenta previa, low-lying placenta, antepartum hemorrhage, short cervical length, preterm labour, and cesarean. This document represents an abstraction of the evidence rather than a methodological review.
VALIDATION METHODS
This guideline has been reviewed by the Maternal-Fetal Medicine and Diagnostic Imaging committees of the Society of Obstetricians and Gynaecologists of Canada (SOGC) and approved by the SOGC Board of Directors.
BENEFITS, HARMS, AND/OR COSTS
Women with placenta previa or low-lying placenta are at increased risk of maternal, fetal and postnatal adverse outcomes that include a potentially incorrect diagnosis and possibly unnecessary hospitalization, restriction of activities, early delivery, or cesarean delivery. Optimization of diagnosis and management protocols has potential to improve maternal, fetal and postnatal outcomes.
SUMMARY STATEMENTS (GRADE RATINGS IN PARENTHESES)
RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
Topics: Canada; Cervix Uteri; Cesarean Section; Delivery, Obstetric; Female; Humans; Infant, Newborn; Obstetric Labor, Premature; Placenta Previa; Pregnancy; Pregnancy Complications; Premature Birth
PubMed: 32591150
DOI: 10.1016/j.jogc.2019.07.019 -
Obstetrical & Gynecological Survey Jul 2022The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but... (Review)
Review
IMPORTANCE
The risk of venous thromboembolism (VTE) increases during pregnancy and the postpartum period. Deep vein thrombosis is the most common VTE during pregnancy, but pulmonary embolism is typically of greater concern as it contributes to far higher morbidity and mortality. Diagnosis and treatment of VTE during pregnancy differ substantially from the general nonpregnant population.
OBJECTIVE
This review describes the epidemiology, risk factors, clinical presentation, diagnosis, and treatment of VTE during pregnancy and the postpartum period.
EVIDENCE ACQUISITION
First, we reviewed the VTE guidelines from professional societies in obstetrics, cardiology, hematology, emergency medicine, pulmonology, and critical care. Second, we examined references from these documents and used PubMed to identify recent articles that cited the guidelines. Finally, we searched PubMed and Google Scholar for articles published since 2018 that included terms for pregnancy and the epidemiology, risk factors, diagnostic imaging, or treatment of VTE.
RESULTS
Venous thromboembolism risk increases throughout pregnancy and peaks shortly after delivery. More than half of pregnancy-related VTE are associated with thrombophilia; other major risks include cesarean delivery, postpartum infection, and the combination of obesity with immobilization. Most VTE can be treated with low molecular weight heparin, but cases of limb- or life-threatening VTE require consideration of thrombolysis and other reperfusion therapies.
CONCLUSIONS AND RELEVANCE
Venous thromboembolism is far more frequent in antepartum and postpartum women than age-matched controls, and clinical suspicion for VTE in this population should incorporate pregnancy-specific risks. Treatment of limb- or life-threatening antepartum or postpartum VTE requires multispecialty coordination to optimize maternal and fetal outcomes.
Topics: Diagnostic Techniques and Procedures; Female; Heparin, Low-Molecular-Weight; Humans; Postpartum Period; Pregnancy; Risk Factors; Venous Thromboembolism
PubMed: 35792687
DOI: 10.1097/OGX.0000000000001043 -
American Journal of Obstetrics and... Aug 2021Fetal and neonatal alloimmune thrombocytopenia, the platelet equivalent of hemolytic disease of the fetus and newborn, can have devastating effects on both the fetus and... (Review)
Review
Fetal and neonatal alloimmune thrombocytopenia, the platelet equivalent of hemolytic disease of the fetus and newborn, can have devastating effects on both the fetus and neonate. Current management of fetal and neonatal alloimmune thrombocytopenia in a subsequent affected pregnancy involves antenatal administration of intravenous immune globulin and prednisone to the pregnant woman to prevent the development of severe fetal thrombocytopenia and secondary intracranial hemorrhage in utero. That therapy has proven to be highly effective but is associated with maternal side effects and is expensive. This commentary describes 4 advances that could substantially change the current approach to detecting and managing fetal and neonatal alloimmune thrombocytopenia in the near future. The first would be an introduction of a program to screen all antepartum patients in this country for pregnancies at risk of developing fetal and neonatal alloimmune thrombocytopenia. Strategies to implement this complex process have been described. A second advance is testing of cell-free fetal DNA obtained from maternal blood to noninvasively determine the fetal human platelet antigen 1 genotype. A third, in preliminary development, is creation of a prophylactic product that would be the platelet equivalent of Rh immune globulin (RhoGAM). Finally, a fourth major potential advance is the development of neonatal Fc receptor inhibitors to replace the current medical therapy administered to pregnant women with an affected fetus. Neonatal Fc receptor recycles plasma immunoglobulin G to increase its half-life and is the means by which immunoglobulin G crosses the placenta from the maternal to the fetal circulation. Blocking the neonatal Fc receptor is an ideal way to prevent maternal immunoglobulin G antibody from causing fetal and neonatal alloimmune thrombocytopenia in a fetus at risk of developing that disorder. The pertinent pathophysiology and rationale for each of these developments will be presented in addition to our thoughts relating to steps that must be taken and difficulties that each approach would face for them to be successfully implemented.
