-
[show abstract]
[hide abstract]
ABSTRACT: Complete neurocognitive recovery after eclampsia has been questioned with the expression of neurocognitive deficits by affected women and demonstration of cerebral white matter lesions on magnetic resonance imaging years after eclampsia. We hypothesized that formerly eclamptic women may experience impaired vision-related quality of life (QOL) and visual field loss as a result of the presence of such lesions in the cerebral visual areas.
Using the National Eye Institute Visual Function Questionnaire-39/Nederlands questionnaire, vision-related QOL was compared between formerly eclamptic women and control participants after normotensive pregnancies. Furthermore, in formerly eclamptic women, visual fields were assessed using automated perimetry, and presence of white matter lesions was evaluated using cerebral magnetic resonance imaging. Presence of a relationship between these lesions and National Eye Institute Visual Function Questionnaire-39/Nederlands scores was estimated.
Forty-seven formerly eclamptic women and 47 control participants participated 10.1±5.2 and 11.5±7.8 years after their index pregnancy, respectively. Composite scores and 4 out of 12 National Eye Institute Visual Function Questionnaire-39/Nederlands subscale scores were significantly lower in formerly eclamptic women than in control participants (P<.01 for composite scores). This could not be explained by visual field loss, because all formerly eclamptic women who underwent perimetry (n=43) demonstrated intact visual fields. White matter lesions were present in 35.7% of formerly eclamptic women who underwent magnetic resonance imaging (n=42) and were associated with lower vision-related QOL scores (P<.05 for composite scores).
Formerly eclamptic women express lower vision-related QOL than control participants, which seemed at least partly related to the presence of white matter lesions. However, such women do not have unconscious visual field loss. Vision-related QOL impairment expressed by formerly eclamptic women may therefore be related to problems with higher-order visual functions.
II.
Obstetrics and Gynecology 05/2012; 119(5):959-66. · 4.73 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Labetalol is often used in severe preeclampsia (PE). Hypotension, bradycardia and hypoglycemia are feared neonatal side effects, but may also occur in (preterm) infants regardless of labetalol exposure. We analyzed the possible association between intrauterine labetalol exposure and such side effects.
From 1 January 2003 through 31 March 2008, all infants from mothers suffering severe PE admitted to one tertiary care center were included. Severe PE was defined according to the International Society for the Study of Hypertension in Pregnancy (ISSHP) criteria. Infants exposed to labetalol in utero (labetalol infants) were compared with infants, who were not exposed to labetalol (controls). Neonatal records were reviewed for hypotension (RR<mean gestational age in weeks), bradycardia (heartrate<100/min) and hypoglycaemia (glucose<2.7 mmol/L) in the first 48 postnatal hours.
Of 109 infants, 55 had been exposed to labetalol, whereas 54 were not (controls). Gestational age at delivery and birthweight were similar in both groups (31.8 vs. 32.8 weeks (p=0.06) and 1510 vs. 1639 grams (p=0.25), respectively for the labetalol vs. control group). Hypotension occurred significantly more in conjunction with labetalol exposure (16, (29.1%) vs. 4 (7.4%); p=0.003), irrespective of the route of administration. Patent ductus arteriosus (PDA) was present in 9 (56%) of hypotensive labetalol infants compared to 1 (24%) infant in the hypotensive control group (NS). In a multivariate regression model, labetalol exposure, the need for intubation and PDA appeared independently associated with hypotension (P<0.001). Hypoglycemia occurred in 26 (47.3%) of labetalol infants and in 23 (42.6%) of control infants (p=0.62). Bradycardia occurred in 4 (7.3%) of labetalol infants and in 1 (1.9%) of control infants (p=0.18). Hypoglycemia was more common in premature infants (n=45 (48,9%) vs. n=4 (23.5%), p=0.05) in both labetalol and control infants.
Hypotension is more common after maternal labetalol exposure, regardless of the dosage and route of administration. The need for intubation and the presence of a PDA also play a role. Hypoglycemia is a very common finding in this population and is merely related to prematurity and independent of labetalol exposure as was the incidental occurrence of bradycardia. These findings on the neonatal side effects of maternal labetalol treatment in preeclampsia underline the importance of frequent blood glucose and blood pressure measurements in the first days of life, especially in intubated preterm infants with a PDA.
Early human development 04/2012; 88(7):503-7. · 2.12 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: We investigated the cerebrovascular effects of continuous infusion of low-dose oxytocin in normal pregnant women undergoing induction of labor. In our prospective observational study, middle cerebral artery velocity was measured with transcranial Doppler ultrasound in 25 healthy, normotensive, nonsmoking patients undergoing induction of labor. No vasoactive drugs were used before or during the study period. Measurements were made at baseline and 15, 30, 60, and 120 minutes after oxytocin initiation. Mean arterial pressure, cerebral perfusion pressure, resistance index, resistance area product, and cerebral flow index at different times were calculated and compared using one-way analysis of variance (ANOVA) for repeated measures or Friedman repeated-measures ANOVA as appropriate, with P<0.05 regarded as significant. No significant systemic or cerebrovascular changes were noted after oxytocin initiation, and there was no correlation between the dosage administered and any hemodynamic parameter. Induction-dose oxytocin does not significantly affect selected cerebral hemodynamic parameters in the first 2 hours after initiation.
American Journal of Perinatology 03/2011; 28(7):579-84. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Because the onset of labour represents a genuine diagnostic problem, labour at term is usually ascertained based on undefined subjective criteria. This can have far-reaching consequences. When the onset of labour is not duly diagnosed, dysfunctional labour may remain unrecognized and timely treatment could be wrongly withheld. Conversely, when a woman is declared to be in labour too early, erroneous interventions may follow. It is assumed that correct diagnosis of the onset of labour contributes to the effective correction of slow progression and to a reduction in the rising caesarean section rate. To diagnose the onset of labour, knowledge of physiology as well as pathophysiology in labour is required. A plea for verbal clarity amongst caregivers as well as consistent, evidence-based diagnosis of the onset of labour is made in this article.
Nederlands tijdschrift voor geneeskunde 01/2011; 155:A2273.
-
[show abstract]
[hide abstract]
ABSTRACT: Recently, information has emerged that formerly eclamptic women may suffer cognitive impairment. This may be related to cerebral white matter lesions. The few available reports demonstrate inconsistent results. We sought to elucidate cognitive performance after eclampsia in a pilot study. Twenty-six eclamptic, 20 preeclamptic, and 18 healthy parous women performed the Sustained Attention to Response Task (SART; the ability to sustain mindful processing of repetitive stimuli that would otherwise lead to habituation) and the Random Number Generation Task (RNG; executive functioning, i.e., inhibition and updating/monitoring). Average age was 40 years, elapsed time since index pregnancy was 9 years. Education levels did not differ. There were no intercurrent illnesses. No significant differences were found on SART and RNG scores between groups. This study was not able to demonstrate evidence for impaired sustained attention and executive functioning after eclampsia. Studies including a much wider range of neurocognitive tests amplified to posterior brain regions with larger groups are necessary.
American Journal of Perinatology 04/2010; 27(9):685-90. · 1.32 Impact Factor
-
Gerda G Zeeman
[show abstract]
[hide abstract]
ABSTRACT: Pre-eclampsia is mainly responsible for the world's large maternal mortality rates, mostly due to acute cerebral complications. This review provides insight into the pathogenesis of the neurologic complications of hypertensive disease in pregnancy. In addition, practical relevance for clinical care is highlighted. Pertaining to pregnancy, the blood pressure level at which cerebral autoregulation operates and possible deregulation occurs is unknown, but is likely to be variable. From clinical observation, eclampsia may occur despite a mild clinical picture and before the development of hypertension or proteinuria. Furthermore, failure of cerebrovascular autoregulatory mechanisms in response to either an acute and/or relatively large blood pressure increase may be more important than the absolute blood pressure value. It may be the acuity of the blood pressure rise in the setting of endothelial dysfunction that interrupts the delicate balance between capillary and cellular perfusion pressures that leads to the neurological complications of pre-eclampsia.
