Franziska Pettit

Pre-eclampsia causes adverse maternal outcomes across the gestational spectrum

OBJECTIVE To determine if women with early onset pre-eclampsia (EOP) have worse maternal outcomes than those who present later. Specifically, we aimed to determine whether term preeclamptic women and their infants have better outcomes than either their late pre-term or early onset counterparts. STUDY DESIGN Between 1991 and 2011, 4657 pregnancies complicated by hypertension were recorded in our database; 2148 (45%) had pre-eclampsia (PE). Six hundred ninety six cases (32%) that had accurate data for the gestation at which PE developed were analysed. Pre-eclampsia was defined as per the International Society for the Study of Hypertension in Pregnancy guidelines. Maternal outcomes included (1) episodes of severe hypertension, (2) proteinuria, (3) acute kidney injury, (4) abnormal liver function, (5) thrombocytopenia and (6) neurological complications. Perinatal outcomes were also analysed. RESULTS Eighty seven (13%) of 696 cases had EOP; 226 (32%) had late pre-term PE and 383 (55%) term PE. Maternal age was similar amongst the three groups. Women with late pre-term and term PE had similar rates of maternal and foetal outcomes. Compared with term PE, women with EOP had similar rates of adverse maternal outcomes, however their babies had significantly increased rates of morbidity and mortality. CONCLUSION Pre-eclampsia causes significant maternal organ involvement regardless of gestation at onset. Outcomes for babies of women with EOP are significantly worse than for those who present later. Overall, women presenting with PE after 34 weeks have generally good maternal and foetal outcomes in a unit equipped to manage such cases.

Postpartum physiology, psychology and paediatric follow up study (P4 Study) – Study protocol

BACKGROUND Women who have had hypertension in pregnancy are at greater risk of long term cardiovascular disease (CVD). Little is known about their cardiovascular risk postpartum or the effects on the womans mental health and the outcomes of their infants. In this project we will study the physiological and psychological health of women and the physical health and development of their infants six months, two years and five years after birth. We will establish normal blood pressure (BP) and metabolic function for women who were normotensive in pregnancy and use these to assess women who had gestational hypertension (GH) or preeclampsia (PE). DESIGN/METHODS Women will be asked to participate if they have given birth in the preceding six months. They will be excluded if they had diabetes, hypertension, renal or other serious maternal disease prior to pregnancy or congenital anomaly in the pregnancy. We will recruit 292 women who were normotensive and their babies, 100 who had GH and 100 who had PE and their babies. They will be assessed at six months, two and five years after birth. At each assessment mothers will have their blood pressure (BP) assessed peripherally with a liquid crystal sphygmomanometer and 24h ambulatory blood pressure monitoring (ABPM), and centrally with non-invasive applanation tonometry. Additional physiological testing will include: body composition; energy balance; vascular compliance; cardiac function; liver and renal function, lipids and biochemistry; glucose and insulin; and urinalysis. Psychological status will be assessed with validated self-report questionnaires for depression, anxiety, post-traumatic stress disorder (PTSD) and mother-infant bonding. The babies will have a medical examination by a paediatrician at each assessment. Their behavioural development will be assessed with an Ages and Stages Questionnaire completed by their mother at each assessment and a developmental assessment by a child psychologist at two and five years. CONCLUSIONS This study will re-define normal BP and other physiological parameters for young parous women thereby permitting a more sensitive assessment of post-partum BP and other cardiovascular risk markers in women who have had GH or PE. It will also determine the extent, if any, of psychological disorders in these women and developmental or other concerns in their babies. TRIALS REGISTRATION Australian and New Zealand Clinical Trials Registry Number: ACTRN12613001260718.

Indications for delivery in pre-eclampsia

OBJECTIVE Examine the frequency with which the most accepted indicators for delivery in pre-eclampsia are used in a population with predominantly late-onset (birth > 32 weeks) pre-eclampsia (PE). METHODS Retrospective cohort study using the St George Public Hospital (SGH) Hypertension in Pregnancy database. Demographic, pregnancy, and outcome details were extracted and verified by comparison with data collection sheets. RESULTS From 2001 to 2013, 908 women (970 babies) with PE were included, of which a subgroup of 303 women (33%) had clearly delineated delivery triggers available. This subgroup of women had similar demographic and outcome characteristics to the total PE population. In this group, the most common maternal trigger for delivery apart from gestational age 37+ weeks was difficult to control/severe hypertension (114 cases, 38%) and the most common fetal trigger intrauterine growth restriction (IUGR: 14 cases, 4%). 78 (35%) of term women had no specific delivery trigger other than gestation. A primary maternal trigger and/or associated complication was slightly more common in those delivering <37 weeks vs 37+ weeks (52 vs 38%, p = .03), while a fetal or combined maternal/fetal complication was over four times more common in preterm women (25 vs 6%, p < .001). CONCLUSION In our population of predominantly late-onset PE, maternal triggers for delivery (predominantly severe hypertension) far outweigh fetal triggers (predominantly IUGR). Fetal and mixed indicators for delivery were relatively more common in women delivering preterm, possibly reflecting the severity of placental dysfunction in this subgroup.

