Michael de Swiet

THE CLASSIFICATION AND DIAGNOSIS OF THE HYPERTENSIVE DISORDERS OF PREGNANCY: STATEMENT FROM THE INTERNATIONAL SOCIETY FOR THE STUDY OF HYPERTENSION IN PREGNANCY (ISSHP)

The literature relating to classification of the hypertensive disorders in pregnancy and diagnostic definitions of each hypertensive category has been and remains confusing to clinicians and investigators (1). One encounters an assortment of terms and schemes, some quite complex and detailed, and on occasion, the same term (e.g., pregnancy-induced hypertension) is used to include different disorders by various authors. This lack of consensus on classification and diagnosis is one reason for controversies in a variety of areas, including counseling, management, and documenting immediate and remote outcomes. Cognizant of these problems, the Council of the ISSHP appointed a committee to consider these issues, adopting many of their recommendations at the 12th World Congress in Paris, France, in July 2000. The following is a summary of the adopted report. The first charge to this committee, formed in October 1998, was to monitor the progress of the two working groups that were in the process of updating previous reports, one for the Australasian Society for the Study of Hypertension in Pregnancy (ASSHP) and the other for the National High Blood Pressure Education Program (NHBPEP) in the United States. These have now been published (2,3) and have been considered along with currently published criteria (e.g., the older ISSHP (4), WHO (3, and Canadian Hypertension Society (6) reports).

Clinical outcome in a series of cases of obstetric cholestasis identified via a patient support group

Objective  To explore the clinical features of obstetric cholestasis pregnancies in UK white Caucasians.

Association of raised titres of antibodies to Chlamydia pneumoniae with a history of pre-eclampsia

Objective  To establish the prevalence of Chlamydia pneumoniae (C. pneumoniae) infection in a pregnant UK population and to investigate whether C. pneumoniae infection is more common in women with a previous history of pre‐eclampsia.

Preeclampsia with Abnormal Liver Function Tests Is Associated with Cholestasis in a Subgroup of Cases

Objective: To investigate whether women with preeclampsia and abnormal liver function tests have raised serum bile acids. Design: Measurement of serum bile acids in serum specimens collected at the John Radcliffe Hospital, Oxford. Setting: Imperial College School of Medicine. Sample: Stored sera from 37 women with preeclampsia and abnormal liver function tests and from 19 controls. Methods: Enzymic total bile acid assay. Main outcome measures: Total bile acid levels. Results: Women with preeclampsia and abnormal liver function tests had higher median bile acid levels than controls (5.7 vs. 3.2, p = 0.01). The reason for the raised median serum bile acid levels in the patient group is that three (8%) women with preeclampsia had markedly raised serum bile acids levels. There were no obvious clinical or biochemical features specific to these patients. Conclusions: The pathological mechanisms causing hepatic impairment in some women with preeclampsia may predispose to cholestasis. As some women with preeclampsia and abnormal liver function complain of pruritus, we recommend checking the serum bile acids in this group of women. If these acids are raised the fetal prognosis may be adversely affected.

Maternal mortality in the UK and the need for obstetric physicians

Most deaths are now caused by preventable or treatable medical conditions

Impaired vasoconstriction in pregnancy-induced hypertension assessed using Doppler fluximetry

Objective To determine whether there is a difference in peripheral vascular reactivity between normal women and those with pregnancy-induced hypertension. Methods Capillary blood flow (flux) was recorded in the skin over the ankle in 26 pregnant women with pregnancy-induced hypertension at term. Twelve of these women had proteinuria, and 14 were nonproteinuric. Leg lowering was used to activate the venoarteriolar reflex, and the resultant change in flux, expressed as a percentage change from the baseline, was used as an index of vascular reactivity. The results were compared with those of a control group comprising 23 matched normotensive women. The study was repeated on all of the women after delivery. Results Women with hypertension showed a median (range) increase in flux of +24.4% (−15.5% to +151.1%), significantly different from controls: −39.3% (−80.9% to −4.3%, P < .001). This difference persisted regardless of the presence or absence of proteinuria. Responses in women with pregnancy-induced hypertension were significantly different after delivery (median −60.7%; range −158.5% to −19.5%, P < .001) when compared with predelivery responses. Similar changes as a result of delivery were seen in women with proteinuric (medians +25.9% and −57.9%, P < .002) and nonproteinuric (medians +7.8% and −62.8%, P < .001) hypertension but not in controls. Postdelivery responses in women with hypertension were no different from those of controls. Conclusion Women with pregnancy-induced hypertension have abnormal cutaneous vascular reactivity that returns to normal after delivery.

A randomised trial of low dose aspirin for primiparae in pregnancy (Golding)/Barbados low dose aspirin study in pregnancy (BLASP) (Rotchell et al.)

Sic Two articles recently published in the British Journal of Obstetrics and Gynaecologv by Golding and Rotchell et al. (Vol 105, March 1998)I.j conclude that low dose aspirin is not helpful in reducing the risk of preeclampsia in primiparae or among a general population in the West Indies. In the Barbados trial enrolment was between 12 and 32 weeks and the preparations used was 75 mg aspirin daily. However, almost half the women were enrolled after 20 weeks gestation and of those enrolled before 20 weeks we do not know when this took place. Finally, only 42% of patients took their tablets for greater than 95% of the time. In the Jamaican trial the dose of aspirin used was 60 mg daily and the mean gestation at enrolment was 19.6 i 5.9 weeks (mean k 1 SD). Finally, only 57.2% of patients complied with their treatment. These large scale trials are similar to others, such as CLASPz or NIH4, when again enrolment only took place during the second trimester. Before people draw irreversible conclusions about the role of low dose aspirin in the prevention of pre-eclampsia the following points should be taken into consideration: