They are describing HELLP syndrome. With these weeks of gestation and with the fetus recently matured (she has already been given two doses of corticosteroids), the attitude is immediate termination.

34-week primigravida with blood pressure of 165/95 and headache of two days of evolution. Laboratory tests: hemoglobin 10.5 g/dL, platelets 98,000/mm3, AST 356 IU/L (0-31), ALT 234 IU/L (0-31), LDH 878 IU/L (125-243). The laboratory is called because of the presence of schistocytes in the peripheral blood smear. She received the second dose of corticosteroids for fetal maturation 24 hours ago. On obstetric ultrasound the estimated fetal weight is in the 1st percentile for gestational age and the umbilical artery Doppler shows absence of end-diastolic flow. Which of the following is the most indicated clinical approach?

Expectant management with antihypertensive drugs and magnesium sulfate until the maternal platelets improve.

Expectant attitude with antihypertensive treatment at home and controls every 48 hours.

Termination of gestation when she completes fetal lung maturation.

HELLP syndrome manifesting as abnormal fetal umbilical artery blood flow and rapidly worsening laboratory indexes: A case report.

HELLP syndrome, a rare but serious obstetric complication, is often overdiagnosed due to its nonspecific symptoms and inappropriate clinical testing. A 30-year-old nulliparous pregnant Chinese woman at gestational age of 28+1 weeks was admitted to our hospital because Doppler ultrasonography at a local hospital had detected loss of fetal umbilical artery end-diastolic blood flow lasting 12 hours. On admission to our hospital, the patient showed elevated blood pressure (148/84 mm Hg), but blood pressure and laboratory indicators after admission were normal. However, the patient developed abdominal pain during hospitalization. Dexamethasone was given after admission to our hospital to promote fetal lung maturation, magnesium sulfate was given to protect fetal brain nerves, and maternal blood pressure was closely monitored. In addition, fetal umbilical artery blood flow was dynamically monitored. After three days in hospital with normal blood pressure, the patient developed abdominal pain accompanied by diarrhea. She was positive for Murphy's sign and laboratory tests showed no obvious abnormalities. Acute cholecystitis was suspected, but symptomatic and supportive treatment did not relieve abdominal pain and her blood pressure increased progressively to 212/130 mm Hg. Magnesium sulfate was given immediately to prevent spasm, and nitroglycerin was administered intravenously against hypertension. Liver enzymes, blood coagulation, and routine urinalysis were abnormal. The patient was diagnosed with HELLP syndrome, and an emergency cesarean section was performed. HELLP syndrome. After the cesarean section, platelet (PLT) count continuously decreased and transaminase and bilirubin levels continously increased. The newborn was transferred to the neonatal intensive care unit after birth and discharged at a corrected gestational age of 34 weeks. By postoperative day 6, laboratory indicators had returned to normal and the patient was discharged. Our case highlights that HELLP syndrome is a serious complication, and it should be diagnosed carefully and not arbitrarily on the basis of some abnormal indicators and stable clinical manifestations. Accurate early identification, active monitoring and management are essential for improving prognosis and avoiding maternal or infant mortality.

OS078. Fetal growth restriction: A marker of severity of early-onset pre-eclampsia?

Pre-eclampsia (PE), particularly early-onset PE (PE requiring delivery before 34 weeks), is commonly associated with fetal growth restriction (FGR). The evidence for an association between FGR and a more severe PE phenotype is controversial. The main aim of this study was to investigate whether the presence of FGR in women with early-onset PE is associated with more severe maternal disease compared to those with appropriately grown fetuses (AGA). This was a retrospective cohort study of women with early-onset PE between 2001 and 2010 at University College London Hospital. The diagnosis of PE was made according to the criteria defined by the International Society of the Study of Hypertension in Pregnancy (ISSHP). PE was diagnosed when the systolic blood pressure was 140mmHg or more and/or the diastolic blood pressure 90mmHg or more on at least two occasions four hours apart developing after 20 weeks of gestation in previously normotensive women with proteinuria of 300 mg or more in 24h or two readings of at least ++ on dipstick analysis of midstream or catheter urine specimens if no 24-h collection is available. FGR was defined as birthweight less than the 5th centile, with abnormal umbilical artery Doppler (raised pulsatility index, absent or reversed end-diastolic flow). Maternal, fetal and neonatal data were collected and study groups compared using Chi-square test or Fisher's exact test (categorical variables), and Mann Whitney-U test (continuous variables). Data analysis was performed using SPSS 16.0. In women with early-onset PE (n=134), FGR (n=66, 49%) was associated with significantly higher perinatal mortality (p=0.02). Gestational age at delivery was significantly lower in the FGR group (median, IQR: 29.0 weeks, 28.0-32.8 vs 32.0, 30.0-33.2, p=0.01). However, maternal indicators of PE severity, including blood pressure (3)160mmHg systolic or (3)110mmHg diastolic, ALT>100U/L, platelet count <100×10(9)/L, use of magnesium sulphate or use of antihypertensive therapy, were similar in the two groups. In women with early onset PE, FGR was associated with worse perinatal outcome, but was not associated with a more severe maternal PE phenotype. This may be because the presence of FGR in these women leads to earlier iatrogenic delivery, before the maternal condition deteriorates, but further studies are needed to investigate this.

Preeclampsia: an update.

Preeclampsia was formerly defined as a multisystemic disorder characterized by new onset of hypertension (i.e. systolic blood pressure (SBP) ≥ 140 mmHg and/or diastolic blood pressure (DBP) ≥ 90 mmHg) and proteinuria (> 300 mg/24 h) arising after 20 weeks of gestation in a previously normotensive woman. Recently, the American College of Obstetricians and Gynecologists has stated that proteinuria is no longer required for the diagnosis of preeclampsia. This complication of pregnancy remains a leading cause of maternal morbidity and mortality. Clinical signs appear in the second half of pregnancy, but initial pathogenic mechanisms arise much earlier. The cytotrophoblast fails to remodel spiral arteries, leading to hypoperfusion and ischemia of the placenta. The fetal consequence is growth restriction. On the maternal side, the ischemic placenta releases factors that provoke a generalized maternal endothelial dysfunction. The endothelial dysfunction is in turn responsible for the symptoms and complications of preeclampsia. These include hypertension, proteinuria, renal impairment, thrombocytopenia, epigastric pain, liver dysfunction, hemolysis-elevated liver enzymes-low platelet count (HELLP) syndrome, visual disturbances, headache, and seizures. Despite a better understanding of preeclampsia pathophysiology and maternal hemodynamic alterations during preeclampsia, the only curative treatment remains placenta and fetus delivery. At the time of diagnosis, the initial objective is the assessment of disease severity. Severe hypertension (SBP ≥ 160 mm Hg and/or DBP ≥ 110 mmHg), thrombocytopenia < 100.000/μL, liver transaminases above twice the normal values, HELLP syndrome, renal failure, persistent epigastric or right upper quadrant pain, visual or neurologic symptoms, and acute pulmonary edema are all severity criteria. Medical treatment depends on the severity of preeclampsia, and relies on antihypertensive medications and magnesium sulfate. Medical treatment does not alter the course of the disease, but aims at preventing the occurrence of intracranial hemorrhages and seizures. The decision of terminating pregnancy and perform delivery is based on gestational age, maternal and fetal conditions, and severity of preeclampsia. Delivery is proposed for patients with preeclampsia without severe features after 37 weeks of gestation and in case of severe preeclampsia after 34 weeks of gestation. Between 24 and 34 weeks of gestation, conservative management of severe preeclampsia may be considered in selected patients. Antenatal corticosteroids should be administered to less than 34 gestation week preeclamptic women to promote fetal lung maturity. Termination of pregnancy should be discussed if severe preeclampsia occurs before 24 weeks of gestation. Maternal end organ dysfunction and non-reassuring tests of fetal well-being are indications for delivery at any gestational age. Neuraxial analgesia and anesthesia are, in the absence of thrombocytopenia, strongly considered as first line anesthetic techniques in preeclamptic patients. Airway edema and tracheal intubation-induced elevation in blood pressure are important issues of general anesthesia in those patients. The major adverse outcomes associated with preeclampsia are related to maternal central nervous system hemorrhage, hepatic rupture, and renal failure. Preeclampsia is also a risk factor for developing cardiovascular disease later in life, and therefore mandates long-term follow-up.

