Prevention of Preeclampsia and Intrauterine Growth Restriction With Aspirin Started in Early Pregnancy: A Meta-Analysis

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Changes in incidence of iatrogenic and spontaneous preterm births over time: a population-based study

OBJECTIVE

To examine the proportion of iatrogenic births among all preterm births over a 26-year period.

PATIENTS AND METHODS

A registry-based survey of preterm deliveries between 1987 and 2012 analyzed by the onset of labor: spontaneous with intact membranes, preterm premature rupture of membranes (PPROM) or iatrogenic. Stratification into categories by gestation (22 weeks to 27 weeks and 6 days, 28 weeks to 31 weeks and 6 days, 32 weeks to 33 weeks and 6 days, 34 weeks to 36 weeks and 6 days) was performed. Preterm birth rates were analyzed using the Mantel-Haenszel linear-by-linear association χ2-test (P<0.05 significant). Logistic regression was used to account for potential confounders.

RESULTS

Overall preterm birth rate was 5.9% (31328 deliveries) including 2358 (0.4%) before 28 completed weeks, 3388 (0.6%) between 28 weeks and 31 weeks 6 days, 3970 (0.8%) between 32 weeks and 33 weeks and 6 days, and 21611 (4.1%) between 34 weeks and 36 weeks and 6 days There was an increase in overall preterm birth rate (P<0.001). The rate of iatrogenic preterm births and PPROM increased over time (P<0.001 and P<0.014, respectively). Rates of spontaneous preterm birth decreased (P<0.001). After accounting for potential confounders, year of birth remained an independent risk factor for iatrogenic preterm delivery in all four gestational age categories (P<0.001).

CONCLUSION

The incidence of iatrogenic preterm birth is increasing with a concomitant decrease in the incidence of spontaneous preterm birth. Attempts to analyze, interpret and decrease preterm birth rates should consider spontaneous and iatrogenic preterm births separately.

Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 30-34 weeks' gestation

BACKGROUND

Preeclampsia (PE) affects 2-3% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality. We have proposed a 2-stage strategy for the identification of pregnancies at high risk of developing PE. The objective of the first stage, at 11-13 weeks' gestation, is a reduction in the prevalence of the disease through pharmacological intervention in the high-risk group. The objective of the second stage, during the second and/or third trimesters, is to improve perinatal outcome through close monitoring of the high-risk group for earlier diagnosis of the clinical signs of the disease and selection of the appropriate, time, place, and method of delivery.

OBJECTIVE

The objective of the study was to examine the performance of screening for PE by a combination of maternal factors with early third-trimester biomarkers.

STUDY DESIGN

This was a cohort study and data were derived from consecutive women with singleton pregnancies attending for their routine hospital visit at 30-34 weeks' gestation in 3 maternity hospitals in England between March 2011 and December 2014. In the first phase of the study, only uterine artery pulsatility index (UTPI) was measured and then measurement of mean arterial pressure (MAP) was added, and in the final phase, the serum concentration of placental growth factor (PLGF) was measured and then soluble fms-like tyrosine kinase-1 (SFLT) was added. We had data on UTPI, MAP, PLGF, and SFLT from 30,935, 29,042, 10,123, and 8,264 pregnancies, respectively. The Bayes theorem was used to combine the a priori risk from maternal factors with various combinations of biomarker multiple of the median values. Ten-fold cross-validation was used to estimate the performance of screening for PE requiring delivery at < 37 weeks' gestation (preterm-PE) and those delivering at ≥ 37 weeks (term-PE). The empirical performance was compared with model predictions.

RESULTS

In pregnancies that developed PE, the values of MAP, UTPI, and SFLT were increased and PLGF was decreased. For all biomarkers the deviation from normal was greater for preterm-PE than term-PE, and therefore, the performance of screening was inversely related to the gestational age at which delivery become necessary for maternal and/or fetal indications. Combined screening by maternal factors, MAP, UTPI, PLGF, and SFLT predicted 98% (95% confidence interval, 88-100%) of preterm-PE and 49% (95% confidence interval, 42-57%) of term-PE, at a false-positive rate of 5%. These empirical detection rates are compatible with the respective model-based rates of 98% and 54%, but the latter were optimistically biased.

CONCLUSION

Combination of maternal factors and biomarkers in the early third trimester could predict nearly all cases of preterm-PE and half of those with term-PE, at 5% false-positive rate.

Study protocol for the randomised controlled trial: combined multimarker screening and randomised patient treatment with ASpirin for evidence-based PREeclampsia prevention (ASPRE)

INTRODUCTION

Pre-eclampsia (PE) affects 2-3% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality. Prophylactic use of low-dose aspirin in women at risk for PE may substantially reduce the prevalence of the disease. Effective screening for PE requiring delivery before 37 weeks (preterm PE) can be provided by a combination of maternal factors, uterine artery Doppler, mean arterial pressure, maternal serum pregnancy-associated plasma protein A and placental growth factor at 11-13 weeks' gestation, with a detection rate of 75% at a false-positive rate of 10%. We present a protocol (V.6, date 25 January 2016) for the ASpirin for evidence-based PREeclampsia prevention (ASPRE) trial, which is a double-blinded, placebo-controlled, randomised controlled trial (RCT) that uses an effective PE screening programme to determine whether low-dose aspirin given to women from 11 to 13 weeks' gestation will reduce the incidence of preterm PE.

METHODS AND ANALYSIS

All eligible women attending for their first trimester scan will be invited to participate in the screening study for preterm PE. Those found to be at high risk of developing preterm PE will be invited to participate in the RCT. Further scans will be conducted for assessment of fetal growth and biomarkers. Pregnancy and neonatal outcomes will be collected and analysed. The first enrolment for the pilot study was in April 2014. As of April 2016, 26 670 women have been screened and 1760 recruited to the RCT. The study is registered on the International Standard Randomised Controlled Trial Number (ISRCTN) registry.

TRIAL REGISTRATION NUMBER

ISRCTN13633058.

Do low-risk nulliparous women with abnormal uterine artery Doppler in the third trimester have poorer perinatal outcomes? A longitudinal prospective study on uterine artery Doppler in low-risk nulliparous women and correlation with pregnancy outcomes

OBJECTIVE

To evaluate uterine artery (UtA) Doppler over the course of pregnancy in low-risk nulliparous women and to analyze whether an abnormal uterine artery pulsatility index (UtA-PI) at a 32-34 week' scan implies poorer perinatal outcomes.

