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Just Accepted by The Journal of Maternal-Fetal & Neonatal Medicine
Hypertensive Disease of Pregnancy in the ICU: A Multicenter Study
Daniela N. Vasquez MD, Andrea V. Das Neves MD, Graciela Zakalik MD, Vanina B. Aphalo MD, Angela M. Sanchez, Elisa Estenssoro MD, Alfredo D. Intile MD, Héctor S. Canales MD, Cecilia I. Loudet MD, José L. Scapellato MD, Pablo M. Desmery MD for the Argentinean CIOP Group
doi: 10.3109/14767058.2014.974540
Abstract
Objective: To describe characteristics, outcomes and clinical presentations for hypertensive disease of pregnancy (HDP) in patients admitted to 3 ICUs in Argentina.
Methods: Case-series multicenter study.
Results: There were 184 patients with HDP. Mean age 26±8; 90% did not present comorbidity; APACHEII 9[6-14]; SOFA24 2[1-4]; ICU-LOS 3[2-6] days and hospital-LOS 8[5-12] days. Gestational age 34±5 weeks; 46% (85) nulliparous and 71% received routine prenatal care. Maternal mortality 3.3% (6)- 50% attributed to intracranial hemorrhage (ICH). Neonatal mortality 13.6%. Diagnostic categories: eclampsia (64; 35%), severe
preeclampsia (60; 32.6%), HELLP (33; 17.9%), eclampsia-HELLP (18; 9.8%) and other (chronic/gestational-hypertension) (9: 4.7%). Severe hypertension in 46%, multiple organ dysfunction in 23%, acute respiratory distress in 8.7% and acute renal failure in 8%. Variables independently associated with eclampsia: maternal age (OR 1.07 [1.02-1.13], gestational age (OR 1.14 [1.04-1.24]) and nulliparity (OR 2.40 [1.19-4.85]).
Conclusions: Although patients were young and the majority received appropriate prenatal care, they spent considerable time in hospital and presented severe morbidity. Maternal mortality was 3.3% and in half of these cases it was attributed to ICH. Eclampsia and severe preeclampsia represented two thirds of the diagnostic categories. Variables independently associated with eclampsia were maternal and gestational ages and nulliparity.
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Hypertensive Disease of Pregnancy in the ICU: A Multicenter Study
Daniela N. Vasquez MDa,b
, Andrea V. Das Neves MDb, Graciela Zakalik MD
c, Vanina B. Aphalo MD
a, Angela M.
Sanchez 3 , Elisa Estenssoro MD
b , Alfredo D. Intile MD
a, Héctor S. Canales MD
b, Cecilia I. Loudet MD
b, José L.
Scapellato MDa, Pablo M. Desmery MD
a for the Argentinean CIOP Group
a Intensive Care Unit, Sanatorio Anchorena, Capital Federal, Argentina
b Intensive Care Unit, HIGA Gral. San Martín, La Plata, provincia de Buenos Aires, Argentina
c Intensive Care Unit, Hospital L. Lagomaggiore, Mendoza, Argentina
Corresponding Author:
Daniela N. Vasquez, MD
Intensive Care Unit, Sanatorio Anchorena, Ciudad de Buenos Aires, Argentina; Intensive Care Unit, Hospital
General de Agudos Gral. San Martín, La Plata, Buenos Aires, Argentina
Address: 426# 1896, Villa Elisa, La Plata, Buenos Aires, Argentina CP 1894
Phone number: 542214733200
Fax number: 542214733200
Email address: [email protected]
Co-Editor: Maria-Teresa Pérez
Text words: 2987
Short title: Hypertensive Pregnancy in the ICU
Keywords: hypertensive disease of pregnancy, eclampsia, preeclampsia, HELLP, critical care, intracranial
hemorrhage
Funding: None
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ABSTRACT
Objective: To describe characteristics, outcomes and clinical presentations for hypertensive disease of pregnancy
(HDP) in patients admitted to 3 ICUs in Argentina.
Methods: Case-series multicenter study.
