MRI characteristics of brain edema in preeclampsia/eclampsia patients with posterior reversible encephalopathy syndrome

BACKGROUND

The neuroimaging manifestations of eclampsia and preeclampsia often overlap, mainly presenting as posterior reversible encephalopathy syndrome (PRES). The purpose of this retrospective study was to compare the extent and nature of brain edema in eclampsia and preeclampsia patients with PRES based on MRI characteristics.

METHODS

One hundred fifty women diagnosed with preeclampsia-eclampsia and undergoing cranial MRI were enrolled; 24 of these were diagnosed as having eclampsia. According to clinicoradiologic diagnosis of PRES, eligible patients were classified as having eclampsia with PRES (group E-PRES) and preeclampsia with PRES (group P-PRES). A scale on T2W FLAIR-SPIR images was established to evaluate the extent of brain edema, and the score of brain edema (SBE) of both groups was compared. In patients of the two groups who also underwent DWI sequence, the presence or absence of hyperintensity on DWI and hypointensity on ADC maps were determined to compare the nature of brain edema. Furthermore, clinical and biochemical data of the two groups were compared.

RESULTS

The incidence of PRES in eclampsia patients was significantly higher than that in preeclampsia patients (87.50% vs. 46.03%, P<0.001). The SBE of all regions and typical regions in group E-PRES patients were significantly higher than those in group P-PRES patients (15.88±8.72 vs. 10.90±10.21, P=0.021; 8.52±3.87 vs. 5.01±4.19, P=0.002; respectively). The presence of hyperintensity on DWI was determined more frequently in group E-PRES patients than group P-PRES patients (71.43% vs. 32.00%, P=0.024). Age, systolic blood pressure, white blood cell count, neutrophil count and percentage of neutrophils were significantly different between the two groups (P<0.05).

CONCLUSIONS

Certain MRI characteristics that reflect the extent and nature of brain edema were different between eclampsia and preeclampsia patients with PRES. Additional prospective studies are still required to explore whether these MRI characteristics of brain edema may further become a potential predictor for eclamptic seizures in preeclampsia patients with PRES.

Sonographic Evaluation of Pulmonary Interstitial Edema in Patient With Preeclampsia

ABSTRACT

The aim of this study was to sonographically detect pulmonary edema, which is a major problem in pregnant women with preeclampsia, in the interstitial phase. We evaluated 41 preeclampsia patients and 21 control subjects prospectively. In the preeclampsia group, 26 patients had severe features, whereas the other 15 patients had none. To detect early fluid loading in lungs, sonographic B lines were counted from the intercostal space by using ultrasonography, and left ventricular loading findings were examined for corporation by using transthoracic echocardiography both before and after birth. In severe preeclampsia, the number of B lines before and after birth is statistically significant compared with the other groups. In addition, the total number of B lines calculated at 24 hours after delivery was significantly lower than that calculated before delivery (P < 0.018). In terms of prenatal E values, a statistically significant difference was found between all groups (P < 0.001). A strong positive and statistically significant relationship was found between B lines and prenatal E/e' (r = 0.768; P < 0.001). The overall accuracy rate of the prenatal E/e' and E value for estimation of the B line number classification is 0.791 (95% confidence interval, 0.674-0.908; P < 0.001) and 0.829 (95% confidence interval, 0.722-0.936; P < 0.001), respectively. Pulmonary edema is a serious complication in patients with severe preeclampsia and may be detected interstitially in some patients, even if it does not occur clinically.

An efficient and combined placental T 1 -ADC acquisition in pregnancies with and without pre-eclampsia

PURPOSE

To provide a new approach to jointly assess microstructural and molecular properties of the human placenta in vivo fast and efficiently and to present initial evidence in cohorts of healthy pregnancies and those affected by pre-eclampsia.

METHODS

Slice and diffusion preparation shuffling, built on the previously proposed ZEBRA method, is presented as a robust and fast way to obtain T 1 and apparent diffusivity coefficient (ADC) values. Joint modeling and evaluation is performed on a cohort of healthy and pre-eclamptic participants at 3T.

RESULTS

The datasets show the ability to obtain robust and fast T 1 -ADC measurements. Significant decay over gestation in T 1 (-11 ms/week, P < . 05 ) and a trend toward significance in ADC (-0.23 mm/ s 2 /week, P = .08) values can be observed in a control cohort. Values for the pre-eclamptic pregnancies show a negative trend for both ADC and T 1 .

CONCLUSIONS

The presented sequence allows the simultaneous acquisition of 2 of the most promising quantitative parameters to study placental insufficiency-identified individually as relevant in previous studies-in under 2 minutes. This allows dynamic assessment of physiological processes, reduced inconsistency in spatial comparisons due to reduced motion artefacts and opens novel avenues for analysis. Initial results in pre-eclamptic placentas, with depicted changes in both ADC and T 1 , illustrate its potential to identify cases of placental insufficiency. Future work will focus on expanding the field-of-view using multi-band acceleration techniques and the expansion to larger and more diverse patient groups.

Prediction of preeclampsia using a combination of serum micro RNA-210 and uterine artery Doppler ultrasound

The objective was to determine whether a combination of serum micro RNA-210 level and uterine artery Doppler can predict preeclampsia in pregnant women at 16-24 weeks gestation. A prospective observational study conducted in singleton pregnant women at 16-24 weeks of gestation who had prenatal care at the King Chulalongkorn Memorial Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand between 2017 and 2018. Uterine artery Doppler ultrasound and blood testing for serum micro RNA-210 were performed. Pregnancy outcomes were recorded. Optimal cut-off for uterine artery pulsatility index (PI) and serum micro RNA-210 were obtained to calculate the predictive values for preeclampsia. Data from 443 participants were analyzed. Twenty-two cases developed preeclampsia (5.0%) and seven of these preeclamptic cases had early-onset preeclampsia (1.6%). Pregnant women with preeclampsia had higher mean PI of the uterine artery (1.34 ± 0.52 vs 0.98 ± 0.28, p = 0.004), higher detection rates of diastolic notching (45.5% vs 11.2%, p < 0.001), and lower median serum micro RNA-210 level (22.86 vs 795.78, p < 0.001) than pregnant women without preeclampsia. Using abnormal serum micro RNA-210 level, abnormal mean PI or uterine artery diastolic notches to predict for preeclampsia, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 95.5%, 54.9%, 10.0%, and 99.6%, respectively. For early-onset preeclampsia prediction, the sensitivity, specificity, PPV, and NPV were 100.0%, 53.2%, 3.3%, and 100.0%, respectively. This study demonstrated that a combination of serum micro RNA-210 and uterine artery Doppler is effective in predicting preeclampsia in the second trimester.

Relationship between proteinuria and optical coherence tomographic features of the chorioretina in patients with pre-eclampsia

This retrospective study aimed to evaluate the correlation between ophthalmologic factors and proteinuria in patients with pre-eclampsia using swept-source optical coherence tomography (OCT) and OCT angiography. In total, 61 pregnant patients diagnosed with pre-eclampsia were recruited during their hospital stay. The authors investigated the relationship between urine protein–creatinine ratio (PCR) and chorioretinal measurements including choroidal thickness (CT), choroidal vascularity index (CVI), foveal avascular zone (FAZ), vascular density (VD), ganglion cell layer+ (GCL+) and GCL++. The associations between mean arterial pressure (MAP) and ophthalmologic factors were also evaluated. Central subfield CT of the right eye (p = 0.031) and paracentral CT of both eyes were related to higher PCR (≥1.35 mg/mg). A significant association with PCR after logarithm transformation was noted (r = 0.284, p = 0.026). Retinal measurements (FAZ, VD, GCL+ and GCL++) and CVI were not related with PCR. There was a positive association between MAP and PCR after logarithm transformation (r = 0.296, p = 0.021); however, chorioretinal factors were not related with MAP. In pregnant women with pre-eclampsia, CT using OCT is a novel factor that is correlated with PCR. Ocular structural alteration in patients with pre-eclampsia may be one of systemic vascular changes caused by pre-eclampsia rather than hypertension.

Application of ultrasound-based radiomics technology in fetal-lung-texture analysis in pregnancies complicated by gestational diabetes and/or pre-eclampsia

OBJECTIVES

To analyze and compare, using ultrasound-based radiomics technology, fetal-lung texture in pregnancies affected by gestational diabetes mellitus (GDM) and/or pre-eclampsia (PE) and in normal pregnancies, overall and at different gestational ages.

METHODS

In this retrospective study, 430 high-throughput features per fetal-lung image were extracted from 548 fetal-lung ultrasound images (obtained at the level of the four-chamber view of the heart) in 548 pregnant women who delivered between July 2018 and August 2019 at the Obstetrics and Gynecology Hospital of Fudan University. Images had been obtained during ultrasound examinations between 28 and 41 weeks of gestation. The data were divided randomly into training set (80% of fetal-lung images) and independent test set (20% of images), and 20% of the images in the training set were then selected as the validation set. A standard machine-learning model based on ultrasound-based radiomics technology was created using features of fetal-lung texture extracted from the images, and a regression model was used to evaluate the relationship between lung-texture features, GDM and/or PE and gestational age.

RESULTS

Of the 548 pregnancies included, 108 were affected by GDM alone, 71 by PE alone and 25 by both GDM and PE, and 344 were normal. The overall performance of the GDM and PE prediction model was superior to that of the gestational-age prediction model, with an area under the receiver-operating-characteristics curve of 0.95-0.99, sensitivity of 78.8-97.1% in the validation set and 74.5-91.3% in the independent test set, specificity of 79.8-94.3% in the validation set and 75.7-88.4% in the independent test set and accuracy of 81.0-95.3% in the validation set and 80.6-86.4% in the independent test set.

CONCLUSIONS

Using ultrasound-based radiomics technology, fetal lungs from pregnancies grouped according to whether they were affected by GDM and/or PE could be distinguished from each other and from fetal lungs of normal pregnancies, and lungs from pregnancies at different gestational ages could be distinguished. These findings support further research to explore the use of this non-invasive technology to predict neonatal respiratory complications in women with PE, GDM or their combination. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal cardiac function at 35-37 weeks' gestation in pregnancies that subsequently develop pre-eclampsia

OBJECTIVE

To compare fetal cardiac morphology and function between pregnancies that subsequently developed pre-eclampsia (PE) and those that remained normotensive.