METHODS

An observational prospective study was carried out including 616 low-risk nulliparous women. Women with any of the following were excluded: fetal abnormalities, multiple pregnancy, and heparin, metformin or hypotensive treatment. Maternal characteristics, mean arterial pressure measurements and UtA Doppler findings were recorded longitudinally.

RESULTS

Complete pregnancy data were available for 489/616 women (79.3%). Of these, 385 women had a normal UtA-PI throughout pregnancy (Group 0), while 50 (10.1%) had an UtA-PI > 95th percentile in the first or the second trimester that normalized in the third trimester (Group 1), and 56 (11.4%) had an abnormal UtA-PI in the third trimester (Group 2). We found that the rate of pre-eclampsia (PE) was higher in Group 2 (7/56 versus 4/435, p = 0.003) as was the rate of intrauterine growth restriction (IUGR) (6/56 versus 14/435, p = 0.02).

CONCLUSIONS

Low-risk nulliparous women with abnormal UtA Doppler findings in the third trimester are at a higher risk of developing PE and having a baby with IUGR.

Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines

Preeclampsia is becoming an increasingly common diagnosis in the developed world and remains a high cause of maternal and fetal morbidity and mortality in the developing world. Delay in childbearing in the developed world feeds into the risk factors associated with preeclampsia, which include older maternal age, obesity, and/or vascular diseases. Inadequate prenatal care partially explains the persistent high prevalence in the developing world. In this review, we begin by presenting the most recent concepts in the pathogenesis of preeclampsia. Upstream triggers of the well described angiogenic pathways, such as the heme oxygenase and hydrogen sulfide pathways, as well as the roles of autoantibodies, misfolded proteins, nitric oxide, and oxidative stress will be described. We also detail updated definitions, classification schema, and treatment targets of hypertensive disorders of pregnancy put forth by obstetric and hypertensive societies throughout the world. The shift has been made to view preeclampsia as a systemic disease with widespread endothelial damage and the potential to affect future cardiovascular diseases rather than a self-limited occurrence. At the very least, we now know that preeclampsia does not end with delivery of the placenta. We conclude by summarizing the latest strategies for prevention and treatment of preeclampsia. A better understanding of this entity will help in the care of at-risk women before delivery and for decades after.

Prevention of Hypertensive Disorders of Pregnancy: a Novel Application of the Polypill Concept

Nearly all of the annual 287,000 global maternal deaths are preventable. Hypertensive disorders of pregnancy (HDP) are among the major causes. A novel fixed-dose combination pill or polypill to prevent cardiovascular disease is a promising strategy for prevention of HDP. The aim of this study was to identify eligible candidates for a polypill for the prevention of HDP. A comprehensive review of systematic reviews on drug and dietary interventions to prevent HDP was conducted. Interventions were evaluated based on efficacy, dose, route of administration, and side effects. Fourteen interventions were assessed. Low-dose aspirin and calcium were identified as candidates for a polypill, with risk reduction estimations for pregnancy-induced hypertension and preeclampsia ranging between 10 and 62 %, depending on patient population characteristics including a priori risk, and gestation age at start of intervention. Their effect may be augmented through the addition of vitamin D, vitamin B12, and folic acid. The effect and optimal composition needs to be evaluated in future trials. Given the persistent burden of maternal and perinatal mortality associated with HDP, prevention of these disorders is key-especially in low-resource settings. The polypill approach with a combination of aspirin, calcium, vitamin D, vitamin B12, and folic acid is a promising strategy to improve maternal and perinatal health outcomes.

The clinical significance of antiphospholipid antibodies in systemic lupus erythematosus

Antiphospholipid syndrome (APS) is the association of thrombosis and/or pregnancy morbidity with antiphospholipid antibodies (aPL). Thirty to forty percent of systemic lupus erythematosus (SLE) patients are tested positive for aPL, which may have an impact on the SLE presentation, management, and prognosis. Compared with SLE patients without aPL, those with aPL have a higher prevalence of thrombosis, pregnancy morbidity, valve disease, pulmonary hypertension, livedo reticularis, thrombocytopenia, hemolytic anemia, acute/chronic renal vascular lesions, and moderate/severe cognitive impairment; worse quality of life; and higher risk of organ damage. The use of low-dose aspirin (LDA) is controversial for primary thrombosis and pregnancy morbidity prevention because of the lack of strong prospective controlled data. Similarly, the use of anticoagulation is controversial for patients with an aPL-related nephropathy. Until further studies are available, physicians should discuss the risk/benefits of LDA or anticoagulation as well as the available literature with patients.

Maternal serum soluble fms-like tyrosine kinase-1 at 22 and 32 weeks in the prediction of pre-eclampsia

OBJECTIVE

To investigate the potential value of repeat measurements of maternal serum concentration of soluble fms-like tyrosine kinase-1 (sFlt-1) at 22 and 32 weeks' gestation in the prediction of pre-eclampsia (PE) in women delivering after 32 weeks.

METHODS

The data were derived from prospective screening for adverse obstetric outcomes in women attending their routine hospital visit at 19-24 and/or 30-34 weeks' gestation in one of two maternity hospitals in England. Serum sFlt-1 was measured in 7565 and 8264 singleton pregnancies at 19-24 and 30-34 weeks, respectively. Bayes' theorem was used to combine the a-priori risk from maternal factors with sFlt-1 multiples of the median (MoM) values. The performance of screening for PE developing after the 30-34-week visit by sFlt-1, measured at 19-24, 30-34 and at both 19-24 and 30-34 weeks was examined.

RESULTS

In pregnancies with PE, sFlt-1 in both the second and third trimesters was increased and the deviation from normal was inversely related to the gestational age at which delivery became necessary for maternal or fetal indications. Serum sFlt-1 at 19-24 weeks was not useful in predicting PE beyond the 30-34-week visit, but the addition of sFlt-1 at 19-24 weeks improved the prediction of PE provided by sFlt-1 at 30-34 weeks. Screening by maternal factors and sFlt-1 at 30-34 weeks predicted 94% of preterm PE and 54% of term PE, at a false-positive rate of 10%; this was improved to 99% and 64%, respectively, by the additional measurement of sFlt-1 at 19-24 weeks.

