Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222

Single-nucleus transcriptional profiling of the placenta reveals the syncytiotrophoblast stress response to COVID-19

BACKGROUND

COVID-19 in pregnancy is associated with placental immune activation, inflammation, and vascular malperfusion, but its impact on syncytiotrophoblast biology and function is unclear.

OBJECTIVE

This study aimed to determine the effects of maternal COVID-19 on placental syncytiotrophoblasts using single-nucleus transcriptional profiling and to compare placental stress responses in COVID-19 and preeclampsia.

STUDY DESIGN

For transcriptional characterization of syncytiotrophoblasts, we used the single-nucleus RNA sequencing platform, single-cell combinatorial indexing RNA sequencing (sci-RNA-seq3), to profile placental villi and fetal membranes from unvaccinated patients with symptomatic COVID-19 at birth (n = 4), gestational age-matched controls (n = 4), and a case of critical COVID-19 in the second trimester with delivery at term (n = 1). Clustering of nuclei and differential gene expression analysis was performed in Seurat. Gene ontology analysis was conducted using Enrichr. High-confidence transcriptional target analysis was used to identify key transcription factor nodes governing the syncytiotrophoblast response to maternal SARS-CoV-2 infection. Bioinformatic approaches were further used to compare the COVID-19 dataset to published preeclampsia gene signatures. Tissue analysis, including immunofluorescence, was conducted to validate the transcriptional data and to compare COVID-19 and preeclampsia placental histology for an expanded cohort of placentas: controls (n = 6), asymptomatic COVID-19 (n = 3), symptomatic COVID-19 (n = 5), and preeclampsia with severe features (n = 7).

RESULTS

The analyzed dataset comprised 15 cell clusters and 47,889 nuclei. We identified 3 clusters of syncytiotrophoblasts representing fusing and mature nuclei with overlapping but distinct transcriptional responses to COVID-19. Bioinformatic analyses indicated that COVID-19 is associated with the following alterations in syncytiotrophoblasts: (1) endoplasmic reticulum stress and activation of stress signaling pathways, including the unfolded protein response and integrated stress response; (2) regulation of gene expression by CCAAT/enhancer-binding protein beta (CEBPB), a master transcription factor of the syncytiotrophoblast lineage; and (3) upregulation of preeclampsia-associated genes. Using complementary methods, we confirmed increased levels of stress response proteins (eg, BiP, G3BP1) in syncytiotrophoblasts, unfolded protein response signaling (spliced XBP1 mRNA), and CEBPB activation (phosphorylation) in COVID-19. Increased cytotrophoblast proliferation (Ki-67) was also detected in COVID-19, consistent with a trophoblast response to injury. Markers of stress detected in preeclampsia demonstrated similarities in the placental stress phenotype of COVID-19 and preeclampsia.

CONCLUSION

Maternal COVID-19 is associated with syncytiotrophoblast endoplasmic reticulum stress and activation of the syncytiotrophoblast lineage transcription factor, CEBPB. Similarities between syncytiotrophoblast stress in COVID-19 and preeclampsia provide insights into their clinical association.

Insights from preventability assessments across 42 state and city maternal mortality reviews in the United States

BACKGROUND

The rising trend in maternal mortality over the past 3 decades sets the United States apart from all other high-income countries. Multidisciplinary state and city Maternal Mortality Review Committees conduct comprehensive reviews of maternal deaths, including assessments of preventability and contributing factors.

OBJECTIVE

Assess preventability of and contributing factors to maternal mortality in the U.S.

STUDY DESIGN

This study is a secondary analysis of cross-sectional, population-based data from the most recent, publicly available Maternal Mortality Review Committee data from 40 state and 2 cities in the U.S. Preventability were analyzed among all deaths during pregnancy or within 1 year postpartum from any cause (pregnancy-associated deaths) and deaths during pregnancy or within 1 year postpartum from causes related to pregnancy or its management, but not from accidental causes (pregnancy-related deaths). We also explored preventability by cause-of-death and contributing factors grouped as community, patient-family, provider, facility, and health system factors.

RESULTS

Of deaths that occurred after 2010, between 53% to 93.8% of pregnancy-associated deaths and 45% to 100% of pregnancy-related deaths were deemed preventable across the 42 states and cities. Across the 10 states reporting pregnancy-related death preventability by cause-of-death, Maternal Mortality Review Committees deemed preventable >90% of deaths from preeclampsia-eclampsia and mental health conditions, >80% of deaths from hemorrhage and cardiovascular conditions, about 70% of deaths from infection and thrombotic embolism, and about 40% of deaths from amniotic fluid embolism and stroke. A total of 3345 contributing factors were described in Maternal Mortality Review Committee reports from 14 states in relation to 739 pregnancy-related deaths. While collectively patient-family and provider factors were most frequently noted as contributing to pregnancy-related deaths, the contribution of such factors varied between 6% to 56% and 18% to 42.3%, respectively, across the states. Based on data from 20 Maternal Mortality Review Committees with available information, racism or discrimination were noted in relation to 37.7% of pregnancy-related deaths.

CONCLUSION

A large proportion of pregnancy-associated deaths and pregnancy-related deaths in the U.S. are preventable. However, likely due to differences in Maternal Mortality Review Committee membership, available data, and judgement employed to determine preventability, wide variation exists in the proportion of deaths deemed preventable and factors identified as contributing to such deaths across states. There is need to reevaluate the definitions, structure, and outputs for maternal death preventability assessments currently employed by a majority Maternal Mortality Review Committees to adequately inform state and national programming and policies.

Placenta Accreta Spectrum Disorder Associated With Late Onset Pre-Eclampsia: A Case Report

Placenta Accreta Spectrum (PAS) disorder is a condition characterized by abnormal adherence and various levels of invasive placentation, whereas the physiopathology of pre-eclampsia (PE) involves insufficient trophoblast invasion of maternal blood vessels in early pregnancy and subsequent placental insufficiency. In this case report, we elaborate on these two pathologies and describe the case of a patient with PAS disorder, who developed term PE.

Preeclampsia risk prediction from prenatal cell-free DNA screening

Preeclampsia is characterized by placental dysfunction and results in significant morbidity, but reliable early prediction remains challenging. We investigated whether clinically obtained prenatal cell-free DNA (cfDNA) screening (PDNAS) using whole-genome sequencing (WGS) data can be leveraged to predict preeclampsia risk early in pregnancy (≤16 weeks). Using 1,854 routinely collected clinical PDNAS samples (median, 12.1 weeks) with low-coverage (0.5×) WGS data, we developed a framework to quantify maternal and fetal tissue signatures using nucleosome accessibility, revealing early placental and endothelial dysfunction. These signatures informed a prediction model for preeclampsia risk, which achieved a validation performance of 0.85 area under the receiver operating characteristic curve (AUC) (81% sensitivity at 80% specificity) for preterm phenotypes several months prior to disease onset in a separate cohort of 831 consecutively collected samples, and subsequently confirmed in an external cohort of 141 samples (AUC 0.84, 79% sensitivity). We demonstrate that assessment of cfDNA nucleosome accessibility from early-pregnancy cfDNA sequence data enables the detection of early placental and endothelial-tissue aberrations and may aid in the determination of preeclampsia risk.

Impacts of Lifestyle Intervention by a Nurse-Led Smartphone Application on Blood Pressure, Weight, and Pregnancy Outcomes in Pregnant Women With Gestational Hypertension: A Randomized Controlled Trial

High blood pressure and excess weight during pregnancy can have adverse outcomes. This randomized controlled trial evaluated the effects of a nurse-led smartphone application-based lifestyle intervention on blood pressure, body weight, and pregnancy outcomes in pregnant women with gestational hypertension between August and December 2023. Pregnant women, between 20 and 28 weeks of gestation, were allocated to the intervention or control group. Control group (n = 99) received standard high-risk pregnancy management, while intervention group (n = 96) also received lifestyle guidance via a nurse-led smartphone application. Intervention group experienced longer gestations (p = 0.007), higher neonatal weights (p = 0.028), and lower incidences of pre-eclampsia (p < 0.001), small for gestational age infants (p = 0.003), and preterm births (p = 0.023) compared to control group. The mixed-effect models for repeated measures showed that the nurse-led smartphone application intervention had no impact on body mass index, while significantly reducing systolic and diastolic blood pressure measurements (β = -1.666, 95% confidence interval, CI: -2.814 to -0.519, p = 0.005 and β = -2.247, 95% CI: -3.349 to -1.145, p < 0.001, respectively). Both systolic and diastolic blood pressures showed a downward trend from 28 weeks (p < 0.05). The nurse-led smartphone application-based lifestyle intervention significantly reduced adverse pregnancy outcomes and positively influenced blood pressure management in pregnant women with gestational hypertension.

Real-world evidence for the utility of serum soluble fms-like tyrosine kinase 1/placental growth factor test for routine clinical evaluation of hospitalized women with hypertensive disorders of pregnancy

BACKGROUND

An imbalance of the antiangiogenic factor, soluble fms-like tyrosine kinase-1, and proangiogenic factor, placental growth factor, in the circulation is a reliable predictor for the development of preeclampsia with severe features and related adverse outcomes. In 2023, the US Food and Drug Administration approved a serum soluble fms-like tyrosine kinase-1/placental growth factor test at a cutoff of 40 to aid in the risk assessment of women hospitalized for hypertensive disorders of pregnancy for the progression to preeclampsia with severe features between 23 and 35 weeks.

OBJECTIVE

This study aimed to generate real-world evidence for clinical utility for serum soluble fms-like tyrosine kinase-1/placental growth factor test when made available to clinicians in a timely fashion as an aid in risk stratification of development of preeclampsia with severe features within 2 weeks of testing among hospitalized patients with hypertensive disorders of pregnancy.

STUDY DESIGN

Hospitalized patients with hypertensive disorders of pregnancy between 23 weeks to 34 weeks and 6 days of gestation were prospectively studied from June 2023 to January 2024 after the implementation of serum soluble fms-like tyrosine kinase-1/placental growth factor testing into routine clinical practice. Serum samples were obtained from patients via venipuncture and analyzed on an automated immunoassay platform (placental growth factor and soluble fms-like tyrosine kinase-1 assays; Thermo Fisher Scientific). Before implementation, physicians were educated on appropriate use and management guidelines on the basis of biomarkers but made pragmatic management decisions independently. Results of soluble fms-like tyrosine kinase-1/placental growth factor tests were available to clinicians within 24 hours of venipuncture. The association between soluble fms-like tyrosine kinase-1/placental growth factor ≥40 and progression to preeclampsia with severe features and adverse maternal/perinatal outcomes were assessed.

