Maternal deaths caused by eclampsia in Brazil: a descriptive study from 2000 to 2021.

Objective: Eclampsia is a hypertensive disorder that occurs during pregnancy and can lead to death. The literature has gaps by not providing comprehensive data on the epidemiology of the disease, restricting analysis to limited temporal intervals and geographical locations. This study aims to characterize the epidemiological profile of women who died from eclampsia in Brazil from 2000 to 2021. Methods: The maternal mortality data were obtained from the Sistema de Informações sobre Mortalidade, with the following variables of interest selected: "Federative Unit," "Year," "Age Range," "Race/Color," and "Education Level." The collection of the number of live births for data normalization was conducted in the Sistema de Informações sobre Nascidos Vivos. Statistical analyses were performed using GraphPad Prism, calculating odds ratio for variables and fixing number of deaths per 100,000 live births for calculating maternal mortality ratio (MMR). Results: There was a downward trend in maternal mortality rate during the study period. Maranhão stood out as the federative unit with the highest MMR (17 deaths per 100.000 live births). Mothers aged between 40 and 49 years (OR = 3.55, CI: 3.11-4.05) presents higher MMR. Additionally, black women showed the highest MMR (OR = 4.67, CI: 4.18-5.22), as well as mothers with no educational background (OR = 5.83, CI: 4.82-7.06). Conclusion: The epidemiological profile studied is predominantly composed of mothers with little or no formal education, self-declared as Black, residing in needy states and with advanced aged. These data are useful for formulating public policies aimed at combating the issue.

Prevalence of Preeclampsia in Brazil: An Integrative Review / Prevalência de pré-eclâmpsia no Brasil: Uma revisão integrativa

Abstract Objective To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. Methods We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. Results We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. Conclusion The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

Resumo Objetivo Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. Métodos Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. Resultados Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. Conclusão A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

Prevalence of Preeclampsia in Brazil: An Integrative Review.

OBJECTIVE: To review literature and estimate the occurrence of preeclampsia and its complications in Brazil. METHODS: We performed an integrative review of the literature, and included observational studies published until August 2021 on the SciELO and PubMed databases that evaluated preeclampsia among pregnant women in Brazil. Other variables of interests were maternal death, neonatal death, hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome, and eclampsia. Three independent reviewers evaluated all retrieved studies and selected those that met inclusion criteria. A metanalysis of the prevalence of preeclampsia and eclampsia was also performed, to estimate a pooled frequency of those conditions among the studies included. RESULTS: We retrieved 304 studies after the initial search; of those, 10 were included in the final analysis, with a total of 52,986 women considered. The pooled prevalence of preeclampsia was of 6.7%, with a total of 2,988 cases reported. The frequency of eclampsia ranged from 1.7% to 6.2%, while the occurrence of HELLP syndrome was underreported. Prematurity associated to hypertensive disorders ranged from 0.5% to 1.72%. CONCLUSION: The frequency of preeclampsia was similar to that reported in other international studies, and it is increasing in Brazil, probably due to the adoption of new diagnostic criteria. The development of a national surveillance network would be essential to understand the problem of hypertensive disorders of pregnancy in Brazil.

OBJETIVO: Revisar a literatura e estimar a ocorrência de pré-eclâmpsia e suas complicações no Brasil. MéTODOS: Foi realizada uma revisão integrativa da literatura, com a inclusão de estudos observacionais publicados até agosto de 2021, nas bases de dados PubMed e SciELO, que avaliavam pré-eclâmpsia em mulheres brasileiras. Outras variáveis de interesse foram morte materna, morte neonatal, síndrome de hemólise, enzimas hepáticas elevadas e plaquetopenia (hemolysis, elevated liver enzymes, and low platelet count, HELLP, em inglês) e eclâmpsia. Três revisores independentes avaliaram os estudos identificados e selecionaram aqueles que preenchiam os critérios de inclusão. Foi realizada uma meta-análise da prevalência de pré-eclâmpsia e eclâmpsia, para estimar sua frequência acumulada com relação aos estudos incluídos. RESULTADOS: Foram identificados 304 estudos, 10 dos quais foram incluídos na análise final, num total de 52.986 mulheres. A frequência acumulada de pré-eclâmpsia foi de 6,7%, com um total de 2.988 casos. A frequência de eclâmpsia variou de 1,7% a 6,2%, ao passo que a ocorrência de síndrome de HELLP foi pouco relatada. A prematuridade associada a hipertensão foi de 0,5% a 1,7%. CONCLUSãO: A frequência de pré-eclâmpsia foi similar à de estudos internacionais; no entanto, ao longo dos últimos anos, ela vem aumentando no Brasil, possivelmente como reflexo da adoção de novos critérios diagnósticos. A criação de uma rede nacional de vigilância seria fundamental para entender o problema da hipertensão na gestação no país.