Two-stage approach for prediction of small-for-gestational-age neonate and adverse perinatal outcome by routine ultrasound examination at 35-37 weeks' gestation.

Justification of prenatal screening for small-for-gestational-age (SGA) fetuses near term is based on, first, evidence that such fetuses/neonates are at increased risk of stillbirth and adverse perinatal outcome, and, second, the expectation that these risks can be reduced by medical interventions, such as early delivery. However, there are no randomized studies demonstrating that routine screening for SGA fetuses and appropriate interventions in the high-risk group can reduce adverse perinatal outcome. Before such meaningful studies can be undertaken, it is essential that the best approach for effective identification of SGA neonates is determined, and that the contribution of SGA neonates to the overall rate of adverse perinatal outcome is established. In a previous study of pregnancies undergoing routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation, we found that, first, screening by estimated fetal weight (EFW) < 10<supth</sup percentile provided poor prediction of SGA neonates and, second, prediction of > 85% of SGA neonates requires use of EFW < 40<supth</sup percentile. To examine the contribution of SGA fetuses to the overall rate of adverse perinatal outcome and, to propose a two-stage approach for prediction of a SGA neonate at routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. This was a prospective study of 45 847 singleton pregnancies undergoing routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation. First, we examined the relationship between birth-weight percentile and adverse perinatal outcome, defined as stillbirth, neonatal death or admission to the neonatal unit for ≥ 48 h. Second, we used a two-stage approach for prediction of a SGA neonate and adverse perinatal outcome; in the first stage, fetal biometry was used to distinguish between pregnancies at very low risk (EFW ≥ 40<supth</sup percentile) and those at increased risk (EFW < 40<supth</sup percentile) and, in the second stage, the pregnancies with EFW < 40<supth</sup percentile were stratified into high-, intermediate- and low-risk groups based on the results of EFW and pulsatility index in the uterine arteries, umbilical artery and fetal middle cerebral artery. Different percentiles of EFW and Doppler indices were used to define each risk category, and the performance of screening for a SGA neonate and adverse perinatal outcome in pregnancies delivered at ≤ 2, 2.1-4 and > 4 weeks after assessment was determined. We propose that the high-risk group would require monitoring from initial assessment to delivery, the intermediate-risk group would require monitoring from 2 weeks after initial assessment to delivery, the low-risk group would require monitoring from 4 weeks after initial assessment to delivery, and the very low-risk group would not require any further reassessment. First, although in neonates with low birth weight (< 10<supth</sup percentile) the risk of adverse perinatal outcome is increased, 84% of adverse perinatal events occur in the group with birth weight ≥ 10<supth</sup percentile. Second, in screening by EFW < 10<supth</sup percentile, the predictive performance for a SGA neonate is modest for those born at ≤ 2 weeks after assessment (83% and 69% for neonates with birth weight < 3<suprd</sup and < 10<supth</sup percentiles, respectively), but poor for those born at 2.1-4 weeks (65% and 45%, respectively) and > 4 weeks (40% and 30%, respectively) after assessment. Third, improved performance of screening, especially for those delivered at > 2 weeks after assessment, is potentially achieved by a proposed new approach for stratifying pregnancies into management groups based on findings of EFW and Doppler indices (prediction of birth weight < 3<suprd</sup and < 10<supth</sup percentiles for deliveries at ≤ 2, 2.1-4 and > 4 weeks after assessment: 89% and 75%, 83% and 74%, and 88% and 82%, respectively). Fourth, the predictive performance for adverse perinatal outcome of EFW < 10<supth</sup percentile is very poor (26%, 9% and 5% for deliveries at ≤ 2, 2.1-4 and > 4 weeks after assessment, respectively) and this is improved by the proposed new approach (31%, 22% and 29%, respectively). This study presents an approach for stratifying pregnancies undergoing routine ultrasound examination at 35 + 0 to 36 + 6 weeks' gestation into four management groups based on findings of EFW and Doppler indices. This approach potentially has a higher predictive performance for a SGA neonate and adverse perinatal outcome than that of screening by EFW < 10<supth</sup percentile. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Conservative management of eclampsia and severe pre-eclampsia--A Bangladesh experience.

To observe whether the pregnancy can be safely continued for a reasonable period to gain fetal maturity in cases of eclampsia and severe pre-eclampsia. Fifty-one patients were followed up in a specialized care (eclampsia) unit in Dhaka Medical College and Hospital between January 1998 and October 2000. Twenty-one patients with complaints of headache and blurred vision, and 30 patients with history of convulsion, all at gestational age < 36 weeks, were enrolled for this study. Magnesium sulfate was used to prevent convulsion in severe pre-eclampsia and to control convulsion in eclampsia. After conducting a baseline assessment, pregnancy was continued to gain fetal maturity. Patients were monitored closely. Diastolic blood pressure, 24-hour urinary total protein (UTP), and serum uric acid were chosen as the main parameters to detect the deterioration of a patient's condition. Pregnancy was terminated when deterioration occurred, as determined clinically or by 1 or more of the above parameters. Dexamethasone was used during the waiting period for fetal lung maturity. Patient outcomes were analyzed. At admission, the patients' mean gestational age ( SD) was 30.65 2.38 weeks, and the range was 24-34 weeks. Mean diastolic blood pressure was 109.06 11.61 mm Hg, 24-hour UTP was 2.25 1.73 g/24 h, and serum uric acid level was 5.5 1.12 mg/dL. Pregnancy was continued for a mean of 13.27 8.26 days (range, 3-35 days). Thirty-two babies (62.75%) with birth weight 1.0-2.5 kg (2.02 0.45) were born alive. Six of them (18.75%) weighing between 1.0 and 1.5 kg at birth were referred to the intensive care unit, and 1 (3.13%) weighing 1 kg at birth died within 5 minutes after birth. Among live-born babies, 93.75% were in good condition at the time of discharge from the hospital. Intrauterine death occurred in 19 (37.25%).cases. Twelve of them delivered spontaneously within 7 days of death and 7 required induction. In all cases, maternal condition was satisfactory. In carefully selected cases and with close supervision, pregnancy may be continued in women with eclampsia and severe pre-eclampsia to increase fetal maturity without increasing the risk to the mother.