CONCLUSIONS

Measurement of sFlt-1 in the second trimester improves the prediction of PE provided by screening in the early third-trimester. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Maternal serum PAPP-A and free β-hCG at 12, 22 and 32 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of maternal serum pregnancy-associated plasma protein-A (PAPP-A) and free β-human chorionic gonadotropin (β-hCG) at 12, 22 and 32 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of these biomarkers in screening for PE.

METHODS

Serum PAPP-A and free β-hCG were measured in 94 989 cases at 11-13 weeks, 7597 at 19-24 weeks and 8088 at 30-34 weeks' gestation. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with PAPP-A and free β-hCG. The empirical and model-based performance of screening for preterm PE requiring delivery < 37 weeks' gestation and term PE with delivery ≥ 37 weeks was estimated.

RESULTS

Combined screening with maternal factors and serum PAPP-A at 11-13 and 30-34 weeks and with maternal factors and serum free β-hCG at 19-24 and 30-34 weeks improved the prediction provided by maternal factors alone for preterm PE. The detection rate, at a 10% false-positive rate, for preterm PE by screening with maternal factors was about 45% which improved to 51% and 53% by combined screening with PAPP-A at 11-13 weeks and 30-34 weeks, respectively, and 55% and 54% by combined screening with free β-hCG at 19-24 weeks and 30-34 weeks, respectively. Measurement of serum PAPP-A and free β-hCG was not useful in the prediction of term PE.

CONCLUSIONS

Measurement of serum PAPP-A and free β-hCG could improve the prediction of preterm PE provided by maternal characteristics and medical history alone. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Placental volume and uterine artery Doppler evaluation at 11 + 0 to 13 + 6 weeks' gestation in pregnancies conceived with in-vitro fertilization: comparison between autologous and donor oocyte recipients

OBJECTIVE

To compare first-trimester uterine artery pulsatility index (UtA-PI) and three-dimensional (3D) placental volume in pregnancies conceived through in-vitro fertilization (IVF) using autologous or donor oocytes and pregnancies conceived naturally, and to relate these measurements to the development of pre-eclampsia (PE).

METHODS

UtA-PI and placental volume were measured at 11 + 0 to 13 + 6 weeks of gestation in 416 IVF pregnancies (307 with autologous and 109 with donor oocytes) and in 498 spontaneously conceived pregnancies. We recruited nulliparous women with singleton pregnancy. The measured mean UtA-PI and placental volume values were converted to multiples of the expected normal median (MoM), adjusted for gestational age. MoM values of IVF pregnancies were compared with MoM values of the naturally conceived pregnancies and related to PE development.

RESULTS

Placental volume was significantly reduced in IVF pregnancies (K = 169.3; P < 0.0001) compared with natural pregnancies. No difference was found in UtA-PI MoM between the two groups. Among IVF pregnancies, significantly lower placental volumes were seen in those that received donor oocytes when compared with those with autologous oocytes (z = 3.89; P < 0.001). In IVF pregnancies that developed PE, lower values of placental volume were demonstrated with respect to normotensive pregnancies (donor: U = 6.8; P = 0.009; autologous: U = 5.1; P = 0.023), whereas no difference was found in UtA-PI. Multivariate logistic regression analysis demonstrated that placental volume (odds ratio (OR), 1.97 (95% CI, 1.33-2.27)) and donor oocytes in IVF pregnancy (OR, 2.24 (95% CI, 1.5-2.83)) were independent predictors of PE, whereas autologous oocytes in IVF pregnancy were not found to be significant in the model.

CONCLUSIONS

First-trimester placental volume, as assessed by 3D ultrasound, is reduced in IVF pregnancies and this reduction is more marked in those involving donor oocyte recipients. The relative decrease in placental volume in IVF pregnancies that developed PE suggests an etiological mechanism different from uterine perfusion in such patients. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Do knowledge of uterine artery resistance in the second trimester and targeted surveillance improve maternal and perinatal outcome? UTOPIA study: a randomized controlled trial

OBJECTIVES

To ascertain whether screening for pre-eclampsia (PE) and intrauterine growth restriction (IUGR) by uterine artery (UtA) Doppler in the second trimester of pregnancy and targeted surveillance improve maternal and perinatal outcomes in an unselected population.

METHODS

This was a multicenter randomized open-label controlled trial. At the routine second-trimester anomaly scan, women were assigned randomly to UtA Doppler or non-Doppler groups. Women with abnormal UtA Doppler were offered intensive surveillance at high-risk clinics of the participating centers with visits every 4 weeks that included measurement of maternal blood pressure, dipstick proteinuria, fetal growth and Doppler examination. The primary outcome was a composite score for perinatal complications, defined as the presence of any of the following: PE, IUGR, spontaneous labor < 37 weeks' gestation, placental abruption, stillbirth, gestational hypertension, admission to neonatal intensive care unit and neonatal complications. Secondary outcomes were a composite score for maternal complications (disseminated intravascular coagulation, maternal mortality, postpartum hemorrhage, pulmonary edema, pulmonary embolism, sepsis), and medical interventions (for example, corticosteroid administration and induction of labor) in patients developing placenta-related complications.

RESULTS

In total, 11 667 women were included in the study. Overall, PE occurred in 348 (3.0%) cases, early-onset PE in 48 (0.4%), IUGR in 722 (6.2%), early-onset IUGR in 93 (0.8%) and early-onset PE with IUGR in 32 (0.3%). UtA mean pulsatility index > 90(th) percentile was able to detect 59% of early-onset PE and 60% of early-onset IUGR with a false-positive rate of 11.1%. When perinatal and maternal data according to assigned group (UtA Doppler vs non-Doppler) were compared, no differences were found in perinatal or maternal complications. However, screened patients had more medical interventions, such as corticosteroid administration (relative risk (RR), 1.79 (95% CI, 1.4-2.3)) and induction of labor for IUGR (RR, 1.36 (95% CI, 1.07-1.72)). In women developing PE or IUGR, there was a trend towards fewer maternal complications (RR, 0.46 (95% CI, 0.19-1.11)).

