Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222

Preeclampsia pathogenesis and prediction - where are we now: the focus on the role of galectins and miRNAs

Preeclampsia is a complex, progressive multisystem hypertensive disorder during pregnancy that significantly contributes to increased maternal and perinatal morbidity and mortality. Two screening algorithms are in clinical use for detecting preeclampsia: first-trimester screening, which has been developed and validated for predicting early-onset preeclampsia but is less effective for late-onset disease; and the sFlt-1:PlGF biomarker ratio (soluble tyrosine kinase and placental growth factor) used in suspected cases of preeclampsia. This ratio has a high negative predictive value, allowing for the reliable exclusion of the disease. Both of these screening tests have not met expectations. This review attempts to summarize the current knowledge on the pathogenesis and prediction of preeclampsia and to draw attention to novel biomarkers with a focus on microRNAs and galectins. Although these molecules belong to two distinct biological classes, they functionally converge in regulating placental and immune pathways. Ample evidence supports their involvement in the molecular mechanisms underlying preeclampsia. Based on current knowledge, galectin-13, C19MC members, and miRNA-210 are associated with the trophoblast/placenta and conditions of placental ischemia or hypoxia. Their levels differ significantly in pregnant women at risk of preeclampsia as early as the late first and early second trimester, making them potential markers for predicting preeclampsia.

Excessive bile acids level predisposes to adverse perinatal outcomes in women with abnormal pre-pregnancy body mass index

BACKGROUND

Both low/high pre-pregnancy body mass index (BMI) and increased bile acid levels during pregnancy (known as gestational hypercholanemia) were risk factors for adverse pregnancy outcomes, with limited information on their joint effects.

METHODS

A total of 63,066 pregnant women were involved in a large retrospective cohort study from May 2014 to December 2018 in Shanghai, China. Data of pregnancy outcomes including hypercholanemia, hypertensive disorders in pregnancy (HDP), preterm delivery, and small for gestation age (SGA), were obtained for multivariable logistic analysis.

RESULTS

Pre-pregnancy BMI was negatively associated with serum total bile acid (TBA) concentrations during gestation and the risk of hypercholanemia (p < 0.001). Low pre-pregnancy BMI and hypercholanemia coexisting were related to a 2.71-fold risk (95% confidence intervals [CI], 2.10-3.50) of SGA. Whereas, overweight/obese (OWO) with hypercholanemia are associated with 5.34-fold risk (95% CI 3.93-7.25) of HDP when compared with normal weight women without hypercholanemia. Women with excessive gestational weight gain (GWG) and hypercholanemia had a higher risk of HDP (odds ratio [OR] 3.56, 95% CI 2.91-4.36), and macrosomia (OR 2.95, 95% CI 2.42-3.60), compared with non-hypercholanemia women with adequate GWG. Whereas, women with inadequate GWG and hypercholanemia had increased risks of preterm delivery (OR 1.87, 95% CI 1.44-2.43), and SGA (OR 2.32, 95% CI 1.82-2.96).

CONCLUSIONS

Low maternal BMI before pregnancy was an independent risk factor for hypercholanemia. Additionally, pre-pregnancy underweight or OWO may amplify the effect of hypercholanemia on adverse pregnancy outcomes. Thus, pre-pregnancy BMI should be considered in the management of adverse perinatal outcomes related to gestational hypercholanemia.

Pregnancy urine biomarkers for effectively preeclampsia prediction: a systematic review and meta-analysis

Preeclampsia (PE) is a common multi-organ disorder in pregnancy. Urine as a source for test samples is noninvasive and easy to obtain. This study followed the Priority Reporting Project for Systematic Evaluation and Meta-Analysis protocol. We searched PubMed and Web of Science databases for studies relating to urine biomarker analysis for PE from inception to the 28th of February 2023. The Chi-squared test was utilized to evaluate the statistical heterogeneity of the results. The combined sensitivity, combined specificity, combined positive likelihood ratio, combined negative likelihood ratio, combined diagnostic odds ratio for urine analysis in the context of PE were calculated. Sixty-five studies were eventually included in the final analysis. In only hypertensive disorders of pregnancy (HDP) pregnant women, the the area under the summary receiver operating characteristic curve (AUC) of urine analysis to predict PE was 0.93 (0.91-0.95). The results show that spot random urine analysis or shortened-hour urinary analysis for the diagnosis of PE is a credible alternative method when 24-h urine collection is difficult to complete. The protein/creatinine ratio from spot random urine analysis may be an effective biomarker of the further progression of HDP into PE.

Sociodemographic and Health-Related Risk Factors Associated With Planned and Emergency Cesarean Births in Mexico

BACKGROUND

Cesarean delivery is a contributing factor to many delivery care and postpartum maternal morbidities, especially when a cesarean delivery is unnecessary. Mexico has one of the highest cesarean birth rates in Latin America, and as such, our objective was to identify the sociodemographic, reproductive, maternal care, and health-related characteristics associated with the prevalence of planned and emergency cesarean births in Mexico.

METHODS

Using nationally representative data from a Mexican probabilistic survey (ENSANUT 2021), we examined and developed a cross-sectional analysis of women aged 12 to 19 with a live-birth and women 20 to 49 years who had their last live-birth within five years before the survey (n = 1330). We used multinomial logistic regression analysis to examine predictors associated with planned and emergency cesarean births.

RESULTS

The live-births within our sample included 50.7% vaginal, 27.5% emergency cesarean births, and 21.8% planned cesarean births. Younger age groups at delivery, speaking an indigenous language, and receiving delivery care at open public services are negatively associated with having any cesarean birth. Receiving delivery care at private institutions and having hypertension during pregnancy increases the odds of having both planned and emergency cesarean births. Emergency cesarean births are positively associated with tertiary education and negatively correlated with the parity of three or more children, while planned cesarean births are more likely for women with a parity of two.

DISCUSSION

Efforts to reduce unnecessary cesarean births should include evidence-based medicine recommendations, actions to avoid the first cesarean birth, and providing pregnant women with counseling to support informed decisions.

Postpartum remote blood pressure monitoring and risk of hypertensive-related readmission: systematic review and meta-analysis of randomized controlled trials

OBJECTIVES

To assess the efficacy of remote blood pressure monitoring to prevent readmission due to complications of hypertensive disorders of pregnancy.

METHODS

The search was conducted using MEDLINE, EMBASE, Web-of-Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane-Library as electronic databases from the inception of each database to November 2023. Selection criteria included randomized controlled trials of postpartum individuals randomized to remote blood pressure monitoring or telehealth strategies vs. routine-care. The primary outcome was postpartum readmission, defined as postpartum hospital admission after discharge. Secondary maternal outcomes included stroke, eclampsia, ICU-admission, maternal death, emergency department visit, ascertainment of a blood pressure measurement within 7-10 days after delivery, attendance of the 4-6-week postpartum visit. The summary measures were reported as relative risk (RR) or as mean difference (MD) with 95 % confidence intervals (CI).

RESULTS

Four RCTs including 714 individuals randomized to either telematic reporting of blood pressure measurements (n=356, 49.8 %) or standard postpartum care (n=358, 50.1 %). There were no significant differences in the rate of hospital readmission due to hypertensive related causes (5.3 % vs. 11.8 %). However, emergency department visit rate differed significantly among the two groups (9.0 % vs. 4.4 %). With regards to postpartum follow up, blood pressure assessment at 10 days postpartum and 4-6-week postpartum visit attendance rate were similar. No included RCT provided data on maternal secondary outcome like pulmonary edema, stroke, maternal death, and ICU admission.

CONCLUSIONS

Remote blood pressure monitoring is not superior to standard care to prevent hypertensive related readmission and increases emergency department visits.

Tailored Prenatal Care Delivery for Pregnant Individuals: ACOG Clinical Consensus No. 8

SUMMARY

Prenatal care is one of the most common preventive services in the United States; it is designed to improve the health and well-being of pregnant and birthing individuals and their children through evidence-based services. Despite the prevalence of prenatal care, formalized models of prenatal care delivery have changed little since they were first published in 1930. The purpose of this Clinical Consensus document is to offer guidance on a transformative approach to the provision of prenatal care in three key areas: 1) addressing unmet social needs, 2) frequency of prenatal visits and monitoring, and 3) incorporation of telemedicine and alternative care modalities. Implementing a sustainable paradigm shift in a century-old care-delivery approach will take time; however, this document will guide maternity care professionals and their teams in the use of new prenatal care delivery models.

Impact of PlGF immunoassay imprecision on preeclampsia risk assessment with the sFlt-1 to PlGF ratio

OBJECTIVE

The US Food and Drug Administration recently approved the ratio of soluble FMS-like tyrosine kinase 1 (sFlt-1) to placental growth factor (PlGF) using the Thermo Fisher Scientific B·R·A·H·M·S KRYPTOR autoanalyzer-the first preeclampsia marker used for clinical testing. We evaluated the analytical precision of the sFlt-1 and PlGF assays, focusing on the effects of PlGF imprecision on the sFlt-1 to PlGF ratio interpretation and clinical reliability for preeclampsia risk assessment.

METHODS

We measured sFlt-1 and PlGF on the KRYPTOR instrument using a homogeneous sandwich fluoroimmunoassay. Between-day precision was assessed using 3 levels of commercial quality control (QC) materials and analyzed over 3 months. In all, 180 samples obtained from 161 hospitalized pregnant women were analyzed to assess the relationship between PlGF levels and the sFlt-1 to PlGF ratio.

RESULTS

The sFlt-1 assay demonstrated good precision (coefficient of variation (s/x̄) × 100 [CV] = approximately 3.0%) across all QC levels, while the PlGF assay exhibited higher imprecision, particularly at low QC levels (CV = 7.7%-11.3%). Long-term QC monitoring revealed a downward drift in PlGF values, with improved stability after reagent lot changes. Despite higher imprecision at lower PlGF levels (23.1-34.7 ng/L), the clinical interpretation of the sFlt-1 to PlGF ratio remained robust because low PlGF consistently correlated with ratios well above the critical cutoff of 40.

CONCLUSIONS

Despite the suboptimal precision observed at low QC levels and potential drifts in PlGF results, the sFlt-1 to PlGF ratio remains a reliable tool for preeclampsia risk assessment. This study highlights the need for critical evaluation of analytical performance beyond FDA approval and the importance of assessing the potential impact of assay imprecision on patient care for individual biomarkers.

Prior preterm preeclampsia and hemostatic balance in the non-pregnant state

OBJECTIVE

To evaluate whether a history of preterm preeclampsia (PreP) is associated with abnormal hemostatic features during the non-pregnant state, relative to people without a history of preeclampsia.

STUDY DESIGN

We conducted a retrospective sub-analysis of three prospective IRB approved studies in which individuals were evaluated outside of pregnancy during the follicular phase of their menstrual cycles. We compared parameters between subjects with prior PreP (n = 21) with a combined cohort (NL, n = 74) of healthy nulliparous subjects (n = 57) and subjects with a prior normotensive pregnancy (n = 17). T-tests were employed with P < 0.05 accepted for significance.

MAIN OUTCOME MEASURES

Levels of eight coagulation factors, protein C (PC), and thrombin generation (TG) were assessed in the presence or absence of thrombomodulin (TM) to evaluate the activation of the anticoagulant PC pathway.

