The impact of chronic hypertension and pregestational diabetes on pregnancy outcomes

Cerebral autoregulation in different hypertensive disorders of pregnancy

OBJECTIVE

Cerebrovascular complications that are associated with hypertensive disorders of pregnancy (preeclampsia, chronic hypertension [CHTN], and gestational hypertension [GHTN]) are believed to be associated with impaired cerebral autoregulation, which is a physiologic process that maintains blood flow at an appropriate level despite changes in blood pressure. The nature of autoregulation dysfunction in these conditions is unclear. We therefore evaluated autoregulation in 30 patients with preeclampsia, 30 patients with CHTN, and 20 patients with GHTN and compared them with a control group of 30 normal pregnant women.

STUDY DESIGN

The autoregulatory index (ARI) was calculated with the use of simultaneously recorded cerebral blood flow velocity in the middle cerebral artery (transcranial Doppler ultrasound), blood pressure (noninvasive arterial volume clamping), and end-tidal carbon dioxide during a 7-minute period of rest. ARI values of 0 and 9 indicate absent and perfect autoregulation, respectively. We use analysis of variance with Bonferroni test vs a control group. Data are presented as mean ± standard deviation.

RESULTS

ARI was significantly reduced in preeclampsia (ARI, 5.5 ± 1.6; P = .002) and CHTN (ARI, 5.6 ± 1.7; P = .004), but not in GHTN (ARI, 6.7 ± 0.8; P = 1.0) when compared with control subjects (ARI, 6.7 ± 0.8). ARI was more decreased in patients with CHTN who subsequently experienced preeclampsia than in those who did not (ARI, 3.9 ± 1.9 vs 6.1 ± 1.2; P = .001). This was not true for women with GHTN or control subjects who later experienced preeclampsia.

CONCLUSION

Pregnant women with CHTN or preeclampsia (even after exclusion of superimposed preeclampsia) have impaired autoregulation when compared with women with GHTN or normal pregnancy. Whether the decreased ARI in patients with CHTN who later experience preeclampsia is due to preexistent differences or early affected cerebral circulation remains to be determined.

A prospective cohort study of a woman's own gestational age and her fecundability

STUDY QUESTION

What is the magnitude of the association between a woman's gestational age at her own birth and her fecundability (cycle-specific probability of conception)?

SUMMARY ANSWER

We found a 62% decrease in fecundability among women born <34 weeks of gestation relative to women born at 37-41 weeks of gestation, whereas there were few differences in fecundability among women born at later gestational ages.

WHAT IS KNOWN ALREADY

One study, using retrospectively collected data on time-to-pregnancy (TTP), and self-reported data on gestational age, found a prolonged TTP among women born <37 gestational weeks (preterm) and with a birthweight ≤1500 g. Other studies of women's gestational age at birth and subsequent fertility, based on data from national birth registries, have reported a reduced probability of giving birth among women born <32 weeks of gestation.

STUDY DESIGN, SIZE, DURATION

We used data from a prospective cohort study of Danish pregnancy planners ('Snart-Gravid'), enrolled during 2007-2011 and followed until 2012. In all, 2814 women were enrolled in our study, of which 2569 had complete follow-up.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Women eligible to participate were 18-40 years old at study entry, in a relationship with a male partner, and attempting to conceive. Participants completed a baseline questionnaire and up to six follow-up questionnaires until the report of pregnancy, discontinuation of pregnancy attempts, beginning of fertility treatment, loss to follow-up or end of study observation after 12 months.

MAIN RESULTS AND THE ROLE OF CHANCE

Among women born <34 gestational weeks, the cumulative probability of conception was 12, 28 and 48% within 3, 6 and 12 cycles, respectively. Among women born at 37-41 weeks of gestation, cumulative probability of conception was 47, 67 and 84% within 3, 6 and 12 cycles, respectively. Relative to women born at 37-41 weeks' gestation, women born <34 weeks had decreased fecundability (fecundability ratio (FR) 0.38, 95% confidence interval (CI): 0.17-0.82). Our data did not suggest reduced fecundability among women born at 34-36 weeks of gestation or at ≥42 weeks of gestation (FR 1.03, 95% CI: 0.80-1.34, and FR 1.13, 95% CI: 0.96-1.33, respectively).