CONCLUSIONS

Routine second-trimester UtA Doppler ultrasound in an unselected population identifies approximately 60% of women at risk for placental complications; however, application of this screening test failed to improve short-term maternal and neonatal morbidity and mortality. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

First trimester screening for pre-eclampsia

The commercial availability of tests in the first trimester of pregnancy that predict the later development of pre-eclampsia has prompted considerable debate regarding their clinical utility and the degree to which they fulfil the longstanding principles of screening. Such tests have been shown to achieve detection rates for early pre-eclampsia (requiring delivery prior to 34 weeks) of over 90%, for a false positive rate of 10%. However, their capacity to predict later onset pre-eclampsia, which accounts for the bulk of the disease burden, is much more limited. The relatively few studies validating the performance of these tests in different populations have demonstrated significant variations in performance. Moreover, prospective research confirming that the administration of aspirin to those screened to be high risk reduces the incidence of pre-eclampsia is yet to be completed, and there may be harms in restricting aspirin therapy to this group, given its broader beneficial effect. In light of these limitations, further development of these tests is recommended prior to their introduction to clinical practice.

First- and second-trimester maternal serum markers of pre-eclampsia in twin pregnancy

OBJECTIVE

To evaluate the distribution of first- and second-trimester maternal serum markers in twin pregnancy with and without pre-eclampsia.

METHODS

One-hundred and forty-four twin and 109 unaffected singleton pregnancies were recruited from the same institution. First- and second-trimester maternal blood samples were stored and measured retrospectively for serum placental growth factor (PlGF), pregnancy-associated plasma protein-A (PAPP-A), free β-human chorionic gonadotropin (β-hCG) and α-fetoprotein (AFP). All had measurement of first-trimester serum markers, and 167 (66%) had second-trimester tests. Values were expressed in multiples of the gestation-specific median (MoMs) in singletons, adjusted for maternal weight, as appropriate.

RESULTS

Pre-eclampsia was diagnosed in 12 (9.0%) twin pregnancies of 133 continuing beyond 22 weeks. In unaffected twin pregnancies, all serum markers were statistically significantly increased (P < 0.0001), consistent with a doubling of concentration. Among twin pregnancies, those with pre-eclampsia had a significantly reduced median PlGF compared with surviving unaffected twin pregnancies (0.96 MoM vs 1.46 MoM; P < 0.0002, two-tailed), whilst median PAPP-A, which is known to be reduced in affected singleton pregnancies, was increased (3.91 MoM vs 2.43 MoM; P < 0.0005, two-tailed). The levels of free β-hCG (P < 0.02) and AFP (P < 0.05) were also significantly raised, but to a lesser extent than was the level of PAPP-A. Using a logistic regression algorithm based on first- and second-trimester PlGF and PAPP-A, together with previously published uterine artery Doppler and mean arterial pressure measurements in the same series, the predicted pre-eclampsia detection rate was 65% for a 10% false-positive rate.

CONCLUSIONS

In twin pregnancy, the predicted detection rate of pre-eclampsia using first- and second-trimester maternal serum and biophysical markers is good. In contrast to singleton pregnancy, PAPP-A levels are raised in the first trimester of twin pregnancies destined to develop pre-eclampsia and therefore a different prediction algorithm is needed. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Uterine artery pulsatility index at 12, 22, 32 and 36 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of uterine artery pulsatility index (UtA-PI) at 12, 22, 32 and 36 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of this biomarker in screening for PE.

METHODS

UtA-PI was measured in 92 712 singleton pregnancies at 11-13 weeks, in 67 605 cases at 19-24 weeks, in 31 741 at 30-34 weeks and in 5523 at 35-37 weeks. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with UtA-PI. The performance of screening for PE requiring delivery < 32, at 32 + 0 to 36 + 6, < 37 and ≥ 37 weeks' gestation was estimated. The results of combined screening were compared to those of screening by UtA-PI and by maternal factors alone.

RESULTS

In pregnancies that developed PE, UtA-PI was increased and the separation in multiples of the median (MoM) values from normal was greater with earlier, compared to later, gestational age at which delivery for PE became necessary. Additionally, the slope of regression lines of UtA-PI MoM with gestational age at delivery in pregnancies that developed PE increased with increasing gestational age at screening. The detection rate (DR), at a 10% false-positive rate (FPR), for PE delivering < 32 weeks was 71% and 88% with combined screening at 11-13 and 19-24 weeks, respectively, and the DR for PE delivering at 32 + 0 to 36 + 6 weeks was 52%, 63% and 71% with screening at 11-13, 19-24 and 30-34 weeks, respectively. However, the DR of PE delivering ≥ 37 weeks was only about 40%, irrespective of the gestational age at screening. The performance of screening by the approach utilizing Bayes' theorem was superior to that of using a percentile cut-off of UtA-PI for gestational age.

CONCLUSIONS

The performance of combined screening with maternal factors and UtA-PI is superior for detection of early, compared to late, PE and, to a certain extent, improves with advancing gestational age at screening. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Prevention of pre-eclampsia by low-molecular-weight heparin in addition to aspirin: a meta-analysis

OBJECTIVE

To estimate the impact of adding low-molecular-weight heparin (LMWH) or unfractionated heparin to low-dose aspirin started ≤ 16 weeks' gestation on the prevalence of pre-eclampsia (PE) and the delivery of a small-for-gestational-age (SGA) neonate.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was performed by searching the medical databases PubMed, EMBASE, Web of Science and Cochrane Central. Pregnant women randomized to receive LMWH or unfractionated heparin in addition to low-dose aspirin were compared with those who received low-dose aspirin alone. Outcome measures were PE, severe PE, early-onset PE and SGA. Pooled relative risks (RRs) with 95% CI were calculated using a random-effects model.

RESULTS

Eight RCTs met the inclusion criteria; the indication for recruitment was previous recurrent miscarriage in five studies (three included women with thrombophilia) and a history of severe or early-onset PE in three studies (including women with thrombophilia in one). LMWH was administered in seven studies and unfractionated heparin in one. In women with a history of PE, treatment with LMWH and aspirin, compared with aspirin alone, was associated with a significant reduction in development of PE (three trials (n = 379); RR, 0.54 (95% CI, 0.31-0.92); P = 0.03) and in delivery of SGA neonates (two trials (n = 363); RR, 0.54 (95% CI, 0.32-0.91); P = 0.02). These outcomes were not significantly reduced in women with recurrent miscarriage who received LMWH and aspirin, compared with aspirin alone. The small number of studies precluded sensitivity analyses and the evaluation of publication biases. Blinding to the allocation treatment was absent in all RCTs.