Seminars in perinatology 07/2009; 33(3):166-72. · 2.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the extent of hemoconcentration in nulliparous women with eclampsia.
Total blood volume was measured before delivery using autologous (51)chromium-tagged erythrocytes in 29 nulliparous women with eclampsia. (These studies were completed in 1958-1978 when such tests were not contraindicated in gravid women). This was repeated several weeks postpartum at which time all of the women had become normotensive. Blood volume determinations were then compared with those from a cohort of 44 normotensive pregnant women.
Eclamptic women had a mean 9 (+/-15)% increase in blood volume at delivery compared with their mean nonpregnant blood volume. Normal pregnant women had a mean 47% (+/- 15) increase in blood volume compared with their nonpregnant values. In both groups, nonpregnant mean volumes were very similar (2930 +/- 450 versus 3070 +/- 390 mL). In 12 women with eclampsia in the index pregnancy, paired blood volume determinations were again done in the late third trimester in 14 subsequent normotensive pregnancies. This time they had a mean 45% (+/-17) increase compared with their nonpregnant mean blood volume (p < 0.001) which was almost identical to the 47% expansion in the normal cohort.
Women with eclampsia have significantly decreased blood volumes at term compared with normally pregnant women. In subsequent normotensive pregnancies, blood volume expansion in these women is normal.
Hypertension in Pregnancy 05/2009; 28(2):127-37. · 1.69 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Eclampsia is thought to have no long-term neurological consequences. We aimed to delineate the neurostructural sequelae of eclampsia, in particular brain white matter lesions, utilizing high-resolution 3-Tesla magnetic resonance imaging (MRI).
Formerly eclamptic women were matched for age and year of index pregnancy with normotensive parous controls. The presence and volume of brain white matter lesions were compared between the groups.
MRI scans of 39 women who formerly had eclampsia and 29 control women were performed on average 6.4 +/- 5.6 years following the index pregnancy at a mean age of 38 years. Women with eclampsia demonstrated subcortical white matter lesions more than twice as often as compared with controls (41% vs 17 %; odds ratio, 3.3; 95% confidence interval, 1.05-10.61; P = .04).
Cerebral white matter lesions occur more often in women who formerly had eclampsia compared with women with normotensive pregnancies. The exact pathophysiology underlying these imaging changes and their clinical relevance remain to be elucidated.
American journal of obstetrics and gynecology 04/2009; 200(5):504.e1-5. · 3.28 Impact Factor
-
Nederlands tijdschrift voor geneeskunde 02/2009; 153(1-2):20-4.
-
[show abstract]
[hide abstract]
ABSTRACT: Epidemiological data indicate that women with preeclampsia are more likely to develop cardiovascular disease (CVD) later in life. Population-based studies relate preeclampsia to an increased risk of later chronic hypertension (RR, 2.00 to 8.00) and cardiovascular morbidity/mortality (RR, 1.3 to 3.07), compared with normotensive pregnancy. Women who develop preeclampsia before 36 weeks of gestation or have multiple hypertensive pregnancies are at highest risk (RR, 3.4 to 8.12). The underlying mechanism for the remote effects of preeclampsia is complex and probably multifactorial. Many risk factors are shared by CVD and preeclampsia, including endothelial dysfunction, obesity, hypertension, hyperglycemia, insulin resistance, and dyslipidemia. Therefore, it has been proposed that the metabolic syndrome may be a possible underlying mechanism common to CVD and preeclampsia. Follow-up and counseling of women with a history of preeclampsia may offer a window of opportunity for prevention of future disease.
