Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. The current definition and treatment recommendations for elevated blood pressure (BP) during pregnancy in the United States have remained unchanged for many years, unlike the recommendations for hypertension treatment in the general population. Clinical studies have provided convincing evidence that women with hypertensive pregnancy disorders are at both immediate and long-term risk for cardiovascular complications; these findings suggest that consideration be given to lowering the presently recommended BP thresholds, both for the initiation of therapy and for therapeutic targets, and to simplifying the approach to the management of elevated BP in pregnancy. This review focuses on the current treatment strategies for hypertensive pregnancy disorders, new developments in the field of hypertension, in general, and in pregnant patients, in particular, and their potential impact on contemporary BP goals and the use of specific antihypertensive medications in pregnancy.

Acute kidney injury (AKI) is costly and is associated with increased mortality and morbidity. An understanding of the renal physiologic changes that occur during pregnancy is essential for proper evaluation, diagnosis, and management of AKI. As in the general population, AKI can occur from prerenal, intrinsic, and post-renal causes. Major causes of pre-renal azotemia include hyperemesis gravidarum and uterine hemorrhage in the setting of placental abruption. Intrinsic etiologies include infections from acute pyelonephritis and septic abortion, bilateral cortical necrosis, and acute tubular necrosis. Particular attention should be paid to specific conditions that lead to AKI during the second and third trimesters, such as preeclampsia, HELLP syndrome, acute fatty liver of pregnancy, and TTP-HUS. For each of these disorders, delivery of the fetus is the recommended therapeutic option, with additional therapies indicated for each specific disease entity. An understanding of the various etiologies of AKI in the pregnant patient is key to the appropriate clinical management, prevention of adverse maternal outcomes, and safe delivery of the fetus. In pregnant women with pre-existing kidney disease, the degree of renal dysfunction is the major determining factor of pregnancy outcomes, which may further be complicated by a prior history of hypertension.

INTRODUCTION: Postoperative acute kidney injury (AKI) following arthroplasty has not been well studied. Our aim was to identify factors associated with increased risk of AKI. METHODS: The medical records for adult patients who underwent elective total joint arthroplasty during June 1, 2007 to May 31, 2010 at the Mayo Clinic were reviewed to identify patients with normal preoperative kidney function who experienced perioperative AKI, defined as an increase in serum creatinine (sCr) by 26.4 μmol·L(-1). For each AKI case, two controls were identified and matched for age, sex, and type of operation. Medical records were abstracted for demographics, comorbid conditions, and preoperative, intraoperative, and postoperative variables. Conditional logistic regression analyses were performed to identify risk factors for AKI. RESULTS: Of the 9,171 patients who underwent joint replacement operations, 167 with normal preoperative renal function developed AKI with a median [25(th), 75(th)] increase in sCr of 35.4 [26.4, 44.2] μmol·L(-1). No patient required dialysis. A higher than normal body mass index, diabetes mellitus, the number of baseline antihypertensive medications, cerebral or peripheral vascular disease, use of general anesthesia, and perioperative blood transfusions were independently associated with risk for AKI. Hospital length of stay and intensive care admissions were greater in AKI patients, and in 12.0% of patients, sCr remained at least 26.4 μmol·L(-1) higher than preoperative baseline at least three months after surgery. CONCLUSION: In this case-control investigation, we identified several factors associated with the development of postoperative AKI. Recognition of these risk factors could allow for the adoption of perioperative renal protective strategies in patients undergoing arthroplasty.

A unique quality improvement (QI) curriculum was implemented within the Division of General Internal Medicine to improve QI knowledge through multidisciplinary, team-based education, which also met the QI requirement for the American Board of Internal Medicine (ABIM) Maintenance of Certification (MOC) and the Mayo Quality Fellows program. Participants completed up to 4 QI learning modules, including pretest and posttest assessments. A participant who successfully completed all 4 modules received certification as a Silver Quality Fellow and credit toward the quality requirement for ABIM MOC. Of 62 individuals invited to participate, 33 (53%) completed all 4 modules and corresponding pretests and posttests. Participants substantially improved knowledge in all 4 quality modules. Study group participants' pretest scores averaged 71.0%, and their posttest scores averaged 92.7%. Posttest scores of reference group participants compared favorably, averaging 89.2%. Initial assessments showed substantial knowledge improvements and successful implementation of staff-developed QI projects.

