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Query: UMLS:C0018801 (heart failure)
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The authors take into consideration specific cases of pregnancy with remarkable oedema caused by cardiac insufficiency, gestosis, pre-eclampsia and eclampsia. They emphasize that in these conditions and in other similar ones use of diuretics cannot be precluded. They report the case of a pregnant woman with severe cardiac insufficiency and considerable oedema observed at the Obstetric Clinical of Rome University. Thanks to diuretic therapy, the pregnancy could be followed through to full term.
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PMID:[The indications and need for diuretics in pregnancy]. 146 89

High blood pressure (BP) complicates approximately 10% of all pregnancies. Hypertension in pregnancy falls into four categories: (1) preeclampsia-eclampsia, (2) chronic hypertension of whatever cause, (3) preeclampsia-eclampsia superimposed to chronic hypertension or renal disease, and (4) transient or late hypertension (gestational hypertension). Preeclampsia, the association of hypertension, proteinuria, and edema, accounts for more than 50% of all the hypertensive disorders of pregnancy and is a major cause of fetal and maternal morbidity and mortality. Unfortunately, distinguishing between preeclampsia and other causes of hypertension on clinical grounds can be difficult because of the lack of specific tests for differential diagnosis. Increased vascular resistance has been claimed as the primary cause of preeclampsia; however, a variable hemodynamic profile with relatively high cardiac outputs, normal filling pressures, and inappropriately high systemic vascular resistances is now reported by most investigators. Imbalance between vasodilator and vasoconstrictor eicosanoids may account for platelet activation and increased responsiveness to pressor peptides. Altered prostacyclin (PGI2) to thromboxane A2 (TxA2) ratio in maternal uteroplacental vascular bed may favor local platelet activation and vasoconstriction contributing to placental insufficiency and fetal distress. Alternatively, recent evidence seems to suggest that fetal umbilical placental circulation may be the site of the primary vascular injury. Whether low-dose aspirin prevents preeclampsia because it inhibits the excessive maternal TxA2 or whether the partial inhibition of fetal TxA2 is also of therapeutic value remains to be established. Treatment of severe hypertension in pregnancy is probably important to prevent cardiac failure or cerebrovascular accidents in the mother. The need for pharmacological therapy of mild to moderate hypertension is still debated, since no formal studies are available to clarify whether pharmacological treatment in such instances effectively reduces maternal or fetal risk. For the treatment of preeclampsia, hydralazine and nifedipine may be used when delivery is not applicable. Labetalol and diazoxide are effective for hypertensive emergencies. Life-threatening hypertension that does not respond to more conventional therapy is an indication for the use of sodium nitroprusside. For chronic hypertension, alpha-methyldopa remains the treatment of choice; if ineffective, hydralazine or beta-blockers are suitable. Effectiveness and safety of other molecules remain elusive.
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PMID:Prevention and treatment of pregnancy-associated hypertension: what have we learned in the last 10 years? 188 20

A retrospective study of the primary causes of maternal deaths in the eclamptics treated in the Lagos University Teaching Hospital (LUTH) over a 20-year period, from 1st January 1967 through 31st December 1986, was carried out. During this period, a total of 845 cases of eclampsia were treated and 91 maternal deaths were associated with eclampsia or its complications. The maternal deaths included 66 predelivery and 25 postpartum eclamptics respectively. Most of the maternal deaths (n = 86) occurred in unbooked cases of eclampsia. The maternal mortality rate was 105/1000 eclamptic deliveries. The common primary causes of deaths in eclampsia in the LUTH during the period under study were renal failure (14.5%), cerebrovascular haemorrhage (12.7%), cardio-pulmonary failure (12.7%), disordered intravascular coagulation syndrome (DIC) (10.9%), and cardiac failure (8%). The Post Mortem Rate (PMR) in the dead eclamptics in the LUTH was 60%. Scrutiny of data suggested that many of the maternal deaths could have been avoided if the patients were brought to the hospital in good time for treatment.
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PMID:The causes of maternal deaths in eclampsia in Lagos, Nigeria. 206 83

2 studies have been done in China: 1) a longitudinal study on maternal mortality in Beijing from 1949 to 1983; and 2) a cross-sectional study on maternal mortality in the year 1984 in 21 of 29 provinces, municipalities, and autonomous regions. A maternal and child health network for care and referral of abnormal cases was set up with ambulances and transfusion facilities in place and training for traditional birth attendants. Aseptic delivery reduced the number of deaths due to sepsis from 213/100,000 live births to 4.2 in 5 years and to 0 in 9 years. Deaths from hemorrhage (including ruptured uterus) dropped by 86% in 5 years. With legalized abortion came a dramatic fall in maternal mortality from 685,100/000 live births to 15, a decrease of 98%. In 1949, 27% of women who died in childbirth had received hospital care; another 27% had no cure. In 1958, however, 80% of the fetal cases had obtained hospital care; the remaining 20% had been seen by a traditional practitioner or health worker. From 1959-68, the total maternal mortality was 1.3-28.1/1 00,000. From 69-78, the turmoil of the cultural revolution had "ill effects" on maternal and child health but by 1979, order was brought back again. The cross-sectional study covered a population of about 177 million. About 2.5 million live births occurred. 1211 maternal deaths were registered for a maternal mortality rate of 48.4/100,000. Maternal mortality varied a good deal in different parts of the country--from 17.7 in Shanghai to 108.2 in the region of the Hai people in Ningxia in northwest China. Maternal mortality rates correspond roughly to the level of economic development. The 5 main causes of death were hemorrhage, heart failure, pregnancy- induced hypertension (including eclampsia), postpartum infection and liver failure.
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PMID:Maternal mortality in China. 263 3

There were 37 maternal deaths among the 109,221 livebirths registered during the period 1977-86 in Bahrain, Arabian Gulf. The maternal mortality rate was 33.9/100,000 for the 10-year study period; however, disaggregation reveals a decline in this rate from 42.3/100,000 in 1977-81 to 26.9/100,000 in 1982-86. This decline presumably reflects streamlining of the Ministry of Health's maternity services, including a central maternity hospital with all modern facilities that serves as a referral center for all of Bahrain, 2 peripheral hospitals with provision for blood transfusion and surgical deliveries, and 3 maternity units managed by fully qualified midwives. About 80% of deliveries are covered by these maternity services; only 2.5% of deliveries occur in the home. Despite this highly developed maternity care system, 18 of the maternal deaths were due to direct obstetric cause: hemorrhage, 7; pre-eclampsia and eclampsia, 5; abortion septicemia, 2; bowel perforation during cesarean section, 1; thromboembolism, 2; and amniotic fluid embolism, 1. The causes of the 19 indirect maternal deaths were: pulmonary embolism, 5; infection, 7; cardiac failure, 2; cerebrovascular accident, 2; pulmonary hypertension, 1; and uncertain, 2. Of interest is the finding that sickle cell disease was the underlying cause of maternal death in 12 of the 37 deaths in this series. Sickle cell disease was implicated in 3 of the deaths from hemorrhage, all 5 deaths from pulmonary embolism, 2 deaths from septicemia, and the 2 cases of cardiac failure. In this series, 50% of the patients with sickle cell disease had thromboembolic crises following treatment of anemia with packed cell transfusion. Blood transfusion, especially of packed cells, should be given with caution to these patients since it may precipitate vaso-occlusive crisis by increasing blood viscosity. Since sickle cell disease represents a high risk during pregnancy in this Arab population, such patients should have frequent prenatal check-ups and deliver in a well-equipped hospital.
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PMID:Maternal mortality in Bahrain with special reference to sickle cell disease. 321 81

A retrospective review of maternal mortality in the obstetric unit of Bangkok's Ramathibodi Hospital in 1969-82 was conducted. In this 14-year period, there were 72,872 live births and 26 maternal deaths, yielding a maternal mortality rate of 0.4/1000. Direct obstetric causes accounted for 77% of these deaths. The distribution of the 20 direct obstetric deaths was as follws: septic abortion (10 cases), puerperal infection (3 cases), pre-eclampsia (1 case), eclampsia (2 cases), amniotic fluid embolism (3 cases), and placenta percreta with uterine rupture (1 case). Among the 6 deaths attributable to indirect causes, viral hepatitis was responsible for 3, systemic lupus erythematosus was the cause in 2 cases, and cardiac failure occurred in the final case. The maternal mortality rate was 0.8/1000 amond women 19 years of age and below and 0.6/1000 among women 35 years of age and above compared with 0.2/1000 among those 20-34 years of age. Maternal mortality was 0.6/1000 for cesarean section delivery compared with 0.1 for normal delivery. Ongoing statistical analyses of maternal mortality are urged to serve as the basis for preventive measures.
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PMID:Maternal mortality in Ramathibodi Hospital: a 14-year review. 383 Dec 6

