PP047. Outpatient management of pregnancy complicated by mild hypertensive disorders.

INTRODUCTION: Antenatal day care units have been experienced as an alternative to inpatient care for women with pregnancy complications including hypertensive disorders. OBJECTIVES: To assess the outcomes of outpatient management in women with gestational hypertension and mild preeclampsia and compare them to inpatient management. METHODS: Perinatal records of 294 patients (OUT group) attending the obstetric outpatient clinic were reviewed and compared with records of 398 women (IN group) attending the obstetric unit of the same tertiary referral center. The patients were divided as: GH, gestational hypertension (OUT: 194; IN: 244), GH with Intrauterine Growth Restriction (OUT: 52; IN: 78) and PE, mild preeclampsia (OUT: 48; IN: 76). The groups were comparable for age, parity, body mass index and gestational age at enrollment. RESULTS: When compared with patients treated in hospital, GH OUT women showed a higher gestational age at delivery (38±1.7 vs 35.5±2.3 weeks; p<0.001), longer time to delivery (62.0±4.8 vs 31.3±5.4days; p<0.001), higher birthweight (3251±389 vs 2271±759.1g; p<0.001), and a lower admission to neonatal intensive care unit (21.3% vs 0%; p<0.001) (hospitalization rate: 25%). Similarly, Mild PE women treated as out patient showed later gestational age at delivery (37±1.2 vs 34.4±1.7weeks), longer time to delivery (55.4±6.9 vs 35.3±4.5days), higher birthweight (3168±363 vs 2196±685.17g), and a lower admission to NICU (15.6% vs 35.5%) (hospitalization rate: 55.6%), than the inpatient controls. In the gestational hypertension with IUGR no significant differences were observed between out- and in-patient management. CONCLUSION: Women attending day care units have better or comparable perinatal outcomes than inpatients. Ambulatory management at a day-care unit is an option for monitoring and following up women with mild gestational hypertension or preeclampsia remote from term. Hospitalization remains an absolute indication if worsening of preeclampsia is diagnosed.

Amniotic levels of nitric oxide in women with fetal intrauterine growth restriction.

OBJECTIVE: Many biochemical observations have shown that nitric oxide (NO) is involved in the vascular angiogenic activity of the fetoplacental unit. The aim of this study was to determine whether NO is implicated in the pathogenesis of intrauterine growth restriction (IUGR). METHODS: We retrospectively assessed amniotic fluid NO from second-trimester amniocentesis of 20 healthy normotensive women who subsequently developed IUGR and 20 controls. The same women were re-assessed at the third trimester when IUGR had developed and when the same 20 controls had shown normal pregnancy. Amniotic fluid NO was detected by discontinuous spectrophotometry and the Griess reaction. RESULTS: At the second trimester, NO levels in women with subsequent IUGR were significantly lower than in controls (4.1 +/- 0.2 microg/mg creatinine vs. 6.02 +/- 1.57 microg/mg creatinine, p < 0.001). At the third trimester, in women with IUGR, NO levels were significantly higher than in normal pregnancies (7.4 +/- 1.5 vs. 5.02 +/- 0.9 microg/mg creatinine, p < 0.001), and directly correlated with gestational age when growth restriction was diagnosed (r = 0.69, p < 0.001). CONCLUSIONS: Low levels of NO during the early second trimester may represent an impaired stimulus to vascular formation and endothelial regulation, inducing placental disease and subsequent fetal growth restriction. High levels of amniotic fluid NO during the third trimester may represent a compensation factor for maintaining adequate uteroplacental perfusion in pregnancies with IUGR.

Amniotic levels of vascular endothelial growth factor and nitric oxide at the second trimester in Down's syndrome.

OBJECTIVE: Since placentae in trisomy 21 show trophoblastic hypoplasia and hypovascularity, we investigated amniotic fluid vascular endothelial growth factor (VEGF) and nitric oxide (NO) in normal pregnancy and pregnancy complicated by trisomy 21. Furthermore, we investigated a possible role of NO in neurodegeneration of the brain in Down's syndrome. METHODS: We retrospectively assessed NO and VEGF on mid-trimester amniotic fluid from 15 women who had fetal Down's syndrome, and compared the results with those of 15 controls matched for age and gestation. RESULTS: In pregnancies complicated by trisomy 21, NO levels were significantly higher than in healthy controls (p < 0.001), whereas VEGF levels were significantly lower than in healthy controls (p < 0.05). CONCLUSIONS: Our results suggest that the high levels of NO and the low levels of VEGF observed in the amniotic fluid of fetuses with Down's syndrome may be a sign of an imbalance of placental vascularization and altered endothelial function. Overproduction of NO could contribute to pathological cell death in the central nervous system, a process that has been demonstrated in many neurodegenerative diseases.

