BACKGROUND:Magnesium sulfate is highly effective for the prophylactic treatment of preeclampsia with severe features, as well as the prevention of recurrent eclamptic seizures. The consequences of developing eclampsia despite treatment with magnesium sulfate prophylaxis have received little attention. OBJECTIVE:Our aim was to describe maternal and perinatal consequences in patients who develop eclampsia despite treatment with magnesium sulfate therapy. STUDY DESIGN:This was a retrospective study of all patients with eclampsia over 13 years at a single institution. Eclampsia was diagnosed in accordance with the criteria outlined in the 2013 Executive Summary of the American College of Obstetricians and Gynecologists. Hospital records of patients experiencing eclampsia and their perinatal outcomes were independently reviewed by two faculty obstetricians in the Maternal-Fetal Medicine Division. RESULTS:During the 13-year study period, a total of 166,492 patients were delivered at our institution, with 15,689 (9.4%) receiving magnesium sulfate for seizure prophylaxis in the setting of preeclampsia with severe features or for treatment of eclampsia. One hundred twenty-three patients developed eclampsia (7.4 per 10,000 births), with 94 eclamptic seizures occurring in-hospital. Of these, 26 (21%) seizures occurred despite receiving magnesium sulfate prophylaxis in the setting of preeclampsia with severe features or prior eclampsia. Two-thirds of the 26 (65%) patients developed eclampsia despite a therapeutic (4.8-8.4 mg/dL) serum magnesium concentration following magnesium sulfate administration prior to the convulsion(s). Six occurred prior to routine evaluation of serum magnesium level 2 hours following the loading dose and 3 patients experienced an eclamptic seizure associated with a sub-therapeutic magnesium serum concentration. Maternal outcomes of these 26 patients were as follows: 10 (38%) experienced multiple eclamptic seizures despite magnesium sulfate therapy, 8 (31%) underwent immediate endotracheal intubation following the eclamptic seizure, 6 (23%) developed HELLP syndrome, 5 (19%) required admission to the intensive care unit, 3 (12%) developed aspiration pneumonia, and 3 (12%) experienced placental abruption. Compared to patients with in-hospital eclampsia prior to receiving magnesium sulfate, patients with eclampsia following magnesium sulfate were more likely to have more than one seizure (P<.01), require endotracheal intubation (P=.03), and develop HELLP syndrome (P<.01). The infants of patients with eclampsia following administration of magnesium sulfate were more likely to be admitted to the neonatal intensive care unit (P=.02). CONCLUSION:While magnesium sulfate is highly effective in preventing eclampsia, there are patients who experience eclamptic seizures despite magnesium sulfate with resultant morbidity. Eclampsia occurred in 26 (28%) of 94 patients experiencing in-hospital eclamptic seizures at our institution despite receiving magnesium sulfate. Of these 26 patients, the serum magnesium level was within the desired therapeutic range in 65% of patients before the eclamptic episode. Patients who developed eclampsia despite receiving magnesium sulfate prophylaxis experienced significant severe maternal morbidity, including more than one eclamptic seizure, maternal tracheal intubation, HELLP syndrome, and their infants were more likely to be admitted to the neonatal ICU.

For centuries, convulsions unique to pregnancy have been described. In this time, varying therapies-from phlebotomy to narcotics-have been suggested as the treatment of choice for eclampsia. Building upon the discovery of magnesium salts to control convulsions due to tetanus, magnesium sulfate became a suggested treatment for eclampsia. Throughout the 20th century, several large, clinical trials verified magnesium sulfate as the treatment of choice for eclampsia. In this report, the history of eclampsia management and the study of magnesium sulfate are described. The intent of the report is to highlight the key clinical features with use of magnesium sulfate, the present understanding of the mechanism of action, and the rigor of the studies by which it was established as the current definitive prophylaxis and therapy for eclampsia. Because of the unique pharmacologic properties, it is critical that obstetric providers understand the foundational studies to establish dosing and identified risks with magnesium sulfate application. Additionally, alleged putative effects of magnesium sulfate administration, such as prolongation of labor, are also addressed. Finally, the challenges with the use of magnesium sulfate in the prevention of eclampsia are summarized given the varying definitions of preeclampsia. This report serves as a chronicle to summarize the story of how one of the most commonly used agents in obstetrics became the standard of present-day care.

