Preeclampsia (PE) is a pregnancy-specific condition and isassociated with high maternal mortality and morbidity as well as risk ofperinatal death, preterm birth, and intrauterine growth restriction.It occurs in 4 to 7 per cent of pregnant women worldwide. Theetiology of preeclampsia remains unclear despiteextensive research. The clinical pathway of severe pre-eclampsia may be correlatedwith progressive deterioration in both maternal and fetal outcomes. Thus,because delivery is the only wayof arresting the disease, there is broadagreement on delivery in the presence of multi-organ dysfunction, fetaldistress or once a gestation of 34 weeks has been reached.1) Ganesh KS et al in case-control study conducted atDistrict Lady Goschen Hospital Kannadadistrict, Karnataka, South India in 2016, comprised of 100 pregnant women with pre-eclampsia as cases and 100 controls werethose pregnant women without pre-eclampsia. It reviews that riskof pre-eclampsia needs to be identified early and high-quality antenatal careshould be provided for better maternal and fetal outcomes by minimizingcomplications.2) Mooij et al in aretrospective medical record study that was performed in Ndala Hospital,Tanzania for a period of July 2011 and December 2012 including patientsdiagnosed with severe pre-eclampsiaor eclampsia.
Out of the 3398 deliveries, 26 were diagnosed with severe pre-eclampsia and 55 witheclampsia (0.8 and 1.6 %) along with 6 maternal deaths in patients diagnosedwith eclampsia (case fatality rate 11 %). Eclampsia convulsions were categorised as antepartum (44 %),intrapartum (42 %) and postpartum (15 %). About 100 % of eclampsia patients with convulsions were effectivelytreated with Magnesium.
It concludes that 2.4 % of women were diagnosed withsevere pre-eclampsia or eclampsia. Significantly better outcomes can beachieved by effective management of hypertension and starting induction of labourat the earliest indication.
3) Singh A et al in this retrospective, observationalstudy of pre-eclampsia diagnosed patients for a period of three years (2012 to2014) at a tertiary care hospital of Delhi. It results in analysis of 224patients of total of which 40% were booked and 76.8% cases were of age group21-30 years, with 58.9% primigravida patients. About 82.1% with gestational ageof ?34 weeks and 5.4% were below 30 weeks.
LSCS (lower segment cesareansection) was performed in 14.2% severe pre-eclampsia patients and 7.2% mildpre-eclampsia cases. The most common complication was prematurity in about67.9% of cases, followed by birth asphyxia in 21.
4% of patients and perinatalmortality in 12.5% cases. Partial HELLP and HELLP were observed in 37.5% ofpatients, eclampsia in 1.8% patients; other complications included DIC(disseminated intravascular coagulation) and pulmonary edema in 3.
6% of caseseach and maternal mortality rate was 1.8%. It concludes that adverse outcomesof pre-eclampsia can be minimized by quality obstetric care only. Hence theremay be a need for research into the prevention, early diagnosis, and managementincluding neonatal care of pre-eclampsia.4) Shamsi U etal in a case-control study to assess the risk factors associated with preeclampsiain maternity hospitals of Karachi and Rawalpindi, for time period of January 2006 to December 2007 involved 131cases of PE and 262 controls without preeclampsia. It resulted in amultivariate analysis, which classified preeclampsia risk factors as follows:women with family history of hypertension (adjusted OR 2.06, 95% CI;1.27-3.
35), gestational diabetes (adjusted OR 6.57, 95% CI; 1.94 -22.25),pre-gestational diabetes (adjusted OR 7.36, 95% CI; 1.37-33.
66) and mentalstress during pregnancy (adjusted OR 1.32; 95% CI; 1.19-1.46 for each 5 unitincrease in Perceived stress scale score). The study reviews that these factorscan be applied as a screening tool for preeclampsia prediction. Identificationof the previously mentioned predictors would improve the ability to diagnoseand monitor women at risk for preeclampsia, in turn minimizing the adversematernal and fetal outcomes.5)Kim YM et al in a NeedsAssessment study of emergency obstetric and newborn care (EmONC) services in Afghanistan for management of severe PreEclampsia/Eclampsia cases over a period of one year (2009-10). Assessment of supplies, equipmentsand services issued at 78 of the 127 facilities providing EmONC services andinterview of 224 providers was done.
The study reviews that majority offacilities had the medications and supplies required for management of severe Preeclampsia / Eclampsia,including anticonvulsant of choice MgSO4. 1/3rd of smallestfacilities and 1/2 of larger facilities reported to use diazepam a 2nd linedrug. It was summarized that 96% of doctors and 89% of midwives percieved thatMgSO4 must be utilized in severe PE/E management, but 42% of doctors and 58% ofmidwives also believed that diazepam use was needed in absence of MgSO4. Studysuggests the need to elucidate service delivery guidelines, provide refreshertraining, and reinforce best practices with supervision, with emphasis on the preferenceof MgSO4 over diazepam and on the significance of continuing antihypertensive therapyafter delivery.
6) Vata et al has done 4 year retrospective hospitalbased study on 172 records outof 7702 patients The incidence rate of preeclampsia was 2.23 % in Dilla University Referral HospitalThe common mean ages of 19.2, 22.5 and 27.