RESULTS

Of the 65 patient encounters, 36 had a soluble fms-like tyrosine kinase-1/placental growth factor <40 (55.4%). The rate of delivery for indications related to hypertensive disorders of pregnancy within 2 weeks was significantly lower among encounters with a low ratio vs high ratio (2/36 [5.6%] vs 21/29 [72.4%]) even after controlling for relevant confounders (adjusted hazard ratio, 7.52; 95% confidence interval, 3.05-18.54; P<.001). A diagnosis of preeclampsia with severe features within 2 weeks of testing was also less likely among the encounters with soluble fms-like tyrosine kinase-1/placental growth factor ratio <40 when compared with soluble fms-like tyrosine kinase-1/placental growth factor ratio ≥40 (2/36 [5.6%] vs 23/29 [79.3%], P<.001; positive predictive value of 79% [95% confidence interval, 0.65-0.94] and negative predictive value of 0.94 [95% confidence interval, 0.87-1.00]). The positive and negative likelihood ratios for the development of preeclampsia with severe features within 2 weeks of testing were 6.13 and 0.09, respectively. Encounters with a soluble fms-like tyrosine kinase-1/placental growth factor ratio <40 were less likely to experience a maternal or fetal adverse event as compared with encounters with soluble fms-like tyrosine kinase-1/placental growth factor ratio ≥40 (3/36 [8.3%] vs 10/29 [34.5%], P=.01). Among 36 encounters involving low soluble fms-like tyrosine kinase-1/placental growth factor values, 22 had had equivocal clinical or laboratory criteria resembling preeclampsia at presentation but were expectantly managed on the basis of biomarkers, and none developed preeclampsia with severe features or adverse outcomes at 2 weeks. The median latency defined as days between biomarker measurement and delivery in patients with a low biomarker ratio was 33 (interquartile ratio, 23-47) vs 7 (interquartile ratio, 4-14) days among patients with a high ratio (P<.001). Corticosteroid use within 2 weeks was also significantly reduced in the low biomarker group when compared with the high biomarker group (8/35 [22.9%] vs 24/29 [82.8%], P<.001).

CONCLUSION

In this study, the incorporation of soluble fms-like tyrosine kinase-1/placental growth factor ratio into clinical practice serves as a dependable supplement in assessing risk for progression to preeclampsia with severe features and adverse outcomes in patients with hypertensive disorders of pregnancy in the United States. Among patients with a low ratio, pregnancy may be prolonged, which results in better neonatal outcomes without harm to the mother.

Stem Cell Markers LGR5, LGR4 and Their Immediate Signalling Partners are Dysregulated in Preeclampsia

Leucine-rich repeat-containing G protein-coupled receptors 5/4 (LGR5/LGR4) are critical stem cell markers in epithelial tissues including intestine. They agonise wingless-related integration site (WNT) signalling. Until now, LGR5/LGR4 were uncharacterised in placenta, where analogous functions may exist. We characterised LGR5/LGR4, their ligands/targets in human placenta, with further assessments on dysregulation in preeclampsia/fetal growth restriction (FGR). LGR5 mRNA was unaltered in first trimester (n = 11), preterm (n = 9) and term (n = 11) placental lysate. LGR5 was enriched in human trophoblast stem cells (hTSCs) and downregulated with differentiation to extravillous trophoblasts (p < 0.0215) and syncytiotrophoblasts (p < 0.0350). In situ hybridisation localised LGR5 to unique, proliferative MKI67 + mononuclear trophoblasts underlying syncytium which concurred with proposed progenitor identities in single-cell transcriptomics. LGR5 expression was significantly reduced in placentas from early-onset preeclampsia (p < 0.0001, n = 81 versus n = 19 controls), late-onset preeclampsia (p = 0.0046, n = 20 versus n = 33 controls) and FGR (p = 0.0031, n = 34 versus n = 17 controls). LGR4 was elevated in first trimester versus preterm and term placentas (p = 0.0412), in placentas with early-onset preeclampsia (p = 0.0148) and in FGR (p = 0.0417). Transcriptomic analysis and in vitro hTSC differentiation to both trophoblast lineages suggested LGR4 increases with differentiation. Single-nucleus RNA sequencing of placental villous samples supported LGR5 and LGR4 localisation findings. Hypoxia/proinflammatory cytokine treatment modelling elements experienced by the placenta in placental insufficiency pathogenesis did not significantly alter LGR5/LGR4. Ligands R-spondins 1/3/4, and neutralising targets ring finger protein 43 (RNF43) and zinc and ring finger 3 (ZNRF3) were also reduced in placentas from preeclamptic pregnancies. This study is the first to describe LGR5/LGR4 and their signalling partner expression in human placenta. Their dysregulations in the preeclamptic placenta allude to disruptions to integral trophoblast stem cell function/differentiation that may occur during placental development related to WNT signalling.

Maternal Hypertension and Adverse Neurodevelopment in a Cohort of Preterm Infants

Importance

Whether maternal hypertensive disorders of pregnancy (HDP) confer independent neurodevelopmental deficit risks in premature infants is controversial. Previous studies are limited by inadequate confounding variable control and other biases.

Objective

To evaluate the associations between maternal HDP, especially preeclampsia, and neurodevelopmental outcomes of preterm infants at 2 years' corrected age.

Design, Setting, and Participants

Regional prospective cohort study of 395 preterm infants (≤32 weeks' gestation) from 5 level III and IV southeast Ohio neonatal intensive care units from September 2016 to November 2019. Data analysis was conducted in August 2022.

Exposure

HDP, defined by maternal diagnosis of chronic or gestational hypertension or preeclampsia during pregnancy.

Main Outcomes and Measures

Structural brain magnetic resonance imaging was performed at term-equivalent age. Neurodevelopment was assessed by Bayley Scales of Infant and Toddler Development (BSID), Third Edition, between 22 and 26 months' corrected age. Multivariable regression was used to identify the independent association of HDP and preeclampsia on cognitive (primary outcome), language, and motor development, controlling for several confounders. Mediation analyses were performed to understand if the association with HDP was mediated by its association with birth weight or brain abnormalities.

Results

In a cohort of 395 infants, the median (IQR) gestational age was 29.6 (27.6-31.4) weeks, birth weight was 1230 (950-1628) g, and 210 (53.2%) were male. Of these, 170 (43%) were HDP-exposed, of which 104 of 170 (61%) were exposed to preeclampsia. A total of 341 children (87%) completed the BSID. In adjusted analyses, HDP exposure was negatively associated with BSID cognitive scores (-3.69; 95% CI, -6.69 to -0.68; P = .02) and language scores (-4.07; 95% CI, -8.03 to -0.11; P = .04). Preeclampsia exposure showed similarly negative but greater associations for BSID scores (-4.85; 95% CI, -8.63 to -1.07; P = .01 for cognitive and -6.30; 95% CI, -11.49 to -1.09; P = .02 for language scores). Mediation analysis revealed that the association between HDP and cognitive scores was partially mediated by its adverse association with brain abnormalities at term-equivalent age (24% of the total effect; -0.82; 95% CI, -1.72 to -0.13; P = .02).

Conclusions and Relevance

In this preterm cohort study, maternal HDP was independently associated with adverse cognitive and language development, with accentuated associations observed in preeclampsia-exposed preterm infants, emphasizing the clinical importance of recognizing HDP as a risk, enabling targeted risk management strategies for closer monitoring and aggressive early intervention in affected populations.

"It's a priority": a qualitative analysis of the implementation of a maternal equity safety bundle in Massachusetts

BACKGROUND

Black-White inequities in severe maternal morbidity in the United States are extreme and growing. Maternal safety bundles (MSBs) have been associated with closing racial equity gaps in maternal health in some states. The objective of this study was to explore clinician perspective and experiences of implementing an Equity maternal safety bundle across five hospitals in Massachusetts to address inequities in perinatal care and birth outcomes.

METHODS

Focus group discussions and interviews were conducted in Fall 2022 and Fall 2023 (before and after Equity MSB implementation) among obstetric nurses, resident physicians, and attending physicians. Discussions were facilitated using a semi-structured guide developed using the Consolidated Framework for Implementation Research (CFIR). Transcripts were independently coded by two analysts using NVivo 14. A codebook was developed using CFIR for deductive coding. We added inductive codes as appropriate. We calculated Cohen's kappa coefficients to assess interrater reliability. Themes were generated through an iterative process and compared across study time points.

RESULTS

Fifteen clinicians participated at each time point with similar distributions across race, ethnicity, gender, and profession. Seven themes emerged from these interviews: 1) the importance of leadership support to prioritize equity, 2) a culture of equity as a facilitator for implementation, 3) the need for improved processes for self-reported race, ethnicity, and language data collection, stratification, and dissemination, 4) staff, time, and funding as necessary resources, 5) the need for an early focus on staff education, 6) existing siloes between physicians and nurses and exclusion of trainees as barriers to implementation, and 7) differences between an Equity-MSB and other MSBs.

CONCLUSIONS

Leadership prioritization of equity and a culture of equity emerged as facilitators to successful implementation of elements of the Equity MSB. Challenges identified included resistance to change among colleagues, limited resources, and clinician siloes. When compared to previously implemented MSBs, participants found that leadership made this work a priority. As future hospital teams embark on implementing equity-focused action, these known facilitators and barriers should be considered and addressed during the pre- and early-implementation phases.

Relationship between prepregnancy BMI and gestational weight gain(GWG) with preeclampsia: a study based on restricted cubic spline

OBJECTIVE

This study aimed to evaluate the nonlinear associations between prepregnancy body mass index(BMI), gestational weight gain(GWG), and the risk of preeclampsia(PE) using maternal and infant cohort data, thereby providing a scientific foundation for preventive strategies.

METHODS

Pregnant women with regular obstetric checkups in Urumqi Youai Hospital were selected as study subjects from January 2020 to June 2024. They were divided into the PE group and the non-PE group. Baseline information and pregnancy outcomes were collected, and logistic regression analysis was employed to ascertain the impacts of diverse factors on the odds of developing PE; the restricted cubic spline was used to test the nonlinear relationship between prepregnancy BMI and GWG with PE.