METHODS

This was a prospective observational study in 1574 pregnancies at 35-37 weeks' gestation, including 76 that subsequently developed PE. We carried out comprehensive assessment of fetal cardiac morphology and function including novel imaging modalities, such as speckle-tracking echocardiography, and measured uterine artery pulsatility index, mean arterial pressure (MAP), serum placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and cerebroplacental ratio (CPR). The findings in the group that subsequently developed PE were compared to those in pregnancies that remained normotensive.

RESULTS

In fetuses of mothers who subsequently developed PE, compared to those from normotensive pregnancies, there was a more globular right ventricle, as shown by reduced right ventricular sphericity index, reduced right ventricular systolic contractility, as shown by reduced global longitudinal strain, and reduced left ventricular diastolic function, as shown by increased E/A ratio. On multivariable regression analysis, these indices demonstrated an association with PE, independent of maternal characteristics and fetal size. In pregnancies that subsequently developed PE, compared to those that remained normotensive, MAP, sFlt-1 and the incidence of low birth weight were higher, whereas serum PlGF, CPR and the interval between assessment and delivery were lower. These findings demonstrate that, in pregnancies that develop PE, there is evidence of impaired placentation, reflected in low PlGF and reduced birth weight, placental ischemia, evidenced by increased sFlt-1 which becomes apparent in the interval of 2-4 weeks preceding the clinical onset of PE, and consequent fetal hypoxia-induced redistribution in the fetal circulation, reflected in the low CPR.

CONCLUSION

Although the etiology of the observed fetal cardiac changes in pregnancies that subsequently develop PE remains unclear, it is possible that the reduction in right-heart systolic function is the consequence of high afterload due to increased placental resistance, whilst the early left ventricular diastolic changes could be due to fetal hypoxia-induced redistribution in the fetal circulation. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Sex differences in uterine artery Doppler during gestation in pregnancies complicated by placental dysfunction

BACKGROUND

There is growing evidence of sex differences in placental vascular development. The objective of this study was to investigate the effect of fetal sex on uterine artery pulsatility index (PI) throughout gestation in a cohort of normal and complicated pregnancies.

METHODS

A prospective longitudinal study was conducted in 240 pregnant women. Pulsed wave Doppler ultrasound of the proximal uterine arteries was performed at a 4-weekly interval between 14 and 40 weeks of gestation. The patients were classified retrospectively as normal or complicated (one or more of maternal preeclampsia, preterm birth, or small for gestational age). To assess if the change in uterine artery PI during gestation differed between normal and complicated pregnancies and between fetal sexes, the uterine artery PI was modeled using a linear function of gestational age and the rate of change was estimated from the slope.

RESULTS

While the uterine artery PI did not differ over gestation between females and males for normal pregnancies, the trajectory of this index differed by fetal sex for pregnancies complicated by either preeclampsia, preterm birth, or fetal growth restriction (p < 0.0001). The male fetuses in the complicated pregnancy group had an elevated slope compared to the other groups (p < 0.0001), suggesting a more progressive deterioration in uteroplacental perfusion over gestation.

CONCLUSIONS

The uterine artery PI is widely used to assess uteroplacental function in clinical settings. The observation that this metric changes more rapidly in complicated pregnancies where the fetus was male highlights the importance of sex when interpreting hemodynamic markers of placental maturation.

Point-of-care lung ultrasound patterns in late third-trimester gravidas with and without preeclampsia

BACKGROUND

Transthoracic point-of-care ultrasonography of the lungs has become a standard technique in critical care medicine for the evaluation of patients with respiratory signs or symptoms but has not been well studied in pregnancy.

OBJECTIVE

To compare lung ultrasound patterns in third-trimester gravidas with and without preeclampsia and assess interobserver agreement between 3 obstetrical providers and a physician expert in critical care lung ultrasound.

STUDY DESIGN

This is a prospective observational study of 262 women with singleton pregnancies between 32 0/7 and 41 6/7 weeks' gestation. Lung ultrasound examinations were performed and interpreted by a team of obstetrical care providers and then interpreted by an expert in point-of-care lung ultrasound. The number of B-lines in each of the 4 lung fields, indicating the accumulation of fluid in the interstitial space and the alveoli, was evaluated. The primary outcome was a positive study for pulmonary interstitial edema, defined as an ultrasound study with 3 or more B-lines in 2 or more bilateral lung fields. The secondary outcome was a lung ultrasound study with 1 or 2 B-lines in 1 or more lung fields or 3 B-lines in 1 lung field. Interobserver agreement in lung ultrasound interpretation between obstetrical care providers and an expert in critical care point-of-care ultrasonography of the lung was assessed.

RESULTS

Among healthy gravidas, no subject had a lung ultrasound examination positive for pulmonary interstitial edema. Notably, 2 patients with preeclampsia had positive lung ultrasound studies, and both had respiratory symptoms or signs of pulmonary edema. One or 2 B-lines or 3 B-lines in 1 lung field were identified in 11.4% of healthy gravidas and 18.6% of patients with preeclampsia. There was no difference in lung ultrasound patterns between healthy gravidas and those with preeclampsia. The obstetrical care providers and the lung ultrasound expert had a high proportion of agreement regarding the interpretation of negative lung ultrasound examinations. The 2 patients with clinical signs of pulmonary edema were judged to have positive studies by both the obstetrical team and the expert; however, the obstetrical team classified more studies as positive.

CONCLUSION

Lung ultrasound patterns in women with preeclampsia without respiratory symptoms or clinical signs of pulmonary edema are similar to the lung ultrasound patterns of healthy gravidas. Point-of-care lung ultrasound can be used to evaluate third-trimester gravidas with preeclampsia and respiratory complaints or signs concerning for pulmonary edema. Formal training is important before the widespread adoption of point-of-care lung ultrasound by obstetrical healthcare providers.

First trimester screening for pre-eclampsia and intrauterine growth restriction using three-dimensional Doppler angiography (SPIRIT): protocol for a multicentre prospective study in nulliparous pregnant women

INTRODUCTION

Pre-eclampsia (PE) and intrauterine growth restriction (IUGR) are two major pregnancy complications, related to chronic uteroplacental hypoperfusion. Nowadays, there is no screening or diagnostic test for uteroplacental vascularisation deficiency in pregnant women. Since 2004, 3 three-imensional power Doppler (3DPD) angiography has been used for the evaluation of uteroplacental vascularisation and three vascular indices are usually calculated: Vascularisation Index (VI), Flow Index (FI) and vascularisation-FI (VFI). A high intraobserver and interobserver reproducibility and a potential interest for placental function study were reported by our team and others.The main objective of our study is to determine differences in 3DPD indices at first trimester between pregnancies defined at their outcome as uncomplicated pregnancy, PE (mild and severe) and IUGR in nulliparous women.

METHODS AND ANALYSIS

This is a national multicentre prospective cohort study conducted in four French maternity units. We expect to include 2200 women in a period of 36 months. The nulliparous pregnant women will be recruited during their first trimester consultation (11-13+6 gestation week (GW)).The 3DPD and uterine artery Doppler acquisition will be included in the current routine 11-13+6 GW ultrasound. Also, additional blood samples will be taken for biomarker analysis (PAPP-A and P1GF) and biological collection. Uteroplacental VIs (FI and VFI) will be measured. For each subgroup (uncomplicated pregnancy, PE and IUGR), mean values in 3DPD indices will be computed and compared using a pairwise t test with a Bonferroni correction p value adjustment.

ETHICS AND DISSEMINATION

The study was approved by the French Ethics Committee, the Comité de Protection des Personnes SUD MEDITERRANEE IV on 13 February 2018 with reference number 17 12 03. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT03342014; Pre-results. PHRCN-16-0567.

Screening for pre-eclampsia at 11-13 weeks' gestation: use of pregnancy-associated plasma protein-A, placental growth factor or both

OBJECTIVE

First-trimester screening for pre-eclampsia (PE) is useful because treatment of the high-risk group with aspirin reduces the rate of early PE with delivery at < 34 weeks' gestation by about 80% and that of preterm PE with delivery at < 37 weeks by 60%. In previous studies, we reported that the best way of identifying the high-risk group is by a combination of maternal factors, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI) and serum placental growth factor (PlGF). An alternative biochemical marker is pregnancy-associated plasma protein-A (PAPP-A), which is used widely as part of early screening for trisomy. The objective of this study was to examine the additive value of PlGF and PAPP-A in first-trimester screening for preterm PE by maternal factors, MAP and UtA-PI and define the risk cut-off and screen-positive rate to achieve a desired detection rate of PE if PAPP-A rather than PlGF was to be used for first-trimester screening.

METHODS

This was a non-intervention screening study. The data were derived from prospective screening for adverse obstetric outcomes in women with singleton pregnancy attending for a routine first-trimester hospital visit. Patient-specific risks of delivery with PE at < 37 weeks' gestation were calculated using the competing-risks model to combine the prior distribution of gestational age at delivery with PE, obtained from maternal characteristics and medical history, with multiples of the median (MoM) values of MAP, UtA-PI, PlGF and PAPP-A. The performance of screening in the total population and in subgroups of women of white and black racial origin was estimated. McNemar's test was used to compare the detection rate, for a fixed screen-positive rate, of screening with and without PlGF and PAPP-A. Risk cut-offs and screen-positive rates to achieve desired detection rates of preterm PE were determined in screening with and without PlGF and PAPP-A.