RESULTS

There were no differences in TG or factor composition between healthy nulliparous and healthy primiparous people. In contrast, the PreP cohort had increased levels of factors II, V, VII, IX, X, XI, and PC compared to the NL cohort without this history. In dynamic assays examining TG in the presence of TM, the PreP group had reduced rates (nM/min) of formation and diminished peak levels when compared to the NL group.

CONCLUSIONS

Increased procoagulant factor levels are typically associated with increased TG, suggesting here that individuals with prior PreP would have a procoagulant shift in the non-pregnant state. However, the observed concurrent increase in anticoagulant PC linked with a decrease in dynamic TG suggests a possible compensatory mechanism to maintain hemostatic balance.

Sedentary behavior during pregnancy and risk of pre-eclampsia and/or gestational hypertension: A systematic review

BACKGROUND

Despite improvements in perinatal care, pre-eclampsia remains a major cause of maternal and neonatal morbidity and mortality. Gestational hypertension and blood pressure are important intermediate endpoints for pre-eclampsia. Sedentary behavior has emerged as an independent risk factor for chronic disease, regardless of physical activity levels.

OBJECTIVES

To systematically review the evidence on sedentary behavior during pregnancy and in the year before conception and its effect on risk of pre-eclampsia, gestational hypertension, combined hypertensive disorders of pregnancy, and blood pressure.

SEARCH STRATEGY

A systematic search of Ovid MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Scopus, Web of Science, and EuropePMC preprints was performed up to May 25, 2023.

SELECTION CRITERIA

Observational and experimental studies investigating the association between sedentary behavior and pre-eclampsia, gestational hypertension, combined hypertensive disorders of pregnancy, and blood pressure in pregnant individuals.

DATA COLLECTION AND ANALYSIS

Effect estimates, a measure of uncertainty, and study and participant characteristics were extracted from study reports. A narrative synthesis is presented with forest plot visualizations. Quality assessment was conducted using the Newcastle-Ottawa Scale for cohort/case-control studies and the Appraisal Tool for Cross-Sectional Studies.

MAIN RESULTS

Of the 12 observational studies meeting eligibility criteria, two studies reported on the outcome of gestational hypertension; no significant association was found between amount of time spent sedentary and gestational hypertension risk. Four studies reported on pre-eclampsia risk and found no association between sedentary behavior and pre-eclampsia risk. Four studies assessed a combined outcome of total hypertensive disorders of pregnancy; of these, one study reported greater odds of hypertensive disorders among sedentary individuals compared with non-sedentary individuals, and one study found that cases spent more time on the computer relative to controls. Five studies investigated blood pressure in pregnancy; of these, one study reported a positive correlation between systolic blood pressure and sedentary behavior, and one study reported higher second-trimester diastolic blood pressure in groups with high versus low sedentary behavior.

CONCLUSIONS

We found little evidence of an association between sedentary behavior and pre-eclampsia, gestational hypertension, or blood pressure. This is in contrast to the large body of evidence supporting the protective effect of physical activity on hypertensive disorders of pregnancy. Heterogeneity in the methods used to estimate sedentary behavior limited the ability to quantify this association. Additional high-quality observational studies or randomized trials are warranted to reach more definitive conclusions.

Reference Range Determination for the sFlt-1/PlGF Ratio in a Diverse Cohort of Pregnant Women in the United States

BACKGROUND

The serum soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio is an established tool for predicting preeclampsia in many countries but is not widely adopted in the United States. This study aimed to determine reference ranges for the Elecsys® sFlt-1/PlGF ratio and the sFlt-1 and PlGF immunoassays (Roche Diagnostics International Ltd) in a diverse US population of healthy pregnant women.

METHODS

This was a prospective, noninterventional sample and data collection study performed between November 2022 and November 2023 at 9 collection sites and one measurement site in the United States. Evaluable women were ≥18 years old, apparently healthy, between 23 + 0 to 40 + 6 gestational weeks with a singleton pregnancy and had one serum sample collected. Reference ranges for 23 + 0 to 40 + 6 gestational weeks and 5 gestational windows within this range were determined using a nonparametric method.

RESULTS

Of 818 recruited women, 561 were evaluable for the analysis and were representative of the US population in terms of self-reported race, ethnicity, and maternal age. Reference ranges for the sFlt-1/PlGF ratio, as determined by the 2.5th and 97.5th percentiles (90% CIs), were 0.9 (0.7, 1.0) to 13.5 (11.6, 14.9) for a US intended use population at 23 + 0 to 34 + 6 gestational weeks (n = 380) and 0.9 (0.7, 1.1) to 40.8 (29.0, 47.2) for the entire evaluable population at 23 + 0 to 40 + 6 gestational weeks.

CONCLUSIONS

Reference ranges were determined for sFlt-1/PlGF and the sFlt-1 and PlGF immunoassays in a diverse, healthy US population of pregnant women at 23 + 0 to 40 + 6 gestational weeks.

Postpartum care after preeclampsia: Lack of knowledge and inadequate counseling on long-term consequences

BACKGROUND

Preeclampsia has long-term consequences, with an increased risk of cardiovascular disease. Objective To assess womeńs knowledge about preeclampsia (PE) and to what extent the postpartum healthcare provided was aligned with evidence-based guidelines. Methods A cross-sectional study conducted between 2021 and 2022, in two referral maternity hospitals in southeast Brazil. Women diagnosed with PE in the current pregnancy were contacted by weeks after childbirth and interviewed about the length of hospital stay, use of antihypertensive drugs, scheduled visits, place of care, professionals involved in postpartum care, blood pressure monitoring and knowledge about PE. A descriptive analysis was conducted. Results One hundred and twenty-four women with PE were invited to the study, and 100 answered the questionnaire six weeks postpartum, with a response rate of 80 %. Most women were young (aged 20-34 years), predominantly white, multiparous, and had underlying medical conditions. Route of delivery was predominantly cesarean section (75 %), with a high preterm birth rate (75 %). Half of hospital stays lasted 3-5 days. All women were referred to primary care and 49 % had a scheduled visit recommended during the first week postpartum. Around one-third of the women were not using antihypertensive medication 6 weeks postpartum. Main counselling received: maintenance of blood pressure measurements (65 %), management of medications (53 %), follow-up visits (41 %) and lifestyle changes were encouraged (35 %). However, 98 % of the women were unaware of the long-term repercussions of PE and only 35 % felt supported during postpartum medical care. Conclusion Early return to specialized care was lacking and guidance on the long-term risks after preeclampsia was inadequate.

Placental Biomarker Testing for Evaluation of Suspected Preeclampsia

BACKGROUND

Worldwide, hypertensive disorders of pregnancy (HDP) are a leading cause of maternal and neonatal morbidity and mortality (Semin Perinatol 2009;33:130-7). This is especially true in the United States where preeclampsia is a leading cause of premature births (Hypertens Pregnancy 2016;35:510-9 and Lancet 2008;371:164-75). Moreover, this disorder is costly due to the financial burden of the health services needed to care for mothers with preeclampsia and their very often preterm infants (Am J Obstet Gynecol 2017;217:235-6). Recently, placental biomarkers have been shown to aid in assessment of the risk of severe preeclampsia. In 2023, the FDA approved the use of soluble feline McDonough sarcoma (fms)-like tyrosine kinase-1 to placental growth factor ratio (sFlt-1/PlGF) as an additional tool for preeclampsia risk assessment between 23 and 35 weeks' gestation in high-risk patients in the United States. Use of these biomarkers will improve maternal and fetal/neonatal outcomes and may assist in decreasing the healthcare burden of these patients by adding to risk assessment and the current diagnosis and management of pregnancies with HDP.

CONTENT

The pathophysiology of preeclampsia stems from abnormal placentation that results in an imbalance of pro- and antiangiogenic factors leading to endothelial and vascular dysfunction and the clinical syndrome of preeclampsia (J Clin Invest 2003;111:649-58). The role of the sFlt-1/PlGF in the prediction of progression to preeclampsia has been demonstrated in multiple studies.

SUMMARY

The goal of this review is to demonstrate the role of placental biomarkers (sFlt-1 and PlGF) in the pathophysiology of preeclampsia, with an emphasis on clinical applications and cost-effectiveness in the United States, using real-world applications as examples.

Maternal Immune Activation During Pregnancy and Obstetric Outcomes: A Population-Based Cohort Study

OBJECTIVE

Maternal immune activation has been proposed as a mechanism for adverse pregnancy outcomes, yet the mechanisms and effects of timing remain unclear. Immune disruption in early gestation may be particularly detrimental as this is an important period for placental development, which has been associated with the pathology of adverse obstetric outcomes. To increase our understanding of risk factors for adverse obstetric outcomes, we aim to investigate the association between multiple inflammatory and angiogenic markers during early pregnancy and adverse pregnancy outcomes in a large population-based cohort.

DESIGN

Prospective population-based pregnancy cohort study (n = 7513).

SETTING

Rotterdam, the Netherlands.

POPULATION

Pregnant women in Rotterdam between April 2002 and January 2006.

METHODS

Serum inflammatory markers (high-sensitivity (HS)-C-reactive protein (CRP), interleukin (IL)-1β, IL-6, IL-17a, IL-23, interferon (IFN)-γ) and angiogenic factors (sFlt-1 and PlGF) were analysed in repeated measures around 13-20 weeks gestation. A cytokine index was created using principal component analysis.

MAIN OUTCOME MEASURES

Hypertensive disorders of pregnancy, spontaneous preterm birth and small for gestational age at birth.

RESULTS

HS-CRP, but not the cytokine index, was associated with increased risk of spontaneous preterm birth after multiple testing correction. We found no association of HS-CRP or the cytokine index with hypertensive disorders of pregnancy and small for gestational age at birth after multiple testing correction. Inflammatory and angiogenic factors were associated with each other, yet effect sizes were small.

CONCLUSIONS

We found no strong evidence of a link between early gestation typical inflammatory marker levels and the risk of adverse pregnancy outcomes.

Even low levels of anticardiolipin antibodies are associated with pregnancy-related complications: A monocentric cohort study

INTRODUCTION

Moderate and high levels of anticardiolipin antibodies (aCL), especially in the setting of the antiphospholipid syndrome, are associated with adverse obstetric outcomes. However, the clinical relevance of low aCL levels (<40 MPL/GPL units) is still a matter of debate. The aim of the study was to evaluate obstetric outcomes in pregnancies with low immunoglobulin M (IgM) and/or immunoglobulin G (IgG) aCL positivity. The association between low aCL positivity and maternal baseline characteristics was also studied.

MATERIAL AND METHODS

The retrospective monocentric cohort study of prospectively collected data involved a total 3047 singleton pregnancies that underwent the first-trimester screening involving an aCL test and delivered on site. Obstetric outcomes were compared between the low-titer aCL group (IgM ≥7 MPL units and <40 MPL units and/or IgG ≥10 GPL units and <40 GPL units) and the aCL negative group (IgM <7 MPL units and IgG <10 GPL units, reference group). In addition, obstetric outcomes were evaluated with regard to the antibody isotype: IgM-positive group (IgM <40 MPL units, IgG negative) and IgG-positive group (IgG <40 GPL units, IgM negative or <40 MPL units).

