Nnabuike Chibuoke Ngene

Physiology of blood pressure relevant to managing hypertension in pregnancy

Abstract Purpose: Pregnancy causes physiological changes in maternal organ systems, and blood pressure (BP) is one of the variables affected. This review is focusing on the physiology of BP relevant to the management of hypertension in pregnancy. Materials and methods: A detailed literature search was performed using electronic databases (including WorldCat, PubMed, MEDLINE, Google Scholar) to retrieve and review reports related to physiology of BP in pregnancy. Results: During pregnancy, there is vasodilation caused by mediators such as increased levels of progesterone and nitric oxide. The vasodilation leads to a reduction in vascular resistance, BP, and renal blood flow. In compensation, the following postulated events occur: activation of renin-angiotensin-aldosterone axis, resetting of osmotic threshold for thirst, and an increase in the production of vasopressin. Sodium and water conservation ensue to increase the total body water, end-diastolic volume, cardiac output, and BP. The increase in cardiac output incompletely compensates for the decreased vascular resistance, and BP therefore decreases in midpregnancy and returns to prepregnancy level toward term. Conclusions: An understanding of the physiological changes in BP is essential for appropriate management of pregnancy-related hypertension.

Characteristics of women having first-trimester termination of pregnancy at a district hospital in KwaZulu-Natal

Termination of pregnancy (TOP) is requested by some women for a variety of reasons and it is plausible that profling their characteristics might help to target selected groups for counselling. This study aimed to determine the characteristics of women having a legal first-trimester TOP at a regional hospital in KwaZulu-Natal. The medical records of 254 women were retrospectively sampled and analysed from a total of 758 women who had a first-trimester TOP between January and December 2008. The women were aged 14-45 years (the most common age group was 20-29 years, a mean age of 25.3 years and a standard deviation of 5.9). The majority (75.6%) reported that they had at least one child who was alive, 1.6% had previously had a TOP, 93.3% were single and 28.4% resided outside the health district in which the hospital was situated. Eighty-nine per cent had not used contraception before the index pregnancy. Fifty-eight per cent requested a TOP between 9 and 12 weeks of gestation (a mean of 8 weeks). Ninety-six p...

Role of angiogenic factors in the pathogenesis and management of pre-eclampsia

The cause of pre‐eclampsia is unknown. Different postulates have been developed to explain its pathogenesis. The two‐stage theory and angiogenic imbalance are two notable postulates of the disease. Together, they propose that there is a lack of cytotrophoblastic invasion of the uterine spiral arteries in pre‐eclampsia. The lumen of these arteries remains narrow instead of converting to the wide channels seen in normal pregnancy, and result in poor placental perfusion. Coupled with maternal susceptibility, this process leads to the release of mediators, including an excess of anti‐angiogenic factors that result in the clinical manifestations of the disease. Circulating levels of anti‐angiogenic factors such as soluble fms‐like tyrosine kinase‐1 increase, whereas pro‐angiogenic factors such as placental growth factor decrease. Assessment of the circulating concentrations of these angiogenic factors, such as the soluble fms‐like tyrosine kinase‐1/placental growth factor ratio, has diverse clinical relevance in pre‐eclampsia. The present review describes the role of angiogenic factors in the pathogenesis and management of pre‐eclampsia.

Assigning appropriate primary cause of death and indication for medical procedures

The most appropriate primary cause of death in a patient who had multiple medical conditions is that medical condition which initiated the chain of events that led to the other medical conditions that resulted in death. In clinical practice, there are deceased patients who had several medical conditions that could lead to death (primary causes of death) without biological plausibility that any of the medical conditions initiated the chain of events that resulted in the other medical conditions. To assign the single most appropriate primary cause of death to such a deceased patient is challenging. Under such circumstances, the International classification of diseases and related health problems, tenth revision (ICD-10) guidelines recommend that the medical practitioner certifying the death should decide on the primary cause to be assigned. The ICD-10 also acknowledges that the recommendation is arbitrary. Similar difficulty is also encountered when a single indication is being assigned to a patient for a medical procedure when there are multiple indications for such a procedure. The ICD-10 and its clinical modification (ICD-10-CM) which provides the guidelines for assigning indication for a medical procedure use criteria that are insufficient. In the present article, comprehensive, easy and objective clinicopathological criteria on how to assign the single most appropriate primary cause of death or indication for a medical procedure are recommended. The new criteria (referred to NJ model II) may be used to improve the ICD-10.

Antepartum uterine rupture in a twin gestation presenting as an advanced extrauterine pregnancy in a patient with a previous lower segment Caesarean section

We present a case of spontaneous antepartum uterine rupture through a previous lower segment Caesarean section (LSCS) scar with clinical features mimicking an advanced extrauterine pregnancy (AEUP) in a twin pregnancy at 28 weeks gestation. This report illustrates the need to consider a diagnosis of a ruptured uterus in any patient with a previous abdominal delivery who presents with mild abdominal tenderness and an ultrasonographic image suggestive of demised fetus in the intra-peritoneal cavity.

