Browsing by Author "Seed, Paul T."

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    Maternal and perinatal adverse outcomes in women with pre-eclampsia cared for at facility-level in South Africa : a prospective cohort study
    (Edinburgh University Global Health Society, 2018) Nathan, Hannah L.; Seed, Paul T.; Hezelgrave, Natasha L.; De Greeff, Annemarie; Lawley, Elodie; Conti-Ramsden, Frances; Anthony, John; Steyn, Wilhelm; Hall, David R.; Chappell, Lucy C.; Shennan, Andrew H.
    Background: Hypertensive disorders of pregnancy contribute to 14% of all maternal deaths, the majority of which occur in low- and middle-income countries. The aim of the study was to describe the maternal and perinatal clinical outcomes of women with pre-eclampsia living in middle- and low-income countries. Methods The study was a prospective observational study of women with pre-eclampsia (n = 1547, 42 twin pregnancies) at three South African tertiary facilities. Using stepwise logistic regression model area under the receiver operating characteristic curve (AUROC) values, the association between maternal baseline and admission characteristics and risk of adverse outcomes was evaluated. Main outcome measures were eclampsia, kidney injury and perinatal death. Results In 1547 women with pre-eclampsia, 16 (1%) died, 147 (9.5%) had eclampsia, four (0.3%) had a stroke and 272 (17.6%) had kidney injury. Of the 1589 births, there were 332 (21.0%) perinatal deaths; of these, 281 (84.5%) were stillbirths. Of 1308 live births, 913 (70.0%) delivered <37 completed weeks and 544 (41.7%) delivered <34 weeks’ gestation. Young maternal age (AUROC = 0.76, 95% confidence interval (CI) = 0.71- 0.80) and low Body Mass Index BMI (AUROC 0.65, 95% CI = 0.59-0.69) were significant predictors of eclampsia. Highest systolic blood pressure had the strongest association with kidney injury, (AUROC = 0.64, 95% CI = 0.60-0.68). Early gestation at admission was most strongly associated with perinatal death (AUROC = 0.81, 95% CI = 0.77-0.84). Conclusions The incidence of pre-eclampsia complications, perinatal death and preterm delivery in women referred to tertiary care in South Africa was much higher than reported in other low- and middle-income studies and despite access to tertiary care interventions. Teenage mothers and those with low BMI were at highest risk of eclampsia. This information could be used to inform guidelines, the research agenda and policy.
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    Pregnancy-related acute kidney injury in preeclampsia : risk factors and renal outcomes
    (American Heart Association, 2019) Conti-Ramsden, Frances I.; Nathan, Hannah L.; De Greeff, Annemarie; Hall, David R.; Seed, Paul T.; Chappell, Lucy C.; Shennan, Andrew H.; Bramham, K.
    ENGLISH ABSTRACT: Preeclampsia is a common cause of acute kidney injury (AKI) in low- and middle-income countries, but AKI incidence in preeclampsia, its risk factors, and renal outcomes are unknown. A prospective observational multicenter study of women admitted with preeclampsia in South Africa was conducted. Creatinine concentrations were extracted from national laboratory databases for women with maximum creatinine of ≥90 μmol/L (≥1.02 mg/dL). Renal injury and recovery were defined by Kidney Disease Improving Global Outcomes creatinine criteria. Predefined risk factors, maternal outcomes, and neonatal outcomes were compared between AKI stages. Of 1547 women admitted with preeclampsia 237 (15.3%) met AKI criteria: 6.9% (n=107) stage 1, 4.3% (n=67) stage 2, and 4.1% (n=63) stage 3. There was a higher risk of maternal death (n=7; relative risk, 4.3; 95% CI, 1.6–11.4) and stillbirth (n=80; relative risk, 2.2; 95% CI, 1.8–2.8) in women with AKI compared with those without. Perinatal mortality was also increased (89 of 240; 37.1%). Hypertension in a previous pregnancy was the strongest predictor of AKI stage 2 or 3 (odds ratio, 2.24; 95% CI, 1.21–4.17). Renal recovery rate reduced with increasing AKI stage. A third of surviving women (76 of 230 [33.0%]) had not recovered baseline renal function by discharge. Approximately half (39 of 76; 51.3%) of these women had no further creatinine testing post-discharge. In summary, AKI was common in women with preeclampsia and had high rates of associated maternal and perinatal mortality. Only two-thirds of women had confirmed renal recovery. History of a previous hypertensive pregnancy was an important risk factor.
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    Shock index thresholds to predict adverse outcomes in maternal hemorrhage and sepsis : a prospective cohort study
    (Wiley, 2019) Nathan, Hannah L.; Seed, Paul T.; Hezelgrave, Natasha L.; De Greeff, Annemarie; Lawley, Elodie; Anthony, John; Steyn, Wilhelm; Hall, David R.; Chappell, Lucy C.; Shennan, Andrew H.
    Introduction: Shock index (SI) is a predictor of hemodynamic compromise in obstetric patients. The SI threshold for action is not well understood. We aimed to evaluate SI thresholds as predictors of outcomes in obstetric patients. Material and methods: We undertook a prospective cohort study at three South African hospitals of women with postpartum hemorrhage (n = 283) or maternal sepsis (n = 126). The “first” and “worst” SI following diagnosis were recorded. SI was compared with conventional vital signs as predictors of outcomes. The performance of SI <.9, SI .9‐1.69 and SI ≥1.7 to predict outcomes (maternal death; Critical Care Unit admission; major procedure; hysterectomy) and hemorrhage‐specific outcomes (lowest hemoglobin <70 g/l; blood transfusion ≥4 IU) were evaluated. Results: “First” SI was one of two best performing vital signs for every outcome in postpartum hemorrhage and sepsis. In hemorrhage, risk of all outcomes increased with increasing “first” SI; for blood transfusion ≥4 IU odds ratio was 4.24 (95% confidence interval 1.25‐14.36) for SI ≥1.7 vs SI .9‐1.69. In sepsis, risk of all outcomes increased with increasing “worst” SI. Sensitivity, specificity, positive and negative predictive values of “first” SI <.9 vs SI ≥.9 for maternal death were 100.0%, 55.2%, 4.6% and 100.0%, respectively, in hemorrhage and 80.0%, 50.4%, 12.3% and 96.7%, respectively, in sepsis. Conclusions: The shock index was a consistent predictor of outcomes compared with conventional vital signs in postpartum hemorrhage and sepsis. SI <.9 performed well as a rule‐out test and SI .9‐1.69 and SI ≥1.7 indicated increased risk of all outcomes in both cohorts. These thresholds may alert to the need for urgent intervention and prevent maternal deaths.