RESULTS

Overall, the occurrence of pregnancy-related complications was significantly higher (27.91% vs. 19.32%, p = 0.034) in the low-titer aCL group. Concerning the antibody isotype, a higher rate of pregnancy-related complications was observed in the IgG-positive group (54.55% vs. 19.32%, p = 0.001), but not in the IgM-positive group (22.43% vs. 19.32%, p = 0.454). The stillbirth rate did not reach statistical significance. Low-titer aCL pregnancies were more frequently of advanced maternal age (p < 0.001), suffered from autoimmune diseases (p < 0.001), chronic hypertension (p = 0.040), and hereditary thrombophilia (p = 0.040). In addition, they had more often a positive history of stillbirth (p < 0.001), underwent conception via assisted reproductive technologies (p < 0.001), were administered low-dose aspirin (p < 0.001), low-molecular-weight heparin (p = 0.018) and immunomodulatory drugs (p < 0.001), and delivered earlier (p = 0.018).

CONCLUSIONS

Even low aCL levels are associated with a higher incidence of pregnancy-related complications, but only in the case of IgG antibody isotype presence. Screening for aCL in the first trimester has some prognostic value, but further studies are needed to determine whether its potential implementation into routine clinical practice would improve antenatal care.

Neonatal outcomes between trial of labor and cesarean delivery for extreme preterm infants

OBJECTIVE

To compare adverse neonatal outcomes between trial of vaginal delivery and upfront cesarean delivery for singleton infants born at 24 to 28 weeks of gestation.

METHODS

This is a retrospective cohort study that was conducted at a university-affiliated tertiary medical center between 2011 and 2022, involving singleton pregnancies delivered between 240/7 and 276/7 weeks of gestation. Participants were divided into two groups based on their intended mode of delivery: a trial of labor (TOL) group and an upfront cesarean delivery (CD) group. The primary outcome was defined as neonatal death. The secondary outcome was defined as any of the following: intraventricular hemorrhage, necrotizing enterocolitis, bronchopulmonary dysplasia, neonatal sepsis, periventricular leukomalacia, disseminated intravascular coagulation, umbilical cord arterial PH <7.1, or use of postpartum mechanical ventilation. Analyses were performed using an intention-to-treat approach.

RESULTS

Overall, 199 patients were enrolled, with 64 in the TOL group and 135 in the upfront CD group. Neonatal deaths occurred in 48 cases (24.2%) across the entire cohort, with no significant difference between the TOL (18.8%) and upfront CD (26.7%) groups (P = 0.223). Rates of other composite adverse outcome were comparable between the groups (26.6% vs. 31.9%, P = 0.448), respectively. A sub-analysis comparing patients with pre-existing contraindications for vaginal delivery, without maternal or fetal indications for delivery, to those in the TOL group who experienced spontaneous onset of labor showed no differences in primary or secondary outcomes between the groups.

CONCLUSION

We found no difference in adverse neonatal outcomes between TOL and upfront CD for singletons born at 24-28 weeks gestation.

Outcomes of Postpartum Preeclampsia: A Retrospective Cohort Study of 1.3 Million Pregnancies

OBJECTIVE

We assessed the association between postpartum preeclampsia and the risk of adverse maternal and neonatal outcomes. Evidence suggests that postpartum preeclampsia is initiated antenatally, but the impact on birth outcomes is unclear.

DESIGN

Retrospective cohort study.

SETTING

All deliveries in hospitals of Quebec, Canada.

POPULATION

1 317 181 pregnancies between 2006 and 2022.

METHODS

We identified patients who developed preeclampsia in the postpartum period. Using log-binomial regression models, we estimated adjusted risk ratios (RR) and 95% confidence intervals (CI) for the association of postpartum or antepartum preeclampsia with adverse pregnancy outcomes relative to no preeclampsia.

MAIN OUTCOME MEASURES

Preterm birth, placental abruption, severe maternal morbidity and recurrent preeclampsia.

RESULTS

Postpartum preeclampsia was less frequent than antepartum preeclampsia (n = 4123 [0.3%] vs. 51 269 [3.9%]). Postpartum preeclampsia was associated with preterm birth (RR 1.45, 95% CI 1.34-1.57), placental abruption (RR 1.36, 95% CI 1.16-1.59) and severe maternal morbidity (RR 6.48, 95% CI 5.87-7.16) compared with no preeclampsia. Antepartum preeclampsia was also associated with these outcomes. Moreover, patients with postpartum preeclampsia in a first pregnancy were at risk of adverse outcomes in a subsequent pregnancy, particularly recurrent preeclampsia (RR 7.77, 95% CI 6.54-9.23).

CONCLUSIONS

Postpartum preeclampsia is associated with adverse outcomes at delivery, despite being detected only postnatally. Our findings suggest that patients with adverse birth outcomes may benefit from blood pressure measurements up to 6 weeks following delivery.

Exercise during pregnancy (frequency, intensity, type, time, volume): birth outcomes in women at risk of hypertensive disorders of pregnancy

Background

Hypertensive disorders of pregnancy (HDP) hold negative health implications for mothers and offspring. While the beneficial influence of prenatal exercise on reducing HDP risk has been previously shown, there is a lack of specific information on the effect on birth outcomes in at-risk women, and in-depth analysis of appropriate exercise dose is lacking.

Objective

We aimed to elucidate the effects of exercise training FITT-V (frequency, intensity, type, time, volume) on hypertension and birth outcomes in pregnant women.

Study Design

This study is a retrospective, secondary analysis of pooled data from three blinded, prospective, randomized controlled trials. Women at risk of HDP (11 control, 27 exercise) were identified from the population and monitored in supervised exercise sessions throughout pregnancy. Upon delivery, birth measures were obtained. Pearson correlations and stepwise regressions determined associations. Tests for outcomes between exercise types were completed using one-way ANOVA.

Results

Women at risk of HDP with higher total exercise volume trended lower systolic blood pressure during pregnancy (P=.07). In at-risk women, total and weekly exercise volume were then associated with gestational age at birth (R=0.42, P=.03; R=0.46, P=.02) and increased birthweight (R=0.43, P=.03). Weekly exercise duration predicted birthweight (P=.02) independent of gestational age at birth.

Conclusion

The current findings add to a body of literature showing the beneficial influence of exercise during pregnancy on HDP risk, and importantly the effect on exposed offspring. Prenatal exercise improved birth outcomes in women with higher HDP risk in a dose-dependent manner, whereby higher exercise volume and duration are associated with improvements in birth outcomes.

Placental Endocannabinoid System: Focus on Preeclampsia and Cannabis Use

BACKGROUND

The endocannabinoid system (ECS) plays an important role in the early stages of pregnancy, while cannabis use during pregnancy associates with a greater risk of preeclampsia. This study quantified the placental ECS component mRNA levels in gestational age-matched healthy pregnant women, women with preeclampsia, and women who used cannabis throughout their pregnancy. Next, it compared the effects of the endogenous ECS agonists anandamide and 2-arachidonoylglycerol with those of the cannabinoid receptor type 1 and 2 agonists HU-210 and HU-308 in chorionic plate arteries.

METHODS

Placental mRNA levels were quantified by quantitative polymerase chain reaction. Vascular reactivity was studied with and without selective cannabinoid receptor type 1 and 2 antagonists.

RESULTS

mRNA levels of 1,2-diacylglycerol lipase α, responsible for 2-arachidonoylglycerol generation, were lowered in preeclampsia, while mRNA levels of the anandamide-synthesizing enzyme N-acyl phosphatidylethanolamine-specific phospholipase D were upregulated in cannabis users. Anandamide-induced relaxation in healthy pregnancy was mediated via cannabinoid receptors type 1 and 2, while 2-arachidonoylglycerol induced relaxation via cannabinoid receptor type 1. In preeclampsia, the effects of anandamide and 2-arachidonoylglycerol were unaltered but no longer involved cannabinoid receptors, while in cannabis users their effects were absent. HU-210 and HU-308 relaxed healthy, but not preeclamptic vessels. The NO donor sodium nitroprusside similarly relaxed healthy and preeclamptic vessels, while its effects in cannabis users were greatly reduced.

CONCLUSIONS

The ECS is disturbed in preeclampsia, and endogenous ECS agonists lose their capacity to dilate in cannabis users, while such use also diminishes NO signaling. These data provide mechanistic evidence against cannabis use during pregnancy.

First-trimester uterine artery pulsatility index and preeclampsia risk in pregnancies after artificial frozen embryo transfer: analysis of over 27,000 pregnancies

BACKGROUND

Accumulating evidence indicates that pregnancies after artificial cycle frozen embryo transfer are associated with an increased risk of preeclampsia. Uterine artery Doppler, along with maternal factors and serum biomarkers, is a crucial biomarker for first-trimester preeclampsia screening, aiding in identifying "high-risk" patients. Guidelines strongly recommend administering aspirin (150 mg/d) in these women, owing to robust evidence demonstrating a 62% reduction in the incidence of preeclampsia. Although previous studies suggested lower uterine artery pulsatility index after frozen embryo transfer, no previous studies explored the impact of the type of endometrial preparation in Uterine Artery Doppler or its influence on estimating first-trimester preeclampsia risk.

OBJECTIVE

The study aims to evaluate the possible impact of endometrial preparation for frozen embryo transfer on the uterine artery pulsatility index during the first-trimester preeclampsia screening.

STUDY DESIGN

This is a retrospective single-center study including 27,289 singleton pregnancies (naturally conceived or after assisted reproductive treatment) who underwent the first-trimester ultrasound screening at our University Hospital between January 2010 and May 2023. Overall, 27,289 pregnancies were included: 23,410 naturally conceived and 3879 following assisted reproductive technologies including 391 after ovulation induction and intrauterine insemination, 888 in vitro fertilization and fresh embryo transfer, and 2600 natural or artificial frozen embryo transfer cycles. An analysis of covariance was conducted to assess if there is an association between the uterine artery pulsatility index value and the mode of conception, adjusting for confounding factors (age, weight, smoking, and oocyte donation).

RESULTS

Overall, pregnancies after artificial frozen embryo transfer demonstrated significantly lower first-trimester uterine artery pulsatility index as compared with all other modes of conception in a multivariable regression analysis adjusted for age, weight, smoking, and oocyte donation. The percent difference was 22.6 [confidence interval, CI 95%: 20.6; 24.5] compared to naturally conceived pregnancy, 24.5 [CI 95%: 20.7; 28.1] to ovulation induction or intrauterine insemination, 24.8 [CI 95%: 22.9; 27.6] to fresh embryo transfer and 21.7 [CI 95%: 17.6; 25.5] compared to natural cycle frozen embryo transfer. When calculating the risk for initiating preventive aspirin administration, the number of patients with increased risk (>1/100) who initiated prophylactic aspirin was significantly lower in the artificial cycle frozen embryo transfer group (7.8% vs 16.0% in natural cycle P<.001 vs 11.0% in Fresh embryo transfer P=.01 vs 10.5% in ovulation induction or intrauterine insemination P=.14 vs 9.3% in naturally conceived pregnancy P=.03). Surprisingly although significantly fewer patients were considered at high risk for preeclampsia in the artificial cycle frozen embryo transfer group, analysis of the actual incidence of preeclampsia demonstrated 3 times higher preeclampsia incidence in artificial cycle group 5.3% (122/2284) as compared with naturally conceived 1.4% (321/23,410), ovulation induction and intrauterine insemination 1.3% (5/391) or natural cycle pregnancies 1.6% (5/316) and more than 2 times higher when compared to fresh embryo transfer pregnancies 2.3% (20/888), P<.001.

