No association between maternal psychological symptoms and infant outcome after pregnancy complicated by early-onset hypertensive disorders.

AIM: The aim of this work was to study the effect of maternal psychological symptoms on infant development 1 year after early-onset hypertensive disorders of pregnancy. METHODS: All mothers were enrolled in the Pre-eclampsia, Eclampsia TRial Amsterdam. Mothers were asked to complete the 90-item Symptom Check List (SCL-90) at the corrected ages of their infants of 0, 3 and 12 months. The total sum score of these three checklists was calculated. Infants were examined at the corrected age of 12 months using the Bayley Scales of Infant Development (Mental Developmental Index [MDI] and Psychomotor Developmental Index [PDI] subscales). The Bayley scores were compared between infants of mothers with SCL-90 sum scores in the highest 25% and lowest 75%. RESULTS: For 141 mother-infant pairs (80%) all three SCL-90 checklists and Bayley scores were available. Mean gestational age was 32 weeks and 90% of the infants were growth restricted. The mean MDI was 87 in the highest 25% and 89 in the lowest 75% group. This was 79 versus 80 for the PDI. CONCLUSION: In this population of high-risk growth-restricted infants born after a pregnancy complicated by early-onset hypertensive disorders, there is no additional impact of negative maternal psychological symptoms on infant development after 1 year.

Relationship between thrombophilic disorders and type of severe early-onset hypertensive disorder of pregnancy.

OBJECTIVE: To determine whether specific subtypes of early-onset hypertensive disorders of pregnancy (haemolysis, elevated liver enzymes, low platelets [HELLP] syndrome; severe preeclampsia; eclampsia; and fetal growth restriction) differ in increased prevalences of thrombophilic disorders. DESIGN: Cohort study. SETTING: Two university hospitals in Amsterdam, the Netherlands. POPULATION: 216 patients participating in a randomized clinical trial with severe and early-onset hypertensive disorders of pregnancy. METHODS: More than 3 months after delivery, all patients were invited for a thrombophilia screening protocol, including hereditary thrombophilic disorders (Factor II or V-Leiden mutation, APC-resistance, protein S deficiency), antiphospholipid antibodies (anticardiolipin antibodies and lupus anticoagulant activity), and hyperhomocysteinemia (before and after methionin challenge). Disease expression was classified by HELLP syndrome, severe preeclampsia, or neonatal birth weight ratio below the median (0.65). Univariate and multinomial regression analyses examined the association of disease expression with thrombophilic disorders, and other associated factors (chronic hypertension, smoking, body mass index, positive family history of cardiovascular morbidity, and demographic parameters). MAIN OUTCOME MEASURES: incidence of thrombophilic disorders in different subtypes of disease. RESULTS: Overall prevalence of thrombophilic disorders in 206 (95%) screened women was 36%. Chronic hypertension was present in 32%, and 34% had a positive family history of cardiovascular morbidity. Multinomial regression analysis showed that hereditary thrombophilia was more frequent among women with infants with a birth weight ratio <0.65 than in women with HELLP syndrome or severe preeclampsia (p = 0.01, OR 5.1 (1.5 to 7.3) and OR 3.4 (1.1 to 10.6), respectively). High body mass index was less frequent in women with HELLP syndrome than in those with severe preeclampsia or fetal growth restriction (p = 0.06, OR 0.5 (0.3 to 0.9) and OR 0.4 (0.2 to 1.0), respectively). CONCLUSION: In this population, the high prevalence of thrombophilic factors and chronic hypertension was confirmed. There were small differences between groups. Hereditary thrombophilic disorders were associated with fetal growth restriction but not with type of maternal disease, suggesting an effect on placental function. Maternal body mass index was lower in women with HELLP syndrome.

Psychosocial impact of early-onset hypertensive disorders and related complications in pregnancy.

OBJECTIVE: The objective of the study was to examine the psychosocial impact of severe hypertensive disorders during pregnancy. STUDY DESIGN: All women (n = 216) in a prospective study cohort with severe hypertensive disorders of pregnancy were invited at term age, 3 months, and 1 year postterm to complete the 90-item Symptom Check List (SCL-90) questionnaire for assessment of their psychosocial condition. The association of hypothesized determinants was tested by binary logistic analysis. RESULTS: Psychosocial impact decreased over time in all women (P < .01). Women with an adverse infant outcome had a worse score at term age (P = .04). The only parameter relating significantly to SCL-90 score in multivariate analysis was gestational age at inclusion. One year postterm, 72% resumed work and 9% were still on sick leave. CONCLUSION: Severe hypertensive disorders of pregnancy have a high psychological impact, especially when gestational age at onset of disease is below 30 weeks or if adverse infant outcome occurs.

Prediction of maternal complications and adverse infant outcome at admission for temporizing management of early-onset severe hypertensive disorders of pregnancy.

OBJECTIVE: We explored the association between clinical parameters at admission and the subsequent development of major maternal complications or adverse infant outcome in women with hypertensive complications of pregnancy remote from term. STUDY DESIGN: We drew data from a randomized trial of temporizing management in 216 patients with hemolysis, elevated liver enzymes, and low platelets syndrome; severe preeclampsia; eclampsia; or hypertension-related fetal growth restriction and gestational ages between 24 and 34 completed weeks. End points were adverse infant outcome (perinatal death, severe morbidity) and major maternal complications (major morbidity; recurrent and newly acquired hemolysis, elevated liver enzymes, and low platelets; eclampsia) after admission. End point prevalences were comparable between the treatment and control groups. The association with age, parity, ethnicity, body mass index, gestational age, estimated fetal weight, blood pressure, antihypertensive medication, pulse rate, hemoglobin concentration, admitting center, diagnosis at inclusion, chronic hypertension, and thrombophilia was explored by logistic regression analysis. RESULTS: Adverse infant outcome was predominantly influenced by gestational age (odds ratio 0.4 per week increment). Major maternal complications were correlated to multiparity (odds ratio 0.4) and estimated fetal weight (odds ratio 0.9 per 100-g increment). CONCLUSION: Prediction at admission of the clinical course of the disease and the development of additional maternal complications was not feasible.

