Sergio Ferrazzani

Proteinuria and outcome of 444 pregnancies complicated by hypertension

The purpose of this study was to determine the role of proteinuria on pregnancy outcome in 444 hypertensive women with singleton pregnancies. The patients were divided into three hypertensive groups: 98 with chronic hypertension, 199 with nonproteinuric gestational hypertension, and 147 with proteinuric preeclampsia and chronic hypertension with superimposed proteinuric preeclampsia. The presence of increased proteinuria (greater than 0.3 gm/L) predicted an adverse pregnancy outcome. Furthermore, the majority of small-for-gestational-age infants occurred in the group with proteinuric preeclampsia (52%), whereas the rate of small-for-gestational-age infants was 18% and 12% in the group with nonproteinuric gestational hypertension and chronic hypertension, respectively. The group with chronic hypertension did not show any increased risk for fetal outcome. Perinatal mortality rate was extremely poor in the group with proteinuric preeclampsia at 129 per 1000, four times higher than those of the other two groups.

The duration of hypertension in the puerperium of preeclamptic women: Relationship with renal impairment and week of delivery

OBJECTIVE The purpose of the study was to determine whether the duration of hypertension in the puerperium of preeclamptic women was related to certain clinical features of disease severity. STUDY DESIGN We studied 269 singleton pregnancies divided into two groups: 159 with gestational hypertension and 110 with preeclampsia. The normalization time of blood pressure in puerperium was estimated as the interval between the delivery day and the first day when each of two to four self-measurements per day of diastolic blood pressure was observed to be < or = 80 mm Hg for at least 3 consecutive days. RESULTS Normalization time was shorter in gestational hypertension than in preeclampsia (6 +/- 5.5 [means +/- SD] vs 16 +/- 9.5, respectively, p < 0.0001). Normalization time of gestational hypertension showed a significant correlation with uric acid (r = 0.20, p < 0.025); normalization time of preeclampsia displayed significant correlations with the week of delivery (r = -0.34, p < 0.005), uric acid (r = 0.34, p < 0.025), and urea nitrogen (r = 0.29, p < 0.025), respectively. After stratification by parity, in both groups the correlations of normalization time with renal data were observed only among multiparous women, whereas in preeclampsia the link of normalization time with the week of delivery remained highly significant in both subgroups. CONCLUSIONS The differences observed between gestational hypertension and preeclampsia suggest that distinct mechanisms or a different maternal answer to the same mechanism(s), in maintaining high blood pressure in puerperium, are present in the two groups. Normalization time might reflect the recovery time of the endothelial damage in preeclampsia.

Uterine myomectomy in pregnant women

Objective: To determine whether myomectomy during pregnancy in selected patients improves outcome. Methods: Retrospective analysis of 18 patients who underwent myomectomy between the 6th and 24th week of gestational age. Surgical management of tumors was required on the basis of the characteristics of the myomas and symptoms. The dimensions and site of myomas, symptoms of the patients, time and mode of delivery, and pregnancy outcome were analyzed. Results: One woman was lost to follow-up, and one suffered a miscarriage. The remaining 16 patients delivered healthy babies between the 36th and 41st week; 14 delivered by cesarean section, and 2 vaginally. Conclusion: We suggest that myomectomy during pregnancy may be considered safe in selected patients. Moreover, it permits good pregnancy outcome with healthy babies delivered at term.

Effect of maternal carbohydrate metabolism on fetal growth.

Objective To determine the effect of maternal carbohydrate metabolism and anthropometric characteristics on fetal growth. Methods Eight pregnant women in the third trimester with unexplained fetal growth restriction (FGR) and 11 women with normal pregnancies in the third trimester were evaluated for maternal carbohydrate metabolism, using oral glucose tolerance tests and hyperinsulinemic-euglycemic clamps. These data and maternal anthropometric characteristics subsequently were related to relative birth weight, defined as observed birth weight × 100/50th percentile birth weight. Results The women with FGR pregnancies were more insulin sensitive than were controls (21.6 ± 66 4.4 versus 16.7 ± 4.8 mmol/kg × min, P < .05) and showed reduced insulin and glucose areas under the curve (96,293 ± 25,870 versus 145,291 ± 49,356 pmol/L, P < .03; 1057.0 ± 184.7 versus 1210.1 ± 85.9 mmol/L, P < .05, respectively). No differences were seen in fasting plasma glucose, insulin and human placental lactogen samples, age, height, pregravid weight, weight gain, and parity. In all patients, maternal insulin sensitivity and weight gain correlated well with relative birth weight (r = −.65, P < .002; r = .68, P < .001, respectively). When the same analysis was computed separately in the groups, insulin sensitivity exhibited a strong negative correlation with relative birth weight in the FGR group but not in controls (r = −.84, P < .007; r = −.54, P = .08, respectively). Conversely, in control women the best correlation between relative birth weight and the other variables studied was seen with maternal weight gain (r = .82, P < .002). Conclusion Women with unexplained FGR have a differ-ent glucose metabolic pattern than do normals. We speculate that increased insulin sensitivity leads to a reduction in metabolic substrates for fetal growth.