SLE is a multi-organ autoimmune disease that affects women of childbearing age. Renal involvement in the form of either active lupus nephritis (LN) at the time of conception, or a LN new onset or flare during pregnancy increases the risks of preterm delivery, pre-eclampsia, maternal mortality, fetal/neonatal demise, and intrauterine growth restriction. Consequently, current recommendations advise that the affected woman achieve a stable remission of her renal disease for at least 6 months before conception. Hormonal and immune system changes in pregnancy may affect disease activity and progression, and published evidence suggests that there is an increased risk for a LN flare during pregnancy. The major goal of immunosuppressive therapy in pregnancy is control of disease activity with medications that are relatively safe for a growing fetus. Therefore, the use of mycophenolate mofetil, due to increasing evidence supporting its teratogenicity, is contraindicated during pregnancy. Worsening proteinuria, which commonly occurs in proteinuric renal diseases toward the end of pregnancy, should be differentiated from a LN flare and/or pre-eclampsia, a pregnancy-specific condition clinically characterized by hypertension and proteinuria. These considerations present challenges that underscore the importance of a multidisciplinary team approach when caring for these patients, including a nephrologist, rheumatologist, and obstetrician who have experience with these pregnancy-related complications. This review discusses the pathogenesis, maternal and fetal risks, and management pertinent to SLE patients with new onset or a history of LN predating pregnancy.

Preeclampsia is a disorder of hypertension and proteinuria that affects 6 - 8% of normal pregnancies. Recent research has revealed many molecular mechanisms that may contribute to systemic endothelial dysfunction, glomerular capillary endotheliosis, dysregulation of the glomerular filtration apparatus, and podocyte loss. An ischemic placenta elaborates soluble FMS-like tyrosine kinase 1 (sFlt-1), a soluble receptor for vascular endothelial growth factor (VEGF). A variety of mediators, including nitric oxide, Angiotensin II receptor autoantibodies (AT1AA), and endothelin-1 may serve to maintain placental ischemia and systemic endothelial dysfunction. Endothelin-1 and decreased vascular endothelial growth factor may adversely affect overall expression and distribution of podocyte foot process proteins, leading to proteinuria. Podocyte derangements may lead to podocyte apoptosis and loss, as evidenced by the detection of live podocytes and podocyte products in the urine of preeclamptic women. In this review, we explore recent research elucidating the interactions of placenta, endothelium, and podocyte leading to the clinical syndrome of preeclampsia.

The objective of this study was to analyze genome-wide differential methylation patterns in maternal leukocyte DNA in early pregnant and non-pregnant states. This is an age and body mass index matched case-control study comparing the methylation patterns of 27,578 cytosine-guanine (CpG) sites in 14,495 genes in maternal leukocyte DNA in early pregnancy (n = 14), in the same women postpartum (n = 14), and in nulligravid women (n = 14) on a BeadChip platform. Transient widespread hypomethylation was found in early pregnancy as compared with the non-pregnant states. Methylation of nine genes was significantly different in early pregnancy compared with both postpartum and nulligravid states (< 10% False Discovery Rate). Early pregnancy may be characterized by widespread hypomethylation compared with non-pregnant states; there is no apparent permanent methylation imprint after a normal term gestation. Nine potential candidate genes were identified as differentially methylated in early pregnancy and may play a role in the maternal adaptation to pregnancy.

