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Hypertension (Dallas, Tex. : 1979) Jun 2024Preeclampsia is a pregnancy-specific hypertensive disorder associated with an imbalance in circulating proangiogenic and antiangiogenic proteins. Preclinical evidence...
BACKGROUND
Preeclampsia is a pregnancy-specific hypertensive disorder associated with an imbalance in circulating proangiogenic and antiangiogenic proteins. Preclinical evidence implicates microvascular dysfunction as a potential mediator of preeclampsia-associated cardiovascular risk.
METHODS
Women with singleton pregnancies complicated by severe antepartum-onset preeclampsia and a comparator group with normotensive deliveries underwent cardiac positron emission tomography within 4 weeks of delivery. A control group of premenopausal, nonpostpartum women was also included. Myocardial flow reserve, myocardial blood flow, and coronary vascular resistance were compared across groups. sFlt-1 (soluble fms-like tyrosine kinase receptor-1) and PlGF (placental growth factor) were measured at imaging.
RESULTS
The primary cohort included 19 women with severe preeclampsia (imaged at a mean of 15.3 days postpartum), 5 with normotensive pregnancy (mean, 14.4 days postpartum), and 13 nonpostpartum female controls. Preeclampsia was associated with lower myocardial flow reserve (β, -0.67 [95% CI, -1.21 to -0.13]; =0.016), lower stress myocardial blood flow (β, -0.68 [95% CI, -1.07 to -0.29] mL/min per g; =0.001), and higher stress coronary vascular resistance (β, +12.4 [95% CI, 6.0 to 18.7] mm Hg/mL per min/g; =0.001) versus nonpostpartum controls. Myocardial flow reserve and coronary vascular resistance after normotensive pregnancy were intermediate between preeclamptic and nonpostpartum groups. Following preeclampsia, myocardial flow reserve was positively associated with time following delivery (=0.008). The sFlt-1/PlGF ratio strongly correlated with rest myocardial blood flow (=0.71; <0.001), independent of hemodynamics.
CONCLUSIONS
In this exploratory cross-sectional study, we observed reduced coronary microvascular function in the early postpartum period following preeclampsia, suggesting that systemic microvascular dysfunction in preeclampsia involves coronary microcirculation. Further research is needed to establish interventions to mitigate the risk of preeclampsia-associated cardiovascular disease.
Topics: Humans; Female; Pre-Eclampsia; Pregnancy; Adult; Vascular Resistance; Coronary Circulation; Vascular Endothelial Growth Factor Receptor-1; Microcirculation; Positron-Emission Tomography; Placenta Growth Factor; Postpartum Period; Severity of Illness Index; Fractional Flow Reserve, Myocardial; Coronary Vessels; Microvessels
PubMed: 38563161
DOI: 10.1161/HYPERTENSIONAHA.124.22905 -
Mymensingh Medical Journal : MMJ Apr 2024Postpartum acute kidney injury (AKI) is a condition characterized by a sudden and rapid decline in kidney function that occurs shortly after childbirth. Several risk... (Observational Study)
Observational Study
Postpartum acute kidney injury (AKI) is a condition characterized by a sudden and rapid decline in kidney function that occurs shortly after childbirth. Several risk factors may be associated with postpartum acute kidney injury (AKI). Understanding the possible risk factors is essential for timely intervention and improved maternal healthcare. The aim of the study was to assess the risk factors of postpartum acute kidney injury patients. This prospective observational study took place at Mymensingh Medical College Hospital, from March 2020 to April 2021. It was carried out in the Departments of Nephrology and Departments of Obstetrics & Gynecology, where 153 postpartum acute kidney injury (AKI) patients were enrolled through purposive sampling. The study collected data on patient demographics, etiology and presentation. Statistical analysis was conducted using SPSS (Statistical Package for the Social Sciences) version 26.0, with a significance threshold set at p<0.05 for all tests. Among participants, puerperal sepsis (77.8%) and toxemia of pregnancy (58.8%) were prevalent risk factors. Intrauterine death was rare (1.3%). Other risk factors such as postpartum hemorrhage 22.2%, HELLP syndrome 11.1%, and antepartum hemorrhage 15.0% were found. A statistically significant difference in postpartum hemorrhage prevalence (p=0.038) was noted between hemodialysis and non-hemodialysis patients. Puerperal sepsis is the most common risk factor for postpartum acute kidney injury, closely followed by toxemia of pregnancy. Intrauterine death is rare, while postpartum hemorrhage significantly affects subjects, with variations noted between hemodialysis and non-hemodialysis patients.