Results: There were 184 patients with HDP. Mean age 26±8; 90% did not present comorbidity; APACHEII 9[6-14];
SOFA24 2[1-4]; ICU-LOS 3[2-6] days and hospital-LOS 8[5-12] days. Gestational age 34±5 weeks; 46% (85)
nulliparous and 71% received routine prenatal care. Maternal mortality 3.3% (6)- 50% attributed to intracranial
hemorrhage (ICH). Neonatal mortality 13.6%. Diagnostic categories: eclampsia (64; 35%), severe preeclampsia (60;
32.6%), HELLP (33; 17.9%), eclampsia-HELLP (18; 9.8%) and other (chronic/gestational-hypertension) (9: 4.7%).
Severe hypertension in 46%, multiple organ dysfunction in 23%, acute respiratory distress in 8.7% and acute renal
failure in 8%. Variables independently associated with eclampsia: maternal age (OR 1.07 [1.02-1.13], gestational
age (OR 1.14 [1.04-1.24]) and nulliparity (OR 2.40 [1.19-4.85]).
Conclusions: Although patients were young and the majority received appropriate prenatal care, they spent
considerable time in hospital and presented severe morbidity. Maternal mortality was 3.3% and in half of these cases
it was attributed to ICH. Eclampsia and severe preeclampsia represented two thirds of the diagnostic categories.
Variables independently associated with eclampsia were maternal and gestational ages and nulliparity.
Abstract words: 198
INTRODUCTION
Hypertensive Disease of Pregnancy (HDP) is one of the main causes of maternal death in the world; its
related morbidity and mortality are higher in low-income versus high-income countries. In Latin America and the
Caribbean, HDP is the leading cause of maternal mortality at 26% versus 16% in developed countries [1]. In
Argentina, HDP is the leading cause of maternal mortality [2] and is still one of the major causes of obstetric patient
admissions to intensive care unit (ICU) in the world [3].
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During the last century, the incidence and case fatality rate of eclampsia has fallen in high-income
countries. This decline may be attributed to widespread prenatal care, easy access to hospitals and guideline
implementation. In low income countries most deaths related to HDP are still associated with eclampsia [4].
There is more information concerning eclampsia [5-9] than the entire spectrum of HDP [10-13], with only
half of studies illustrating complete clinical presentation of this disorder. There are few studies on HDP coming
from Central [11] and South America [5, 10, 13], to our knowledge none come from Argentina. Our primary
objective was to describe characteristics, outcomes and clinical presentations for HDP in patients requiring
admission to ICUs of three hospitals in Argentina with the aim of localizing deficiencies and offering models to
improve outcomes related with HDP. The secondary objective was to compare patients from the public and private
health sectors in order to find potential differences in the abovementioned variables.
METHODS
This was a retrospective observational case-series multicenter study which included pregnant/postpartum
(<42 days) patients with HDP requiring admission to 3 ICUs in Argentina, one center from the private health sector
and two from the public, between 1998 and 2010.
The private clinic (Sanatorio Anchorena) is located in Buenos Aires City, has 186-beds, and 2,000 children
are born per year. One of the public hospitals (Hospital Gral. San Martin) is a university-affiliated 449-bed centre in
La Plata City, Buenos Aires Province, where 3,000 babies are delivered annually. The other public hospital
(Hospital Lagomaggiore) is also a university-affiliated 400-bed centre but located in Mendoza City, Mendoza
Province, with annual delivery rate of 7,000. All hospitals are referral centres and offer the same standard
healthcare. The three ICUs were medical–surgical units managed by intensivists- 12 beds in the private hospital and
14 (Buenos Aires) and 8 (Mendoza) in the public hospitals.
Demographic data, comorbidity (Charlson score) [14], risk factors for preeclampsia not incorporated in
Charlson (obesity, chronic hypertension, preeclampsia/eclampsia in previous pregnancy) [15], obstetric history
including ante/postpartum admission, gestational age, parity, delivery type and clinical presentation were recorded.