[Hypertensive disorders in pregnancy].

Hypertension in pregnancy is defined by a systolic blood pressure > or = 140 mm Hg and a diastolic blood pressure of > or = 90 mm Hg or by a rise in blood pressure of systolic > or = 30 mm Hg and diastolic > or = 15 mm Hg. High blood pressures are found in 5-10% of all pregnancies. The outcome of pregnancy is influenced by the fact whether there occurs a proteinuria in addition to hypertension. While the prognosis of an isolated hypotension is good, the combination of hypertension and proteinuria leading to preeclampsia is the primary cause of maternal death in many countries and is responsible for 20-25% of perinatal mortality. A simple classification divides between chronic hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension and transient hypertension. With chronic hypertension pregnancy outcome is determined by a preexisting nephropathy and the occurrence of a superimposed preeclampsia. Preeclampsia and superimposed preeclampsia are pregnancy induced multiorganic diseases, endangering both the mother and the fetus. Transient hypertension is a benign pathology, which occurs toward the end of pregnancy usually on the basis of a latent essential hypertension, which is laid open through pregnancy. While a severe chronic hypertension in pregnancy must be treated to prevent a hypertensive maternal encephalopathy, a less severe chronic hypertension should not be treated as the risk of a superimposed preeclampsia and the maternal and fetal outcome cannot be influenced by antihypertensive therapy. The incidence of preeclampsia is 3-5% in nulliparae and 0.5% in multiparae. Preeclampsia is a severe and dangerous pathology with an unknown etiology. Pregnancy termination is the only causal therapy. At present it is still recommended to terminate a severe preeclampsia after stabilizing the mother, irrespective of gestational age. In less severe preeclampsia occurring before 32 weeks of gestation, termination of pregnancy can be postponed under intensive monitoring and a prophylaxis with magnesium sulfate in order to accelerate the fetal lung maturation with glucocorticoids. A conservative management in the case of a HELLP-syndrome (Haemolyis, Elevated Liver enzymes, Low Platelets), which is a very severe form of preeclampsia, is not recommended because it hasn't been validated in prospective controlled studies. The most dangerous complication of preeclampsia is eclampsia, which is defined by general tonic-clonic convulsions before or after birth. The most effective prophylaxis of eclamptic attacks is the intravenous therapy with magnesium sulfate. A primary prohylaxis for preeclampsia doesn't exist. Treatment with low-dose aspirin in high-risk patients, i.e. after a severe preeclampsia, in cases of chronic hypertension, in cases of nephropathy and in cases with antiphospholipid-syndrome++ can be recommended. The prophylactic use of low-dose heparin, which has lead to a significant decreased incidence of preeclampsia in retrospective analysis, is now the object of a randomized, controlled trial in our hospital. All women who suffered from a preeclampsia should have a check-up after 3-6 months. Preexisting pathologies are found in up to 40% of patients, mostly in multiparae, i.e. chronic hypertension, nephropathy, endocrine pathologies, anomalies of blood coagulation and antiphospolipid-syndrome.

[Treatment of severe preeclampsia: until when and for what risks/benefits?].

The four major hypertensive disorders related to pregnancy are preeclampsia, chronic hypertension, preeclampsia superimposed upon chronic hypertension, and gestational hypertension. The development of hypertension and proteinuria in pregnancy is usually due to preeclampsia, particularly in a primigravida. These findings typically become apparent in the latter part of the third trimester and progress until delivery, but some women develop symptoms in the latter half of the second trimester, or intrapartum, or the early postpartum period. Preeclampsia is characterized as mild or severe. Severe hypertension, coagulopathy, thrombocytopenia, liver function abnormalities, and fetal growth restriction are features of severe disease. Laboratory evaluation should assess haemoglobin/hematocrit and platelet count, renal and hepatic function, as well as assessment of fetal well-being and growth. Timing of delivery is based upon gestational age, maternal and fetal condition, and the severity of preeclampsia. Maternal end organ dysfunction and nonreassuring tests of fetal well-being are indications for delivery at any gestational age. Antihypertensive treatment aims at protecting the mother from severe hypertensive encephalopathy, but may jeopardize the fetus. We recommend antenatal corticosteroids (betamethasone) be given to women with preeclampsia at 26 to 34 weeks of gestation. Magnesium sulfate is more effective than phenytoin for prevention of eclamptic seizures.

Obstetrics

Fetal assessments Obstetric ultrasonography is routinely used for dating the gestational age of a pregnancy from the size of the fetus, determine the number of fetuses and placentae, evaluate for an ectopic pregnancy and first trimester bleeding, the most accurate dating being in first trimester before the growth of the foetus has been significantly influenced by other factors. Ultrasound is also used for detecting congenital anomalies (or other foetal anomalies) and determining the biophysical profiles (BPP), which are generally easier to detect in the second trimester when the foetal structures are larger and more developed. Specialised ultrasound equipment can also evaluate the blood flow velocity in the umbilical cord, looking to detect a decrease/absence/reversal or diastolic blood flow in the umbilical artery.

Obstentrics_Williams

Frequent evaluation: vital signs, UOP Serial lab evaluation of re n.aI function and for HELLP syndrome Daily fetal assessment and evaluation of serial growth and amnionic fluid FIGURE 40-14 Clinical management algorithm for severe preeclampsia at <34 weeks. HELLP = hemolysis, elevated liver enzyme levels, low platelet count; L&D = labor and delivery; MgS04= magnesium sulfate; UOP = urine output. (Adapted from the Society for 2008; Budden, 2006; Gaugler-Senden, Maternal-Fetal Medicine, 2011.) 2006). Maternal complications developed in 60 percent, and there was one maternal death. he perinatal mortality rate was 650 per 1000 births. At this time, no comparative studies attest to perinatal benefits of such expectant treatment versus early delivery in the face of serious maternal complications, which approach rates of 50 percent. We do not recommend such management.

Intrauterine growth restriction

The optimal timing of delivery for a fetus with IUGR is unknown. However, the timing of delivery is currently based on the cause of IUGR and parameters collected from the umbilical artery doppler. Some of these include: pulsatility index, resistance index, and end-diastolic velocities, which are measurements of the fetal circulation. Fetuses with an anticipated delivery before 34 weeks gestation are recommended to receive corticosteroids to facilitate fetal maturation. Anticipated births before 32 weeks should receive magnesium sulfate to protect development of the fetal brain. Outcomes Postnatal complications

[Clinical analysis of eleven patients with chronic myeloproliferative disorders complicating pregnancy].

