Transverse position. Using rotation to aid normal birth-OUTcomes following manual rotation (the TURN-OUT trial): a randomized controlled trial.

BACKGROUND: The fetal occiput transverse position in the second stage of labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation in the second stage of labor is considered a safe and easy to perform procedure that has been used to prevent operative deliveries. OBJECTIVE: This study aimed to determine the efficacy of prophylactic manual rotation in the management of the occiput transverse position for preventing operative delivery. We hypothesized that among women who are at ≥37 weeks' gestation with a baby in the occiput transverse position early in the second stage of labor, manual rotation compared with a "sham" rotation will reduce the rate of operative delivery. STUDY DESIGN: A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 3 tertiary hospitals was conducted in Australia. The primary outcome was operative (cesarean, forceps, or vacuum) delivery. Secondary outcomes were cesarean delivery, serious maternal morbidity and mortality, and serious perinatal morbidity and mortality. Outcomes were analyzed by intention to treat. Proportions were compared using χ2 tests adjusted for stratification variables using the Mantel-Haenszel method or Fisher exact test. Planned subgroup analyses by operator experience and technique of manual rotation (digital or whole hand rotation) were performed. The planned sample size was 416 participants (trial registration: ACTRN12613000005752). RESULTS: Here, 160 women with a term pregnancy and a baby in the occiput transverse position in the second stage of labor, confirmed by ultrasound, were randomly assigned to receive either a prophylactic manual rotation (n=80) or a sham procedure (n=80), which was less than our original intended sample size. Operative delivery occurred in 41 of 80 women (51%) assigned to prophylactic manual rotation and 40 of 80 women (50%) assigned to a sham rotation (common risk difference, -4.2% [favors sham rotation]; 95% confidence interval, -21 to 13; P=.63). Among more experienced proceduralists, operative delivery occurred in 24 of 47 women (51%) assigned to manual rotation and 29 of 46 women (63%) assigned to a sham rotation (common risk difference, 11%; 95% confidence interval, -11 to 33; P=.33). Cesarean delivery occurred in 6 of 80 women (7.5%) in the manual rotation group and 7 of 80 women (8.7%) in the sham group. Instrumental (forceps or vacuum) delivery occurred in 35 of 80 women (44%) in the manual rotation group and 33 of 80 women (41%) in the sham group. There was no significant difference in the combined maternal and perinatal outcomes. The trial was terminated early because of limited resources. CONCLUSION: Planned prophylactic manual rotation did not result in fewer operative deliveries. More research is needed in the use of manual rotation from the occiput transverse position for preventing operative deliveries.

Persistent occiput posterior position outcomes following manual rotation: a randomized controlled trial.

BACKGROUND: Persistent occiput posterior position in labor is associated with adverse maternal and perinatal outcomes. Prophylactic manual rotation from the occiput posterior position to the occiput anterior position in the second stage of labor is considered a safe and easy to perform procedure that in observational studies has shown promise as a method for preventing operative deliveries. OBJECTIVE: This study aimed to determine the efficacy of prophylactic manual rotation in the management of occiput posterior position for preventing operative delivery. The hypothesis was that among women who are at least 37 weeks pregnant and whose baby is in the occiput posterior position early in the second stage of labor, manual rotation will reduce the rate of operative delivery compared with the "sham" rotation. STUDY DESIGN: A double-blinded, parallel, superiority, multicenter, randomized controlled clinical trial in 4 tertiary hospitals was conducted in Australia. A total of 254 nulliparous and parous women with a term pregnancy and a baby in the occiput posterior position in the second stage of labor were randomly assigned to receive either a prophylactic manual rotation (n=127) or a sham rotation (n=127). The primary outcome was operative delivery (cesarean, forceps, or vacuum delivery). Secondary outcomes were cesarean delivery, combined maternal mortality and serious morbidity, and combined perinatal mortality and serious morbidity. Analysis was by intention to treat. Proportions were compared using chi-square tests adjusted for stratification variables using the Mantel-Haenszel method or the Fisher exact test. Planned subgroup analyses by operator experience and by manual rotation technique (digital or whole-hand rotation) were performed. RESULTS: Operative delivery occurred in 79 of 127 women (62%) assigned to prophylactic manual rotation and 90 of 127 women (71%) assigned to sham rotation (common risk difference, 12; 95% confidence interval, -1.7 to 26; P=.09). Among more experienced operators or investigators, operative delivery occurred in 46 of 74 women (62%) assigned to manual rotation and 52 of 71 women (73%) assigned to a sham rotation (common risk difference, 18; 95% confidence interval, -0.5 to 36; P=.07). Cesarean delivery occurred in 22 of 127 women (17%) in both groups. Instrumental delivery (forceps or vacuum) occurred in 57 of 127 women (45%) assigned to prophylactic manual rotation and 68 of 127 women (54%) assigned to sham rotation (common risk difference, 10; 95% confidence interval, -3.1 to 22; P=.14). There was no significant difference in the combined maternal and perinatal outcomes. CONCLUSION: Prophylactic manual rotation did not result in a reduction in the rate of operative delivery. Given manual rotation was associated with a nonsignificant reduction in operative delivery, more randomized trials are needed, as our trial might have been underpowered. In addition, further research is required to further explore the potential impact of operator or investigator experience.