RESULTS

13,294 pregnant women were included in the study, and 559 (4.20%) had PE.The prevalence of PE in underweight, normal-weight, overweight, and obese women was 1.72%, 2.85%, 6.60%, and 16.05%, respectively. However, after adjusting for confounders, only overweight and obesity were significantly associated with elevated PE odds. Logistic regression results showed that the OR was 1.68(95% CI:1.30-2.18) for the comparison between overweight and normal BMI groups, the OR was 3.16(95%CI:2.08-4.79) for the comparison between obesity and normal BMI groups. Restricted cubic spline showed that the association between prepregnancy BMI and the odds of PE showed an inverse L-shaped curve, with an inflection point of 21.5 kg/m2; the association between GWG and the odds of PE showed a J-shaped curve, with a GWG of 10.94-15.90 kg being at the lowest odds for the development of PE. For pregnant women with prepregnancy underweight, the odds of PE were significantly increased when their GWG exceeded 21.63 kg. Similarly, for those with prepregnancy normal weight, a significant elevation in the odds of PE was observed when their GWG surpassed 15.90 kg.

CONCLUSION

There is a non-linear relationship between prepregnancy BMI, GWG, and PE, and prepregnancy weight management and gestational weight monitoring are important for the prevention of PE.

Circulating Potassium/Magnesium Ratio, Thyroid Stimulating Hormone, Fasting Plasma Glucose, Oxidized LDL/Albumin Ratio, and Urinary Iodine Concentration Are Possible Entities for Screening for Preeclampsia in Low-Resource Settings

Background and Objectives: Several micro- and macro-nutrient malnutrition states that are routinely assessed during clinical care of women in the antenatal period have been proposed as risk factors for preeclampsia. However, there is a paucity of data on the potential use of these biomarkers for detection of preeclampsia. The aim of this case-control study was to investigate the association of biomarkers from routine clinical tests, and those specific to micro- and macro-nutrient malnutrition, with the risk of preeclampsia. Materials and Methods: Venous blood samples of 250 participants with preeclampsia and 150 pregnant women without preeclampsia were collected and assayed immediately for the full blood count, urea and electrolytes, high-density cholesterol (HDL), total cholesterol, triglycerides, low-density lipoprotein cholesterol (LDL), oxidized low-density lipoprotein cholesterol (OxLDL), and selenium, in addition to urine iodine concentration (UIC). Results: The serum potassium/magnesium ratio (K+/Mg2+), UIC, fasting plasma glucose (FPG), thyroid stimulating hormone (TSH), lymphocyte percentage (L/WBC%), and the oxidized LDL/albumin ratio (OxLDL/Alb) were identified as independent predictors of preeclampsia. Conclusions: Serum potassium/magnesium ratio and other analytes essential for various biological processes, some of which are assayed during routine care, were significantly associated with preeclampsia, warranting further exploration as potential screening biomarkers in low-resource settings.

Oxidative Stress in Maternal and Offspring Kidney Disease and Hypertension: A Life-Course Perspective

Kidney disease and hypertension are interconnected, prevalent conditions that affect both pregnant women and children. Oxidative stress occurs when reactive oxygen species or reactive nitrogen species exceed the capacity of antioxidant systems. It plays a critical role in kidney development, resulting in kidney programming and increased risks for kidney disease and hypertension across the life course. Animal models have significantly advanced our understanding of oxidative stress-related kidney programming, the molecular mechanisms involved, and early-life antioxidant interventions to prevent kidney disease. This review critically examines the influence of perinatal oxidative stress on kidney development, highlighting its long-term effects on kidney outcomes and susceptibility to hypertension. It also explores the potential of antioxidant-based interventions in preventing kidney disease and hypertension. Furthermore, the review addresses the existing gap between insights gained from animal models and their translation into clinical practices, emphasizing the challenges and opportunities for future research in this area.

Adverse Pregnancy Outcomes and Cardiovascular Disease: A Spanish Cohort

Background and Aims: Emerging evidence suggests adverse pregnancy outcomes (APOs) may increase future cardiovascular risk. This study aimed to assess in a Spanish cohort the long-term risk of cardiovascular disease in women with APOs compared to those without such complications. Methods: A retrospective longitudinal cohort study was conducted at Hospital Vall d'Hebron (Barcelona, Spain), including pregnant women delivering between January 2010 and December 2015. Women with pre-existing medical conditions were excluded. APOs included preeclampsia, gestational diabetes, preterm birth, late miscarriage, and stillbirth. Cardiovascular events were defined as acute myocardial infarction or stroke. Both APO and non-APO groups were compared for their risk of cardiovascular events in the years following delivery, using unadjusted and adjusted models. Results: Out of 12,071 pregnant women delivered at Hospital Vall d'Hebron during the study period. 10,734 met the inclusion criteria (8234 in the non-APO group and 2500 in the APO group). The adjusted model revealed a significant association between APOs and cardiovascular events post-delivery (HR 2.5; 95% CI 1.4-4.4). Furthermore, an increased number of APOs (≥2) correlated with a higher risk of post-delivery cardiovascular events (HR 8.6; 95% CI 2.8-26.8). Conclusions: Women with adverse pregnancy outcomes (APOs), particularly those experiencing preeclampsia, preterm birth, and late miscarriage, exhibit an elevated long-term risk of cardiovascular events. Our findings highlight that these associations persist even after adjusting for traditional cardiovascular risk factors, indicating that APOs may independently influence long-term cardiovascular health. This underscores the importance of recognizing pregnancy as a critical window for early cardiovascular health interventions and counseling. Addressing these risks proactively could improve long-term health outcomes for women with a history of APOs.

Evaluating maternal serum sortilin levels: a potential biomarker for predicting preeclampsia

OBJECTIVE

To determine the role of sortilin in the pathogenesis of preeclampsia by examining serum sortilin levels in maternal blood.

METHODS

This prospective case-control study was conducted from May to November 2023 at the Perinatology Clinic of Ankara Etlik City Hospital. The study cohort was divided into two groups: Group 1 consisted of 44 pregnant women diagnosed with preeclampsia, and Group 2 served as the control group, comprising 44 healthy pregnant women. The groups were matched individually, with controls selected based on similar maternal age and gestational age at the time of sample collection.

RESULTS

Maternal sortilin levels were significantly elevated in preeclampsia patients compared to controls. Using a cut-off value of > 3.57 ng/mL, sortilin levels could distinguish preeclampsia cases with a sensitivity of 90.9%, a specificity of 45.5%, and an area under the curve (AUC) of 0.679 (p = 0.002). At a cut-off of > 3.57 ng/mL, it was significantly associated with composite adverse neonatal outcomes, with a sensitivity of 89.6%, a specificity of 36.1%, and an AUC of 0.620 (p = 0.045). In addition, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and protein in 24-hour urine, which are important components in the diagnosis and severity of preeclampsia, were significantly correlated maternal blood sortilin levels.

CONCLUSION

Our findings indicate that maternal sortilin levels are elevated in patients with preeclampsia compared to those in a healthy pregnant control group. Furthermore, maternal sortilin levels may predict adverse neonatal outcomes. In addition, sortilin levels are correlated key clinical markers of preeclampsia severity.

The Use of Statins During Pregnancy in Patients Diagnosed With Preeclampsia: A Systematic Review

Preeclampsia is a hypertensive disorder of pregnancy characterized by endothelial dysfunction, inflammation, and angiogenic imbalance, contributing to significant global maternal and fetal morbidity. Statins, particularly pravastatin, have shown promise in mitigating preeclampsia through their pleiotropic effects, including upregulation of nitric oxide, reduction of oxidative stress, and improvement of placental vascular function. Recent clinical trials have exhibited pravastatin's safety in pregnancy and efficacy in reducing preterm preeclampsia and improving maternal and neonatal outcomes. Trials such as the StAmP (Statins to Ameliorate Preeclampsia) and INOVASIA (Indonesia Pravastatin to Prevent Preeclampsia Study) and Costantine et al studies highlight pravastatin's favorable safety profile with no significant maternal or fetal adverse effects. While some studies report limited statistical significance in biomarker changes, pravastatin consistently improves neonatal outcomes such as birth weight, Apgar scores, and neonatal intensive care unit stays. These findings support pravastatin as a potential therapeutic option for preeclampsia management. Further larger-scale trials are needed to confirm optimal dosing, long-term safety, and its future role in clinical practice.

Indole-3-lactic acid derived from tryptophan metabolism promotes trophoblast migration and invasion by activating the AhR/VCAN pathway

BACKGROUND

Preeclampsia (PE) is a life-threatening condition that is unique to human pregnancy, and it is a leading cause of maternal and neonatal morbidity and mortality. Currently, the only definitive treatment for PE is delivery of the placenta. Several studies have suggested that the gut microbiota and its derived metabolites may be associated with PE. Our previous work indicated that the level of indole-3-lactic acid (ILA), which is a metabolite derived from tryptophan (Trp) metabolism in the gut, is increased in PE patients. However, the effects of ILA on trophoblast function and its underlying mechanisms remain largely unknown.

METHODS

Transwell assays were conducted to assess the effects of ILA on trophoblast migration and invasion. Moreover, the aryl hydrocarbon receptor (AhR) signaling pathway was examined by qRT-PCR, western blotting and siRNA transfection. Additionally, RNA-seq analysis was performed to explore the mechanism underlying the ILA-mediated effects on trophoblast function. Finally, in vivo trophoblast invasion was evaluated through immunohistochemical analysis.

RESULTS

Our data demonstrated that ILA promoted HTR-8/SVneo cell migration and invasion through AhR signaling pathway activation. Mechanistically, VCAN upregulation played a key role in mediating the effects of ILA on trophoblasts after AhR activation. Notably, ILA supplementation improved spiral artery remodeling and increased trophoblast invasion in PE-like mice, primarily by increasing VCAN levels.

CONCLUSIONS

These data strongly suggest that elevated ILA in PE serve as a protective mechanism against trophoblast dysfunction. Therefore, we propose that ILA may be a novel and promising therapeutic approach for treating PE by enhancing trophoblast functions.

The Role of Race in Pregnancy, Hypertension, and Long-Term Outcomes

PURPOSE OF REVIEW

This review aims to discuss racial and ethnic differences in the prevalence of hypertensive disorders of pregnancy (HDP), disparities in peripartum and postpartum outcomes, and strategies to improve health equity.