The American Journal of the Medical Sciences 11/2007; 334(4):291-5. · 1.39 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Recently, persistent brain white matter lesions were demonstrated in eclamptic women when imaged 6 weeks after delivery. Moreover, many of these women complain about cognitive limitations years after the eclamptic pregnancy. Therefore, in a cohort of such women, we assessed cognitive failures in daily life.
Thirty formerly eclamptic women completed the Cognitive Failures Questionnaire. Scores were compared with scores of formerly preeclamptic (n = 31) and healthy parous control participants (n = 30) with the use of a priori Student t test. Groups were matched in terms of current age and years elapsed since index pregnancy.
Women who have had eclampsia scored significantly higher on the Cognitive Failures Questionnaire, compared with healthy parous control subjects (43.5 +/- 14.6 vs 36.1 +/- 13.9, respectively; P < .05).
Women who have had eclampsia reported significantly more cognitive failures years after the index pregnancy. It is hypothesized that this might be due to some degree of cerebral white matter damage. This subjective assessment of cognitive function must be confirmed with objective neurocognitive testing and related to neuroimaging findings.
American journal of obstetrics and gynecology 11/2007; 197(4):365.e1-6. · 3.28 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Previous studies have demonstrated that pregnancy prevents protective hypertension-induced remodeling of cerebral arteries using nitric oxide synthase (NOS) inhibition to raise mean arterial pressure (MAP). In the present study, we investigated whether this effect of pregnancy was specific to NOS inhibition by using the Dahl salt-sensitive (SS) rat as a model of hypertension. Nonpregnant (n = 16) and late-pregnant (n = 17) Dahl SS rats were fed either a high-salt diet (8% NaCl) to raise blood pressure or a low-salt diet (<0.7% NaCl). Third-order posterior cerebral arteries were isolated and pressurized in an arteriograph chamber to measure active responses to pressure and passive remodeling. Several vessels from each group were stained for protein gene product 9.5 to determine perivascular nerve density. Blood pressure was elevated in both groups on high salt. The elevated MAP was associated with significantly smaller active and passive diameters (P < 0.05) and inward remodeling in the nonpregnant hypertensive group only. Whereas no structural changes were observed in the late-pregnant hypertensive animals, both late-pregnant groups had diminished myogenic reactivity (P < 0.05). Nerve density in both the late-pregnant groups was significantly greater when compared with the nonpregnant groups, suggesting that pregnancy has a trophic influence on perivascular innervation of the posterior cerebral artery. However, hypertension lowered the nerve density in both nonpregnant and late-pregnant animals. It therefore appears that pregnancy has an overall effect to prevent hypertension-induced remodeling regardless of the mode of hypertension. This effect may predispose the brain to autoregulatory breakthrough, hyperperfusion, and eclampsia when MAP is elevated.
AJP Heart and Circulatory Physiology 02/2007; 292(2):H1071-6. · 3.71 Impact Factor
-
Gerda G Zeeman
[show abstract]
[hide abstract]
ABSTRACT: Obstetric patients are generally young and healthy. However, the potential for catastrophic complications is real, and despite the therapeutic advances of the last few decades, maternal morbidity and mortality continue to occur. This may be related to the pregnancy itself, aggravation of a preexisting illness, or complications of the (operative) delivery.
The purpose of this review is two-fold: first, to provide an update on currently available reports pertaining to important critical care issues of the obstetric patient population and, second, to present current comprehensive treatment options for preeclampsia and massive obstetric hemorrhage because both are responsible for the majority of maternal mortality and morbidity worldwide.
The most common reasons for intensive care unit admission are hypertensive disorders and massive obstetric hemorrhage. Timely delivery and prompt initiation of antihypertensive therapy for severe hypertension form the mainstay of care in preeclampsia. Restoration of circulating blood volume and rapid control of bleeding and impaired coagulation are the main factors in the management of massive obstetric hemorrhage. Puerperal morbidity has become the main topic of quality of care issues in maternity care. Although the Acute Physiology and Chronic Health Evaluation II score is commonly used in the intensive care unit, it does not seem to be appropriate for pregnant women because it overestimates their mortality rates. A high-dependency care unit suits the needs for at least half of the obstetric patient population in need of higher acuity care and will save considerable cost.