Does low dose aspirin prescribed for risk of early onset preeclampsia reduce the prevalence of preterm prelabor rupture of membranes?

Background: Placental dysfunction, inflammation and degradation of fetal membranes has been hypothesized as a cause of preterm prelabor of rupture of membranes.Objective: To examine the effect of aspirin, an anti-inflammatory agent, on the prevalence of preterm prelabor rupture of membranes (PPRoMs).Methods: A retrospective analysis was conducted to examine the effect of aspirin on the prevalence of PPRoM. Aspirin (150 mg, nocte) was prescribed to women who were identified through a screening program at 11-13+6 weeks' gestation as being at high risk for developing early-onset preeclampsia. Women who were at low risk for developing preeclampsia did not receive aspirin. The prevalence of PPRoM was compared with an observational cohort.Results: In the observational cohort, there were 3027 women, including 32 (1.1%) cases of PPRoM. The prevalence of PPRoM in the high risk group was 3.1% (4/128) and was statistically significantly higher compared to the low risk group (1.0%) (28/2899). The relative risk was 3.02 (95% CI 1.2-7.7; p= .04). In the interventional cohort, there were 7280 women, with 114 (1.6%) cases of PPRoM. The prevalence of PPRoM in the high risk group who were treated with aspirin was 1.8% (14/766) compared to 1.5% (100/6516) in the low risk group (p= .54). The prevalence of PPRoM in high risk patients in the observational group (who did not receive aspirin) compared with the high risk patients in the interventional group (who were treated with aspirin) was not statistically significant (p= .31).Conclusions: PPRoM is significantly associated with a description of high risk for ePET; although, this algorithm is not a good screening tool for predicting PPRoM. Aspirin treatment of women deemed high risk for ePET is safe in the context of PPRoM and there may be some reduction in prevalence of PPRoM in treated high risk women; although, this study was not powered to demonstrate a small reduction in the prevalence of PPRoM. The findings merit further investigation through a larger prospective study with adequate sample size.

First-Trimester Prediction of Preterm Prelabour Rupture of Membranes.