8 and 31.5 were found with preeclampsiawith a pattern of incrementing severitywith the younger population. Studyconcludes that there is a need toestablish guidelines for the management and prevention of preeclampsia forEhiopia.7) Duley L performed a Retrospective review of community and hospital-based data obtainedfrom the WHO data base for estimates of maternal mortality related with hypertensive disorders ofpregnancy (HDP) in Africa, Asia, Latin America and the Caribbean.
Study’s results suggest that estimates of deaths weresimilar in countries under study with Africa presenting with higher totalmortality. About 10-15% of maternal deaths were found to be associated withhypertensive disorders of pregnancy, and eclampsia was cause of 10% of maternalmortality overall. It concludes that maternal deaths related to hypertensivedisorders of pregnancy are the most difficult to prevent. Optimized assessmentof interventions for reduction in these deaths is urgently required.8) LisonkovaS et al examinedpopulation-based incidence of early-onset (<34 weeks) and late-onsetpreeclampsia (?34 weeks) among all singleton deliveries (n = 456,668), inWashington State for study period of 2003-2008. Cox and logistic regressionmodels were utilized to attain adjusted hazard ratios and odds ratios (AORs)for risk factors and birth outcomes, respectively.
Results show that of total3.1% cases were of preeclampsia with its incidence rising sharply withgestation age; early- and late-onset preeclampsia had incidence rates of 0.38%and 2.72%, respectively. Study reviews that Early- and late-onset preeclampsiahas some etiological features in common, differing in several risk factors, andleads to varying outcomes. Both the preeclampsia types should be treated as separateentities from an etiological and prognostic point of view.9) AnanthCV et al in his population basedretrospective study of National hospital discharge survey datasets over 1980-2010in United States including about 120 million women studied the rates ofpreeclampsia. The age-period-cohortanalysis indicates a strong age effect, i.
e. higher maternal age was associated with the greatest risk of pre-eclampsia, and overall pre-eclampsiarate was found to be 3.4%.
It concludesthat population prevalence variations of obesity and smoking were related withperiod and cohort trends in pre-eclampsia but did not explain the trends. Healthresults of rising obesity rates in the U S underscore that efforts to reduceobesity may improve the maternal and perinatal outcomes.10) Parra-CorderoM et al in this case-control studythat involved pre-eclampsia diagnosisof total 5367 pregnant women with no specific symptoms, by routinetrans-vaginal uterine artery (UtA) Doppler at 11 + 0 to 13 + 6 weeks, of thesewomen later diagnosed with preeclampsia were 70, with 53 late-onset (delivery ? 34weeks) pre-eclampsia and 17 had early-onset (< 34 weeks) pre-eclampsia.
The study concludes that early or late pre-eclampsia was representedwith an anti-angiogenic state and flawed placentation over the three months.Regression models involving maternal characteristics, UtA Doppler and Placentalgrowth factor (PlGF) that can probably anticipate nearly half of cases thatwill develop early-onset pre-eclampsia. There is need for study to help designan improved and highly population-specific pre-eclampsia diagnosis testing overthe first three months of pregnancy.11) ErezO et al in his case-control longitudinal study, including 90 normal pregnantwomen and 76 patients with late-onset preeclampsia (diagnosed at ?34 week). In early pregnancy (8-22 weeks) elevated matrixmetalloproteinase 7 (MMP-7) and later in pregnancy (after 22 weeks) low PlGFare the strongest predictors for the sequential development of late-onsetpreeclampsia. Thus the study suggests that the optimal prediction of patientsat risk may include a two-step diagnostic process.
12) Saxena N et al in herprospective study on 150 pregnant patients diagnosed with severe pre-eclampsiaand eclampsia (>20 weeks of gestation) with the aim to study the maternaland fetal outcome for the period of one year in a tertiary center. Resultsreveal that out of 150 patients 47% were Primi and 69% were 20-30 years of age.Of 75 preeclampsia patients, 11 suffered convulsions and 75 experiencedconvulsions on admission and four patients died. Most common complaint being headache.Caesarean section was the prevailingmode of delivery in about 72 (48%) women, due to failed induction. From thetotal, 59% complications were related to placental abruption, renal dysfunctionand failure, postpartum hemorrhage, DIC, pulmonary edema and embolism. Itconcludes that eclampsia was shown to have higher complications in both motherand child. Early diagnosis, better antenatal care, and proper management ofsevere pre-eclampsia can minimize the incidence of eclampsia.
13) Torjusen H in a prospective cohort study inNorway, for time period of years 2002–2008 including 28?192 pregnant women. The prevalence of pre-eclampsia was5.3% (n=1491).
Lower risk of pre-eclampsia was seen in women who proclaimed tohave eaten ‘mostly’ or ‘often’ organic vegetables (n=2493, 8.8%) compared tothose who ‘sometimes’ or ‘never/rarely’ had them. High intake of organic fruit,milk, eggs, cereals or a combined index reflecting organic consumption reportedto have no relation with pre-eclampsia.