Background: Preeclampsia with severe features (SPE) is a multisystem syndrome associated with long-term cardiovascular morbidity. Serum concentrations of N-terminal B-type natriuretic peptide (NT-proBNP) and high sensitivity cardiac troponin-T (hs-cTnT) are sensitive markers of cardiac stretch and ischemia, respectively.Objective: Our aim was to examine NT-proBNP and hs-cTnT in patients with SPE during labor. We hypothesized that patients with severe preeclampsia would have increased serum concentrations of these analytes as compared with normotensive laboring patients. Study Design. This was a prospective cohort study of intrapartum patients with SPE and normotensive controls. Patients were recruited at the time of SPE diagnosis or admission to the labor unit, and those with medical conditions that could predispose to baseline cardiac dysfunction were excluded. Serum from venous blood was collected for NT-proBNP and hs-cTnT measurement at three time points: 0-2 h, 4 h, and 12 h after admission. A mixed random effects regression model was used to compare analyte levels at each time point and to compare trends over time. The primary outcome was NT-proBNP concentration at each collection time point in patients with severe pre-eclampsia as compared to normotensive controls. Power analysis yielded a goal sample of 25 patients with a 12 h and at least 1 other sample in each arm. Two-tailed P values less than 0.05 were considered statistically significant. P value adjustment for multiple comparisons was performed.Results: Of 78 patients analyzed, 36 had severe preeclampsia and 42 were normotensive controls with 25 in each cohort having a 12 h and at least 1 other sample. The NT-proBNP trend was significantly different in the two cohorts (P < 0.001). After adjustment for multiple comparisons, the mean serum concentration of NT-proBNP was elevated in the severe preeclampsia group at 0-2 and 4 h, but not at 12 h. After similar adjustment, detectable serum concentrations of hs-cTnT were more frequent in patients with severe preeclampsia at all three timepoints.Conclusion: Intrapartum serum concentrations of NT-proBNP were elevated nearly twofold in patients with SPE when compared with normotensive controls, with the most pronounced differences found during early labor. Detectable but low serum concentrations of hs-cTnT were more common in women with severe preeclampsia as compared with normotensive controls. These findings suggest cardiac dysfunction with SPE may be present at the time of admission and contribute to features of maternal cardiovascular morbidity and mortality.

serious or life-threatening disease or condition.5,7 It was initially formalized for the development of drugs to treat HIV infection; moreover, it continues to provide timely access to the treatment of cancers and other diseases.5 The accelerated in further study to "verify and describe clinical benefit, where there is uncertainty as to the relation of the surrogate endpoint to clinical benefit, or of the observed clinical benefit to the ultimate outcome."4-7 the practice of medicine, the medical services, the price or availability of medical products, and whether they are reimbursed by health insurance or Medicare.8 The FDA regulates the manufacturing of drugs and determines whether the scientific evidence is sufficient to allow marketing of the drug to the American public, and the FDA defines the labeling of the drug for the benefit and safety of the public.4,7-10

To evaluate the prevalence of adverse maternal and neonatal outcomes associated with obesity. We hypothesized that obesity confers a dose-dependent risk for these outcomes. This was a retrospective cohort study of singleton pregnancies delivered between 24 and 42 weeks gestation at an urban county hospital between 2013 and 2021. Body mass index (BMI) at first prenatal visit was used as a proxy for pre-pregnancy weight. Patients were excluded if no first trimester BMI was available. During the study period, 58497 patients delivered a singleton infant, of which 12365 (21.1%), 5429 (9.3%), and 3482 (6.0%) had class I, II, and III obesity, respectively. Non-obese patients were more likely to be younger and nulliparous with a mean delivery gestational age of 39 weeks across all groups. Increasing obesity was associated with a dose-dependent increase in cesareans (27% for non-obese versus 46% for class III obesity). There was an association between increasing obesity and peripartum complications, including severe preeclampsia (8% in non-obese versus 19% in class III obesity) and gestational diabetes (5% in non-obese versus 15% in class III obesity). Infants born to patients with class III obesity versus non-obese patients were more likely to develop grade III-IV intraventricular hemorrhage (RR 4.58, 95%, CI 2.10-9.99), sepsis (RR 3.76, 95% CI 2.00-7.06), respiratory distress syndrome (RDS) (RR 2.66, 95% CI 2.15-3.29), and have an initial cord gas pH < 7 (RR 2.48, 95%CI 1.68-3.66) (Figure). Increasing BMI is associated with a dose-dependent increase in associated adverse maternal and neonatal outcomes. Infants born to patients with higher classes of obesity have significant associated morbidity including a 2 to 4 times increased risk of neonatal acidosis, grades III-IV IVH, sepsis, and RDS.

