89 Cardiogenic shock in pregnancy: Analysis from the national inpatient sample

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Abstracts / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 6 (2016) 178–252

supplemental calcium) to improve the care of pregnant women. The importance of these intervention lies in the fact that over two-thirds of pregnant women in the two countries receive some form of ANC services, and daily dietary calcium intake is known to be inadequate in Bangladesh. doi:10.1016/j.preghy.2016.08.169

for identifying women at risk for developing PE. Current efforts are now underway to verify the performance of the new test with characterized urine specimens from women who had normative pregnancies or were diagnosed with PE. 1 Towards biomarker-based tests that can facilitate decisions about prevention and management of preeclampsia in lowresource settings. Nathalie Acestor et al, Clin Chem Lab Med. 2016 Jan;54(1):17-27

Clinical science

doi:10.1016/j.preghy.2016.08.170

88 Development of a next-generation point-of-care biomarkerbased diagnostic for detection of preeclampsia

Clinical science

Preeclampsia in low and middle income countries Rebecca Suzanne Barney, Brandon T. Leader, Arthur Lee (Path, Seattle United States) Author: Rebecca Barney, Arthur Lee, Brandon T. Leader. PATH, 2201 Westlake Avenue, Seattle, Washington. Introduction: Accurate and timely diagnosis of women at high risk for preeclampsia (PE) is key to accessing proper interventions and improving clinical outcomes. New biomarkers for PE have shown potential for earlier and more accurate identification of women at increased risk. While a few biomarkers exist in commercially available diagnostics, these products are often expensive and too complex for use outside of a hospital setting. PATH has developed a point-of-care, field-friendly diagnostic for use in lowresource settings, specifically in regional and local antenatal care programs. Objectives: PATH conducted research and development (R&D) to produce a new prototype lateral flow rapid diagnostic test (RDT) for detection of promising preeclampsia biomarker candidates. Methods: Initial biomarker candidates were identified in a previously published landscape analysis.1 Two candidates, one bloodbased and one urinary biomarker, were chosen for laboratory assay development. We selected these biomarkers based on commercial availability of antibodies, existing patents, and potential for achieving functional analytical sensitivity. Enzyme link immunosorbent assays (ELISAs) were first developed for both biomarkers. The most promising ELISA antibody pairs were transferred and optimized for use in a lateral flow RDT format. In parallel to laboratory activities, early commercial due diligence activities were conducted, including outreach to test developers and reagent manufacturers, as well as a patent review to better understand the potential for future commercialization if the current R&D phase was successful. Results: Blood-based biomarker R&D was suspended, as we were unable to obtain the necessary limit of detection (LOD) in ELISA development. Resources were then directed into the development of the urinary biomarker assay. Conversely, laboratory-based R&D on the selected urine-based biomarker has not only successfully progressed through ELISA development, but moved into a lateral flow RDT format. Results of initial evaluations of the performance of the new prototype RDT using synthetic urine or buffer spiked with biomarker analyte demonstrated clinically acceptable LOD for use as an assay to differentiate between normal pregnancies and those at increased risk for developing PE. The next step of active work is to validate the new RDT with forthcoming clinical urine specimens. Conclusions: Commercial and technical due diligence have allowed us to identify a pool of promising PE biomarker candidates to move forward into early R&D based on their potential for adaptation into a low-cost, field-friendly RDT format. To date, our program, supported through USAID’s Saving Lives at Birth award, has been successful in developing a promising new alpha-prototype RDT for a urinary biomarker that could potentially have clinical application