Factors associated with severe maternal outcomes in patients with eclampsia in an obstetric intensive care unit: A cohort study.

ABSTRACT: To describe the clinical profile, management, maternal outcomes and factors associated with severe maternal outcome (SMO) in patients admitted for eclampsia.A retrospective cohort study was carried out. All women admitted to the Obstetric Intensive Care Unit (ICU) at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Northeast of Brazil, from April 2012 to December 2019 were considered for inclusion and patients with the diagnosis of eclampsia were selected. Patients who, after reviewing their medical records, did not present a diagnosis of eclampsia were excluded from the study. Severe maternal outcome (SMO) was defined as all cases of near miss maternal mortality (MNM) plus all maternal deaths during the study period. The Risk Ratio (RR) and its 95% confidence interval (95% CI) were calculated as a measure of the relative risk. Multiple logistic regression analysis was performed to control confounding variables. The institute's internal review board and the board waived the need of the informed consent.Among 284 patients with eclampsia admitted during the study period, 67 were classified as SMO (23.6%), 63 of whom had MNM (22.2%) and 5 died (1.8%). In the bivariate analysis, the following factors were associated with SMO: age 19 years or less (RR = 0.57 95% CI 0.37-0.89, P = .012), age 35 years or more (RR = 199 95% CI 1.18-3.34, P = .019), the presence of associated complications such as acute kidney injury (RR = 3.85 95% CI 2.69-5.51, P < .001), HELLP syndrome (RR = 1.81 95% CI 1.20-2.75, P = .005), puerperal hemorrhage (PPH) (RR = 2.15 95% CI 1.36-3.40, P = .003) and acute pulmonary edema (RR = 2.78 95% CI 1.55-4.96, P = .008). After hierarchical multiple logistic regression analysis, the factors that persisted associated with SMO were age less than or equal to 19 years (ORa = 0.46) and having had PPH (ORa = 3.33).Younger age was a protective factor for developing SMO, while those with PPH are more likely to have SMO.

Genetic association of ERAP1 and ERAP2 with eclampsia and preeclampsia in northeastern Brazilian women.

The clinical spectrum of hypertensive disorders of pregnancy (HDP) is determined by the interplay between environmental and genetic factors, most of which remains unknown. ERAP1, ERAP2 and LNPEP genes code for multifunctional aminopeptidases involved with antigen processing and degradation of small peptides such as angiotensin II (Ang II), vasopressin and oxytocin. We aimed to test for associations between genetic variants in aminopeptidases and HDP. A total of 1282 pregnant women (normotensive controls, n = 693; preeclampsia, n = 342; chronic hypertension with superimposed preeclampsia, n = 61; eclampsia, n = 74; and HELLP syndrome, n = 112) were genotyped for variants in LNPEP (rs27300, rs38034, rs2303138), ERAP1 (rs27044, rs30187) and ERAP2 (rs2549796 rs2927609 rs11135484). We also evaluated the effect of ERAP1 rs30187 on plasma Ang II levels in an additional cohort of 65 pregnant women. The genotype C/C, in ERAP1 rs30187 variant (c.1583 T > C, p.Lys528Arg), was associated with increased risk of eclampsia (OR = 1.85, p = 0.019) whereas ERAP2 haplotype rs2549796(C)-rs2927609(C)-rs11135484(G) was associated with preeclampsia (OR = 1.96, corrected p-value = 0.01). Ang II plasma levels did not differ across rs30187 genotypic groups (p = 0.895). In conclusion, ERAP1 gene is associated with eclampsia whereas ERAP2 is associated with preeclampsia, although the mechanism by which genetic variants in ERAPs influence the risk of preeclampsia and eclampsia remain to be elucidated.

A population-based study of preeclampsia and eclampsia in Ecuador: ethnic, geographical and altitudes differences.