CONCLUSION

Pregnancies following frozen embryo transfer in artificial cycle are associated with significantly lower uterine artery pulsatility index during first-trimester preeclampsia screening. This results in a significantly lower number of patients being classified as high-risk for developing preeclampsia, despite accumulating evidence that artificial cycles are linked to an increased risk of preeclampsia. Therefore, the first-trimester preeclampsia risk algorithm should be adjusted to accurately assess risk for those patients undergoing artificial cycle frozen embryo transfer, to prevent the undertreatment of patients who are at very high risk of developing preeclampsia and may benefit from prophylactic aspirin.

Reduced AT2R Signaling Contributes to Endothelial Dysfunction After Preeclampsia

BACKGROUND

Women who had preeclampsia (a history of preeclampsia) have a >4-fold risk of developing cardiovascular disease compared with women who had an uncomplicated pregnancy (history of healthy pregnancy). Despite the remission of clinical symptoms after pregnancy, vascular endothelial dysfunction persists postpartum, mediated in part by exaggerated Ang II (angiotensin II)-mediated constriction. However, the role of vasodilatory AT2Rs (Ang II type 2 receptors) in this dysfunction is unknown. We examined the functional role of AT2R in the microvasculature postpartum and whether acute activation of AT2R improves microvascular endothelial function after preeclampsia.

METHODS

Overall, 24 women (n=12/group) participated. We measured cutaneous vascular conductance responses to (1) graded infusion of compound 21 (AT2R agonist; 10-14-10-8M) alone or with NG-nitro-l-arginine methyl ester (NO synthase inhibitor; 15 mM) and (2) a standardized local heating protocol in control and 10-11M compound 21-treated sites. Expression of Ang II receptor subtypes I and II in biopsied venous endothelial cells was quantified using immunofluorescence.

RESULTS

AT2R-mediated dilation (P<0.01) and the NO-dependent contribution (P=0.003) of this response were reduced in women with a history of preeclampsia. Endothelial AT2R expression was lower in women with a history of preeclampsia (P<0.01), but there were no differences in endothelial AT1R (Ang II type 1 receptor) expression (P>0.05). Acute activation of AT2R during local heating improved endothelium (P<0.01) and NO-dependent (P<0.01) dilation in women with a history of preeclampsia but had no effect in women with a history of healthy pregnancy (both P>0.05).

CONCLUSIONS

Reductions in AT2R-mediated dilation contribute to attenuated or impaired endothelial function in women who had a pregnancy complicated by preeclampsia. Furthermore, AT2R activation may improve endothelial function through NO-dependent mechanisms in otherwise healthy women who had preeclampsia before the onset of cardiovascular disease.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT05937841.

Prediction of hypertension and diabetes in twin pregnancy using machine learning model based on characteristics at first prenatal visit: national registry study

OBJECTIVE

To develop a prediction model for hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) in twin pregnancy using characteristics obtained at the first prenatal visit.

METHODS

This was a cross-sectional study using national live-birth data in the USA between 2016 and 2021. The association of all prenatal candidate variables with HDP and GDM was tested on univariable and multivariable logistic regression analyses. Prediction models were built with generalized linear models using the logit link function and classification and regression tree (XGboost) machine learning algorithm. Performance was assessed with repeated 2-fold cross-validation and the area under the receiver-operating-characteristics curve (AUC) was calculated. A P value < 0.001 was considered statistically significant.

RESULTS

A total of 707 198 twin pregnancies were included in the HDP analysis and 723 882 twin pregnancies were included in the GDM analysis. The incidence of HDP and GDM increased significantly from 12.6% and 8.1%, respectively, in 2016 to 16.0% and 10.7%, respectively, in 2021. Factors associated with increased odds of HDP in twin pregnancy were maternal age < 20 years or ≥ 35 years, infertility treatment, prepregnancy diabetes mellitus, non-Hispanic Black race, overweight prepregnancy BMI, prepregnancy obesity and Medicaid as the payment source for delivery (P < 0.001 for all). Obesity Class II and III more than doubled the odds of HDP. Factors associated with increased odds of GDM in twin pregnancy were maternal age ≤ 24 years or ≥ 30 years, infertility treatment, prepregnancy hypertension, non-Hispanic Asian race, maternal birthplace outside the USA and prepregnancy obesity (P < 0.001 for all). Maternal age ≥ 30 years, non-Hispanic Asian race and obesity Class I, II and III more than doubled the odds of GDM. For both HDP and GDM, the performances of the machine learning model and logistic regression model were mostly similar, with negligible differences in the performance domains tested. The mean ± SD AUCs of the final machine learning models for HDP and GDM were 0.620 ± 0.001 and 0.671 ± 0.001, respectively.

CONCLUSIONS

The incidence of HDP and GDM in twin pregnancies in the USA is increasing. The predictive accuracy of the machine learning models for HDP and GDM in twin pregnancies was similar to that of the logistic regression models. The models for HDP and GDM had modest predictive performance, were well calibrated and did not have poor fit. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Endothelial damage and complement dysregulation in fetuses from pregnancies complicated by preeclampsia

INTRODUCTION

Our objective was to evaluate the endothelial function profile and complement system in fetuses from preeclamptic pregnancies using ex vivo and in vitro approaches.

MATERIAL AND METHODS

A total of 66 singleton pregnancies were prospectively recruited comprising 34 cases of preeclampsia and 32 normotensive pregnancies matched for baseline characteristics. In the ex vivo approach, soluble tumor necrosis factor-a receptor 1 (sTNFR1), vascular cell adhesion molecule-1 (sVCAM-1), intercellular adhesion molecule-1 (sICAM-1), Von Willebrand factor (sVWF), terminal complement complex (sC5b-9), Factor H, complement component C3a and Factor Bb were analyzed in fetal cord blood samples. In the in vitro model, vascular cell adhesion molecule-1 (VCAM-1), intercellular adhesion molecule-1 (ICAM-1), Von Willebrand factor (VWF), vascular endothelial cadherin (VE-Cadherin), endothelial nitric oxide synthase (eNOS), reactive oxygen species (ROS) and C5b-9 deposits were evaluated on endothelial cells in culture exposed to fetal sera or plasma.

RESULTS

Increased sVCAM-1, sICAM- l and decreased Factor H and Factor Bb concentrations were detected in preeclampsia fetuses as compared to fetuses from normotensive mothers (509.4 ± 28 vs. 378.4 ± 34.3 ng/mL, 161.1 ± 11.9 vs. 114.8 ± 6.8, 199.6 ± 18.3 vs. 267.1 ± 15.4 ng/mL and 6.6 ± 0.7 vs. 10.3 ± 1.4 μg/mL respectively, p < 0.05) with similar results in sTNFR1, sVWF, sC5b-9 and C3a. Endothelial cells exposed to fetal sera from preeclampsia showed incremented expression of VCAM-1(38.1 ± 1.4% vs. 28.3 ± 1.6%, p < 0.01), ICAM-1 (12 ± 0.9% vs. 8.6 ± 0.6%, p < 0.05), VWF (43.5 ± 2.9% vs. 3.7 ± 0.3%, p < 0.05), and ROS (5 × 1013 ± 1 × 1012 vs. 3.5 × 1013 ± 1.4 × 1012, p < 0.01) with similar expression of VE-Cadherin and eNOS as compared to those exposed to control fetuses. While soluble C5b-9 was similar between the study groups (851.4 ± 177.5 vs. 751.4 ± 132.81 ng/mL, p > 0.05), significantly less C5b-9 deposits on endothelial cells were induced by fetal plasma from preeclamptic compared to normotensive mothers (fold change 0.08 ± 0.02 vs. 0.48 ± 0.13, p < 0.01).

CONCLUSIONS

High levels of endothelial adhesion molecules and oxidative stress products suggest endothelial damage and reduced in vitro deposition of C5b-9 indicates complement dysregulation in preeclampsia fetuses. More research is necessary to study the impact of preeclampsia on fetal vascular health and innate immunity.

The impact of maternal age and body mass index on hypertensive disorders of pregnancy: Moving beyond the cut-off effect

OBJECTIVES

Maternal age (MA) and body mass index (BMI) are known risk factors for hypertensive disorders of pregnancy (HDP). Different threshold values are used to calculate preeclampsia risk scores, but the appropriateness of a cut point model has not been extensively evaluated. This is because the effects of both MA and BMI occur continuously. We aimed to investigate the relationship between MA, BMI, and HDP, respecting the continuous nature of the two independent variables.

STUDY DESIGN

We retrospectively selected all nulliparous women with singleton pregnancies who delivered after 22 gestational weeks from January 2005 to December 2019 (25,165 women). We used univariate and multivariable logistic regression analyses implementing linear, quadratic, cubic, and penalized splines functions to test, investigate, and describe the relationship between continuous BMI, continuous MA, and risk of HDP.

MAIN OUTCOME MEASURES

MA, BMI, and infertility treatments are independently associated with the risk of developing all HDP in nulliparous women. The impacts of MA and BMI on the risk of developing HDP occur gradually, and penalized splines functions resulted in the best model to describe these associations with a different model for each HDP. No interaction factors were retained between MA, BMI, and infertility treatments.

CONCLUSIONS

Given the relevance of HDP on maternal mortality, an accurate identification of women at increased risk of developing the disease is crucial. In an era where technology is rapidly advancing, new models for customized risk assessment of HDP, considering the continuous nature of MA and pregestational BMI, must be implemented.

The Association of Adverse Perinatal Outcomes in Pregnancies with Gestational Diabetes and Excessive Gestational Weight Gain According to Obesity Status

Obesity, gestational diabetes mellitus (GDM), and excessive gestational weight gain (EGWG) are associated with adverse outcomes. It is unclear which carries the greatest risk. In this study, the relationship of obesity, GDM, and EGWG independently and concomitantly was analyzed to determine if one is a greater risk factor than the other.A retrospective cohort study of singleton gestations at Geisinger from October 2007 to March 2023 was performed. Exclusion criteria were pregravid body mass index (BMI) <18 kg/m2, gestational age (GA) <34 weeks, pregestational diabetes or chronic hypertension, prior cesarean delivery (CD) or contraindication to vaginal delivery. Patients were grouped by BMI class, and the order of groups within each BMI for the test for trend were no GDM/no EGWG, GDM/no EGWG, no GDM/EGWG, and GDM/EGWG. The rates of hypertensive disorders of pregnancy (HDP), severe HDP, CD, large for gestational age (LGA), shoulder dystocia, and neonatal intensive care unit (NICU) admission at ≥35 weeks were evaluated. A test for trend and odds ratios with 95% CIs were reported. p-values were reported across the GDM/EGWG groups per BMI category.A total of 42,627 pregnancies were included. At each BMI category, HDP, severe HDP, CD, LGA, and shoulder dystocia generally increased from patients with no GDM/no EGWG to those with GDM/no EGWG to those with no GDM/EGWG to those with GDM/EGWG. NICU admission at ≥35 weeks did not follow this progression.EGWG poses a greater risk than GDM regardless of pregravid BMI for HDP, severe HDP, CD, LGA, and shoulder dystocia. Attention should be given to determine the optimal strategy to manage pregnancies experiencing EGWG. · Isolated EGWG in pregnancy is associated with a greater risk of targeted maternal adverse outcomes.. · The combination of EGWG, GDM, and obesity poses the greatest risk during pregnancy.. · Attention should be given to determining the optimal role for antenatal surveillance for patients with EGWG..