Obstetric hemorrhage remains the leading cause of maternal morbidity and mortality worldwide. Thromboelastography and rotational thromboelastometry are laboratory methods of assessing the kinetics of blood clot formation through real-time measurement of viscoelastic clot strength and may aid in management of severe hemorrhage. Although first described more than 70 years ago, viscoelastic testing devices are now available that allow for rapid point-of-care use of this technology to aid in real-time management of blood product replacement in cases of severe hemorrhage. These devices can be used to visually estimate multiple facets of hemostasis-coagulation, platelet function, and fibrinolysis-within 10-20 minutes. They have been used successfully in cardiac surgery, trauma, and liver transplantation and have potential for use in management of obstetric hemorrhage. Goals with their use include targeted transfusion of blood and its components for specific coagulation deficiencies. To date, however, published experiences with the use of these viscoelastic tests for obstetric hemorrhage have been limited. Because of the increasing use of the point-of-care tests by anesthesiologists, surgeons, and intensivists, the purpose of this report is to familiarize obstetricians with the technology involved and its use in severe hemorrhage complicating pregnancy.

( Am J Obstet Gynecol . 2022;227:622.e1–622.e6) Complications of eclamptic seizures include postpartum hemorrhage, placental abruption, stroke, pulmonary edema from heart failure, aspiration pneumonia, preterm delivery, stillbirth, and neonatal death. Though first published in 1974, the relationship between fetal heart rate decelerations and eclampsia has not characterized the timing, duration, and frequency of these changes. This study aimed to describe and characterize fetal heart rate changes following eclampsia and determine obstetric management following seizures.

OBJECTIVES:Acute kidney injury (AKI)-complicating pregnancy is used as a marker of severe maternal morbidity (SMM) and frequently associated with obstetric hypertensive disorders. We examined AKI in pregnancies complicated by late-onset preeclampsia with severe features (SPE) using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. We compared outcomes of pregnancies with and without AKI and stratified by stage of disease. We further differentiated renal dysfunction at the time of admission and compared outcomes to those who developed AKI after admission. STUDY DESIGN:This was a retrospective cohort study of women with care established before 20 weeks and diagnosed with preeclampsia with severe features with delivery at ≥34 weeks. Women with chronic hypertension or suspected underlying renal dysfunction were excluded. KDIGO criteria were applied to stratify staging of renal disease. Demographics and perinatal outcomes were compared using Chi-square analysis and Wilcoxon's rank-sum test with p < 0.05 considered significant. RESULTS:From January 2015 through December 2019, a total of 3,515 women meeting study criteria were delivered. Of these, 517 (15%) women met KDIGO criteria for AKI at delivery with 248 (48%) having AKI at the time of admission and the remaining 269 (52%) after admission. Stratified by severity, 412 (80%) had stage 1 disease, 89 (17%) had stage II, and 16 (3%) had stage III. Women with AKI had higher rates of cesarean delivery (risk ratio [RR] = 1.3; 95% confidence interval [CI]: 1.17-1.44), postpartum hemorrhage (RR = 1.46; 95% CI: 1.29-1.66), and longer lengths of stay. Other associated outcomes included NICU admission (RR = 1.72; 95% CI: 1.19-2.48), 5-minute Apgar score ≤ 3 (RR = 5.11; 95% CI: 1.98-13.18), and infant length of stay. CONCLUSION:Of women with late preterm SPE, 15% were found to have AKI by KDIGO criteria. The majority (80%) of AKI was stage I disease, and approximately half of the cases were present by the time of admission. KEY POINTS:· AKI was found in 15% of our cohort with 80% stage I disease.. · Half of the cases of AKI were present on admission.. · Few adverse perinatal outcomes are associated with AKI..