Topics: Female; Humans; Pregnancy; Acute Kidney Injury; Postpartum Hemorrhage; Postpartum Period; Pre-Eclampsia; Risk Factors; Sepsis; Prospective Studies
PubMed: 38557516
DOI: No ID Found -
Journal of Obstetrics and Gynaecology... Apr 2024This guideline provides recommendations for the prevention of Rh D alloimmunization (isoimmunization) in pregnancy, including parental testing, routine postpartum and...
OBJECTIVE
This guideline provides recommendations for the prevention of Rh D alloimmunization (isoimmunization) in pregnancy, including parental testing, routine postpartum and antepartum prophylaxis, and other clinical indications for prophylaxis. Prevention of red cell alloimmunization in pregnancy with atypical antigens (other than the D antigen), for which immunoprophylaxis is not currently available, is not addressed in this guideline.
TARGET POPULATION
All Rh D-negative pregnant individuals at risk for Rh D alloimmunization due to potential exposure to a paternally derived fetal Rh D antigen.
OUTCOMES
Routine postpartum and antepartum Rh D immunoprophylaxis reduces the risk of Rh D alloimmunization at 6 months postpartum and in a subsequent pregnancy.
BENEFITS, HARMS, AND COSTS
This guideline details the population of pregnant individuals who may benefit from Rho(D) immune globulin (RhIG) immunoprophylaxis. Thus, those for whom the intervention is not required may avoid adverse effects, while those who are at risk of alloimmunization may mitigate this risk for themselves and/or their fetus.
EVIDENCE
For recommendations regarding use of RhIG, Medline and Medline in Process via Ovid and Embase Classic + Embase via Ovid were searched using both the trials and observational studies search strategies with study design filters. For trials, the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Database of Abstracts of Reviews of Effects via Ovid were also searched. All databases were searched from January 2000 to November 26, 2019. Studies published before 2000 were captured from the grey literature of national obstetrics and gynaecology specialty societies, luminary specialty journals, and bibliographic searching. A formal process for the systematic review was undertaken for this update, as described in the systematic review manuscript published separately.
VALIDATION METHODS
The authors rated the quality of evidence and strength of recommendations using the SOGC's modified GRADE approach. See Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).
INTENDED AUDIENCE
The intended users of this guideline include prenatal care providers such as obstetricians, midwives, family physicians, emergency room physicians, and residents, as well as registered nurses and nurse practitioners.
TWEETABLE ABSTRACT
An updated Canadian guideline for prevention of Rh D alloimmunization addresses D variants, cffDNA for fetal Rh type, and updates recommendations on timing of RhIG administration.
SUMMARY STATEMENTS
RECOMMENDATIONS.
Topics: Humans; Rh Isoimmunization; Female; Pregnancy; Rho(D) Immune Globulin; Rh-Hr Blood-Group System
PubMed: 38553007
DOI: 10.1016/j.jogc.2024.102449 -
Cureus Feb 2024The magnitude and risk factors for postpartum haemorrhage (PPH) have been extensively investigated, although little is currently known about the incidence and predictors...
BACKGROUND
The magnitude and risk factors for postpartum haemorrhage (PPH) have been extensively investigated, although little is currently known about the incidence and predictors of severe PPH, specifically among women affected by prenatal anaemia in Nigeria.
OBJECTIVES
The study determined the incidence and antepartum risk factors of severe PPH in anaemic pregnant women in five health institutions in Lagos, Southwest Nigeria.