BACKGROUND: Preterm prelabour rupture of membranes (PPRoM) is commonly associated with preterm delivery and affects up to 3% of all pregnancies. It is associated with high rates of morbidity and mortality for the mother and the newborn. OBJECTIVES: To identify risk factors for PPRoM and develop a model for first-trimester prediction of risk of PPRoM. METHODS: A retrospective analysis of a series of women who had first-trimester (11-13+6 weeks) screening for aneuploidy and pre-eclampsia and delivered in the same institution was performed. Univariate and multivariate logistic regression analyses were used to identify maternal and pregnancy factors and then develop a clinical prediction model for PPRoM. RESULTS: 10,280 women were screened between April 2010 and October 2016. 144 (1.4%) had PPRoM. Maternal factors predictive of PPRoM included nulliparity (parous women, OR 0.53; 95% CI 0.4-0.8), pre-existing diabetes mellitus (DM) (Type 1 DM, OR 6.7; 95% CI 2.3-19.4, Type 2 DM, OR 5.3; 95% CI 1.6-18.3), maternal age group (p = 0.004), and BMI category (p = 0.012). Uterine artery pulsatility index (UAPI) and biochemical parameters (PAPP-A, free ßHCG) did not reach statistical significance. The predictive model had moderate efficacy with an area under the ROC curve of 0.67. CONCLUSIONS: Several maternal characteristics collected during first-trimester screening predict PPRoM. Biomarkers currently measured during first-trimester screening (PAPP-A, ßHCG, and UAPI) do not predict PPRoM. Whilst a predictive model can be generated with information currently collected at 11-13+6 weeks, this has only modest screening performance. First-trimester screening provides a structured framework where other predictors could improve model performance, and future studies should focus on the addition of other risk factors and biomarkers that may improve screening efficacy.

Prospective Validation of First-Trimester Ultrasound Characteristics as Predictive Tools for Twin-Twin Transfusion Syndrome and Selective Intrauterine Growth Restriction in Monochorionic Diamniotic Twin Pregnancies.

OBJECTIVE: Monochorionic diamniotic (MCDA) twins are at increased risk of adverse outcome due to unequal placental sharing and placental vascular communications between the fetal circulations. Most centres perform ultrasound examination every 2-3 weeks to identify these complications. Identifying a high-risk cohort of MCDA twins in the first trimester would allow more efficient surveillance. We have attempted to validate first-trimester ultrasound characteristics as predictive tools for twin-twin transfusion syndrome (TTTS) and selective intrauterine growth restriction (sIUGR) in MCDA twins. MATERIAL AND METHODS: This is a prospective cohort study including MCDA twins enrolled at the time of first-trimester combined screening. Differences in crown-rump length (CRL), nuchal translucency (NT) thickness, ductus venosus pulsatility index for veins (DV PIV), presence or absence of tricuspid regurgitation and right ventricular E/A ratio were assessed. Receiver operating characteristic (ROC) curves were used to assess the potential value of these measures as predictive tools for identifying a cohort of MCDA pregnancies at high risk of adverse pregnancy outcome. RESULTS: Sixty-five MCDA pregnancies were included in the analysis. Nine (14%) developed TTTS, 17 (26%) developed sIUGR. The best predictive marker for TTTS was NT discordance of ≥20% (ROC AUC = 0.79; 95% CI 0.59-0.99). Combining measures did not improve performance (AUC = 0.80; 95% CI 0.62-0.99). CONCLUSION: NT discordance was the most effective characteristic at predicting TTTS but still had a relatively poor positive predictive value (36%). Intertwin differences in CRL, DV PIV and E/A ratio were not predictive of subsequent pregnancy complications. None of these characteristics have sufficient efficacy to be used to triage MCDA twin pregnancies ongoing obstetric surveillance.

The association between induction of labour at 38 to 39 weeks pregnancy and indication for caesarean delivery: An observational study.

BACKGROUND: Induction of labour is associated with a reduction in caesarean delivery, but the mechanism of action and which groups of women might benefit remain unknown. AIMS: To assess the association between induction of labour at 38-39 weeks pregnancy, and caesarean delivery: (i) overall; (ii) for slow progress in labour; and (iii) for suspected fetal compromise. MATERIAL AND METHODS: Retrospective observational study in two Sydney hospitals from 2009 to 2016, among nulliparous women with induction of labour at 38 or 39 completed weeks pregnancy and a singleton, cephalic presenting fetus. The comparator was all planned vaginal births beyond 39(+1/7) weeks, whether or not labour was induced. Binary and multinomial multiple logistic regressions adjusting for multiple confounders were performed. RESULTS: There were 2388 and 15 259 women in the study and comparison groups respectively. Induction of labour was associated with caesarean delivery overall only for women <25 years of age (adjusted odds ratio 1.63; 95% CI 1.17-2.27) and was not associated with caesarean delivery for slow progress. Induction of labour was positively associated with increased caesarean delivery for suspected fetal compromise among young women (<30 years), with the association weakening as maternal age increased. The association between induction of labour and caesarean delivery was different for slow progress compared with suspected compromise (P = 0.005). CONCLUSIONS: Induction of labour has different effects on the likelihood of caesarean delivery for slow progress and for suspected fetal compromise. Women <30 years of age are at higher risk of caesarean delivery for suspected fetal compromise, potentially due to uterine hyperstimulation.