The Ministry of Health in Argentina considers prenatal care “standard” if it meets the minimum number of visits, at
least 5, for a full term pregnancy without considering quality of care [16]. When some care was taken but did not
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reach the standard requirements indicated above we used the term “minimal prenatal care”. Also registered were
length of stay in ICU (ICU-LOS) and in hospital (hospital-LOS), severity-of-illness scores during first 24h in ICU,
using the worst values for each parameter, (Acute Physiology and Chronic Evaluation-II [APACHE]II [17] and
Sequential Organ Failure Assessment [SOFA] [18]), ICU interventions (mechanical ventilation (MV), days on MV,
Therapeutic Intervention Scoring System-28 [TISS28] [19], central lines), and complications in ICU such as acute
respiratory distress syndrome (ARDS) [20], multiple-organ dysfunction syndrome (MODS) (dysfunction of ≥2
organs using SOFA) [17], renal dysfunction according to SOFA (creatinine ≥1.2mg/dl) and creatinine upper-cut-
point value for pregnant patients (creatinine ≥0.9mg/dl) [21]. ICU and hospital maternal mortality and foetal–
neonatal losses were recorded.
HDP was classified according to specific criteria [22, 23]. Preeclampsia is defined as systolic blood
pressure (SPB)≥140mmHg or diastolic blood pressure (DBP)≥90mmHg along with proteinuria (≥300 mg/24h or
≥+1 dipstick reading) occurring after gestational-week 20. Gestational hypertension (GH) is characterized by similar
conditions only without proteinuria. Eclampsia is defined by presence of seizures in patients with preeclampsia.
Severe preeclampsia exists if any of the following variables are present: SPB≥160mmHg or DBP≥110mmHg,
neurological abnormalities (headache, hyperreflexia, confusion), visual disturbances, abdominal pain, oliguria or
creatinine incrementation, pulmonary edema, thrombocytopenia, elevated aminotransferase or LDH levels,
nonreassuring foetal testing or early preeclampsia (<35 weeks). Chronic hypertension (CH) is present before
pregnancy, diagnosed during first half of pregnancy, or still not resolved 12 weeks after delivery. Hemolysis,
elevated liver enzymes, low platelets (HELLP) was defined using Mississippi Class 3 classification (LDH ≥600
UI/l; AST/ALT ≥40 UI/l; platelets 100000-150000/mm3) to homogenize definitions [24].
Statistical analysis
Categorical variables are shown as numbers (%) and continuous variables as mean±SD or median[IQR],
according to their distribution. Continuous normally and non-normally distributed variables were compared with
Student t-test and Wilcoxon test respectively, and categorical variables were compared with chi-square or Fisher
tests. Multiple comparisons between categorical variables were performed using multiple chi-square test with
Bonferroni corrections. P-value ≤0.05 was considered significant.
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A multivariate analysis adjusting for potential confounders was performed to evaluate relationships
between predictors and outcome variables. A multiple logistic regression model was built using severe morbidity
(MODS/eclampsia) and intervention in ICU (MV) as dependent variables. Variables included in the model were
those related to outcome variables in univariate analysis with p≤0.20. The multivariate model was built manually,
including variables with a significance level of p≤0.05 on Wald test and/or confounding effects (variation coefficient
≥20%). The model was calibrated with Hosmer–Lemeshow goodness-of-fit test to evaluate discrepancy between
observed and expected values. SPSS15 (SPSS, Inc., Chicago, Il, USA) was used for analysis.
Sample Size Calculation
Sample size was calculated considering that HDP represents 40% of obstetric patients admitted to ICU
[25]. Therefore, with 0.40 expected proportion, 0.15 confidence interval width and 90% confidence level, the group
total was at least 116 patients.
Ethical Considerations
This study was approved by IRB of each centre and was performed in accordance with ethical standards
laid down in 1964 Declaration of Helsinki and later amendments. Informed written consent was waived.
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RESULTS
Over the study period, 184 patients were admitted presenting with HDP, 161 in public health sector and 23
in private. At point of data collection, these patients represented 40%(98) of 245 obstetric patients admitted to
Hospital San Martin, 37.5%(63) of 168 obstetric patients admitted to Hospital Lagomaggiore and 38%(23) of 61
obstetric patients admitted to Sanatorio Anchorena.
Table 1 presents characteristics and outcomes of the group and differences for both health sectors. Most
patients did not present comorbidity as represented in their Charlson score and only 8 patients had diabetes (4.3 %).