89 Cardiogenic shock in pregnancy: Analysis from the national inpatient sample Medical complications of pregnancy related to hypertensive syndromes Jennifer Banayan a, Sarosh Rana a, Ariel Mueller b, Avery Tung a, Hadi Ramadan a, Zoltan Arany c, Junaid Nizamuddin a, Victor Novack b, Barbara Scavone a, Samuel M. Brown d, Sajid Shahul a (a University of Chicago, Chicago, United States, b Beth Israel Deaconess Medical Center, Boston, United States, c University of Pennsylvania, Philadelphia, United States, d University of Utah, School of Medicine, Utah, United States) Background: A rising proportion of maternal deaths are now attributable to cardiovascular disease. In pregnant women, postpartum cardiomyopathy (PPCM) or amniotic fluid embolism (AFE), and physiological changes of pregnancy such as increased blood volume and cardiac output, decreased systemic vascular resistance, and physiologic anemia may lead to cardiogenic shock (CS). The epidemiology and outcomes of CS during pregnancy are poorly characterized. We analyzed the National Inpatient Sample from 2002 to 2013 to determine the incidence, risk factors and outcomes of CS during pregnancy. Methods and results: Of 52,973,186 antepartum or delivery, and 821,006 postpartum hospitalizations, 2044 were complicated by CS. CS occurred most often in the postpartum period (58.83%) as compared with delivery (23.47%) or antepartum (17.70%). The mortality rate in peripartum women with CS was 18.81% vs 0.2% without CS. Associated factors for CS during the antepartum or delivery period included PPCM, AFE, pulmonary thromboembolism, valvular disease, drug abuse, coagulopathy, fluid/electrolyte disorders, and peripheral vascular disorders. Factors associated with postpartum CS included PPCM, pulmonary thromboembolism, coagulopathy, fluid/electrolyte disorders, valvular disease, drug abuse, stroke, preeclampsia, and renal failure. Factors associated with death included cardiac arrest, renal failure, sepsis, younger age and delayed mechanical circulatory support. In women with CS, the use of mechanical circulatory support increased from 5.38% in 2002 to 14.2% in 2013. The mean time to mechanical support was longest during delivery (10.56 days, 95% CI: 2.55–18.56), followed by postpartum (4.95 days, 95% CI: 3.37–6.53) and antepartum (1.13 days, 95% CI: 0.21–2.06) hospitalizations. Overall, maternal survivors of CS received mechanical circulatory support sooner than those who died (4.36 days, 95%CI: 2.49–6.24 vs 12.46 days, 95%CI: 4.64–20.29, P < 0.001) . In women who received early mechanical circulatory support (defined as 66 days, the mean time to mechanical circulatory support), mortality was considerably less than in women who had increased times (>6 days) to mechanical circulatory support (18.08% vs 38.11%, OR = 0.29, 95% CI 0.1–0.86).

Abstracts / Pregnancy Hypertension: An International Journal of Women’s Cardiovascular Health 6 (2016) 178–252

Conclusions: Although uncommon, CS is increasing during pregnancy, occurs most commonly in the postpartum period and is associated with dramatically higher mortality. The use of mechanical circulatory support in this critically ill population is increasing and early mechanical circulatory support may decrease mortality. Further work is needed to better characterize the causes of death from CS. doi:10.1016/j.preghy.2016.08.171

Clinical science 90 Petograph: Innovative and comprehensive monitoring tool for the integrated management of pre-eclampsia and eclampsia in low resource setting Preeclampsia in low and middle income countries Suleiman Abubakar Tsamiya (Kampala International University, Western-Campus, Ishaka, Uganda) Background: Pre-eclampsia is a form of hypertensive disorder of pregnancy characterized by hypertension, proteinuria and oedema after 20 completed weeks of gestation.It is the second preventable cause of maternal mortality and morbidity. Aim: To develop a universal monitoring tool, for the effective management of pre-eclampsia in low resource setting. Methodology/principle: A. WHAT IS A PETOGRAPH? This is a new monitoring tool, invented to provide integrated graphical presentation of clinical condition of patients diagnosed of preeclampsia–eclampsia, in order to achieve prompt and effective intervention. It is an acronym meaning Pre- Eclamptic TOxaemia GRAPH (PETOGRAPH) B. WHY IS PETOGRAPH INVENTED i.To provide timely and effective care for pre-eclampsia. ii.To improve the quality of care and outcome of pregnant women who develop pre-eclampsia and eclampsia. iii.To provide evidence-based clinical practices in the management of women with pre-eclampsia and eclampsia. iv.To provide information that can effectively guide decision making for early intervention. v.To use the petograph as a data collection tool for Maternal Death Surveillance and Response (MDSR). C.WHERE DO WE USE THE PETOGRAPH 1.Health facility equipped with resources to manage preeclampsia–eclampsia 2.P.E.T (Pre-eclamptic Toxaemia) room 3.Labour room 4.Theatre 5.Antenatal care clinic D. WHO SHOULD USE THE PETOGRAPH 1.Doctors 2.Midwives 3.Clinical officers E. WHEN DO WE OPEN/FILL A PETOGRAPH Petograph is open after making a provisional diagnosis of preeclampsia–eclampsia Criteria for Diagnosis i.Gestational age (weeks of amenorrhea) at least 28 completed weeks (age of viability) ii.Persistent blood pressure of >160/110 mmHg iii.Proteinuria of at least0.3g/24 h iv. Oedema