Exposure to phthalates and replacements during pregnancy in association with gestational blood pressure and hypertensive disorders of pregnancy

Exposure to endocrine-disrupting chemicals such as phthalates may increase risk of hypertensive disorders of pregnancy (HDP). Prior studies lack investigation of chemical mixtures, phthalate replacements, or key periods of susceptibility including early pregnancy. In the present study, we used a longitudinal approach to evaluate gestational exposure to phthalates and replacements, as both single-pollutants and mixtures, in association with blood pressure and diagnosis of preeclampsia or any HDP. The Human Placenta and Phthalates prospective pregnancy cohort includes 291 participants recruited from two U.S. clinics. Urinary metabolites of ten phthalates and replacements were quantified at up to 8 time points per individual and averaged to create early (12-15 weeks) and overall (12-38 weeks) pregnancy exposure biomarkers. We collected data on gestational blood pressure (mean = 6.2 measures per participant) and diagnosis of preeclampsia (n = 26 cases) or any HDP (n = 44 cases). Linear mixed effects models estimated associations between exposure biomarkers and repeated blood pressure measures. We estimated exposure biomarker associations with preeclampsia and HDP using Cox proportional hazards or logistic regression models, respectively. Quantile g-computation was used to estimate joint effects of a phthalate or replacement mixture with each outcome. Early pregnancy exposure biomarkers demonstrated greater associations with adverse outcomes compared to overall pregnancy. A one-interquartile range increase in early pregnancy di-isononyl phthalate metabolites (ƩDiNP) was associated with a 1.13 mmHg (95 % confidence interval [CI]: 0.25, 2.37) and 0.90 mmHg (CI: 0.16, 1.65) increase in systolic and diastolic blood pressure, respectively. We also found positive but nonsignificant associations of early pregnancy mono-3-carboxypropyl phthalate, di-2-ethylhexyl terephthalate metabolites, and the high molecular weight phthalate mixture with blood pressure. Early pregnancy ƩDiNP was furthermore associated with increased odds of HDP (odds ratio: 1.37, CI: 1.03, 1.82), but not preeclampsia. In sum, early gestational exposure to DiNP and other high molecular weight phthalates may contribute to HDP.

Association between triglyceride-glucose index in early pregnancy and risk of preeclampsia: a multicenter retrospective cohort study

BACKGROUND

Previous evidence has indicated that insulin resistance may be an early pathological state of preeclampsia (PE). As a novel biomarker, the triglyceride glucose (TyG) index can reflect the level of insulin resistance in the body. The present study aimed to investigate the association between the TyG index and risk of PE.

METHODS

This study included 41,694 singleton pregnant women, comprising 2,308 PE patients and 39,386 healthy controls from three tertiary hospitals from January 2019 to June 2024. Datas were retrospectively collected via medical record review. The TyG index was measured before 20 weeks of gestation, and participants were grouped via the TyG index quartiles. The primary outcome was PE, and the secondary outcomes were preterm birth and low birth weight (LBW). Multivariable logistic regression was used to calculate the odds ratios (ORs) for the TyG index quartiles compared to the lowest quartile for the primary and secondary outcomes. Subgroup analyses were conducted to evaluate the effect of age, body mass index (BMI), parity and TyG test week on these associations. The predictive efficacy of the TyG index for PE was assessed using receiver operating characteristic (ROC) curve analysis.

RESULTS

After adjusting for confounders, compared to TyG index Q1, a higher TyG index was positively associated with PE (TyG index Q3 OR = 1.23, 95% confidence interval (CI): 1.06-1.43, P = 0.0067; TyG index Q4 OR = 1.31, 95% CI: 1.11-1.53, P = 0.0011) and preterm birth (TyG index Q4 OR = 1.18, 95% CI: 1.01-1.37, P = 0.0376), negatively associated with LBW (TyG index Q3 OR = 0.84, 95% CI: 0.74-0.97, P = 0.0147). In Model I, a significant association was observed between higher TyG quartiles and preterm birth (P = 0.0472 for Q3 and P = 0.0000 for Q4), but this association was not significant in Model II after adjusting for confounders. Subgroup analyses revealed that age, pre-pregnancy BMI, parity and test week did not influence these associations (interaction P > 0.05). The area under the ROC curve (AUC) for the predictive model was 0.596 (95% CI: 0.584-0.608), with a sensitivity of 65.4% and a specificity of 49.6%.

CONCLUSION

The present findings suggested that the TyG index associated with a high risk of PE. Clinical evaluation incorporating the TyG index during early pregnancy may help in screening for patients at high risk of PE.

Uncovering therapeutic targets for Pre-eclampsia and pregnancy hypertension via multi-tissue data integration

BACKGROUND

Pre-eclampsia (PE) and pregnancy hypertension (PH) are common and serious complications during pregnancy, which can lead to maternal and fetal death in severe cases. Therefore, further research on the potential therapeutic targets of PE and PH is of great significance for developing new treatment strategies.

METHODS

This study used the summary data-based Mendelian randomization (SMR) method to analyze expression quantitative trait loci (eQTL) data from blood, aorta, and uterus with Genome-wide association studies (GWAS) data on PE and PH, exploring potential genetic loci involved in PE and PH. Since proteinuria is a clinical manifestation of PE, we also analyzed genes related to the kidney and PE. The HEIDI test was used for heterogeneity testing, and results were adjusted using FDR. The cis-eQTL data were obtained from the blood summary-level data of the eQTLGen Consortium and the aorta and uterus data from the V8 release of the GTEx eQTL summary data. The GWAS data for PE and PH were obtained from the FinnGen Documentation of R10 release. This study utilized the STROBE-MR checklist for reporting Mendelian Randomization (MR) studies.

RESULTS

This study identified several potential therapeutic targets by integrating eQTL data from blood, uterus, and aorta with GWAS data for PE and PH, as well as kidney eQTL data with GWAS data for PE. Additionally, the study discovered some genes with common roles in PE and PH, offering new insights into the shared pathological mechanisms of these two conditions. These findings not only provide new clues to the pathogenesis of PE and PH but also offer crucial foundational data for the development of future therapeutic strategies.

CONCLUSION

This study revealed multiple potential therapeutic targets for PE and PH, providing new insights for basic experimental research and clinical treatment to mitigate the severe consequences of PE and PH.

CLINICAL TRIAL NUMBER

Not applicable.

Association between the glucose pattern in oral glucose tolerance test and adverse pregnancy outcomes among non-diabetic women

BACKGROUND

This study aimed to explore whether the patterns of the oral glucose tolerance test (OGTT) could function as a predictive factor for adverse pregnancy outcomes in pregnant women without gestational diabetes mellitus (GDM).

METHODS

A retrospective cohort study was carried out, involving a total of 23,577 pregnant women. The participants were classified into three groups according to the area under the curve (AUC) of the OGTT performed between 24 and 28 weeks of gestation. Based on the tertiles of the AUC-OGTT magnitude, three distinct glucose patterns were identified: small AUC (SA) with an AUC-OGTT ≤ 12.26, medium AUC (MA) with an AUC-OGTT between 12.26 and 13.81, and large AUC (LA) with an AUC-OGTT > 13.81. Logistic regression analysis was utilized to assess the association between different AUC-OGTT patterns and the risk of adverse pregnancy outcomes.

RESULTS

The incidence of adverse pregnancy outcomes, including preeclampsia, preterm birth, macrosomia, and cesarean delivery, showed a progressive increase from the SA to the MA to the LA pattern. A positive dose-response relationship was observed between the AUC-OGTT and adverse pregnancy outcomes. In the logistic regression analysis, with the SA pattern as the reference, the MA pattern was associated with a higher risk of macrosomia and cesarean delivery (both P < 0.001). Even after adjusting for potential covariates, the relative risks for these outcomes were 1.34 (95% CI: 1.14, 1.56) and 1.09 (95% CI: 1.01, 1.16), respectively (both P < 0.05). Additionally, the LA pattern was associated with a higher risk of preeclampsia, preterm birth, macrosomia, and cesarean delivery (all P < 0.01). After adjusting for potential covariates, the relative risks for preterm birth, macrosomia, and cesarean delivery were 1.20 (95% CI: 1.03, 1.41), 1.68 (95% CI: 1.44, 1.95), and 1.15 (95% CI: 1.07, 1.23), respectively (all P < 0.05). Moreover, these risks differed according to maternal age and preconception body mass index (BMI).

CONCLUSIONS

The present study highlights the relationship between OGTT patterns and adverse pregnancy outcomes in Chinese women without GDM. Identifying the MA and LA patterns as unfavorable factors for adverse pregnancy outcomes can provide crucial information for clinicians to develop personalized risk assessment and intervention strategies, which may contribute to improving pregnancy outcomes.

The Role of Mid-Trimester BUN and Creatinine Assessment in Predicting Preeclampsia: Retrospective Case-Control Study

Background and Objectives: Preeclampsia (PE) is a major cause of adverse perinatal outcomes. Early diagnosis of pregnant women at risk of PE can facilitate disease prevention and management. However, the presence of different phenotypes of the disease complicates its prediction. In particular, the challenges in the early diagnosis of term PE cases necessitate research on PE prediction in the second and third trimesters. This study aims to examine the association between PE development and mid-trimester blood urea nitrogen (BUN), serum creatinine, and the BUN/creatinine ratio in pregnant women. Materials and Methods: This retrospective case-control study was conducted on women diagnosed with PE. Pregnant women who underwent routine biochemical blood tests between the 18th and 24th weeks of gestation and subsequently gave birth at our hospital between January 2022 and May 2023 were categorized into three groups. Accordingly, healthy women who had term deliveries were classified as Group 1 (150 cases), women diagnosed with PE were classified as Group 2 (58 cases), and those diagnosed with severe PE were classified as Group 3 (44 cases). Results: There were no significant differences in age, gravidity, parity, body mass index, or gestational week at blood sampling between the patient and control groups (p > 0.05). When comparing the mean blood urea nitrogen, serum creatinine, and BUN/creatinine ratios, a significant difference was observed between the control group and those who developed PE (p = 0.001, p < 0.001, and p = 0.031, respectively). Univariate analysis revealed a significant association between BUN levels and PE development (OR 1.083; 95% CI, 1.031-1.139; p = 0.002). A stronger association was observed between serum creatinine levels and PE development (OR 112.344; 95% CI, 11.649-1083.416; p < 0.001). However, no significant association was found between the BUN/creatinine ratio and PE in univariate analysis (OR 1.003; 95% CI, 0.979-1.028; p > 0.05). Mid-trimester BUN and serum creatinine levels were significantly higher in patients who developed PE and severe PE. The AUC value for the BUN parameter in predicting PE was 0.614 (AUC 0.614; 95% CI, 0.539-0.689; p = 0.002). A BUN cut-off value of 16.2 mg/dL predicted disease development with a sensitivity of 52.9% and a specificity of 74%. Similarly, the AUC value for the serum creatinine parameter in predicting PE was 0.644 (AUC 0.644; 95% CI, 0.574-0.751; p < 0.001). A serum creatinine cut-off value of 0.58 mg/dL was able to predict disease development with 37.2% sensitivity and 88% specificity. No significant AUC value was obtained for the BUN/creatinine ratio (p > 0.05). Conclusions: Our findings indicate that elevated BUN and serum creatinine levels measured during the mid-trimester (18-24 weeks) are associated with an increased risk of developing preeclampsia.

