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W11.4 Termination of pregnancy on maternal indications
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State of the Art Lectures, Plenary Presentations and Oral Communications / Pregnancy Hypertension 1, Supplement 1 (2010) S1–S41
the patients should be accepted life support in the intensive care unit to reduce the fatality rate, respectively. Large samples are need for further application study.
W11.3 Eclampsia: experience of 47 cases in rural Tanzania Shamil Cooray 1 , Sumudu Samarasekera 1 , Sally Edmonds 2 , Clare Whitehead 1 , Stephen Tong 1 . 1 Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia; 2 Tuele Hospital, Muheza, Tanzania Background: Eclampsia is a major killer of pregnant women in the developed world and Tanzania has one of the highest rates of maternal mortality worldwide. Early recognition and treatment of pre-eclampsia may help prevent maternal mortality and morbidity. Aim: To characterise the presentation of eclampsia in rural Tanzania. Methods: A prospective study of all women presenting with eclampsia at Muheza District Designated Hospital, in rural north-east Tanzania, between May 2007 and April 2008. Results: 47 women presented with eclampsia during the study period. Three women died and there were eight perinatal deaths. 89% of women were booked and had received antenatal care. Maternal demographics are shown in Table 1. 53% of seizures occurred antepartum, 13% intrapartum and 34% postpartum (up to 13 days post delivery). Only six percent of patients were diagnosed with severe pre-eclampsia prior to seizure and 63% percent of seizures occurred out of hospital. 20% were asymptomatic prior to seizure. Prodromal symptoms present included headache (78%), visual disturbance (44%), epigastric pain (20%), and nausea and vomiting (2%). 62% of patients received treatment with magnesium sulphate, 35% received concurrent diazepam and 33% received only diazepam. Hypertension was treated with hydralazine in 74% of cases. Table 1. Maternal demographics of 47 women presenting with eclampsia Age (years) Nulliparity (n) Past history of pre-eclampsia (n) Malaria in pregnancy (n) Systolic BP (mmHg) Diastolic BP (mmHg) Birthweight (kg) Gestational age at delivery
22 (16–42) 28 5 14 160 (110-230) 104 (70-140) 2.8 (1.5-4.5) 36 (24-40)
There were two women admitted to the ICU and there was one case of eclampsia. There were no neonatal survivors. Conclusion: Over a period of five years there were 26 cases of termination for maternal indications in one of the ten tertiary perinatal clinics in The Netherlands. For hypertensive disorders alone there were 14 cases. There is need for a medical and legal framework that guides meticulous decision making and uniform reporting of these cases.
W11.5 Invasive versus non-invasive monitoring of acute severe hypertension in women with pre-eclampsia Eduard Langenegger, Sangieta Dalla, Greg Petro, David Hall. University of Stellenbosch, South Africa Objective: The aim of this study was to compare the accuracy of two non-invasive methods of blood pressure measurement with intra-arterial measurement in women with pre-eclampsia and acute severe hypertension. Methods: This descriptive, cross-sectional study, prospectively enrolled 23 women with confirmed pre-eclampsia and acute severe hypertension for continuous intra-arterial blood pressure monitoring. Simultaneous monitoring was performed with a manual and an automated, non-invasive device during episodes of acute severe hypertension. The paired T-test was used to compare measured values. The accuracy of a MAP ≥ 125 mmHg in detecting a systolic blood pressure ≥160 mmHg was also determined. Results: There was poor correlation between intra-arterial and automated as well as intra-arterial and manual systolic values (r=0.3441, p<0.005; r=0.4112, p< .001 respectively). Better correlation was found amongst diastolic values. The differences between the mean intra-arterial (94±11 mmHg) and automated (96±12 mmHg) values as well as intra-arterial and manual diastolic measurements (94±14 mmHg), were not significant (p=0.20; p=0.65 respectively). A mean arterial pressure ≥125 mmHg was not accurate in detecting a systolic value ≥160 mmHg, with low sensitivities (17.2 - 35.9%) and specificities (0 - 50%) for all three methods. Conclusions: When compared to intra-arterial monitoring, the automated and manual methods showed poor correlation with systolic but better correlation with diastolic values. A mean arterial pressure ≥ 125mmHg was not accurate in detecting systolic peaks. When protection against cerebral haemorrhage is paramount, intra-arterial measurement of systolic values is best.