RESULTS

The study population was composed of 60 875 singleton pregnancies, including 1736 (2.9%) that developed PE. There are three main findings of this study. First, the performance of first-trimester screening for PE by a combination of maternal factors, MAP, UtA-PI and PlGF is superior to that of screening by maternal factors, MAP, UtA-PI and PAPP-A; for example, in screening by maternal factors, MAP, UtA-PI and PlGF, at a screen-positive rate of 10%, the detection rate of PE with delivery at < 37 weeks' gestation was 74.1%, which was 7.1% (95% CI, 3.8-10.6%) higher than in screening by maternal factors, MAP, UtA-PI and PAPP-A. Second, addition of serum PAPP-A does not improve the prediction of PE provided by maternal factors, MAP, UtA-PI and PlGF. Third, the risk cut-off and screen-positive rate to achieve a given fixed detection rate of preterm PE vary according to the racial composition of the study population and whether the biomarkers used for screening are MAP, UtA-PI and PlGF or MAP, UtA-PI and PAPP-A. For example, in screening by a combination of maternal factors, MAP, UtA-PI and PlGF in white women, if the desired detection rate of preterm PE was 75%, the risk cut-off should be 1 in 136 and the screen-positive rate would be 14.1%; in black women, to achieve a detection rate of 75%, the risk cut-off should be 1 in 29 and the screen-positive rate would be 12.5%. In screening by a combination of maternal factors, MAP, UtA-PI and PAPP-A in white women, if the desired detection rate of preterm PE was 75%, the risk cut-off should be 1 in 140 and the screen-positive rate would be 16.9%; in black women, to achieve a detection rate of 75%, the risk cut-off should be 1 in 44 and the screen-positive rate would be 19.3%.

CONCLUSION

In first-trimester screening for PE, the preferred biochemical marker is PlGF rather than PAPP-A. However, if PAPP-A was to be used rather than PlGF, the same detection rate can be achieved but at a higher screen-positive rate. © 2020 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Uterine Artery Doppler Ultrasonography for First Trimester Prediction of Preeclampsia in Individuals at Risk from Low-Resource Settings

Background and objectives: The objective of this study was to evaluate the potential of first trimester uterine artery Doppler ultrasonography for the early prediction of preeclampsia (PE), in at-risk pregnant women. Materials and Methods: This was a prospective longitudinal study, including 120 Caucasian pregnant women with risk factors for PE. The potential of pulsatility indexes (PI) and notch was assessed as a tool for preeclampsia screening. Results: Doppler examination of the uterine artery performed early at 11-14 WA allows the detection of pregnancies that will develop PE with a sensitivity of 61.5% and a specificity of 63.8% based on PI analysis. Predictive power increases slightly by adding bilateral notch (sensitivity = 65.4%; specificity = 66%). Conclusions: Uterine artery Doppler examination is an effective non-invasive screening test for the development of PE in pregnancies at risk, particularly appropriate in health systems with limited means of evaluating other biomarkers.

What Is the Role of the Maternal Ophthalmic and Cervical Internal Carotid Arteries in Predicting Maternal Adverse Outcomes in Preeclampsia?

OBJECTIVES

We aimed to investigate the efficacy of maternal ophthalmic artery (OA) and cervical internal carotid artery (CICA) in predicting adverse maternal outcomes and gestational age at birth in preeclampsia (PE).

METHODS

The study was performed at the Zeynep Kamil Women and Children's Diseases Training and Research Hospital. Measurements were made in 2 groups consisting of 50 pregnant women with PE and 50 healthy pregnant women. The peak systolic velocity (PSV), end-diastolic velocity, PI, RI, first diastolic peak velocity, systolic/diastolic (S/D) ratio, and peak ratio of the maternal OA were measured by a transorbital Doppler ultrasound (US) scan. The PSV, end-diastolic velocity, PI, RI, and S/D ratio of the CICA were measured. The differences of Doppler indices between groups with P < .05 were considered statistically significant. Cutoff values were calculated, which could be used to predict adverse maternal outcomes and gestational age at birth.

RESULTS

The RI and PI values of the OA were lower, and the first diastolic peak velocity, PSV, and peak ratio values were higher among the PE group. The RI and S/D values of the CICA were significantly lower in the PE group compared to the healthy group. The OA RI was determined to be the strongest US variable in predicting adverse maternal outcomes and gestational age at birth, with a cutoff value of 0.72, 76% sensitivity, and 76% specificity.

CONCLUSIONS

Maternal OA Doppler indices can be used as US markers to predict adverse maternal outcomes.

The evaluation of ventricular functions by speckle tracking echocardiography in preeclamptic patients

Preeclampsia is a maternal disorder of pregnancy characterized by concomitant increase in preload and afterload with end organ dysfunction. The aim of our study is to evaluate left ventricular (LV) and right ventricular (RV) functions with speckle tracking echocardiography in preeclamptic patients. Fifty-five preeclamptic (mean age: 30.7 ± 5.9 years) and 35 healthy pregnant women (mean age: 28.8 ± 5.7 years) of the same race, similar age and gestational week were consecutively included. The diagnosis of preeclampsia was based on the criteria proposed by the American College of Obstetricians and Gynecologists. LV and RV functions were assessed by both conventional and speckle tracking echocardiography after the 30th gestational week and at the postpartum 6th months. The preeclamptic patients had significantly larger left atrium, thicker interventricular septum, higher systolic pulmonary artery pressure and mitral E/e' ratio compared to controls during pregnancy while LV ejection fraction was similar. Preeclamptic patients had significantly lower LV and RV global longitudinal strain (GLS) during pregnancy compared to controls (- 18.0 ± 2.6% vs. - 19.8 ± 2.1% p = 0.001 and - 26.7 ± 3.3% vs. 28.9 ± 3.3% p = 0.002, respectively). In the postpartum period, while LVGLS values of preeclamptic patients increased significantly (- 18.0 ± 2.6% vs. - 20.4 ± 2.4% p < 0.001) and became similar to those of controls at the sixth month, the RVGLS decreased significantly (- 26.7 ± 3.3% vs. - 25.8 ± 2.7% p = 0.003) making the difference in RVGLS between the preeclamptic patients and controls more prominent. Preeclampsia may impair LV and RV function. Long-term follow up with larger sample is needed to determine the clinical relevance of the observed changes in strain.

Assessment of uteroplacental vascularisation in early first-trimester pregnancy with contrast-enhanced ultrasound and 3D power Doppler angiography: protocol for a prospective, cross-sectional, multicentre and non-randomised open study ("HOPE Study")

INTRODUCTION

Knowledge about the mechanisms leading to the establishment of uteroplacental vascularisation is inadequate, and some of what has been thought to be known for decades has recently been challenged by showing that the intervillous space, the major area of maternal-fetal exchange, appears to be perfused by maternal blood at as early as 6 weeks of gestation. The vascular flow then seems relatively constant until 13 weeks when it appears to increase suddenly.

OBJECTIVES

The principal objective is to quantify the perfusion of the intervillous space by contrast-enhanced ultrasonography (CEUS) during the first-trimester at three different gestational ages (8, 11 and 13 weeks). The secondary objectives are to: (1) describe the indicators of vascularisation of the placenta (intervillous space) and the myometrium at the three gestational ages, measured by CEUS and three-dimensional power Doppler (3DPD) angiography; (2) compare the diagnostic performance of CEUS and 3DPD for the demonstration and quantification of uteroplacental vascularisation and (3) establish a biological collection of placentas to increase knowledge about placental development and functions during pregnancy.

METHODS AND ANALYSIS

This is a prospective, cross-sectional, multicentre and non-randomised open study. We will include 42 women with ongoing pregnancy and divided into three groups of gestational ages (ie, 14 women by per group): 8, 11 and 13 weeks of gestation. 3DPD and then CEUS will be performed and the data about the perfusion kinetics and the 3DPD indices will be calculated and then compared with each other and for each gestational age.

ETHICS AND DISSEMINATION

The appropriate French Ethics Committee Est III approved this study and the related consent forms on 5 April 2016, and the competent authority (Agence Nationale de Sécurité du Médicament et des Produits de Santé) authorised the study on 21 June 2016. The results of this study will be published in a peer-reviewed journal and will be presented at relevant conferences.

TRIAL REGISTRATION NUMBERS

ClinicalTrials.gov registry (NCT02884297); EudraCT registry (2015-005655-27).

First trimester Doppler velocimetry of the uterine artery ipsilateral to the placenta improves ability to predict early-onset preeclampsia

This study sought to investigate the effects of placental laterality on the measurements of uterine artery (UtA) Doppler velocimetry and their application in predicting early-onset preeclampsia (PE).We conducted a prospective cohort study on all women with singleton, uncomplicated pregnancies scheduled for first-trimester nuchal translucency at our institution. Pulsatility index (PI) for both UtAs was measured by Doppler velocimetry, and placental laterality was determined. Additionally, pregnancy outcome data were abstracted from the medical records. Receiver operating characteristic curves (ROCs) were plotted.Of the 304 patients enrolled, 247 met the inclusion criteria. Among these patients, 240 had uncomplicated delivery, while 7 had early delivery at <34 weeks due to PE. For the uncomplicated pregnancies, PI measurements of the UtA ipsilateral to the placenta were similar (left versus right UtA: 1.06 ± 0.38 vs. 1.04 ± 0.40; P = .745). However, PI measurements of the UtA contralateral to the placenta differed significantly (left versus right UtA: 1.45 ± 0.51 vs. 1.3 ± 0.47; P = .027). In predicting early-onset PE, the ideal cut-off value for the placental side PI was 1.91, with sensitivity 100% and specificity 96.3%. For nonplacental side PI, the ideal cut-off value for PI was 1.975, with sensitivity 57.1% and specificity 79.2%. Using the mean of the left and right UtA PI, the ideal cut-off value was 1.63, with sensitivity 100% and specificity 74.2%.ROC analysis confirmed that PI measurements of the UtA on the placental side were significantly lower than those on the contralateral side, PI measurements of the UtA ipsilateral to the placenta were similar.