RECENT FINDINGS

Racial disparities in HDP are significant contributors to maternal morbidity and mortality. The prevalence of preeclampsia has increased over the last 20 years, with the highest prevalence among non-Hispanic Black, non-Hispanic American Indian and Alaska Native individuals. Black birthing individuals are at increased risk for cardiovascular-related morbidity and mortality, particularly from complications of HDP. Factors such as social determinants of health and systemic racism have a significant impact on disparities in maternal and fetal outcomes related to HDP. System changes and provider implicit bias training can help address systemic racism. Interventions aimed at improving access to care, such as telehealth and home blood pressure monitoring, as well as incorporating health system navigators that provide peripartum and postpartum support can improve outcomes and promote health equity.

Statins for preventing preeclampsia

OBJECTIVES

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To evaluate the relative benefits and harms of statins for preeclampsia prevention in pregnant women.

Genetic Variations in Vascular Endothelial Growth Factor and Their Impact on Preeclampsia: Insights into Risk, Severity, and Pregnancy Outcomes

Vascular endothelial growth factor (VEGF) plays a crucial role in angiogenesis and placental development, which are vital for a healthy pregnancy. Preeclampsia (PE), a hypertension condition that can cause major difficulties for both the mother and the fetus, has been linked to VEGF gene polymorphisms in several studies. PE susceptibility has been associated with several VEGF polymorphisms, including VEGF -2578C/A, -634G/C, +936C/T, and +405G/C, with differing outcomes in various ethnicities. Some polymorphisms, like VEGF -2578C/A, are linked to the disease's progression, whereas others, like VEGF +405G/C, may protect severe PE. The findings are still uncertain, though, with some studies reporting noteworthy outcomes and others finding no correlation. Further complicating our knowledge of VEGF's role in PE is the possibility that the interaction between maternal and fetal VEGF polymorphisms may affect PE risk. Studies on environmental variables and placental and fetal VEGF gene polymorphisms point to a complicated interaction in influencing the severity and susceptibility of PE. The precise genetic processes behind PE are still unknown, despite the mounting evidence, necessitating additional research to confirm possible biomarkers and treatment targets. In at-risk pregnancies, a better understanding of the connection between VEGF polymorphisms and PE may help with risk assessment and management techniques.

Glucose time in range trajectories during pregnancy and association with adverse perinatal outcomes: a joint latent-class trajectory modeling approach

BACKGROUND

While time in range (TIR) summarized over pregnancy is associated with adverse outcomes among individuals with preexisting type 1 or 2 diabetes, the impact of TIR trajectories with advancing gestation is unknown.

OBJECTIVE

To identify glucose TIR trajectories across pregnancy and evaluate their association with perinatal outcomes among patients with preexisting diabetes.

STUDY DESIGN

Retrospective, single-center cohort study of pregnant patients with type 1 or 2 diabetes who used continuous glucose monitoring (CGM) and delivered in 2019 to 2023. Weekly TIR (65-140 mg/dL) was computed starting at 10 weeks' gestation, and joint latent-class trajectory modeling identified discrete TIR trajectory groups. Patients were classified into groups, and multivariable logistic regression estimated the associations between groups and perinatal outcomes.

RESULTS

Of 179 pregnant patients, 91 had type 1 and 88 had type 2 diabetes. We identified four TIR trajectory groups using data from over 5.1 million CGM measurements: (1) good control, stable (n=48), (2) moderate control, initial improvement, and late decline (n=22), (3) moderate control, late improvement (n=63), and (4) poor control, initial worsening and late improvement (n=46). All perinatal outcomes differed by TIR trajectory. Groups 2, 3, and 4 with suboptimal control in early pregnancy were associated with higher odds of preterm birth, indicated preterm birth, and NICU admission, compared to group 1. Groups 3 and 4, which had the lowest TIR during second and early third trimesters, were associated with higher odds of large-for-gestational-age (LGA). Only group 4 was associated with higher odds of preeclampsia and neonatal hypoglycemia.

CONCLUSION

Achieving glycemic control in the second and early third trimesters during fetal and placental growth and development is important to reduce the risk of adverse pregnancy outcomes, particularly LGA. Third-trimester TIR decline may impact risk of preterm birth and NICU admission.

Advances in Our Understanding of Cardiovascular Diseases After Preeclampsia

Preeclampsia is a syndrome of hypertension in association with target organ dysfunction, including proteinuria, which manifests during pregnancy and the immediate postpartum period. The pathophysiology of preeclampsia originates from impaired trophoblastic invasion of the placental resulting in malperfusion and involves multiple mechanistic pathways that include anti-angiogenic factors, endothelial dysfunction, and immune dysregulation. Preeclampsia caries an increased risk of subclinical cardiovascular disease including left ventricular remodeling, diastolic dysfunction, coronary artery calcification, peripheral vascular abnormalities, and microvascular dysfunction and clinical cardiovascular disease including stroke, heart failure, myocardial infarction, and death from a cardiovascular cause. This review will highlight several common mechanistic pathways shared between preeclampsia and cardiovascular diseases that provide insight into potential targets for risk reduction and disease process mitigation that can be examined in future trials.

Effect of Homozygous Sickle Cell Anemia on Perinatal Outcomes: A Retrospective Cohort Study

Backgrounds: Sickle cell anemia (SCA) is a multisystemic disorder that causes hemolytic anemia and impaired tissue perfusion due to sickling of red blood cells. Although there is a belief that adverse perinatal outcomes are frequent in pregnant women with SCA, this association has not been clearly established. The aim of this study was to compare the perinatal outcomes of women with homozygous mutated SCA who gave birth with those without the mutation. Methods: The study included 26 SCA patients with homozygous mutation and 108 pregnant women without mutation who gave birth in our center. Demographic and obstetric data, laboratory findings, and fetal findings of both groups were compared. Results: Statistically significant differences were found between the groups in terms of maternal age, body mass index (BMI), gravida, and parity (p ≤ 0.001, p = 0.035, p ≤ 0.001, p ≤ 0.001, respectively). Mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), red blood cell count (RBC), hemoglobin (Hb), and hematocrit (Hct) values were significantly lower in the SCA group. We also observed that more blood transfusions were performed during pregnancy and the postpartum period in the SCA group. Low birth weight, more neonatal intensive care unit admissions, and a higher cesarean section rate were present in the SCA group. During pregnancy, women with SCA were most frequently admitted to the hospital for acute painful crises. Preeclampsia was not more common in the SCA group. Conclusions: SCA carries serious risks for the mother and fetus during pregnancy. Therefore, the relationship between the disease and pregnancy requires more detailed research.

Useful Biomarkers for Preeclampsia: Evaluating the Diagnostic Potential of FIB-4 and FIB-5 Indices

Background/Objectives: Preeclampsia is a systemic condition that can result in liver impairment and potentially lead to negative outcomes for both the mother and baby. Various indices have been created to facilitate the early detection of liver issues. Among these, the Fibrosis-4 index (FIB-4) and Fibrosis-5 index (FIB-5) have been utilized for several years to forecast liver dysfunction. In our research, we aimed to apply these indices to patients with preeclampsia for the first time. Methods: This retrospective study, conducted at Giresun University from 2017 to 2024, included 207 patients with preeclampsia and 205 healthy controls. Data on maternal age, BMI, obstetric history, delivery method, gestational age, birth weight, and Apgar scores were extracted from medical records for analysis and biochemical parameters. Data were analyzed statistically. Results: The study found that FIB-4 index values were significantly higher and FIB-5 index values were lower in preeclampsia patients compared to the controls. FIB-4 demonstrated a better diagnostic performance with higher sensitivity and specificity. Although the difference between the two indices was not statistically significant, both were independently predictive of preeclampsia. The correlation coefficient showed that FIB-4 was positively correlated with spot urine protein/creatinine ratio (SPCR) and aspartate aminotransferase (AST), while FIB-5 was negatively correlated with these parameters and with alkaline phosphatase. Conclusions: This study found that FIB-4 and FIB-5 are useful for predicting preeclampsia, with FIB-4 showing superior diagnostic performance. These findings highlight their potential in the early detection and management of preeclampsia. Further research is needed for clinical validation.

Pregnancy-onset obstructive sleep apnea and ambulatory blood pressure

STUDY OBJECTIVE

Elevated nocturnal blood pressure (BP) increases the risk for hypertensive disorders of pregnancy (HDP). Though obstructive sleep apnea (OSA) increases the risk for HDP, data on OSA, and 24-hour ambulatory blood pressure monitoring (ABPM) in pregnancy are scarce. We aim to examine the BP profile of women with pregnancy-onset OSA.

METHODS

Pregnant women with overweight/obesity and snoring were recruited at <13 weeks gestation and underwent level III home sleep apnea testing and 24-hour ABPM at enrollment and at 31-34 weeks' gestation. Women with OSA at enrollment were excluded. Mean differences in nocturnal BP and 24-hour BP measurements, between women with pregnancy-onset OSA and women without OSA, were computed by multivariable linear regression.

RESULTS

Participants (40/101) had pregnancy-onset OSA (respiratory event index (REI) ≥5 events per hour) in the third trimester. Despite no significant differences in baseline BP, nocturnal systolic and diastolic BP were significantly higher in women with pregnancy-onset OSA compared to women without OSA, after adjusting for multiple covariates (mean difference 5.49 (1.45-9.52) and 3.89 (0.19-7.60), respectively). Differences in systolic BP persisted into the daytime in the OSA group. Lack of nocturnal dipping was highly prevalent in both groups, but the difference was not significant in the adjusted model.

CONCLUSIONS

Pregnancy-onset OSA in the 3rd trimester is associated with elevated nocturnal BP and daytime systolic BP. The lack of nocturnal dipping irrespective of REI cut-off in pregnant women at risk for SDB further demonstrates the limitations of REI in defining pathology in pregnancy.

Global burden, trends and inequalities of maternal hypertensive disorders among reproductive-age women of advanced maternal age, 1990-2021: a population-based study

Background

Maternal hypertensive disorders (MHD) are leading causes of maternal morbidity and mortality worldwide, particularly among reproductive-age women of advanced maternal age (AMA), representing a significant global public health challenge.

Objective

This study aimed to analyze the global trends, inequalities, and disparities in the burden of MHD among reproductive-age AMA women from 1990 to 2021.

Methods

We conducted a population-based study using data from the Global Burden of Disease (GBD) 2021 study, covering 204 countries and territories. The study included women aged 35-49 years with hypertensive disorders during pregnancy. We assessed age-standardized incidence rate (ASIR) and age-standardized death rate (ASDR) of MHD among reproductive-age AMA women. Temporal trends were evaluated using joinpoint regression analysis, while health inequalities were measured using the concentration index and the slope index of inequality (SII).