W13.1 Conclusions: In this study eclampsia was rarely proceeded by the diagnosis of severe pre-eclampsia. In 20% of women seizures occurred as the first sign of pre-eclampsia, without other prodromal symptoms. This presents a challenge for the prevention of preeclampsia in both the developing and developed world.
Being born small programs fetal growth restriction and a nephron deficit in the next generation in the absence of maternal hypertension in pregnancy
W11.4
Background: Intrauterine growth restriction caused by uteroplacental insufficiency increases the risk of adult cardiovascular disease. We have shown that growth restriction is associated with a nephron deficit in males and females, with hypertension in males only at 6 months. Females have increased uterine arterial wall stiffness, which may restrict uterine blood flow, altering fetal development, providing mechanistic pathways for intergenerational programming. Our aim was to explore whether growth restriction and nephron deficits associated with F1 growth restriction are evident in the next (F2) generation and whether maternal hypertension was evident in pregnancy. Methods: Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted, R) or sham surgery (Control, C) on day 18 of pregnancy in WKY rats (F0). F1R and F1C females (F1) were mated with normal males. Fetal and placental weights and nephron number (unbiased stereology) were measured in F2 offspring at 20 days gestation and maternal blood pressure (tail cuff) measured at 18 days gestation. Results: F1 female blood pressure prior to and in pregnancy was not different between groups nor was maternal body, heart or kidney weights. F2R female, but not male fetuses were smaller than controls (p<0.05) with no differences in placental weight. F2R male fetuses had 20% fewer nephrons (606±35) compared to F2C (764±44) (n=3/group; p<0.05, female analyses ongoing). Conclusions: Our study demonstrates that nephron deficits programmed by uteroplacental insufficiency are transmitted to the next generation of male offspring. Alterations in maternal blood pressure during pregnancy were not associated with this intergenerational programming.
Termination of pregnancy on maternal indications Leonoor van Eerden 1 , Annemieke Bolte 1 , Gerda Zeeman 2 . 1 VU Medical Center, The Netherlands; 2 University Medical Center Groningen, The Netherlands Background: Very early onset preeclampsia and other maternal indications, such as sepsis or severe hemorrhage, could justify termination of pregnancy at the limits of fetal viability. In The Netherlands there is no national protocol concerning termination of pregnancy for maternal indications, also there is an unsure obligation to report a case. Objective: The objective of this study is to make an inventory of all terminations of pregnancy for maternal indications in The Netherlands between 20 and 26 weeks’ gestation. We will distinguish between the different indications for which the termination took place. In the hypertension group a subgroup analysis will be made. Primary endpoint is the maternal outcome. Secondary outcome is the fetal outcome. Methods: We conducted a retrospective chart review in The VU Medical Centre, one of the ten tertiary perinatal clinics in The Netherlands. We reviewed all cases between 2000 and 2004 where termination of pregnancy for maternal indications took place before 26 weeks’ gestation. Results: There were 26 cases of termination for maternal indications. In 14 of these cases termination was performed for hypertensive disorders, 10 cases for maternal sepsis and 2 cases for other indications. In the hypertension group intrauterine growth restriction was suspected in 8 cases. Birthweight was below 500 grams in 7 cases (range 285-649 grams).
Mary Wlodek 1 , Linda Gallo 1 , Marc Mazzuca 1 , Luise Cullen-McEwen 2 , Karen Moritz 3 . 1 The University of Melbourne, Australia; 2 Monash University, Australia; 3 University of Queensland, Australia
State of the Art Lectures, Plenary Presentations and Oral Communications / Pregnancy Hypertension 1, Supplement 1 (2010) S1–S41
the patients should be accepted life support in the intensive care unit to reduce the fatality rate, respectively. Large samples are need for further application study.