Hypertension is the most common medical disorder encountered during pregnancy. Hypertensive disorders are one of the major causes of pregnancy-related maternal deaths in the United States. We will present a comprehensive update of the literature pertinent to hypertension in pregnancy. The paper begins by defining and classifying hypertensive disorders in pregnancy. The normal vascular and renal physiological changes which occur during pregnancy are detailed. We will summarize the intriguing aspects of pathophysiology of preeclampsia, emphasizing on recent advances in this field. The existing diagnostic tools and the tests which have been proposed for screening preeclampsia are comprehensively described. We also highlight the short- and long-term implications of preeclampsia. Finally, we review the current management guidelines, goals of treatment and describe the potential risks and benefits associated with various antihypertensive drug classes. Preeclampsia still remains an enigma, and the present management focuses on monitoring and treatment of its manifestations. We are hopeful that this in depth critique will stimulate the blossoming research in the field and assist practitioners to identify women at risk and more effectively treat affected individuals.

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. The current definition and treatment recommendations for elevated blood pressure (BP) during pregnancy in the United States have remained unchanged for many years, unlike the recommendations for hypertension treatment in the general population. Clinical studies have provided convincing evidence that women with hypertensive pregnancy disorders are at both immediate and long-term risk for cardiovascular complications; these findings suggest that consideration be given to lowering the presently recommended BP thresholds, both for the initiation of therapy and for therapeutic targets, and to simplifying the approach to the management of elevated BP in pregnancy. This review focuses on the current treatment strategies for hypertensive pregnancy disorders, new developments in the field of hypertension, in general, and in pregnant patients, in particular, and their potential impact on contemporary BP goals and the use of specific antihypertensive medications in pregnancy.

Pregnancy is associated with physiological and pathological changes in platelet numbers and function, which can be of clinical concern because of risks for maternal and fetal or neonatal bleeding. Thrombocytopenia in pregnancy is frequently encountered and may be due to increased platelet turnover and plasma dilution, immune-mediated mechanisms, or a complication of a more severe underlying pregnancy-related disorder such as preeclampsia. Inherited defects in platelet function and number may also manifest during pregnancy with the risk of bleeding dependent on the underlying problem. In some women, the diagnosis of thrombocytopenia will precede pregnancy but in others, the problem is first identified when routine pregnancy blood tests are performed. An accurate diagnosis and risk assessment in the antenatal period are essential for developing specific plans for any antenatal interventions and for management of delivery and the postpartum periods, and the neonate. Management of pregnant women with platelet disorders requires a multidisciplinary approach and close collaboration between the obstetric and hematology teams.

A pheochromocytoma in a pregnant patient is one of the most threatening medical conditions for mother, fetus, and physician. Although extraordinarily rare with a frequency of 0.002% of all pregnancies, this tumor is notorious for its devastating consequences. As in non-pregnant patients, the signs and symptoms are quite variable but not specific, with hypertension being one of the most prominent signs. Confusion with the much more prevalent forms of pregnancy-related hypertension is the main cause of overlooking the diagnosis. If undiagnosed, maternal and fetal mortality is around 50%. Conversely, early detection and proper treatment during pregnancy decrease the maternal and fetal mortality to <5 and 15% respectively. For the biochemical diagnosis, plasma or urinary metanephrines are the tests of first choice since they have a nearly maximal negative predictive value. For reliable localization, only magnetic resonance imaging is suitable, with a sensitivity of more than 90%. When the tumor is diagnosed in the first 24 weeks of gestation, it should be removed by laparoscopic adrenalectomy after 10-14 days of medical preparation with the same drugs as in non-pregnant patients. If the tumor is diagnosed in the third trimester, the patient should be managed until the fetus is viable using the same drug regimen as for regular surgical preparation. Cesarean section with tumor removal in the same session or at a later stage is then preferred since vaginal delivery is possibly associated with higher mortality. Despite all technical diagnostic and therapeutic progress over the last decades, the key factor for further reduction of maternal and fetal mortality is early awareness and recognition of the potential presence of a pheochromocytoma in a pregnant patient with hypertension.

Nurses are increasingly encountering pregnant/postpartum women with hypertensive disorders of pregnancy, of which preeclampsia is one of the most common. The Joint Commission published a Sentinel Event Alert in 2010 on prevention of maternal death. This report notes that one of the 5 leading causes of pregnancy-related mortality between 1991 and 1997 was "hypertensive disorder." Preeclampsia presents significant risk to the health of the mother and the fetus. Clearly, nurses must understand the pathophysiology, assessment, management, recurrence risk, and long-term implications of preeclampsia to participate fully in a management plan that promotes safe patient care.