CONCLUSIONS

Based on limited evidence, the addition of LMWH to low-dose aspirin could reduce the prevalence of PE and SGA in women with a history of PE. This observation should be the basis of a well-conducted future trial rather than a recommendation for immediate clinical application. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Mean arterial pressure at 12, 22, 32 and 36 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of mean arterial pressure (MAP) at 12, 22, 32 and 36 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of this biomarker in screening for PE.

METHODS

MAP was measured in 77 343 cases at 11-13 weeks, in 31 120 cases at 19-24 weeks, in 29 802 at 30-34 weeks and 5543 at 35-37 weeks. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with MAP. The performance of screening for PE requiring delivery < 32, at 32 + 0 to 36 + 6 and ≥ 37 weeks' gestation was estimated.

RESULTS

In pregnancies that developed PE, MAP was increased and the separation in multiples of the median (MoM) values from normal was greater with an earlier, compared to later, gestational age at which delivery for PE became necessary. Additionally, the slope of the regression lines of MAP MoM with gestational age at delivery in pregnancies that developed PE increased with advancing gestational age at screening. The detection rate (DR), at a false-positive rate of 10%, for PE delivering < 32 weeks was 66% and 72% with screening at 12 and 22 weeks, respectively. The DR for PE delivering at 32 + 0 to 36 + 6 weeks was 54%, 56% and 81% with screening at 12, 22 and 32 weeks. The DR for PE delivering ≥ 37 weeks was 45%, 43%, 49% and 59% with screening at 12, 22, 32 and 36 weeks, respectively.

CONCLUSIONS

The performance of combined screening with maternal factors and MAP is superior in screening for early, compared to late, PE and, to a certain extent, improves with advancing gestational age at screening. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis and Management of IUGR in Pregnancy Complicated by Type 1 Diabetes Mellitus

This review discusses available literature on the diagnosis and management of intrauterine growth restriction (IUGR) in women with type 1 diabetes. IUGR is diagnosed when ultrasound-estimated fetal weight is below the 10th percentile for gestational age. IUGR diagnosis implies a pathologic process behind low fetal weight. IUGR in pregnancy complicated by type 1 diabetes is usually caused by placental dysfunction related to maternal vasculopathy. Prevention of IUGR should ideally start before pregnancy. Strict glycemic control and intensive treatment of nephropathy and hypertension are essential. Low-dose aspirin initiated before 16 gestational weeks can also reduce IUGR risk in women with vasculopathy. Umbilical and uterine artery Doppler studies can guide diagnosis and surveillance of fetuses with IUGR. Decisions regarding the timing of delivery should be based on assessment of umbilical artery Doppler. The risk of prematurity and impaired fetal lung maturation should always be considered, especially in fetuses younger than 32 weeks.

Clinical risk factors for pre-eclampsia determined in early pregnancy: systematic review and meta-analysis of large cohort studies

OBJECTIVE

To develop a practical evidence based list of clinical risk factors that can be assessed by a clinician at ≤ 16 weeks' gestation to estimate a woman's risk of pre-eclampsia.

DESIGN

Systematic review and meta-analysis of cohort studies.

DATA SOURCES

PubMed and Embase databases, 2000-15.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Cohort studies with ≥ 1000 participants that evaluated the risk of pre-eclampsia in relation to a common and generally accepted clinical risk factor assessed at ≤ 16 weeks' gestation.

DATA EXTRACTION

Two independent reviewers extracted data from included studies. A pooled event rate and pooled relative risk for pre-eclampsia were calculated for each of 14 risk factors.

RESULTS

There were 25,356,688 pregnancies among 92 studies. The pooled relative risk for each risk factor significantly exceeded 1.0, except for prior intrauterine growth restriction. Women with antiphospholipid antibody syndrome had the highest pooled rate of pre-eclampsia (17.3%, 95% confidence interval 6.8% to 31.4%). Those with prior pre-eclampsia had the greatest pooled relative risk (8.4, 7.1 to 9.9). Chronic hypertension ranked second, both in terms of its pooled rate (16.0%, 12.6% to 19.7%) and pooled relative risk (5.1, 4.0 to 6.5) of pre-eclampsia. Pregestational diabetes (pooled rate 11.0%, 8.4% to 13.8%; pooled relative risk 3.7, 3.1 to 4.3), prepregnancy body mass index (BMI) >30 (7.1%, 6.1% to 8.2%; 2.8, 2.6 to 3.1), and use of assisted reproductive technology (6.2%, 4.7% to 7.9%; 1.8, 1.6 to 2.1) were other prominent risk factors.

CONCLUSIONS

There are several practical clinical risk factors that, either alone or in combination, might identify women in early pregnancy who are at "high risk" of pre-eclampsia. These data can inform the generation of a clinical prediction model for pre-eclampsia and the use of aspirin prophylaxis in pregnancy.

Trends in the incidence of pre-eclampsia and eclampsia in Taiwan between 1998 and 2010

OBJECTIVE

The aim of our study was to determine the relationship between age and the incidence of pre-eclampsia and eclampsia.

MATERIALS AND METHODS

We analyzed data collected by the National Health Insurance Bureau between 1998 and 2010. Data were obtained from the Taiwanese Department of Health website and the Department of Internal Affairs.

RESULTS

The incidence of pre-eclampsia increased significantly (from 0.87% to 1.21%), but the incidence of eclampsia did not change significantly (from 0.04% to 0.05%) between 1998 and 2010. The incidence of pre-eclampsia in the 20-24-year age group was 0.60 ± 0.09%. The relative risk of pre-eclampsia in the different age groups was as follows: aged <20 years, 1.02-fold (p = 1.0); 25-29 years, 1.35-fold (p = 0.041); 30-34 years, 1.79-fold (p < 0.001); 35-39 years, 2.99-fold (p < 0.001); and ≥40 years, 5.13-fold (p < 0.001). The incidence of eclampsia in the 20-24-year age group was 0.04 ± 0.01%. The incidence of eclampsia in only the ≥40-years age group significantly increased by 2.49-fold (p = 0.001).