BACKGROUND: In Ecuador eclampsia and preeclampsia were identified as the third cause of maternal death. Like other Latin-American countries, Ecuador has human settlements living from 0 to more than 4000 m of altitude and comprising a wide ethnic-diversity across all these altitude changes. These characteristics offer the possibility to study a wide variety of possible risk factors for preeclampsia and eclampsia. METHODS: We conducted a population-based retrospective study of all deliveries in Ecuador from 2015 through 2017. The main variables analyzed were: altitude, ethnic self-identification, geographic location, and maternal age. The data comes from the Ecuadorian National Institute of Statistics and Census (INEC) and the Ecuadorian Ministry of Health. Data information regarding maternal parity and socioeconomic status was not available from official records. Logistic regression analysis was used to study the relationship between preeclampsia and eclampsia with the variable of interest. Geospatial statistical analysis was done to identify statistically significant spatial clusters of preeclampsia and eclampsia cases. RESULTS: The incidence of preeclampsia was estimated between 5.11 (5.05-5.18) and 6.23 (6.16-6.30), and 0.25 (0.23-0.26) for eclampsia. Native American have a lower incidence regarding preeclampsia compared to other ethnic groups. High altitude has a significant odds ratio (OR = 2.31, 1.93-2.78) of preeclampsia. Montubio residing in middle altitude (1500-3500 m) have the highest risk of preeclampsia (OR = 18.13, 9.53-34.50). Afro-Ecuadorians also have an increased risk of preeclampsia associated with altitude (OR = 2.36, 1.78-3.14). Ethnicity was not identified as a risk factor for eclampsia. Early and older maternal age was associated with an increased risk of preeclampsia and eclampsia. Women living more than 20 km from the obstetric unit have an OR = 2.61 (2.32-2.95, p-value< 0.01) and OR = 1.87 (1.82-1.92, p-value< 0.01) of developing eclampsia and preeclampsia respectively. CONCLUSIONS: Preeclampsia is widespread across low and high-altitude areas, while eclampsia is mostly located at lower altitudes. Montubios living at middle or high altitudes represents the ethnic group with a higher risk of preeclampsia. No ethnic effect was identified as a potential risk factor for eclampsia. Moreover, in eclampsia the associated risk of young women seems to be higher than in preeclampsia.

Pregnant adolescents admitted to the intensive care unit have better outcomes than pregnant adult women: A retrospective cohort study in Brazil.

OBJECTIVE: To compare the outcomes of adolescent versus adult women during pregnancy and puerperium admitted to a dedicated intensive care unit (ICU) in Manaus, Amazonas, Brazil. METHODS: In a retrospective cohort study, we retrieved data from the medical charts of 557 adolescent (<20 years) and adult (≥20 years) women. The association between demographic and clinical variables and the outcomes were compared in univariate and multivariate analyses. RESULTS: The maternal severity index (MSI) of adult women was significantly higher than in adolescents. In univariate log-binomial regression analysis, pneumothorax and circulatory dysfunction were positively associated with the composite primary outcome of death or transfer (for more complex care), whereas eclampsia was negatively associated. Being an adolescent was not associated with this outcome, not even when adjusting for potential confounders. Conversely, being an adolescent was associated with fewer complications (secondary outcome) even after adjusting for potential confounders (type of admission, eclampsia, pre-eclampsia, surgical site infection, abdominal hemorrhage, drug abuse, metabolic syndrome, malnutrition, pneumothorax, or circulatory dysfunction). CONCLUSION: In Manaus, Amazonas, Brazil, adult women admitted to the ICU because of gestational or birth complications had worse outcomes compared with adolescents.

Why magnesium sulfate 'coverage' only is not enough to reduce eclampsia: Lessons learned in a middle-income country.