OBJECTIVE: Infection with the pork tapeworm can result in neurocysticercosis caused by infestation of central nervous system tissues by the parasite cysts. Parenchymal brain infection can cause symptoms from mass effect that include headache, seizures, confusion, and even coma. Our objective was to describe the clinical course of neurocysticercosis infections in pregnant women. METHODS: This was a case series that described clinical findings and pregnancy outcomes of women diagnosed with neurocysticercosis from 1994 through 2016 at a single institution. Their medical records were reviewed, cranial computed tomography and magnetic resonance imaging scans were assessed, and the infections were classified according to the criteria of the 2018 Infectious Diseases Society of America and the American Society of Tropical Medicine and Hygiene. RESULTS: Overall, 37 pregnant women with neurocysticercosis were identified. Of the 37 women, 32 were symptomatic, and 16 each had severe headaches or new-onset seizures or other neurologic sequelae. Some of these women had multiple symptoms. Others were diagnosed when neuroimaging was done for a history of neurocysticercosis or evaluation of a preexisting seizure disorder. The most common treatment was with anthelmintics—albendazole, praziquantel, or both—usually given with anticonvulsants and corticosteroids to decrease inflammation. There were eight women in whom invasive neurosurgical procedures were performed, usually for hydrocephaly. Overall, 32 healthy neonates were born at term, and there was one preterm delivery at 34 weeks of gestation. The four pregnancy losses included two molar pregnancies, one anembryonic miscarriage, and a 23-week stillbirth of a pregnancy complicated by preeclampsia with severe features. CONCLUSION: Neurocysticercosis in pregnant women may be asymptomatic or result in headaches, seizures, confusion, nausea and vomiting, altered mental status, or obtundation. Anthelmintic treatment is usually successful, but in some women neurosurgical procedures are necessary to relieve obstructive hydrocephaly.