W11.3 Eclampsia: experience of 47 cases in rural Tanzania Shamil Cooray 1 , Sumudu Samarasekera 1 , Sally Edmonds 2 , Clare Whitehead 1 , Stephen Tong 1 . 1 Department of Obstetrics and Gynaecology, Monash University, Clayton, Australia; 2 Tuele Hospital, Muheza, Tanzania Background: Eclampsia is a major killer of pregnant women in the developed world and Tanzania has one of the highest rates of maternal mortality worldwide. Early recognition and treatment of pre-eclampsia may help prevent maternal mortality and morbidity. Aim: To characterise the presentation of eclampsia in rural Tanzania. Methods: A prospective study of all women presenting with eclampsia at Muheza District Designated Hospital, in rural north-east Tanzania, between May 2007 and April 2008. Results: 47 women presented with eclampsia during the study period. Three women died and there were eight perinatal deaths. 89% of women were booked and had received antenatal care. Maternal demographics are shown in Table 1. 53% of seizures occurred antepartum, 13% intrapartum and 34% postpartum (up to 13 days post delivery). Only six percent of patients were diagnosed with severe pre-eclampsia prior to seizure and 63% percent of seizures occurred out of hospital. 20% were asymptomatic prior to seizure. Prodromal symptoms present included headache (78%), visual disturbance (44%), epigastric pain (20%), and nausea and vomiting (2%). 62% of patients received treatment with magnesium sulphate, 35% received concurrent diazepam and 33% received only diazepam. Hypertension was treated with hydralazine in 74% of cases. Table 1. Maternal demographics of 47 women presenting with eclampsia Age (years) Nulliparity (n) Past history of pre-eclampsia (n) Malaria in pregnancy (n) Systolic BP (mmHg) Diastolic BP (mmHg) Birthweight (kg) Gestational age at delivery
22 (16–42) 28 5 14 160 (110-230) 104 (70-140) 2.8 (1.5-4.5) 36 (24-40)
There were two women admitted to the ICU and there was one case of eclampsia. There were no neonatal survivors. Conclusion: Over a period of five years there were 26 cases of termination for maternal indications in one of the ten tertiary perinatal clinics in The Netherlands. For hypertensive disorders alone there were 14 cases. There is need for a medical and legal framework that guides meticulous decision making and uniform reporting of these cases.
W11.5 Invasive versus non-invasive monitoring of acute severe hypertension in women with pre-eclampsia Eduard Langenegger, Sangieta Dalla, Greg Petro, David Hall. University of Stellenbosch, South Africa Objective: The aim of this study was to compare the accuracy of two non-invasive methods of blood pressure measurement with intra-arterial measurement in women with pre-eclampsia and acute severe hypertension. Methods: This descriptive, cross-sectional study, prospectively enrolled 23 women with confirmed pre-eclampsia and acute severe hypertension for continuous intra-arterial blood pressure monitoring. Simultaneous monitoring was performed with a manual and an automated, non-invasive device during episodes of acute severe hypertension. The paired T-test was used to compare measured values. The accuracy of a MAP ≥ 125 mmHg in detecting a systolic blood pressure ≥160 mmHg was also determined. Results: There was poor correlation between intra-arterial and automated as well as intra-arterial and manual systolic values (r=0.3441, p<0.005; r=0.4112, p< .001 respectively). Better correlation was found amongst diastolic values. The differences between the mean intra-arterial (94±11 mmHg) and automated (96±12 mmHg) values as well as intra-arterial and manual diastolic measurements (94±14 mmHg), were not significant (p=0.20; p=0.65 respectively). A mean arterial pressure ≥125 mmHg was not accurate in detecting a systolic value ≥160 mmHg, with low sensitivities (17.2 - 35.9%) and specificities (0 - 50%) for all three methods. Conclusions: When compared to intra-arterial monitoring, the automated and manual methods showed poor correlation with systolic but better correlation with diastolic values. A mean arterial pressure ≥ 125mmHg was not accurate in detecting systolic peaks. When protection against cerebral haemorrhage is paramount, intra-arterial measurement of systolic values is best.