[The relative weight of Doppler of the uterine artery and 24-h ambulatory blood pressure monitoring in predicting hypertension in pregnancy and preeclampsia]. / Il peso relativo del Doppler delle arterie uterine e del monitoraggio ambulatoriale 24-h della pressione arteriosa nella predittività dell'ipertensione in gravidanza e della preeclampsia.

OBJECTIVE: To assess the combined use and the "relative weight" of Uterine Artery Doppler Velocimetry and 24-h Ambulatory Blood Pressure Monitoring (ABPM) to predict Gestational Hypertension (GH) and Preeclampsia (PE). METHODS: The predictivity of Doppler of uterine artery flow at 24 weeks and of ABPM at 24-30 weeks was assessed in 75 normotensive primigravidae, considering the subsequent onset of GH and/or PE. RESULTS: In our series the sensitivity of Doppler versus GH is 62%, and 57% vs PE. The altered ABPM shows a sensitivity of 97% vs GH and 99% vs PE. In the cases with the both tests positive it was 97% vs GH, and 99% vs PE. In the subgroup of patients with altered Doppler velocimetry and normal ABPM, the sensitivity vs GH and PE is 12% (PPV = 12%). A second subgroup with normal Doppler velocimetry and altered ABPM shows a sensitivity of 94% vs GH (PPV = 88%), and 99% vs PE (PPV = 33%). CONCLUSIONS: Uterine Artery Doppler Velocimetry and 24-h Ambulatory Blood Pressure Monitoring (ABPM) have a good predictive power for GH and PE, but the combined use improves the efficacy to identify an abnormal outcome of pregnancy. When evaluating for relative weight, the ABPM is more powerful in predicting for GH and PE than Doppler assessment. However, the high specificity of Doppler velocimetry reduces the false-positive ratio in the combined screening during the 2nd trimester of pregnancy.

Performance of Doppler ultrasonography as a screening test in low risk pregnancies: results of a multicentric study.

To assess the efficacy of the Doppler velocimetry of the uterine and umbilical arteries as a screening test for preeclampsia and fetal growth retardation, we studied 916 low risk pregnancies. The S/D ratios of the uterine and umbilical arteries were obtained at 19 to 24 weeks and at 26 to 31 weeks of gestational age. Mean values, receiver operator curves, and the diagnostic accuracy of the tests were calculated for the following end-points: (1) pregnancy-induced hypertension, (2) low birth weight for gestational age, (3) small for gestational age with abnormal outcome, (4) pregnancy-induced hypertension needing preterm delivery. The prevalences for these outcomes were 3.4%, 4.6%, 1%, and 0.7%, respectively. The study was blinded. The umbilical and uterine artery S/D ratios were significantly higher in the abnormal than in the normal outcome group. When uterine arteries were studied at 19 to 24 weeks, sensitivity was 59% in the detection of pregnancy-induced hypertension, 11% in the detection of small for gestational age fetuses, 33% in the detection of small for gestational age fetuses with abnormal outcome, and 83% in the detection of pregnancy induced hypertension needing preterm delivery; the corresponding values for specificity were 69%, 94%, 94%, and 68%. At 26 to 31 weeks the sensitivity values were respectively, 69%, 58%, 75%, and 100% and specificity values were 80%, 59%, 39%, and 79%. When umbilical arteries were studied at 19 to 24 weeks, sensitivity was 38% in the detection of pregnancy-induced hypertension, 46% in the detection of small for gestational age fetuses, 78% in the detection of small for gestational age fetuses with abnormal outcome, and 67% in the detection of pregnancy-induced hypertension needing preterm delivery. The corresponding values of specificity were 74% for all four groups. At 26 to 31 weeks the sensitivity values were 38%, 43%, 87%, and 67%, respectively, and specificity values were 80% for all four groups. We concluded that Doppler examinations of the uterine and umbilical arteries can detect, at midpregnancy, the severe forms of pregnancy-induced hypertension and small for gestational age fetuses but they cannot be used to screen a low risk population in which the prevalence of the disease is low, and hence the positive predictive value is low.

Doppler velocimetry of the uterine artery as a screening test for gestational hypertension.