OBJECTIVES: Determine the eclampsia prevalence and factors associated with eclampsia and recurrent seizures in Suriname and evaluate quality-of-care indicator 'magnesium sulfate (MgSO4) coverage'. STUDY DESIGN: A two-year prospective nationwide cohort study was conducted in Suriname and included women with eclampsia at home or in a healthcare facility. MAIN OUTCOME MEASURES: We calculated the prevalence by the number of live births obtained from vital registration. Risk factor denominator data concerned hospital births. Descriptive statistics and multivariate regression analysis were performed. RESULTS: Seventy-two women with eclampsia (37/10.000 live births) were identified, including two maternal deaths (case-fatality 2.8%). Nulliparity, African-descent and adolescence were associated with eclampsia. Adolescents with eclampsia had significantly lower BPs (150/100 mmHg) than adult women (168/105 mmHg). The first seizure occurred antepartum in 54% (n = 39/72), intrapartum in 19% (n = 14/72) and postpartum in 26% (n = 19/72). Recurrent seizures were observed in 60% (n = 43/72). MgSO4 was administered to 99% (n = 69/70) of women; however 26% received no loading dosage and, in 22% of cases MgSO4 duration was <24 h, i.e. guideline adherence existed in only 43%. MgSO4 was ceased during CS in all women (n = 40). Stable BP was achieved before CS in 46%. The median seizure-to-delivery interval was 27 h, and ranged from four to 36 h. CONCLUSION: Solely 'MgSO4 coverage' is not a reliable quality-of-care indicator, as it conceals inadequate MgSO4 dosage and timing, discontinuation during CS, stabilization before delivery, and seizure-to-delivery interval. These other quality-of-care indicators need attention from the international community in order to reduce the prevalence of eclampsia.

The WHO Safe Childbirth Checklist implementation: impact on the prescription of magnesium sulphate through a one-year longitudinal study.

BACKGROUND: Preeclampsia is a relatively frequent condition during pregnancy and childbirth. The administration of magnesium sulphate as a prophylactic and treatment measure is an evidence-based practice for eclampsia; however, it is not consistently used, compromising the health of pregnant women. This study aimed to assess compliance with recommendations of the International Society for the Study of Hypertension in Pregnancy (ISSHP) for the use of MgSO4 in pregnant women with preeclampsia, before and after the implementation of the World Health Organization Safe Childbirth Checklist (SCC). METHODS: This quasi-experimental study was conducted between July 2015 and July 2016 at a third-level maternity hospital in northeastern Brazil, where the SCC was implemented. Compliance (underuse and overuse of MgSO4) was assessed in biweekly samples of 30 deliveries assessed 6 months before and 6 months after SCC implementation, using indicators based on international guidelines. A total of 720 deliveries were assessed over 1 year using an ad hoc application for reviewing medical records. Aggregated adequate use was estimated for the study period, and the time series measurements were compared to a control chart to assess change. RESULTS: The incidence of preeclampsia was 39.9% (287/720). Among these, 64.8% (186/287) had severe signs or symptoms and needed MgSO4. Underuse (no prescription when needed) of MgSO4 was observed in 74.7% (139/186) of women who needed the drug. Considering all women, non-compliance with the prescription protocol (underuse and overuse) was 20.0% (144/720). After introducing the SCC, the use of MgSO4 in women with preeclampsia with severe features increased from 19.1 to 34.2% (p = 0.025). Longitudinal analysis showed a significant (p < 0.05) ascending curve of adequate use of MgSO4 after the SCC was implemented. CONCLUSIONS: Compliance with recommendations for the use of MgSO4 in preeclampsia was low, but improved after implementation of the SCC. Interventions to improve compliance based on diagnosis and treatment reminders may help in the implementation of this good practice.

Desenlaces materno-fetales de los embarazos con trastornos hipertensivos: un estudio transversal / Maternal and fetal outcomes of pregnancies with hypertensive disorders: a cross-sectional study

INTRODUCCIÓN Y OBJETIVO: Los trastornos hipertensivos asociados al embarazo son considerados un problema de salud pública. Se busca describir las características clínicas y desenlaces materno-fetales de las pacientes con esta patología, atendidas en el Hospital Universitario de Santander (HUS) durante el primer semestre de 2017. MÉTODOS: Estudio observacional retrospectivo de corte transversal. Se incluyeron las pacientes en estado de embarazo o puerperio con diagnóstico o sospecha de trastorno hipertensivo; se excluyeron aquellas que no pudieron ser clasificadas o no correspondían a éstos. RESULTADOS: Se analizaron 181 historias clínicas; la edad de las pacientes osciló entre 14 y 44 años; el 43,7% eran primigestantes; el 40,3% tuvo un control prenatal inadecuado y el 27,5% tenía antecedente de trastorno hipertensivo en gestaciones previas. El 75,1% de las pacientes fueron clasificadas como preeclampsia, 18,2% con hipertensión gestacional, 4,4% con hipertensión más preeclampsia sobreagregada y 2,2% con hipertensión crónica. El 16,9% de las pacientes con preeclampsia debutaron antes de la semana 34, de las cuales el 91,3% tenían criterios de severidad; mientras que entre las demás, el 84% presentaron criterios de severidad. CONCLUSIONES: La preeclampsia fue el trastorno hipertensivo más frecuente, predominó la presentación tardía y severa con importantes tasas de complicación maternas y fetales. Mediante la implementación de estrategias de detección temprana y adecuada atención de los trastornos hipertensivos asociados al embarazo podrían mejorarse los desenlaces materno-fetales.