Smoking during pregnancy is among the leading preventable causes of adverse maternal and fetal outcomes. Smoking prevalence among young women is the primary determinant of smoking prevalence during pregnancy. Smoking among women of childbearing age is associated with reduced fertility, increased complications of pregnancy, and a variety of adverse fetal outcomes. There is increasing evidence of lasting adverse effects on offspring. Guidelines for smoking cessation during pregnancy have been developed. This article reviews the epidemiology of smoking during pregnancy, the adverse effects of smoking on the mother, fetus, and offspring, and recommended approaches to smoking cessation for pregnant women.

BACKGROUND Hypertensive disorders in pregnancy are common in our environment. The aetiology is unknown and the prognostic indicators of the severity of maternal and fetal complications are variable. The level of uric acid, which is one of the prognostic indicators, is altered in normal pregnancy and as pregnancy advances. Base line values are thus extremely important to enable reasonable prognostic assessment in hypertensive pregnancies. OBJECTIVES To determine levels of serum uric acid during normal pregnancy in University of Nigeria Teaching Hospital (UNTH) Enugu. STUDY DESIGN settings and methods: Sixty- five pregnant and 65 non-pregnant women with age range 20-38 years were recruited. The pregnant women were in their second and third trimesters, attending antenatal clinic at the University of Nigeria Teaching Hospital Enugu. Serum levels of uric acid were determined for the entire subjects. RESULTS The serum uric acid levels were significantly lower in the pregnant women than in controls (P < 0.001). 0.15 +/- 0.03 mmol/L in the second trimester, 0.14 +/- 0.02 mmol/L in the third trimester and 0.29 +/- 0.04 mmoL for control. CONCLUSION The low levels in pregnancy and as pregnancy progresses should be taken into consideration when monitoring hypertensive disorders in pregnancy using serum uric acid. Thus levels that are within normal for non pregnant population may indeed be an indication for intervention in pregnancies complicated by preeclampsia.

This article reviews 4 categories of hypertensive disorders of pregnancy: chronic hypertension, gestational hypertension, preeclampsia, and preeclampsia superimposed on chronic hypertension. It focuses on the diagnosis and management of preeclampsia with emphasis on the pharmacologic management of blood pressure during pregnancy. Preeclampsia is one of the most common medical disorders affecting pregnancy, with significant maternal and fetal morbidity and mortality. The most serious maternal complications of preeclampsia include intracerebral hemorrhage, eclampsia, and renal failure, as well as hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and posterior reversible encephalopathy syndrome (PRES).

Sepsis is one of the main causes of maternal death, being related to infections from obstetric origin (infected abortion, chorioamnionitis, puerperal infection) or non-obstetric (resulting from infections which occur in other areas). This review aims at describing the mechanisms involved in the physiopathology of this entity and at updating the clinical approach to sepsis, recommended in international guidelines (early goal-directed therapy--precocious resuscitation, or precocious treatment guided by goals), as well as at calling attention to the influence of pregnancy both in the clinical manifestation and in the therapeutic management of septic conditions.

'Fetal programming' describes the association of alterations of the intrauterine fetal environment and the subsequent development of cardiovascular, metabolic and endocrine disorders in adult life. It is now commonly accepted that beside these so-called lifestyle disorders hypertensive disorders in pregnancy have also an intrauterine determination. It is commonly agreed that women born with low birth weight do have an elevated risk for the development of hyper-tensive pregnancy disorders, which is pronounced especially in those women born with low birth weight, who become obese in later life. Until now the exact pathophysiological mechanisms remain elusive: beside placental mechanisms intrauterine alterations in kidney development and insulin resistance seem to be major key factors. The pathophysiological similarities and risks of hypertensive pregnancy disorders (especially preeclampsia) and these 'lifestyle disorders'- both are also considered to be mutual risk factors for the development of the other disorder - suggest the possibility of a general impairment of the maternal cardiovascular system by intrauter-ine factors.