Doppler ultrasound was used to study the main uterine artery flow velocity waveforms in an unselected population of 272 primiparous women at 22 weeks' gestation. The incidences of subsequent complications were as follows: gestational hypertension alone, 4.4%; intrauterine fetal growth retardation alone, 4%; and gestational hypertension with intrauterine growth retardation, 3.6%. The flow velocity waveform was considered abnormal when the resistance index in the uterine artery was greater than 0.58. This identified 9.5% of the population as 'at risk' and predicted either of the above outcomes with an overall sensitivity of 74% (kappa index, 0.72). The sensitivity of prediction for gestational hypertension alone was 50% while for proteinuric gestational hypertension it was 88%. The best result was obtained for the prediction of pregnancies affected by both gestational hypertension and intrauterine growth retardation, where the sensitivity was 100%.

[Telephone transmission of the cardiotocographic recording from the office to the obstetrical clinic]. / Trasmissione telefonica del tracciato cardiotocografico dal consultorio alla clinica ostetrica.

The authors describe their experience in telephonic transmission of cardiographic recordings. With a Corometrics 116 and 410 unit installed in a remote facility, 61 CTG recordings were tele transmitted and received by a Toshiba personal computer. The comparison between original and transmitted CTG record was excellent and a very low percentage of signal loss during transmission (3.2%). The advantages of telephone transmission of CTG in peripheral areas are stressed.

[Computerized cardiotocographic assessment with the "8000 System". I. Construction of normal curves]. / Valutazione cardiotocografica computerizzata con "Sistema 8000". I. Construzione di curve di normalità.

The construction of referral curves for the computerized ctg parameters may increase the clinical efficacy of the examinations in tracings of unfavourable interpretation. With the help of "System 8000" software, the longitudinal variation of computerized parameters fetal movements/hour, fetal movements in high and low variability, accelerations, length of high and low variability periods, mean range and value of short variability have been analyzed in a group of 12 low risk patients followed biweekly from the 24-26th week of gestation through term. While accelerations, minutes of low and high variability showed an absence of significative variation during pregnancy (F = 1.78; F = 9.3, F = 4.5 P = n.s.), significant (p less than 0.001) variation showed the other parameters. Number of movements/h and movements in high variability had an increase from 24-26 weeks to 32-34 weeks and a progressive further decrease till term; movements in low variability disappear after 32-34 weeks of gestation; mean range and short variability increase until 34 weeks and remained stable till end. Therefore the results obtained are in use for the high risk fetuses that perform a computerized ctg registration: nevertheless, the longitudinal evaluation reveals the maturation of fetal central nervous control on heart rate and fetal movements after the 34-36th weeks of gestation as a shown from behavioural states evaluation.

Fetal behavioural states and hypertensive pregnancy.

Delay in fetal maturation in diabetic and accelerated fetal maturation in hypertensive pregnancies have been reported in the past. The spontaneous activity of fetal nervous system during pregnancy was followed longitudinally in a group of 29 normal pregnancies from 28 x th to 40 x th week of gestation by means of fetal behavioural states determination. 1 F state (quiet sleep) progressively increases from median values of 5.0% to values of 22.5-25% at term of pregnancy. This state represents the positive activity of inhibitory centers has been related to a positive evolutionary process of brain maturation according to preceding experiences conducted on experimental models and preterm babies followed with EEG and direct observation in the early neonatal period. The method of behavioural states determination has been applied to a group of 33 gestational diabetes (GDM) pregnant women followed longitudinally, and a clear reduction of development of 1 F state has been evidentiated, with significant differences (p less than 0.001) at 35-36 weeks of gestation versus the control group. The normal values are reached in concomitance with L/S value of maturity. In 30 pregnant women affected by gestational hypertension (GH) different result are obtained: 1 F state seems to develop earlier, and is increased (p less than 0.001) around 30-32 weeks versus the control group if a fetal growth reduction is present. The value of 1 F behavioural state in the evaluation of fetal condition of pathological pregnancies is discussed.

Telephonic transmission of cardiotocographic recordings from a remote facility to an obstetric unit.

The Authors describe their experience in telephonic transmission of cardiotocographic recordings. With a Corometrics 116 and 410 unit installed in a remote facility, 61 CTG recordings were tele-transmitted and received by a Toshiba personal computer. The concordance between original and transmitted CTG record was excellent and a very low percentage of signal loss during transmission (3.2%) was found. The advantages of telephone transmission of CTG in peripheral areas are stressed.