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Objectives Plasma volume expansion may benefit both mother and child in the temporising management of severe and early onset hypertensive disorders of pregnancy. Design Randomised clinical trial.Setting Two university hospitals in Amsterdam, The Netherlands.Population Two hundred and sixteen patients with a gestational age between 24 and 34 completed weeks with severe pre-eclampsia, haemolysis, elevated liver enzymes and low platelets (HELLP) syndrome or severe fetal growth restriction (FGR) with pregnancy-induced hypertension, admitted between 1 April 2000 and 31 May 2003. Methods One hundred and eleven patients were randomly allocated to the treatment group, (plasma volume expansion and a diastolic BP target of 85 -95 mmHg) and 105 to the control group (intravenous fluid restriction and BP target of 95 -105 mmHg). Main outcome measures Neonatal neurological development at term age (Prechtl score), perinatal death, neonatal morbidity and maternal morbidity. Results Baseline characteristics were comparable between groups. The median gestational age was 30 weeks.In the treatment group, patients received higher amounts of intravenous fluids (median 813 mL/day vs 14 mL/day; P < 0.001) with a concomitant decreased haemoglobin count (median À0.6 vs À0.2 mmol/L; P < 0.001). Neither neurological scores nor composite neonatal morbidity differed. A trend towards less prolongation of pregnancy (median 7.4 vs 11.5 days; P ¼ 0.054) and more infants requiring oxygen treatment >21% (66 vs 46; P ¼ 0.09) in the treatment group was observed. There was no difference in major maternal morbidity (total 11%), but there were more caesarean sections in the treatment group (98% vs 90%; P < 0.05). Conclusion The addition of plasma volume expansion in temporising treatment does not improve maternal or fetal outcome in women with early preterm hypertensive complications of pregnancy.

In normal pregnancy, large cardiovascular changes take place. A generalized fall in vascular tone by systemic vasorelaxation causes increased blood volume, heart rate and cardiac output. In the preclinical phase, differences have been observed between normal and hypertensive pregnancies in the function of the autonomic nervous system, cardiac output and plasma volume, the volume remaining at the non-pregnant level. In the clinical phase of pre-eclampsia the typical case picture is one of a vasoconstrictive state with low plasma volume and cardiac output, high blood pressure and systemic vascular resistance in combination with signs of organ damage [proteinuria, hemolysis elevated liver enzymes low platelets (HELLP) syndrome]. Hemodynamic management is necessary in severe disease to prevent maternal complications. Management primarily focuses on pharmacological treatment of blood pressure. Clinicians make educated choices from a limited array of available drugs: beta-receptor antagonists, nifedipine, dihydralazine, methyldopa or ketanserine. Other drugs have restricted use in pregnancy. Management of low circulating volume with plasma expanders remains a subject of controversy.

Objective Maternal cardiovascular adaptations to pregnancy are necessary for an adequate fetomaternal circulation. However, the time course of physiological haemodynamic changes during the second half of pregnancy remains unclear. Various methods, invasive and noninvasive, are described to measure these changes. The thoracic electrical bioimpedance (TEB) technique is a method which is especially suitable to measure haemodynamic changes over time. The aim of the study was to determine both individual and group trends of haemodynamic changes in healthy pregnant women during the second half of pregnancy by means of TEB. Outcome variables are heart rate (HR), stroke volume (SV), cardiac output (CO) and blood pressure.Design Longitudinal study.Setting Outpatient antenatal care clinic of university hospital.Population A total of 22 healthy nonsmoking women with an uncomplicated singleton pregnancy and without pre-existing vascular disorders were invited.Methods TEB and blood pressure measurements were performed at each regular visit from about 24 weeks of gestation through term age.Main outcome measures Trends were calculated with the random effects model.Results Data obtained from 19 women were analysed, with a median of eight (range 3-11) measurements. HR showed a linear increase (P < 0.0005) and a quadratic trend (P < 0.0005). SV decreased linearly (P = 0.046), without a quadratic course. CO remained stable over time.Conclusion During the second half of physiological pregnancy, significant trends could be determined. An increase in HR, a decrease in SV, a stable CO and an increase in systolic and diastolic blood pressures were found.

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