To investigate the clinical characteristics, the antenatal management, the outcome and prognosis of chronic myeloproliferative disorders(CMPD) complicating pregnancy. Retrospectively analyze the clinical data of eleven patients with CMPD complicating pregnancy hospitalized in Peking University People's Hospital from 2000 to 2009, including five patients with essential thrombocythemia, one with primary myelofibrosis and five with chronic myeloid leukemia. (1) Five pregnancies had periodic antenatal care and laboratory monitorings like full blood count. Reasonable anti-coagulation therapy was given to prevent the complications. One patient with PMF diagnosed before conception had her first pregnancy ended with mild pre-eclampsia and intrauterine death at the gestational age of 32 weeks. During the first trimester of her second pregnancy two years later, the test for anti-β2 glycoprotein antibody was positive. She received low-dose aspirin and low-molecular-weight heparin as anti-coagulants. An uneventful course was obtained and she delivered a healthy term infant. (2) Five pregnancies had occasional antenatal examination, including two patients with ET and three patients with CML. One patient with ET developed severe pre-eclampsia at the gestational age of 25 weeks. Umbilical artery Doppler showed reversed end-diastolic velocity. The management with anti-convulsants, anti-hypertensives and anti-coagulants showed no effect. An emergency cesarean section had to be performed because of the aggressive hypertension and placental abruption, with still birth as a result. Two pregnancies never had an antenatal care. Both of them were admitted on labor and the diagnoses of CML were made. (3) Four pregnancies developed oligohydramnios and three developed preelampsia (two severe pre-eclampsia and one mild pre-eclampsia). There was no other hemorrhage and thrombosis event. (4) Eight pregnancies reached full-term with four cesarean sections and four vaginal births. Two preterm cesarean sections were performed because of a progressive oligohydramnios. The ten live neonates weighed 1820 - 3600 g. All were appropriate for gestational age, except one fetal growth retardation (FGR) developed in one patient with severe pre-eclampsia. (5) As for the CMPD, the eleven patients were all in stable conditions. Three patients with CML received hydroxyurea in the third trimester, four with ET and one with CML had platelet-pheresis before delivery with favorable effect. All patients were uneventful postpartum, except one with CML who died in 5 months after childbirth. The pregnancy outcomes for patients with CMPD are mostly good. However, antenatal care should pay more attention to the complications such as thromboembolic accidents, pre-eclampsia, still birth and fetal growth retardation. Management including reasonable anti-coagulation therapy should be considered, which may help improve the prognosis.

Antepartum Care -- Function -- Second Trimester Antepartum Care (15 0/7 - 28 6/7 weeks)

Care also includes repeat blood pressure recordings, maternal weight, fundal height, and fetal heart rate. Fetal heart rates can be detected via Doppler ultrasound, in nonobese patients, at as early as 10 weeks gestation. Because the second trimester encompasses a vast majority of the rapid fetal growth period, several essential screening and laboratory tests are collected during this trimester. Earlier in the second trimester, the second portion of combined-trimester fetal aneuploidy testing or single-test quadruple maternal screening is collected between 16 to 20 weeks gestation. In addition to this, fetal sonography for the anatomic survey is performed during 18 to 20 weeks gestation.

First_Aid_Step2

Affected infants are commonly born to women with systemic diseases that lead to uteroplacental insuffciency (intrauterine infection, hypertension, anemia). Other risk factors include maternal substance abuse, placenta previa, and multiple gestations. First step: Diagnose by confrming serial fundal height measurements with ultrasound. Second step: Ultrasound the fetus for EFW (although as pregnancy advances, ultrasound fetal weight estimates become increasingly unreliable). First step: Explore the underlying etiology and correct if possible. If near due date: Administer steroids (e.g., betamethasone) to accelerate fetal lung maturity. Then: Perform fetal monitoring with NST, CST, BPP, and umbilical artery Doppler velocimetry. A nonreassuring status near term may prompt delivery. ↑ perinatal morbidity and mortality. Defned as a birth weight > 90th percentile. A common sequela of gestational diabetes.

[Effects of betamethasone administration on maternal-fetal Doppler velocimetry].

The effect of antenatal betamethasone on fetal parameters includes a transient reduction of fetal heart rate variation and of fetal body movements. An effect on maternal-fetal blood flow has also been shown, with non-univocal results. To evaluate the effect of antenatal betamethasone in third trimester singleton high-risk pregnancies by Doppler technology. Thirty-six pregnant women who received a full course of betamethasone (12 mg i.m. two times, 24 hrs apart) were studied. The Doppler examination included the assessment of the pulsatility index (PI) of the umbilical artery (UA PI), the middle cerebral artery (MCA PI) and of resistance index of uterine arteries (Ut RI) before treatment, and 48 and 96 hrs after second dose of betamethasone. No significant variation was noted in UA PI through betamethasone therapy. MCA PI decreased significantly 48 hours from the last injection of betamethasone (p = 0.004), and returned to basal values at 96 hours. No difference was found for the other Doppler parameters examined. When serial Doppler studies were analyzed according to the gestational age, in the group < 32 wks' gestation, MCA PI decreased significantly after 48 hours (p < 0.006) and returned to pre-treatment values after 96 hours from the last betamethasone dose. Conversely, no difference was found in Doppler serial measurements in any of the analyzed districts in the subgroup > or = 32 wks' gestation. Betamethasone treatment is associated with an increase in end diastolic flow of the middle cerebral artery, as reflected by a significant, although transient, reduction of MCA PI, especially at gestational ages < 32 weeks.

Society for Maternal-Fetal Medicine Consult Series #52: Diagnosis and management of fetal growth restriction: (Replaces Clinical Guideline Number 3, April 2012).

Fetal growth restriction can result from a variety of maternal, fetal, and placental conditions. It occurs in up to 10% of pregnancies and is a leading cause of infant morbidity and mortality. This complex obstetrical problem has disparate published diagnostic criteria, relatively low detection rates, and limited preventative and treatment options. The purpose of this Consult is to outline an evidence-based, standardized approach for the prenatal diagnosis and management of fetal growth restriction. The recommendations of the Society for Maternal-Fetal Medicine are as follows: (1) we recommend that fetal growth restriction be defined as an ultrasonographic estimated fetal weight or abdominal circumference below the 10th percentile for gestational age (GRADE 1B); (2) we recommend the use of population-based fetal growth references (such as Hadlock) in determining fetal weight percentiles (GRADE 1B); (3) we recommend against the use of low-molecular-weight heparin for the sole indication of prevention of recurrent fetal growth restriction (GRADE 1B); (4) we recommend against the use of sildenafil or activity restriction for in utero treatment of fetal growth restriction (GRADE 1B); (5) we recommend that a detailed obstetrical ultrasound examination (current procedural terminology code 76811) be performed with early-onset fetal growth restriction (<32 weeks of gestation) (GRADE 1B); (6) we recommend that women be offered fetal diagnostic testing, including chromosomal microarray analysis, when fetal growth restriction is detected and a fetal malformation, polyhydramnios, or both are also present regardless of gestational age (GRADE 1B); (7) we recommend that pregnant women be offered prenatal diagnostic testing with chromosomal microarray analysis when unexplained isolated fetal growth restriction is diagnosed at <32 weeks of gestation (GRADE 1C); (8) we recommend against screening for toxoplasmosis, rubella, or herpes in pregnancies with fetal growth restriction in the absence of other risk factors and recommend polymerase chain reaction for cytomegalovirus in women with unexplained fetal growth restriction who elect diagnostic testing with amniocentesis (GRADE 1C); (9) we recommend that once fetal growth restriction is diagnosed, serial umbilical artery Doppler assessment should be performed to assess for deterioration (GRADE 1C); (10) with decreased end-diastolic velocity (ie, flow ratios greater than the 95th percentile) or in pregnancies with severe fetal growth restriction (estimated fetal weight less than the third percentile), we suggest weekly umbilical artery Doppler evaluation (GRADE 2C); (11) we recommend Doppler assessment up to 2-3 times per week when umbilical artery absent end-diastolic velocity is detected (GRADE 1C); (12) in the setting of reversed end-diastolic velocity, we suggest hospitalization, administration of antenatal corticosteroids, heightened surveillance with cardiotocography at least 1-2 times per day, and consideration of delivery depending on the entire clinical picture and results of additional evaluation of fetal well-being (GRADE 2C); (13) we suggest that Doppler assessment of the ductus venosus, middle cerebral artery, or uterine artery not be used for routine clinical management of early- or late-onset fetal growth restriction (GRADE 2B); (14) we suggest weekly cardiotocography testing after viability for fetal growth restriction without absent/reversed end-diastolic velocity and that the frequency be increased when fetal growth restriction is complicated by absent/reversed end-diastolic velocity or other comorbidities or risk factors (GRADE 2C); (15) we recommend delivery at 37 weeks of gestation in pregnancies with fetal growth restriction and an umbilical artery Doppler waveform with decreased diastolic flow but without absent/reversed end-diastolic velocity or with severe fetal growth restriction with estimated fetal weight less than the third percentile (GRADE 1B); (16) we recommend delivery at 33-34 weeks of gestation for pregnancies with fetal growth restriction and absent end-diastolic velocity (GRADE 1B); (17) we recommend delivery at 30-32 weeks of gestation for pregnancies with fetal growth restriction and reversed end-diastolic velocity (GRADE 1B); (18) we suggest delivery at 38-39 weeks of gestation with fetal growth restriction when the estimated fetal weight is between the 3rd and 10th percentile and the umbilical artery Doppler is normal (GRADE 2C); (19) we suggest that for pregnancies with fetal growth restriction complicated by absent/reversed end-diastolic velocity, cesarean delivery should be considered based on the entire clinical scenario (GRADE 2C); (20) we recommend the use of antenatal corticosteroids if delivery is anticipated before 33 6/7 weeks of gestation or for pregnancies between 34 0/7 and 36 6/7 weeks of gestation in women without contraindications who are at risk of preterm delivery within 7 days and who have not received a prior course of antenatal corticosteroids (GRADE 1A); and (21) we recommend intrapartum magnesium sulfate for fetal and neonatal neuroprotection for women with pregnancies that are <32 weeks of gestation (GRADE 1A).

Two-stage screening for preterm preeclampsia at 11-13 weeks' gestation.

Screening for preeclampsia at 11-13 weeks' gestation by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor (triple test) can predict about 90% of preeclampsia, with delivery at <32 weeks (early-preeclampsia), and 75% of preeclampsia with delivery at <37 weeks (preterm preeclampsia), at a screen-positive rate of 10%. In pregnancies identified as being at high risk for preeclampsia by such screening, administration of aspirin (150 mg/d from 11 to 14 weeks' gestation to 36 weeks) reduces the rate of early preeclampsia by about 90% and preterm preeclampsia by about 60%. Recording of maternal history and blood pressure are part of routine prenatal care, but measurement of uterine artery pulsatility index and placental growth factor require additional costs. To explore the possibility of carrying out first-stage screening in the whole population by maternal factors alone or a combination of maternal factors, mean arterial pressure and uterine artery pulsatility index or maternal factors, mean arterial pressure, and placental growth factor and proceeding to second-stage screening by the triple test only for a subgroup of the population selected on the basis of the risk derived from first-stage screening. The data for this study were derived from prospective nonintervention screening for preeclampsia at 11<sup+0</sup to 13<sup+6</sup weeks' gestation in 61,174 singleton pregnancies. Patient-specific risks of delivery with preeclampsia at <37 and <32 weeks' gestation were calculated using the competing risks model to combine the prior distribution of the gestational age at delivery with preeclampsia, obtained from maternal characteristics and medical history, with various combinations of multiple of the median values of mean arterial pressure, uterine artery pulsatility index, and placental growth factor. We estimated the detection rate of preterm-preeclampsia and early-preeclampsia at overall screen-positive rate of 10%, 15%, and 20% from a policy in which first-stage screening of the whole population is carried out by some of the components of the triple test and second-stage screening by the full triple test on women selected on the basis of results from first-stage screening. If the method of first-stage screening is maternal factors, then measurements of mean arterial pressure, uterine artery pulsatility index, and placental growth factor can be reserved for only 70% of the population, achieving similar detection rate and screen-positive rate as with screening the whole population with the triple test. In the case of first-stage screening by maternal factors, mean arterial pressure, and uterine artery pulsatility index, then measurement of placental growth factor can be reserved for only 30-40% of the population, and if first-stage screening is by maternal factors, mean arterial pressure, and placental growth factor, measurement of uterine artery pulsatility index can be reserved for only 20-30% of the population. Empirical results were consistent with model-based performance. Two-stage screening and biomarker testing for only part of the population will have financial benefits over conducting the test for the entire population.

[Atypical preeclampsia and perinatal success: a case report].

Preeclampsia is a multi systemic syndrome of variable severity, pregnancy specific, consequence of an abnormal vascular response to placentation, with increase in peripheral vascular resistance, stimulation of platelet aggregation, activation of the coagulation cascade, and endothelial dysfunction. In the majority of cases, it will present with gestational hypertension and proteinuria, after 20 weeks, nevertheless, in other cases, it has presented as an atypical form (with absence of hypertension and/or proteinuria) behaving like severe preeclampsia. We report the case of a patient, 32 year old primigravida, with a 26.6 weeks gestation, that comes to the office with postprandial projectile vomiting. At the time of admission, she presents with sudden headache, phosphenes, and tinnitus, associated to epigastric pain, with a blood pressure of 110/70 mmHg; fetal heart rate of 146 bpm, normal lower limbs and reflexes. The Complete Blood Count and liver function tests are within normal values, urinalysis with proteinuria. Normal hepatic ultrasound. Obstetric ultrasound; with fetal measurements of 2.6 weeks below, with flattening of the growth curve, Doppler flowmetry with an increase in placental resistance and oligohydramnios. Given the clinical manifestations compatible with severe preeclampsia, magnesium sulfate, and antenatal corticosteroid therapy are initiated, and abdominal termination of pregnancy is decided. A female newborn is obtained, of 595 g, Apgar 4/7. On immediate puerperium, she presents with an increase in blood pressure of 150/90 mmHg, discharged with normal blood pressure 96 hours later. The newborn girl was discharged when she reached a weight of 2000 g. Today, she is neurologically unimpaired.

[Effect of heparin on the ratio of peak systolic to least diastolic flow velocity of umbilical artery at second-trimester pregnancies].

To evaluate the efficiency of heparin on the ratio of peak systolic to least diastolic flow velocity (S/D) of umbilical artery flow velocity waveforms at second-trimester pregnancies. Sixty-seven pregnant women carrying 72 fetuses (5 twins) whose fetal umbilical artery flow S/D ratios were more than the 95(th) percentage were divided into study and control groups. In study group, 35 women carrying 38 fetuses were treated with heparin at a dose of 6250 U or 12,500 U + 5% glucose 500 ml intravenously per day for a mean of (3.7 +/- 2.1) days, ranging from 1 to 10 days. In control group, another 32 women with 34 fetuses were treated regularly with dextran-40,500 ml and 10% glucose 500 ml + rooted salvia 30 ml; and 10% glucose 500 ml + 654-II 20 mg for a mean of (6.8 +/- 2.8) days, ranging from 3 to 14 days. After treatment the S/D ratios were re-examined, and compared between two groups. The mean of decreased S/D ratios per day in heparin group and control group was 0.37 (t = 3.620, P < 0.01) and 0.135 (t = 3.061, P < 0.01), respectively. There was significant deference between two groups (t = 1.998, P < 0.05). The treatment time was significantly shorter in heparin group than in the control (t = 3.435, P < 0.01). The effective rate was significantly higher in heparin group than in the control (chi(2) = 10.636, P < 0.01). In the control group, there were 10 cases with S/D ratio increasing continuously. Two of them died of S/D ratio infinity. None of the study group died. Heparin can significantly decrease the high S/D ratios of umbilical artery flow velocity waveforms at second trimester of pregnancy. It is effective for improving fetal outcomes.

Intrauterine hypoxia

Underlying etiology of intrauterine hypoxia serves as a potential therapeutic target. If maternal preeclampsia is the underlying cause of fetal growth restriction (FGR) antihypertensive therapy and magnesium sulfate are potential therapies. Antihypertensive treatment is used to reduce blood pressure and prevent pulmonary edema and cerebral hemorrhages. An effective course of antihypertensive treatments should reduce blood pressure to below 160/110 mmHg. Magnesium sulfate acts as a vasodilator, reducing vascular resistance and protect the blood-brain barrier (BBB). The goal of these treatments is to prolong pregnancy and increase fetal survival. Each day gained by treatment in utero increases fetal survival and intact survival by 1%–2% up to 28 weeks gestation.

HELLP syndrome

There is a general consensus regarding the main three diagnostic criteria of HELLP syndrome, which include hepatic dysfunction, thrombocytopenia and microangiopathic haemolytic anaemia in patients suspected to have preeclampsia. A blood smear will often exhibit abnormalities, such as schistocytes, bur cells, and helmet cells, which indicate erythrocyte damage. Thrombocytopenia, which is the earliest coagulopathy present in all HELLP syndrome patients, is indicated by low platelet count (below 100 x 109 L-1) or by testing the levels of fibrin metabolites and antithrombin III. Elevated serum levels of certain proteins, in particular, LDH, alanine transaminase (ALT) and aspartate transaminase (AST), are indicative of hepatic dysfunction. Extremely high serum levels of these proteins, specifically LDH levels > 1,400 IU/L, AST levels > 150 IU/L and ALT levels > 100 IU/L, significantly elevate the risk of maternal mortality.

First_Aid_Step2

Check fetal heart tracing, maternal temperature, WBC count, and uterine tenderness for evidence of chorioamnionitis. Depends on GA and fetal lung maturity. Term: First check GBS status and fetal presentation; then labor may be induced or the patient can be observed for 24–72 hours. > 34–36 weeks’ gestation: Labor induction may be considered. < 32 weeks’ gestation: Expectant management with bed rest and pelvic rest. Antibiotics: Given to prevent infection and to prolong the latency period in the absence of infection. Antenatal corticosteroids (e.g., betamethasone or dexamethasone × 48 hours): Can be given to promote fetal lung maturity in the absence of intra-amniotic infection prior to 32 weeks’ GA. If signs of infection or fetal distress develop, give antibiotics (ampicillin and gentamicin) and induce labor. Preterm labor and delivery, chorioamnionitis, placental abruption, cord prolapse. Defned as onset of labor between 20 and 37 weeks’ gestation.

Hemodynamic, hematological and hemorrheological evaluation of post-term pregnancy.

To evaluate the hemorrheological modifications in post-term pregnant women. Pregnant women (n = 48) at > 280 days' gestation, were tested on alternate days by nonstress test; ultrasound assessment of amniotic fluid volume, placental grading, hourly measurement of fetal urine production, and maternal fetal Doppler analysis. We further recorded maternal: plasma viscosimetry, red blood cells, hemoglobin, hematocrit, platelet count, mean platelet volume, fibrinogen, antithrombin III, creatinine, uric acid, plasma calcium, hPL, and estriol. We analyzed the last values obtained within 48 hours prior to delivery. The subjects were divided into Group I (40 wks to 40 wks+3 days; n = 16); Group II (40 wks+4 days to 41 wks; n = 16); Group III (> 41 wks; n = 16). The time-averaged maximum velocity of the fetal descending thoracic aorta was lower at Doppler analysis in Group III (29.0 +/- 3.5 cm/s) than in Group I (34.0 +/- 4.3 cm/s; p < 0.05). A decrease of the middle cerebral/umbilical pulsatility index ratio (1.75 in the Group I vs 1.52 in the Group III; p < 0.05) was shown. Furthermore, the incidence of oligohydramnios; Grannum placental grade III; plasma viscosity and coagulation parameters were significantly higher in Group III patients. The plasma viscosity resulted positively correlated with uric acid, and inversely correlated with fibrinogen, antithrombin III and platelet number values. From the present data we conclude that post-term pregnancy may mimic a mild 'fetal growth restriction'.

Effect of aspirin in pregnant women is dependent on increase in bleeding time.