Effect of early use of low-dose aspirin therapy on late-onset preeclampsia.

OBJECTIVE: Low-dose aspirin (LDA) therapy has been found to be effective in preventing the development of early-onset preeclampsia. However, its effect on late-onset preeclampsia has not been described. Our study was aimed at determining if LDA therapy prescribed from early in pregnancy modified the severity of late-onset preeclampsia. MATERIALS AND METHODS: A retrospective analysis of all women who were screened for early-onset preeclampsia at 11-13+6 weeks' gestation between April 2012 and October 2014 at our institution, and who subsequently developed late-onset preeclampsia. The treatment group consisted of women who were prescribed LDA therapy from early in pregnancy as a result of the screening. The control group consisted of women who did not receive LDA therapy. RESULTS: The aspirin group was associated with earlier delivery at 38.0 (37.5-38.5) weeks' gestation versus 39.0 (38.7-39.4) weeks' gestation for the nonaspirin group (p < .01). The aspirin group was also associated with lower absolute birth weight 2851 (2646-3055) versus 3215 (3068-3362) grams in the nonaspirin group (p < .01). However, when normalised for gestational age at delivery, the proportion of foetuses that were small for gestation age (< 10th centile) were not significantly different between the two groups [28% in aspirin group versus 23% in nonaspirin group; p = .62]. No other significant difference was noted. CONCLUSIONS: There was no difference in the clinical severity of late-onset preeclampsia between women screened as high risk for early-onset preeclampsia and subsequently prescribed LDA during their pregnancy, compared to women found to be at low risk and not prescribed LDA.

Outcomes of induction of labour in nulliparous women at 38 to 39 weeks pregnancy by clinical indication: An observational study.

BACKGROUND: Knowledge of the outcomes of induction of labour for different indications is sparse. AIMS: To describe the mode of birth and other outcomes for nulliparous women induced at 38-39 weeks gestational age by indication for induction of labour. MATERIAL AND METHODS: This was a retrospective observational study in a tertiary referral hospital, and a metropolitan teaching hospital in Sydney. The study population was nulliparous women with induction of labour at 38 or 39 completed weeks of pregnancy and a singleton, cephalic presenting baby planning a vaginal birth, from 2009 to 2016. The indication for induction of labour was classified into 12 groups. Mode of birth and other maternal and perinatal outcomes were described in each group, for women who spontaneously laboured at 38 or 39 weeks, and for women who gave birth from 40 completed weeks onward. The main outcome measure was mode of birth. RESULTS: There were 3330 women with induction of labour at 38 or 39 weeks gestation. Rates of vaginal birth varied widely, ranging from 54% when the indication for induction was suspected large fetus, to 82% when the indication was suspected fetal compromise, and was 74% overall. Indications for caesarean delivery also varied by indication for induction. Among women giving birth ≥40 weeks gestational age, 75% had a vaginal birth. CONCLUSIONS: In nulliparous women, rates of vaginal birth following induction of labour at 38 or 39 weeks gestation vary widely according to the indication for induction. These data are useful for antenatal counselling.

Characteristics and service needs of women and babies admitted to residential parenting units in New South Wales: A mixed-methods study.