LIMITATIONS, REASONS FOR CAUTION

Data on gestational age, obtained from the Danish Medical Birth Registry, were more likely to be based on date of last menstrual period than early ultrasound examination, possibly leading to an overestimation of gestational age at birth. Such overestimation, however, would not explain the decrease in fecundability observed among women born <34 gestational weeks. Another limitation is that the proportion of women born before 34 weeks of gestation was low in our study population, which reduced the precision of the estimates.

WIDER IMPLICATIONS OF THE FINDINGS

By using prospective data on TTP, our study elaborates on previous reports of impaired fertility among women born preterm, suggesting that women born <34 weeks of gestation have reduced fecundability.

STUDY FUNDING/COMPETING INTERESTS

The study was supported by the National Institute of Child Health and Human Development (R21-050264), the Danish Medical Research Council (271-07-0338), and the Health Research Fund of Central Denmark Region (1-01-72-84-10). The authors have no competing interests to declare.

Prospective risk of fetal death with gastroschisis

OBJECTIVE

To evaluate the ongoing risk of intrauterine fetal demise (IUFD) in fetuses with gastroschisis compared to non-anomalous fetuses.

METHODS

This was a retrospective cohort study of all births in the United States in 2005-2006, as recorded in the National Center for Health Statistics natality database. Risk of IUFD in fetuses with gastroschisis was compared to non-anomalous fetuses, utilizing total at-risk fetuses as the denominator.

RESULTS

Risk of IUFD in fetuses with gastroschisis was 4.5%, compared to 0.6% in non-anomalous fetuses (p < 0.001). When controlling for gestational age and other confounders, the adjusted odds ratio for IUFD in fetuses with gastroschisis was 7.06 (95% CI: 3.33-14.96). After 32 weeks, risk of IUFD/ongoing pregnancy was greater at each week of gestation in fetuses with gastroschisis.

CONCLUSIONS

Risk of IUFD for fetuses with gastroschisis is greater than in non-anomalous fetuses. This risk increases significantly after 32 weeks' gestation. Demographic variables are associated with higher rates of gastroschisis and ultimately IUFD. These data may be useful in consideration of timing of delivery.

Brain-derived neurotrophic factor is expressed in rat and human placenta and its serum levels are similarly regulated throughout pregnancy in both species

OBJECTIVE

Pregnancy is characterized by several metabolic changes that promote fat gain and later onset of insulin resistance. As Brain-derived neurotrophic factor (BDNF) decreases hyperglycaemia and hyperphagia, we aimed to investigate the potential role of placental and circulating BDNF levels in these pregnancy-related metabolic changes in rats and humans.

DESIGN AND METHODS

We identified the mRNA and protein expression of placental BDNF and its receptor TrkB using real-time PCR, Western blot and immunohistochemical approaches in both rat and humans. Serum BDNF was measured by ELISA. We also did a longitudinal prospective cohort study in 42 pregnant women to assess BDNF levels and correlations with other metabolic parameters.

RESULTS

We found that BDNF and TrkB are expressed in both rat and human placenta. In rat, both placental mRNA and serum levels are increased throughout pregnancy, whereas their protein levels are significantly decreased at the end of gestation. Serum BDNF levels in pregnant women are significantly lower in the first trimester when compared to the second and third trimester (P < 0·0148, P < 0·0012, respectively). Serum BDNF levels were negatively correlated with gestational age at birth and fasting glucose levels.

CONCLUSION

Our findings suggest that both BDNF and its receptor TrkB are expressed in rodent and human placenta being regulated during pregnancy. Taken together, these findings support a role of BDNF in the regulation of several metabolic functions during pregnancy.

Maternal and newborn outcomes among women with schizophrenia: a retrospective population-based cohort study

OBJECTIVE

More women with schizophrenia are becoming pregnant, such that contemporary data are needed about maternal and newborn outcomes in this potentially vulnerable group. We aimed to quantify maternal and newborn health outcomes among women with schizophrenia.

DESIGN

Retrospective cohort study.

SETTING

Population based in Ontario, Canada, from 2002 to 2011.

POPULATION

Ontario women aged 15-49 years who gave birth to a liveborn or stillborn singleton infant.