CONCLUSION

The incidence of pre-eclampsia was correlated with maternal age. The incidence of pre-eclampsia was the lowest in the 20-24-year age group and soared in the >35-year age groups.

Maternal serum placental growth factor at 12, 22, 32 and 36 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of maternal serum placental growth factor (PlGF) at 12, 22, 32 and 36 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of this biomarker in screening for PE.

METHODS

Serum PlGF was measured in 40 212 cases at 11-13 weeks, in 10 282 cases at 19-24 weeks, in 10 400 at 30-34 weeks and 4043 at 35-37 weeks. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with serum PlGF. The performance of screening for PE requiring delivery < 32, at 32 + 0 to 36 + 6 and ≥ 37 weeks' gestation was estimated.

RESULTS

In pregnancies that developed PE, serum PlGF was decreased and the separation in multiples of the median (MoM) values from normal was greater with earlier, compared to later, gestational age at which delivery for PE became necessary. Additionally, the slope of the regression lines of PlGF MoM with gestational age at delivery in pregnancies that developed PE increased with advancing gestational age at screening. The detection rates (DRs), at a false-positive rate (FPR) of 10%, for PE delivering < 32 weeks were 79% and 97% with screening at 12 and 22 weeks, respectively. The DRs for PE delivering at 32 + 0 to 36 + 6 weeks were 57%, 65% and 90% with screening at 12, 22 and 32 weeks. The DRs for PE delivering ≥ 37 weeks were 40%, 37%, 54% and 64% with screening at 12, 22, 32 and 36 weeks, respectively.

CONCLUSIONS

The performance of combined screening with maternal factors, medical history and PlGF is superior in screening for early, compared to late, PE and improves with advancing gestational age at screening. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Maternal serum soluble fms-like tyrosine kinase-1 at 12, 22, 32 and 36 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of maternal serum soluble fms-like tyrosine kinase-1 (sFlt-1) at 12, 22, 32 and 36 weeks' gestation in singleton pregnancies that develop pre-eclampsia (PE) and examine the performance of this biomarker in screening for PE.

METHODS

Serum sFlt-1 was measured in 7066 cases at 11-13 weeks, 8079 cases at 19-24 weeks, 8472 at 30-34 weeks and 4043 at 35-37 weeks. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with serum levels of sFlt-1. The performance of screening for PE in women requiring delivery < 32, between 32 + 0 and 36 + 6 and ≥ 37 weeks' gestation was estimated.

RESULTS

In pregnancies that developed PE, serum sFlt-1 was increased and the separation in multiples of the median (MoM) values from normal was greater with earlier, compared to later, gestational age at which delivery for PE became necessary. In pregnancies that developed PE, the slope of the regression lines of sFlt-1 MoM with gestational age at delivery increased with advancing gestational age at screening. Measurement of sFlt-1 at 11-13 weeks did not improve the prediction of PE achieved by maternal factors alone, sFlt-1 at 19-24 weeks improved the prediction of PE delivering < 37 weeks but not for PE delivering ≥ 37 weeks, sFlt-1 at 30-34 weeks improved the prediction of PE delivering < 37 and PE delivering ≥ 37 weeks and sFlt-1 at 35-37 weeks improved the prediction of PE delivering ≥ 37 weeks. The detection rates (DRs), at a false-positive rate (FPR) of 10%, of PE delivering < 32 weeks were 52% and 65% with screening at 12 and 22 weeks, respectively. The DRs for PE delivering between 32 + 0 and 36 + 6 weeks were 44%, 44% and 93% with screening at 12, 22 and 32 weeks. The DR for PE delivering ≥ 37 weeks were 37%, 37%, 52% and 69% with screening at 12, 22, 32 and 36 weeks, respectively.

CONCLUSIONS

The performance of combined screening with maternal factors, medical history and serum sFlt-1 is superior for detection of early, compared to late, PE and improves with advancing gestational age at screening. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Maternal serum alpha-fetoprotein at 12, 22 and 32 weeks' gestation in screening for pre-eclampsia

OBJECTIVE

To examine the distribution of maternal serum alpha-fetoprotein (AFP) at 12, 22 and 32 weeks' gestation in singleton pregnancies which develop pre-eclampsia (PE) and examine the performance of this biomarker in screening for PE.

METHODS

Serum AFP was measured in 17 071 cases at 11-13 weeks, in 8583 cases at 19-24 weeks and 8609 cases at 30-34 weeks' gestation. Bayes' theorem was used to combine the a-priori risk from maternal characteristics and medical history with AFP. The performance of screening for PE requiring delivery < 32, at 32 + 0 to 36 + 6, < 37 and ≥ 37 weeks' gestation was estimated.

RESULTS

In pregnancies that developed PE, serum AFP multiples of the median (MoM) was increased at 11-13 and 19-24 weeks' gestation, but not at 30-34 weeks, and the values were inversely related to gestational age at delivery. Combined screening with maternal factors and serum AFP improved the prediction provided by maternal factors alone for PE delivering < 37 weeks, but not for PE delivering ≥ 37 weeks. The performance of screening for preterm PE was better at 19-24 weeks than at 11-13 weeks and the detection rate (DR) for a given false-positive rate (FPR) was higher for PE delivering < 32 weeks than for PE delivering at 32 + 0 to 36 + 6 weeks. The DRs, at 10% FPR, of combined screening at 11-13 weeks for PE delivering < 32 and at 32 + 0 to 36 + 6 weeks were 54% and 45%, respectively, and these improved to 72% and 53% with screening at 19-24 weeks.

CONCLUSIONS

Measurement of serum AFP at 11-13 and 19-24 weeks' gestation improves the prediction of preterm PE provided by maternal factors alone. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[Can we prevent preeclampsia?]