METHODS
A secondary analysis was performed using the data of pregnant women with anaemia from the "" study that was conducted between January and June 2023. This study included n=570 pregnant women affected by anaemia who gave birth in five hospitals in the Lagos metropolis of Nigeria. The study outcome was severe PPH, defined as an estimated blood loss of at least 1000 mL within 24 hours of childbirth. A backward stepwise conditional approach in a multivariable logistic regression model was utilised to identify the independent risk factors for severe PPH in anaemic pregnant women.
RESULTS
Of the 570 women with prenatal anaemia enrolled in the primary study, 42 (7.4%) had severe PPH. The identified independent risk factors for severe PPH were maternal obesity (adjusted OR = 3.85, 95% CI = 1.85-8.02), antepartum haemorrhage in index pregnancy (adjusted OR = 2.98, 95% CI = 1.29-6.90), uterine fibroids (adjusted OR = 6.10, 95% CI = 2.39-15.52), delivery gestational age ≥39 weeks (adjusted OR = 2.62, 95% CI = 1.23-5.56), and delivery by caesarean birth (adjusted OR = 16.75, 95% CI = 5.81-48.31).
CONCLUSION
About one in 13 anaemic pregnant women enrolled in the study developed severe PPH during childbirth. Maternal obesity, antepartum bleeding in the current pregnancy, co-existing uterine fibroids in pregnancy, delivery gestational age beyond 38 weeks, and caesarean birth in the current pregnancy were factors that were significantly associated with severe PPH in anaemic pregnant women. These findings underscore the importance of increased vigilance during both the antenatal and peripartum periods to identify women with these risk factors for the initiation of timely interventions to prevent severe PPH.
PubMed: 38550501
DOI: 10.7759/cureus.54980 -
Radiographics : a Review Publication of... Apr 2024Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both...
Severe obstetric hemorrhage is a leading cause of maternal mortality and morbidity worldwide. Major hemorrhage in the antepartum period presents potential risks for both the mother and the fetus. Similarly, postpartum hemorrhage (PPH) accounts for up to a quarter of maternal deaths worldwide. Potential causes of severe antepartum hemorrhage that radiologists should be familiar with include placental abruption, placenta previa, placenta accreta spectrum disorders, and vasa previa. Common causes of PPH that the authors discuss include uterine atony, puerperal genital hematomas, uterine rupture and dehiscence, retained products of conception, and vascular anomalies. Bleeding complications unique to or most frequently encountered after cesarean delivery are also enumerated, including entities such as bladder flap hematomas, rectus sheath and subfascial hemorrhage, and infectious complications of endometritis and uterine dehiscence. RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material. See the invited commentary by Javitt and Madrazo in this issue.
Topics: Pregnancy; Female; Humans; Postpartum Hemorrhage; Placenta; Cesarean Section; Puerperal Disorders; Hematoma
PubMed: 38547034
DOI: 10.1148/rg.230164 -
Revista Da Associacao Medica Brasileira... 2024The aim of this study was to investigate the effect of water immersion during the first stage of labor on maternal and neonatal oxidative stress and the association...
OBJECTIVE
The aim of this study was to investigate the effect of water immersion during the first stage of labor on maternal and neonatal oxidative stress and the association between serum and dietary total antioxidant capacity.
METHODS
Women were divided into two groups: those immersed in water during the first stage of labor (n=30) and those who had conventional birth (n=33). Total oxidative stress and total antioxidant status levels were examined in antepartum and postpartum maternal serum and neonatal cord blood samples. Dietary total antioxidant capacity was determined by the food frequency questionnaire.
RESULTS
Vitamin C and dietary total antioxidant capacity consumption were found to be higher in the water immersion group (106.92 mg/day and 18.94 mmol/gün, respectively) than the conventional birth group (92.69 mg/day and 15.99 mmol/gün, respectively) (p<0.05). Women immersed in water during the first stage of labor had lower total oxidative stress levels in antepartum and postpartum maternal serum and neonatal cord blood samples than those who had conventional birth (5.43±2.42 mmol/L and 5.59±3.35 mmol/L vs. 8.58±5.53 mmol/L and 12.68±16.58 mmol/L; p<0.05). Dietary total antioxidant capacity was found to be negatively correlated with total oxidative stress levels in antepartum and postpartum maternal serum and neonatal cord blood samples (p=0.012, p=0.047, p=0.035, and p<0.05).