BACKGROUND AND OBJECTIVE: Hypertensive disorders of pregnancy are considered a public health issue. The aim is to describe the clinical features, maternal - fetal outcomes of patients with this disease, who were admitted at the University Hospital of Santander (Bucaramanga, Colombia) during the first half of 2017. METHOD: Cross-sectional retrospective observational study. Patients in pregnancy or puerperium with diagnosis of hypertensive disorder were included; those who could not be classified or did not correspond were excluded. RESULTS: 181 clinical charts were analyzed, the age of the patients ranged between 14 and 44 years, 43.7% were nulliparous, 40.3% had an inadequate prenatal control and 27.5% had history of hypertensive disorder in previous pregnancies. 75.1% were classified as preeclampsia, 18.2% as gestational hypertension, 4.4% as hypertension and superimposed preeclampsia and 2.2% with chronic hypertension; 16.9% of the patients were of an early-onset preeclampsia before week 34, of which 91.3% had criteria of severity; among the others, 84% presented criteria of severity. CONCLUSION: Preeclampsia was the most frequent hypertensive disorder, late and severe presentation prevailed with important maternal and fetal complication rates. Through the implementation of early detection strategies and adequate care of hypertensive disorders associated with pregnancy maternal and fetal outcomes could be improved.

Incidence of eclampsia and related complications across 10 low- and middle-resource geographical regions: Secondary analysis of a cluster randomised controlled trial.

BACKGROUND: In 2015, approximately 42,000 women died as a result of hypertensive disorders of pregnancy worldwide; over 99% of these deaths occurred in low- and middle-income countries. The aim of this paper is to describe the incidence and characteristics of eclampsia and related complications from hypertensive disorders of pregnancy across 10 low- and middle-income geographical regions in 8 countries, in relation to magnesium sulfate availability. METHODS AND FINDINGS: This is a secondary analysis of a stepped-wedge cluster randomised controlled trial undertaken in sub-Saharan Africa, India, and Haiti. This trial implemented a novel vital sign device and training package in routine maternity care with the aim of reducing a composite outcome of maternal mortality and morbidity. Institutional-level consent was obtained, and all women presenting for maternity care were eligible for inclusion. Data on eclampsia, stroke, admission to intensive care with a hypertensive disorder of pregnancy, and maternal death from a hypertensive disorder of pregnancy were prospectively collected from routine data sources and active case finding, together with data on perinatal outcomes in women with these outcomes. In 536,233 deliveries between 1 April 2016 and 30 November 2017, there were 2,692 women with eclampsia (0.5%). In total 6.9% (n = 186; 3.47/10,000 deliveries) of women with eclampsia died, and a further 51 died from other complications of hypertensive disorders of pregnancy (0.95/10,000). After planned adjustments, the implementation of the CRADLE intervention was not associated with any significant change in the rates of eclampsia, stroke, or maternal death or intensive care admission with a hypertensive disorder of pregnancy. Nearly 1 in 5 (17.9%) women with eclampsia, stroke, or a hypertensive disorder of pregnancy causing intensive care admission or maternal death experienced a stillbirth or neonatal death. A third of eclampsia cases (33.2%; n = 894) occurred in women under 20 years of age, 60.0% in women aged 20-34 years (n = 1,616), and 6.8% (n = 182) in women aged 35 years or over. Rates of eclampsia varied approximately 7-fold between sites (range 19.6/10,000 in Zambia Centre 1 to 142.0/10,000 in Sierra Leone). Over half (55.1%) of first eclamptic fits occurred in a health-care facility, with the remainder in the community. Place of first fit varied substantially between sites (from 5.9% in the central referral facility in Sierra Leone to 85% in Uganda Centre 2). On average, magnesium sulfate was available in 74.7% of facilities (range 25% in Haiti to 100% in Sierra Leone and Zimbabwe). There was no detectable association between magnesium sulfate availability and the rate of eclampsia across sites (p = 0.12). This analysis may have been influenced by the selection of predominantly urban and peri-urban settings, and by collection of only monthly data on availability of magnesium sulfate, and is limited by the lack of demographic data in the population of women delivering in the trial areas. CONCLUSIONS: The large variation in eclampsia and maternal and neonatal fatality from hypertensive disorders of pregnancy between countries emphasises that inequality and inequity persist in healthcare for women with hypertensive disorders of pregnancy. Alongside the growing interest in improving community detection and health education for these disorders, efforts to improve quality of care within healthcare facilities are key. Strategies to prevent eclampsia should be informed by local data. TRIAL REGISTRATION: ISRCTN: 41244132.

