Cardiovascular origins of preeclampsia

Usefulness of USCOM® evaluation in women with chronic hypertension who developed severe preeclampsia with low platelets and elevated liver enzymes

Cardiovascular changes that occur during pregnancy have been recently described and are matter of debate; during gestation we observe an increase in cardiac output and a reduction of peripheral total vascular resistance (TVR). In pregnancies complicated by hypertensive disorders, instead, these changes are lacking, with a persisting low cardiac output and high peripheral resistances. In this case report, we observed that in patients with chronic hypertension TVR are high, while the cardiac output is able to face the needs of pregnancy. The increase in TVR before the decision to deliver, due to bad blood pressure control despite therapy, may precede the alterations in blood tests (platelet decreasing and high liver enzymes). This data may be useful for monitoring patients with chronic hypertension and identifying those at higher risk of developing HELLP/severe preeclampsia.

Copeptin and mid-regional pro-atrial natriuretic peptide in women with suspected or confirmed pre-eclampsia: comparison with sFlt-1/PlGF ratio

OBJECTIVES

Arginine vasopressin (AVP) and atrial natriuretic peptide (ANP) may contribute to the pathogenesis of pre-eclampsia (PE), but their role remains to be elucidated. Our aims were to evaluate the surrogates of AVP and ANP, C-terminal pro-AVP (copeptin) and mid-regional pro-ANP (MR-proANP), as biomarkers for the prediction of PE-related pregnancy complications and whether they are associated with angiogenic markers and/or clinical manifestations of PE.

METHODS

This was a retrospective analysis of a prospective cohort study that enrolled pregnant women with suspected or confirmed PE, between December 2013 and April 2016. From each patient, a blood sample was obtained at study entry and serum levels of copeptin, MR-proANP, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured. We evaluated the ability of sFlt-1, PlGF, sFlt-1/PlGF ratio, copeptin and MR-proANP, assessed either alone or combined with traditional predictors (gestational age, parity, diastolic blood pressure and proteinuria), to predict maternal complications and fetal/neonatal complications. Models were compared using concordance statistic (C-index).

RESULTS

A total of 526 women were evaluated in the study. Women with confirmed PE displayed elevated serum copeptin and MR-proANP levels in comparison to those with suspected PE but no hypertensive disease of pregnancy. When combined with traditional predictors, the sFlt-1/PlGF ratio displayed a higher C-index than copeptin and MR-proANP (0.76, 0.63 and 0.67, respectively, vs 0.60 for the traditional predictors alone) for the prediction of maternal complications. Similarly, for the prediction of fetal/neonatal complications, the sFlt-1/PlGF ratio displayed a higher C-index than copeptin and MR-proANP when added to the traditional model (0.83, 0.79 and 0.80, respectively, vs 0.79 for the traditional predictors alone). When subdividing women according to sFlt-1/PlGF ratio (≥ 85 vs < 85), no differences in copeptin levels were observed, while MR-proANP level was elevated in women with sFlt-1/PlGF ratio ≥ 85. Multiple regression analysis revealed that copeptin and MR-proANP were independent determinants of proteinuria.

CONCLUSIONS

Copeptin and MR-proANP have limited value in predicting PE-related complications when compared with the sFlt-1/PlGF ratio. However, both copeptin and MR-proANP were associated with proteinuria, with copeptin exerting this effect independently of the sFlt-1/PlGF ratio. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

High-sensitivity cardiac troponin I in women with a history of early-onset preeclampsia

OBJECTIVE

Preeclampsia is associated with an elevated risk of cardiovascular disease later in life. Women with a history of preeclampsia are at risk of developing hypertension as well as ischemic heart disease. Identification of women at the highest risk is important to initiate preventive strategies. We investigated whether high-sensitivity cardiac troponin I (hs-cTnI) levels are associated with a history of early-onset preeclampsia, and with hypertension in these high-risk women.