Topics: Antigens, Human Platelet; Cell-Free Nucleic Acids; Drug Development; Female; Genotype; Glucocorticoids; Histocompatibility Antigens Class I; Humans; Immunoglobulin G; Immunoglobulins, Intravenous; Immunologic Factors; Integrin beta3; Maternal-Fetal Exchange; Noninvasive Prenatal Testing; Prednisone; Pregnancy; Prenatal Diagnosis; Receptors, Fc; Risk Assessment; Thrombocytopenia, Neonatal Alloimmune
PubMed: 33839095
DOI: 10.1016/j.ajog.2021.04.211 -
Lancet (London, England) Nov 2022Pregnancy-related venous thromboembolism is a leading cause of maternal morbidity and mortality, and thromboprophylaxis is indicated in pregnant and post-partum women... (Randomized Controlled Trial)
Randomized Controlled Trial
Intermediate-dose versus low-dose low-molecular-weight heparin in pregnant and post-partum women with a history of venous thromboembolism (Highlow study): an open-label, multicentre, randomised, controlled trial.
BACKGROUND
Pregnancy-related venous thromboembolism is a leading cause of maternal morbidity and mortality, and thromboprophylaxis is indicated in pregnant and post-partum women with a history of venous thromboembolism. The optimal dose of low-molecular-weight heparin to prevent recurrent venous thromboembolism in pregnancy and the post-partum period is uncertain.
METHODS
In this open-label, randomised, controlled trial (Highlow), pregnant women with a history of venous thromboembolism were recruited from 70 hospitals in nine countries (the Netherlands, France, Ireland, Belgium, Norway, Denmark, Canada, the USA, and Russia). Women were eligible if they were aged 18 years or older with a history of objectively confirmed venous thromboembolism, and with a gestational age of 14 weeks or less. Eligible women were randomly assigned (1:1), before 14 weeks of gestational age, using a web-based system and permuted block randomisation (block size of six), stratified by centre, to either weight-adjusted intermediate-dose or fixed low-dose low-molecular-weight heparin subcutaneously once daily until 6 weeks post partum. The primary efficacy outcome was objectively confirmed venous thromboembolism (ie, deep-vein thrombosis, pulmonary embolism, or unusual site venous thrombosis), as determined by an independent central adjudication committee, in the intention-to-treat (ITT) population (ie, all women randomly assigned to treatment). The primary safety outcome was major bleeding which included antepartum, early post-partum (within 24 h after delivery), and late post-partum major bleeding (24 h or longer after delivery until 6 weeks post partum), assessed in all women who received at least one dose of assigned treatment and had a known end of treatment date. This study is registered with ClinicalTrials.gov, NCT01828697, and is now complete.
FINDINGS
Between April 24, 2013, and Oct 31, 2020, 1339 pregnant women were screened for eligibility, of whom 1110 were randomly assigned to weight-adjusted intermediate-dose (n=555) or fixed low-dose (n=555) low-molecular-weight heparin (ITT population). Venous thromboembolism occurred in 11 (2%) of 555 women in the weight-adjusted intermediate-dose group and in 16 (3%) of 555 in the fixed low-dose group (relative risk [RR] 0·69 [95% CI 0·32-1·47]; p=0·33). Venous thromboembolism occurred antepartum in five (1%) women in the intermediate-dose group and in five (1%) women in the low-dose group, and post partum in six (1%) women and 11 (2%) women. On-treatment major bleeding in the safety population (N=1045) occurred in 23 (4%) of 520 women in the intermediate-dose group and in 20 (4%) of 525 in the low-dose group (RR 1·16 [95% CI 0·65-2·09]).
INTERPRETATION
In women with a history of venous thromboembolism, weight-adjusted intermediate-dose low-molecular-weight heparin during the combined antepartum and post-partum periods was not associated with a lower risk of recurrence than fixed low-dose low-molecular-weight heparin. These results indicate that low-dose low-molecular-weight heparin for thromboprophylaxis during pregnancy is the appropriate dose for the prevention of pregnancy-related recurrent venous thromboembolism.
FUNDING
French Ministry of Health, Health Research Board Ireland, GSK/Aspen, and Pfizer.
Topics: Female; Humans; Pregnancy; Male; Heparin, Low-Molecular-Weight; Venous Thromboembolism; Anticoagulants; Postpartum Period; Pulmonary Embolism; Postpartum Hemorrhage
PubMed: 36354038
DOI: 10.1016/S0140-6736(22)02128-6