CONCLUSION
Women immersed in water during the first stage of labor had lower total oxidative stress levels in their postnatal maternal serum and neonatal cord blood samples and dietary total antioxidant capacity was also a factor associated with low total oxidative stress levels.
Topics: Female; Humans; Infant, Newborn; Antioxidants; Case-Control Studies; Immersion; Oxidative Stress; Water; Pregnancy
PubMed: 38511756
DOI: 10.1590/1806-9282.20230996 -
MedRxiv : the Preprint Server For... Mar 2024Preeclampsia is a pregnancy-specific hypertensive disorder associated with an imbalance in circulating pro- and anti-angiogenic proteins. Preclinical evidence implicates...
BACKGROUND
Preeclampsia is a pregnancy-specific hypertensive disorder associated with an imbalance in circulating pro- and anti-angiogenic proteins. Preclinical evidence implicates microvascular dysfunction as a potential mediator of preeclampsia-associated cardiovascular risk.
METHODS
Women with singleton pregnancies complicated by severe antepartum-onset preeclampsia and a comparator group with normotensive deliveries underwent cardiac positron emission tomography (PET) within 4 weeks of delivery. A control group of pre-menopausal, non-postpartum women was also included. Myocardial flow reserve (MFR), myocardial blood flow (MBF), and coronary vascular resistance (CVR) were compared across groups. Soluble fms-like tyrosine kinase receptor-1 (sFlt-1) and placental growth factor (PlGF) were measured at imaging.
RESULTS
The primary cohort included 19 women with severe preeclampsia (imaged at a mean 16.0 days postpartum), 5 with normotensive pregnancy (mean 14.4 days postpartum), and 13 non-postpartum female controls. Preeclampsia was associated with lower MFR (=-0.67 [95% CI -1.21 to -0.13]; =0.016), lower stress MBF (=-0.68 [95% CI, -1.07 to -0.29] mL/min/g; =0.001), and higher stress CVR (=+12.4 [95% CI 6.0 to 18.7] mmHg/mL/min/g; =0.001) vs. non-postpartum controls. MFR and CVR after normotensive pregnancy were intermediate between preeclamptic and non-postpartum groups. Following preeclampsia, MFR was positively associated with time following delivery (=0.008). The sFlt-1/PlGF ratio strongly correlated with rest MBF (=0.71; <0.001), independent of hemodynamics.
CONCLUSIONS
In this exploratory study, we observed reduced coronary microvascular function in the early postpartum period following severe preeclampsia, suggesting that systemic microvascular dysfunction in preeclampsia involves the coronary microcirculation. Further research is needed to establish interventions to mitigate risk of preeclampsia-associated cardiovascular disease.
PubMed: 38496439
DOI: 10.1101/2024.03.04.24303728 -
Global Pediatric Health 2024To create a prediction model for preterm neonatal mortality. A secondary analysis was conducted using data from a prospective cohort study, the Project to Understand...
To create a prediction model for preterm neonatal mortality. A secondary analysis was conducted using data from a prospective cohort study, the Project to Understand and Research Preterm Pregnancy Outcome South Asia. The Cox proportional hazard model was used and adjusted hazard ratios (AHR) with 95% confidence intervals (95% CI) were reported. Overall, 3446 preterm neonates were included. The mean age of preterm neonates was 0.65 (1.25) hours and 52% were female. The preterm neonatal mortality rate was 23.3%. The maternal factors predicting preterm neonatal death was any antepartum hemorrhage, AHR 1.99 (1.60-2.47), while neonatal predictors were preterm who received positive pressure ventilation AHR 1.30 (1.08-1.57), temperature <35.5°C AHR 1.18 (1.00-1.39), and congenital malformations AHR 3.31 (2.64-4.16). This study identified key maternal and neonatal predictors of preterm neonatal mortality, emphasizing the need for targeted interventions and collaborative public health efforts to address disparities and regional variations.
PubMed: 38487208
DOI: 10.1177/2333794X241236617 -
Health Technology Assessment... Mar 2024Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during...
