[show abstract][hide abstract] ABSTRACT: Platelet count has been proposed as a screening test for generalized coagulopathy in women with preeclampsia. We performed this study to determine the relationship between platelet counts and the risk of abnormal coagulation and adverse maternal outcomes in women with preeclampsia.
We used data from women in the PIERS (Pre-eclampsia Integrated Estimate of RiSk) database. Abnormal coagulation was defined as either an international normalized ratio result greater than and/or a serum fibrinogen level less than the BC Women's Hospital laboratory's pregnancy-specific normal range. The relationship between platelet counts and adverse maternal outcomes was explored using a logistic regression analysis. The sensitivity, specificity, positive predictive value, and negative predictive value of platelet counts in identifying abnormal coagulation or adverse maternal outcomes were calculated.
Abnormal coagulation occurred in 105 of 1405 eligible women (7.5%). The odds of having abnormal coagulation were increased for women with platelet counts < 50 × 10(9)/L (OR 7.78; 95% CI 3.36 to 18.03) and between 50 and 99 × 10(9)/L (OR 2.69; 95% CI 1.44 to 5.01) compared with women who had platelet counts above 150 × 10(9)/L. Platelet counts < 100 × 10(9)/L were associated with significantly increased odds of adverse maternal outcomes, most specifically blood transfusion. A platelet count of < 100 × 10(9)/L had good specificity in identifying abnormal coagulation and adverse maternal outcomes (92% [95% CI 91% to 94%] and 92% [95% CI 91% to 94%], respectively), but poor sensitivity (22% [95% CI 15% to 31%] and 16% [95% CI 11% to 23%], respectively).
A platelet count < 100 × 10(9)/L is associated with an increased risk of abnormal coagulation and maternal adverse outcomes in women with preeclampsia. However, the platelet count should not be used in isolation to guide care because of its poor sensitivity. Whether or not a platelet count is normal should not be used to determine whether further coagulation tests are needed.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 09/2011; 33(9):900-8.
[show abstract][hide abstract] ABSTRACT: We sought to determine the role of respiratory assessment by cardiorespiratory symptoms and/or oxygen saturation by pulse oximetry (SpO2) in predicting adverse maternal outcomes in women admitted to hospital with preeclampsia.
These data derive from an international, prospective multicentre cohort study, PIERS (Pre-eclampsia Integrated Estimate of RiSk), which assesses predictors of adverse outcomes in women admitted to tertiary perinatal units with preeclampsia. Univariate and multivariate analyses of cardiorespiratory symptoms and pulse oximetry were performed to assess their ability to predict a combined adverse maternal outcome developed through international Delphi consensus.
SpO2 successfully predicted adverse maternal outcomes; the area under the receiver-operator characteristic curve (AUC ROC) was 0.71 (95% CI 0.65 to 0.77). Combining the symptoms of chest pain and/or dyspnea with pulse oximetry improved this predictive ability (AUC ROC 0.73; 95% CI 0.67 to 0.78). When SpO2 was stratified into risk groups using inflection points on the ROC curve, the highest risk group (SpO2 90% to 93%) had an odds ratio of 18.1 (95% CI 8.2 to 40.2) for all outcomes within 48 hours when compared with the baseline group (SpO2 98% to 100%).
Assessing SpO2 aids in the assessment of maternal risk in women admitted to hospital with preeclampsia. An SpO2 value of ≤ 93% confers particular risk. The symptom complex of chest pain and/or dyspnea adds to the association.
Journal of obstetrics and gynaecology Canada: JOGC = Journal d'obstetrique et gynecologie du Canada: JOGC 07/2011; 33(7):705-14.
[show abstract][hide abstract] ABSTRACT: Pre-eclampsia is a leading cause of maternal deaths. These deaths mainly result from eclampsia, uncontrolled hypertension, or systemic inflammation. We developed and validated the fullPIERS model with the aim of identifying the risk of fatal or life-threatening complications in women with pre-eclampsia within 48 h of hospital admission for the disorder.
We developed and internally validated the fullPIERS model in a prospective, multicentre study in women who were admitted to tertiary obstetric centres with pre-eclampsia or who developed pre-eclampsia after admission. The outcome of interest was maternal mortality or other serious complications of pre-eclampsia. Routinely reported and informative variables were included in a stepwise backward elimination regression model to predict the adverse maternal outcome. We assessed performance using the area under the curve (AUC) of the receiver operating characteristic (ROC). Standard bootstrapping techniques were used to assess potential overfitting.