Behavioral, electrophysiological and neuropathological characteristics of the occurrence of hypertension in pregnant rats

Pre-eclampsia (PE) affects approximately 2 to 8% of pregnant women, causing blood pressure above 140 × 90 mmHg and proteinuria, normally after the 20th gestation week. If unsuccessfully treated, PE can lead to self-limited seizures (Eclampsia) that could eventually result in death of the mother and her fetus. The present study reports an experimental model of preeclampsia hypertension in pregnant (HP) and non-pregnant (H) Wistar rats by partially clamping one of their renal arteries. Pregnant (P) and non-pregnant (C) controls were provided. Differently from controls (C and P), H and HP animals presented a steady rise in BP two weeks after renal artery clamping. Injection of pentylenetetrazol (PTZ) induced behavioral and electroencephalographic seizures in all groups, which were increased in number, duration, amplitude and power accompanied by decreased latency in HP animals (p < 0.05). Consistent results were obtained in in vitro experimentation. Immunohistochemistry of hippocampus tissue in HP animals showed decreased density of neurons nuclei in CA1, CA3 and Hilus and increased density of astrocytes in CA1, CA3 and gyrus (p < 0.05). The present findings show that the clamping of one renal arteries to 0.15 mm and PTZ administration were able to induce signs similar to human PE in pregnant Wistar rats.

Quality assessment of uterine artery Doppler measurement in first-trimester combined screening for pre-eclampsia

OBJECTIVE

To assess the quality of mean uterine artery (UtA) pulsatility index (PI) measurement in a first-trimester pre-eclampsia screening program.

METHODS

Consecutive women with a singleton pregnancy attending first-trimester screening for fetal chromosomal abnormalities also had combined screening for pre-eclampsia based on the Fetal Medicine Foundation (FMF) algorithm, at a large practice in Sydney, Australia, from May 2014 to February 2017. Distributions of mean UtA-PI multiples of the median (MoM) on a logarithmic scale were plotted in relation to the normal median with 95% CI for each operator and for each month. Central tendency and dispersion and cumulative sum charts were produced. Mean UtA-PI MoM values between 0.95 and 1.05 were considered ideal and those between 0.90 and 1.10 were considered acceptable. The screen-positive rates for preterm pre-eclampsia in different groups of sonographers according to their mean log₁₀ UtA-PI MoM were calculated and compared using the chi-square test.

RESULTS

A total of 21 010 women attended for first-trimester ultrasound and had screening for pre-eclampsia. The overall median UtA-PI MoM was 1.042 (interquartile range (IQR), 0.85-1.26). Of 46 sonographers, 42 (91.3%) performed more than 50 examinations and, of those, 41 (97.6%) measured UtA-PI within the acceptable range. Sonographers measuring UtA-PI MoM on average below 0.95 and those measuring it above 1.05 had, respectively, lower and higher screen-positive rates when compared with those with measurements within the 0.95-1.05 UtA-PI MoM interval (7.2% and 13.2% vs 11.2%, respectively, P < 0.001).

CONCLUSION

UtA Doppler is measured well among trained operators when following an established protocol. While slight variations are expected, systematic error in this measurement impacts on the screen-positive rate. Therefore, a quality control process should be in place and retraining of staff may be required. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Multi-modal functional MRI to explore placental function over gestation

PURPOSE

To investigate, visualize and quantify the physiology of the human placenta in several dimensions - functional, temporal over gestation, and spatial over the whole organ.

METHODS

Bespoke MRI techniques, combining a rich diffusion protocol, anatomical data and T2* mapping together with a multi-modal pipeline including motion correction and extracted quantitative features were developed and employed on pregnant women between 22 and 38 weeks gestational age including two pregnancies diagnosed with pre-eclampsia.

RESULTS

A multi-faceted assessment was demonstrated showing trends of increasing lacunarity, and decreasing T2* and diffusivity over gestation.

CONCLUSIONS

The obtained multi-modal acquisition and quantification shows promising opportunities for studying evolution, adaptation and compensation processes.

Cost-effectiveness of first-trimester screening with early preventative use of aspirin in women at high risk of early-onset pre-eclampsia

OBJECTIVE

Pre-eclampsia (PE) remains a leading cause of maternal and fetal morbidity and mortality. A first-trimester screening algorithm predicting the risk of early-onset PE has been developed and validated. Early prediction coupled with initiation of aspirin at 11-13 weeks in women identified as high risk is effective at reducing the prevalence of early-onset PE. The aim of this study was to evaluate the cost-effectiveness of this first-trimester screening program coupled with early use of low-dose aspirin in women at high risk of developing early-onset PE, in comparison to current practice in Canada.

METHODS

A decision analysis was performed based on a theoretical population of 387 516 live births in Canada in 1 year. The clinical and financial impact of early preventative screening using the Fetal Medicine Foundation algorithm for prediction of early-onset PE coupled with early (< 16 weeks) use of low-dose aspirin in those at high risk was simulated and compared with current practice using decision-tree analysis. The probabilities at each decision point and associated costs of utilized resources were calculated based on published literature and public databases.

RESULTS

Of the theoretical 387 516 births per year, the estimated prevalence of early PE based on first-trimester screening and aspirin use was 705 vs 1801 cases based on the current practice. This was associated with an estimated total cost of C$9.52 million with the first-trimester screening program compared with C$23.91 million with current practice for the diagnosis and management of women with early-onset PE. This equals an annual cost saving to the Canadian healthcare system of approximately C$14.39 million.

CONCLUSIONS

The implementation of a first-trimester screening program for PE and early intervention with aspirin in women identified as high risk for early PE has the potential to prevent a significant number of early-onset PE cases with a substantial associated cost saving to the healthcare system in Canada. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Placental Elasticity as a New Non-invasive Predictive Marker of Pre-eclampsia

Point shear wave elastography is an ultrasonography technique used to evaluate tissue elasticity. We examined whether placental elasticity is useful for predicting the onset of pre-eclampsia. Two hundred twenty-one participants were divided into two groups: one group at low risk (n = 185) and the other at high risk (n = 36) for pre-eclampsia. The two groups were compared with respect to shear wave velocity (SWV) of the placenta. Use of SWV as a predictor of pre-eclampsia was also investigated by creating a receiver operating characteristic (ROC) curve. The ROC curve was used to set a cutoff SWV value for predicting pre-eclampsia. The SWV of the high-risk group was significantly higher than that of the low-risk group (p < 0.001). Thirteen participants developed pre-eclampsia after SWV measurements, and the SWVs of these participants were significantly higher than those of participants in who pre-eclampsia did not develop. The cutoff value and area under the ROC curve were 1.188 m/s and 0.9118, respectively. Placental elasticity was significantly increased even before the onset of pre-eclampsia onset and, thus, may be a parameter used to predict the onset of pre-eclampsia.

Preeclampsia in 2018: Revisiting Concepts, Physiopathology, and Prediction

Preeclampsia currently remains one of the leading causes of death and severe maternal morbidity. Although its prevalence is still underestimated in some places due to underreporting, preeclampsia is a disease that health professionals need to know how to deal with and take action. For this reason, the studies about the theme remain along with the advances in their understanding that often implies improvement and change of concepts and conducts. The complexity of its etiology is a challenge and requires further studies for its full understanding. Apparently, poor adaptation of the maternal organism to the conceptus, marked by the nonoccurrence of changes in the uterine spiral arteries, determines a series of systemic repercussions that compound the various forms of preeclampsia presentation. In recent years, the use of acetylsalicylic acid to prevent cases of early onset of the disease has been consolidated and, alongside, studies have advanced the development of accessible and effective methods of identifying women at risk of preeclampsia. The aim of this review is to discuss updates on the occurrence, concept, pathophysiology, repercussion, prevention, and prediction of preeclampsia.

Transverse technique: complementary approach to measurement of first-trimester uterine artery Doppler

OBJECTIVES

To define a protocol for the first-trimester assessment of uterine artery pulsatility index (UtA-PI) using the new transverse technique, to evaluate UtA-PI measured using the transverse approach vs that obtained using the conventional sagittal approach and to determine if accelerated onsite training (in both methods) of inexperienced sonographers can achieve reproducible UtA-PI measurements comparable with those obtained by an experienced sonographer.

METHODS

This was a prospective observational study of women with a singleton pregnancy attending for routine combined first-trimester screening at 11 to 13 + 6 weeks' gestation. The study consisted of two parts, each conducted at a different center (Part 1 in Calgary, Canada and Part 2 in Hong Kong). In Part 1, UtA-PI measurements were performed using the transverse and sagittal techniques by four sonographers trained in both methods, in 10 cases each, and measurement indices (PI), time required and subjective difficulty in obtaining satisfactory measurements were compared. The one sample t-test and Wilcoxon signed rank test were used when appropriate. Bland-Altman plots were used to assess measurement agreement, and intraclass correlation coefficient (ICC) was used to evaluate measurement reliability. A target plot was used to assess measures of central tendency and dispersion. In Part 2, one experienced and three inexperienced sonographers prospectively measured UtA-PI using both approaches in 42 and 35 women, respectively. Inexperienced sonographers underwent accelerated onsite training by the experienced sonographer. Measurement approach and sonographer order were on a random basis. ICC, Bland-Altman and Passing-Bablok analyses were performed to assess measurement agreement and reliability and effect of accelerated training.

RESULTS

In Part 1, no difference was observed between the two techniques in mean time to acquire the measurements (118 s for sagittal vs 106 s for transverse; P = 0.38). The four sonographers reported that the transverse technique was subjectively easier to perform (P = 0.04). Bias and ICC for mean UtA-PI between sagittal and transverse measurements were -0.05 (95% limits of agreement, -0.48 to 0.37) and 0.94, respectively. Measurements obtained using the transverse technique after correcting for gestational age were significantly closer to the expected distribution than those obtained using the sagittal technique. In Part 2, there were no significant differences in median UtA-PI measured using the different approaches for both experienced and inexperienced sonographers (P > 0.05 for all sonographers). Mean UtA-PI measurement reliability between approaches was high for the experienced (ICC = 0.92) and inexperienced (ICC > 0.80) sonographers. UtA-PI measurement approaches did not deviate from linearity, while bias ranged from -0.10 to 0.07. The median time required was similar between the techniques (56.1 s for sagittal vs 49.3 s for transverse; P = 0.054).