Results

Between 1990 and 2021, the global ASIR of MHD decreased from 568.10 (95% UI: 412.06-738.55) to 491.49 (95% UI: 368.78-619.84) per 100,000 population (AAPC: -0.46%, 95% CI: -0.54% to -0.38%), and ASDR declined from 2.57 (95% UI: 2.23-2.97) to 1.44 (95% UI: 1.19-1.76) per 100,000 population (AAPC: -1.83%, 95% CI: -1.99% to -1.67%). Substantial disparities persisted across socio-demographic index (SDI) regions, with high and high-middle SDI regions showing increasing incidence trends (AAPC: 2.36% and 1.45%, respectively). The slope index of inequality (SII) for ASIR improved from -3,052.73 (95% CI: -3,329.55 to -2,775.91) to -1,209.36 (95% CI: -1,393.12 to -1,025.61) per 100,000 women, while the SII for ASDR decreased from -11.29 (95% CI: -12.38 to -10.20) to -3.66 (95% CI: -4.13 to -3.20) deaths per 100,000 women. The concentration index for ASIR showed slight improvement (from -0.46 to -0.34), while ASDR inequality marginally worsened (from -0.62 to -0.66).

Conclusion

Despite overall declines in MHD burden, significant disparities persist, particularly in low SDI regions. These findings highlight the need for targeted public health interventions to reduce inequalities, improve healthcare access, and enhance maternal outcomes for reproductive-age AMA women globally.

Unveiling Gestational Diabetes: An Overview of Pathophysiology and Management

Gestational diabetes mellitus (GDM) is characterized by an inadequate pancreatic β-cell response to pregnancy-induced insulin resistance, resulting in hyperglycemia. The pathophysiology involves reduced incretin hormone secretion and signaling, specifically decreased glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), impairing insulinotropic effects. Pro-inflammatory cytokines, including tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6), impair insulin receptor substrate-1 (IRS-1) phosphorylation, disrupting insulin-mediated glucose uptake. β-cell dysfunction in GDM is associated with decreased pancreatic duodenal homeobox 1 (PDX1) expression, increased endoplasmic reticulum stress markers (CHOP, GRP78), and mitochondrial dysfunction leading to impaired ATP production and reduced glucose-stimulated insulin secretion. Excessive gestational weight gain exacerbates insulin resistance through hyperleptinemia, which downregulates insulin receptor expression via JAK/STAT signaling. Additionally, hypoadiponectinemia decreases AMP-activated protein kinase (AMPK) activation in skeletal muscle, impairing GLUT4 translocation. Placental hormones such as human placental lactogen (hPL) induce lipolysis, increasing circulating free fatty acids which activate protein kinase C, inhibiting insulin signaling. Placental 11β-hydroxysteroid dehydrogenase type 1 (11β-HSD1) overactivity elevates cortisol levels, which activate glucocorticoid receptors to further reduce insulin sensitivity. GDM diagnostic thresholds (≥92 mg/dL fasting, ≥153 mg/dL post-load) are lower than type 2 diabetes to prevent fetal hyperinsulinemia and macrosomia. Management strategies focus on lifestyle modifications, including dietary carbohydrate restriction and exercise. Pharmacological interventions, such as insulin or metformin, aim to restore AMPK signaling and reduce hepatic glucose output. Emerging therapies, such as glucagon-like peptide-1 receptor (GLP-1R) agonists, show potential in improving glycemic control and reducing inflammation. A mechanistic understanding of GDM pathophysiology is essential for developing targeted therapeutic strategies to prevent both adverse pregnancy outcomes and the progression to overt diabetes in affected women.

The relationship between folic acid deficiency and preeclampsia-like phenotypes in rats

BACKGROUND

Pre-eclampsia is a significant contributor to maternal and neonatal morbidity and mortality. However, its etiology remains elusive. More and more studies have highlighted the potential involvement of folic acid metabolism in the development of pre-eclampsia. Folic acid is known to be important for DNA synthesis and methylation processes, which are crucial during pregnancy. Disruptions in these pathways may contribute to the pathogenesis of pre-eclampsia. Clinical studies investigating associations between folic acid supplementation and pre-eclampsia produced inconsistent results. The research aims to explore the potential link between folic acid deficiency and the development of pre-eclampsia-like symptoms in rat models, shedding light on the possible role of one-carbon metabolic pathways in the etiology of pre-eclampsia.

METHODS

Establishing a rat model with severe and moderate folate deficiency by providing female rats with a folate-deficient diet from birth or weaning, respectively. The effects on folate and homocysteine levels during pregnancy were then studied.

RESULTS

Both groups exposed to folate deficiency exhibited decreased levels of 5-methyltetrahydrofolic acid in both plasma and red blood cells, along with increased levels of homocysteine in plasma, compared to the control group. Consistent high blood pressure and urinary protein excretion were not significantly different among the three groups. However, fetuses from the folate-deficient group exhibited noticeably lower body weight compared to those from the folate-replete group.

CONCLUSIONS

Folate deficiency alone may not be sufficient to cause pre-eclampsia in rats, but it does increase the risk of offspring being small for their gestational age at birth.

Experiences of Obstetrician-Gynecologists Providing Pregnancy Care After Dobbs

Importance

Following the Dobbs v Jackson Women's Health Organization (Dobbs) decision in June 2022, which overturned the federal right to abortion, Wisconsin physicians faced the threat of an 1849 state law widely interpreted to criminalize provision of abortion except in life-saving emergencies. Physicians and their institutions were left to interpret whether and how they could treat and/or refer certain pregnant patients.

Objective

To document how the post-Dobbs legal landscape shaped Wisconsin obstetrician-gynecologists' (OB-GYNs') ability to provide health care to patients facing pregnancy-related risks and complications, with particular attention to the mediating role of health care institutions.

Design, Setting, and Participants

In this qualitative study, 21 OB-GYNs were recruited between June 2022 and December 2023 from rural and urban areas with varying hospital affiliations, scopes of practice, and individual demographics to participate in semistructured, remote interviews.

Exposure

An 1849 abortion law that suspended abortion care in Wisconsin between June 2022 and December 2023.

Main Outcomes and Measures

Physicians' perceptions of (1) how the legal landscape shaped management of pregnancy and related complications, and (2) how institutional-level factors contributed to physicians' experiences caring for pregnant patients following Dobbs.

Results

This study included 21 OB-GYNs (mean [SD] age, 43 [5.88] years; 16 [76.2%] female; 5 [23.8%] non-White and 16 [76.2%] White) who practiced obstetrics in Wisconsin. OB-GYNs described how the threat of criminalization following Dobbs was detrimental to physicians' ability to provide pregnancy care. Absence of legal clarity surrounding the 1849 law led to confusion and wide variations in institutional comfort and clinical practice, which resulted in substandard, delayed, and fragmented patient care. Overwhelmingly, the threat of criminalization after Dobbs exacerbated barriers for physicians providing comprehensive pregnancy care and patients seeking it.

Conclusions and Relevance

In this qualitative study of OB-GYNs practicing in an abortion-restrictive state, threat of criminalization in post-Dobbs Wisconsin resulted in uncertainty and confusion for OB-GYNs and worse care for pregnant patients. The absence of clear guidance and support from institutional and health care system leadership emerged as a particularly salient missed opportunity. These experiences, which contribute to a critical evidence base on the harms of abortion restrictions, are relevant to states facing similar bans that criminalize or restrict health care.

The Effect of Nursing Interventions in Women With Gestational Hypertension: A Systematic Review and Meta-Analysis

Pregnancy-related hypertensive disorders are significant global causes of maternal morbidity and mortality. Quality nursing care is essential for pregnant women with hypertension to ensure a healthy pregnancy and delivery. This study aimed to systematically synthesize evidence on the effectiveness of nursing interventions for women with gestational hypertension. A systematic review and meta-analysis were conducted following PRISMA guidelines. Literature was searched across seven electronic databases from August 1 to September 27, 2023. Thirteen studies, encompassing 1458 women with gestational hypertension, were included. Quality assessment indicated that 10 randomized controlled trials were rated as good, one as fair, and all quasi-experimental studies as good quality. Various nursing interventions were analyzed, including training programs, home-based comprehensive nursing, case management, vascular symptom management, music therapy, and clinical nursing pathways. Meta-analysis results revealed that nursing interventions significantly reduced systolic and diastolic blood pressure, anxiety, depression, and hospital length of stay. These findings suggest that nursing interventions can effectively improve health outcomes for women with gestational hypertension, positively impacting at least one outcome in all included studies. PROSPERO REGISTRATION NUMBER: CRD42023444829.

Association between deep learning radiomics based on placental MRI and preeclampsia with fetal growth restriction: A multicenter study

PURPOSE

Preeclampsia (PE) is associated with placental insufficiency and could lead to adverse pregnancy outcomes. The study aimed to develop a placental T2-weighted image-based automatic quantitative model for the identification of PE pregnancies and disease severity.

METHODS

Between July 2013 and September 2022, the retrospective multicenter study featured 420 pregnant women, including 140 cases of PE and 280 cases of normotensive pregnancies. The semi-supervised approach was used to gain an automatic segmentation for placental MRI. The radiomics, deep learning, and deep learning radiomics (DLR) models were built.

RESULTS

In PE pregnancies, 65 (46.4 %) fetuses developed PE with fetal growth restriction (FGR), and 75 (53.6 %) cases were PE without FGR. The Dice of semi-supervised placental segmentation was 0.917. The AUCs of the DLR signature for discriminating PE pregnancies from normotensive pregnancies were 0.839 (95 % CI: 0.793-0.886), 0.858 (95 % CI: 0.742-0.974), 0.888 (95 % CI: 0.783-0.992), and 0.843 (95 % CI: 0.731-1.000) in the training, test, internal validation, and external validation sets, respectively. This DLR analysis model performed well in discriminating between PE with FGR and normotensive pregnancies (AUC = 0.918, 95 % CI: 0.879-0.957) and PE without FGR (AUC = 0.742, 95 % CI: 0659-0.824).

CONCLUSION

The automatic radiomics analysis has been developed to identify PE pregnancies by determining DLR features on placental T2-weighted images, and to predict FGR exposed to PE.