W13.1 Conclusions: In this study eclampsia was rarely proceeded by the diagnosis of severe pre-eclampsia. In 20% of women seizures occurred as the first sign of pre-eclampsia, without other prodromal symptoms. This presents a challenge for the prevention of preeclampsia in both the developing and developed world.
Being born small programs fetal growth restriction and a nephron deficit in the next generation in the absence of maternal hypertension in pregnancy
W11.4
Background: Intrauterine growth restriction caused by uteroplacental insufficiency increases the risk of adult cardiovascular disease. We have shown that growth restriction is associated with a nephron deficit in males and females, with hypertension in males only at 6 months. Females have increased uterine arterial wall stiffness, which may restrict uterine blood flow, altering fetal development, providing mechanistic pathways for intergenerational programming. Our aim was to explore whether growth restriction and nephron deficits associated with F1 growth restriction are evident in the next (F2) generation and whether maternal hypertension was evident in pregnancy. Methods: Uteroplacental insufficiency was induced by bilateral uterine vessel ligation (Restricted, R) or sham surgery (Control, C) on day 18 of pregnancy in WKY rats (F0). F1R and F1C females (F1) were mated with normal males. Fetal and placental weights and nephron number (unbiased stereology) were measured in F2 offspring at 20 days gestation and maternal blood pressure (tail cuff) measured at 18 days gestation. Results: F1 female blood pressure prior to and in pregnancy was not different between groups nor was maternal body, heart or kidney weights. F2R female, but not male fetuses were smaller than controls (p<0.05) with no differences in placental weight. F2R male fetuses had 20% fewer nephrons (606±35) compared to F2C (764±44) (n=3/group; p<0.05, female analyses ongoing). Conclusions: Our study demonstrates that nephron deficits programmed by uteroplacental insufficiency are transmitted to the next generation of male offspring. Alterations in maternal blood pressure during pregnancy were not associated with this intergenerational programming.
Termination of pregnancy on maternal indications Leonoor van Eerden 1 , Annemieke Bolte 1 , Gerda Zeeman 2 . 1 VU Medical Center, The Netherlands; 2 University Medical Center Groningen, The Netherlands Background: Very early onset preeclampsia and other maternal indications, such as sepsis or severe hemorrhage, could justify termination of pregnancy at the limits of fetal viability. In The Netherlands there is no national protocol concerning termination of pregnancy for maternal indications, also there is an unsure obligation to report a case. Objective: The objective of this study is to make an inventory of all terminations of pregnancy for maternal indications in The Netherlands between 20 and 26 weeks’ gestation. We will distinguish between the different indications for which the termination took place. In the hypertension group a subgroup analysis will be made. Primary endpoint is the maternal outcome. Secondary outcome is the fetal outcome. Methods: We conducted a retrospective chart review in The VU Medical Centre, one of the ten tertiary perinatal clinics in The Netherlands. We reviewed all cases between 2000 and 2004 where termination of pregnancy for maternal indications took place before 26 weeks’ gestation. Results: There were 26 cases of termination for maternal indications. In 14 of these cases termination was performed for hypertensive disorders, 10 cases for maternal sepsis and 2 cases for other indications. In the hypertension group intrauterine growth restriction was suspected in 8 cases. Birthweight was below 500 grams in 7 cases (range 285-649 grams).
Mary Wlodek 1 , Linda Gallo 1 , Marc Mazzuca 1 , Luise Cullen-McEwen 2 , Karen Moritz 3 . 1 The University of Melbourne, Australia; 2 Monash University, Australia; 3 University of Queensland, Australia