Randomized trials with low-dose aspirin to prevent preeclampsia and intrauterine growth restriction have yielded conflicting results. In particular, 3 recent large trials were not conclusive. Study designs, however, varied greatly regarding selection of patients, dose of aspirin, and timing of treatment, all of which can be determinants of the results. Retrospectively analyzing the conditions associated with failure or success of aspirin may therefore help to draw up new hypotheses and prepare for more specific randomized trials. We studied a historical cohort of 187 pregnant women who were considered at high risk for preeclampsia, intrauterine growth restriction, or both and were therefore treated with low-dose aspirin between 1989 and 1994. Various epidemiologic, clinical, and laboratory data were extracted from the files. Univariate and multivariate analyses were performed to search for independent parameters associated with the outcome of pregnancy. Age, parity, weight, height, and race had no influence on the outcome. The success rate was higher when treatment was given because of previous poor pregnancy outcomes than when it was given for other indications, and the patients with successful therapy had started aspirin earlier than had those with therapy failure (17.7 vs 20.0 weeks' gestation, P =.04). After multivariate analysis an increase in Ivy bleeding time after 10 days of treatment by >2 minutes was an independent predictor of a better outcome (odds ratio 0.22, 95% confidence interval 0.09-0.51). Borderline statistical significance was observed for aspirin initiation before 17 weeks' gestation (odds ratio 0.44, 95% confidence interval 0.18-1. 08). Abnormal uterine artery Doppler velocimetric scan at 20-24 weeks' gestation (odds ratio 3.31, 95% confidence interval 1.41-7.7), abnormal umbilical artery Doppler velocimetric scan after 26 weeks' gestation (odds ratio 37.6, 95% confidence interval 3.96-357), and use of antihypertensive therapy (odds ratio 6.06, 95% confidence interval 2.45-15) were independent predictors of poor outcome. Efficacy of aspirin seems optimal when bleeding time increases >/=2 minutes with treatment, indicating a more powerful antiplatelet effect. This suggests that the dose of aspirin should be adjusted according to a biologic marker of the antiplatelet effect. A prospective trial is warranted to test this hypothesis.

Percutaneous umbilical cord blood sampling

If the fetus is viable, the procedure is performed close to an operating room in case an emergency cesarean section is necessary due to complications caused by the procedure. Currently, there is no definite age of viability because this depends on the fetus’ ability to survive outside the womb, which in cases of premature births, can depend on access to medical care and technology needed to keep the fetus alive through the neonatal stage. Fetal viability typically occurs at about 24 to 25 weeks of gestation. When the fetus is in between the ages of 24–34 weeks, a glucocorticoid is given to the patient about 24 hours before the procedure to stimulate lung maturity. An ultrasound is performed before the procedure to view the position of the fetus and may be used during the procedure to help guide the needle. The mother’s blood is drawn for comparison against fetal blood, and intravenous access is established in the mother in order to supply medications as needed. To reduce the

Preeclampsia: a link between trophoblast dysregulation and an antiangiogenic state.

A 24-year-old nulliparous woman developed mildly elevated blood pressure (140-150/90-100 mmHg) without proteinuria (20 mg protein in a 24-hour urine collection) at 30⁶/⁷ weeks of gestation. The fetus was small for gestational age (estimated fetal weight under the fifth percentile). At 32⁵/⁷ weeks of gestation, the patient complained of epigastric pain, blood pressure was 180/110 mmHg, proteinuria was documented (780 mg protein in a 24-hour urine collection), schistocytes were detected in the peripheral smear, platelet count was 60,000 cells per mm³, and serum glutamic oxaloacetic transaminase was 234 U/l. The patient was diagnosed with severe preeclampsia/HELLP syndrome. Antenatal steroids were administered to induce fetal lung maturity. She and her family want to know the causes of this condition, what treatment is available, and whether there are any long-term implications of this diagnosis.

Fetomaternal Outcome in Women with Pregnancy Induced Hypertension versus Normotensive Pregnancy.

A hypertensive disorder in pregnancy comprises one of the deadly triad along with hemorrhage and infection-that contributes greatly to maternal morbidity and mortality. The aim of this study was to compare the feto-maternal outcome in pregnancy induced hypertension with normotensive pregnant women. A cross sectional prospective study was conducted in Paropakar Maternity and Women's Hospital from 1st February 2018 to 1st May 2018. All pregnant women seeking help for hypertension during this period was included in the study and were followed up to six weeks of postpartum period. Total 40 patients were enrolled in each arm. The highest number of pregnancy induced hypertension cases was seen in age group 20-24years (32.5%) and were mostly primigravidas (60%). The commonest symptom in Pregnancy induced hypertension was headache 47.5 %. The mean hemoglobin value was 11.91 gm/dl, mean SGPT (Gestational hypertension 25.44 IU/L, preeclampsia 55.25 IU/L and eclampsia 32.17 IU/L) and mean platelet count was 1, 95,140 lakh/cumm in pregnancy induced hypertension. Mean prothrombin time in gestational hypertension was 13.78±0.7 seconds. Most common maternal complication was preterm labor and fetal complication was prematurity. The most common mode of delivery was vaginal. Pregnancy induced hypertension was more common in primigravida with young age group of 20-24 years and presented commonly with complain of headache. Preterm labor was the most common maternal complication similarly prematurity was the commonest fetal complication seen in pregnancy induced hypertension. Vaginal delivery was the commonest mode of delivery. Blood investigation showed significant thrombocytopenia in eclampsia and decreased prothrombin time in gestational hypertension.

[Dopplerometry in the 2nd trimester of pregnancy].

Ultrasonic device Toshiba 140 A/G was used to examine 118 women at pregnancy terms 10 to 30 weeks. Umbilical artery, intraplacental arteries, and retroplacental blood flow were assessed. All the women were divided into two groups by the results of retrospective analysis of dopplerograms. Group 1 were 47 women whose intraplacental blood flow values were higher than umbilical artery blood stream parameters. Group 2 were 71 women with the umbilical artery pulsation index higher than in intraplacental vessels. In group 2 blood clotting disorders were more incident (p < 0.01) presenting as platelet hyperaggregation and/or hypercoagulation and sometimes as increased plasma concentrations of fibrin and fibrinogen degradation products. Study of intraplacental and retroplacental blood flow helps differentiate between preclinical and compensated stages of placental insufficiency and thus timely administer the needed drug therapy with due consideration for the time of discirculatory abnormalities, predominantly uteroplacental or fetoplacental.

[Clinical trends in 520 twin pregnancies in 22 years].

In the last 22 years 520 twin pregnancies were seen at the Department of Obstetrics and Gynecology, University of Ulm. The material was analyzed retrospectively according to the 4 time periods 1965-1974, 1975-1980, 1981-1983, and 1984-1987. An equal-size group of singleton pregnancies was used as control. 1. By the 20th week the diagnosis had been established in 67% between 1984 and 1987 and 29% between 1975 and 1980. 2. A cervical cerclage was most commonly done between 1981 and 1983 (75%). The frequency decreased afterwards and a cerclage was only done in 18% in 1987. 3. Tocolytic agents were used in 7% between 1965 and 1974 and in two thirds of cases in the last years. 4. Hospital admission before delivery was most common between 1975 and 1980 (33%). In the last 7 years it was only half as common (15%). 5. There was no difference in the frequency of preeclampsia and eclampsia between singleton and twin pregnancies in the last years. 6. Maternal hemoglobin levels below 10% were more common in twin pregnancies than in the control group: Before delivery 11%, after delivery 22% in the twin pregnancies, compared with 6% and 4% in the singleton pregnancies. 7. There was no increase in the duration of pregnancy in the last 22 years. The difference between actual birth date and estimated date of delivery remained about the same in the 4 examined time periods: 21 days, 20 days, 21 days, 27 days. There was a slight increase in the frequency of delivery before the 37th week in twin pregnancies: 38%, 41%, 43%, 47%.