A randomised controlled trial comparing two temporising management strategies, one with and one without plasma volume expansion, for severe and early onset pre-eclampsia.

OBJECTIVES: Plasma volume expansion may benefit both mother and child in the temporising management of severe and early onset hypertensive disorders of pregnancy. DESIGN: Randomised clinical trial. Setting Two university hospitals in Amsterdam, The Netherlands. POPULATION: Two hundred and sixteen patients with a gestational age between 24 and 34 completed weeks with severe pre-eclampsia, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or severe fetal growth restriction (FGR) with pregnancy-induced hypertension, admitted between 1 April 2000 and 31 May 2003. METHODS: One hundred and eleven patients were randomly allocated to the treatment group, (plasma volume expansion and a diastolic BP target of 85-95 mmHg) and 105 to the control group (intravenous fluid restriction and BP target of 95-105 mmHg). MAIN OUTCOME MEASURES: Neonatal neurological development at term age (Prechtl score), perinatal death, neonatal morbidity and maternal morbidity. RESULTS: Baseline characteristics were comparable between groups. The median gestational age was 30 weeks. In the treatment group, patients received higher amounts of intravenous fluids (median 813 mL/day vs 14 mL/day; P < 0.001) with a concomitant decreased haemoglobin count (median -0.6 vs-0.2 mmol/L; P < 0.001). Neither neurological scores nor composite neonatal morbidity differed. A trend towards less prolongation of pregnancy (median 7.4 vs 11.5 days; P= 0.054) and more infants requiring oxygen treatment >21% (66 vs 46; P= 0.09) in the treatment group was observed. There was no difference in major maternal morbidity (total 11%), but there were more caesarean sections in the treatment group (98%vs 90%; P < 0.05). CONCLUSION: The addition of plasma volume expansion in temporising treatment does not improve maternal or fetal outcome in women with early preterm hypertensive complications of pregnancy.

A randomized trial of plasma volume expansion in hypertensive disorders of pregnancy: influence on the pulsatility indices of the fetal umbilical artery and middle cerebral artery.

OBJECTIVE: The purpose of this study was to investigate the effect of plasma volume expansion on the pulsatility indices of the fetal umbilical and middle cerebral arteries. STUDY DESIGN: Two hundred sixteen patients with severe preeclampsia, HELLP (hemolysis, elevated liver enzymes, and low platelet count) syndrome, eclampsia, hypertension-related fetal growth restriction, and gestational ages between 24 and 34 completed weeks of gestation were assigned randomly for temporizing treatment with plasma volume expansion (n = 111 patients; 250 mL hydroxyethyl starch 6% twice daily in 4 hours, and NaCl 0.9% between doses of hydroxyethyl starch and with intravenous medication) or without plasma volume expansion (n = 105; only NaCl 0.9% when necessary with medication). Measurements of the pulsatility index of the umbilical and middle cerebral arteries were performed at admission, after 16 to 48 hours, 60 to 120 hours, and 7 to 11 days. RESULTS: Median gestational age was 30 weeks in both groups. Infused volumes of plasma volume expansion in the treatment group (total median, 813 mL/d) were associated with a significant decrease of hemoglobin concentration. Changes from baseline measurements of the umbilical and middle cerebral arteries were not different between the groups nor within subgroups during the first 7 to 11 days. CONCLUSION: Plasma volume expansion did not influence the pulsatility indices of the umbilical and middle cerebral arteries.

Plasma volume and blood pressure regulation in hypertensive pregnancy.

BACKGROUND: Pre-eclampsia is a multisystem disorder, peculiar to and frequent in human pregnancy. It remains a leading cause of maternal and neonatal morbidity and mortality. Hemodynamic disturbances are the most prominent features of the syndrome. PURPOSE: To provide an overview of plasma volume regulation and blood pressure control mechanisms outside pregnancy, and of the changes in normal pregnancies and in pregnancies complicated by hypertensive disorders. Furthermore, to discuss the rationale of several hemodynamic interventions. RESULTS: In normal pregnancy, large cardiovascular changes take place. A generalized fall in vascular tone by systemic vasorelaxation causes increased blood volume, heart rate and cardiac output. In the preclinical phase, differences have been observed between normal and hypertensive pregnancies in the function of the autonomic nervous system, cardiac output and plasma volume, the volume remaining at the non-pregnant level. In the clinical phase of pre-eclampsia the typical case picture is one of a vasoconstrictive state with low plasma volume and cardiac output, high blood pressure and systemic vascular resistance in combination with signs of organ damage [proteinuria, hemolysis elevated liver enzymes low platelets (HELLP) syndrome]. Hemodynamic management is necessary in severe disease to prevent maternal complications. Management primarily focuses on pharmacological treatment of blood pressure. Clinicians make educated choices from a limited array of available drugs: beta-receptor antagonists, nifedipine, dihydralazine, methyldopa or ketanserine. Other drugs have restricted use in pregnancy. Management of low circulating volume with plasma expanders remains a subject of controversy.