Effect of a novel vital sign device on maternal mortality and morbidity in low-resource settings: a pragmatic, stepped-wedge, cluster-randomised controlled trial.

BACKGROUND: In 2015, an estimated 303 000 women died in pregnancy and childbirth. Obstetric haemorrhage, sepsis, and hypertensive disorders of pregnancy account for more than 50% of maternal deaths worldwide. There are effective treatments for these pregnancy complications, but they require early detection by measurement of vital signs and timely administration to save lives. The primary aim of this trial was to determine whether implementation of the CRADLE Vital Sign Alert and an education package into community and facility maternity care in low-resource settings could reduce a composite of all-cause maternal mortality or major morbidity (eclampsia and hysterectomy). METHODS: We did a pragmatic, stepped-wedge, cluster-randomised controlled trial in ten clusters across Africa, India, and Haiti, introducing the device into routine maternity care. Each cluster contained at least one secondary or tertiary hospital and their main referral facilities. Clusters crossed over from existing routine care to the CRADLE intervention in one of nine steps at 2-monthly intervals, with CRADLE devices replacing existing equipment at the randomly allocated timepoint. A computer-generated randomly allocated sequence determined the order in which the clusters received the intervention. Because of the nature of the intervention, this trial was not masked. Data were gathered monthly, with 20 time periods of 1 month. The primary composite outcome was at least one of eclampsia, emergency hysterectomy, and maternal death. This study is registered with the ISRCTN registry, number ISRCTN41244132. FINDINGS: Between April 1, 2016, and Nov 30, 2017, among 536 223 deliveries, the primary outcome occurred in 4067 women, with 998 maternal deaths, 2692 eclampsia cases, and 681 hysterectomies. There was an 8% decrease in the primary outcome from 79·4 per 10 000 deliveries pre-intervention to 72·8 per 10 000 deliveries post-intervention (odds ratio [OR] 0·92, 95% CI 0·86-0·97; p=0·0056). After planned adjustments for variation in event rates between and within clusters over time, the unexpected degree of variability meant we were unable to judge the benefit or harms of the intervention (OR 1·22, 95% CI 0·73-2·06; p=0·45). INTERPRETATION: There was an absolute 8% reduction in primary outcome during the trial, with no change in resources or staffing, but this reduction could not be directly attributed to the intervention due to variability. We encountered unanticipated methodological challenges with this trial design, which can provide valuable learning for future research and inform the trial design of future international stepped-wedge trials. FUNDING: Newton Fund Global Research Programme: UK Medical Research Council; Department of Biotechnology, Ministry of Science & Technology, Government of India; and UK Department of International Development.

Discriminatory Accuracy of Preeclampsia Risk Factors in Primary Care.

BACKGROUND: Although it is common to use risk factors in the screening for preeclampsia, they do not always accurately identify patients who truly have this condition. AIM OF THE STUDY: To determine the discriminatory accuracy of known preeclampsia risk factors, both individually and in combination. METHODS: We studied patients undergoing prenatal care who were diagnosed with preeclampsia or eclampsia (n = 160 cases) in primary care and those who were not (n = 430 controls). Data on history of preeclampsia, type 2 diabetes, chronic hypertension, multiple gestation, first pregnancy, pregnancy interval ≥10 years, overweight/obesity, mean arterial pressure (MAP) ≥80 mmHg, and age (<20 years and ≥40 years) were obtained using a dichotomous scale. Discriminatory accuracy indicators were true-positive (TP) and false-positive (FP) rates, positive and negative likelihood ratios (LR+ and LR-), diagnostic odds ratio (DOR), and the area under the receiver-operating characteristic (AUROC) curve; stratified by parity. The case-control status was the reference standard. RESULTS: Certain combinations performed better than individual factors, independent of parity status. Among multiparous women, MAP ≥80 mmHg together with previous preeclampsia and overweight/obesity accumulated the greatest number of discriminatory accuracy indicators, with acceptable values: TP, 72.2%; FP, 1.5%; LR+, 48.4; LR-, 0.3; DOR, 171.6; and AUROC, 0.85. CONCLUSIONS: Discriminatory accuracy was low for almost all individual preeclampsia risk factors. However, the accuracy improved after some factors were combined. To the best of our knowledge, this is the first study to examine the discriminatory accuracy of preeclampsia risk factors used for screening high-risk pregnancies in primary care in Mexico.