Home blood pressure monitoring and mobile health application practices among pregnant persons with and at risk of hypertensive disorders of pregnancy

OBJECTIVES

To examine training in and current home blood pressure monitoring (HBPM) practices in pregnancies with hypertensive disorders of pregnancy (HDP) or risk factors for HDP; and to explore interest in using mHealth applications for communicating with healthcare providers.

STUDY DESIGN

A cross-sectional survey was conducted on HBPM practices/training and interest in using mobile health (mHealth) applications among pregnant persons at an academic medical center.

OUTCOME MEASURES

The main outcomes measured were the proportion of participants who received training for HBPM, and the proportion interested in using mHealth applications for communication with providers related to managing HDP.

RESULTS

Of the 103 participants, 41 (39.8%) used HBPM. Of those who did HBPM, 36.6% received training from their healthcare providers. Training more often included instructions on positioning and how to perform HBPM, and rarely included advice on validated HBPM devices. Nearly all participants (98.1%) owned a smartphone, and 19.4% had a smartwatch. A significant majority expressed interest in using a secure mobile app for communication with providers (78.6%), and 88.3% were interested in wearing a smartwatch for remote monitoring. There were no significant differences in interest levels based on race, age, residence, or education, while there was higher interest (100% vs. 67%) in mobile apps for communication among those with HDP vs. risk factors for HDP.

CONCLUSIONS

Despite a low level of training for HBPM, there was high interest in using mHealth applications. Leveraging mHealth technology could help overcome the challenges of providing training for HBPM.

Hypertensive pregnancy disorder, an under-recognized women specific risk factor for heart failure?

During pregnancy, the maternal cardiovascular (CV) system undergoes major haemodynamic alterations ensuring adequate placental perfusion and a healthy pregnancy course. Hypertensive disorders of pregnancy (HDP) occur in almost 10% of gestations and preeclampsia, a more severe form, in 3-4%. Women with HDP demonstrated impaired myocardial function, biventricular chamber dysfunction and adverse biventricular remodelling. Shortly after delivery, women who experienced HDP express increased risk of classic CV risk factors such as hypertension, renal disease, abnormal lipid profile, and diabetes. Within the first two decades following a HDP, women experience increased rates of heart failure, chronic hypertension, ischaemic heart and cerebral disease. The mechanism underlying the relationship between HDP in younger women and CV disease later in life could be explained by sharing pre-pregnancy CV risk factors or due to a direct impact of HDP on the maternal CV system conferring a state of increased susceptibility to future metabolic or haemodynamic insults. Racial disparities in CV risk and social determinants of health also play an important role in their remote CV risk. Although there is general agreement that women who suffered from HDP should undertake early CV screening to allow appropriate prevention and timely treatment, a screening and intervention protocol has not been standardized due to limited available evidence. In this review, we discuss why women with hypertensive pregnancy may be disproportionately affected by heart failure with preserved ejection fraction and how cardiac remodelling during or after pregnancy may influence its development.

Ophthalmic Artery Doppler as a Predictor of Adverse Neonatal Outcomes in Women With Preeclampsia

OBJECTIVE

This study aimed to evaluate the association between ophthalmic artery (OA) Doppler indices and adverse neonatal outcomes in women with pregnancies complicated by preeclampsia (PE).

METHODS

A prospective cross-sectional study involving 110 pregnant women who were diagnosed with PE in the first 24 h of hospitalization was conducted at three hospitals in southeastern Brazil from April 2020 to December 2022. The ophthalmic parameters analyzed were the resistance index (RI), pulsatility index (PI), first peak systolic velocity (PSV1), second peak systolic velocity (PSV2), ratio of PSV2 to PSV1 (PSV ratio or the peak ratio [PR]), and end-diastolic velocity (EDV). The outcome measures were neonatal death (during hospitalization), neonatal intensive care unit (ICU) admission, gestational age at delivery < 32 weeks, birth weight < 1500 g, birth weight < 10th percentile, the presence of comorbidities associated with prematurity, the use of invasive mechanical ventilation, an Apgar score at the 5th minute < 7.0, and signs of neurological impairment.

RESULTS

Pregnant women with severe features of PE showed higher values of systolic (152.8 ± 20.7 vs. 136.3 ± 11.9, p = 0.000) and diastolic (98.1 ± 12.8 vs. 88.1 ± 10.8, p = 0.000) blood pressure values and lower gestational age at admission (31.5 ± 3.8 vs. 33.7 ± 4.3, p = 0.009) than PE without severe features. No significant differences were found between the mean values of the OA Doppler indices when comparing the presence or absence of neonatal outcomes in the women with PE.

CONCLUSIONS

OA Doppler, while valuable for the prediction, diagnosis, and evaluation of adverse maternal outcomes, does not independently predict adverse neonatal outcomes in women with severe features of PE.

Management of Postpartum Preeclampsia and Hypertensive Disorders (MOPP): Postpartum Tight vs Standard Blood Pressure Control

BACKGROUND

It is unknown whether tightly controlled blood pressure in the postpartum period will improve outcomes.

OBJECTIVES

The purpose of this study was to assess the effect of a lower treatment threshold (≥130/80 mm Hg) for initiating and titrating antihypertensive medication on reducing emergency department visits in postpartum patients with hypertension.

METHODS

A prospective cohort of postpartum patients was recruited in a multicenter study between March 2023 and March 2024 and treated to maintain blood pressure <130/80 mm Hg using remote blood pressure monitoring. These patients were compared to a propensity score-matched retrospective cohort from February 2021 to February 2023 who were treated to maintain blood pressures <150/100 mm Hg. Eligible patients were 18 or older with a diagnosis of hypertensive disorder. The primary outcome was an emergency department visit for hypertension.

RESULTS

There were 392 patients enrolled in the interventional cohort and 1,204 patients identified in the retrospective cohort. After the propensity score match, 276 and 429 patients remained in the prospective and retrospective groups, respectively. Emergency department visits for hypertensive disorders occurred in 10 patients (3.6%) in the intervention and 36 patients (8.4%) in the retrospective cohort (risk difference -4.8; 95% CI: -8.2 to -1.3; doubly robust OR: 0.32; 95% CI: 0.10-1.01). At 6 weeks postpartum, compared to the retrospective group, the intervention group had systolic and diastolic blood pressure that was 4.4 mm Hg (95% CI: -6.8 to -2.0) and 3.1 mm Hg (95% CI: -4.9 to -1.2) lower, respectively.

CONCLUSIONS

Tighter blood pressure control was associated with reduced postpartum emergency department visits for hypertensive disorders.

Insufficient expression of COL6A1 promotes the development of early-onset severe preeclampsia by inhibiting the APJ/AKT signaling pathway

Early-onset severe preeclampsia (eosPE) is one of the most severe complications of pregnancy. To identify the genes related to the development of eosPE. We downloaded and integrated analyzed microarray data from GSE44711, GSE66273, and GSE74341, which contains the expression profile of placental tissues from patients with eosPE and healthy controls. Our analysis revealed that collagen type VI alpha 1 (COL6A1) was downregulated in the eosPE placenta compared to normal pregnancy. COL6A1 promoted the migration, invasion and tube formation ability of HTR8/SVneo cells, HUVECs and primary extravillous trophoblasts (EVTs). To explore the underlying mechanisms, we conducted transcriptome sequencing, which indicated that the Apelin/APJ signaling pathway was affected by COL6A1 knockdown. In addition, we found that APJ expression was lower in the placental tissue of patients with eosPE compared to healthy pregnancies. Inhibition of APJ suppressed the invasion, migration, and tube formation abilities of trophoblasts. We also observed that COL6A1 increased the levels of p-AKT and p-mTOR, while the APJ inhibitor ML221 impaired this effect. Furthermore, transwell and tube formation assays demonstrated that ML221 attenuated the capabilities enhanced by COL6A1, an effect that could be rescued by the AKT activator SC79. Overall, these findings indicate that insufficient expression of COL6A1 attenuates the migration, invasion, and endothelial-like tube formation of HTR8/SVneo cells and primary EVTs via the APJ/AKT/mTOR pathway, thereby promoting the development of eosPE.

Effect of postpartum oral furosemide use on postpartum readmissions and blood pressure trends

BACKGROUND

Oral furosemide postpartum improves the time to hypertension resolution in randomized control trials. Further investigation is needed to determine the impact of furosemide in routine clinical practice.

OBJECTIVE

Real world study to assess impact of furosemide on rates of postpartum hypertension and readmissions for patients with hypertensive disorders of pregnancy.

STUDY DESIGN

A prospective cohort study of postpartum patients with hypertensive disorders of pregnancy at a single institution between October 2021 and April 2022. Patients were enrolled in the remote postpartum blood pressure monitoring program (RPM) as standard of care. Use of oral furosemide for 5 days postpartum was implemented per protocol for all patients with gestational hypertension and preeclampsia. Data was obtained until six weeks postpartum. Exclusion criteria included age less than 18 years old, patients with chronic hypertension alone without superimposed preeclampsia, and patients who did not provide consent for data collection. The primary outcome was hospital readmission within six weeks postpartum. The secondary outcome was blood pressure values across those six weeks. Hypertension was defined as any blood pressure value with SBP ≥ 140 mmHg or DBP ≥ 90 mmHg.

RESULTS

Overall, 545 patients were enrolled in the RPM program during the study period, 306 of them consented to data collection and 258 patients were ultimately included after meeting all inclusion criteria with no exclusions. Of these, 203 patients received furosemide. Overall, 47.7 % of patients had gestational hypertension, 40.3 % of patients had preeclampsia with or without severe features, and 12.0 % of patients had superimposed preeclampsia with or without severe features. In total, 24.2 % of patients were discharged home on an antihypertensive medication in addition to furosemide. The overall rate of readmission was 13.2 %. There was no difference between patients who received oral furosemide versus those who did not (12.8 % vs 14.6 %, p = 0.74). Rates of hypertension at the one-week postpartum visit between those two groups did not differ significantly (32.8 % [oral furosemide] vs 36.2 % [no furosemide], p = 0.66). Diastolic blood pressures at the six-week follow-up visit were lower in the furosemide group (74 [69,81] vs 82 [76,89]; p = 0.02) among patients registered to care who completed the six-week visit.

CONCLUSION

The addition of furosemide did not result in improved blood pressure control by the first week postpartum or fewer hospital readmissions. However, diastolic blood pressure trended lower at the six-week visit in patients who received furosemide.

Can Peripheral Arterial Tonometry and Biomarkers Help Identify Women Who Will Have Progressively Worsening Hypertensive Disorders of Pregnancy?