Trophoblastic embolism is subclinical in normal pregnancy, pronounced in eclampsia, and massive in hydatidiform mole. Self-limited acute respiratory distress arises in 3% to 10% of molar pregnancies at the time of uterine evacuation. Infrequently death occurs; the principal findings are trophoblastic emboli in the pulmonary arterioles, edema of the lungs, and dilatation of the right side of the heart. Hyperthyroidism may develop, and fibrin may line the alveolar walls. Pathogenetic mechanisms include heart failure, hyperthyroidism, dilutional anemia, and pulmonary arteriolar blockage. Infusions of fluid and whole blood tend to cause pulmonary overload, which may precipitate right-sided heart failure. Preferred therapy consists of diuresis and ventilatory support, especially with oxygen under positive end-expiratory pressure.
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PMID:Trophoblastic pulmonary embolism. 626 19

22 patients with severe preeclampsia-eclampsia were treated in our Intensive Care Unit from 1972 to 1978. Control of convulsions was achieved by diazepam, diphenylhydantoin and phenobarbital. In 11 comatose patients brain monitoring was carried out by frequent neurological examination and use of computerized x-ray tomography; aspiration of gastric contents was prevented by nasotracheal intubation. Brain oedema therapy included controlled hyperventilation, steroids and mannitol (7 patients). 10 patients with respiratory failure (due to pulmonary oedema, "shock lung" or aspiration pneumonitis) were treated by mechanical ventilation. Diastolic blood pressure above 100 mm Hg was reduced by hydralazine. Diuresis was induced by normalization of hypovolaemia with albumin and plasma expanders. Six patients died (27%); main causes of death included intracerebral haemorrhage, brain oedema, heart failure, acute pulmonary thromboembolism and bleeding from DIC.
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PMID:[Intensive care of severe preeclampsia-eclampsia. A report on 22 cases (author's transl)]. 742 60

During 1983-1992 in Turkey, 17 maternal deaths occurred out of 100,531 live births at the Zubeyde Hanim Maternity Hospital in Ankara for a maternal mortality ratio (MMR) of 16.9/100,000 live births. Hemorrhage (41.2%) and pulmonary embolism (35.3%) were the leading causes of maternal death. Cases referred to the hospital after home deliveries accounted for 57% of the hemorrhage-related deaths. Other causes of maternal death were eclampsia (11.7%), puerperal infection (5.9%), and heart failure attributed to rheumatic heart disease (5.9%). The MMR fell over time from 22.6 (1983-1984) to 12.8 (1991-1992). Women younger than 20 and those 35 and older suffered from the highest MMRs. MMR increased with parity (8 for primigravida, 10 for parity 1-2, 27.3 for parity 3-4, and 62.1 for parity =or 5). Cesarean delivery was associated with a higher MMR than vaginal delivery (44.7 vs. 14.1). This association was likely a result of pregnancy complications that led to a cesarean section rather than the cesarean section itself.
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PMID:Maternal mortality in a maternity hospital in Turkey. 766 Jul 64

We report a 18 years old woman that was admitted with a history of four days of cardiac failure with acute pulmonary edema, high blood pressure, left ventricular dilatation and moderate to severe systolic dysfunction. Twenty four hours after admission she had a miscarriage, expelling a mole. The diagnosis of hyperthyroidism caused by a mole and early pre eclampsia was confirmed and the patient was managed with diuretics and dopamine. Symptoms abated, thyroid function tests, cardiac function and size returned to normal values and the patient was discharged asymptomatic, ten days after admission.
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PMID:[Gestational hyperthyroidism: a case associated to molar pregnancy]. 1137 99


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