Complicaciones neurológicas en la materna crítica / Neurological complications in critically ill pregnant women

Introducción: Las pacientes obstétricas pueden presentar numerosas complicaciones que ponen en peligro sus vidas con necesidad de ingreso en unidades de cuidados intensivos. Objetivo: Caracterizar clínicamente las maternas críticas con complicaciones neurológicas. Métodos: Se realizó un estudio observacional, descriptivo, retrospectivo en el Hospital Clínico Quirúrgico Hermanos Ameijeiras durante el período de enero de 2007 a diciembre de 2016. Para el análisis de los datos se efectuó el cálculo de frecuencias absolutas y relativas, se aplicaron medidas de tendencia central (media) y dispersión (rango) y para conocer la posible asociación entre las variables cualitativas se aplicó el Test de chi-cuadrado con una significación de p<0,05. Resultados: Las complicaciones neurológicas se presentaron en 33,3 por ciento de las pacientes, las más frecuentes fueron: eclampsia (65,7 por ciento), infarto cerebral (9,0 por ciento) y la trombosis venosa cerebral (8,6 por ciento). Las nulíparas (51,4 por ciento) y la edad mayor de 35 años (42,8 por ciento) fueron los factores de riesgo más observados. La hipertensión arterial fue el antecedente patológico personal principal y se evidenció asociación entre las complicaciones neurológicas y la causa directa de la muerte (p=0,00043). Conclusiones: Las complicaciones neurológicas fueron frecuentes en las maternas críticas y constituyen causa directa de muerte. Como complicación más frecuente se presentó la eclampsia(AU)

Introduction: Obstetric patients can present numerous complications that put in danger their lives, and they need of admission in intensive care units. Objective: To characterize in a clinical way the critically ill pregnant women with neurological complications. Methods: An observational, descriptive, retrospective study was conducted in Hermanos Ameijeiras. Clinical-Surgical Hospital during the period from January, 2007 to December, 2016. There was carried out the calculation of absolute and relative frequencies for the analysis of the data; there were applied measures of central (average) trends and dispersion (range), and to know the possible association between the qualitative variables the Chi-square´s Test was performed with a significance of p < 0.05. Results: The neurological complications appeared in 33,3 percent of the patients and the most frequent were: eclampsia (65,7 percent), cerebral infarction (9,0 percent) and cerebral venous thrombosis (8,6 percent). Being a nulliparous women (51,4 percent) and age of more than 35 years (42,8 percent) were the most common risk factors. Arterial hypertension was the main pathological background and the association between the neurological complications and the direct cause of the death (p=0.00043) was demonstrated. Conclusions: The neurological complications were frequent in critically ill pregnant women and they constitute a direct cause of death. The most frequent complication was eclampsia(AU)

Prevalencia de Síndrome de Hellp en el servicio de ginecología y obstetricia del Hospital Central del Instituto de Previsión Social. 2017 / Prevalence of Hellp Syndrome in the gynecology and obstetrics service of the Central Hospital of the Instituto de Previsión Social