Other risk factors for preeclampsia not included in Charlson were more frequent (chronic hypertension=22 patients-
12% of population; obesity =6, 3.2% and preeclampsia in previous pregnancy =5, 2.7%). Total maternal mortality
was 3.3%(6 patients), all from public sector. Causes of admission for patients who died were severe preeclampsia
(4), eclampsia (1) and eclampsia-HELLP (1); notably, half of these patients (3) presented intracranial hemorrhage
(ICH). Of 154 neonates for whom data was obtained, 21(13.6%) did not survive.
As for obstetric history, most patients entered ICU during postpartum (145;80%). Gestational age on
admission was 34±5 weeks and gravidity 1[1-3]; 85 patients (46%) were nulliparous. Nine patients (5%) presented
with twin pregnancies. Most patients performed at least one maternal health checkup (115/142;81%); numbers were
lower in public sector (97/124;78%) vs. private (18/18;100%); p0,024. Standard prenatal was adhered to by
71%(77/108) of patients, 65%(59/90) from public sector and 100%(18/18) (p0,001) from private. Denominators
changed due to missing data. For patients with known routes of delivery (168), 3 (2%) were discharged from ICU
pregnant, 15(9%) had vaginal deliveries and 150(89%) underwent cesarean sections.
HDP was comprised of different categories: eclampsia (64;35%), severe preeclampsia (60;32.6%), HELLP
(33;17.9%), eclampsia-HELLP (18;9.8%), CH (5;2.7%) and GH (4;2%).
Regarding clinical presentation, mean SBP/DBP on admission were 160±30/100±20 mmHg. However,
11% of patients (21) did not present hypertension on admission: representing 18%(6) of patients with HELLP,
17%(3) of patients with eclampsia-HELLP, 9%(6) of patients with eclampsia and 8%(5) of patients with severe
preeclampsia. Severe hypertension on admission [22] was present in almost half of patients (85;46%). Forty four
percent of patients (81) presented only severe systolic hypertension, 26%(48) severe diastolic hypertension and
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24%(44) both. Most frequent clinical disturbances were neurological (101/113;89%), gastrointestinal (46/70;66%),
renal (55/87;63%) and visual (34/65;52%) (Figure 1). Laboratory data on admission and differences between public
and private patients are presented in Table 2. The 24-hour-proteinuria test was recorded in 31 patients (17%).
Severe complications suffered by patients with HDP in ICU were: MODS (42;23%), ARDS (16;8.7%),
acute renal failure (ARF) (15;8%), pulmonary edema (4;2.2%), abruptio placentae (3;1.6%), ICH (3;1.6%), retinal
detachment (2;1%) and liver hematoma (2;1%). Incidence of renal dysfunction using creatinine cut-off point for
pregnancy [21] was 55%(87/158); 65%(85/135) in public and 9%(2/23) in private sector (p0.000). These numbers
decreased to 27%(43/158) when SOFA was used; 32%(43/135) in public and 0% (0/23) in private sector (p0.002).
Most frequent interventions in ICU were: MV (45;24.5%), central lines (39;21%), arterial invasive monitoring
(5;3%), hysterectomy (5;3%) and dialysis (4;2%).
Comparison of different categories are presented in Table 3. The two last categories (CH and GH) were
considered in the same group for analysis. Significant differences in maternal age, gestational age, SOFA and
complications in ICU were found among categories. Additionally, variables independently associated with
development of eclampsia were: maternal/gestational age and nulliparity (Table 4).
Risk factors for severe morbidity and interventions in ICU were investigated using MODS and MV as
outcome measurements, respectively. Adjusting for age, diagnostic category, severe systolic and diastolic
hypertension, health sector, comorbidity and prenatal care, the only variable independently associated with both
outcomes was APACHEII (OR-MODS 1.20[1.06-1.36] and OR-MV 1.17[1.04-1.31]).