CONCLUSIONS

This novel transverse approach for the measurement of UtA-PI in the first trimester appears to be comparable with the sagittal approach in terms of reliability, reproducibility and time required, and may be easier to perform. Providing accelerated onsite training can be helpful for improving the reliability of UtA-PI measurements and could potentially facilitate the broad implementation of first-trimester pre-eclampsia screening. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Effects of perinatal blood pressure on maternal brain functional connectivity

Perinatal hypertensive disorder including pre-eclampsia is a systemic syndrome that occurs in 3–5% of pregnant women. It can result in various degrees of brain damage. A recent study suggested that even gestational hypertension without proteinuria can cause cardiovascular or cognitive impairments later in life. We hypothesized that perinatal hypertension affects the brain functional connectivity (FC) regardless of the clinical manifestation of brain functional impairment. In the present study, we analyzed regional global connectivity (rGC) strength (mean cross-correlation coefficient between a brain region and all other regions) using resting-state functional magnetic resonance imaging to clarify brain FC changes associated with perinatal blood pressure using data from 16 women with a normal pregnancy and 21 pregnant women with pre-eclampsia. The rGC values in the bilateral orbitofrontal gyri were negatively correlated with diastolic blood pressure (dBP), which could not be explained by other pre-eclampsia symptoms. The strength of FC seeding at the left orbitofrontal gyrus was negatively correlated with dBP in the anterior cingulate gyri and right middle frontal gyrus. These results suggest that dBP elevation during pregnancy can affect the brain FC. Since FC is known to be associated with various brain functions and diseases, our findings are important for elucidating the neural correlate of cognitive impairments related to hypertension in pregnancy.

Evaluation of Umbilical Vein Blood Volume Flow in Preeclampsia by Angle-Independent 3D Sonography

OBJECTIVES

To investigate the association between umbilical vein blood volume flow and the condition of preeclampsia in an at-risk maternal patient cohort. Umbilical vein volume flow was quantified by a 3-dimensional (3D) sonographic technique that overcomes several limitations of standard sonographic flow measurement methods.

METHODS

A total of 35 patients, each with a singleton pregnancy, were recruited to provide 5 patients with preeclampsia, derived as a subset from a 26-patient at-risk group, and 9 patients with normal pregnancies. An ultrasound system equipped with a 2.0-8.0-MHz transducer was used to acquire multivolume 3D color flow and power mode data sets to compute the mean umbilical vein volume flow in patients with normal pregnancies and preeclampsia.

RESULTS

The gestational ages of the pregnancies ranged from 29.7 to 34.3 weeks in the patients with preeclampsia and from 25.9 to 34.7 weeks in the patients with normal pregnancies. Comparisons between patients with normal pregnancies and those with preeclampsia showed weight-normalized flow with a moderately high separation between groups (P = .11) and depth-corrected, weight-normalized flow with a statistically significant difference between groups (P = .035). Umbilical vein volume flow measurements were highly reproducible in the mean estimate, with an intrapatient relative SE of 12.1% ± 5.9% and an intrameasurement relative SE of 5.6% ± 1.9 %. In patients who developed pregnancy-induced hypertension or severe pregnancy-induced hypertension, umbilical vein volume flow suggested gestational hypertensive disorder before clinical diagnosis.

CONCLUSIONS

Results indicate that mean depth-corrected, weight-normalized umbilical vein volume flow is reduced in pregnancies complicated by preeclampsia and that volume flow may indicate hypertensive disorder earlier in gestation. Volume flow measurements are highly reproducible, and further study in a larger clinical population is encouraged to determine whether 3D volume flow can complement the management of preeclampsia and, in general, at-risk pregnancy.

Cardiac maladaptation in term pregnancies with preeclampsia

OBJECTIVES

To study biventricular cardiac changes with conventional echocardiography and new echocardiographic speckle tracking technologies such strain, twist and torsion in pregnant women with preeclampsia at term and normotensive control term pregnant women.

STUDY DESIGN

For this prospective single centre case-control study, we consecutively recruited 30 women with preeclampsia at term as cases and 40 healthy control term pregnant women. All women underwent transthoracic echocardiographic examination at the time point of inclusion into the study.

MAIN OUTCOME MEASURES

Signs of systolic and/or diastolic cardiac maladaptation to the increased volume load associated with pregnancy.

RESULTS

Conventional echocardiography revealed mild left sided diastolic impairment in the form of significantly increased E/E' in preeclampsia (7.58 ± 1.72 vs. 6.18 ± 1.57, p = 0.001) compared to normotensive controls, but no evidence of systolic impairment. With speckle tracking analysis, significant decreases in left ventricular global (-13.32 ± 2.37% vs. -17.61 ± 1.89%, p < 0.001), endocardial (-15.64 ± 2.79% vs. -19.84 ± 2.35%, p < 0.001) and epicardial strain (-11.48 ± 2.15% vs. -15.73 ± 1.66%, p < 0.001) as well as left ventricular longitudinal strain rate (-0.84 ± 0.14 s^-1 vs. -0.98 ± 0.12 s^-1, p < 0.001) and left ventricular early diastolic strain rate (0.86 ± 0.30 s^-1 vs. 1.24 ± 0.26 s^-1, p < 0.001) could be observed in women with term preeclampsia.

CONCLUSIONS

The findings of this study demonstrate that pregnant women with term preeclampsia with minimal functional changes on conventional echocardiography, demonstrated significant subclinical myocardial changes on speckle tracking analysis.

Three-dimensional indices of renal perfusion in normal pregnancy and pre-eclampsia

INTRODUCTION

We compared renal perfusion in normal pregnant women and women with pre-eclampsia using three-dimensional (3D) ultrasound. We measured the flow index (FI), vascular index (VI) and vascularisation flow index (VFI) which are believed to reflect vascularity and flow intensity.

METHODS

Fourteen patients with normal pregnancy and 16 patients with pre-eclampsia were recruited. Imaging was conducted using a Voluson E8 machine and a 6-MHz trans-abdominal probe. The inferior border of the maternal left kidney was scanned. Volumes were acquired using 3D power Doppler angiography (3D-PDA). The FI, VI and VFI were generated using 'histogram' facility.

RESULTS

Maternal characteristics between normal pregnant women and women with pre-eclampsia were not different in terms of maternal age, gestation or body mass index. Depth of insonnation was not different between groups. The FI, VI and the VFI were not different between groups. The mean (SD) for FI was 27.9 (7.4) vs. 27.1 (6.5) between women with normal pregnancy vs. women with pre-eclampsia. For VI, mean (SD) was 72.3(31.6) vs. 79.4 (28.7) respectively. For VFI, mean (SD) was 20.8 (10.8) vs. 20.8 (8.1) respectively. Using the Mann-Whitney U test, no statistical differences between groups were apparent. There was no correlation between FI measurements and maternal creatinine (Pearson's R square = 0.04; p = 0.45) or with maternal urea levels (Pearson's R square = 0.20; p = 0.10).

CONCLUSION

Using 3D ultrasound, we failed to demonstrate a difference in maternal renal perfusion in normal pregnancy compared to pre-eclampsia. The lack of observed difference may be a reflection of the high variability in 3D measurements (i.e. poor investigative tool) rather than a true lack of difference in renal perfusion.

Perinatal outcome and placental apoptosis in patients with late-onset pre-eclampsia and abnormal uterine artery Doppler at diagnosis

OBJECTIVE

To determine the rate of placental apoptosis and adverse perinatal outcome in patients with late-onset pre-eclampsia (PE) and abnormal uterine artery (UtA) Doppler at diagnosis.

METHODS

This was a prospective cohort study of women with singleton pregnancy diagnosed with late PE, performed between August 2011 and January 2014 at the Maternal-Fetal Medicine Unit of Hospital Carlos Van Buren. Patients were stratified according to UtA Doppler status at diagnosis (pulsatility index (PI) ≤ or > 95^th percentile). Logistic regression analysis was performed to identify associations between abnormal UtA Doppler and adverse maternal and perinatal outcomes. In a subset of this cohort for whom placental samples were available, immunohistochemical analysis of the placenta was performed to identify the rate of apoptosis and its association with UtA Doppler by comparing samples from those with normal and those with abnormal UtA Doppler and normotensive controls. Non-parametric linear trend analysis was performed for assessment of the apoptotic index.

RESULTS

Eighty-six patients were included in the final analysis. Of these, UtA-PI was above the 95^th percentile in 33 (38.4%) patients. Gestational age at diagnosis and delivery were significantly lower in this group compared with patients with normal UtA Doppler. Abnormal UtA Doppler was associated with increased risk of severe PE (odds ratio (OR) = 7.5; 95% CI, 2.76-20.46; P < 0.001), late preterm delivery (OR = 13.7; 95% CI, 4.53-41.46; P < 0.001), small-for-gestational age at birth (OR = 12.3; 95% CI, 3.17-47.57; P < 0.001) and admission to the neonatal intensive care unit (OR = 12.8; 95% CI, 2.61-62.36; P = 0.002). Moreover, UtA Z-score demonstrated a significant inverse correlation with birth-weight Z-score (r = -0.34; P = 0.0013). Mean placental apoptotic index demonstrated an ascending linear trend according to UtA Doppler status (P = 0.04).

CONCLUSIONS

In patients with late PE, UtA Doppler was useful for clinical classification and as an indicator of placental histological findings. Correlation between UtA Doppler and the apoptotic index provides new evidence of a subgroup of late PE with a placental origin. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Ophthalmic artery Doppler for prediction of pre-eclampsia: systematic review and meta-analysis

OBJECTIVE

To determine the accuracy of ophthalmic artery Doppler in pregnancy for the prediction of pre-eclampsia (PE).

METHODS

MEDLINE, EMBASE, CINAHL and The Cochrane Library were searched for relevant citations without language restrictions. Two reviewers independently selected studies that evaluated the accuracy of ophthalmic artery Doppler to predict the development of PE and extracted data to construct 2 × 2 tables. Individual patient data were obtained from the authors if available. A bivariate random-effects model was used for the quantitative synthesis of data. Logistic regression analysis was employed to generate receiver-operating characteristics (ROC) curves and obtain optimal cut-offs for each investigated parameter, and a bivariate analysis was employed using predetermined cut-offs to obtain sensitivity and specificity values and generate summary ROC curves.