HomeCirculationVol. 146, No. 6Treatment of Chronic Hypertension in Pregnancy: Is It Time for a Change? Free AccessArticle CommentaryPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessArticle CommentaryPDF/EPUBTreatment of Chronic Hypertension in Pregnancy: Is It Time for a Change? C. Edward Wells and F. Gary Cunningham C. Edward WellsC. Edward Wells Correspondence to: C. Edward Wells, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9032. Email E-mail Address: [email protected] https://orcid.org/0000-0003-1386-9971 Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas. Search for more papers by this author and F. Gary CunninghamF. Gary Cunningham Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas. Search for more papers by this author Originally published8 Aug 2022https://doi.org/10.1161/CIRCULATIONAHA.122.060548Circulation. 2022;146:433–434After decades of improvement in pregnancy-related maternal mortality in the United States, mortality began to increase in the late 1990s. A higher incidence of pregnancy-related hypertensive disorders, which are known to be associated with maternal deaths, has been implicated in these unfavorable trends. Ananth et al1 reported results from a population-based study of all hypertension-related pregnancy deaths in the United States over the past 4 decades. Whereas maternal mortality risk associated with all hypertensive disorders (including the preeclampsia syndrome and chronic hypertension) has increased in the United States, deaths associated with preeclampsia decreased. Maternal mortality risk associated with preeclampsia declined 3-fold over the most recent 40-year period, whereas chronic hypertension–related maternal mortality risk increased 15-fold. Important additional observations from this report include a sharp increase in hypertension-related mortality associated with advancing maternal age, a strong racial disparity among Black compared with White women, and an important role of increasing obesity rates, particularly in preeclampsia/eclampsia-related maternal mortality rates, all of which underscores the need for an improved management strategy for chronic hypertension in pregnancy.For half a century, treatment of pregnant women with chronic hypertension has been approached cautiously out of concern that rigorous blood pressure control might be detrimental to the fetus, owing to diminished placental perfusion resulting in fetal growth abnormalities and stillbirths. Although pharmacologic treatment was beneficial to women with severe hypertension, data were limited regarding treatment of mild hypertension in pregnancy. Management was initially limited to salt-restricted diets, and even as efficacious therapeutic agents were developed, antihypertensive therapy during pregnancy was still proscribed. By the 1980s, there was general agreement that women with mild chronic hypertension had good maternal and perinatal outcomes, and drug treatment was used only for those with severe hypertension, typically defined as ≥160/110 mm Hg. In 1990 and again in 2000,3 a working group convened by the National Heart, Lung, and Blood Institute recommended drug treatment only if the systolic blood pressure exceeded 150 to 160 mm Hg or the diastolic pressure exceeded 100 to 110 mm Hg. A task force assembled by the American College of Obstetricians and Gynecologists made similar recommendations.4CHIPS (Control of Hypertension in Pregnancy Study) was an international, open, multicenter, randomized, controlled trial designed to compare tight versus less-tight control of mild or moderate hypertension among pregnant women with chronic hypertension. Pregnancies managed with tight blood pressure control had perinatal outcomes that did not differ from those managed with less-tight control. The only maternal benefit was a lower frequency of severe maternal hypertension in the tight control cohort.5To further evaluate chronic hypertension in pregnancy, the CHAP trial (Chronic Hypertension and Pregnancy) was designed to compare 2 levels of blood pressure control in pregnant women with chronic hypertension.2 In this open-label, pragmatic, multicenter, randomized trial supported by the National Heart, Lung, and Blood Institute, women with either a new or known diagnosis of mild chronic hypertension in pregnancy, with a singleton fetus at a gestational age of less than 23 weeks, were randomized to receive either antihypertensive treatment during pregnancy targeting a blood pressure goal of less than 140/90 mm Hg (active treatment) or to receive no antihypertensive therapy unless maternal blood pressure reached or exceeded 160 mm Hg systolic or 105 mm Hg diastolic (control group). From 2015 through 2021, a total of 2408 women were enrolled in the trial, with 1208 randomized to the active treatment group and 1200 to the control group. The first choices for an antihypertensive agent were labetalol or extended-release nifedipine. The primary outcome was a composite of preeclampsia with severe features, medically indicated preterm birth at <35 weeks gestation, placental abruption, or perinatal death. Safety outcomes for the neonate included birthweight <5th and 10th percentiles for gestational age.The primary composite outcome was significantly lower in the active treatment group compared with the control group (30.2% versus 37.0%; P<0.001). There were also significantly fewer primary adverse outcomes in the active treatment cohort, including preeclampsia with severe features (RR, 0.80 [95% CI, 0.70–0.92]) and medically indicated preterm birth <35 weeks (RR, 0.73 [95% CI, 0.60–0.89]). The safety outcomes for neonates with birthweights below the 5th and 10th percentiles did not differ significantly between the 2 groups. Secondary maternal outcomes were also significantly better in the active treatment group compared with the control group. The incidence of severe maternal hypertension (including those with preeclampsia) was 36.1% compared with 44.3% (RR, 0.82 [95% CI, 0.74–0.90]) in the active versus control groups, respectively. The incidence of any preeclampsia (severe or nonsevere) was 24.4% versus 31.1%, respectively (RR, 0.79 [95% CI, 0.69–0.89]). Several neonatal outcomes were also improved in the active treatment group compared with the control group. Preterm birth before 37 weeks gestation was observed in 27.5% of the active treatment group compared with 31.4% in the control group (RR, 0.87 [95% CI, 0.77–0.99]) and low birthweight infants <2500 grams in 19.2% and in 23.1%, respectively (RR, 0.83 [95% CI, 0.71–0.97]). These findings support the conclusion that targeting a blood pressure goal of <140/90 mm Hg was associated with improved maternal and neonatal outcomes without adversely affecting fetal growth.What do these findings mean for clinical practice? Immediately after publication of the CHAP trial results, the American College of Obstetricians and Gynecologists issued a Clinical Guidance Practice Advisory recommending the use of a blood pressure threshold of 140/90 mm Hg for the initiation and titration of antihypertensive therapy for chronic hypertension in pregnancy rather than the threshold previously recommended of 160/110 mm Hg. This was quickly followed by a draft proposal by the Society for Maternal-Fetal Medicine recommending treatment of mild chronic hypertension in pregnancy to a blood pressure goal of <140/90 mm Hg (Table).Table. Guidelines for the Diagnosis and Goals of Treatment of Chronic Hypertension in PregnancyGuidelineThreshold for treatment, mm HgGoal of treatment, mm Hg2022 American College of Obstetricians and Gynecologists140/90: threshold for initiation or titration of medical therapy2022 Society For Maternal-Fetal Medicine Draft Proposal≥140/90<140/902018 International Society for the Study of Hypertension in Pregnancy≥140/90110 to 140/852020 Hypertension Canada≥140/90Diastolic blood pressure 852019 National Institute for Health and Care Excellence≥140/90Target blood pressure 135/85Although these findings are encouraging, we should not lose sight of the fact that adverse maternal and fetal outcomes are substantively higher in women with chronic hypertension in pregnancy. The maternal mortality rate for the trial cohort was 120 per 100 000 live births—6-fold higher compared with all US births. The perinatal mortality rate was likewise significantly higher, at ≈40 per 1000 births compared with <10 per 1000 for the nation.We began with the following question: Treatment of chronic hypertension in pregnancy—is it time for a change? The answer is Yes.Article InformationSources of FundingNone.Disclosures Dr Cunningham reports royalties received from McGraw Hill and Wolters Kluwer. Dr Wells reports royalties received from McGraw Hill.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Circulation is available at www.ahajournals.org/journal/circFor Sources of Funding and Disclosures, see page 434.Correspondence to: C. Edward Wells, MD, Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9032. Email edward.wells@utsouthwestern.eduReferences1. Ananth CV, Brandt JS, Hill J, et al. Mortality due to hypertensive disorders in the United States, 1979-2018.Hypertension. 2021; 78:1414–1422. doi: 10.1161/HYPERTENSIONAHA.121.17661LinkGoogle Scholar2. Tita AT, Szychowski JM, Boggess K, et al. Treatment for mild chronic hypertension during pregnancy.N Engl J Med. 2022; 386:1781–1792. doi: 10.1056/NEJMoa2201295CrossrefMedlineGoogle Scholar3. Report of the National High Blood Pressure Education Program Working Group on High Blood Pressure in Pregnancy.Am J Obstet Gynecol. 2000; 183:S1–S22.CrossrefMedlineGoogle Scholar4. Hypertension in pregnancy: report of the American College of Obstetricians and Gynecologists’ Task Force on Hypertension in Pregnancy.Obstet Gynecol. 2013; 122:1122–1131. doi: 10.1097/01.AOG.0000437382.03963.88CrossrefMedlineGoogle Scholar5. Magee LA, von Dadelszen P, Rey E, et al. Less-tight versus tight control of hypertension in pregnancy.N Engl J Med. 2015; 372:407–417. doi: 10.1056/NEJMoa1404595CrossrefMedlineGoogle Scholar eLetters(0)eLetters should relate to an article recently published in the journal and are not a forum for providing unpublished data. Comments are reviewed for appropriate use of tone and language. Comments are not peer-reviewed. Acceptable comments are posted to the journal website only. Comments are not published in an issue and are not indexed in PubMed. Comments should be no longer than 500 words and will only be posted online. References are limited to 10. Authors of the article cited in the comment will be invited to reply, as appropriate.Comments and feedback on AHA/ASA Scientific Statements and Guidelines should be directed to the AHA/ASA Manuscript Oversight Committee via its Correspondence page.Sign In to Submit a Response to This Article Previous Back to top Next FiguresReferencesRelatedDetails August 9, 2022Vol 146, Issue 6 Advertisement Article InformationMetrics © 2022 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.122.060548PMID: 35939547 Originally publishedAugust 8, 2022 PDF download Advertisement SubjectsHypertension

