Search

Objective To evaluate the association between deferred delivery in early‐onset pre‐eclampsia and offspring outcome and maternal cardiovascular, renal and metabolic function in the postpartum period. Design Observational study. Setting Tertiary referral hospital. Population Nulliparous women diagnosed with pre‐eclampsia before 34 weeks’ gestation who participated in a routine postpartum cardiovascular risk assessment programme. Women with hypertension, diabetes mellitus or renal disease prior to pregnancy were excluded. Methods Regression analyses were performed to assess the association between pregnancy prolongation and outcome measures. Main outcome measures Offspring outcome and prevalence of deviant maternal cardiovascular, renal and metabolic function. Results The study population included 564 women with a median pregnancy prolongation of 10 days (interquartile range [IQR] 4–18) who were assessed at on average 8 months (IQR 6–12) postpartum. Pregnancy prolongation after diagnosis resulted in a decrease in infant mortality (adjusted odd ratio [aOR] 0.907, 95% CI 0.852–0.965 per day prolongation). This improvement in offspring outcome was associated with an elevated risk of moderately increased albuminuria (aOR 1.025, 95% CI 1.006–1.045 per day prolongation), but not with aberrant cardiac geometry, cardiac systolic or diastolic dysfunction, persistent hypertension or metabolic syndrome. Conclusion Pregnancy prolongation in early‐onset pre‐eclampsia is associated with improved offspring outcome and survival. These effects do not appear to be deleterious to short‐term maternal cardiovascular and metabolic function but are associated with a modest increase in risk of residual albuminuria. Tweetable abstract Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function., Tweetable abstract Pregnancy prolongation in pre‐eclampsia has only a limited effect on postpartum maternal cardiovascular function.

Objective To determine the performance of a glycosylated fibronectin (GlyFn) point‐of‐care (POC) test for pre‐eclampsia (PE) in a large Southeast Asian cohort (India) in comparison to previously described biomarkers. Design A total of 798 pregnant women at ≥20 weeks of gestation were enrolled in a prospective case‐control study. Study participants included 469 normotensive women with urinary mg protein/mmol creatinine ratio, Tweetable abstract The Lumella™ point‐of‐care test had excellent performance in diagnosing PE in a large Southeast Asian cohort.

Summary Objective Women with pre‐eclampsia have elevated circulating levels of soluble fms‐like tyrosine kinase‐1 (sFlt‐1). Statins can reduce sFlt‐1 from cultured cells and improve pregnancy outcome in animals with a pre‐eclampsia‐like syndrome. We investigated the effect of pravastatin on plasma sFlt‐1 levels during pre‐eclampsia. Design Blinded (clinician and participant), proof of principle, placebo‐controlled trial. Setting Fifteen UK maternity units. Population We used a minimisation algorithm to assign 62 women with early‐onset pre‐eclampsia (24+0–31+6 weeks of gestation) to receive pravastatin 40 mg daily (n = 30) or matched placebo (n = 32), from randomisation to childbirth. Primary outcome Difference in mean plasma sFlt‐1 levels over the first 3 days following randomisation. Results The difference in the mean maternal plasma sFlt‐1 levels over the first 3 days after randomisation between the pravastatin (n = 27) and placebo (n = 29) groups was 292 pg/ml (95% CI −1175 to 592; P = 0.5), and over days 1–14 was 48 pg/ml (95% CI −1009 to 913; P = 0.9). Women who received pravastatin had a similar length of pregnancy following randomisation compared with those who received placebo (hazard ratio 0.84; 95% CI 0.50–1.40; P = 0.6). The median time from randomisation to childbirth was 9 days (interquartile range [IQR] 5–14 days) for the pravastatin group and 7 days (IQR 4–11 days) for the placebo group. There were three perinatal deaths in the placebo‐treated group and no deaths or serious adverse events attributable to pravastatin. Conclusions We found no evidence that pravastatin lowered maternal plasma sFlt‐1 levels once early‐onset pre‐eclampsia had developed. Pravastatin appears to have no adverse perinatal effects. Tweetable abstract Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds., Tweetable abstract Pravastatin does not improve maternal plasma sFlt‐1 or placental growth factor levels following a diagnosis of early preterm pre‐eclampsia #clinicaltrial finds.

Objective To assess the effectiveness of introducing condom‐catheter uterine balloon tamponade (UBT) for postpartum haemorrhage (PPH) management in low‐ and middle‐income settings. Design Stepped wedge, cluster‐randomised trial. Setting Eighteen secondary‐level hospitals in Uganda, Egypt and Senegal. Population Women with vaginal delivery from October 2016 to March 2018. Methods Use of condom‐catheter UBT for PPH management was introduced using a half‐day training and provision of pre‐packaged UBT kits. Hospitals were randomised to when UBT was introduced. The incident rate (IR) of study outcomes was compared in the control (i.e. before UBT) and intervention (i.e. after UBT) periods. Mixed effects regression models accounted for clustering (random effect) and time period (fixed effect). Main outcome measures Combined IR of PPH‐related invasive surgery and/or maternal death. Results There were 28 183 and 31 928 deliveries in the control and intervention periods, respectively. UBT was used for 9/1357 and 55/1037 women diagnosed with PPH in control and intervention periods, respectively. PPH‐related surgery or maternal death occurred in 19 women in the control period (IR = 6.7/10 000 deliveries) and 37 in the intervention period (IR = 11.6/10 000 deliveries). The adjusted IR ratio was 4.08 (95% confidence interval 1.07–15.58). Secondary outcomes, including rates of transfer and blood transfusion, were similar in the trial periods. Conclusions Introduction of condom‐catheter UBT in these settings did not improve maternal outcomes and was associated with an increase in the combined incidence of PPH‐related surgery and maternal death. The lack of demonstrated benefit of UBT introduction with respect to severe outcomes warrants reflection on its role. Tweetable abstract Stepped wedge trial shows UBT introduction does not reduce the combined incidence of PPH‐related surgery or death., Tweetable abstract Stepped wedge trial shows UBT introduction does not reduce the combined incidence of PPH‐related surgery or death.