AIMS AND OBJECTIVES: To examine the characteristics and service needs of women and babies admitted to residential parenting services (RPS) in the first year following birth in New South Wales, Australia. BACKGROUND: In Australia, there is a tiered system to support maternal, child and family health, which includes RPS. DESIGN: Sequential explanatory mixed-methods design. METHODS: Individual patient data were obtained from a random review of 10% of all medical records (n = 300 of 3,011 admissions) of women with an infant of <12 months of age who were admitted to RPS in 2013. Following review of the medical records, qualitative data were collected via interviews with eight women who accessed RPS. Chi-square analysis and Student's t test were used to analyse quantitative data. Qualitative data were analysed using a descriptive interpretive approach. An integrative approach was taken in reporting the findings. RESULTS: Women admitted to the RPS were on average 32 years of age, were Australian born (72%) and had a university qualification (40%), and most were employed. The majority of women were primiparous (60%) and had a vaginal birth (61%). Women with male infants were much more likely to be admitted to the RPS (58%) compared to the NSW male-to-female ratio (51.3% vs. 48.7%). Over 50% of women reported mental health issues with 27% having an Edinburgh Postnatal Depression Scale score ≥13 on admission. The primary reason women sought parenting support was for sleep and settling (83%). During their stay, services used by women included social workers (44%), psychologists (52%) and psychiatrists (4.5%). CONCLUSION: Women who access RPS report psychosocial and mental health issues. Services provided by RPS support women during this challenging early parenting period by providing multidisciplinary, holistic and peer support. RELEVANCE TO CLINICAL PRACTICE: A high prevalence of mental health issues identified in this study indicated a need for ongoing training and support for RPS staff. Ensuring clinicians have the appropriate skill sets to best support their clientele will maximise the outcomes for women and families who access RPS during the early parenting period.

All Hypertensive Disorders of Pregnancy Increase the Risk of Future Cardiovascular Disease.

Hypertensive disorders of pregnancy are associated with vascular dysfunction in the pregnancy and an increased risk of long-term cardiovascular disease (CVD) in the mother. What remains to be understood is whether the length, severity of the disease, the treatment of hypertension in pregnancy, or the subtype of hypertensive disorders of pregnancy are significant predictors of future CVD. We undertook a retrospective cohort study to review all women who gave birth at a tertiary hospital in Sydney between the years 1980 and 1989 (n=31 656). A cohort of women was further defined by having hypertension during the antenatal, intrapartum, or postnatal periods (n=4387). Randomly selected records of women (n=1158) with a hypertensive disorder of pregnancy were individually reviewed to collect data on their pregnancy and pregnancy outcomes. The entire cohort then underwent linkage analysis to future CVDs. Women who presented with gestational hypertension were at greater risk of future hypertension and ischemic heart disease compared with the women who were diagnosed with preeclampsia. There was no significant difference between the women who were treated with antihypertensive medication and the women who did not receive antihypertensive medication or the duration of hypertensive disorders of pregnancy and future admission for CVD, although severity of hypertension tracked with increased risk of future hypertension in all groups. This study demonstrated that all women who present with any of the subtypes of hypertensive disorders in pregnancy are at significant risk of future CVD compared with women who remain normotensive during their pregnancy.

Benchmarking the Hypertensive Disorders of Pregnancy.

INTRODUCTION: The Hypertensive Disorders of Pregnancy (HDP) affect 7-10% of pregnancies worldwide and are one of the leading causes of mortality and morbidity in the perinatal period. An accurate assessment of mortality and morbidity is essential to provide effective care and treatment and benchmarking of these issues is required to enhance outcomes and define standards. AIM: To benchmark outcomes for women and babies following a diagnosis of hypertension between obstetric units in similar settings. METHODS: Utilising a set of pre-defined clinical indicators, Individual Patient Data analysis techniques applied to the medical records of all women diagnosed with a HDP over a 12month period at six obstetric units within Australia and Canada. Statistical analysis included contingency table sand means testing oas appropriate utilising IBM SPSS V.18. RESULTS: Overall HDP rate of 7.6% of all deliveries, with a 3.0% preeclampsia rate. Outcomes differed significantly between units and did not cluster within any individual unit.

