Abstract
Results of pregnancies in renal transplanted women from a single centre
V Cararach MD PhD*, S Herrero MD PhD*, J Bellart MD PhD*, F Botet MD PhD* and F Oppenheimer MD PhD†
*Servicio de Medicina Materno-Fetal, Servicio de Neonatología; †Unidad de Transplante Renal, Hospital Clínic-University of Barcelona, Catalonia, Spain
Aim
To compare maternal and perinatals results in two similar periods.
Material and Methods
From 1973 to 2008 a total of 54 pregnancies of 22 or more weeks of gestation were managed in 47 women delivering a total of 57 newborns. Although the obstetrical, neonatal and nephrologic teams have been the same along these years, the medical systems and techniques have changed, and we have divided our cases into two periods: 1 from 1973 to 1991 (n = 29) and 2 from 1992 to 2007 (n = 24). No cases were excluded. In period 1 the immunosuppressive drugs used were Azathioprine and Prednisone, and in period 2 mainly Cyclosporine and Prednisone. Results of the two groups will be compared.
Results
There were no maternal deaths in either of the periods. There were three perinatal deaths, all before 1992. Three babies (13.8%) in period 1 and two (11.5%) in period 2 were delivered before 32 weeks and 15 (51.7%) vs 11 (42.3%) before 37 weeks. Fifteen newborns (51.7%) in period 1 and 11 (52.0%) in period 2 weighed less than 2500. There were more PROM cases in period 1, and more preeclampsia and IUGR in period 2. Evolution of creatinine during pregnancy looks similar in both periods but after three or more years the increase in creatinine values was bigger in period 2.
Conclusion
Perinatal results are better in the second period, but the increase found in creatinine levels is of concern on renal function in this period.
The timely management of a phaeochromocytoma in pregnancy: series of three cases
Anita Banerjee*, Andrew McCarthy †, Vinnie Sodhi*, Bill Fleming*, Karim Meeran* and Catherine Williamson*
*Hammersmith Hospital; †Queen Charlotte's Hospital (Hammersmith Hospital), London, UK
Case report
We report three cases of phaeochromocytoma in pregnancy. Medical management was utilized for up to 16 weeks and surgical removal of the tumour was deferred in all cases until five to eight weeks postpartum. All cases had good maternal and fetal outcomes.
A 30-year-old woman presented with labile blood pressure (BP) at 24 weeks of gestation. Noradrenaline levels were elevated in the 24-hour urine samples to 4470 nmol/24 hour. Abdominal ultrasound demonstrated a 5.2 × 5.7 cm mass. She was rehydrated with intravenous fluids and treated with phenoxybenzamine and propanolol. An elective caesarean section at 37.5 weeks, under continued alpha and beta-blockade, resulted in a normotensive baby girl. Adrenalectomy was performed five weeks postpartum.
A 38-year-old woman presented with labile BP at 19 weeks of gestation. Noradrenaline levels were elevated in the 24-hour urine samples to 1130 nmol/24 hour. A magnetic resonance image scan demonstrated a 14.7 × 10 cm mass displacing the left kidney.
She was rehydrated with intravenous fluids and treated with phenoxybenzamine and propanolol. Caesarean section at 35 weeks was performed under intravenous alpha and beta-blockade. This resulted in a normotensive baby girl. Adrenalectomy was performed six weeks postpartum.
A 28-year-old woman was shown to have a right adrenal mass on routine obstetric ultrasound at 20 weeks of gestation. Noradrenaline levels were elevated in the 24-hour urine samples to 2286 nmol/24 hour. She was rehydrated with intravenous fluids. She was brought to our care at 37 weeks and remained on intravenous alpha-blockade until delivery a week later. Laparoscopic adrenalectomy was performed two months postpartum.
Points for discussion
Pharmacological treatment of phaeochromocytoma in pregnancy; Optimal timing of phaeochromocytoma surgery in patients who were diagnosed
pregnant.
The applicability of a novel clinical classification of preeclampsia
Claire Parker BSc*, M Antoine BSc† and B Walters FRACP FRANZCOG*
*The University of Western Australia; †King Edward Memorial Hospital, Western Australia
The term ‘preeclampsia’ is used as a unitary diagnosis. There is no agreed division into subsets. Nevertheless, there are several clinically recognizable types that are included under the rubric ‘preeclampsia’. The aim of this study was to test whether a system that categorizes cases of preeclampsia into subsets is applicable in the clinical setting.