RESULTS

A total of 87 citations matched the search criteria of which three studies, involving 1119 pregnancies, were included in the analysis. All included studies had clear description of the index and reference tests, avoidance of verification bias and adequate follow-up. Individual patient data were obtained for all three included studies. First diastolic peak velocity of ophthalmic artery Doppler at a cut-off of 23.3 cm/s showed modest sensitivity (61.0%; 95% CI, 44.2-76.1%) and specificity (73.2%; 95% CI, 66.9-78.7%) for the prediction of early-onset PE (area under the ROC curve (AUC), 0.68; 95% CI, 0.61-0.76). The first diastolic peak velocity had a much lower sensitivity (39.0%; 95% CI, 20.6-61.0%), a similar specificity (73.2%; 95% CI, 66.9-78.7%) and a lower AUC (0.58; CI, 0.52-0.65) for the prediction of late-onset PE. The pulsatility index of the ophthalmic artery did not show a clinically useful sensitivity or specificity at any cut-off for early- or late-onset PE. Peak ratio above 0.65 showed a similar diagnostic accuracy to that of the first diastolic peak velocity with an AUC of 0.67 (95% CI, 0.58-0.77) for early-onset PE and 0.57 (95% CI, 0.51-0.63) for late-onset disease.

CONCLUSIONS

Ophthalmic artery Doppler is a simple, accurate and objective technique with a standalone predictive value for the development of early-onset PE equivalent to that of uterine artery Doppler evaluation. The relationship between ophthalmic Doppler indices and PE cannot be a consequence of trophoblast invasion and may be related to maternal hemodynamic adaptation to pregnancy. The findings of this review justify efforts to elucidate the effectiveness and underlying mechanism whereby two seemingly unrelated maternal vessels can be used for the prediction of a disease considered a 'placental disorder'. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Understanding abnormal uterine artery Doppler waveforms: A novel computational model to explore potential causes within the utero-placental vasculature

INTRODUCTION

Uterine artery (UtA) Doppler indices are one of the most commonly employed screening tests for pre-eclampsia worldwide. Abnormal indices appear to result from increased uterine vascular resistance, but anatomical complexity and lack of appropriate animal models mean that little is known about the relative contribution of each of the components of the uterine vasculature to the overall UtA Doppler waveform. Previous computational models suggested that trophoblast-mediated spiral artery remodeling has a dominant effect on the UtA Doppler waveform. However, these models did not incorporate the myometrial arterio-venous anastomoses, which have significant potential to affect utero-placental haemodynamics.

METHODS

We present a more anatomically complete computational model, explicitly incorporating a structural description of each component of the uterine vasculature, and crucially including myometrial arterio-venous anastomoses as parallel pathways for blood-flow away from the placental bed. Wave transmission theory was applied to the network to predict UtA waveforms.

RESULTS

Our model shows that high UtA resistance indices, combined with notching, reflect an abnormal remodeling of the entire uterine vasculature. Incomplete spiral artery remodeling alone is unlikely to cause abnormal UtA Doppler waveforms as increased resistance in these arteries can be 'buffered' by upstream anastomoses. Critically, our results indicate that the radial arteries, may have a more important effect on utero-placental flow dynamics, and the UtA Doppler waveform than previously thought.

CONCLUSIONS

This model suggests that to appropriately interpret UtA Doppler waveforms they must be considered to be reflecting changes in the entire system, rather than just the spiral arteries.

Systemic Evaluation of Vascular Dysfunction by High-Resolution Sonography in an Nω -Nitro-l-Arginine Methyl Ester Hydrochloride-Induced Mouse Model of Preeclampsia-Like Symptoms

OBJECTIVES

The purpose of this study was to evaluate vascular function, including arterial resistance and endothelial function, by high-resolution sonography in an N_ω -nitro-l-arginine methyl ester hydrochloride (l-NAME)-induced mouse model of preeclampsia-like symptoms.

METHODS

Pregnant mice were subcutaneously injected with a saline solution (control; n = 10) or l-NAME (n = 10) between the 7th and 18th days of gestation. The resistive index and pulsatility index (RI and PI, indicators of arterial resistance) of the uteroplacental, umbilical, femoral, and common carotid arteries and the flow-mediated dilatation (index of endothelial function) of the femoral artery were measured by high-frequency sonography in both groups.

RESULTS

We noted significant increases in the RI and PI of the uteroplacental and umbilical arteries and a decrease in the flow-mediated dilatation of the femoral artery in the l-NAME group compared with the control group. We also found that the RI and PI of the uteroplacental and umbilical arteries were negatively correlated with fetal weight and crown-rump length. The results of the multivariate analysis using a logistic regression model indicated that the flow-mediated dilatation at 120 seconds was an independent diagnostic criterion for the l-NAME-induced preeclampsia-like model. A receiver operating characteristic analysis showed that flow-mediated dilatation at 120 seconds had the greatest area under the curve of 0.934, with an optimal cutoff point of 11.1%, yielding sensitivity of 100% and specificity of 84.6%.

CONCLUSIONS

The PI and RI of the fetomaternal vasculature can identify fetuses in "high-risk" pregnancies, and flow-mediated dilatation is a reliable indicator for predicting preeclampsia. Assessment of vascular function by high-resolution sonography provides a useful platform for preeclampsia-related basic research with high reproducibility.

Proposed clinical management of pregnancies after combined screening for pre-eclampsia at 35-37 weeks' gestation

OBJECTIVE

To estimate the patient-specific risk of pre-eclampsia (PE) at 35-37 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1), and stratify women into high-, intermediate- and low-risk management groups.

METHODS

This was a prospective observational study in women attending a third-trimester ultrasound scan at 35-37 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE at < 4 weeks from assessment and PE at < 42 weeks' gestation were calculated using the competing-risks model to combine the prior risk from maternal characteristics and medical history with MoM values of MAP, UtA-PI, PlGF and sFlt-1. On the basis of these risks, the population was stratified into high-, intermediate- and low-risk groups. Different risk cut-offs were used to vary the proportion of the population stratified into each risk category and the performance of screening for delivery with PE at < 40 and ≥ 40 weeks' gestation was estimated.

RESULTS

The study population of 3703 singleton pregnancies included 38 (1.0%) with PE < 40 weeks' gestation and 22 (0.6%) with PE ≥ 40 weeks. Using a risk cut-off of 1 in 50 for PE delivering at < 4 weeks after assessment to define the high-risk group and a risk cut-off of < 1 in 100 for PE delivering at < 42 weeks' gestation to define the low-risk group, the proportion of the population stratified into high, intermediate and low risk was 12.7%, 28.8% and 58.5%, respectively. The high-risk group contained 92% of pregnancies with PE at < 40 weeks' gestation and 73% of those with PE at ≥ 40 weeks. The intermediate-risk group contained a further 27% of women with PE at ≥ 40 weeks. In the low-risk group, none of the women developed PE at < 40 or ≥ 40 weeks' gestation.

CONCLUSION

The study presents risk stratification of PE by the combined test at 35-37 weeks, aiming to identify a high-risk group in need of intensive monitoring from the time of the initial assessment and up to 40 weeks' gestation, an intermediate-risk group in need of reassessment at 40 weeks' gestation and a low-risk group that can be reassured that they are unlikely to develop PE. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Proposed clinical management of pregnancies after combined screening for pre-eclampsia at 19-24 weeks' gestation

OBJECTIVE

To estimate the patient-specific risk of pre-eclampsia (PE) at 19-24 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1), and stratify women into high-, intermediate- and low-risk management groups.

METHODS

This was a prospective observational study in women attending a second-trimester ultrasound scan at 19-24 weeks as part of routine pregnancy care. Patient-specific risks of delivery with PE < 32 weeks and < 36 weeks' gestation were calculated using the competing-risks model to combine the prior risk from maternal characteristics and medical history with MoM values of MAP, UtA-PI, PlGF and sFlt-1. On the basis of these risks, the population was stratified into high-, intermediate- and low-risk groups. Different risk cut-offs were used to vary the proportion of the population stratified into each risk category and the performance of screening for delivery with PE at < 32 weeks' gestation, at 32-35 weeks and at ≥ 36 weeks was estimated. In addition to empirical performance, we also derived model-based performance because the number of cases of PE delivering < 32 weeks was low.

RESULTS

The study population of 7748 singleton pregnancies included 268 (3.5%) that subsequently developed PE. Using a risk cut-off of 1 in 100 for PE delivering < 32 weeks' gestation and a risk cut-off of 1 in 300 for PE delivering < 36 weeks, the proportion of the population stratified into high-, intermediate- and low-risk was 0.9%, 17.2% and 81.9%, respectively. The high-risk group contained 97% of pregnancies with PE < 32 weeks and 45% of those with PE at 32-35 weeks. The intermediate-risk group contained a further 46% of women with PE at 32-35 weeks. The low-risk group contained only 0.03% of pregnancies with PE < 32 weeks and 9% of those with PE at 32-35 weeks.

CONCLUSION

Risk stratification of PE by the combined test at 19-24 weeks' gestation can identify, first, a group which constitutes < 1% of the total population and contains > 95% of those that will develop PE < 32 weeks and are in need of intensive monitoring at 24-31 weeks and, second, a group which constitutes < 20% of the total and contains > 90% of those that will develop PE at 32-35 weeks and are in need of reassessment at 32 weeks. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

sFlt-1/PlGF for prediction of early-onset pre-eclampsia: STEPS (Study of Early Pre-eclampsia in Spain)

OBJECTIVE

A high ratio of soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) has been linked to pre-eclampsia (PE). We evaluated the sFlt-1/PlGF ratio as a predictive marker for early-onset PE in women at risk of PE.

METHODS

This prospective, Spanish, multicenter study included pregnant women with a risk factor for PE, including intrauterine growth restriction, PE, eclampsia or hemolysis, elevated liver enzymes and low platelet count syndrome in previous pregnancy, pregestational diabetes or abnormal uterine artery Doppler. The primary objective was to show that the sFlt-1/PlGF ratio at 20, 24 and 28 weeks' gestation was predictive of early-onset PE (< 34 + 0 weeks). Serum sFlt-1 and PlGF were measured at 20, 24 and 28 weeks. Multivariate logistic regression was used to develop a predictive model.