Hypertension in pregnancy and long-term cardiovascular mortality: a retrospective cohort study.

BACKGROUND: There is growing evidence that hypertensive disorders of pregnancy are associated with increased long-term cardiovascular mortality in the mother. Hypertension in pregnancy, until recently, however, has been ignored largely as a risk factor for future cardiovascular disease and mortality because the link between the 2 is not fully understood. OBJECTIVE: To determine the association between women with hypertension in pregnancy and long-term cardiovascular disease mortality. STUDY DESIGN: All women who delivered at a metropolitan hospital between the periods of January 1, 1980, and December 31, 1989, were identified by use of the International Statistical Classification of Diseases and Related Health Problems, 9th Revision, Australian Modification. RESULTS: The total number of deliveries in the given time period was 31,656, with 4387 (14%) of the women identified as having had hypertension in their pregnancy. Using information from the New South Wales Births, Deaths and Marriages Registry and the Australian Bureau of Statistics Death Registry, we identified a total of 651 deaths from this cohort (n = 31,656). There were 521 deaths among the women who remained normotensive in their pregnancy and 129 deaths for women who had hypertension during their pregnancy. Overall, the women with hypertensive disorders of pregnancy were at greater risk of death than the women who remained normotensive in their pregnancy (odds ratio 1.56; 95% confidence interval 1.28-1.89; P < .001). CONCLUSION: Women with a history of hypertension in their pregnancy are at an increased risk of future cardiovascular mortality, and this work identifies a group of women who may benefit from early screening and intervention strategies to help decrease their risk of future cardiovascular disease.

Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery?

OBJECTIVE: To evaluate if ultrasound-determined occipito-transverse position early in the second stage of labor is associated with operative delivery. DESIGN: Retrospective review of two prospective cohort studies. SETTING: An Australian tertiary referral hospital. POPULATION: Women with term, cephalic singleton pregnancies. METHODS: Retrospective analysis of data from two prospective studies. Logistic regression was undertaken to assess the independent contribution of the occipito-transverse position to operative delivery. MAIN OUTCOME MEASURE: Operative delivery (cesarean section, forceps or vacuum extraction). RESULTS: Among 422 women included, the occipito-transverse position was present in 80, occipito-anterior in 303 and the occipito-posterior in 39. Compared with occipito-anterior, the adjusted odds ratio for operative delivery was 2.1 (95% confidence interval 1.2-3.8, p = 0.02) for the occipito-transverse position, and 7.4 (95% confidence interval 3.2-17) for the occipito-posterior position. Factors that independently predicted operative delivery were nulliparity, abnormal second stage cardiotocography, maternal place of birth and epidural analgesia. The length of second stage of labor was longer for the occipito-transverse group than for the occipito-anterior group (median 2 h 7 min vs. 1 h 36 min, p = 0.003). CONCLUSION: The occipito-transverse position early in the second stage of labor was associated with an increased operative delivery rate.

Cardiovascular risk, lipids and pregnancy: preeclampsia and the risk of later life cardiovascular disease.

It has been widely thought that the effects of hypertension in pregnancy reversed after delivery and hypertension values returned to their pre-pregnancy level as it was seen as a disease of short duration in otherwise healthy young women. However, recent studies have demonstrated that the principal underlying abnormality, endothelial dysfunction, remains in women who had preeclampsia and that it is this damage that increases the risk of developing cardiovascular disease (CVD) in later life. The contributions of hypertension and dyslipidaemia before and during the pregnancy are also important and contribute to future risk. Serum lipids are complex and change dramatically in pregnancy. In general there is an increase in most plasma lipid components, notably triglycerides, total cholesterol and the major particles of HDL and LDL. Aberrations or exaggerations in this shift (i.e. decrease HDL and a greater increase in LDL) are associated with poor outcomes of pregnancy such as preeclampsia. Long term cardiovascular disease is influenced by preeclampsia and in part potentially by the lipid changes which escalate late in disease. Whether we can influence the risk of preeclampsia by controlling cardiovascular risk factors preceding or during preeclampsia, or cardiovascular disease after preeclampsia is yet to be determined. Ultimately, strategies to control lipid concentrations will only be viable when we understand the safety to the mother at the time of the pregnancy, and to the foetus both immediately and in the very long term. Strategies to control blood pressure are well established in the non-pregnant population, and previous preeclampsia and gestational hypertension should be considered in any cardiovascular risk profile. Whether control of blood pressure in the pregnancy per se is of any longer term benefit is also yet to be determined.