Acute kidney injury (AKI) is a marker of severe maternal morbidity (SMM), although its definition and relevance in an obstetric population is unclear. Hypertensive disease of pregnancy is a salient etiology of renal dysfunction, especially in women with preexisting chronic hypertension (CHTN). We aimed to examine AKI in pregnancies with CHTN with superimposed preeclampsia with severe features (SPE) using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. This retrospective cohort study of deliveries between January 1, 2015 and December 31, 2019 includes women with CHTN who registered for prenatal care before 20 weeks and and developed SPE with delivery ≥ 34 weeks. Women with preexisting renal dysfunction defined by baseline serum creatinine ≥ 1.0 mg/dL were excluded. We stratified timing of development of AKI and staging using the KDIGO criteria. We compared demographics and perinatal outcomes between those with and without AKI. Demographics and perinatal outcomes were compared using chi-square analysis and Wilcoxon rank-sum test, as appropriate, with p < 0.05 considered significant. Of 656 women with CHTN and SPE, 7% (47) had AKI by the KDIGO criteria (Figure 1). Of these women, 42% (20/47) had AKI present at the time of admission and 58% (27/47) after admission for delivery. Of these 47 women with AKI, 80% (38) of women had stage I and 20% (9) had stage II/III dysfunction by KDIGO criteria. There were no significant differences with the exception of maternal length of stay (7 v 6 days, p = 0.004; Table 1) between women with and without AKI. There were no clinically relevant outcomes associated with severity of stage of renal dysfunction. Of pregnant women with CHTN and superimposed SPE, 7% had evidence of AKI by KDIGO criteria with predominantly stage I disease. Almost half of identified cases were present at the time of admission and, with the exception of maternal length of stay, no clinically relevant perinatal outcomes were identified. These observations can be used to inform the value of using AKI as a hospital quality indicator vis a vis SMM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Acute kidney injury (AKI) complicating pregnancy is used as a marker of severe maternal morbidity (SMM) and frequently associated with hypertensive disorders. Our aim was to examine AKI in pregnancies complicated by preeclampsia with severe features (SPE) using the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. This was a retrospective cohort study of women with care established before 20 weeks with diagnosis of SPE and delivery > or = 34 weeks at an academic public hospital. To mitigate confounding of underlying renal dysfunction, women with chronic hypertension were excluded. KDIGO criteria for diagnosis of AKI were applied to stratify stages of renal disease at admission and during the delivery episode. Demographics and perinatal outcomes were compared using chi square with P<0.05 considered significant. From January 2015 through December 2019, 4028 women with SPE were delivered meeting inclusion criteria and 1096 (27%) of these met KDIGO criteria for AKI during their delivery episode. Of those with AKI, 690 (63%) had AKI at the time of admission and the remaining 406 (37%) developed AKI after admission. Of women with AKI, 1080 (98%) had stage I; 9 (0.82%) stage II; and 7 (0.63%) stage III renal disease stratified by KDIGO criteria. Demographic differences between those with and without AKI include younger age, race or ethnicity, and nulliparity (Table). Women with AKI had significantly higher rates of cesarean delivery, postpartum hemorrhage, and longer lengths of stay. More than a fourth of women with SPE delivered at > or = 34 weeks were found to have AKI by KDIGO criteria. The vast majority of AKI was stage I disease, and more than 60% were present on admission. AKI at time of delivery is associated with adverse outcomes. Future efforts defining SMM indicators could consider whether AKI is already present at the time of admission or develops intrapartum.