Pharmacokinetic Characterization of Labetalol in Pregnancy (The CLIP Study): A Prospective Observational Longitudinal Pharmacokinetic/Pharmacodynamic Cohort Study During Pregnancy and Postpartum

Background/Objectives: Hypertensive disorders of pregnancy are a leading cause of pregnancy-related deaths in the United States, accounting for 7% of maternal mortality. Labetalol and nifedipine are the first-line drugs for the management of hypertension in pregnancy, but there are little data guiding the choice of one drug over the other. The current pilot longitudinal study aims to characterize the pharmacokinetics (PK) and pharmacodynamics (PD) of labetalol stereoisomers throughout pregnancy and postpartum. Methods: This is a single-center clinical study recruiting up to 40 pregnant individuals ≥ 18 years of age at the time of enrollment, taking labetalol as per the standard of care. The exclusion criteria include any pathophysiology impacting the PK of labetalol, e.g., liver failure. Maternal plasma, urine, amniotic fluid, cord blood, and breast milk will be collected, and labetalol stereoisomers will be measured using a validated LC-MS/MS assay. Heart rate and blood pressure will be measured as the PD endpoints. These may be assessed throughout a participant's dosing interval at scheduled PK study visits, which will occur every 6-10 weeks during pregnancy, at delivery, during the 1st week postpartum, and up to 20 weeks postpartum. The primary aim is to characterize the PK and PD of labetalol during pregnancy and in the postpartum period. The secondary aim is to determine the extent of breast milk excretion of and infant exposure to labetalol from breast milk. The data will be analyzed using population PK modeling to evaluate the PK/PD relationship and ultimately develop trimester-specific dosing recommendations. Results/Conclusions: To our knowledge, this is the first study aiming to characterize the PK of labetalol stereoisomers across pregnancy and postpartum, utilizing individual stereoisomer data to evaluate the PK/PD relationship, and collecting postpartum samples, including breast milk, to model infant exposure to labetalol through breast milk. This study will provide important PK/PD data and knowledge which will be combined with large multi-center clinical trial data to develop trimester-specific dosing regimens for anti-hypertensive agents.

The construction and validation of a prediction model of hypertensive disease in pregnancy

The HDP prediction model was constructed and validated by using the demographic characteristics, blood routine and biochemical screening indicators in early pregnancy to reduce the incidence of HDP. 16,112 pregnant women admitted to Yuyao People's Hospital from May 1, 2018 to April 30, 2022 were randomly divided into modeling group (n = 11279) and validation group (n = 4833) according to a ratio of 7:3. Demographic characteristics, blood routine and biochemical screening data of 8-12+ 6 weeks gestation were obtained from Ningbo Health Records system. Univariate analysis and multivariate binary Logistic regression analysis were used to determine the independent risk factors of HDP, and the scoring system was established by using the nomogram. Univariate analysis and multivariate binary Logistic regression analysis showed that Age, BMI, previous medical history, HB, TG, HDL and ALB were independent risk factors for HDP (P < 0.001). In the modeling group, AUC = 0.809, sensitivity = 74.30%, specificity = 73.10%, and in the validation group, AUC = 0.801, sensitivity = 77.60%, specificity = 68.90%. Hosmer-Lemeshow goodness of fit test showed that modeling group: P = 0.195 > 0.05, validation group: P = 0.775 > 0.05. The prediction model of early pregnancy Age, BMI, previous medical history, HB, TG, HDL and ALB can effectively predict the occurrence of HDP.

Imaging and quantification of placental terminal villi microvasculature and nuclear characteristics in preeclampsia

Globally, at least 10 % of maternal deaths, caused by obstetric complications during pregnancy, are linked to preeclampsia or eclampsia. Preeclampsia-induced placental hypoxia leads to vascular injury and syncytial knot formation in terminal villi. Early delivery of preeclampsia placentas complicates comparisons with normotensive term placentas, while the placenta's non-planar structure limits the effectiveness of 2D histology for vascular analysis. This study used multiphoton microscopy to quantify 3D morphological differences in terminal villi between late-onset preeclampsia and control pregnancies. 7 late-onset preeclampsia (Gestational age: 37.3 weeks) and 10 control (Gestational age: 38.3 weeks) placentas were stained for nuclei and vasculature, optically cleared using ethyl-cinnamate, imaged with multiphoton microscopy, and analysed semi-automatically. Image quantification revealed a 42 % decrease in vascular fraction and a 97 % increase in syncytial knot density in late-onset preeclampsia samples, both statistically significant. No differences were observed in surface area-to-volume ratios, individual syncytial knot volume, or microvascular characteristics, including branchpoint density, vessel length, branching angle, straightness, and diameter. By analysing placentas at comparable gestational ages, we demonstrated that late-onset preeclampsia is characterized by decreased vascular content and increased syncytial knot density, while individual syncytial knot size and microvascular architecture remain unchanged. These findings enhance our understanding of late-onset preeclampsia pathophysiology and could provide a basis to distinguish late-onset preeclampsia from other phenotypes, such as early-onset preeclampsia, highlighting potential differences in disease mechanisms.

Maternal and Neonatal Outcomes in Gestational Hypertension for Delivery at 37 versus 38 to 40 Weeks

This study aimed to compare neonatal and maternal outcomes for mothers with gestational hypertension delivered at 37 weeks' gestation compared with 38 to 40 weeks.Single-center, retrospective chart review of women with gestational hypertension delivered between 370/7 and 406/7 weeks' gestation over a 29-month period.A total of 337 mother-infant dyads with gestational hypertension were included: 194 delivered at 37 weeks' gestation (cohort 1) and 143 delivered at 38 to 40 weeks' gestation (cohort 2). Preeclampsia developed in 12% of cohort 1 and 8% of cohort 2 (p = 0.242). No significant differences in severe hypertensive-related complications were found between the cohorts. Neonatal outcomes including neonatal intensive care unit admission, respiratory support, phototherapy, and length of stay were all more frequent in cohort 1.For women with gestational hypertension, delivery at 38 to 40 weeks was not associated with increased maternal complications but was associated with fewer neonatal complications when compared with delivery at 37 weeks. · Gestational hypertension is a common complication of pregnancy.. · Mothers with gestational hypertension are often induced early.. · Neonatal adverse outcomes increase with early delivery.. · Optimal timing of delivery for pregnancies complicated by gestational hypertension is unknown..

Alpha-fetoprotein (AFP) is reduced at 36 weeks' gestation in pregnancies destined to deliver small for gestational age infants

Alpha-fetoprotein (AFP) is a protein commonly used to screen for aneuploidy in pregnancy. This study measured circulating AFP in maternal plasma at 36 weeks' gestation preceding diagnosis of term preeclampsia or delivery of a small for gestational age infant (SGA; <10 % birthweight centile) in a case-cohort design (122 SGA; 23 preeclampsia; 182 controls). AFP was significantly reduced in SGA < 5th birthweight centile (n = 51; P = 0.002) but not changed preceding preeclampsia diagnosis. This suggests that AFP is reduced near term preceding SGA diagnosis and may have potential as a biomarker if combined with other candidate molecules.

Cystatin 6 (CST6) and Legumain (LGMN) are potential mediators in the pathogenesis of preeclampsia

Preeclampsia results from placental insufficiency and causes maternal endothelial dysfunction and multi-organ damage. Our in-silico analysis identified Cystatin 6 (CST6), a cysteine protease inhibitor, as located on the placental surface where it might be released into maternal circulation. This study aimed to characterise CST6 and one of its high affinity targets, Legumain (LGMN), in preeclampsia and assess its biomarker potential by measuring levels in maternal circulation. Placental CST6 mRNA expression was significantly increased in 78 pregnancies complicated by early-onset preeclampsia (delivering at < 34 weeks' gestation) relative to 30 gestation matched controls (P < 0.0001). LGMN mRNA expression was significantly decreased (P = 0.0309). Circulating CST6 was increased in 35 pregnancies complicated by early-onset preeclampsia (< 34 weeks' gestation) relative to 27 gestation matched controls (P = 0.0261), and LGMN levels remained unchanged. At 36 weeks' gestation, circulating CST6 was significantly increased (P = 0.001), while LGMN was significantly decreased (P = 0.0135) in 21 pregnancies preceding diagnosis of preeclampsia at term, compared to 184 pregnancies that did not develop preeclampsia. Human trophoblast stem cells (hTSC) were differentiated into syncytiotrophoblast or extravillous trophoblast (EVT) to evaluate CST6 and LGMN expression in these trophoblast lineages. CST6 and LGMN mRNA expression were significantly increased across 96 h after syncytiotrophoblast (P = 0.0066 and P = 0.0010 respectively) and EVT differentiation (P = 0.0618 and P = 0.0016 respectively), with the highest expression in syncytiotrophoblast. Computational analysis of two publicly available single-cell and single-nuclei RNA sequencing datasets correlated with the expression pattern observed in vitro. When syncytiotrophoblast cells were exposed to hypoxia (1% O2 vs. 8% O2), CST6 expression significantly increased (P = 0.0079), whilst LGMN expression was unchanged. The vascular endothelium may serve as an additional source of circulating CST6 and LGMN in preeclampsia.  Induction of dysfunction in endothelial cells by TNFα, caused reduced CST6 expression (P = 0.0036), whilst LGMN expression remained unchanged. Administering recombinant CST6 to endothelial cells enhanced markers of endothelial dysfunction and LGMN expression in the presence of TNFα. These findings indicate an inverse relationship between CST6 and LGMN in the placenta and maternal circulation in preeclampsia. We suggest elevated circulating levels of CST6 may be induced by placental hypoxia. This study provides novel insight into the dysregulation of CST6 and LGMN in preeclampsia and introduces their potential roles in human pregnancy and associated pathology.

Genetic Risk and First-Trimester Cardiovascular Health Predict Hypertensive Disorders of Pregnancy in Nulliparous Women

BACKGROUND

Hypertensive disorders of pregnancy (HDPs) (preeclampsia/eclampsia and gestational hypertension) are a leading cause of maternal and perinatal morbidity and mortality and are associated with long-term maternal cardiovascular disease. High genetic risk and poor cardiovascular health (CVH) are each associated with HDPs, but whether genetic risk for HDP is modified by CVH status in early pregnancy is unknown.

OBJECTIVES

In this study, the authors sought to test the independent and joint associations of genetic risk and first-trimester CVH with development of HDP.

METHODS

We examined genotyped participants from the nuMoM2b (Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be), a prospective observational cohort that enrolled nulliparous individuals with singleton pregnancies from 2010 to 2013 at 8 U.S. clinical sites. Genetic risk was calculated according to a validated genetic risk score for HDP. A first-trimester CVH score was closely adapted from the American Heart Association Life's Essential 8 model. Genetic risk and CVH were each categorized as low (bottom quintile), intermediate (quintile 2-4), or high (top quintile). The primary outcome was development of HDP. Multivariable-adjusted logistic regression was used to test the independent and joint associations of genetic risk and CVH with development of HDPs.

RESULTS

Among 7,499 participants (mean age 27.0 years), the median first-trimester CVH score was 77.1 (Q1-Q3: 67.1-85.7). Overall, 1,032 participants (13.8%) developed an HDP (487 [6.5%] preeclampsia, 545 [7.3%] gestational hypertension). Genetic risk and CVH were each independently and additively associated with HDP (high vs low genetic risk: adjusted OR [aOR]: 2.21 [95% CI: 1.78-2.77; P < 0.001]; low vs high CVH: aOR: 2.92 [95% CI: 2.28-3.74; P < 0.001]). There was no significant interaction between genetic risk and CVH regarding risk of HDPs (Pinteraction > 0.05). HDP incidence ranged from 4.5% (low genetic risk, high CVH) to 25.7% (high genetic risk, low CVH). Compared with low CVH, high CVH was associated with 53%-74% lower risk of HDP across genetic risk strata. Findings were consistent when examining preeclampsia/eclampsia and gestational hypertension separately.