Changes in retinal microvascular caliber precede the clinical onset of preeclampsia.

Preeclampsia is a leading cause of maternal morbidity and mortality. The degree of maternal cardiovascular dysfunction that precedes the onset of preeclampsia is largely unknown. This prospective cohort study aimed to characterize differences in vivo in retinal microvascular caliber and blood pressure throughout pregnancy in relation to preeclampsia development. Women were recruited from Royal Prince Alfred Hospital, Sydney, Australia, of which 92 women were included in the study. Retinal images and blood pressures were collected at 13, 19, 29, and 38 weeks of gestation. Retinal vessels were analyzed as the central retinal arteriolar equivalent corrected for mean arterial blood pressure and the central retinal venular equivalent corrected for mean arterial blood pressure, using generalized linear models adjusted for age and body mass index. The preeclampsia group were significantly older (P=0.002) and had a significantly higher mean body mass index (P=0.005). The central retinal arteriolar equivalent corrected for mean arterial blood pressure was significantly reduced at 13 (P=0.03), 19 (P=0.007), and 38 (P=0.03) weeks of gestation in the preeclampsia group. The central retinal venular equivalent corrected for mean arterial blood pressure was also significantly lower at 13 (P=0.04) and 19 (P=0.001) weeks of gestation in the women who progressed to preeclampsia. This study directly documents increased peripheral resistance in vivo, observed as the combination of constricted retinal arterioles or venules and elevated blood pressure, in women who later developed preeclampsia. This difference preceded the clinical signs of preeclampsia.

High blood pressure during pregnancy is associated with future cardiovascular disease: an observational cohort study.

OBJECTIVES: The study aimed to determine if having a hypertensive disorder of pregnancy (HDP) is a risk factor for future cardiovascular disease (CVD), independent of age and body mass index (BMI). DESIGN: Data were sourced from the baseline questionnaire of the 45 and Up Study, Australia, an observational cohort study. SETTING: Participants were randomly selected from the Australian Medicare Database within New South Wales. PARTICIPANTS: A total of 84 619 women were eligible for this study, of which 71 819 were included. These women had given birth between the ages of 18 and 45 years, had an intact uterus and ovaries, and had not been diagnosed with high blood pressure prior to their first pregnancy. RESULTS: HDP was associated with higher odds of having high blood pressure (<58 years: adjusted OR 3.79, 99% CI 3.38 to 4.24; p<0.001 and ≥58 years: 2.83, 2.58 to 3.12; p<0.001) and stroke (<58 years: 1.69, 1.02 to 2.82; p=0.008 and ≥58 years: 1.46, 1.13 to 1.88; p<0.001) in later life. Women with HDP had a younger age of onset of high blood pressure (45.6 vs 54.8 years, p<0.001) and stroke (58 vs 62.5 years, p<0.001). Women who had HDP and whose present day BMI was <25 had significantly higher odds of having high blood pressure, compared with women who were normotensive during pregnancy (<58 years: 4.55, 3.63 to 5.71; p<0.001 and ≥58 years, 2.94, 2.49 to 3.47; p<0.001). Women who had HDP and a present day BMI≥25 had significantly increased odds of high blood pressure (<58 years: 12.48, 10.63 to 14.66; p<0.001 and ≥58 years, 5.16, 4.54 to 5.86; p<0.001), compared with healthy weight women with a normotensive pregnancy. CONCLUSIONS: HDP is an independent risk factor for future CVD, and this risk is further exacerbated by the presence of overweight or obesity in later life.