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F. HOW DOES THE PETOGRAPH WORKS The petograph has eight (8) components 1. Biodata 2. Clinical history 3. Physical findings 4. Investigation results 5. Provisional diagnosis 6. Treatment plan 7. Graph 8. Particulars of the managing clinician Results: Awaiting validation study results currently on going in five secondary and tertiary health centres in Uganda. Report on data collation and analysis to be available by 2nd week of July 2016. Conclusion: To be concluded with validation results. doi:10.1016/j.preghy.2016.08.172

Clinical science 91 Morning and evening home blood pressure among pregnant women Hemodynamics Hirohito Metoki a, Michihiro Satoh a, Takahisa Murakami a, Mami Ishikuro b, Noriyuki Iwama c, Taku Obara d, Masahiro Kikuya b, Takayoshi Ohkubo e, Hidekazu Nishigori d, Nobuo Yaegashi d, Yutaka Imai f, Kunihiko Hoshi g (a Tohoku Medical and Pharmaceutical University, Sendai, Japan, b Tohoku University, Tohoku Medical Megabank Organization, Sendai, Japan, c Osaki Citizen Hospital, Osaki, Japan, d Tohoku University Hospital, Sendai, Japan, e Teikyo University, Tokyo, Japan, f Tohoku University School of Pharmaceutical Sciences, Sendai, Japan, g Suzuki Memorial Hospital, Iwanuma, Japan) Objectives: Home blood pressure is theoretically ideal tool for longitudinal measurement during pregnancy. We previously reported that the home blood pressure was affected by environmental temperature and had stronger association with offspring’s birth weight than conventional blood pressure. In this study we compared morning and evening home blood pressure during pregnancy. Methods: We used database from the BOSHI study which participated pregnant women from October 2006 to September 2011 at a maternity hospital in Miyagi Prefecture, Japan. The participants were asked to measure their own blood pressures every morning and if possible every evening at home while they were pregnant. A linear mixed model was used for analysis of the BP course throughout pregnancy. The SAS package (version 9.4) was used for the statistical analyses. Results: Total 488 pregnant woman was included into the analysis. The average number of days home blood pressure measured was 77.9 days in the morning and 66.3 days in the evening. Home blood pressure values during pregnancy measured in the morning were a little but significantly higher than that measured in the evening (D = 0.9/2.6, P = 0.02/<0.0001 for systolic/diastolic blood pressure). The difference between morning and evening blood pressure values were 1.6/2.9 (95CI: 0.7–2.5/2.2–3.7), 0.3/2.1 (95CI: 0.1 to 0.8/1.7– 2.5), and 0.5/2.0 (95CI: 0.05 to 1.0/1.6–2.5), for 12, 20, and 36 weeks of gestation, respectively. Conclusions: Although systolic blood pressure showed significantly higher values throughout pregnancy, the significant difference weakened in later pregnancy. For diastolic blood pressure, the significant difference during pregnancy remained throughout pregnancy. Because we only compared blood pressure during pregnancy,