Mario Merialdi

Prediction of adverse maternal outcomes in pre-eclampsia: development and validation of the fullPIERS model

BACKGROUNDnPre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder.nnnMETHODSnWe developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting.nnnFINDINGSn261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility.nnnINTERPRETATIONnThe fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia.nnnFUNDINGnCanadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.

Nutritional Interventions during Pregnancy for the Prevention or Treatment of Maternal Morbidity and Preterm Delivery: An Overview of Randomized Controlled Trials

This overview assesses the effectiveness of nutritional interventions to prevent or treat maternal morbidity, mortality and preterm delivery. Cochrane systematic reviews and other up-to-date systematic reviews and individual randomized controlled trials were sought. Searches were carried out up to July 2002. Iron and folate supplements reduce anemia and should be included in antenatal care programs. Calcium supplementation to women at high risk of hypertension during pregnancy or low calcium intake reduced the incidence of both preeclampsia and hypertension. Fish oil and vitamins E and C are promising for preventing preeclampsia and preterm delivery and need further testing. Vitamin A and beta-carotene reduced maternal mortality in a large trial; ongoing trials should provide further evaluation. No specific nutrient supplementation was identified for reducing preterm delivery. Nutritional advice, magnesium, fish oil and zinc supplementation appear promising and should be tested alone or together in methodologically sound randomized controlled trials. Anema in pregnancy can be prevented and treated effectively. Considering the multifactorial etiology of the other conditions evaluated, it is unlikely that any specific nutrient on its own, blanket interventions or magic bullets will prevent or treat preeclampsia, hemorrhage, obstructed labor, infections, preterm delivery or death during pregnancy. The few promising interventions for specific outcomes should be tested or reconsidered when results of ongoing trials become available. Until then, women and their families should receive support to improve their diets as a general health rule, which is a basic human right.

A Risk Prediction Model for the Assessment and Triage of Women with Hypertensive Disorders of Pregnancy in Low-Resourced Settings: The miniPIERS (Pre-eclampsia Integrated Estimate of RiSk) Multi-country Prospective Cohort Study

Beth Payne and colleagues use a risk prediction model, the Pre-eclampsia Integrated Estimate of RiSk (miniPIERS) to help inform the clinical assessment and triage of women with hypertensive disorders of pregnancy in low-resourced settings. Please see later in the article for the Editors Summary

Short Maternal Stature Increases Risk of Small-for-Gestational-Age and Preterm Births in Low- and Middle-Income Countries: Individual Participant Data Meta-Analysis and Population Attributable Fraction

BACKGROUNDnSmall-for-gestational-age (SGA) and preterm births are associated with adverse health consequences, including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease.nnnOBJECTIVESnThe specific aims of this study were to estimate the association between short maternal stature and outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and preterm birth associated with short maternal stature.nnnMETHODSnWe conducted an individual participant data meta-analysis with the use of data sets from 12 population-based cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low- and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure categories of < 145 cm, 145 to < 150 cm, and 150 to < 155 cm (reference: ≥ 155 cm) and outcomes of SGA, preterm birth, and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference. The associations were then meta-analyzed.nnnRESULTSnAll short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to define SGA, women < 145 cm had the highest adjusted risk ratios (aRRs) (term SGA-aRR: 2.03; 95% CI: 1.76, 2.35; preterm AGA-aRR: 1.45; 95% CI: 1.26, 1.66; preterm SGA-aRR: 2.13; 95% CI: 1.42, 3.21). Similar associations were seen for SGA defined by the US reference. Annually, 5.5 million term SGA (18.6% of the global total), 550,800 preterm AGA (5.0% of the global total), and 458,000 preterm SGA (16.5% of the global total) births may be associated with maternal short stature.nnnCONCLUSIONSnApproximately 6.5 million SGA and/or preterm births in LMIC may be associated with short maternal stature annually. A reduction in this burden requires primary prevention of SGA, improvement in postnatal growth through early childhood, and possibly further intervention in late childhood and adolescence. It is vital for researchers to broaden the evidence base for addressing chronic malnutrition through multiple life stages, and for program implementers to explore effective, sustainable ways of reaching the most vulnerable populations.