Objectives and methods
The case-notes of 100 women with preeclampsia were examined to determine whether it
was possible to apply a classification that utilized the following descriptive
categories of preeclampsia. Each case was allocated to one category. An operating
definition of each of these clinical types was used and tested against each case:
Chronic progressive preeclampsia; Relapsing remitting preeclampsia; Acute fulminating preeclampsia.
Results
It was found that the classification was applicable to cases diagnosed as preeclampsia and that it was possible to allocate all cases to one of the defined categories.
Conclusion
Further research is necessary to determine whether this clinical heterogeneity in preeclampsia is indicative of aetiological or pathogenetic differences. To regard preeclampsia as a single undifferentiated diagnostic entity may not be appropriate.
Remote blood pressure monitoring in pregnant women with chronic kidney disease: preliminary results from the pregnancy and kidney disease (prekid) clinic
Reem Asad MD, Johannes Keunen MD PhD and Michelle Hladunewich MD BSc(Med) MSc FRCP(C)
Mount Sinai Hospital, University of Toronto, Canada
Background
Hypertensive disorders of pregnancy lead to serious maternal and fetal outcomes. Adequate blood pressure (BP) control is essential as both hypertension and hypotension can lead to adverse outcomes. BP variation throughout pregnancy may render this task challenging and close monitoring is required in high-risk patients with underlying kidney disease. Telehealth, including Telemonitoring and Telemanagement, is a rapidly evolving field with promising results in various medical conditions including chronic hypertension. Transient use in this special high-risk population is novel.
Methods
This is a descriptive cohort study of high-risk pregnant patients offered home BP monitoring devices (LifeStat, Saskatchewan Drive, Regina, SK Canada). Readings were transmitted using bluetooth technology via the phone line to a secure website. Interval and frequency of monitoring was increased as indicated. Changes in medications were advised via email or telephone. The target BP was set between 120–140 mmHg systolic and 70–90 mmHg diastolic. BP control, as well as fetal and maternal outcomes, is described.
Results
Eight patients (age range: 28–37 years) with pre-existing kidney disease were given remote monitors. All were on anti-hypertensive therapy prior to pregnancy and had proteinuria. Aetiologies of kidney disease included immunoglobulin A nephropathy, focal segmental glomerulosclerosis (FSGS), Type 1 diabetes, lupus nephritis, reduced glomerular filtration rate due to childhood hemolytic uremic syndrome (HUS) and reflux. To date, a total of 1510 home BP readings were obtained for the cohort versus a total of 60 clinic BP readings. Systolic and diastolic BP measurements were within the set-target at an average of 64.9% and 71.9% of time, respectively. Out-of-target values were reviewed and intervention took place as appropriate and the majority of patients had BP medications adjusted at least twice remotely. The mean gestational age was 36.8 ± 2.4 weeks and the mean gestational birth weight was 2630 ± 702 g.
Conclusion
Telemonitoring of hypertensive disorders in pregnancy is reliable and accurate. Close monitoring and adequate BP control was possible at different stages of pregnancy. In this group of high-risk patients, the average gestational age and weight at delivery appeared to be higher than values historically described in the literature. However, future studies are required to definitively determine the benefit of utilizing this technology in BP control, preservation of renal function, and reduction of adverse maternal and fetal outcomes.
Hypertensive disorders of pregnancy requiring ICU admission: 10-year retrospective study
Carlos Verissimo, Jorge Costa, Irina Ramilo, Teresa Matos, Isabel Santos and Isilda Rocha
Hospital Fernando Fonseca, Lisbon, Portugal
Introduction
Obstetric patients requiring admission to an intensive care unit (ICU) are not frequent but they challenge clinical expertise. Hypertensive disorders of pregnancy (HDP) are a heterogeneous group of diseases that impose severe maternal, fetal and neonatal mortality, and morbidity. Critical care offers the possibility of continuous monitoring and direct intervention. Several severity indices (APACHE IV, SAPS II, etc.) assess the predicted mortality, and length of stay (LOS) in ICU.