CONCLUSIONS

Lower genetic risk and higher first-trimester CVH were independently and additively associated with lower risk of developing HDPs in nulliparous individuals. Favorable CVH in early pregnancy may mitigate high genetic risk for HDP.

Predicting interval from diagnosis to delivery in preeclampsia using electronic health records

Preeclampsia is a major cause of maternal and perinatal mortality with no known cure. Delivery timing is critical to balancing maternal and fetal risks. We develop and externally validate PEDeliveryTime, a class of clinically informative models which resulted from deep-learning models, to predict the time from PE diagnosis to delivery using electronic health records. We build the models on 1533 PE cases from the University of Michigan and validate it on 2172 preeclampsia cases from the University of Florida. PEDeliveryTime full model contains only 12 features yet achieves high c-index of 0.79 and 0.74 on the Michigan and Florida data set respectively. For the early-onset preeclampsia subset, the full model reaches 0.76 and 0.67 on the Michigan and Florida test sets. Collectively, these models perform an early assessment of delivery urgency and might help to better prioritize medical resources.

COVID-19 vaccination and pregnancy-induced hypertension risk in women undergoing assisted reproduction

STUDY QUESTION

Does COVID-19 vaccination affect the risk of pregnancy-induced hypertension (PIH) in women undergoing ARTs, and does this risk differ based on vaccine type (inactivated vs recombinant) and timing relative to embryo transfer?

SUMMARY ANSWER

Women who received inactivated COVID-19 vaccines before undergoing ART had a significantly increased risk of developing PIH, particularly when vaccinated with two or more doses or when embryo transfer occurred within 1 month of vaccination.

WHAT IS KNOWN ALREADY

COVID-19 vaccination during pregnancy reduces the risk of severe COVID-19 illness with no significant safety concerns for the mother or fetus. PIH is a common complication in ART pregnancies, particularly in older women and those with higher BMI, but the effects of different COVID-19 vaccine types on PIH risk in ART pregnancies remain unclear.

STUDY DESIGN, SIZE, DURATION

A retrospective cohort study analyzing 3911 women undergoing ART after receiving COVID-19 vaccines. The study period spanned from 1 December 2020 to 30 September 2022.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Participants were categorized based on COVID-19 vaccination status, vaccine type (inactivated vs recombinant), and the timing of vaccination relative to embryo transfer. The primary outcome was the development of PIH. Multivariate robust Poisson regression was used to assess the association between vaccination and PIH, while subgroup analyses explored the risk across variables like age, BMI, and embryo transfer type.

MAIN RESULTS AND THE ROLE OF CHANCE

Women vaccinated with an inactivated COVID-19 vaccine prior to embryo transfer had a significantly higher incidence of PIH compared to unvaccinated counterparts (relative risk [RR] = 1.45; 95% CI 1.10-1.92; P = 0.009). In contrast, recombinant vaccines did not show a significant association with increased PIH risk (RR = 1.19; 95% CI 0.69-2.05; P = 0.537). The risk was particularly pronounced among women receiving two or more doses of the inactivated vaccines and those who had embryo transfers within 1 month of vaccination. Subgroup analyses showed elevated PIH risk in women aged ≥30 years old, those with BMI ≥22 kg/m2, individuals with secondary infertility, and those undergoing cleavage-stage or fresh embryo transfers.

LIMITATIONS, REASONS FOR CAUTION

The study's retrospective design limits causal inference. The sample is from a single ethnic background, and familial hypertension history was not available, potentially introducing residual confounding.

WIDER IMPLICATIONS OF THE FINDINGS

The study suggests that the type and timing of COVID-19 vaccination may influence PIH risk in ART pregnancies. These findings underscore the need for careful consideration of vaccination type and timing in ART protocols and highlight the importance of further prospective studies to validate these results before influencing clinical decision-making.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the Hunan High-Level Talent Aggregation Project [2022RC4007]; the National Natural Science Foundation of China [72004148]; the Hunan Provincial Enterprise Joint Fund [2024JJ9093]; the Hunan Provincial Grant for Innovative Province Construction [2019SK4012]; the Deutschlandstipendium of the Charite; the non-restricted research grant of Boehringer Ingelheim Ltd.; and the Research Grant of CITIC-Xiangya [YNXM-202304, 202217]. The authors report no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

A nomogram based on peripheral blood count between 12 and 18 weeks of gestation for predicting early-onset pre-eclampsia in pregnant women: a retrospective case-control study

BACKGROUND

Early-onset pre-eclampsia (PE), which delivered before 34 weeks of gestation, is associated with high maternal and pediatric morbidity and mortality. Several studies have examined predictive factors and models to identify individuals at risk for early-onset pre-eclampsia. However, implementing these methods often requires additional tests and increases the financial burden on pregnant women. Our study aimed to determine if early-onset PE development could be predicted using a simple, convenient, and easily accessible test: the peripheral blood count.

METHODS

In this study, we conducted a review of pregnant women who received routine prenatal visit and delivered in our hospital from April 2019 to April 2022. For each patient with PE, we matched them 1:1 with healthy pregnant women who were similar in terms of age, parity, and pre-gestational BMI. We gathered routine peripheral blood cell results between 12 and 18 weeks of gestation and utilized multivariate logistic regression to determine independent risk factors. Subsequently, a nomogram was created to forecast the likelihood of early-onset pre-eclampsia. Lastly, we assessed the model's predictive performance.

RESULTS

In our study, a total of 254 patients with PE were included, comprising of 41 patients with early-onset PE and 213 patients with late-onset PE, as well as 254 cases of normotensive pregnancy. The nomogram included four risk factors: mean corpuscular hemoglobin concentration (MCHC) ≥ 340.50 g/l, neutrophil-to-lymphocyte ratio (NLR) ≤ 4.40, platelet-to-lymphocyte ratio (PLR) ≤ 118.01, and platelet-to-mean platelet volume (PC/MPV) ≤ 17.81. Notably, the nomogram exhibited good diagnostic performance with an area under the curve (AUC) of 0.874, sensitivity of 95.1%, and specificity of 62.2%. Furthermore, the nomogram was validated through a decision curve analysis (DCA), which demonstrated a favorable positive net benefit, and the calibration curve showed a good fit and alignment with the ideal curve.

CONCLUSIONS

Our nomogram, based on four predictors derived from peripheral blood cells and related ratios, offers a practical screening tool for early-onset PE in pregnant women.

Development a nomogram for predicting HELLP syndrome in women complicated with gestational hypertension

OBJECTIVES

The unpredictability of HELLP syndrome and the severe adverse outcomes for both mother and children make it especially important for us to seek predictive model. This study aimed to develop a clinically accessible prediction model for assessing the risk of HELLP syndrome progression in patients with hypertensive disorders of pregnancy (HDP) and find effective factors that may predict the progression of HELLP within 3 days.

METHODS

We used electronic data from Women's Hospital, Zhejiang University School of Medicine, between January 1,2014 and December 31,2023. A total of 808 patients were included in this study, including 607 patients in the non-HELLP syndrome group and 201 patients in the HELLP syndrome group. We collected clinical and laboratory information, and conducted single- and multiple-factor logistic regression analyses to identify independent factors influencing the occurrence of HELLP syndrome and the onset of HELLP syndrome within 3 days. A nomogram was constructed based on these predictors to provide a visual representation of risk estimation. The model's performance was evaluated through internal and external validation, with metrics such as the area under the curve(AUC), receiver operating characteristic curve (ROC), precision, recall, and F1 score. Calibration and decision curve analyses were also performed to assess model robustness and clinical utility.

RESULTS

Multiple logistic regression analysis indicated prenatal BMI, neurologic symptoms, other system symptoms, 24-h urine protein, lowest SBP at admission, lowest DBP at admission, prenatal albumin, prenatal platelet and prenatal blood urea nitrogen as independent factors of HELLP syndrome. The prediction model achieved an AUC of 0.975 (95% CI: 0.966-0.985) in the internal validation dataset with a sensitivity of 0.962(95% CI: 0.962-1.000) and specificity of 0.885(95% CI: 0.962-1.000). The AUC of the external validation dataset was 0.838 (95% CI: 0.785-0.892). The optimal cutoff value calculated using Youden's index was 0.613, with a sensitivity of 0.891(95% CI: 0.473-0.836) and specificity of 0.722(95% CI: 0.667-0.818). In multivariate regression analysis, blood urea nitrogen and the creatinine-to-blood urea nitrogen ratio were significant predictors in predicting HELLP syndrome within 3 days. The sensitivity was found to be 0.68 and 0.65, specificity to be 0.74 and 0.686 respectively.

CONCLUSIONS

This study successfully developed and validated a prediction model that can reliably predict the risk of HELLP syndrome in HDP patients. And blood urine nitrogen and the ratio of creatinine over blood urea nitrogen could be efficient predictors of HELLP syndrome occurring within 3 days.

Pregnancy-Related Heart Disease in the Emergency Department

Pregnancy induces significant physiologic changes that impact the cardiovascular system, potentially exacerbating pre-existing cardiac conditions or precipitating new illnesses. Pregnant patients with cardiac emergencies pose unique challenges, as standard interventions may pose risks to the developing fetus. This article aims to enhance emergency physicians' confidence in managing pregnancy-related cardiac emergencies by providing a structured approach to initial evaluation and stabilization. We review eight common categories of pregnancy-associated cardiac illness: gestational hypertension and pre-eclampsia, cardiomyopathy, arrhythmias, valvular disease, aortopathies, congenital heart disease and pulmonary hypertension, coronary disease, and anticoagulation-related complications. For each condition, we summarize relevant pregnancy-specific pathophysiology and outline evidence-based, personalized emergency management strategies.

Molecular subtyping of hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP), including preeclampsia, affect 1 in 6 pregnancies, are major contributors to maternal morbidity and mortality, yet lack precision medicine strategies. Analyzing transcriptomic data from a prospectively-collected diverse cohort (n = 9102), this study reveals distinct RNA subtypes in maternal blood, reclassifying clinical HDP phenotypes like early/late-onset preeclampsia. The placental gene PAPPA2 strongly predicts the most severe forms of preeclampsia in individuals without pre-existing high risk factors, months before symptoms, and its overexpression correlates with earlier delivery in a dose-dependent manner. Further, molecular subtypes characterized by immune genes are upregulated in less severe forms of HDP. These results reclassify HDP clinical phenotypes into two distinct molecular subtypes, placental-associated or immune-associated. Validation performance for placental-associated HDP yields an AUC of 0.88 in the advanced maternal age population without pre-existing high risk factors. Molecular subtypes create new opportunities to apply precision-based medicine in maternal health.