METHODS

Women with schizophrenia (n = 1391) were identified based on either an inpatient diagnosis or two or more outpatient physician service claims for schizophrenia within 5 years prior to conception. The reference group comprised 432 358 women without diagnosed mental illness within the 5 years preceding conception in the index pregnancy.

MAIN OUTCOME MEASURES

The primary maternal outcomes were gestational diabetes mellitus, gestational hypertension, pre-eclampsia/eclampsia, and venous thromboembolism. The primary neonatal outcomes were preterm birth, and small and large birthweight for gestational age (SGA and LGA). Secondary outcomes included additional key perinatal health indicators.

RESULTS

Schizophrenia was associated with a higher risk of pre-eclampsia (adjusted odds ratio, aOR 1.84; 95% confidence interval, 95% CI 1.28-2.66), venous thromboembolism (aOR 1.72, 95% CI 1.04-2.85), preterm birth (aOR 1.75, 95% CI 1.46-2.08), SGA (aOR 1.49, 95% CI 1.19-1.86), and LGA (aOR 1.53, 95% CI 1.17-1.99). Women with schizophrenia also required more intensive hospital resources, including operative delivery and admission to a maternal intensive care unit, paralleled by higher neonatal morbidity.

CONCLUSIONS

Women with schizophrenia are at higher risk of multiple adverse pregnancy outcomes, paralleled by higher neonatal morbidity. Attention should focus on interventions to reduce the identified health disparities.

Assessment of reproductive health and violence against women among displaced Syrians in Lebanon

BACKGROUND

The current conflict in Syria continues to displace thousands to neighboring countries, including Lebanon. Information is needed to provide adequate health and related services particularly to women in this displaced population.

METHODS

We conducted a needs assessment in Lebanon (June-August 2012), administering a cross-sectional survey in six health clinics. Information was collected on reproductive and general health status, conflict violence, stress, and help-seeking behaviors of displaced Syrian women. Bivariate and multivariate analyses were conducted to examine associations between exposure to conflict violence, stress, and reproductive health outcomes.

RESULTS

We interviewed 452 Syrian refugee women ages 18-45 who had been in Lebanon for an average of 5.1 (± 3.7) months. Reported gynecologic conditions were common, including: menstrual irregularity, 53.5%; severe pelvic pain, 51.6%; and reproductive tract infections, 53.3%. Among the pregnancy subset (n = 74), 39.5% of currently pregnant women experienced complications and 36.8% of those who completed pregnancies experienced delivery/abortion complications. Adverse birth outcomes included: low birthweight, 10.5%; preterm delivery, 26.5%; and infant mortality, 2.9%. Of women who experienced conflict-related violence (30.8%) and non-partner sexual violence (3.1%), the majority did not seek medical care (64.6%). Conflict violence and stress score was significantly associated with reported gynecologic conditions, and stress score was found to mediate the relationship between exposure to conflict violence and self-rated health.

CONCLUSIONS

This study contributes to the understanding of experience of conflict violence among women, stress, and reproductive health needs. Findings demonstrate the need for better targeting of reproductive health services in refugee settings, as well as referral to psychosocial services for survivors of violence.

Maternal morbidity and preterm birth in 22 low- and middle-income countries: a secondary analysis of the WHO Global Survey dataset

Background

Preterm birth (PTB) (<37weeks) complicates approximately 15 million deliveries annually, 60% occurring in low- and middle-income countries (LMICs). Several maternal morbidities increase the risk of spontaneous (spPTB) and provider-initiated (piPTB) preterm birth, but there is little data from LMICs.

Method

We used the WHO Global Survey to analyze data from 172,461 singleton deliveries in 145 facilities across 22 LMICs. PTB and six maternal morbidities (height <145 cm, malaria, HIV/AIDS, pyelonephritis/UTI, diabetes and pre-eclampsia) were investigated. We described associated characteristics and developed multilevel models for the risk of spPTB/piPTB associated with maternal morbidities. Adverse perinatal outcomes (Apgar <7 at 5 minutes, NICU admission, stillbirth, early neonatal death and low birthweight) were determined.

