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Obstetrics

Research

The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse pregnancy outcomes in patients with chronic hypertension
Baha M. Sibai, MD; Matthew A. Koch, MD, PhD; Salvio Freire, MD; Joao Luiz Pinto e Silva, MD; Marilza Vieira Cunha Rudge, MD; Srgio Martins-Costa, MD; Janet Moore, MS; Cleide de Barros Santos, MD; Jose Guilherme Cecatti, MD; Roberto Costa, MD; Jos Geraldo Ramos, MD; Nancy Moss, PhD; Joseph A. Spinnato II, MD
OBJECTIVE: We sought to compare the rates of superimposed pre-

eclampsia and adverse outcomes in women with chronic hypertension with or without prior preeclampsia. STUDY DESIGN: We conducted secondary analysis of 369 women with chronic hypertension (104 with prior preeclampsia) enrolled at 12-19 weeks as part of a multisite trial of antioxidants to prevent preeclampsia (no reduction was found). Outcome measures were rates of superimposed preeclampsia and other adverse perinatal outcomes. RESULTS: Prepregnancy body mass index, blood pressure, and smoking status at enrollment were similar between groups. The rates of su-

perimposed preeclampsia (17.3% vs 17.7%), abruptio placentae (1.0% vs 3.1%), perinatal death (6.7% vs 8.7%), and small for gestational age (18.4% vs 14.3%) were similar between groups, but preterm delivery 37 weeks was higher in the prior preeclampsia group (36.9% vs 27.1%; adjusted risk ratio, 1.46; 95% condence interval, 1.05 2.03; P .032). CONCLUSION: In women with chronic hypertension, previous preeclampsia does not increase the rate of superimposed preeclampsia, but is associated with an increased rate of delivery at 37 weeks.

Cite this article as: Sibai BM, Koch MA, Freire S, et al. The impact of prior preeclampsia on the risk of superimposed preeclampsia and other adverse pregnancy outcomes in patients with chronic hypertension. Am J Obstet Gynecol 2011;204:345.e1-6.

B ACKGROUND AND O BJECTIVE

Despite extensive research on the rate of superimposed preeclampsia and associated adverse outcomes in women with chronic hypertension, data on risk factors are limited and data evaluating the impact of previous preeclampsia on adverse pregnancy outcome in women with chronic hypertension are lacking. We performed a secondary analysis of 369 women with chronic hypertension enrolled as part of a trial of antioxidants to prevent preeclampsia. The primary outcome was the development of superimposed preeclampsia. We also exam-

ined other adverse pregnancy outcomes and risk factors for the development of superimposed preeclampsia.

M ATERIALS AND M ETHODS

The multicenter clinical trial was conducted as a protocol within the National Institute of Child Health and Human Development Global Network for Womens and Childrens Health Research. We enrolled women seeking prenatal care who were 120/7-196/7 weeks pregnant and with a diagnosis of nonproteinuric chronic hypertension or previous preeclampsia in their most recent preg-

From the University of Cincinnati College of Medicine, Cincinnati, OH (Drs Sibai and Spinnato); the Universidade Federal de Pernambuco, Hospital das Clnicas, Recife (Drs Freire and de Barros Santos), Universidade Estadual de Campinas, Campinas (Drs Pinto e Silva and Cecatti), Universidade Estadual Paulista, Botucatu (Drs Rudge and Costa); the Universidade Federal do Rio Grande do Sul, Hospital de Clnicas, Porto Alegre (Drs MartinsCosta and Ramos), Brazil; RTI International, Research Triangle Park, NC (Dr Koch and Ms Moore); and the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Dr Moss).
Presented at the 25th Annual Meeting of the Society for Maternal-Fetal Medicine, San Diego, CA, Feb. 1-6, 2010. This effort was supported by Grants nos. 1 U01 HD40565 and U01 HD44036 cosponsored by the Eunice Kennedy Shriver National Institute of Child Health and Human Development and the Bill and Melinda Gates Foundation. 0002-9378/free 2011 Published by Mosby, Inc. doi: 10.1016/j.ajog.2010.11.027

nancy that progressed 20 weeks gestation. The primary outcome of the trial was the development of preeclampsia, for which women were followed up through the 14th day postpartum. We compared the rates of superimposed preeclampsia and other adverse outcomes, such as perinatal deaths, abruptio placentae, preterm delivery 37 weeks and 34 weeks, small size for gestational age (SGA), and neonatal respiratory distress syndrome, between women with and without previous preeclampsia. We also analyzed other known risk factors that may inuence the rate of superimposed preeclampsia, including maternal age, duration of hypertension, use of antihypertensive medications, body mass index (BMI), systolic and diastolic blood pressures at enrollment, and smoking during pregnancy.