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DISCUSSION
This multicenter study included 184 patients with HDP requiring ICU admission. Although patients were
young and the majority received appropriate prenatal care, they were severely ill on admission, spent considerable
time in hospital and presented severe morbidity and complications uncommon in developed countries. Maternal
mortality was 3.3% and in half these cases it was related to ICH, consistent with development of severe, mostly
systolic, hypertension observed in 50% of the population. Eclampsia and severe preeclampsia represented two thirds
of diagnostic categories. Variables independently associated with eclampsia were maternal and gestational ages and
nulliparity. Most frequent clinical disturbances were neurological, abdominal and renal. Notably, 11% of patients
did not present with hypertension.
HDP represented approximately 40% of obstetric admissions in the ICUs of our study [3]. This percentage
shed light on the burden of hypertensive disease and the importance of developing preventive measures. Patients
spent a median 8 days in hospital and more than half had other children to care for, factors which may have
negatively impacted their home life.
Most patients did not present comorbidity as represented in Charlson. This score does not calibrate for
hypertensive critically ill obstetric patients as it does not include common risk factors for preeclampsia, such as
chronic hypertension or obesity, frequent among our patients. Physicians caring for these patients should bear these
risk factors in mind so not to overlook them. Nulliparity, another risk factor for HDP, was present in 46% of patients
and 62.5% of eclampsia patients; the latter figure consistent with other reports [5, 6, 26].
Maternal mortality was 3.3%, noticeably higher than in high-income countries [6-8, 26]. It was also higher
than in other upper-middle income countries such as Turkey [12] and Brazil [13], which could be explained by
selection bias. While studies in Turkey and Brazil included all patients entering ObGyn, our study included only
patients entering ICU who were likely sicker. The only study coming from another upper-middle income country
(Colombia) [11] involving critical care patients with HDP recorded similar mortality rates. Half of patients who died
presented ICH, similar to other studies from developing countries [11, 12], highlighting the importance of timely
and proper hypertension management [4]. Neonatal mortality was 13.6%, consistent with figures from developing
countries [5, 11, 12] but higher than percentages from developed countries [6-8, 26].
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Eleven percent of patients did not have hypertension, emphasizing the importance of exploring each aspect
of preeclampsia’s definition to avoid missing diagnosis. Almost 50% of patients had severe hypertension, mainly
severe systolic hypertension, whose inadequate management increases risk of ICH [4]. Conversely in the Malaysian
study, only 38% of patients presented with severe hypertension, appearingly better managed as there were no related
strokes or maternal deaths [9]. Most frequent clinical complaint was neurological, mainly headache [5-7, 9, 26].
Epigastric pain and visual disturbances were frequent [5, 7, 9]. This could be explained by severity of our patients’
state but also due to only taking patients for whom data was collected as denominator, not the entire population.
Renal disturbances, such as oliguria and creatinine increments, frequent among our patients, were not reported in
other studies [5-7, 9, 26]. Incidence of renal dysfunction was even higher using creatinine cut-off levels adjusted for
pregnancy versus scores used for general ICU population [27]. Physicians should use correct creatinine cut-off
levels to identify it.
Few studies recorded laboratory abnormalities [11, 12]. Compared to the Turkish study [12], our patients
presented with worse laboratory parameters as illustrated by lower platelets and hemoglobin and higher LDH levels.
This may be related to selection bias previously mentioned, given that our patients were critically ill as opposed to
Yucesoy’s study where patients were in ObGyn. Similarly, patients from the public sector presented with more
laboratory anomalies, such as elevated creatinine and LDH or low platelets, than patients from the private sector. In
most hospitals worldwide, less than half of women admitted for preeclamspia have a 24-hour protein collection
carried out [28]. In our study, numbers were even lower (17%); this could be explained by the retrospective nature
of data, but also by difficulties in obtaining protein collection samples.
The Argentine health system is comprised of public (uninsured) and private (insured) sectors. Uninsured
patients were younger, more severely ill on admission, presented more organ dysfunctions during the first 24 h,
required more interventions in the ICU and recorded longer hospital-LOS [27, 29]. Standard prenatal care was less
among uninsured patients, possibly explaining their sicklier state upon admission.