261 of 2023 women with pre-eclampsia had adverse outcomes at any time after hospital admission (106 [5%] within 48 h of admission). Predictors of adverse maternal outcome included gestational age, chest pain or dyspnoea, oxygen saturation, platelet count, and creatinine and aspartate transaminase concentrations. The fullPIERS model predicted adverse maternal outcomes within 48 h of study eligibility (AUC ROC 0·88, 95% CI 0·84-0·92). There was no significant overfitting. fullPIERS performed well (AUC ROC >0·7) up to 7 days after eligibility.
The fullPIERS model identifies women at increased risk of adverse outcomes up to 7 days before complications arise and can thereby modify direct patient care (eg, timing of delivery, place of care), improve the design of clinical trials, and inform biomedical investigations related to pre-eclampsia.
Canadian Institutes of Health Research; UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development, and Research Training in Human Reproduction; Preeclampsia Foundation; International Federation of Obstetricians and Gynecologists; Michael Smith Foundation for Health Research; and Child and Family Research Institute.
The Lancet 01/2011; 377(9761):219-27. · 39.06 Impact Factor
[show abstract][hide abstract] ABSTRACT: To reduce maternal and perinatal morbidity and mortality associated with the hypertensive disorders of pregnancy by using an active model of guideline implementation.
This study used a preintervention and postintervention cohort comparison design. We interrogated the British Columbia Perinatal Database Registry for 6 years of existing prospectively gathered data (fiscal years 2000-2001 to 2005-2006), introduced the hypertensive disorders of pregnancy guidelines, and assessed the incidence of the combined adverse maternal and perinatal outcomes for the next 2 years (fiscal years 2006-2007 and 2007-2008). The combined adverse maternal outcome was maternal death, life-threatening, or life-altering complications. The combined perinatal outcome included the severe complications of prematurity and hypoxic-ischemic encephalopathy.
Eighteen thousand seventy-six women were diagnosed with hypertensive disorder of pregnancy in British Columbia from 2000-2001 to 2007-2008. Outcomes were compared preguideline (n=13,150 deliveries) and postguideline (n=4,926 deliveries) implementation. The incidence of the combined adverse maternal outcome decreased from 3.1% to 1.9% (relative risk 0.60, 95% confidence interval 0.48-0.75). There was a concomitant fall in the incidence of the combined adverse perinatal outcome.
The active introduction of standardized management of women with a hypertensive disorder of pregnancy is associated with reduced maternal and perinatal risk.
Obstetrics and Gynecology 09/2010; 116(3):659-66. · 4.80 Impact Factor
[show abstract][hide abstract] ABSTRACT: This review reflects both the variable presentation and the systemic nature of preeclampsia. Recommendations for the comprehensive evaluation and management of organ dysfunction associated with pre-eclampsia are included. The main points in the review are that: (1) Preeclampsia is a systemic disorder that may affect many organ systems. (2) For preeclampsia remote from term (<34 weeks), expectant management improves perinatal outcomes, but requires obsessive surveillance to mitigate maternal risks and is a "package." (3) Initial assessment and ongoing surveillance of women with preeclampsia should include assessment of all vulnerable maternal organs as well as of the fetus. (4) Initiate antihypertensive drug treatment immediately if sBP >160 mmHg or dBP more than 110 mmHg, or if sBP 140-159 mmHg and/or dBP 85-109 mmHg (prepregnancy renal disease or diabetes). (5) The treatment of nonsevere pregnancy hypertension should include a treatment goal of dBP 80-105 mmHg (depending on practitioner preference), with one of the following agents, Methyldopa, Labetalol, Nifedipine, or, with special indications (renal or cardiac diseases), diuretics. (6) Drugs to avoid: angiotensin-converting enzyme inhibitors; angiotensin II receptor antagonists; and atenolol. (7) For the acute management of severe hypertension, initially reduce dBP by 10 mmHg and maintain the blood pressure at or below that level with either Nifedipine or Labetalol. (8) For both prophylaxis against and treatment of eclampsia, MgSO4 (4 g IV stat, then 1 g/hr). (9) For recurrent seizures, MgSO4 (2g IV stat, then increase to 1.5 g/hr). (10) Total fluid intake should not exceed 80 ml/hr; tolerate urine outputs as low as 10 ml/hr. (11) Early-onset and/or severe preeclampsia predict later cardiovascular morbidity and mortality; it would seem prudent to offer such women screening and lipid lowering interventions.