R ESULTS
Subjects were enrolled in the antioxidant trial from July 2, 2003, through May 15, 2006. Of 739 women enrolled, 369 had chronic hypertension; 104 had previous preeclampsia and 265 did not. Among these, 52.6% were receiving antihyper345

APRIL 2011 American Journal of Obstetrics & Gynecology

Research
TABLE

Obstetrics

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Pregnancy outcome in those with and without prior preeclampsia

Prior preeclampsiaa Outcome Superimposed preeclampsia Abruptio placentae Perinatal deaths 37 wk 34 wk Preterm delivery 34-36 wk Yes, n (%) (n 104) 18 (17.3) 1 (1.0) 7 (6.7) No, n (%) (n 265) 47 (17.7) 8 (3.1) Adjusted risk ratio (95% CI)b 1.28 (0.782.11) 0.44 (0.013.77) 0.79 (0.331.88) P valueb .34 .68

................................................................................................................................................................................................................................................................................................................................................................................ c c ................................................................................................................................................................................................................................................................................................................................................................................ ................................................................................................................................................................................................................................................................................................................................................................................ ....................................................................................................................................................................................................................................................................................................................................................................... ....................................................................................................................................................................................................................................................................................................................................................................... d d ....................................................................................................................................................................................................................................................................................................................................................................... ................................................................................................................................................................................................................................................................................................................................................................................

23 (8.7)

.59

38 (36.9) 9 (8.7)

70 (27.1) 28 (10.9)

1.46 (1.052.03) 0.79 (0.391.60)

.032 .52

29/94 (30.9) 19 (18.4)

42/237 (18.3) 34 (14.3)

1.95 (1.263.04)

.0033 .33

Small for gestational age

CI, condence interval.
a

................................................................................................................................................................................................................................................................................................................................................................................ e

1.31 (0.762.25)

Respiratory distress syndrome

14 (13.6)

32 (12.4)

1.11 (0.641.93)

.72

................................................................................................................................................................................................................................................................................................................................................................................

In most recent prior pregnancy progressing to at least 20 weeks of gestation; b Cochran-Mantel-Haenszel method, adjusting for study site; c Exact Cochran-Mantel-Haenszel procedure, adjusting for study site; d Of ongoing pregnancies at 34 weeks of gestation; e Denite or suspected.

Sibai. Impact of prior preeclampsia in chronic hypertension. Am J Obstet Gynecol 2011.

tensive therapy at onset of pregnancy. There were no statistically signicant differences between the 2 groups regarding any of the variables studied. After enrollment, 65 (17.6%) developed superimposed preeclampsia. Patients with superimposed preeclampsia were more likely than those without it to have higher systolic and diastolic blood pressures at enrollment. In contrast, the rate of superimposed preeclampsia was not affected by maternal age, BMI, or smoking status during pregnancy. Rates of superimposed preeclampsia did not differ, nor were signicant differences found between groups in all other adverse pregnancy outcomes except the rate of preterm delivery at 37 weeks, which was higher in the previous preeclampsia group (36.9% vs 27.1%; P .032) (Table). The difference in preterm delivery was mainly due to delivery at 340/6 vs 366/7 weeks (P .0033). These differences remained signicant after primigravidas without prior preeclampsia had been excluded. The difference remained signicant among women with ongoing pregnancies at 34 weeks (P .012).

C OMMENT
The principal ndings of the study are that: (1) superimposed preeclampsia occurred in 17.6% of women with chronic 346

hypertension; (2) the rate of superimposed preeclampsia was not different in those with prior preeclampsia (17.3%) and those without such a history (17.7%); (3) the rate of superimposed preeclampsia was dependent on maternal systolic and diastolic blood pressure values 20 weeks gestation, but not on maternal age, BMI, or smoking status during pregnancy; and (4) women with prior preeclampsia had a signicantly higher rate of preterm delivery at 37 weeks gestation (95% condence interval, 1.052.03), but no signicant difference in rates of perinatal deaths, abruptio placentae, SGA infants, or delivery at 34 weeks. It is well established that advanced maternal age, increased BMI (increased risk), and smoking during pregnancy (reduced risk) are risk factors for preeclampsia in women without chronic hypertension. We found only 2 reports that examined the relationship between advanced maternal age and risk of preeclampsia in chronic hypertension; both found no increased risk. In contrast to the only report that examined the relationship between smoking during pregnancy and risk of preeclampsia in chronic hypertension, we found no such association. Thus, more studies designed to answer this question are needed.