Objectives
This study aims at presenting a comprehensive analysis of HDP patients requiring ICU admission in our institution in a 10-year period.
Materials and methods
Retrospective study – all ICU admissions during pregnancy or after delivery were included between 1997 and 2006. Each case was studied for medical history, clinical picture, diagnosis, route of delivery, neonatal results, evolution, complications, interventions, morbidity and mortality. Retrospective application of APACHE IV, APS, SAPS II and SAPS II expanded. HELLP syndrome with normal blood pressure was excluded. Analysis was performed with SPSS (SPSS, Inc., Chicago, IL).
Results
There were 49,833 deliveries. ICU admissions: during pregnancy – three (0.01%); postpartum – 147 (0.29%). All admissions due to HDP (69) occurred after delivery. Diagnosis: eclampsia – nine; severe preeclampsia – 44; mild preeclampsia – 16; HELLP syndrome superimposed 71% of HDP cases. Maternal age: 29.8 + 6.3 years; gestational age (at delivery): 33.2 + 4.3 weeks. Route of delivery: C-section – 90% (52% ASA III); spontaneous – 10%. Multiple pregnancy: 7%. Severity indices: APACHE IV – 47.1 + 13.0; APS – 46.6 + 12.6; SAPS II – 22.1 + 5.3; SAPS II expanded – 3.4 + 0.8. ICU LOS: predicted – APACHE IV: 3.3 + 1.3 days; actual – 3.7 + 2.6. Interventions: mechanical ventilation – 0.6 + 0.5 days; transfusion therapy – 4.5 + 3.2 U/patient; indwelling arterial line – 30%; CVC – 17%; thoracocentesis – 1%; hysterectomy – 1% (due to postpartum haemorrhage). Complications: 31 events in 24 patients; acute renal failure (7%); pleural effusion (6%); HELLP syndrome (4%); eclampsia (1%). Mortality: predicted – APACHE IV: 3.1 + 3.1%; SAPS II: 2.3 + 3.3%; actual – 0%. Neonatal results: stillbirths – 4%; APGAR index 1′ – 6.8 + 2.4; 5′ – 8.4 + 2.2; 10′ – 8.8 + 2.1); weight: 1880 + 792 g.
Discussion and conclusion
Early recognition, thorough evaluation and prompt treatment are crucial to achieve favourable maternal outcome. Multidisciplinary approach is essential. There was no mortality in our series.
Acute pulmonary oedema as a complication of hypertension during pregnancy: the use of individual patient data to ascertain rates and associated factors
Charlene Thornton MScMed*, Peter von Dadelszen PhD†, Angela Makris PhD‡, Jane Tooher MPH‡, Robert Ogle MD§ and Annemarie Hennessy PhD*
*University of Western Sydney; †British Columbia Women's Hospital and Health Centre; ‡Heart Research Institute; §Royal Prince Alfred Women and Babies, Sydney, Australia
Background
Rapid onset interstitial fluid accumulation in the lungs, acute pulmonary oedema, is a potential complication of maternal hypertension, seen particularly in women with preeclampsia and eclampsia, and more commonly occurring in those women delivering via caesarean section. Endothelial damage, and resulting fluid leakage into the alveolar space, probably underlies the development of acute pulmonary oedema in these women. Acute pulmonary oedema has also been linked to increased maternal age, body mass index, parity, undiagnosed cardiomyopathy, multiple gestation, corticosteroid use, colloid therapy and β-sympathomimetic use. Iatrogenic causes linked to non-restrictive intravenous crystalloid fluid administration policies have also been noted. The negative inotropic effect attributed to commonly used anti-hypertensive medications in the obstetric setting, such as nifedipine and labetalol, has also been questioned as a contributing factor in the development of acute pulmonary oedema.
Objectives
To determine the rates of acute pulmonary oedema among women with hypertension during pregnancy in two tertiary referral centres in Australia and Canada.
Methods
Individual patient data were collated utilizing the ICD-10 coding for 2005. Data obtained from this review were analysed utilizing SPSS (SPSS, Inc., Chicago, IL) v.14®, with statistical significance assumed for P values < 0.05.