Frontiers in Bioscience 02/2007; 12:2876-89. · 3.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: HIS issue of the Journal contains the report of an investigation examining the gender ratio of practicing Canadian anesthesiologists and residents, to determine whether or not the current gender balance in medical schools is reflected in the specialty of anesthesia. 1 The results indicate that more practicing anesthesiologists are male than female, but the proportion of women has increased since 1998, especially in the younger age groups. These two findings are in keeping with the relatively recent feminization of medical schools in Canada. What may be surprising to some is that the number of women in anesthesia residency programs in the 2004–2005 year continues to lag significantly behind the number of men (201 women to 316 men). In considering these findings, one may question the reasons for a gender imbalance in the number of residents, and whether this might be due to overt or covert discrimination during the residency selection process. Data from the Canadian Resident Matching Service for the period 1993 to 2005 show that more men than women consistently selected anesthesia as their first specialty choice. 1 Thus, it appears that the gender gap is due to a difference in application rates. To address the question regarding fairness of the residency selection process, a previous study by the same authors shows that males and females were equally likely to be accepted or rejected when anesthesia was their first residency choice. 2 This finding suggests that the selection process for anesthesia residency is fair with respect to gender, and the problem is failure of more women to select anesthesia as a career path. Why might anesthesia be less attractive to female medical students? One possibility is lack of exposure to anesthesia during medical school, but as male and female medical students receive the same exposure to anesthesia clinical rotations, this is unlikely to be a factor in the gender gap. Another possibility is that anesthesiologists have limited opportunity to form relationships with patients due to their perceived relatively brief contact. The desire for a more traditional physician-patient relationship may be a reason why more women choose a specialty such as pediatrics. 3 A third possibility is that, as most anesthesiologists are male, there are fewer female anesthesiologists to serve as role models for female medical students. A study from Australia found that women commented that role models encountered during internship and residency were instrumental in their decision to enter or continue in anesthesia. 4
Canadian Journal of Anaesthesia 06/2006; 53(5):427-31. · 2.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: To present the anesthetic management of a parturient with relapsing polychondritis (RP) and to discuss the anesthetic implications of RP.
A 28-yr-old primiparous woman with known RP, spondyloarthropathy and fibromyalgia presented for urgent Cesarean delivery for breech presentation and prodromal labour. Her pregnancy had been complicated by a hospital admission for an exacerbation of her RP as manifested by hoarseness, increased pain and tenderness of her left ear and nasal bridge cartilages, sinusitis with bloody nasal discharge and increased pain and tenderness of the anterior tracheal rings. Epidural anesthesia was administered for the Cesarean delivery. Her intraoperative and postoperative course was uneventful. Close cooperation among obstetricians, anesthesiologists and rheumatologists resulted in a successful outcome.
Relapsing polychondritis is a syndrome with important anesthetic implications. Multidisciplinary cooperation is essential in managing these high risk parturients.
Canadian Journal of Anaesthesia 12/2005; 52(9):967-70. · 2.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: Obstetric hemorrhage continues to be a significant cause of maternal mortality and morbidity. Blood transfusion in such circumstances may be life saving but involves exposing the patient to additional risks. Limiting blood transfusion and using autologous blood when possible may reduce some of these risks. This article outlines the techniques that may be used to limit and more effectively treat hemorrhage in the obstetric patient, with particular attention paid to reducing the use of allogeneic blood transfusion.
Anesthesiology Clinics of North America 04/2003; 21(1):127-44, vii.
[show abstract][hide abstract] ABSTRACT: To discuss the possible ramifications of neuraxial analgesia and anesthesia in women with tattoos involving their midline lumbar area.
Recently the authors have received requests for epidural anesthesia in three women with tattoos over the midline of their lumbar spine. In one patient the tattoo covered her entire back. In the other two, it was possible to locate a lumbar interspace that did not have tattoo pigment in the overlying skin. All three women received uneventful epidural analgesia. A Medline and EMBASE search for relevant publications using the keywords: epidural, spinal, tattoos, tattooing, complications did not find any reports of complications from inserting a needle through a tattoo. As none were found, the literature on tattoos and on coring with neuraxial anesthesia was reviewed to see if neuraxial anesthesia might be problematic if the needle passed through the tattoo. Coring is a complication of neuraxial anesthesia that may lead to epidermoid tumours in the subarachnoid space. Theoretically, a pigment-containing tissue core from a tattoo could be deposited into the epidural, subdural or subarachnoid spaces, leading to later neurological complications.
There is no information in the literature about possible risks from inserting needles through tattoos during the performance of neuraxial anesthesia. This report discusses the possible implications.
Canadian Journal of Anaesthesia 01/2003; 49(10):1057-60. · 2.13 Impact Factor