Results

8.2% of deliveries were PTB; one-quarter of these were piPTB. 14.2% of piPTBs were not medically indicated. Maternal height <145 cm (AOR 1.30, 95% CI 1.10–1.52), pyelonephritis/UTI (AOR 1.16, 95% CI 1.01–1.33), pre-gestational diabetes (AOR 1.41, 95% CI 1.09–1.82) and pre-eclampsia (AOR 1.25, 95% CI 1.05–1.49) increased odds of spPTB, as did malaria in Africa (AOR 1.67, 95%CI 1.32-2.11) but not HIV/AIDS (AOR 1.17, 95% CI 0.79-1.73). Odds of piPTB were higher with maternal height <145 cm (AOR 1.47, 95% CI 1.23-1.77), pre-gestational diabetes (AOR 2.51, 95% CI 1.81-3.47) and pre-eclampsia (AOR 8.17, 95% CI 6.80-9.83).

Conclusions

Maternal height <145 cm, diabetes and pre-eclampsia significantly increased odds of spPTB and piPTB, while pyelonephritis/UTI and malaria increased odds of spPTB only. Strategies to reduce PTB and associated newborn morbidity/mortality in LMICs must prioritize antenatal screening/treatment of these common conditions and reducing non-medically indicated piPTBs where appropriate.

Superoxide dismutase 1 overexpression in mice abolishes maternal diabetes-induced endoplasmic reticulum stress in diabetic embryopathy

OBJECTIVE

Both oxidative stress and endoplasmic reticulum stress (ER stress) are causal events in diabetic embryopathy. We tested whether oxidative stress causes ER stress.

STUDY DESIGN

Wild-type (WT) and superoxide dismutase 1 (SOD1)-overexpressing day 8.75 embryos from nondiabetic WT control with SOD1 transgenic male and diabetic WT female with SOD1 transgenic male were analyzed for ER stress markers: C/EBP-homologous protein (CHOP), calnexin, eukaryotic initiation factor 2α (eIF2α), protein kinase ribonucleic acid (RNA)-like ER kinase (PERK), binding immunoglobulin protein, protein disulfide isomerase family A member 3, kinases inositol-requiring protein-1α (IRE1α), and the X-box binding protein (XBP1) messenger RNA (mRNA) splicing.

RESULTS

Maternal diabetes significantly increased the levels of CHOP, calnexin, phosphorylated (p)-eIF2α, p-PERK, and p-IRE1α; triggered XBP1 mRNA splicing; and enhanced ER chaperone gene expression in WT embryos. SOD1 overexpression blocked these diabetes-induced ER stress markers.

CONCLUSION

Mitigating oxidative stress via SOD1 overexpression blocks maternal diabetes-induced ER stress in vivo.

[How to manage a patient with chronic arterial hypertension during pregnancy and the postpartum period]

The management of chronic arterial hypertension during pregnancy and postpartum requires first to estimate the risk of the pregnancy, linked with the severity of hypertension, with cardiac and renal involvement, with its cause as well as with the background (obesity, diabetes, possible history of placental vascular pathology). On a very practical approach, antihypertensive drug has to be started or increased if systolic pressure reaches or exceeds 160 mmHg or if diastolic pressure reaches or exceeds 105 mmHg. Below this level, there are no evidence-based medicine data, but it seems reasonable to treat if pressure increases over 150/100 mmHg (140/90 mmHg in case of ambulatory monitoring). Excessive pressure figures control must be avoided as much as insufficient ones: in practice, it is necessary to decrease the treatment dose if figures are below 130/80 mmHg. Three antihypertensive drugs are consensually recommended today: alphametyldopa, calcium-channel blockers and labetalol. Monotherapy is most often sufficient; if needed, two of these drugs can easily be associated, and even three if necessary. Converting enzyme inhibitors and angiotensin receptor II antagonists should not be prescribed to pregnant women. Betablockers and diuretics are not recommended. Whatever is the antihypertensive drug used, it is necessary to detect the signs of bad placenta blood circulation with uterine Doppler ultrasound and regular controls of fetal growth, and to check for appearance of proteinuria, defining then over-imposed pre-eclampsia needing immediate admission to the maternity. After delivery, lacatation suppresion with bromocriptin should not be prescribed.