Objective To calculate the cost‐effectiveness of implementing PlGF testing alongside a clinical management algorithm in maternity services in the UK, compared with current standard care. Design Cost‐effectiveness analysis. Setting Eleven maternity units participating in the PARROT stepped‐wedge cluster‐randomised controlled trial. Population Women presenting with suspected pre‐eclampsia between 20+0 and 36+6 weeks’ gestation. Methods Monte Carlo simulation utilising resource use data and maternal adverse outcomes. Main outcome measures Cost per maternal adverse outcome prevented. Results Clinical care with PlGF testing costs less than current standard practice and resulted in fewer maternal adverse outcomes. There is a total cost‐saving of UK£149 per patient tested, when including the cost of the test. This represents a potential cost‐saving of UK£2,891,196 each year across the NHS in England. Conclusions Clinical care with PlGF testing is associated with the potential for cost‐savings per participant tested when compared with current practice via a reduction in outpatient attendances, and improves maternal outcomes. This economic analysis supports a role for implementation of PlGF testing in antenatal services for the assessment of women with suspected pre‐eclampsia. Tweetable abstract Placental growth factor testing for suspected pre‐eclampsia is cost‐saving and improves maternal outcomes., Tweetable abstract Placental growth factor testing for suspected pre‐eclampsia is cost‐saving and improves maternal outcomes.

Objective To identify clinical features associated with pulmonary embolism (PE) diagnosis and determine the accuracy of decision rules and D‐dimer for diagnosing suspected PE in pregnant/postpartum women Design Observational cohort study augmented with additional cases. Setting Emergency departments and maternity units at eleven prospectively recruiting sites and maternity units in the United Kingdom Obstetric Surveillance System (UKOSS) Population 324 pregnant/postpartum women with suspected PE and 198 pregnant/postpartum women with diagnosed PE Methods We recorded clinical features, elements of clinical decision rules, D‐dimer measurements, imaging results, treatments and adverse outcomes up to 30 days Main outcome measures Women were classified as having PE on the basis of imaging, treatment and adverse outcomes by assessors blind to clinical features and D‐dimer. Primary analysis was limited to women with conclusive imaging to avoid work‐up bias. Secondary analyses included women with clinically diagnosed or ruled out PE. Results The only clinical features associated with PE on multivariate analysis were age (odds ratio 1.06; 95% confidence interval 1.01–1.11), previous thrombosis (3.07; 1.05–8.99), family history of thrombosis (0.35; 0.14–0.90), temperature (2.22; 1.26–3.91), systolic blood pressure (0.96; 0.93–0.99), oxygen saturation (0.87; 0.78–0.97) and PE‐related chest x‐ray abnormality (13.4; 1.39–130.2). Clinical decision rules had areas under the receiver‐operator characteristic curve ranging from 0.577 to 0.732 and no clinically useful threshold for decision‐making. Sensitivities and specificities of D‐dimer were 88.4% and 8.8% using a standard threshold and 69.8% and 32.8% using a pregnancy‐specific threshold. Conclusions Clinical decision rules and D‐dimer should not be used to select pregnant or postpartum women with suspected PE for further investigation. Clinical features and chest x‐ray appearances may have counter‐intuitive associations with PE in this context. Tweetable abstract Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE, Tweetable abstract Clinical decision rules and D‐dimer are not helpful for diagnosing pregnant/postpartum women with suspected PE.

Objective The aim of this study was to investigate the occurrence of hyponatraemia following delivery, with a hypothesis that hyponatraemia has a high prevalence in labouring women. Design Prospective observational study. Setting Consultant-led delivery suite in County Hospital, Kalmar, Sweden. Sample A total of 287 pregnant women at term (37 full gestational weeks). Methods Oral fluids were allowed during labour. Blood samples were collected on admission, after delivery, and from the umbilical artery and vein. Main outcome measure Hyponatraemia defined as plasma sodium ≤130 mmol/l after delivery. Results Hyponatraemia was found in 16 (26%) of the 61 mothers who received more than 2500 ml of fluid during labour. Two-thirds of fluids were orally ingested. Decrease in plasma sodium concentration during labour correlated with duration of labour and the total fluid volume administered. Analysis by multivariate logistic regression showed that hyponatraemia was significantly correlated with fluid volume (P < 0.001) but not with oxytocin administration or epidural analgesia. Hyponatraemia correlated significantly with prolonged second stage of labour, instrumental delivery, and emergency caesarean section for failure to progress (P = 0.002). Conclusions Hyponatraemia is not uncommon following labour. Tolerance to a water load is diminished during labour; therefore, even moderate fluid volumes may cause hyponatraemia. Women should not be encouraged to drink excessively during labour. Oral fluids, when permitted, should be recorded, and intravenous administration of hypotonic fluids should be avoided. When abundant drinking is unrecognised or intravenous fluid administration liberal, life-threatening hyponatraemia may develop. The possibility that hyponatraemia may influence uterine contractility merits further investigation.