Acute fatty liver of pregnancy (AFLP) is a rare, but potentially fatal condition, characterized by hepatic failure typically in the third trimester of pregnancy that is associated with multiorgan involvement resulting in a number of clinical and laboratory abnormalities. The cornerstone of management of AFLP includes prompt recognition, preparation for delivery, and supportive care such as reversal of coagulopathy. Early diagnosis, prompted delivery, and supportive care have resulted in improved maternal morbidity and mortality. This review focuses on the epidemiology, etiology, clinical presentation, diagnosis, management, and resolution of AFLP.

Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, Dallas, Texas Financial Disclosure The authors did not report any potential conflicts of interest.

Acute fatty liver of pregnancy (AFLP) and hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome are both associated with significant maternal and perinatal morbidity and mortality. Because of the overlap of several clinical and laboratory findings differentiation can sometimes be difficult. Both disorders have been of interest for more than 100 years, however they were not completely characterized until the early 1980s. It was not until the 1980s that AFLP and HELLP syndrome, and more specifically their clinical, laboratory, and pathologic findings, were further differentiated in the literature. More recently, the pathophysiologic mechanisms have been elucidated. In this review, we outline the similarities and differences in the clinical presentation, laboratory findings, maternal and perinatal outcomes, and clinical recovery for women diagnosed with these two syndromes. From our observations, we suggest that levels of fibrinogen, creatinine, cholesterol, and total bilirubin be used to assist with differentiating AFLP from HELLP syndrome upon admission in women presenting with either suspected disease. The rationale for identifying the specific conditions is that clinical consequences for recovery vary considerably. Specifically, AFLP is associated with significantly more hepatic and renal dysfunction as well as coagulopathy. Fortunately, both conditions can be managed with supportive measures with overall improved perinatal outcomes including morbidity and mortality.