RESULTS

A total of 819 women were enrolled, of which 729 were suitable for analysis. Of these, 78 (10.7%) women developed PE (24 early onset and 54 late onset). Median sFlt-1/PlGF ratio at 20, 24 and 28 weeks was 6.3 (interquartile range (IQR), 4.1-9.3), 4.0 (IQR, 2.6-6.3) and 3.3 (IQR, 2.0-5.9), respectively, for women who did not develop PE (controls); 14.5 (IQR, 5.5-43.7), 18.4 (IQR, 8.2-57.9) and 51.9 (IQR, 11.5-145.6) for women with early-onset PE; and 6.7 (IQR, 4.6-9.9), 4.7 (IQR, 2.8-7.2) and 6.0 (IQR, 3.8-10.5) for women with late-onset PE. Compared with early-onset PE, the sFlt-1/PlGF ratio was significantly lower in controls (P < 0.001 at each timepoint) and in women with chronic hypertension (P < 0.001 at each timepoint), gestational hypertension (P < 0.001 at each timepoint) and late-onset PE (P < 0.001 at each timepoint). A prediction model for early-onset PE was developed, which included the sFlt-1/PlGF ratio plus mean arterial pressure, being parous and previous PE, with areas under the receiver-operating characteristics curves of 0.86 (95% CI, 0.77-0.95), 0.91 (95% CI, 0.85-0.97) and 0.93 (95% CI, 0.86-0.99) at 20, 24 and 28 weeks, respectively, and was superior to models using the sFlt-1/PlGF ratio alone or uterine artery mean pulsatility index.

CONCLUSIONS

The sFlt-1/PlGF ratio can improve prediction of early-onset PE for women at risk of this condition. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Cardiac diastolic function after recovery from pre-eclampsia

BACKGROUND

Pre-eclampsia is associated with significant changes to the cardiovascular system during pregnancy. Eccentric and concentric remodelling of the left ventricle occurs, resulting in impaired contractility and diastolic dysfunction. It is unclear whether these structural and functional changes resolve completely after delivery.

AIMS

The objective of the study was to determine cardiac diastolic function at delivery and one year post-partum in women with severe pre-eclampsia, and to determine possible future cardiovascular risk.

METHODS

This was a descriptive study performed at Steve Biko Academic Hospital, a tertiary referral hospital in Pretoria, South Africa. Ninety-six women with severe preeclampsia and 45 normotensive women with uncomplicated pregnancies were recruited during the delivery admission. Seventy-four (77.1%) women in the pre-eclamptic group were classified as a maternal near miss. Transthoracic Doppler echocardiography was performed at delivery and one year post-partum.

RESULTS

At one year post-partum, women with pre-eclampsia had a higher diastolic blood pressure (p = 0.001) and body mass index (p = 0.02) than women in the normotensive control group. Women with early onset pre-eclampsia requiring delivery prior to 34 weeks' gestation had an increased risk of diastolic dysfunction at one year post-partum (RR 3.41, 95% CI: 1.11-10.5, p = 0.04) and this was irrespective of whether the patient had chronic hypertension or not.

CONCLUSION

Women who develop early-onset pre-eclampsia requiring delivery before 34 weeks are at a significant risk of developing cardiac diastolic dysfunction one year after delivery compared to normotensive women with a history of a low-risk pregnancy.

Cerebral Magnesium Levels in Preeclampsia; A Phosphorus Magnetic Resonance Spectroscopy Study

BACKGROUND

Magnesium sulfate (MgSO4) is used as a prophylaxis for eclamptic seizures. The exact mechanism of action is not fully established. We used phosphorus magnetic resonance spectroscopy (31P-MRS) to investigate if cerebral magnesium (Mg2+) levels differ between women with preeclampsia, normal pregnant, and nonpregnant women.

METHODS

This cross-sectional study comprised 28 women with preeclampsia, 30 women with normal pregnancies in corresponding gestational week (range: 23-41 weeks) and 11 nonpregnant healthy controls. All women underwent 31P-MRS from the parieto-occipital region of the brain and were interviewed about cerebral symptoms. Differences between groups were assessed by analysis of variance and Tukey's post-hoc test. Correlations between Mg2+ levels and specific neurological symptoms were estimated with Spearman's rank test.

RESULTS

Mean maternal cerebral Mg2+ levels were lower in women with preeclampsia (0.12 mM ± 0.02) compared to normal pregnant controls (0.14 mM ± 0.03) (P = 0.04). Nonpregnant and normal pregnant women did not differ in Mg2+ levels. Among women with preeclampsia, lower Mg2+ levels correlated with presence of visual disturbances (P = 0.04). Plasma levels of Mg2+ did not differ between preeclampsia and normal pregnancy.

CONCLUSIONS

Women with preeclampsia have reduced cerebral Mg2+ levels, which could explain the potent antiseizure prophylactic properties of MgSO4. Within the preeclampsia group, women with visual disturbances have lower levels of Mg2+ than those without such symptoms.

Association between angiogenic factors and signs of arterial aging in women with pre-eclampsia

OBJECTIVE

Pre-eclampsia (PE) is associated with an increased risk of cardiovascular disease later in life. In cases with PE there is a substantial increase in levels of the antiangiogenic factor soluble fms-like tyrosine kinase-1 (sFlt-1) and decreased levels of the proangiogenic factor placental growth factor (PlGF). Elevated levels of sFlt-1 are also found in individuals with cardiovascular disease. The aims of this study were to assess levels of sFlt-1, PlGF and the sFlt-1/PlGF ratio and their correlation with signs of arterial aging by measuring the common carotid artery (CCA) intima and media thicknesses and their ratio (I/M ratio) in women with and without PE.

METHODS

Serum sFlt-1 and PlGF levels were measured using commercially available enzyme-linked immunosorbent assay kits, and CCA intima and media thicknesses were estimated using high-frequency (22-MHz) ultrasonography in 55 women at PE diagnosis and in 64 women with normal pregnancy at a similar gestational age, with reassessment at 1 year postpartum.

RESULTS

During pregnancy, higher levels of sFlt-1, lower levels of PlGF, a thicker intima, a thinner media and a higher I/M ratio of the CCA were found in women with PE vs controls (all P < 0.0001). Further, sFlt-1 and the sFlt-1/PlGF ratio were positively correlated with intima thickness and I/M ratio (all P < 0.0001). At 1 year postpartum, levels of sFlt-1 and the sFlt-1/PlGF ratio had decreased in both groups; however, their levels in the PE group were still higher than in the controls (P = 0.001 and < 0.0001, respectively). Levels of sFlt-1 and the sFlt-1/PlGF ratio remained positively correlated with intima thickness and I/M ratio at 1 year postpartum.

CONCLUSIONS

Higher sFlt-1 levels and sFlt-1/PlGF ratio in women with PE were positively associated with signs of arterial aging during pregnancy. At 1 year postpartum, sFlt-1 levels and the sFlt-1/PlGF ratio were still higher in the PE group and were associated with the degree of arterial aging. © 2016 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

Comparison of screening for pre-eclampsia at 31-34 weeks' gestation by sFlt-1/PlGF ratio and a method combining maternal factors with sFlt-1 and PlGF

OBJECTIVE

To estimate the patient-specific risk of pre-eclampsia (PE) at 31-34 weeks' gestation by a combination of maternal characteristics and medical history with multiples of the median (MoM) values of serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1) and to compare the performance of screening to that achieved by the sFlt-1/PlGF ratio.

METHODS

This was a prospective observational study in women attending a third-trimester ultrasound scan at 31-34 weeks as part of routine pregnancy care. We estimated the performance of screening for PE with delivery within 4 weeks of assessment and PE with delivery from 4 weeks after assessment up to 40 weeks' gestation by the sFlt-1/PlGF ratio and by a method utilizing Bayes' theorem that combines maternal factors and MoM values of sFlt-1 and PlGF. The significance of the difference in screening performance between the two methods was assessed by comparison of the areas under the receiver-operating characteristics curves (AUC).

RESULTS

The study population of 8063 singleton pregnancies included 231 (2.9%) that subsequently developed PE. In the prediction of delivery with PE at < 4 weeks from assessment, the performance of the method utilizing Bayes' theorem was similar to that using the sFlt-1/PlGF ratio (AUC, 0.987 (95% CI, 0.979-0.995) vs 0.988 (95% CI, 0.981-0.994); P = 0.961). In contrast, the performance of screening for delivery with PE at ≥ 4 weeks after assessment up to 40 weeks' gestation was better with the method utilizing Bayes' theorem than that with the sFlt-1/PlGF ratio (AUC, 0.884 (95% CI, 0.854-0.914) vs 0.818 (95% CI, 0.775-0.860); P < 0.0001).

CONCLUSION

At 31-34 weeks' gestation the performance of screening for PE delivering at < 4 weeks from assessment by the method utilizing Bayes' theorem is similar to that using the sFlt-1/PlGF ratio, but the former is superior to the latter in prediction of PE delivering ≥ 4 weeks from assessment. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Lung and cardiac ultrasound for hemodynamic monitoring of patients with severe pre-eclampsia

OBJECTIVE

To evaluate lung and cardiac ultrasound for the assessment of fluid tolerance and fluid responsiveness before and after delivery in pregnant women with severe pre-eclampsia (PE).

METHODS

This was a prospective observational study of singleton pregnant women with severe PE and healthy term controls. Lung ultrasound echo comet score (ECS), which denotes the amount of extravascular lung water, was obtained using the 28-rib interspaces technique. The echocardiographic E/e' ratio, measured by pulsed-wave and tissue Doppler, was used as a marker of diastolic left ventricular function. Fluid responsiveness was assessed by measuring changes in stroke volume (SV) with passive leg raising (PLR). SV was calculated from the left ventricular flow velocity-time integral measured by pulsed-wave Doppler at baseline and after PLR. Change in SV ≥ 12% was considered to indicate fluid responsiveness. Measurements obtained 1 day before delivery and 1 and 4 days after delivery were compared in the two groups (PE vs controls).