Patients were severely ill on admission and presented high incidence of severe morbidity, resulting in
increased interventions. The variable independently associated with severe morbidity (specifically MODS) and
intervention requirements (specifically MV) was APACHEII. Patients also presented complications related to HDP,
exceptional in developed countries, such as liver hematoma or ICH. Applying the three delay model for maternal
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mortality [30], we hypothesized that our patients: delayed deciding to obtain health care, perhaps due to cultural
and/or educational motives; delayed accessing correct health care facilities, given that a quarter of them were
transferred from other types of centers; and/or received inappropriate care once in hospital, in particular correct
hypertension management.
A key component of HDP management is interruption of pregnancy. Although this can be achieved by
inducing labor for vaginal delivery, most of our patients (≈90%) underwent cesarean sections. This figure is
consistent with results from the Colombian study [11], but is higher than figures for patients entering ObGyn
directly [9, 12].
The entire spectrum of HDP was evaluated. The most frequent category in our study was eclampsia,
followed by severe preeclampsia and then HELLP. This differed from the Colombian study [11] in which severe
preeclampsia prevailed, followed by HELLP and then eclampsia, and the Turkish study [12] where the most
common category was mild preeclampsia, followed by severe preeclampsia and, to a lesser extent, eclampsia and
HELLP. The higher incidence of eclampsia could be attributed to the lack of management guidelines for
preeclampsia in the centers included or the low calcium intake as preeclampsia prevention in Argentina in general,
amongst other issues.
In the univariate analysis, patients with eclampsia were younger, presented more advanced gestations and
required MV more often, compared to patients with preeclampsia and CH/GH, consistent with the Colombian study
[11]. Nulliparity was more frequent among patients with eclampsia than patients with severe preeclampsia [8, 26].
Variables independently associated with eclampsia development were maternal/gestational age and nulliparity.
Other variables such as prenatal care, APACHEII score and hypertension level were not associated with eclampsia.
Risk factors potentially related to eclampsia, such as implementation of guidelines for preeclampsia, proper use of
magnesium sulfate or timely delivery, were not investigated. Patients with HELLP and Eclampsia-HELLP presented
significantly higher incidences of MODS and ARF than patients with severe preeclampsia and eclampsia,
respectively [24].
This study has limitations. The retrospective design could result in missing or incomplete data. However, in
the centers included, data were prospectively collected as part of ICU standard operating protocol. The observational
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nature of this study may have led to some confounding, which we attempted to control through multivariate analysis.
Although selection bias may have occurred, as only patients cared for in third level hospitals were included,
conclusions drawn from this study can still be applied to equally sick patients in similar institutions. Finally key
factors, such as magnesium sulfate use, hypertension treatment and timely delivery, were not measured.
The strengths of this study lie in its large sample size, multicenter nature and inclusion of both private and
public sectors, which increase generalization capabilities. Furthermore, extensive evaluation of patients, including
clinical and laboratory aspects-fairly unusual in one study- allow for a more holistic understanding.
Conclusions
This is a multicenter case series study comprised of a large number of pregnant/postpartum patients
requiring ICU admission for HDP. Although prenatal care was adequate in the majority of patients, they were
severely ill on admission, suffered severe morbidity, spent a considerable length of time in hospital and 50% had
other children to care for; these factors may have had economic and/or social implications as well as have impacted
their family unit. Half of patients who died presented ICH, emphasizing importance of proper monitoring and
hypertension treatment. Eclampsia was the leading cause of admission and was independently associated with fixed
risk factors such as maternal age, gestational age and nulliparity. Other measures, such as increasing preventive
calcium intake in pregnant patients and implementing preeclampsia management protocols, could be employed in
order to reduce the incidence of eclampsia.
Acknowledgments: We are profoundly indebted to Maria-Teresa Pérez who co-edited this manuscript and did an
outstanding job revising the English in this paper, and to Jeanette Savero who assisted us with the administrative
elements.
Declaration of interests: The authors report no declarations of interest
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1110.