OBJECTIVE

 This study aimed to (1) evaluate whether endothelial dysfunction, as measured by peripheral arterial tonometry (PAT) indices and biomarker (soluble fms-like tyrosine kinase-1 [sFLT], brain natriuretic peptide [BNP]) levels at 34 weeks gestation, can predict progression from nonsevere to severe hypertensive disorders of pregnancy (HDPs); and (2) develop a clinical risk model for prediction of progression from nonsevere to severe HDP.

STUDY DESIGN

 We prospectively enrolled patients with a singleton gestation carrying a nonsevere HDP diagnosis. Forty-five participants were enrolled for PAT evaluation and serum collection between 340/7 and 366/7 weeks. PAT indices (e.g., Augmentation Index normalized to a heart rate of 75 bpm [AI75]) and biomarker concentrations were assessed at enrollment. The primary outcome was progression from a nonsevere diagnosis in the late preterm period to a diagnosis of preeclampsia with severe features or superimposed preeclampsia. Statistical analyses included two-sample t-tests, Fisher's exact tests, and multivariate modeling.

RESULTS

 Thirteen subjects (30%) progressed to severe disease. No significant differences in mean PAT indices between the outcome groups were found. We found a significant difference in mean sFLT values between the two groups (p = 0.02, area under the curve [AUC] of 0.609), but not in mean BNP values. An endothelial dysfunction index (presence of fetal growth restriction, "high" AI75, and positive systolic blood pressure slope) discriminated between progression and nonprogression (p = 0.03, AUC of 0.707).

CONCLUSION

 sFLT level was a marker of progression from nonsevere to severe HDP. Further, a novel endothelial dysfunction index discriminated between progression and nonprogression to severe disease with good performance.

KEY POINTS

· HDPs are important causes of morbidity and mortality.. · The sequelae of HDPs are not limited to pregnancy.. · Developing accurate tools to predict severe HDPs is of great clinical importance.. · Our index shows promising performance for predicting progression from nonsevere to severe HDPs..

High prevalence of neuroimaging abnormalities in eclampsia: Justifying the routine use of non-contrast CT in resource-limited settings

OBJECTIVES

Eclampsia remains a principal cause of maternal mortality, especially in low- and middle-income countries. The frequent association with Posterior Reversible Encephalopathy Syndrome (PRES) underscores the critical role of neuroimaging in clinical assessment. We aimed to evaluate tomographic findings in women with eclampsia and analyze clinical factors associated with these abnormalities.

STUDY DESIGN

This descriptive, retrospective study was conducted at the Hospital Universitario San Vicente Fundación in Medellín, Colombia. A mandatory registry identified women diagnosed with eclampsia between 2011 and 2023. Non-contrast cranial tomography results and clinical data were analyzed using univariate and multivariate logistic regression to determine factors associated with imaging abnormalities.

MAIN OUTCOME MEASURES

The primary outcomes were the presence of abnormalities on non-contrast cranial CT scans and their association with clinical factors such as antepartum eclampsia and HELLP syndrome.

RESULTS

Of the eighty-one women with eclampsia, sixty-seven underwent non-contrast cranial tomography. Abnormal findings were observed in 52% of cases, with 74% consistent with PRES and 22% showing evidence of hemorrhage. Antepartum eclampsia and HELLP syndrome are significantly associated with abnormal imaging findings, with odds ratios of 11,72 (2.34 - 106,23) and 9,14 (1.72 - 85,72), respectively, after adjusting for potential confounding variables.

CONCLUSION

Given the high prevalence of tomographic abnormalities, non-contrast cranial tomography should be considered for all women with eclampsia, particularly those with antepartum presentations or HELLP syndrome. These findings support the need for revising neuroimaging guidelines to improve the diagnosis and management of neurological complications associated with eclampsia, especially in resource-limited settings.

"Whole genome bisulfite sequencing of serum extracellular vesicle DNA identifies alterations in mitochondrial DNA methylation in early onset preeclampsia"

Early-onset preeclampsia (EOPE) is a serious pregnancy complication. Understanding its underlying mechanisms could lead to improved diagnosis and management. Genome-wide DNA methylation changes in circulating Extracellular Vesicle DNA (EV-DNA) from women with EOPE could serve as a non-invasive approach to identify key regions and genes that could serve as biomarkers to understand placental pathophysiology. In this case-control study, serum extracellular vesicles were isolated from 3rd trimester pregnant women and characterized using Nanoparticle Tracking Analysis and Transmission Electron Microscopy. The circulating EV-DNA samples were subjected to Whole Genome Bisulfite Sequencing analysis (WGBS) to identify differentially methylated CpGs (DMCs) sites in EOPE cases compared to control. A total of 154 DMCs were identified in EV-DNA, of which 131 were hypomethylated and 23 were hypermethylated. Majority of DMCs were of mitochondrial origin. Previously, it has been reported that oxidative stress, decreased trophoblast differentiation, and invasion are linked to preeclampsia pathogenesis and are related to mitochondrial dysfunction. Therefore, DMCs of the mitochondrial genes like MT-ND1, MT-ND4, MT-CO2, MT-CO3, and MT-RNR1 were selected for validation and showed a similar trend by pyrosequencing. The expression of these genes were also altered in circulating extracellular vesicles. Our study shows changes in the DNA methylation patterns of circulating EV-DNA in women with EOPE. These changes, especially in mitochondrial genes, could lead to mitochondrial dysfunction and contribute EOPE pathogenesis. These findings suggest that these alterations could be explored as non-invasive approach to better understand placental health and improve disease management.

Impaired diaphragmatic excursion following magnesium sulfate administration in patients with preeclampsia with severe features: a prospective observational study

Magnesium sulfate is recognized for its muscular relaxant properties on both smooth and skeletal muscles; nevertheless, there are no prior studies examining the impact of magnesium administration on diaphragmatic movement, namely diaphragmatic excursion. Therefore, we aimed to evaluate diaphragmatic excursion as assessed by ultrasound before and after magnesium sulfate administration. Patients with a diagnosis of preeclampsia with severe features were screened for eligibility. Forty-seven patients with preeclampsia with severe features were included and available for final analysis. There was a significant reduction in diaphragmatic excursion 20 minutes after magnesium sulfate administration. Additionally, this study provides new insight into the dose effect between serum magnesium level and diaphragmatic excursion characterized by a negative correlation between serum magnesium level and diaphragmatic excursion, demonstrating that increased serum magnesium level is associated with increased diaphragmatic weakness.

Risk factors for chronic hypertension 5 years after a pregnancy complicated by preeclampsia: a systematic review and meta-analysis

Approximately 30% of women with a history of preeclampsia develop chronic hypertension within 10 years of pregnancy. This systematic review summarizes risk factors before, during, and immediately after pregnancy for the development of chronic hypertension 5 years after preeclampsia. Databases were searched with terms 'preeclampsia' and 'postpartum hypertension' or 'cardiovascular disease' up to 30th October 2023. Observational studies reporting chronic hypertension more than 5 years after preeclampsia were included. Quality was assessed using the Newcastle-Ottawa scale. Wherever possible, a meta-analysis was conducted. Twenty-one cohort and five case-control studies, with a median quality score of 8/10, were included, involving 197 793 patients and reporting 32 risk factors. Preeclampsia in a subsequent pregnancy is associated with chronic hypertension [risk ratio (RR) 2.26, 95% confidence interval (CI) 1.59-3.22, n = 45 626]. Other significant risk factors include early-onset of preeclampsia (<34 weeks gestation), maternal BMI, blood pressure, diabetes, and family history of hypertension.

The relationship between renal function indicators and preeclampsia in the second trimester of pregnancy: a retrospective study

Background

To investigate the relationship between serum renal function indicators and preeclampsia (PE) in pregnant women at second trimester of pregnancy, determine the optimal critical values of the above indicators, and further identify the independent risk factors of PE.

Methods

We assessed the renal function indicators in second trimesters of 137 pregnant women with PE and 137 normal pregnant women who delivered at Shijiazhuang Fourth Hospital between January 2020 to December 2022. Paired t-tests, paired Mann-Whitney U tests, and Chi-square tests were used to evaluate differences of clinical data between the two groups. Receiver operating characteristic (ROC) curves was employed to establish the optimal critical values of the above indicators. A 1:1 matched case-control logistic regression analysis was conducted to identify the independent risk factors for PE.

Results

The levels of serum uric acid and the ratio of serum uric acid to serum creatinine were significantly higher in the PE group compared to the control (P < 0.001), while the serum creatinine levels were higher in control group (P = 0.002). The incidence of adverse maternal (P < 0.001) and neonatal outcomes (P < 0.001) in the PE group were higher than those in the control group. A ROC analysis based on the occurrence of PE showed that the levels of serum uric acid (P < 0.001), serum creatinine (P = 0.006) and the ratio of serum uric acid to serum creatinine (P < 0.001) were statistically significant. After adjusting for confounding factors, elevated serum uric acid (a OR = 1.012, 95% CI [1.005-1.019], P < 0.001) and an increased serum uric acid to serum creatinine ratio (a OR = 1.190, 95% CI [1.053-1.346], P = 0.005) were identified as independent risk factors for PE. There was no significant difference in renal function between maternal and newborn group in relation to the occurrence of adverse outcomes (P > 0.05 vs. all groups).

Conclusions

Through the analysis of renal function indicators in patients with PE in the second trimester of pregnancy and those in a normal control group, it is found that elevated serum uric acid and serum uric acid to serum creatinine ratio in PE individual may serve as indicative markers for the onset of PE. Targeting this subset of the population for monitoring and management during the second trimester could enhance the efficacy of medical interventions.

The impact of aspirin combined with labetalol on coagulation function and pregnancy outcomes in pre-eclamptic pregnant women

BACKGROUND

This study aimed to analyze the impact of aspirin combined with labetalol on coagulation function and pregnancy outcomes in women with pre-eclampsia.

METHODS

A total of 98 pregnant women with pre-eclampsia admitted to our hospital from September 2019 to March 2021 were selected for the retrospective analysis. Patient records were reviewed and divided into a control group (n = 49) who received labetalol and an observation group (n = 49) who received aspirin combined with labetalol. Extracted from the case collection system and observed: clinical efficacy, occurrence of adverse pregnancy outcomes, and adverse reactions.