Our study is the rst to report on the impact of previous preeclampsia on adverse pregnancy outcomes in women with chronic hypertension. We found that women who had prior preeclampsia had no increase in major adverse pregnancy outcomes except for higher rates of preterm delivery at 37 weeks gestation, mainly late preterm births. This higher rate occurred in the absence of increased rate of superimposed preeclampsia, suggesting that previous preeclampsia is an independent risk factor for late preterm delivery in women with chronic hypertension. This increased rate may also be related to the fact that physicians were more aggressive in delivering such patients out of concern that they might be developing preeclampsia. Our study has a few limitations. One limitation relates to the lack of statistical differences in rates of abruptio placentae, SGA infants, perinatal deaths, and delivery at 34 weeks gestation between those with and without previous preeclampsia. Although the reason may be inadequate sample size, the rates of all these outcomes were lower in the prior preeclampsia group. For diagnosis of SGA, we used standards from US populations that might not apply to Brazilian populations. In addition, in women with prior delivery, we did not collect data regarding previous preterm delivery. Such

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history might have explained the increased rate of preterm delivery in women with previous preeclampsia. Finally, this is a secondary analysis, performed without adjustment for multiple comparisons; results should therefore be considered exploratory. In summary, we found that advanced maternal age, increased BMI, prior preeclampsia, and smoking during pregnancy were not associated with the development of superimposed preeclampsia in women with chronic hypertension. Previous preeclampsia may be an independent risk factor for late preterm delivery in women with chronic hypertension.

Obstetrics

Research

CLINICAL IMPLICATIONS

In women with chronic hypertension, previous preeclampsia does not fur-

ther increase the rate of superimposed preeclampsia. Adverse neonatal outcome rates were high even in the absence of superimposed preeclampsia. In women with chronic hypertension, the rate of superimposed preeclampsia is dependent upon systolic and diastolic blood pressure 20 weeks gestation. f

Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium
Asnat Groutz, MD; Joseph Hasson, MD; Anat Wengier, MD; Ronen Gold, MD; Avital Skornick-Rapaport, MD; Joseph B. Lessing, MD; David Gordon, MD
OBJECTIVE: We sought to assess the modern prevalence and risk facRESULTS: Five variables were found to be statistically signicant inde-

tors for third- and fourth-degree perineal tears. STUDY DESIGN: The study population comprised 38,252 women who delivered in one medical center, from January 2005 through December 2009, and met the following inclusion criteria: singleton pregnancy, vertex presentation, and vaginal delivery. Of these, 96 women (0.25%) sustained third- or fourth-degree perineal tears. Maternal and obstetric variables were compared between women with vs without severe perineal tears.

pendent risk factors: Asian ethnicity (odds ratio [OR], 8.9; 95% condence interval [CI], 4.218.9), primiparity (OR, 2.4; 95% CI, 1.53.7), persistent occipito posterior (OR, 2.1; 95% CI, 1 4.5), vacuum delivery (OR, 2.7; 95% CI, 1.6 4.6), and heavier birthweight (OR, 1.001; 95% CI, 11.001). CONCLUSION: Severe perineal tears are uncommon in modern obstetric practice. Signicant risk factors are Asian ethnicity, primiparity, persistent occipito posterior, vacuum delivery, and heavier birthweight.

Cite this article as: Groutz A, Hasson J, Wengier A, et al. Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. Am J Obstet Gynecol 2011;204:347.e1-4.

B ACKGROUND AND O BJECTIVE

Vaginal delivery is well known to be associated with anal sphincter injury. Earlier sonographic studies demonstrated up to 35% incidence rate of occult internal or external anal sphincter disruption following rst vaginal delivery. Mild perineal tears are also very common and were reported to occur in up to 73% of nulliparous parturients. Severe perineal
From the Urogynecology and Pelvic Floor Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
0002-9378/free 2011 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2010.11.019

tears are much less common. Reported prevalence rates vary from 0.6-8% among different populations, and in some countries a signicant increase over the last 3 decades was documented. There is no consensus regarding preventive measures and clinical management of severe perineal tears. There are also conicting data regarding the significance of various obstetric risk factors for such tears. Among multiple examined obstetric parameters, only primiparity, assisted forceps delivery, persistent occipitoposterior position, and heavier birthweight were consistently found as signicant risk factors. The present study was undertaken to evaluate the modern prevalence and risk factors for third- and fourth-degree perineal tears in a single university-afliated

maternity hospital with approximately 10,000 deliveries per year.

M ATERIALS AND M ETHODS

A total of 50,905 consecutive women delivered in Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, from January 2005 through December 2009. Of these, 43.9% were primiparas and 56.1% were multiparas. The study population comprised 38,252 women (75.1% of the obstetric cohort) who met the following inclusion criteria: singleton pregnancy, vertex presentation, and vaginal delivery. Multifetal pregnancies, breech presentations, and cesarean deliveries were excluded from the analysis. Of the study population, 2186 (5.7%) women underwent instrumental assisted deliveries; all were carried out by vacuum extraction. Epidural analgesia was ad347

APRIL 2011 American Journal of Obstetrics & Gynecology