Results
There were no women with acute pulmonary oedema in the Australian unit. Nineteen women were diagnosed with acute pulmonary oedema in the Canadian unit. These women delivered at earlier gestations (36.7 and 37.3 weeks, respectively, P = 0.014) via caesarean section (68% compared with 44%, P = 0.034), following unsuccessful attempts to induce labour (70% and 31%, respectively, P = 0.031), received larger quantities of intravenous fluids (median 9210 mL compared with 5200 mL, P < 0.001) and had a longer hospital stay than the remainder of the cohort (7.3 days compared with 5.9 days, P = 0.048).
Conclusion
The development of acute pulmonary oedema in women with hypertension during pregnancy is associated with high levels of intravenous fluid administration, induction of labour and caesarean section.
Every day at least one woman dies in Brazil due to preeclampsia
Nelson Sass, Leandro Oliveira, Maria Mesquita, Fernanda Gonçalves, Fernanda Araujo, Fernanda Rodrigues, Jussara Sato, Thais Facca, Francisco Sousa and Maria Torloni
Federal University of São Paulo, São Paulo, Brazil
Introduction
Maternal mortality (MM) rate is an important indicator of health-care quality. Hypertensive disorders in pregnancy remain an important cause of MM in Brazil. Why is this condition so dangerous and what can be done to change the situation?
Methods
Assessment of all maternal deaths reported by the Brazilian Health Ministry from 1996
to 2005. Data were obtained from the following websites:
Results
Table 1 shows the MM rates and the proportion of hypertension in pregnancy (HP) from the total deaths.
Conclusion
Despite the efforts to reduce this reality, there are many difficulties to reach the ideal rates. Brazil is a very large country with intense regional differences. The north and north-west regions have higher MM rates than south, but the general Brazilian MM rates have remained unchanged during the last 10 years and approximately one-quarter of the total deaths are related to HP. The antenatal care system has to provide a safety net placed around pregnant women, mainly for those at risk, for example by increasing the number of antenatal check-ups. Obstetricians, midwives and family practitioners need clear guidelines and regional coordinating centres in order to recognize early signs of preeclampsia to offer adequate antenatal screening and efficient management of severe preeclampsia.
The impact of platelet function assessment during aspirin prophylaxis on the incidence of preeclampsia: a retrospective study
Evelyne Rey and Georges-Etienne Rivard
CHU Sainte-Justine, Montreal, Canada
Objectives
To study the impact of platelet function assessment on the risk of preeclampsia (PET) in pregnant women under low-dose aspirin.
Methods
This is a retrospective study including women followed and delivered in our centre between 1 January 2001 and 31 December 2006. The inclusion criteria were: delivery after 20 weeks gestation, single fetus, absence of fetal malformation and chromosomal abnormality, and one or more of the following: pre-existing hypertension, type 1 or 2 diabetes, previous PET or intrauterine death (IUD). Platelet function assessment (PFA) was determined using PFA-100 (Siemens Healthcare). Aspirin dose was adjusted according to PFA result.
Results
Five hundred and twenty-four women met the inclusion criteria: 324 did not use aspirin (no ASA), 100 used ASA but did not have a PFA (ASA–no PFA) and 100 used ASA and had a PFA (ASA–PFA). Numbers of women who were multiparous, had previous PET or IUD, and used antihypertensive drugs before pregnancy were higher in women using ASA. There was no difference in maternal characteristics between the ASA–no PFA and ASA–PFA groups. The incidence of PET was 35%, 34% and 12% in the no ASA, ASA–no PFA and ASA–PFA groups, respectively (P < 0.0001 across the 3 groups and P < 0.0001 between the ASA–PFA group compared with the other groups). After adjusting for parity, ethnicity, previous PET or IUD, use of vitamins before 20 weeks and time interval since last pregnancy, the incidence of PET remained statistically different across the three groups (P = 0.001) and between the ASA–PFA group and the no ASA group (0.008) and the ASA–no PFA group (0.001).
Conclusion
Prospective studies should be performed to confirm the impact of assessing platelet function in pregnant women under low-dose aspirin.