BACKGROUND
Pharmacological prophylaxis to prevent venous thromboembolism is currently recommended for women assessed as being at high risk of venous thromboembolism during pregnancy or in the 6 weeks after delivery (the puerperium). The decision to provide thromboprophylaxis involves weighing the benefits, harms and costs, which vary according to the individual's venous thromboembolism risk. It is unclear whether the United Kingdom's current risk stratification approach could be improved by further research.
OBJECTIVES
To quantify the current decision uncertainty associated with selecting women who are pregnant or in the puerperium for thromboprophylaxis and to estimate the value of one or more potential future studies that would reduce that uncertainty, while being feasible and acceptable to patients and clinicians.
METHODS
A decision-analytic model was developed which was informed by a systematic review of risk assessment models to predict venous thromboembolism in women who are pregnant or in the puerperium. Expected value of perfect information analysis was used to determine which factors are associated with high decision uncertainty and should be the target of future research. To find out whether future studies would be acceptable and feasible, we held workshops with women who have experienced a blood clot or have been offered blood-thinning drugs and surveyed healthcare professionals. Expected value of sample information analysis was used to estimate the value of potential future research studies.
RESULTS
The systematic review included 17 studies, comprising 19 unique externally validated risk assessment models and 1 internally validated model. Estimates of sensitivity and specificity were highly variable ranging from 0% to 100% and 5% to 100%, respectively. Most studies had unclear or high risk of bias and applicability concerns. The decision analysis found that there is substantial decision uncertainty regarding the use of risk assessment models to select high-risk women for antepartum prophylaxis and obese postpartum women for postpartum prophylaxis. The main source of decision uncertainty was uncertainty around the effectiveness of thromboprophylaxis for preventing venous thromboembolism in women who are pregnant or in the puerperium. We found that a randomised controlled trial of thromboprophylaxis in obese postpartum women is likely to have substantial value and is more likely to be acceptable and feasible than a trial recruiting women who have had a previous venous thromboembolism. In unselected postpartum women and women following caesarean section, the poor performance of risk assessment models meant that offering prophylaxis based on these models had less favourable cost effectiveness with lower decision uncertainty.
LIMITATIONS
The performance of the risk assessment model for obese postpartum women has not been externally validated.
CONCLUSIONS
Future research should focus on estimating the efficacy of pharmacological thromboprophylaxis in pregnancy and the puerperium, and clinical trials would be more acceptable in women who have not had a previous venous thromboembolism.
STUDY REGISTRATION
This study is registered as PROSPERO CRD42020221094.
FUNDING
This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR131021) and is published in full in ; Vol. 28, No. 9. See the NIHR Funding and Awards website for further award information.
Topics: Humans; Pregnancy; Female; Anticoagulants; Venous Thromboembolism; Cost-Benefit Analysis; Cesarean Section; Postpartum Period; Obesity; Randomized Controlled Trials as Topic
PubMed: 38476084
DOI: 10.3310/DFWT3873 -
Cureus Feb 2024Cerebral aneurysms are rarely encountered in pregnancy. Their antepartum and intrapartum management remain clinically challenging, primarily due to concern regarding...
Cerebral aneurysms are rarely encountered in pregnancy. Their antepartum and intrapartum management remain clinically challenging, primarily due to concern regarding potential rupture. We present a case of a patient in preterm labor at risk for imminent delivery with a 10mm cerebral aneurysm. She was recommended for cesarean section (CS), yet delivered via spontaneous vaginal delivery in the operating room after induction of general anesthesia for the intended CS. Her aneurysm and neurologic function remained intact postpartum. Cerebral aneurysms <5mm are unlikely to undergo significant growth during pregnancy. The presence of a cerebral aneurysm is not automatically a contraindication to the Valsalva maneuver. The recommendation for which patients with unruptured cerebral aneurysms should deliver by CS, operative vaginal delivery, or unassisted vaginal delivery (i.e., which patients should avoid Valsalva maneuver intrapartum), is complex and requires multidisciplinary discussion.
PubMed: 38465162
DOI: 10.7759/cureus.53822