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Figure Legends
Figure 1: Clinical presentation of patients with hypertensive disease of pregnancy requiring ICU admission
Figure 1: Clinical presentation of patients with hypertensive disease of pregnancy requiring ICU admission
Tables
Table 1: Characteristics and outcomes of 184 patients with hypertensive disease of pregnancy admitted to 3
ICUs in Argentina, including a comparison of patients from the public (uninsured) vs. private (insured)
sector
a Total Public Private p
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N 184 161 23
Age (years) 26 ± 8 25 ± 8.2 32.5 ± 4.2 0.000
Charlson= 0 (no comorbidity) 103/114 (90) 83/94 (88.3) 20/23 (87) 1
APACHE II 9 [6-14] 9 [6-14] 6 [4.75-8] 0.001
SOFA24 2 [1-4] 2 [1-4] 1 [0-3.25] 0.029
TISS 20 ± 6 21 ± 6 17.8 ± 5 0.021
Location prior to ICU admission
Operating room 70/168 (41.7) 58/145 (40) 12/23 (52) 0.000
Ward 43/168 (25.6) 40/145 (27,6) 3/23 (13)
Other hospital 42/168 (25) 41/145 (28,3) 1/23 (4)
Emergency 13/168 (7.7) 6/145 (4) b,c,d
7/23 (31)
ICU-LOS (days) 3 [2-6] 3 [2-6] 4 [2-5] 0.78
Hospital-LOS (days) 8 [5-12] 9 [6-13] 6 [5-7] 0.005
ICU maternal mortality 6 (3.3) 6 0
Hospital maternal mortality 6 (3.3) 6 0
a Data are shown as: mean ± SD, median [IQR], n (%). APACHE II: Acute Physiology and Chronic Evaluation II, SOFA24: Sequential Organ
Failure Assessment (during the first 24 h of admission); location prior to ICU admission (the post-hoc analysis to evaluate where the difference
was resulted in: bemergency room vs. operating room p 0.024, c vs. other hospital p 0.00036;d vs. ward p 0.0036).
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Table 2: Laboratory data on admission of patients with hypertensive disease of pregnancy admitted to 3 ICUs
in Argentina, including comparison of public vs. private sector patients
Total Public Private p
Hematocrit (%) 31 ± 6.65 32 ± 7 34 ± 4.3 0.05
Hemoglobin (g/dl) 10.2 ± 2.4 10 ± 2.3 11 ± 2.7 0.07
Leukocyte (cells/mm3) 14200
[10400-18125]
14200
[10400-18200]
13700
[10400-17500]
0.79
Platelet count
(cells/mm3)
147000
[87000-203000]
138000
[80250-197000]
180000
[151000-231000]
0.008
Urea (g/l) 0.28 [0.20- 0.46] 0.31 [0.2-0.48] 0.21 [0.17-0.27] 0.002
Creatinine (mg/dl) 0.86 [0.67-1.24] 0.94 [0.72-1.35] 0.6 [0.6-0.7] 0.000
Uric acid (mg/dl) 6 [4.9-7.5] 6 [5.11-7.8] 5.5 [4.45-7.2] 0.21
AST (IU/l) 37 [21-99.5] 41.25 [21-112.25] 26 [16-32] 0.023
ALT (IU/l) 27 [15-90] 33.5 [15-96.75] 18 [11-26] 0.028
ALP (IU/l) 310 [203-449] 370 [274-494] 131 [76-198] 0.000
Total bilirubin (mg/dl) 0.53 [0.31-0.9] 0.6 [0.4-0.9] 0.4 [0.2-0.6] 0.007
LDH (UI/l) 728 [418-1416] 874 [544-1570] 262 [205-361] 0.000
Prothrombin (%) 93 ± 16 92 ± 16 100 ± 9 0.13
aPTT (secs.) 31 ± 8 32.5 ± 9 31 ± 3.5 0.40
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Na (mEq/l) 137 ± 5 137 ± 5 135 ± 4 0.08
K (mEq/l) 3.9 [3.5-4.2] 3.9 [3.5-4.3] 3.8 [3.5-4] 0.23
Cl (mmHg) 108 ± 5 108 ± 5 107 ± 3.6 0.27
pH 7.37 ± 0.06 7.36 ± 0.07 7.37 ± 0.03 0.79