Repeatability of USCOM®-measured cardiac output in normotensive non-pregnant and pregnant women

Objectives To investigate the repeatability of ultrasonic cardiac output monitor (USCOM) measurements of cardiac output in normotensive non-pregnant and pregnant women. Study design Using the USCOM, cardiac output was measured, five times successively within 5 min in normotensive non-pregnant (n = 30) and pregnant (n = 30) women of any gestation with uniform technique by a single operator. The data were analysed using multi-level modeling and intra-class correlation. Results There was no statistically significant variation in cardiac output with repeated measurement in normotensive non-pregnant or pregnant women. The intra-class correlation for cardiac output measurements was 0.921 (95% CI 0.887–0.947). Conclusions No extra information is added by making more than one USCOM measurement on the same woman under the same conditions in normotensive pregnant and non-pregnant women. The USCOM demonstrates excellent repeatability in this population. This finding should provide reassurance that single measurements using this system are of value in research and clinical practice.

Cardiovascular Disease Following Hypertensive Pregnancy

Cardiovascular disease, including ischaemic heart disease and cerebrovascular disease, has become the number one cause of death in women worldwide. Having had a pregnancy complicated by pre-eclampsia may be more than just a risk factor for the development of cardiovascular disease later in life. Pre-eclampsia causes significant morbidity and mortality in the acute setting with multisystem involvement. We are now learning that while these acute effects resolve in the short to medium term, their legacy is long-lasting. In this chapter we explore the mechanisms involved in the development of long-term hypertension, chronic kidney disease, ischaemic heart and cerebrovascular disease, diabetes and venous thromboembolism. Ways in which the post-partum period can be used to improve the long-term health of these women are reviewed, including the difficulties in identifying subtle abnormalities in parameters such as post-partum blood pressure because normal values have been based on studies often done on middle-aged men. Unfortunately diet and exercise on their own appear to be ineffective in reducing the risk but are important first steps for new mothers to alter their longer-term risks and improve their journey through subsequent pregnancies.

All that wheezes is not asthma: A cautionary case study of shortness of breath in pregnancy

Background Shortness of breath is a common physiological pregnancy presentation, secondary to both hormonal and mechanical effects. Its pathological causes are common (asthma exacerbation or infection); new-onset cardiac pathology is rarely considered. Case JC, a 39-year old G4P2T1, presented at 34 weeks’ gestation with shortness of breath unrelieved by salbutamol. History included asthma, poly-drug abuse and smoking. Initial presentation was consistent with asthma exacerbation and she was treated as such. There was deterioration of symptoms and on re-examination raised jugular venous pressure was noted with bibasal lung crepitations and cardiac systolic murmur. Echocardiogram showed severe cardiomyopathy (left ventricular ejection fraction 20%). JC was commenced on diuretics, digoxin and fluid restricted. Labour was induced at 35 weeks’ gestation, with birth of a healthy female infant (BW 2475 g) by elective assisted vaginal delivery. Cardiac function improved in subsequent weeks, confirming peripartum cardiomyopathy. Conclusion Peripartum cardiomyopathy affects 1 in 2500–4000 live births. Over 90% of women regain normal cardiac function postpartum with optimal medical management. Peripartum cardiomyopathy presents a diagnostic conundrum as its primary symptoms mimic not only those of normal pregnancy but also a number of other, more common conditions. It is important to consider cardiac causes of shortness of breath initially, and vital to revisit an initial non-cardiac shortness of breath diagnosis if there is no sustained improvement with treatment. In this case, asthma history and initial wheeze on examination impeded correct diagnosis; however, the situation was re-evaluated and correct diagnosis made when the patient’s shortness of breath deteriorated. Subsequent multidisciplinary management and birth in an appropriate setting facilitated the best outcome for both mother and baby.