Preeclampsia (PE), a specific complication of pregnancy, is one of the most frequent causes of maternal and fetal morbidity and mortality in the world. Recently, PE risk calculation algorithms allowing early detection of PE in the first trimester of pregnancy have been described. The aim of early detection would be to rapidly introduce an effective preventive treatment. The aim of our work is to study the different preventive treatments through the literature. Aspirin has some efficiency and reduces the risk of PE from 10 to 24%. It is most effective when the dose exceeds 75mg and when introduced before 16 gestational age. Early introduction of aspirin mainly prevents severe and preterm PE. Low molecular weight heparin (LMWH) and vitamin D appear to be promising therapy for PE but further research is required. Calcium administered at 1g/day reduces the risk of PE especially to patients with low baseline calcium intake. A low dose of calcium could also reduce the risk of PE but this must be confirmed. Other preventive measures (antioxidants, nitric oxide, progesterone, rest, exercise) do not reduce the incidence of PE.

Preeclampsia: Short-term and Long-term Implications

Preeclampsia is a hypertensive disorder that affects 4% of pregnancies and has a high risk of maternal, fetal, and neonatal morbidity and mortality, as well as long-term cardiovascular risk. Recent updates in the definition, diagnosis, and management guidelines for preeclampsia warrant review by general obstetrician-gynecologists. Screening and prevention algorithms for preeclampsia are available, but ultimately the cure remains delivery of the fetus and placenta. Close monitoring for the development and worsening of preeclampsia during pregnancy is essential to optimize both maternal and fetal/neonatal outcomes.

Maternal Origin and Risk of Neonatal and Maternal ICU Admission

OBJECTIVES

To evaluate maternal world region of birth, as well as maternal country of origin, and the associated risk of admission of 1) a mother to a maternal ICU, 2) her infant to a neonatal ICU, or 3) both concurrently to an ICU.

DESIGN

Retrospective population-based cohort study.

SETTING

Entire province of Ontario, Canada, from 2003 to 2012.

PATIENTS

All singleton maternal-child pairs who delivered in any Ontario hospital.

MEASUREMENTS AND MAIN RESULTS

We explored how maternal world region of birth, and specifically, maternal country of birth for the top 25 countries, was associated with the outcome of 1) neonatal ICU, 2) maternal ICU, and 3) both mother and newborn concurrently admitted to ICU. Relative risks were adjusted for maternal age, parity, income quintile, chronic hypertension, diabetes mellitus, obesity, dyslipidemia, drug dependence or tobacco use, and renal disease. Compared with infants of Canadian-born mothers (110.7/1,000), the rate of neonatal ICU admission was higher in immigrants from South Asia (155.2/1,000), Africa (140.4/1,000), and the Caribbean (167.3/1,000; adjusted relative risk, 1.41; 95% CI, 1.36-1.46). For maternal ICU, the adjusted relative risk was 1.79 (95% CI, 1.43-2.24) for women from Africa and 2.21 (95% CI, 1.78-2.75) for women from the Caribbean. Specifically, mothers from Ghana (adjusted relative risk, 2.71; 95% CI, 1.75-4.21) and Jamaica (adjusted relative risk, 2.74; 95% CI, 2.12-3.53) were at highest risk of maternal ICU admission. The risk of both mother and newborn concurrently admitted to ICU was even more pronounced for Ghana and Jamaica.

CONCLUSIONS

Women from Africa and the Caribbean and, in particular, Ghana and Jamaica, are at higher risk of admission to ICU around the time of delivery, as are their newborns.

Maternal Serum Analytes as Predictors of Fetal Growth Restriction with Different Degrees of Placental Vascular Dysfunction

Abnormal levels of maternal serum analytes have been associated with fetal growth restriction (FGR) and preeclampsia secondary to placental vascular dysfunction. Accurately identifying the FGR fetuses at highest risk for adverse outcomes remains challenging. Placental function can be assessed by Doppler analysis of the maternal and fetal circulation. Although the combination of multiple abnormal maternal serum analytes and abnormal Doppler findings is strongly associated with adverse outcomes, the predictive value remains too low to be used as a screening test in a low-risk population. Stratification of cases based on the severity of Doppler abnormalities may improve predictive models.

Inverted Pyramid of Care

First-trimester pregnancy evaluation using fetal and maternal parameters not only allows for diagnoses to be made early in gestation but can also assess the risk of complications that become clinically evident later in pregnancy. This evaluation makes it possible for pregnancy care to be individualized. In select cases, treatment that reduces the risk of complications can be started early in pregnancy. Even though cell free DNA is a significant advance in diagnosing fetal aneuploidy, the combination of first-trimester ultrasound and maternal serum biochemistries casts a much wider diagnostic net; therefore, the 2 technologies are best used in combination.

Hypertension in pregnancy

PURPOSE OF REVIEW

Hypertension in pregnancy contributes substantially to perinatal mortality and morbidity of both the mother and her child. High blood pressure is mainly responsible for this adverse outcome, in particular when associated with preeclampsia. Although preeclampsia is nowadays a well-known clinical-obstetrical entity, and screening for this complication has been part of routine care during pregnancy for nearly 100 years, its cause is still enigmatic.

RECENT FINDINGS

Profound changes of the demographic development of our society, the worldwide rising prevalence of obesity and metabolic disorders, and progress in reproductive medicine will inevitably modify the prevalence of many medical problems in pregnancy. Complications such as gestational diabetes mellitus, chronic hypertension, and preeclampsia will rise and an interdisciplinary approach is necessary to handle these women during pregnancy and also after delivery. Indeed, it is now well established that these women and their offspring born large or small-for-gestational age are at increased risk for severe cardiovascular and metabolic complications later in life.

SUMMARY

Knowledge of the pregnancy course is not only important for an obstetrician but also increasingly inevitable for the general practitioner. Recognition, classification, and adequate management of hypertensive pregnancy disorders and associated complications may considerably reduce perinatal death and morbidity.

The use of ultrasound and other markers for early detection of preeclampsia

Preeclampsia (PE) is a multisystem disorder of pregnancy classically characterized with the onset of hypertension after 20 weeks gestation in the presence of proteinuria. PE typically affects 2-8% of pregnancies and is a leading cause of maternal and perinatal morbidity and mortality. This article reviews the most effective biomarkers used in first trimester screening for PE. It explores their use both in isolation and as part of an algorithm to yield the best detection rates. Screening by a combination of maternal risk factors, uterine artery Doppler, mean arterial pressure, maternal serum PAPP-A and PlGF can identify about 75% of cases of preterm PE for a false-positive rate of 10%. By identifying these patients at high risk for PE, appropriately tailored antenatal surveillance can be instigated and prophylactic pharmacological interventions can be prescribed to improve placentation and ultimately, the outcome for both the mother and fetus.