Introducción: En la actualidad, la mortalidad materna va aumentando, debido a ciertas complicaciones producidas durante la gestación, una de ellas es el Síndrome de HELLP que es considerada una de las complicaciones más severas de las enfermedades hipertensivas del embarazo que mayoritariamente se presenta en embarazadas que cursan con preeclampsia. Objetivo: Determinar la prevalencia de Síndrome de HELLP en el Servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social durante el año 2017. Materiales y método: Estudio observacional descriptivo de corte transversal, muestreo probabilístico aleatorio simple. Fueron incluidas las fichas clínicas de las embarazadas que acudieron al servicio de Ginecología y Obstetricia del Hospital Central del Instituto de Previsión Social desde enero a diciembre del 2017. Resultados: Fueron incluidas en el estudio 177 embarazadas; de las cuales el 14,2% presentó Síndrome de HELLP. La mediana de edad fue de 28 años; el estado civil predominante fue unión libre en un 49,15%; el 62,71% de las gestantes procedieron de áreas urbanas, mayoritariamente del departamento Central y el 33,90% de ellas son ama de casa. La edad gestacional estuvo comprendida predominantemente entre las 33,2 a 37,6 semanas; la mediana del número de controles prenatales fue de 5. Con respecto a las enfermedades hipertensivas del embarazo la mayor parte de las gestantes presentaron preeclampsia. Conclusión: La prevalencia de Síndrome de HELLP en las embarazadas que acudieron al servicio de Ginecología y Obstetricia en el Hospital Central del Instituto de Previsión Social durante el año 2017 fue del 14,2%; dato similar a otros estudios realizados.

Ingresos a Unidad de Cuidados Intensivos de mujeres durante el embarazo y periodo puerperal / Admission of women to an intensive care unit during pregnancy or the postpartum period

Introducción: las complicaciones del embarazo y parto constituyen las principales causas de muerte entre las mujeres en edad reproductiva. Las embarazadas o puérperas que ingresan a Unidad de Cuidados Intensivos (UCI) son en su mayoría casos agudos críticos con riesgo de muerte, que necesitan tratamiento especializa do y complejo. Constituyen un grupo significativo de la práctica obstétrica. Objetivo: determinar las características clínicas y demográficas de las pacientes gestantes o puérperas que ingresaron a UCI del Hospital Nacional de Itauguá durante 5 años (2011-2015) Materiales y métodos: diseño observacional descriptivo de corte trasverso. Fueron incluidas gestantes y puérperas que requirieron ingreso a UCI por complicaciones obstétricas y no obstétricas, descompensación materna, con y sin morbilidad previa. Resultados: necesitaron ingreso a UCI 135 pacientes (0,48%). La edad media fue 27 ± 6,7 años. La muestra estuvo conformada por 21 gestantes (15,5%), 85 puérperas (63%), 27 mujeres con post aborto (20%) y 2 con embarazo ectópico (1,5 %). La complicación obstétrica más frecuente que motivó el ingreso a UCI fue la sepsis y entre las no obstétricas la cardiopatía descompensada. El tiempo medio de internación en la UCI fue 6,47 ± 8,5 días y 50 pacientes (37,03%) necesitaron asistencia respiratoria mecánica. Hubo 19 óbitos (14%) Conclusiones: el ingreso a UCI se observó en 0,48%. La mortalidad en UCI fue 14%.

Introduction: complications of pregnancy and childbirth are the main causes of death among women of childbearing age. Pregnant women or postpartum women entering the Intensive Care Unit (ICU) are mostly acute cases with a high risk of death, which require specialized and complex treatment. They constitute a significant group of obstetric practice. Objective: to determine the clinical and demographic characteristics of the pregnant or puerperal patients who entered the ICU of the National Hospital of Itauguá for 5 years (2011-2015) Materials and methods: descriptive observational cross-sectional design. Pregnant women and postpartum women who required admission to the ICU due to obstetric and non-obstetric complications, maternal decompensation, with and without prior morbidity were included. Results: 135 patients required admission to the ICU. The mean age was 27 ± 6.7 years. The sample consisted of 21 pregnant women (15.5%), 85 postpartum women (63%), 27 women with post abortion (20%) and 2 with ectopic pregnancy (1.5%). The most frequent obstetric complication that led to ICU admission was sepsis and non-obstetric heart disease was decompensated. The mean ICU admission time was 6.47 ± 8.5 days and 50 patients (37.03%) required mechanical ventilation. There were 19 deaths (14%) Conclusions: ICU admission was observed at 0.48%. Mortality in ICU was 14%.

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis.

BACKGROUND: Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear. OBJECTIVE: To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia. SEARCH STRATEGY: MEDLINE, EMBASE and LILACS were searched (inception to July 2015). SELECTION CRITERIA: Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals. DATA COLLECTION AND ANALYSIS: Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia. MAIN RESULTS: We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I(2) 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I(2) 0 %] with intervals longer than 4 years. CONCLUSION: Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.