Emphasis on early detection of maternal problems and prompt referral to tertiary centers with intensive care unit facilities to provide optimum care of the circulation, blood pressure, and respiration at an early stage could minimize the prevalence of multiple organ failure and mortality in critically ill obstetric patients.
Critical Care Medicine 10/2006; 34(9 Suppl):S208-14. · 6.33 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the effect of a 6 gram intravenous bolus of magnesium sulfate on maternal cerebral blood flow in women with preeclampsia.
Velocity-encoded phase-contrast magnetic resonance imaging studies were performed on twelve preeclamptic women prior to and immediately after infusion of a 6 gram magnesium sulfate loading dose. Cerebral blood flow was determined at the bilateral proximal middle and posterior cerebral arteries. Study participants returned 6 weeks postpartum for a non-pregnant measurement of cerebral blood flow. The Wilcoxon paired-sample test was used with statistical significance defined as p<0.05.
There was no significant difference in cerebral vessel diameter nor blood flow for any of the examined arteries between the pre- and post magnesium sulfate therapy states.
The absence of a significant difference in cerebral blood flow of the middle and posterior cerebral arteries before and after infusion of a 6 gram loading dose of magnesium sulfate in women with preeclampsia could suggest the absence of vasoconstriction of the large cerebral arteries in preeclampsia and question the role of magnesium sulfate as a vasodilator of these arteries.
Journal of Maternal-Fetal and Neonatal Medicine 04/2005; 17(3):187-92. · 1.50 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to compare third trimester and nonpregnant cerebral blood flow of women with preeclampsia to normotensive control subjects with the use of magnetic resonance imaging techniques.
Nine normotensive pregnant women and 12 untreated women with preeclampsia underwent velocity-encoded phase contrast magnetic resonance imaging of the bilateral middle and posterior cerebral arteries in the third trimester and at 6 to 8 weeks after delivery. The Student t test was used for comparison, with a probability value of <.05 considered significant.
Third-trimester large cerebral artery blood flow was significantly higher in preeclampsia. Mean vessel diameter was unchanged, except for the left posterior cerebral artery. There was no difference in mean vessel diameter or cerebral blood flow between the 2 groups while the women were not pregnant.
Cerebral blood flow is increased significantly in preeclampsia. We hypothesize that increased cerebral blood flow ultimately could lead to eclampsia through hyperperfusion and the development of vasogenic edema.
American Journal of Obstetrics and Gynecology 11/2004; 191(4):1425-9. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The objective of this study was to perform antiphospholipid antibody screening in women with chronic hypertension to assess whether the presence of such antibodies is associated with adverse pregnancy outcome. Serum for anticardiolipin antibodies and lupus anticoagulant was obtained in pregnant women with chronic hypertension who had no other indications for such testing. The primary outcomes of interest were the development of superimposed preeclampsia, preterm delivery, and fetal growth restriction. Only 8 (9%) of the 87 women enrolled tested positive (> 95th percentile) for anticardiolipin immunoglobulin G. None tested positive for lupus anticoagulant. The presence of antiphospholipid antibodies was not associated with adverse pregnancy outcome. We were unable to demonstrate that screening for antiphospholipid antibodies is a useful clinical practice in women whose only pregnancy complication was chronic hypertension. The significance of such antibodies in this particular group of patients can only be resolved with a large multicenter study.
American Journal of Perinatology 07/2004; 21(5):275-9. · 1.32 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study was undertaken to characterize the neuroimaging findings of cerebral edema associated with eclamptic seizures by use of diffusion-weighted magnetic resonance imaging (MRI).