RESULTS

We included 21 women with severe PE and 12 healthy controls. ECS and E/e' ratio were higher in women with PE than in controls, both before delivery (P = 0.002 and P = 0.02) and 1 day postdelivery (P = 0.02 and P = 0.03); however there was no difference at 4 days postdelivery (P = 0.63 and P = 0.90). The change in SV with PLR before (P = 0.26) and after (P = 0.71) delivery did not differ between groups. An increase in SV ≥ 12% was observed in three (14%) women with PE and four (33%) controls before delivery and in four (19%) women with PE and two (17%) controls 1 day after delivery.

CONCLUSIONS

Severe PE is associated with an increase in extravascular lung water, which could in part be caused by disturbed diastolic left ventricular function. Excess lung water can be identified by lung ultrasound assessment in women with severe PE before the appearance of clinical signs. Only a small proportion of these women are fluid responsive. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Pre-eclampsia: an important risk factor for asymptomatic heart failure

OBJECTIVES

Pre-eclampsia (PE) is associated with both postpartum structural asymptomatic heart disease (i.e. heart failure Stage B (HF-B)) and conventional cardiovascular (CV) risk factors. We aimed to evaluate the extent to which PE, adjusted for conventional CV risk factors, is associated independently with asymptomatic cardiac abnormalities postpartum.

METHODS

In this cross-sectional cohort study, 107 formerly pre-eclamptic women and 41 women with uneventful previous pregnancy (controls) were invited for CV risk assessment 4-10 years postpartum. This included cardiac ultrasound, blood pressure (BP) measurement and evaluation of metabolic syndrome determinants. Asymptomatic structural and functional cardiac abnormalities were classified as HF-B, according to the American Heart Association guidelines. Prehypertension was defined as systolic BP of 120-139 mmHg and/or diastolic BP of 80-89 mmHg. Univariate and multivariate regression analyses were performed to calculate associations of PE and conventional risk factors with HF-B.

RESULTS

The prevalence of asymptomatic HF-B was approximately 3.5-fold higher in the PE group compared with controls (25% vs 7%, P < 0.01); 67% of this group had concentric remodeling and 22% had mildly impaired ejection fraction. After adjustment for postpartum interval, hypertension and high-density lipoprotein, PE was significantly associated with HF-B (adjusted odds ratio, 4.4 (95% CI, 1.0-19.1)). Moreover, in the formerly pre-eclamptic group, prehypertension was associated significantly with HF-B (odds ratio, 4.3 (95% CI, 1.4-12.7)), while metabolic syndrome determinants were not.

CONCLUSION

PE is associated with a four-fold increased female-specific risk of asymptomatic cardiac abnormalities. Prehypertension apparently increases this risk significantly, while metabolic syndrome determinants do not. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Maternal cardiac function at 35-37 weeks' gestation: prediction of pre-eclampsia and gestational hypertension

OBJECTIVE

To investigate the potential value of combining maternal factors with multiples of the normal median values of maternal cardiovascular parameters at 35-37 weeks' gestation in the prediction of pre-eclampsia (PE) and gestational hypertension (GH).

METHODS

In 2764 singleton pregnancies maternal characteristics and medical history were recorded; uterine artery pulsatility index (UtA-PI), mean arterial pressure (MAP) and maternal cardiovascular parameters were measured. Multivariable logistic regression analysis was then used to determine if the maternal factors and maternal cardiovascular parameters made a significant contribution to predicting PE and GH. The performance of screening was determined by the area under receiver-operating characteristics curves.

RESULTS

In pregnancies that subsequently delivered with PE or GH, total peripheral resistance and MAP were higher and maternal cardiac output was lower, mainly owing to a decrease in heart rate in PE and a decrease in stroke volume in GH. The increases in total peripheral resistance and MAP were inversely related to gestational age at delivery. The performance of screening for PE and GH achieved by maternal characteristics and medical history was improved by the inclusion of MAP, but not by UtA-PI or maternal cardiovascular parameters.

CONCLUSIONS

In women developing term PE total peripheral resistance and MAP are increased and maternal cardiac output is reduced. However, assessment of maternal cardiac function at 35-37 weeks' gestation is unlikely to improve the performance of screening for PE provided by maternal factors and MAP alone. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Are There Differences in Placental Volume and Uterine Artery Doppler in Pregnancies Resulting From the Transfer of Fresh Versus Frozen-Thawed Embryos Through In Vitro Fertilization

OBJECTIVE

To compare uterine artery pulsatility index (PI) and 3-dimensional (3D) placental volume values in first-trimester pregnancies conceived naturally or through in vitro fertilization (IVF) technique using either fresh or cryopreserved embryo and to relate these measurements with preeclampsia (PE) development.

METHODS

Uterine artery PI and placental volume were measured at 11 + 0 to 13 + 6 weeks of gestation in 266 IVF pregnancies (139 women with fresh embryo and 127 women with frozen-thawed embryo transfer) and in 266 spontaneously conceived pregnancies matched for maternal age. Nulliparous women with singleton pregnancies were recruited. The mean, highest, and lowest uterine artery PI and placental volume values measured were converted to multiples of the expected normal median (MoM) adjusted for gestational age. The MoM values of IVF pregnancies were compared with those of the naturally conceived group and related to PE development.

RESULTS

No differences were found in uterine artery PI MoM between the 3 groups. Placental volume was significantly lower than in both IVF groups when compared to the controls (fresh embryo IVF Z = 9.33; P ≤ .0001; frozen-thawed embryos IVF Z = 3.1; P = .04). The IVF pregnancies with fresh embryos showed placental volume MoM values significantly lower than in the frozen-thawed embryo IVF pregnancies (U = 5.4; P ≤ .0001). In fresh embryo IVF pregnancies developing PE placental volume values resulted lower than in the normotensive ones (U = 2.11; P = .03), while no differences were found for uterine artery PI values.

CONCLUSION

First-trimester placental volume, as assessed by 3D ultrasound, is reduced in IVF pregnancies, and these differences are more marked in those obtained with fresh embryos than those obtained with cryopreservation. This may explain the better obstetrical and perinatal outcomes occurring with the former technique.

Incidence of posterior reversible encephalopathy syndrome in eclamptic and patients with preeclampsia with neurologic symptoms

BACKGROUND

Posterior reversible encephalopathy syndrome is observed frequently in patients with eclampsia; however, it has also been reported in some patients with preeclampsia.

OBJECTIVES

The aim of this study was to determine the incidence of posterior reversible encephalopathy syndrome in patients with preeclampsia and eclampsia and to assess whether these 2 patient groups share similar pathophysiologic backgrounds by comparing clinical and radiologic characteristics.

STUDY DESIGN

This was a retrospective cohort study of 4849 pregnant patients. A total of 49 patients with eclampsia and preeclampsia and with neurologic symptoms underwent magnetic resonance imaging and magnetic resonance angiography; 10 patients were excluded from further analysis because of a history of epilepsy or dissociative disorder. The age, parity, blood pressure, and routine laboratory data at the onset of symptoms were also recorded.

RESULTS

Among 39 patients with neurologic symptoms, 12 of 13 patients with eclampsia (92.3%) and 5 of 26 patients with preeclampsia (19.2%) experienced the development of posterior reversible encephalopathy syndrome. Whereas age and blood pressure at onset were not significantly different between patients with and without encephalopathy, hematocrit, serum creatinine, aspartate transaminase, alanine transaminase, and lactate dehydrogenase values were significantly higher in patients with posterior reversible encephalopathy syndrome than in those without magnetic resonance imaging abnormalities. In contrast, patients with eclampsia with posterior reversible encephalopathy syndrome did not show any significant differences in clinical and laboratory data compared with patients with preeclampsia with posterior reversible encephalopathy syndrome. In addition to the parietooccipital regions, atypical regions (such as the frontal and temporal lobes), and basal ganglia were also involved in patients with eclampsia and patients with preeclampsia with posterior reversible encephalopathy syndrome. Finally, intraparenchymal hemorrhage was detected in 1 patient with eclampsia, and subarachnoid hemorrhage was observed in 1 patient with preeclampsia.

CONCLUSIONS

Although the incidence of posterior reversible encephalopathy syndrome was high in patients with eclampsia, nearly 20% of the patients with preeclampsia with neurologic symptoms also experienced posterior reversible encephalopathy syndrome. The similarities in clinical and radiologic findings of posterior reversible encephalopathy syndrome between the 2 groups support the hypothesis that these 2 patient groups have a shared pathophysiologic background. Thus, magnetic resonance imaging studies should be considered for patients with the recent onset of neurologic symptoms, regardless of the development of eclampsia.

Competing-risks model in screening for pre-eclampsia by maternal factors and biomarkers at 35-37 weeks' gestation

OBJECTIVE

To develop a model for prediction of term pre-eclampsia (PE) based on a combination of maternal factors and late third-trimester biomarkers.

METHODS

Data were derived from prospective screening for adverse obstetric outcomes in women attending their routine hospital visit at 35-37 weeks' gestation in two maternity hospitals in the UK. Uterine artery pulsatility index (UtA-PI) was measured in 5362 pregnancies, mean arterial pressure (MAP) in 5386 and serum placental growth factor (PlGF) and serum soluble fms-like tyrosine kinase-1 (sFlt-1) in 3920. Bayes' theorem was used to combine the a-priori risk of PE from maternal factors with various combinations of biomarkers, expressed as multiples of the median (MoM). Five-fold cross-validation was used to estimate the performance of screening for PE, requiring delivery at some stage after assessment. The empirical performance of screening was compared to model predictions.

RESULTS

In pregnancies that developed PE, the values of MAP, UtA-PI and sFlt-1 were increased and PlGF was decreased compared to unaffected pregnancies. For all biomarkers evaluated, the deviation from normal was inversely related to the gestational age at which delivery became necessary for maternal or fetal indications. Screening by maternal factors and by a combination of maternal factors with all biomarkers predicted 35% and 84% of PE, respectively, at a 10% false-positive rate.

CONCLUSION

A combination of maternal factors and biomarkers at 35-37 weeks' gestation can provide effective screening for term PE. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.