Neonatal outcome in hypertensive disorders of pregnancy.

BACKGROUND Hypertensive disorders in pregnancy account for increased perinatal morbidity and mortality when compared to uneventful gestations. AIMS To analyze perinatal outcome of pregnancies complicated by different kinds of hypertension to uncomplicated pregnancies in a series of Italian women and to compare our data with series from other countries. STUDY DESIGN The sample was divided into four groups of hypertensive women: chronic hypertension (CH), gestational hypertension (GH), preeclampsia (PE), and chronic hypertension complicated by preeclampsia (CHPE). One thousand normal pregnancies served as controls. SUBJECTS Neonatal features of the offspring of 965 Italian women with hypertension in pregnancy were evaluated. MEASURES Gestational age, birthweight and the rate of small for gestational age were the outcomes. Perinatal asphyxia and mortality were also assessed. RESULTS Gestational age, the mean of birth weight and birth percentile were significantly lower in all groups with hypertensive complications when compared with controls. The rate of very early preterm delivery (<32 weeks) was 7.8% in CH, 5.9% in GH, 21.2% in PE and 37.2% in CHPE while it was to 1.2% in the control group. The rate of SGA was globally 16.2% in CH, 22.8% in GH, 50.7% in PE, 37.2% in CHPE and 5% in controls. The rate of SGA in PE was much higher than reported in series from other countries. CONCLUSION Comparing our data with those reported from other countries, it is evident that the rate of fetal growth restriction in PE we found in our center, is significantly higher even in the presence of a global lower incidence of PE.

Predictors of Pregnancy Outcome in Antiphospholipid Syndrome: A Review

In pregnant women, antiphospholipid syndrome (APS) is associated with an increased risk of preeclampsia, fetal intrauterine growth restriction, and other complications related to uteroplacental insufficiency. In the last two decades, several studies were performed to identify the predictive role of some parameters in relation to obstetric outcome in APS patients. Among these, the uterine velocimetry Doppler is the most studied. It provides a non-invasive method for the study of uteroplacental blood flow, being able to detect a condition of impaired placental perfusion, due to the presence of circulating antiphospholipid antibodies (aPL). To date, the uterine artery Doppler velocimetry resulted to be a useful tool to identify APS pregnancies at higher risk of adverse pregnancy outcome. False-positive IgM for toxoplasmosis, others, rubella, cytomegalovirus, herpes viruses (TORCH) complex is associated to a worse pregnancy outcome because it reflects a dysregulation of the immune system which may amplify placental autoimmune damage. Moreover low levels of complement components are related to an increased incidence of obstetrical complications, suggesting that placental deposition of immune complexes and activation of complement cascade may contribute to placental failure APS related. The abnormal uterine Doppler velocimetry, false-positive TORCH IgM and low levels of complement components can be considered prognostic indexes of poor pregnancy outcome in APS.

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis.

OBJECTIVE We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes. STUDY DESIGN We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI. RESULTS Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1). CONCLUSION Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Emergency cerclage in the presence of protruding membranes: is pregnancy outcome predictable?

Background. The aim of this retrospective study is to verify whether some maternal features are related to pregnancy outcome in cases of emergency mid‐trimester cerclage when membranes are protruding through the dilated cervix.

Poor Pregnancy Outcome and Anticardiolipin Antibodies

The present study reports for the first time on the presence of anticardiolipin antibodies (aCL) in a population of 259 women with a history of recurrent abortion, intrauterine death, and/or neonatal death associated with fetal growth restriction, preeclampsia and abruptio placentae. The overall incidence of aCL in this study group was 20.5%, a statistically significant increase in comparison with a control group. The highest positive rate was observed among women who presented both recurrent abortion and intrauterine death (33.3%), the lowest was observed among women with a history of neonatal death. Our findings confirm that aCL are strongly linked with fetal loss. Thus, before planning a subsequent pregnancy, the presence of aCL should be tested in all women with poor pregnancy outcome.

The impact of primary Sjogren's syndrome on pregnancy outcome: Our series and review of the literature

OBJECTIVE Firstly, to investigate the pregnancy outcome of women with primary Sjogrens Syndrome (pSS) in a case-control study; secondly, to perform a review of the literature in order to clarify if the pregnancy outcome is affected by pSS and influenced by the disease clinical onset. METHOD OF STUDY Thirty-four pregnancies with pSS and 136 controls were retrospectively collected. RESULTS Six pregnancies occurred before the pSS diagnosis and 28 after the pSS diagnosis. Two cases were complicated by intrauterine atrio-ventricular block. A statistically significant increase of the rate of spontaneous abortions, preterm deliveries and cesarean section was found in pSS pregnancies. The mean neonatal birth weight and the mean neonatal birth weight percentile were significantly lower in the offspring of women with pSS in comparison to controls. Similar pregnancy outcome was observed in women with pSS diagnosis before and after the index pregnancy. CONCLUSIONS Women with pSS experienced complicated pregnancies more frequently than controls, regardless of the onset of the symptoms, showing that the immunological disturbance is present throughout the reproductive life.