During the 3-year period ending March 2002, 27 nulliparous women with eclampsia were evaluated with diffusion-weighted MRI and apparent diffusion coefficient mapping. Those with findings of restricted diffusion suggestive of cytotoxic edema underwent neuroimaging again 6 weeks post partum.
All but 2 of these 27 women (93%) had reversible vasogenic edema. Six were also found to have areas of cytotoxic edema consistent with cerebral infarction. Five of these 6 women had persistent imaging findings of infarction when studied post partum, however, without clinical neurologic deficits.
The spectrum of cerebral lesions in eclampsia as seen with MRI varies from initially reversible areas of vasogenic edema that may progress to cytotoxic edema and infarction in up to a fourth of women.
American Journal of Obstetrics and Gynecology 04/2004; 190(3):714-20. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: This study was undertaken to determine blood flow changes in the large cerebral arteries during normal pregnancy.
Ten healthy pregnant volunteers underwent velocity-encoded phase contrast magnetic resonance imaging at 4 time intervals: 14 to 16, 28 to 32, and 36 to 38 weeks' gestation, and at 6 to 8 weeks' postpartum. Analysis consisted of serial paired Student t tests, with P<.05 considered significant.
By using postpartum values for comparison, cerebral blood flow decreased by 14 to 16 weeks in the middle cerebral artery (P<.001), but was not significantly changed in the posterior cerebral artery. Significant decreases occurred in both the middle (P<.0001) and posterior (P=.002) cerebral arteries in late pregnancy.
An approximately 20% reduction in large artery cerebral blood flow occurs during normal pregnancy, secondary to changes in velocity, whereas the area of these vessels remains unchanged. These findings may represent generalized vasodilatation of downstream resistance arterioles, assuming constant blood flow at the tissue level.
American Journal of Obstetrics and Gynecology 11/2003; 189(4):968-72. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to evaluate prospectively midtrimester homocysteine concentration levels for the prediction of superimposed preeclampsia in women with chronic hypertension.
Between March 1, 2000, and February 1, 2002, pregnancies that were complicated by chronic hypertension that required medication had homocysteine, vitamin B(12), and folate concentrations measured between 16 and 20 weeks of gestation. All women received folate supplementation. An upper limit threshold for increased homocysteine was defined as the mean value plus 2 SDs.
Fifty-seven women were enrolled. Mean homocysteine concentration levels were 5.1+/-1.7 micromo/L for the 16 women who had preeclampsia compared with 4.7+/-1.3 micromo/L for the 41 women without preeclampsia (P=.56). Two of 16 women with preeclampsia (13%) had concentration levels that exceeded the 95th percentile (6.9 micromo/L) compared with 2 of 41 women (5%) without preeclampsia (P=.31). The sensitivity and specificity were 13% (95% CI, 1.6-38.3) and 95.1% (95% CI, 83.5-99.4), respectively.
Second-trimester homocysteine concentration levels were not helpful in the prediction of preeclampsia in chronically hypertensive women.
American Journal of Obstetrics and Gynecology 09/2003; 189(2):574-6. · 3.47 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: The purpose of this study was to describe our 2-year experience with 483 critically ill peripartum women and to propose a blueprint for obstetric critical care.
This was a prospective study to evaluate all admissions to the Obstetric Intermediate Care Unit and obstetric admissions to medical/surgical intensive care units. Our findings are followed by general recommendations for the organization of obstetric critical care.
Almost two thirds of the women had obstetric complications that included pregnancy-associated hypertension and obstetric hemorrhage. Medical disorders were most common in the other one third of the women.
An Obstetric Intermediate Care Unit allows for the continuation of care by obstetricians and results in fewer transfers to medical/surgical intensive care units. Patient treatment depends on hospital size and available resources. In most tertiary centers, the critically ill pregnant woman is best cared for by obstetricians in an Obstetric Intermediate Care Unit. In smaller hospitals, transfer to a medical or surgical intensive care unit may be preferable.
American Journal of Obstetrics and Gynecology 03/2003; 188(2):532-6. · 3.47 Impact Factor