Diabetic Nephropathy in Women With Preexisting Diabetes: From Pregnancy Planning to Breastfeeding

In women with preexisting diabetes and nephropathy or microalbuminuria, it is important to deliver careful preconception counselling to assess the risk for the mother and the foetus, for optimizing glycaemic status and to adjust medical treatment. If serum creatinine is normal in early pregnancy, kidney function is often preserved during pregnancy, but complications such as severe preeclampsia and preterm delivery are still common. Perinatal mortality is now comparable with that in women with diabetes and normal kidney function. Besides strict glycaemic control before and during pregnancy, early and intensive antihypertensive treatment is important to optimize pregnancy outcomes. Methyldopa, labetalol, nifedipine and diltiazem are considered safe, whereas angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers should be stopped before or at confirmation of pregnancy. Supplementation with folic acid in early pregnancy and low-dose aspirin from 10 to 12 weeks reduces the risk of adverse pregnancy outcomes. During breastfeeding, several ACE inhibitors are considered safe.

Identifying Key Intervention Opportunities During a Pregnancy Complicated by Diabetes: a Review of Acute Complications of Diabetes During Pregnancy

Diabetes in pregnancy is associated with significant and sometimes devastating acute complications. It is important that all health care providers are aware of possible complications at each stage of pregnancy so that we can prevent these complications whenever possible and reduce morbidity when they do occur. Most complications associated with diabetes during pregnancy have reduced incidence when blood glucose and blood pressure are optimally controlled. Yet, it is always best to try to optimize diabetes and any comorbidities prior to conception.

Competing risks model in screening for preeclampsia by maternal factors and biomarkers at 11-13 weeks gestation

BACKGROUND

Preeclampsia affects approximately 3% of all pregnancies and is a major cause of maternal and perinatal morbidity and death. In the last decade, extensive research has been devoted to early screening for preeclampsia with the aim of reducing the prevalence of the disease through pharmacologic intervention in the high-risk group starting from the first trimester of pregnancy.

OBJECTIVE

The purpose of this study was to develop a model for preeclampsia based on maternal demographic characteristics and medical history (maternal factors) and biomarkers.

STUDY DESIGN

The data for this study were derived from prospective screening for adverse obstetric outcomes in women who attended for their routine first hospital visit at 11-13 weeks gestation in 2 maternity hospitals in England. We screened 35,948 singleton pregnancies that included 1058 pregnancies (2.9%) that experienced preeclampsia. Bayes theorem was used to combine the a priori risk from maternal factors with various combinations of uterine artery pulsatility index, mean arterial pressure, serum pregnancy-associated plasma protein-A, and placental growth factor multiple of the median values. Five-fold cross validation was used to assess the performance of screening for preeclampsia that delivered at <37 weeks gestation (preterm-preeclampsia) and ≥37 weeks gestation (term-preeclampsia) by models that combined maternal factors with individual biomarkers and their combination with screening by maternal factors alone.

RESULTS

In pregnancies that experienced preeclampsia, the values of uterine artery pulsatility index and mean arterial pressure were increased, and the values of serum pregnancy-associated plasma protein-A and placental growth factor were decreased. For all biomarkers, the deviation from normal was greater for early than late preeclampsia; therefore, the performance of screening was related inversely to the gestational age at which delivery became necessary for maternal and/or fetal indications. Combined screening by maternal factors, uterine artery pulsatility index, mean arterial pressure, and placental growth factor predicted 75% (95% confidence interval, 70-80%) of preterm-preeclampsia and 47% (95% confidence interval, 44-51%) of term-preeclampsia, at a false-positive rate of 10%; inclusion of pregnancy-associated plasma protein-A did not improve the performance of screening. Such detection rates are superior to the respective values of 49% (95% confidence interval, 43-55%) and 38% (34-41%) that were achieved by screening with maternal factors alone.

CONCLUSION

Combination of maternal factors and biomarkers provides effective first-trimester screening for preterm-preeclampsia.

Maternal Serum Resistin Is Reduced in First Trimester Preeclampsia Pregnancies and Is a Marker of Clinical Severity

OBJECTIVE

To examine whether resistin levels in first trimester maternal serum are associated with insulin resistance or preeclampsia (PE).

METHODS

A case-control study of maternal serum resistin concentration conducted using 285 normal pregnancies and 123 PE pregnancies matched for gestational age, parity and maternal age. Samples were taken in gestational weeks 10⁺⁰-13⁺⁶.

RESULTS

There was a negative correlation between resistin and clinical severity of PE, but no correlation with IS, TNF-α, body mass index, birth weight and pregnancy length.

CONCLUSIONS

Resistin is reduced in first trimester of PE pregnancies, particularly in severe PE. Inflammation and IS cannot explain this phenomenon.

First trimester prediction of HELLP syndrome

OBJECTIVE

The aim of this study was to evaluate first-trimester maternal characteristics and biomarkers in pregnancies that subsequently develop HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome.

METHOD

Maternal history, biochemical, and biophysical parameters were compared between women who developed HELLP, preeclampsia (PE) without HELLP and controls. After determination of significant variables through univariate analysis a first-trimester prediction model was obtained by applying logistic regression analysis. Performance of the model was evaluated.

RESULTS

Twenty participants with HELLP were compared with 147 patients that developed PE without HELLP and 2810 controls. Women with HELLP were more likely Caucasian, nulliparous and presented a higher mean arterial pressure (MAP) when compared with controls. As opposing to women who developed HELLP, women who developed PE without HELLP were more likely of African-American origin and presented an even higher first-trimester MAP. Enrollment biochemical and biophysical parameters were similar between HELLP and PE or controls. Ethnicity, nulliparity, history of previous PE, history of previous HELLP syndrome, and first-trimester MAP were primary risk factors. A prediction rule for HELLP syndrome had an area under the curve of 0.80, with 75% sensitivity for 79% specificity.

CONCLUSION

The majority of pregnancies that develop HELLP syndrome can be predicted in the first trimester. © 2015 John Wiley & Sons, Ltd.