Outcomes of pregnancy-related acute kidney injury: A retrospective study in the obstetric critical care unit at Kenyatta National Hospital 2020 to 2023

Pregnancy-related acute kidney injury (PrAKI) is defined as a rapid decline in kidney function in the pregnancy or puerperal period that can result in life-threatening organ dysfunction. This study aimed to investigate socio-demographic features of critically ill women with pregnancy-related acute kidney injury as well as their maternal and foetal outcomes. Retrospective analysis of data in patients with pregnancy-related kidney injury in the obstetric critical care unit at a public tertiary referral centre in Kenya between February 2020-2023. Of the 266 patient files reviewed, pregnancy-related acute kidney was found in 203 patients. The main predisposing factors for acute kidney injury were hypertensive disorders in pregnancy (64.1%), obstetric haemorrhage (38.4%) and sepsis (36.5%). According to KDIGO (Kidney Disease Improving Global Outcomes) criteria, 44 patients presented in stage 1 (21.7%), 58 in stage 2 and 101 in stage 3 (49.8%). Patients with KDIGO stage 3 had a higher risk of high SOFA (Sequential Organ Failure Assessment) score (p =< 0.001), longer ICU stay (p = 0.008) and longer duration on ventilation (p = 0.010). Seventy-six patients underwent dialysis (37.4%). Recovery of renal function was complete in 91 patients (44.8%), partial in 41 (20.2%) with dependence on dialysis seen in 23 (23.6%). Forty-eight patients died (23.6%). Risks associated with mortality were mechanical ventilation (p = 0.001) and inotropic support (p =< 0.001) with statistically significant higher mean SOFA scores in those who died versus those who survived (12.6 ± 3.8 p =< 0.001 vs 8.6 ± 3.2). The incidence of PrAKI is still underestimated in the Kenyan setting with the majority of the patients presenting with advanced renal injury. These patients are at higher risk of adverse maternal morbidity and mortality in the critical care setting.

Noninvasive early prediction of preeclampsia in pregnancy using retinal vascular features

Preeclampsia (PE), a severe hypertensive disorder during pregnancy, significantly contributes to maternal and neonatal mortality. Existing prediction biomarkers are often invasive and expensive, hindering their widespread application. This study introduces PROMPT (Preeclampsia Risk factor + Ophthalmic data + Mean arterial pressure Prediction Test), an AI-driven model leveraging retinal photography for PE prediction, registered at ChiCTR (ChiCTR2100049850) in August 2021. Analyzing 1812 pregnancies before 14 gestational weeks, we extracted retinal parameters using a deep learning system. The PROMPT achieved an AUC of 0.87 (0.83-0.90) for PE prediction and 0.91 (0.85-0.97) for preterm PE prediction using machine learning, significantly outperforming the baseline model (p < 0.001). It also improved detection of severe adverse pregnancy outcomes from 35% to 41%. Economically, PROMPT was estimated to avert 1809 PE cases and saved over $50 million per 100,000 screenings. These results position PROMPT as a non-invasive and cost-effective tool for prenatal care, especially valuable in low- and middle-income countries.

RvD2 mitigates TNFɑ-Induced mitochondrial reactive oxygen species through NRF2 signaling in placental trophoblasts

Introduction

Hypertensive disorders of pregnancy (HDP) are marked by elevated levels of TNFα, which increases reactive oxygen species (ROS) and disrupts metabolism of trophoblasts. Resolvin D2 (RvD2), an omega-3 fatty acid-derived lipid mediator, is known to resolve inflammation, but its role in protecting trophoblasts by promoting antioxidant responses to alleviate ROS remains unclear. Nuclear translocation of nuclear factor erythroid 2-related factor 2 (NRF2) controls cellular defense mechanisms against oxidative stress and helps with the maintenance of cellular redox homeostasis. Upon translocation to nucleus, NRF2 activates the antioxidant response element (ARE), inducing the expression of genes that can mitigate ROS. Hence, we hypothesized that RvD2 activates NRF2 and prevents TNFα-induced mitochondrial dysfunction in trophoblasts.

Methods

We investigated RvD2's potential protective mechanisms against TNFα-induced oxidative stress in trophoblasts by pretreating JEG cells with 100 nM RvD2, followed by exposure to 50 or 100 ng/mL TNFα.

Results

We also observed that placental TNFα levels were elevated, while NRF2 protein levels were reduced in human HDP placental tissues compared to normotensive placentas. We demonstrate that RvD2 alone enhances NRF2 nuclear translocation, increases glutathione levels and mitochondrial function, and reduces mitochondrial ROS. In contrast, TNFα alone decreases nuclear NRF2 levels, increases mitochondrial ROS and oxygen consumption rates, and impairs migration. Notably, pretreatment of RvD2 before TNFα exposure protects against mitochondrial ROS, increases NRF2 levels, and restores mitochondrial oxygen consumption rates in trophoblasts.

Discussion

These findings demonstrate that RvD2 functions as a positive regulator of endogenous antioxidant properties by enhancing NRF2 levels and mitigating mitochondrial ROS in placental trophoblasts.

Third-Trimester NT-proBNP for Pre-eclampsia Risk Prediction: A Comparison With sFlt-1/PlGF in a Population-Based Cohort

BACKGROUND

The association between lower first-trimester N-terminal pro B-type natriuretic peptide (NT-proBNP) levels and increased pre-eclampsia risk remains poorly understood, contrasting with the elevated NT-proBNP levels observed at the time of pre-eclampsia diagnosis.

OBJECTIVES

The aim of this study was to assess the utility of third-trimester NT-proBNP for assessing pre-eclampsia risk before onset.

METHODS

NT-proBNP and the soluble Fms-like tyrosine kinase 1 to placental growth factor ratio (sFlt-1/PlGF) were measured in 1,476 pregnant individuals from the Odense Child Cohort at a median gestational age of 29 weeks (Q1-Q3: 28.4-29.4). Pre-eclampsia cases were categorized by timing: 11 individuals (0.7%) developed pre-eclampsia within 4 weeks, while 110 (7.5%) developed pre-eclampsia more than 4 weeks after sampling.

RESULTS

Higher NT-proBNP levels were significantly associated with increased risk of pre-eclampsia within 4 weeks but reduced risk beyond 4 weeks. After adjusting for age, body mass index, nulliparity, systolic blood pressure, and the sFlt-1/PlGF ratio, the adjusted OR was 2.18 (95% CI: 0.88-5.42, P = 0.09) for onset within 4 weeks and 0.72 (95% CI: 0.55-0.93, P = 0.012) for onset beyond 4 weeks. However, combining NT-proBNP with the sFlt-1/PlGF ratio did not improve the predictive accuracy for short- or long-term pre-eclampsia risk compared to the sFlt-1/PlGF ratio alone.

CONCLUSIONS

Unselected NT-proBNP screening in the early third trimester has limited clinical value for predicting short- or long-term pre-eclampsia risk when compared to angiogenic biomarkers.

Predictive performance of sFlt-1, PlGF and the sFlt-1/PlGF ratio for preeclampsia: A systematic review and meta-analysis

BACKGROUND

It is difficult to evaluate whether monitoring serum sFlt-1, PlGF, or sFlt-1/PlGF in pregnant women who are suspected of having PE can significantly shorten the PE diagnosis time.

OBJECTIVES

To estimate the accuracy of sFlt-1, PlGF and sFlt-1/PlGF in preeclampsia prediction.

SEARCH STRATEGY

Databases including PubMed, Web of Science, Medline, CNKI, SinoMed, VIP Journal, and Wanfang Data were searched for eligible studies published until October 7, 2022.

SELECTION CRITERIA

The research subjects were pregnant women with or without PE. The research types were case-control studies and cohort studies. This was an original study involving the detection of at least one of the following in the blood, serum or plasma: sFlt-1, PlGF, and sFlt-1/PlGF.

DATA COLLECTION AND ANALYSIS

StataSE 16.0 was employed, using the Sen, Spe, PLR, and NLR to plot SROC, and subgroup analysis and meta-regression were conducted.

MAIN RESULTS

Meta-analysis showed that the combined Sen of sFlt, PlGF and sFlt-1/PlGF was 0.79 (95 % CI: 0.68-0.87), 0.76 (95 % CI: 0.69-0.82), and 0.83 (95 % CI: 0.77-0.88), respectively; the Spe was 0.86 (95 % CI: 0.77-0.92), 0.83 (95 % CI: 0.78-0.88), and 0.88 (95 % CI: 0.82-0.92), respectively; and the AUC was 0.89, 0.87, and 0.92, respectively. It was found to be attributable to study design, literature quality, sample size, disease subtypes, and cut-off values by using subgroup analysis and meta-regression.

CONCLUSIONS

The sFlt-1/PlGF ratio showed better predictive performance for preeclampsia than sFlt-1 or PlGF alone. However, the predictive value of the latter two cannot be ignored.This study highlights the performance of biomarkers in the diagnosis and prediction of PE, but that there is currently a lack of data to assess the value of using these biomarkers in clinical practice, and that the use of these biomarkers has not yet been shown to improve pregnancy outcomes.

Effects of a Tanzanian prenatal group education program about preeclampsia/eclampsia: A quasi-experimental study

AIM

This study examined the effects of a prenatal group education program in Tanzania which was focused on preeclampsia/eclampsia according to knowledge, behavioral intention, Pregnancy-Related Empowerment Scale, satisfaction, and the incidence of preeclampsia.

METHODS

The study was conducted in two district hospitals in Tanzania and used a facility-based pre-post quasi-experimental design with concurrent control. The prenatal group education program was developed to focus on preeclampsia/eclampsia and consisted of lectures, discussions, and review sessions directed at participatory group education. The intervention group participated in a midwife-facilitated prenatal group education program, whereas the control group received routine care. Data were collected through questionnaires before the intervention and 1 month later. A descriptive analysis of the data was performed.

RESULTS

The study analyzed 95 pregnant women within an intervention group (n = 48) and control group (n = 47). At the 1-month post-test, statistically significant differences were observed between the intervention and control groups in the knowledge score (mean = 3.8, SD = 3.6 vs. mean = -0.8, SD = 3.1, p < .001) and satisfaction score (mean = 4.9 vs. mean = 4.6, p = .032). Between the two groups, there were no significant differences in the scores of behavioral intention, Pregnancy-Related Empowerment Scale, and the incidence of preeclampsia.

CONCLUSION

The prenatal group education program increased the knowledge level regarding preeclampsia and gave higher satisfaction among pregnant women. Knowledge was retained for at least 1 month. Continuity in implementation of this program is recommended.

Accuracy of the smartphone blood pressure measurement solution OptiBP to track blood pressure changes in pregnant women

INTRODUCTION

Hypertensive disorders present significant morbidity and mortality during pregnancy. Although ambulatory blood pressure measurement remains the standard of care for normotensive women, self-monitoring at home is increasingly prevalent. The widespread use of smartphones worldwide has sparked interest in mobile applications that leverage the built-in hardware for blood pressure estimation, yet few trials have assessed their accuracy.

METHODS

This prospective, longitudinal and monocentric study evaluated the accuracy of the OptiBP algorithm against standard oscillometric blood pressure measurements in a sample of pregnant women. Patients scheduled for elective caesarean sections were enrolled during the preoperative anesthesia consultations. Paired blood pressure measurements using OptiBP and the reference method were obtained at multiple time-points in late pregnancy and the postpartum period. Agreement between methods was assessed using the AAMI/ESH/ISO 81060-2:2018 standard thresholds of 5 ± 8 mmHg for mean ± standard deviation of the error (criterion 1) and patient-specific standard deviation of the mean error (criterion 2) and represented graphically by Bland-Altman scatterplots.

RESULTS

Forty-eight women were enrolled of which 32 completed the protocol, yielding 338 total valid measurement pairs. Mean and standard deviation of the error were -1.78 ± 7.94 and 1.19 ± 7.59, and the patient-specific standard deviation of the mean error was 4.68 and 4.52, for SBP and DBP, respectively.

CONCLUSION

Compared with blood pressure measurements taken with an oscillometric device, OptiBP's blood pressure estimates meet the AAMI/ESH/ISO 81060-2:2018 criteria.