RESULTS

The total effective rate in the observation group was higher than that in the control group. After treatment, the observation group had lower systolic blood pressure, diastolic blood pressure, D-D, Scr, β2-MG, and MA levels compared to the control group, and higher TT, PT and APTT levels. The occurrence rate of adverse pregnancy outcomes such as preterm delivery, intrauterine distress, postpartum hemorrhage, and fetal heart abnormalities was lower in the observation group than in the control group. There were no statistically significant differences in adverse reactions such as nausea, vomiting, hypotension, ocular tremor, and facial flushing between the two groups.

CONCLUSION

Aspirin combined with labetalol has ideal therapeutic efficacy in women with pre-eclampsia. It can enhance the antihypertensive effect, improve the coagulation status of the body, protect renal function, improve adverse pregnancy outcomes, and is considered safe and reliable, deserving adoption.

Assessing and Addressing Cardiovascular and Obstetric Risks in Patients Undergoing Assisted Reproductive Technology: A Scientific Statement From the American Heart Association

The use of assisted reproductive technology (ART) is growing, both to assist individuals with infertility and for fertility preservation. Individuals with cardiovascular disease (CVD), or risk factors for CVD, are increasingly using ART. Thus, knowing how to care for patients undergoing ART is important for the cardiovascular clinician. In this scientific statement, we review the ART process and known short-term and long-term risks associated with ART that can adversely affect patients with CVD. We review current knowledge on risks from ART for specific cardiac conditions and provide a suggested approach to evaluating and counseling patients with CVD contemplating ART as well as suggested management before and during the ART process. Individuals with CVD are at increased risk for pregnancy complications, and management of this unique population has been discussed previously. The focus of this scientific statement is on ART. Therefore, discussions on risk assessment, counseling, and management of individuals with CVD during pregnancy are limited, and established guidelines are referenced.

Safety of a trial of labor after cesarean in kidney and liver transplant recipients: A multicenter cohort study

OBJECTIVE

To evaluate the trends, safety, and feasibility of a trial of labor after cesarean (TOLAC) among kidney and liver transplant recipients.

METHODS

This was a retrospective cohort study using the Transplant Pregnancy Registry International. It included recipients of a kidney or liver transplant with a live-birth pregnancy ≥20 weeks following a prior cesarean, with births between 1967 and 2019 from 289 hospitals, primarily in North America. The primary outcomes of severe maternal morbidity (SMM) and neonatal composite morbidity were compared between those with repeat cesarean deliveries (RCDs), vaginal births after cesarean (VBACs), and failed TOLAC. Multivariable regression was conducted to calculate odds ratios and 95% confidence intervals.

RESULTS

The 243 deliveries included in this study were composed of 80.7% RCDs, 10.3% VBACs, and 9.1% with failed TOLAC, with similar demographics between groups. There was no significant difference in incidence of SMM (RCD, 1.0%; VBAC, 4.0%; failed TOLAC, 0%; P = 0.48) or neonatal composite morbidity (RCD, 15.2%; VBAC, 11.5%; failed TOLAC, 4.5%; P = 0.45) between groups. No cases of uterine rupture or neonatal death occurred. Trends in TOLAC demonstrate that the TOLAC rate has declined from 35% in 1989-1994 to 13% in 2014-2019.

CONCLUSIONS

In this cohort of transplant recipients, TOLAC resulted in successful vaginal delivery over half the time, and did not increase the risk of maternal or neonatal morbidity compared with RCD. We encourage offering transplant recipients a trial of labor after appropriate counseling to decrease the overall rate of cesarean delivery and morbidity in this high-risk population.

Intracranial Hemorrhage During Pregnancy: An Interdisciplinary Literature Review and a Rare Case Report of Early-Onset Eclampsia with Intracranial Hemorrhage and HELLP Syndrome

Intracranial hemorrhage is a rare yet potentially devastating event during pregnancy with a significant risk of maternal and fetal mortality and morbidity. The risk of intracranial hemorrhage increases during the third trimester of pregnancy and is greatest during labor and the postpartum period. Interdisciplinary diagnosis and treatment of the pregnant population often begins in the emergency department setting and is key to increasing patient survival rates through immediate and adequate treatment, including emergency medicine, neurosurgical and obstetrical procedures. A unique case report with a diagnostic pathway for intracranial hemorrhage due to eclampsia in a primipara at 24 weeks of gestation is presented, illustrating potential diagnostic dilemmas as the patient rapidly progresses into hemolysis, elevated liver enzymes and low platelets syndrome. A literature review was conducted to uncover the etiology of intracranial hemorrhage during pregnancy, as well as its diagnostic challenges and treatment. Pregnancy should not be viewed as a barrier to performing angiography or endovascular treatment for vascular causes of intracranial hemorrhage. Patient transport to a tertiary reference center and the interdisciplinary cooperation of specialists are key to achieving correct and rapid treatment. Continuous prevention of preeclampsia and patient education are necessary to decrease the incidence of eclampsia and its complications. Key message: Intracranial hemorrhage and eclampsia in pregnant patients are rare yet may result in high rates of maternal and fetal morbidity and mortality. The diagnostic process is difficult and requires interdisciplinary cooperation to start the correct treatment immediately.

Hematologic dynamics during pregnancy and their association with obstetric complications: a retrospective cohort study

Objectives

Pregnancy alters hematologic state as measured by complete blood counts (CBC), but the longitudinal changes in CBC indices that define healthy pregnancies are not well established. Our objectives were (1) to define gestational age-specific reference intervals for CBCs and their longitudinal changes in a large United States-based cohort and (2) to use these reference intervals to examine associations between extreme CBC values and changes and risk of obstetric complications.

Design

Retrospective cohort study including electronic health record-based discovery and validation cohorts.

Setting

Academic medical center and affiliated health system in the United States between 1998 and 2022.

Participants

Individuals with singleton pregnancies delivering after 30 weeks' gestation who presented for prenatal care prior to 20 weeks'. There were 45,992 pregnancies in the discovery cohort, 18% of whom had complications, and 50,603 in the validation cohort, 22% with complications.

Main outcome measures

Composite outcome (hypertensive disorder of pregnancy, small for gestational age birthweight or preterm birth) and its individual components. We analyzed associations between CBC results and outcomes using generalized estimating equations for logistic regression with Bonferroni correction for multiple hypothesis testing.

Results

Hematocrit, hemoglobin, and red cell count values above their reference intervals were associated with increased risk of the composite obstetric complication: OR [95% CI] of 1.4 [1.2, 1.6] p=1.8×10-5 for hematocrit; 1.7[1.4, 1.9] p=1.4×10-10 for hemoglobin; and 1.6[1.4, 1.9] p=3.9×10-9 for red cell count. Extreme increase in hemoglobin (>0.67 g/dL) or red cell count (>0.07 106/mm3) between 7-14 weeks' and 26-29 weeks' gestation was associated with increased risk for preterm birth (OR [95% CI] for hemoglobin 2.0[1.6, 2.6] p=2×10-8 and red cell count: 2.1[1.7, 2.6] p=9×10-14). Reference intervals in this cohort were often wider than those previously published for mean red cell volume, mean red cell hemoglobin, red cell count, and mean red cell hemoglobin concentration.

Conclusions

Elevated measures of red blood cell count and large intra-pregnancy increases in those measures are associated with subsequent obstetric complications.

A randomized trial of postpartum ibuprofen in severe hypertensive disorders of pregnancy

BACKGROUND

Ibuprofen has been shown to increase blood pressure in nonpregnant adults with hypertension, but its impact on blood pressure when used for postpartum analgesia in patients with a hypertensive disorder of pregnancy is less clear, particularly for those with severe hypertension.

OBJECTIVE

To evaluate the impact of ibuprofen on postpartum blood pressure outcomes in patients with hypertensive disorders of pregnancy with severe hypertension.

STUDY DESIGN

In this randomized, double-blind trial, we randomly assigned patients with hypertensive disorders of pregnancy with severe hypertension to receive a postpartum analgesic regimen consisting of either ibuprofen 600 mg or acetaminophen 650 mg (control) every 6 hours. The primary outcome was severe hypertension during postpartum hospitalization. Secondary outcomes included other measures of blood pressure control such as antihypertensive medication use and average postpartum mean arterial pressure, and outpatient blood pressure as well as patient satisfaction, pain control, and diuresis. A sample size of 132 was needed to detect a 35% difference in severe postpartum hypertension.

RESULTS

We enrolled 140 participants from January 2017-October 2019. The prevalence of severe hypertension postpartum did not differ between participants receiving ibuprofen (38.6%) vs control (41.4%); the absolute difference was 2.8 percentage points, 95% confidence interval -13.1% to 18.5%, P=.73. There was no difference between the ibuprofen and control groups for antihypertensive medication use (35.7% vs 40.0%, P=.60) or average postpartum mean arterial pressure (95.7 ± 8.2 vs 95.9 ± 9.5, P=.91, respectively). Measures of outpatient blood pressure, patient satisfaction, diuresis, and pain control were also similar.

CONCLUSION

In patients with hypertensive disorders of pregnancy with severe hypertension, use of ibuprofen postpartum did not increase the prevalence of postpartum severe hypertension. Ibuprofen use did not impact other blood pressure outcomes, pain control, or patient satisfaction. These findings support ibuprofen use during the postpartum period in patients with hypertensive disorders of pregnancy.

Current Approaches and Innovations in Managing Preeclampsia: Highlighting Maternal Health Disparities

Preeclampsia (PE) is a major cause of maternal mortality and morbidity, affecting 3-6% of pregnancies worldwide and ranking among the top six causes of maternal deaths in the U.S. PE typically develops after 20 weeks of gestation and is characterized by new-onset hypertension and/or end-organ dysfunction, with or without proteinuria. Current management strategies for PE emphasize early diagnosis, blood pressure control, and timely delivery. For prevention, low-dose aspirin (81 mg/day) is recommended for high-risk women between 12 and 28 weeks of gestation. Magnesium sulfate is also advised to prevent seizures in preeclamptic women at risk of eclampsia. Emerging management approaches include antiangiogenic therapies, hypoxia-inducible factor suppression, statins, and supplementation with CoQ10, nitric oxide, and hydrogen sulfide donors. Black women are at particularly high risk for PE, potentially due to higher rates of hypertension and cholesterol, compounded by healthcare disparities and possible genetic factors, such as the APOL1 gene. This review explores current and emerging strategies for managing PE and addresses the underlying causes of health disparities, offering potential solutions to improve outcomes.