Assigning appropriate and comprehensive diagnosis for scientific report

The use of currently available guidelines such as the International Classification of Diseases, 10th Revision (ICD-10) and its clinical modification to assign a principal diagnosis to a patient who has multiple principal diagnoses appears unreliable. This is because these guidelines are complex and uses criteria that are highly subjective. Even when one main diagnosis is selected, the comprehensive list of other diseases that the patient has is often not reported such that the overall clinical condition of the patient is obscured. To address these issues, we have proposed: (i) a simple, potentially reliable and stepwise guide that can be used to assign the single most appropriate main principal diagnosis to each patient and illustrated this with case reports (ii) how to simultaneously report the main and other diagnoses in a scientific paper. It is hoped that our proposal (named NJ model for easy referencing) will help standardize how diagnosis is assigned to patients.

Should uterotonic agents be avoided during cesarean hysterectomy for placenta previa accreta

1. Farquhar C, Naoom S, Steiner C. The impact of endometrial ablation on hysterectomy rates in women with benign uterine conditions in the United States. Int J Techn Assess Health Care. 2002;18:625–34. 2. Flynn M. Health care resource use for uterine fibroid tumors in the United States. Am J Obstet Gynecol. 2006;195:955–64. 3. Groff J, Mullen P, Byrd T, Shelton A, Lees E, Goode J. Decision making, beliefs and attitudes toward hysterectomy: a focus group study with medically underserved women in Texas. J Womens Health. 2000;9:S39–50. 4. Araujo T, Aquino E. Risk factors for hysterectomy in Brazil. Cad Sa ude P ublica. 2003;19:S407–17. 5. Bardin L. Content analysis, 1st edn. Lisbon: Edic ~ oes 70, 1977.

Baseline check of blood pressure readings of an automated device in severe pre-eclampsia and healthy normotensive pregnancy

OBJECTIVE The baseline blood pressure (BP) readings of an automated device that have not been validated in pregnancy require comparison with those from a reference standard before the device is utilized in pregnancy. We aimed to perform a baseline check of BP readings of an automated device, Mindray iMEC12 patient monitor, in severe pre-eclampsia and healthy pregnancy. STUDY DESIGN The BP of 50 severe pre-eclamptic and 90 normotensive pregnancies were measured using Mindray iMEC12 patient monitor (test device) and Welch Allyn 767 aneroid sphygmomanometer (reference device). A pass in either the International Organization for Standardization (ISO) or British Hypertension Society (BHS) rating was considered acceptable. The cumulative percentage of absolute BP difference between the test and reference devices within 5, 10 and 15 mmHg were calculated to rate the test device according to the BHS grades (A, B, C or D). The ISO recommends that an accurate device should achieve a mean BP difference ± SD of ≤5 ± 8 mmHg. RESULTS The mean BP difference between the test and reference devices were 1.27 ± 7.51 mmHg and 0.05 ± 6.09 mmHg for systolic and diastolic BPs respectively. The test device achieved the BHS grades B and A rating in systolic and diastolic BPs respectively. In each of the 2 groups (pre-eclamptic and normotensive pregnancies), the test device also satisfied the set pass criteria. CONCLUSIONS In settings that do not have a validated BP device, Mindray iMEC12 patient monitor may be used for BP measurement in normotensive and severe pre-eclamptic pregnancies.

Clinical awareness for health care professionals: Fatal encephalopathy complicating persistent vomiting in pregnancy.

Women with persistent vomiting during pregnancy need early referral to appropriate health facilities. Delayed referral and inappropriate management may lead to metabolic encephalopathy from a variety of causes, including electrolyte derangements or thiamine deficiency (Wernickes encephalopathy) (WE). We present a case of persistent vomiting in pregnancy in which there was delayed referral, inappropriate treatment and failure to associate neurological signs such as terminal neck stiffness with WE, resulting in poor fetomaternal outcomes. In this report, we discuss the following lessons: (i) the need for early transfer of a patient with persistent vomiting and enigmatic clinical features to a higher healthcare facility; (ii) failure to associate neurological signs with complications of hyperemesis gravidarum/WE; (iii) lack of thiamine supplementation; and (iv) the advantages of magnetic resonance imaging over a computed tomography scan in the diagnosis of WE.

Severe hypertension in pregnancy: Using dynamic checklists to save lives.

Severe hypertension is a major cause of morbidity and mortality. The South African Saving Mothers report (2011 - 2013) indicates that cerebral injury due to severe hypertension is resulting in avoidable maternal deaths. This demands that management of severe hypertension in pregnancy needs to be improved. A rapid-acting antihypertensive is recommended for the initial management of severe hypertension during pregnancy. A single dose of a rapid-acting agent may be ineffective, in which case incremental doses of the same medication or another antihypertensive may be required for adequate blood pressure control. To ensure that appropriate antihypertensives at the correct doses are administered, the use of a guideline in a dynamic checklist format is advocated and discussed in this article. It is envisaged that the use of dynamic checklists will be valuable to all healthcare professionals providing care during pregnancy and the puerperium.