Objectives To assess pulmonary artery pressure and cardiac remodeling in pregnancy in women with pulmonary hypertension and compare these findings with studies done beyond three months postpartum. Study design Pregnant women with pulmonary hypertension from 2006 to 2017 were studied. Pulmonary hypertension was diagnosed when the pulmonary artery pressure exceeded 30 mmHg as estimated by right ventricular systolic pressure (RVSP) on echocardiography or 20 mmHg measured directly by mean pulmonary artery pressure (PAPm) with right-heart catheterization (RHC). Disease severity was assigned using threshold cutoffs. Indices of cardiac remodeling were compared during pregnancy after 20 weeks' gestation and again beyond three months postpartum when available. Pulmonary artery pressures obtained by echocardiography versus right-heart catheterization were also compared. Results Forty-six pregnancies complicated by pulmonary hypertension in 41 women were identified. The study included 43 pregnancies that resulted in a livebirth. There were 20 women in whom studies were performed after 20 weeks' gestation and again at least 3 months postpartum or later. Pulmonary artery pressures determined during pregnancy versus beyond three months postpartum were not significantly different when measured by echocardiography (RVSP 53.5 +/- 20.5 mmHg and 46.7 +/- 20.4 mmHg, p = .26) in this limited cohort. In the 10 women in whom pulmonary artery pressures were measured with both echocardiography and right-heart catheterization, the former was found to significantly overestimate directly measured pulmonary artery pressure (63.3 +/- 20.7 versus 37.7 +/- 12.3 mmHg, p < .001). Conclusion Pulmonary artery pressures did not appreciably change during pregnancy after 20 weeks' gestation compared with pressures measured again beyond three months postpartum. Women with pulmonary hypertension did not show evidence of remodeling of left ventricular mass or relative wall thickness when measured in pregnancy after 20 weeks' gestation compared with beyond three months postpartum in this limited cohort. These findings suggest that cardiac remodeling in women with pulmonary hypertension is different from that of normally pregnant women and confirms the need for careful long-term follow-up.

BACKGROUND: The incidence of diabetes in pregnancy has increased dramatically with the rising rates of obesity. Because there are a number of recognized adverse maternal and fetal outcomes associated with diabetes, there have been several attempts to classify this disorder for perinatal risk stratification. One of the first classification systems for pregnancy was developed by White nearly 70 years ago. More recently, efforts to stratify diabetic disease severity according to vasculopathy have been adopted. Regardless of classification system, vasculopathy-associated effects have been associated with worsening pregnancy outcomes. Defining vasculopathy within an organ system, however, has not been consistent. For example, definitions of diabetic kidney disease differ from the previously used threshold of >= 500 mg/d by White for pregnancy to varying thresholds of albuminuria by the American Diabetes Association. OBJECTIVE: To evaluate a proteinuria threshold that was a relevant determinant of perinatal risk in a cohort of women with type 2 diabetes. MATERIALS AND METHODS: This was a retrospective cohort study of women with pregestational diabetes delivered of nonanomalous, singleton, liveborn infants. All women were assessed for baseline maternal disease burden with a 24-hour proteinuria quantification performed before 20 weeks' gestation. Women with <500 mg/d on 24-hour urine collections were included. Perinatal outcomes were analyzed according to the following protein excretion values: 50-100, 101-200, 201-300, and 301-499 mg/d. Based on trends noted in these results and using the prior definition of the American Diabetes Association of 300 mg/d of albumin for diabetic kidney disease, women were then analyzed according to 24-hour urine collections of <= 300 or >300 mg/d. RESULTS: Between 2009 and 2016, a total of 594 women with pregestational diabetes were found to meet study criteria. When analyzed according to protein excretion values 50-100, 101-200, 201-300, and 301-499 mg/d, there were no differences in maternal demographics. The rate of preeclampsia with severe features (P for trend = .02), preterm birth at <37 weeks (P for trend <.001), and birthweight <10th percentile (P for trend = .02) were significantly associated with increasing proteinuria excretion, with the highest rates in the >300 mg/d group. Perinatal outcomes were then examined in the context of 24-hour urine protein excretion values of <= 300 or >300 mg/d, with no differences in maternal demographics. Protein excretion values >300 mg/d were significantly associated with preterm birth <37 weeks (P = .003), preeclampsia with severe features (P = .002), and birthweight <10th percentile (P = .048). CONCLUSION: White's classification in 1949 was developed to stratify perinatal risks based on maternal disease burden, and it was found that urinary protein excretion of >500 mg/d was associated with adverse pregnancy outcomes. In a contemporary cohort of pregnant women, proteinuria >300 mg/d was associated with preterm birth, preeclampsia with severe features, and birthweight <10th percentile.