Results suggest that during pregnancy optingfor organic vegetables was related with minimized risk of pre-eclampsia.Possible reason for this association may be that organic vegetables minimizethe exposure to pesticides.14) KawakitaT in A retrospective cohortstudy involving singleton pregnancies, patients diagnosed with preeclampsia andwithout prior cesarean at ? 34 weeks’ gestation was carried out. Among 5,506 casesof preeclampsia (? 34 weeks’ gestation) 5,104 (92.7%) women were subjected toinductions. Outcomes were compared using adjusted odds ratios (aORs) with 95% confidence intervals (CIs). Itconcludes that induction was not attributed with higher risk of the primaryoutcome, but was related to a maximum risk of ICU admissions and reduced risksof neonatal outcomes.
15) RäisänenS et al in this population-based cross-sectional study, relates the effects on riskof stillbirth by pregnancy history, in Finland during 2000 and 2010, including604047 women (?20 yearsof age) with singleton pregnancies. Per 1000 deliveries the prevalence ofstillbirth was found to be 3.17. For multiparous women with no prior fetal lossin pregnancy after adjusting for major pregnancy complications related with stillbirthsuch as pre-eclampsia, placental abruption, placenta previa.
Comparatively inmultiparous women with prior pregnancy loss, nulliparous women with and priorspontaneous abortion, prevalence of consecutive stillbirth was higher.Irrespectiveof the number of previous deliveries, prior pregnancy loss was reported to bean independent risk factor for abortion or stillbirth.16) DitisheimA et al in this prospective cohort study to describe the early postpartum bloodpressure (BP) profile following preeclampsia. In Total 115 preeclampsia patientsand 41 normal pregnant women were included. Prevalence of various hypertensivephenotypes by applying 24-hour ambulatory BP monitoring (ABPM), 6 to 12 week followingchildbirth, was assessed along with the risk of salt sensitivity and thevariability of BP derived from ABPM parameters.
Study concludesthat, ABPM 6 to 12 weeks postpartum uncovers a high rate of masked and nocturnalhypertension, sustained ambulatory after preeclampsia. This report may assist diagnosewomen who shall be involved in a management program of postpartumcardiovascular risk.17)Timofeeva AV et al in this study intended to evaluate miRNA expressionlevels in the blood plasma and placenta of pregnant women with early and lateonset preeclampsia comparing it with control group to design prerequisites forits early non-invasive diagnosis.Methods like miRNA deep sequencing after whichreal-time quantitative RT-PCR were included, logistic regressionanalysis of data was done.
Inthe patient’s blood plasma with PE, miR-423-5p, 519a-3p, and -629-5p andlet-7c-5p were higher than 2-fold increase compared to those in placenta. Theabove-mentioned miRNAs are related with PE diagnosis. Conclusion implies that for the early diagnosis of PE the miRNA -miR-423-5p may be treated as a potential candidate at the timeof targeted management of pregnancies athigh-risk. 18.
McKinney D et al in this retrospective cohort studyincluding, live-born, without anomalies singleton, deliveries that took place atthe University of Cincinnati Medical Center over the duration of 2008 to 2013. Inclusioncriteria were patients with preeclampsia onset before 34 weeks are completedand on its management. On the basis of presence /absence of fetal growthrestriction 2 study groups were defined.
Its presence was reported to be relatedwith a reduced time interval to delivery in women subjected to expectantmanagement of preeclampsia (<34 weeks). These data may aid in counselingpatients concerning the expected duration of pregnancy, analyze the necessity formaternal transport and guiding decision making regarding steroids therapy. 19) Rabinovich Aet al in this retrospective matched case-control study that compares 81 pretermpregnant women (28 0/7 and 36 6/7 weeks) diagnosed with pre-eclampsia andoligohydramnios low amniotic fluidindex (AFI) in contrast to 81 patients with preterm pre-eclampsia andwithout oligohydramnios( control group ). Around 4.8% of all pre-eclampsia preterm parturients resulted witholigohydramnios. study groupunderwent more cesarean sections.
AFI <5?cm was related with a seriousneonatal morbidity such as fetal distress during labor, and majority were presentedwith lower fetal weight and small for gestational age (SGA). Study concludesthat Oligohydramnios is an independent risk factor for perinatal morbidity inpreterm pre-eclamptic parturients and its presence can guide in decision makingfor patients delivery and also help decide for / against conservativemanagement. 20.Elmugabil A et al in this case-controlstudy carried out in Omdurman Maternity Hospital in Sudan, over the period of 4months in 2014. The preeclampsia patients were cases while healthy parturientswere the control group. Atomicabsorption spectrophotometer was utilized to analyze serum calcium, magnesium,zinc and copper levels. In contrast with the controls, preeclampsia patientsshowed increased serum magnesium 1.
9 (1.4?2.5) vs. 1.4 (1.0?1.
9) mg/dl and decreasedmedian (inter-quartile) calcium 7.6 (4.0?9.6) vs. 8.1 (10.
6?14.2), mg/dl. Inbinary logistic regression, increased magnesium and decreased calcium levels wererelated with preeclampsia. Study concludes significant relations between serumlevels of calcium and magnesium and preeclampsia exists.Reference: