There is increasing evidence that pre-eclampsia, a principal cause of maternal morbidity, may also be a risk factor for future cardiovascular and cerebrovascular events. This review aimed to assess the current evidence and quantify the risks of cardiovascular disease (CVD), cerebrovascular events and hypertension associated with prior diagnosis of pre-eclampsia. Medline and Embase were searched with no language restrictions, as were core journals and reference lists from reviews up until January 2012. Case-control and cohort studies which reported cardiovascular and cerebrovascular diseases or hypertension diagnosed more than 6 weeks postpartum, in women who had a history of pre-eclampsia relative to women who had unaffected pregnancies, were included. Fifty articles were included in the systematic review and 43 in the meta-analysis. Women with a history of pre-eclampsia or eclampsia were at significantly increased odds of fatal or diagnosed CVD [odds ratio (OR) = 2.28, 95% confidence interval (CI): 1.87, 2.78], cerebrovascular disease (OR = 1.76, 95% CI 1.43, 2.21) and hypertension [relative risk (RR) = 3.13, 95% CI 2.51, 3.89]. Among pre-eclamptic women, pre-term delivery was not associated with an increased risk of a future cardiovascular event (RR = 1.32, 95% CI 0.79, 2.22). Women diagnosed with pre-eclampsia are at increased risk of future cardiovascular or cerebrovascular events, with an estimated doubling of odds compared to unaffected women. This has implications for the follow-up of all women who experience pre-eclampsia, not just those who deliver pre-term. This association may reflect shared common risk factors for both pre-eclampsia and cardiovascular and cerebrovascular disease.

Background— Hypertensive disorders of pregnancy are a major contributor to death and disability for pregnant women and their infants. The diagnosis of preeclampsia by using blood pressure and proteinuria is of limited use because they are tertiary, downstream features of the disease. Placental growth factor (PlGF) is an angiogenic factor, a secondary marker of associated placental dysfunction in preeclampsia, with known low plasma concentrations in the disease. Methods and Results— In a prospective multicenter study, we studied the diagnostic accuracy of low plasma PlGF concentration (<5th centile for gestation, Alere Triage assay) in women presenting with suspected preeclampsia between 20 and 35 weeks’ gestation (and up to 41 weeks’ gestation as a secondary analysis). The outcome was delivery for confirmed preeclampsia within 14 days. Of 625 women, 346 (55%) developed confirmed preeclampsia. In 287 women enrolled before 35 weeks’ gestation, PlGF <5th centile had high sensitivity (0.96; 95% confidence interval, 0.89–0.99) and negative predictive value (0.98; 0.93–0.995) for preeclampsia within 14 days; specificity was lower (0.55; 0.48–0.61). Area under the receiver operating characteristic curve for low PlGF (0.87, standard error 0.03) for predicting preeclampsia within 14 days was greater than all other commonly used tests, singly or in combination (range, 0.58–0.76), in women presenting with suspected preeclampsia ( P <0.001 for all comparisons). Conclusions— In women presenting before 35 weeks’ gestation with suspected preeclampsia, low PlGF has high sensitivity and negative predictive value for preeclampsia within 14 days, is better than other currently used tests, and presents an innovative adjunct to management of such women.

No abstract

Abstracts Ursodeoxycholic acid improves feto-placental and offspring metabolic outcomes in intrahepatic cholestasis of pregnancy and in a mouse model of hypercholanaemic pregnancy Abstracts 740The correlation between epigenetic change and neonatal plasma glucose level in maternal gestational diabetes offspring

Objective  To explore the views of health professionals on the factors influencing repeat caesarean section. Design  Qualitative study involving semi‐structured interviews with professionals who care for women in pregnancy and labour. Setting  Acute hospital trust with two maternity units and community midwifery service, Leicestershire, UK. Sample  Twenty‐five midwives and doctors. Methods  Interviews with professionals were undertaken using a prompt guide. All interviews were audiotaped and transcribed verbatim. Analysis was based on the constant comparative method, assisted by QSR N5 software. Main outcome measures  Identification of factors influencing professional decision making about repeat caesarean section. Results  Decision making in relation to repeat caesarean is a complex process involving several parties. Professionals identify the relevance of evidence for decision making for repeat caesarean. However, professionals feel that following strict protocols is of limited value because of the perceived substandard quality of evidence in this area, other external pressures and the contingent, unique and often unanticipated features of each case. Professionals also perceive that the organisation of care plays an important role in rates of repeat caesarean. Conclusions  Decision making for repeat caesarean is a social practice where standardised protocols may have limited value. Attention needs to be given to the multiple parties involved in the decision‐making process. Reflective practice, opinion leadership and role modelling may offer ways forward but will require evaluation.

aObjective To compare semi-quantitative visual and automated methods of urine testing with fully quantitative point of care urinalysis for the detection of significant proteinuria (0.3 g/24 hours) in pregnancy complicated by hypertension. Design A prospective comparative study.Setting A large teaching maternity hospital.Sample One hundred and seventy-one pregnant women referred to the obstetric day-care unit for assessment of newly arisen hypertension. Methods Early morning urine specimens were tested with four dipstick techniques (Multistix 8SG visual and automated and microalbumin/creatinine ratio visual and automated; Bayer, Elkhart, USA) as well as a fully quantitative measure of the microalbumin creatinine ratio with the DCA 2000 (a point of care assay for albumin; Bayer). These results were compared to a 24-hour urine protein measurement and measures of diagnostic accuracy/prediction are reported. Main outcome measures Significant proteinuria (!0.3 g/24 hours) measured by laboratory assay.Results Automated dipstick urinalysis using the Clinitek 50 has significantly better predictive values for significant proteinuria (LR þ 4.27, 95% CI 2.78 to 6.56; LR À 0.225, 95% CI 0.14 to 0.37) than conventional visual dipstick urinalysis (LR þ 2.27, 95% CI 1.47 to 3.51; LR À 0.635, 95% CI 0.49 to 0.82). Dipstick microalbumin/creatinine ratio testing did not improve overall detection rates with automated or visual testing. Fully quantitative point of care measurement of albumin/creatinine ratio (ACR) was significantly better than any dipstick technique (LR þ 14.6, 95% CI 6.74 to 31.8; LR À 0.069, 95% CI 0.030 to 0.16).Conclusions This study confirms that in pregnancy automated dipstick urinalysis is a more accurate screening test for the detection of proteinuria than visual testing. ACR testing can offer a significant improvement over conventional urinalysis if a fully quantitative method of detection is employed that uses pregnancy-specific thresholds. Dipstick assessment of ACR does not improve the detection rate of significant proteinuria.

The accuracy of dipstick urinalysis with a 1+ threshold in the prediction of significant proteinuria is poor and therefore of limited usefulness to the clinician. Accuracy may be improved at higher thresholds (greater than 1+ proteinuria), but available data are sparse and of poor methodological quality. Therefore, it is not possible to make meaningful inferences about accuracy at higher urine dipstick thresholds. There is an urgent need for research in this area of common obstetric practice.

Although receptive to follow-up, the situational factors of being a new mother need to be taken into account to engage successfully with this patient group. Further research is needed to help clarify the extent to which a history of preeclampsia is an independent factor for future cardiovascular disease to provide a solid foundation for effective risk communication.