Characteristics of Randomized Controlled Trials Included in Systematic Reviews of Nutritional Interventions Reporting Maternal Morbidity, Mortality, Preterm Delivery, Intrauterine Growth Restriction and Small for Gestational Age and Birth Weight Outcomes

*UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, WHO, CH–1211 Geneva 27, Switzerland, yCentro Rosarino de Estudios Perinatales (CREP), WHO Collaborative Center in Maternal and Child Health, Rosario 2000, Argentina, **Geneva Foundation for Medical Education and Research, Geneva, Switzerland and zDepartment of Nutrition, WHO, CH–1211 Geneva 27, Switzerland

Effects of calcium supplementation on fetal growth in mothers with deficient calcium intake: a randomised controlled trial

Calcium supplementation in mothers with low calcium intake has been of interest recently because of its association with optimal fetal growth and improved pre-eclampsia-related outcomes. While the effects of calcium supplementation have demonstrated benefits in prolonging gestation and subsequently improving birthweight, no specific studies have identified the longitudinal effects of supplementation on fetal growth in utero. Data were analysed in the context of the World Health Organization trial of calcium supplementation in calcium-deficient women. Five hundred and ten healthy, primiparous pregnant Argentinean women were randomised (at <20 weeks gestation) to either placebo (n = 230) or calcium supplements (1500 mg calcium/day in 3 divided doses; n = 231). Growth parameters in utero were assessed with serial ultrasound scans. Birthweight, length, head, abdominal and thigh circumferences were recorded at delivery. No differences were found in fetal biometric measurements recorded at 20, 24, 28, 32 and 36 weeks gestation between fetuses of women who were supplemented with calcium and those who were not. Similarly, neonatal characteristics and anthropometric measurements recorded at delivery were comparable in both groups. We conclude that calcium supplementation of 1500 mg calcium/day in pregnant women with low calcium intake does not appear to impact on fetal somatic or skeletal growth.

From safe motherhood, newborn, and child survival partnerships to the continuum of care and accountability: Moving fast forward to 2015

The present paper provides an overview of the Safe Motherhood Initiative, Healthy Newborn Partnership, and Child Survival Partnership and their eventual merge into the Partnership for Maternal, Newborn and Child Health (PMNCH) in 2005. The promise and past successes of the PMNCH are highlighted, with a particular focus on the PMNCHs partner‐centric approach showing the importance of collaboration for progress. The aims of the strategic framework for 2012–2015 are presented within the context of the Global Strategy for Womens and Childrens Health, launched in 2010, and growing political momentum to achieve Millennium Development Goals 4 and 5 (reduce child mortality and improve maternal health, respectively). The next 4 years leading to 2015 are critical, and the global community must continue to work together to ensure all women and children are reached with key interventions proven to reduce mortality.

Maternal Obesity: Demography of obesity

Introduction According to the World Health Organization (WHO), overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health [1]. Overweight and obesity are usually diagnosed when weight normalized for height, or body mass index (BMI: weight in kilograms divided by the square of the height in meters, kg/m2), exceeds a defined threshold. In 1995, the WHO proposed a BMI classification for adults as a form of diagnosing excess adiposity [2]. According to this classification, individuals are considered overweight when their BMI is ≥25; those between 25 and 29.9 are designated as pre-obese and they are classified as obese when their BMI reaches or exceeds 30 kg/m2 (Table 1.1). Many authors also use the term “overweight” to designate pre-obese individuals (BMI 25–29.9), which gives rise to some confusion, unless the specific range of BMI is specified. Although BMI does not directly measure the percentage of body fat, it offers a more accurate assessment of excess adiposity than weight alone. Due to its simplicity, BMI categorization is the preferred obesity measurement for clinicians, public health specialists, and researchers, and is currently used worldwide to track adult overweight and obesity prevalence [3]. Although BMI categorization is widely used, it has several limitations. The proposed BMI classification is age and gender independent and it may not reflect the same degree of adiposity in different populations, due to different body proportions in different ethnicities. Therefore, since the health risks associated with increasing BMI are continuous, the interpretation of BMI gradings in relation to risk may differ for different populations. Due to a growing debate in recent years on the need to develop different BMI cut-off points for different ethnic groups, the WHO convened an expert consultation on BMI in Asian populations [4] to address this issue. Despite evidence that Asian individuals may be at higher than average risk at BMIs lower than the existing WHO cut-off point for overweight (25 kg/m2), the experts observed that there is a large heterogeneity among the ideal cut-off points for