Temporal changes in retinal microvascular caliber and blood pressure during pregnancy.

The microvasculature plays an important role in regulating cardiovascular changes in pregnancy, but changes in microvasculature have been difficult to document in vivo. This study objectively quantifies changes in the maternal retinal arteriolar and venular caliber over the course of healthy pregnancy. Healthy pregnant women (n=53) were recruited from Royal Prince Alfred Hospital, Sydney, Australia. Retinal images and mean arterial blood pressures (MAP) were collected at 13, 19, 29, and 38 weeks of gestation and at 6-month postpartum. Retinal vessels were analyzed and summarized as the central retinal arteriolar equivalent and central retinal venular equivalent. Central retinal arteriolar equivalent and central retinal venular equivalent were corrected for MAP. Paired t tests were performed comparing consecutive time points, with a significance level of P<0.01. There was a decrease in MAP between 13- and 19-week gestation (P=0.001) followed by a return to baseline from 19 weeks to delivery. This was correlated by an increase in vessel caliber between 13- and 19-week gestation (central retinal arteriolar equivalent: P<0.001, central retinal venular equivalent: P=0.007) and a return to baseline from 19 weeks to delivery. There were no differences in the central retinal arteriolar equivalent or central retinal venular equivalent (both uncorrected and corrected for MAP) between nulliparous and parous women. The pattern of dilatation and constriction in the microvasculature mirrored the changes in MAP throughout pregnancy, reflecting changes in peripheral resistance. This study provides insights into physiological changes in the microvasculature throughout a healthy pregnancy. These results can be used as a baseline with which to compare the changes observed in pathological conditions of pregnancy.

Acute pulmonary oedema as a complication of hypertension during pregnancy.

OBJECTIVE: To determine rates of and potential causative factors for acute pulmonary oedema (APO) in hypertensive women. METHODS: Statistical analysis, including logistic regression, was applied to the individual patient data (IPD) of all hypertensive women who delivered in 2005 at two comparable units. RESULTS: Of 880 cases analysed, there were no women with APO in unit one and 19 women in unit two. The women with APO received larger quantities of intravenous fluids, delivered at earlier gestations, via Caesarean section, following failed induction of labour and had a longer hospital stay. CONCLUSION: The development of APO in women with hypertension during pregnancy is associated with high levels of intravenous fluid administration.

Does the anti-hypertensive drug clonidine affect the short-term variation in CTG recordings?

BACKGROUND: Cardiotocographic (CTG) recordings of the fetal heart remain standard obstetric practice among hypertensive women. Changes in the short-term variation (STV) in the fetal heart are often attributed to the effect of anti-hypertensive medications, regardless of the fact that this principle has never been validated. AIM: To assess the STV of CTG recordings pre- and post- the anti-hypertensive medication, clonidine. METHODS: Forty hypertensive pregnant women, already receiving the anti-hypertensive clonidine, were recruited. The CTGs were conducted pre- and post-dose administration. The CTGs were assessed by the Sonicaid Team® automated CTG analysis (Oxford Instruments, UK) to avoid CTG assessor bias. Baseline fetal heart rate (FHR) (delta change from pre- and post-dose) and STV were compared using spss v.14® utilising Student t-tests. RESULTS: No statistical difference was found in the pre- and post-baseline FHRs (P = 0.48). The mean delta baseline heart rate before and after drug administration was -0.54 bpm. The STV of the CTGs recorded pre- and post-clonidine dose was also not affected by administration of the drug (P = 0.34). The mean delta STV before and after drug administration was 0.39 ms. Two women received betamethasone 12 mg intramuscularly within the 12-h period prior to CTG recordings to enhance fetal lung maturity. The mean STV for the fetuses of these women pre-drug was 4.8 ms and 13.2 ms post-administration. This was the largest delta seen in all STVs recorded in this dataset. CONCLUSION: The anti-hypertensive drug clonidine does not alter baseline FHRs or affect the STV of the FHR in hypertensive pregnant women.