Guidelines for the management of hypertensive disorders in pregnancy, 2008: the Australian and New Zealand perspective
Barry N J Walters FRACP FRANZCOG*, Mark A Brown MBBS FRACP MD†, Lawrence P McMahon MD BS FRACP‡§, Gustaaf Dekker MD PhD FRANZCOG DCOG**††, George Jack Mangos MBBS MD‡‡, Stephen Gatt MOM OAM§§, Peter Muller MD FACOG FRANZCOG***, M Peter Moore MB CHB FRACP†††, Claire McLintock MD FRACP FRCPA‡‡‡, Michael Paech MBBS DRCOG§§§**** and Sandra Lowe MBBS (Hons) FRACP MD††††
*King Edward Memorial Hospital for Women; †St George Hospital, Kogarah, Sydney; ‡University of Melbourne, Victoria; §Western Hospital, Victoria; **The University of Adelaide; ††Lyell McEwin Hospital; ‡‡University of New South Wales, Sydney; §§Prince of Wales and Sydney Children's Hospitals, Randwick; ***Women's and Children's Hospital, South Australia, Australia; †††Christchurch Hospital; ‡‡‡University of Auckland, New Zealand; §§§The University of Western Australia, Perth; ****King Edward Memorial Hospital for Women and Royal Perth Hospital; ††††University of NSW, Australia
In Australia and New Zealand, care of pregnant women occurs in a range of settings from home-based midwifery services to tertiary referral hospitals. In 1993 and again in 2000, the Australasian Society of Hypertension in Pregnancy issued a consensus statement to guide clinicians in the diagnosis and management of preeclampsia and chronic hypertension. Subsequently, similar documents have been produced in North America, Europe and the UK.
In 2008, the Society of Obstetric Medicine of Australia and New Zealand (SOMANZ) is
publishing an updated set of guidelines aiming to improve the diagnosis and
management of hypertensive disorders of pregnancy. A number of controversial areas of
diagnosis and management are addressed in these guidelines including: Automated blood pressure measurement devices; Diagnosing proteinuria; Investigation of conditions associated with preeclampsia, e.g.
thrombophilias; Diagnosis and management of severe hypertension; Temporizing management for preeclampsia; Drugs for the treatment of hypertension in pregnancy; Other aspects of treatment for preeclampsia, e.g. thromboprophylaxis, fluid
therapy; Fetal surveillance in women with hypertensive disorders; Anaesthetic considerations; Preconception considerations; Auditing outcomes.
Although, there are differences in practice across the world, this ISSHP
meeting presents an opportunity to debate the applicability of these guidelines to
other countries.
An unusual case of breathlessness in pregnancy
K D Lambert BSc MBChB MRCP*, S Barnes MBBS MRCOG† and M Dhanjal BSc MBBS DFFP MRCOG†
*Queen Alexandra Hospital, Portsmouth; †Queen Charlotte Hospital, London, UK
We present a rare case of pregnancy in a woman with a treated intrapulmonary teratoma. A 34-year-old primigravida was diagnosed, 11 years previously, with a large mediastinal mature differentiated teratoma. This was non-responsive to cisplatin, requiring left lung upper lobectomy and reconstruction of the pericardium with porcine tissue. After surgery she remained breathless and easily fatigued, with an exercise tolerance of one flight of stairs. Two years prior to pregnancy her lung function tests reported 60% of the predicted values due to both the lobectomy and resulting left phrenic nerve paralysis. Her gas transfer was normal.
During the pregnancy she was monitored with monthly PEFR and serial growth scans. She was admitted at 22 weeks with complaints of breathlessness associated with chest pain. Investigations for this were negative. Spirometry showed 50% predicted forced expiratory volume in one second (1.85 L) and vital capacity (2.25 L). She was reassured and discharged, remaining stable throughout the remainder of pregnancy.
She was anxious regarding her capacity of delivery. Anaesthetic review recommended regional analgesia, as this would facilitate an active second stage, and discouraged diamorphine use due to its respiratory depressant effects. She was reassured that there were no contraindications to normal vaginal delivery.
This case highlights that pregnant women with dramatically reduced lung function can remain active and achieve term vaginal delivery if they have normal lungs, which is often not the case in severe cystic fibrosis and restrictive lung diseases. This is also the first reported case of a pregnancy with a previous lung teratoma.