Aspirin In The Prevention Of Pre-Eclampsia: Where Are We Now?

Pre-eclampsia is a pregnancy specific multi-systemic disorder that causes maternal and perinatal morbidity and mortality worldwide. It is estimated to complicate between three to five percent of pregnancies and contributes to 8 to 10% of all preterm births1,2. Aspirin inhibits cyclooxygenase in platelets and endothelium in a fashion that alters the balance between the vasoconstrictor thromboxane and the vasodilator prostacyclin. This potentiates vasodilatation and reduces platelet aggregation, contributors to the endothelial dysfunction seen in preeclampsia. Over 100 clinical trials have examined whether or not Aspirin, when prescribed from early pregnancy, can prevent pre-eclampsia, and the consensus is that it reduces the incidence by approximately 10 to 24 % in women that are deemed to be at risk.</p

How much greater is obstetric intervention in women with medical disorders in pregnancy when compared to the general population?

Introduction The purpose of this study was to compare obstetric and neonatal outcomes between women attending a specialised maternal medicine service and the general obstetric population.  Methods Women attending from January 2011 to December 2016 were identified from the clinic database. Medical diagnosis, demographics, obstetric and neonatal outcomes were compared with data from hospital annual report 2014.  Results 1873 women were compared with 8632 women who delivered at the hospital in 2014. Delivery before 34 weeks [82 (4.5%) vs 189 (2.2%)], induction of labour [761 (40.6%) vs 2664 (30.9%)] and delivery by Caesarean Section (CS) [664 (35%) vs 2479 (29%)] were higher p Conclusion Premature delivery, induction of labour and CS rates are higher in women with medical disorders in pregnancy. Encouragingly, 77% of women attempting vaginal birth in this group were successful.</p

Pregnancy and delivery in patients with Charcot–Marie–Tooth disease and related disorders

Background Charcot–Marie–Tooth disease is the most common inherited peripheral neuropathy and many patients with Charcot–Marie–Tooth are women of childbearing age. Guidelines for managing pregnancy in Charcot–Marie–Tooth are lacking. Aims To assess the impact of pregnancy on Charcot–Marie–Tooth and how Charcot–Marie–Tooth affects pregnancy, delivery and postnatal care. Methods A retrospective questionnaire exploring disease course during pregnancy, delivery, pregnancy complications, anaesthetic management and puerperium was administered to 92 patients with Charcot–Marie–Tooth and related disorders. Results Worsening of Charcot–Marie–Tooth symptoms were reported in 37% of pregnant patients which resolved after delivery in half of the patients. No significant increase in pregnancy, delivery and anaesthetic complications were observed and the type of delivery did not significantly differ from the normal population. Conclusions While these results are reassuring, ideally an international prospective study should be done to confirm these results and to develop practice guidelines on the management of pregnancy in Charcot–Marie–Tooth.</p

Maternal morbidity and mortality: an iceberg phenomenon

Objective: To apply the iceberg model, quantifying absolute and relative incidence, to the four main causes of maternal morbidity and mortality in Ireland: haemorrhage, hypertension, sepsis and thrombosis.  Design: Secondary analysis of national data on maternal morbidity and mortality.  Setting: Republic of Ireland.  Population or sample: Approximately 715 000 maternities, 1 200 000 maternal hospitalisations, 2138 cases of severe maternal morbidity (SMM) and 54 maternal deaths.  Methods: Incidence rates and case-fatality ratios were calculated.  Main outcome measures: Maternal death, SMM and hospitalisation.  Results: At the ‘tip of the iceberg’, the incidence of maternal death per 10 000 maternities was 0.09 (95% CI 0.03–0.20) due to thrombosis and 0.03 (95% CI 0–0.11) due to haemorrhage, hypertension disorders or sepsis. For one death due to thrombosis there were 35 cases of pulmonary embolism and 257 thrombosis hospitalisations. For one death due to eclampsia, there were 58 eclampsia cases, 13 040 hospitalisations with pre-existing hypertension and 40 781 hospitalisations with gestational hypertension. For one death due to pregnancy-related sepsis, there were 92 cases of septicaemic shock and 9005 hospitalisations with obstetric sepsis. For one maternal death due to haemorrhage, there were 1029 cases of major obstetric haemorrhage and 53 715 maternal hospitalisations with haemorrhage. For every 100 maternities, there were approximately 16 hospitalisations associated with haemorrhage, 12 associated with hypertension disorders, three with sepsis and 0.2 with thrombosis.  Conclusions: Haemorrhage and hypertension disorders are leading causes of maternal morbidity in Ireland but they have very low case fatality. This indicates that these morbidities are managed effectively but their prevention requires more focus.  Tweetable abstract: Study shows that haemorrhage and hypertension are main causes of #maternalmorbidity in Ireland. Timely interventions for #maternalhealth and focus on prevention of severe and non-severe morbidities are needed. @NPEC #maternityservices #clinicalaudit #qualityimprovement.</p

Major obstetric haemorrhage: incidence, management and quality of care in Irish maternity units

Objective: To assess major obstetric haemorrhage incidence, management and quality of care in Irish maternity units. Design: In collaboration with Irish maternity units the National Perinatal Epidemiology Centre (Leitao et al., 2020) carried out a national clinical audit and surveillance of major obstetric haemorrhage (MOH). Methods: MOH was defined as blood loss of at least 2500 ml, transfusion of five or more units of blood or documented treatment for coagulopathy. Co-ordinators in maternity units completed detailed case assessment forms. The denominator data obtained from the individual units was restricted to live births and stillbirths of babies weighing at least 500 g. International Classification of Diseases diagnostic codes from hospital discharge records were used to identify cases of postpartum haemorrhage (PPH) and blood transfusion. Results: During the time period, 2011-2018, there was a 54 % increase in MOH, a 60 % increase in PPH and a 54 % increase in blood transfusion. For 497 reported cases of MOH in 2011-2013, the median estimated blood loss was 3000 ml (range: 600-13,000 ml) and uterine atony was the most common cause. At least one uterotonic agent was used to arrest the bleeding in 94 % of the 477 MOH cases associated with a vaginal or caesarean delivery. A blood transfusion was received in 93 % of cases. Regarding quality of care, the vast majority of reported cases were described as receiving appropriate care and were well managed. Conclusion: Internationally, obstetric haemorrhage and especially PPH and its increasing trend remains a major challenge for service providers and clinical staff. A standardisation of definitions of PPH/severe PPH/MOH and agreed approaches to quantitation of blood loss would be valuable developments to allow better investigation and shared learning. Reducing the burden of this morbidity through improvements in care should be a real focus of maternity services.</p