pCO2 (mmHg) 32 ± 6 32.6 ± 6 32 ± 5 0.82
pO2 (mmHg) 107 [85-131] 107 [59-130] 107 [69-136] 0.86
HCO3 (mmHg) 18.3 ± 3.2 18.6 ± 3.3 18.6 ± 2.8 0.94
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Table 3: Comparison of patients in terms of characteristics, maternal complications, obstetric history and maternal and fetal-neonatal outcomes
according to hypertensive diagnostic category
Eclampsia Severe preeclampsia HELLP Eclampsia-HELLP Gestational and
chronic hypertension
64 60 33 18 9
Public health sector 58/64 (91%) 50 (83%) 30 (91%) 17 (94%) 6 (67%)
Age (years) 22.5 ± 7.5 a,b
29 ± 8 26 ± 7.5 24 ± 7 32 ± 7
ICU-LOS (days) 4 [2-6] 3.5 [2-7] 2 [1-4] 3 [2-6] 2 [1-6.5]
Hospital-LOS (days) 9 [5-13] 8 [5-12] 7.5 [5-12] 8 [5-16] 6 [5-9]
ICU and hospital maternal
mortality
1 (2%) 4 (7%) 0 (0%) 1 (6%) 0 (0%)
APACHE II 9 [6-13] 9 [6-13.5] 8 [7-15.5] 12 [6.5-15.5] 6.5 [6-11]
TISS 22 ± 6 19 ± 5 19.5 ± 6.5 23 ± 9 17 ± 6
SOFA24 2 [1-4] 1 [0-4] 3 [3-6] c,d
5 [1-11] 1 [0-1]
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Eclampsia Severe preeclampsia HELLP Eclampsia-HELLP Gestational and
chronic hypertension
Charlson= 0 64 (100%) 22/27 (81.5%) 24/28 (86%) 13/14 (93%) 5/6 (83%)
Mechanical ventilation 21 (33%) 11 (19%) 6 (18%) 6 (33%) 1 (11%)
MODS 11/38 (29%) 4/26 (15%) 17/28 (61%) e 9/14 (64%)
f 1/6 (17%)
ARDS 9/45 (20%) 4 (9.5%) 3/29 (10%) 0 (0%) 1 (11%)
Acute renal failure 0 (0%) 6 (10%) 6 (18.2) g 3 (17%)
h 0 (0%)
Gestational age 36 ± 4 a,i
32 ± 5 35 ± 4 35 ± 4 26 ± 11 j,k,l
Nulliparity 40 (62.5%) ll 17 (28%) 15 (45.5%) 11 (61%) 2(22%)
Minimal prenatal care 40/53 (75.5%) 33/39 (85%) 25/28 (89%) 13/18 (72%) 4/6 (67%)
Standard prenatal care 24/38 (63%) 27/33 (82%) 16/20 (80%) 8/13 (61.5%) 2/4 (50%)
Adequate weight for
gestational age
36/45 (80%) 24/35 (69%) 8/20 (40%) 6/12 (50%) 2/4 (40%)
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Fetal-neonatal mortality 4/55 (7%) 11/51 (21.5%) 4/26 (15%) 1/16 (6.25%) 1/6 (11%)
a p 0.005 vs. severe preeclampsia; b p 0.07 vs. gestational and chronic hypertension; c p 0.001 vs. severe preeclampsia; d p 0.00 vs. gestational and chronic hypertension; e p 0.07 vs. severe preeclampsia; f p
0.036 vs. severe preeclampsia; g p 0.011 vs. eclampsia; h p 0.009 vs. eclampsia; i p 0.000 vs. gestational and chronic hypertension; j p 0.011 vs. severe preeclampsia; k p 0.000 vs. HELLP; l p 0.003 vs.
eclampsia-HELLP, ll p 0,001 vs. severe preeclampsia.
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21
Table 4: Multivariate analysis of variables associated with eclampsia among 184 critically ill obstetric patients with
hypertensive disease of pregnancy
Variable Odds Ratio
[95% Confidence Interval]
P
Maternal age 1.07 [1.02-1.13]
0.003
Gestational age 1.14 [1.04-1.24] 0.003
Nulliparity 2.40 [1.19-4.85] 0.014
Variables were adjusted by prenatal care, health sector, comorbidity, antepartum admission to ICU, systolic and diastolic blood pressure, severe
systolic and diastolic hypertension and APACHE
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