[Management of the HELLP syndrome].

Defined by the association of hemolysis, hepatic dysfunction and thrombocytopenia, the Hemolysis, Elevated Liver enzyme, Low Platelets (HELLP) syndrome can complicate preeclampsia and worsen maternal and fetal prognosis. It can be diagnosed in the immediate postpartum (30%) or in the absence of preeclampsia (10-20%). Clinical diagnosis can be difficult because there is no specific symptom. Abdominal pain or vomiting during the third trimester must lead to think about this diagnosis. Biological criteria are well defined: hemolysis by the presence of schistocytes, increased serum total bilirubin >12 mg/L or LDH >600 IU/L, hepatic dysfunction by increased transaminases and thrombocytopenia by a platelet count <100,000/microL. The evolution of those parameters is a major prognostic factor. With the HELLP syndrome, maternal morbidity is dramatically increased compared to isolated preeclampsia with complications such as eclampsia, placental abruptio, disseminated intravascular coagulation, pulmonary edema, acute renal insufficiency, subcapsular liver hematoma. The management of a HELLP syndrome requests level 3 hospital with intensive care units for neonate and mother. The treatment of this syndrome requires termination of the pregnancy as soon a possible, either by cesarean section or by vaginal delivery if cervical conditions are optimal (without any maternal or fetal complications). Before 32 weeks, a more expectative attitude could be acceptable with the prematurity permitting corticotherapy for fetal pulmonary maturation. This corticotherapy can improve temporary biological parameters but there are no proven benefits to consider improvement for long term maternal or fetal prognosis. During the postpartum, evolution is usually spontaneously favorable. Recurrences are not frequent.

Comparison of Hemodynamic and Biochemical Factors and Pregnancy Complications in Women with/without Preeclampsia.

<bBackground:</bPreeclampsia is the second most common cause of maternal mortality in the world after hemorrhage. The present study was conducted to compare the hemodynamic and biochemical levels and pregnancy complications in women with preeclampsia and normal blood pressure. <bMethods:</bThis cross-sectional descriptive study was conducted on two groups of healthy mothers and mothers with preeclampsia. The research sample included 147 people selected among all mothers referred to Kamali Educational and Medical Center of Alborz. The relationship of preeclampsia and its severity with indices such as age, maternal and fetal weight, body mass index, Apgar score, liver enzymes, laboratory indices, Doppler ultrasound, economic status and other hemodynamic and biochemical indices was examined. <bResults:</bThe mean age of patients with normal blood pressure and preeclampsia was 29.2 and 29.9 years, respectively. In the control group, no history of hospitalization in an intensive care unit (ICU) was reported, while in the case group, 28% of mothers were admitted to ICU. In the control group, 93% of the fetal middle cerebral arterial (MCA) index, 95% of UA index, 93% of SD index and 95% of CPR index were normal, while in the case group, 67% of MCA index, 65% of the umbilical arterial (UA) index, 70% of SD index and 36% of CPR index were normal. The mean uric acid was about 32% higher in the case group than the control group. The mean neonatal weight was about 20% higher in mothers with normal blood pressure (2836 g in the control group and 2345 g in the case group). In the multivariate logistic regression, platelet (OR=1, P=.018), pulse rate of mother (OR=1.198, P=.044), uric acid (OR=2.057, P<.001) and LDH (OR=1.006, P=.015) were significant predictors of preeclampsia. <bConclusion:</bBy examining the indices at different ages of pregnancy, the occurrence of preeclampsia can be predicted at the appropriate time and its complications for both the mother and fetus can be thus prevented. Platelet, pulse rate of the mother, uric acid and LDH were significant predictors of preeclampsia, of which just uric acid was a strong predictor, with odds ratio (OR)=2.057 - for example, for one unit increase in uric acid, the odds of preeclampsia increase by about two times. Preeclampsia may cause low birth weight as well.

Ranson criteria

Acute pancreatitis not secondary to gallstones At admission: Blood glucose > 11.11 mmol/L (> 200 mg/dL) Age > 55 years Serum LDH > 350 IU/L Serum AST > 250 IU/L WBC count > 16000 cells/mm3 Within 48 hours: Serum calcium < 2.0 mmol/L (< 8.0 mg/dL) Hematocrit decreased by > 10% Oxygen (hypoxemia with PaO2 < 60 mmHg) BUN increased by 1.8 or more mmol/L (5 or more mg/dL) after IV fluid hydration Base deficit (negative base excess) > 4 mEq/L Sequestration of fluids > 6 L Acute pancreatitis secondary to gallstones At admission: Glucose > 220 mg/dl Age > 70 years LDH > 400 IU/L AST > 250 IU/ 100 ml WBC count > 18000 cells/mm3 Within 48 hours: Serum calcium < 8 mg/dL Hematocrit decreased by > 10% Base deficit > 4 mEq/L BUN increased by > 2 mg/dL Sequestered fluid > 6L

Reducing Perinatal Mortality in India: Two-Years Results of the IRIA Fetal Radiology Samrakshan Program.

<bAim</b  The aim of the study is to determine improvements in perinatal mortality at the end of the first 2 years from the initiation of the Samrakshan program of the Indian Radiological and Imaging Association. <bMethods</b  Samrakshan is a screening program of pregnant women that uses trimester-specific risk assessment protocols including maternal demographics, mean arterial pressure, and fetal Doppler studies to classify women as high risk or low risk for preterm preeclampsia (PE) and fetal growth restriction (FGR). Low dose aspirin 150 mg daily once at bedtime was started for pregnant women identified as high risk in the 11-13 <sup6/7</sup weeks screening. The third-trimester screening focused on the staging of FGR and protocol-based management for childbirth and risk assessment for PE. Outcomes of childbirth including gestational age at delivery, development of PE, and perinatal mortality outcomes were collected. <bResults</b  Radiologists from 38 districts of 16 states of India participated in the Samrakshan program that screened 2,816 first trimester, 3,267 second trimester, and 3,272 third trimester pregnant women, respectively. At 2 years, preterm PE was identified in 2.76%, preterm births in 19.28%, abnormal Doppler study in 25.76% of third trimester pregnancies, and 75.32% of stage 1 FGR delivered at term. The neonatal mortality rate was 9.86/1,000 live births, perinatal mortality rate was 18.97/1,000 childbirths, and maternal mortality was 58/100,000 live births compared with 29.5, 36, and 113, respectively in 2016. <bConclusion</b  Fetal Doppler integrated antenatal ultrasound studies in Samrakshan led to a significant reduction in preterm PE rates, preterm birth rates, and a significant improvement in mean birth weights. Perinatal, neonatal, and maternal mortality rates are significantly better than the targets for 2030 set by the Sustainable Development Goals-3.