METHODS

Approximately 9-10 years after pregnancy, hs-cTnI levels were measured for 339 women of the Preeclampsia Risk Evaluation in FEMales cohort, consisting of 177 women with a history of early-onset preeclampsia and 162 women with a previous uncomplicated index pregnancy. Associations were analyzed using several statistical tests and linear regression analysis.

RESULTS

The median hs-cTnI levels (IQR) were 2.50 ng/l (2.30) in women with a history of early-onset preeclampsia and 2.35 ng/l (2.50) in women without a history of preeclampsia, P = 0.53. Among women with a history of early-onset preeclampsia, the hs-cTnI levels were higher in women who were hypertensive compared with their normotensive counterparts (medians 2.60 versus 2.30; P = 0.03). In addition, blood pressure levels increased with increasing hs-cTnI levels.

CONCLUSION

We did not find a difference in hs-cTnI levels between women with and without a history of early-onset preeclampsia. Nonetheless, hs-cTnI levels were statistically significantly higher in current hypertensive women with a history of preeclampsia compared with their normotensive counterparts. Therefore, hs-cTnI levels might improve risk prediction for women at the highest risk of cardiovascular disease.

Preeclampsia Is a Syndrome with a Cascade of Pathophysiologic Events

This review integrates the currently available information on the molecular, cellular, and systemic mechanisms involved in the pathophysiology of preeclampsia. It highlights that the growth, protection, and promotion of the conceptus requires the modulation of an intact maternal immune system, communication between the mother and fetus, and adaptation of the maternal organic functions. A malfunction in any of these factors, on either side, will result in a failure of the cascade of events required for the normal course of pregnancy. Maladaptive processes, initially aiming to protect the conceptus, fail to anticipate the gradually increasing cardiovascular volume load during the course of pregnancy. As a result, multiple organ dysfunctions install progressively and eventually reach a state where mother and/or fetus are at risk of severe morbidity or even mortality, and where the termination of pregnancy becomes the least harmful solution. The helicopter view on pathophysiologic processes associated with preeclampsia, as presented in this paper, illustrates that the etiology of preeclampsia cannot be reduced to one single mechanism, but is to be considered a cascade of consecutive events, fundamentally not unique to pregnancy.

microRNA-646 inhibits angiogenesis of endothelial progenitor cells in pre-eclamptic pregnancy by targeting the VEGF-A/HIF-1α axis

Pre-eclampsia is a complication that occurs during pregnancy, the pathological feature of which is a change in vascular endothelial homeostasis. microRNA (miR)-646 is an anti-angiogenic miRNA that has been indicated to exhibit potential anti-angiogenic effects in endothelial cells cultured in vitro and in ischemia-induced angiogenesis. However, whether miR-646 has therapeutic potential in placental angiogenesis in pre-eclampsia remains to be determined. In the current study, human peripheral blood-derived endothelial progenitor cells (EPCs) were isolated to study the coordination between miR-646, vascular endothelial growth factor (VEGF)-A and hypoxia-inducible factor (HIF)-1α expression in preeclampsia EPCs. EPCs were isolated from human peripheral blood to demonstrate a potential interaction between miR-646 and targets (VEGF-A) in vitro. The number of EPCs and the expression of miR-646 in patients with preeclampsia was detected, and the effects of miR-646 on EPC function and preeclampsia angiogenesis was assessed. Clinical specimens demonstrated that miR-646 expression was enhanced in pregnancy with preeclampsia. The results indicated that miR-646 suppressed EPCs multiplication, differentiation and migration. miR-646 was observed to exert an anti-angiogenic function by suppressing the expression of angiogenic cytokines VEGF-A and HIF-1α. Additionally, luciferase results displayed that miR-646 downregulated VEGF-A expression by directly binding to a specific sequence in its 3'-untranslated region. The results of the current study demonstrated that the miR-646/VEGF-A/HIF-1α axis is significant for angiogenic properties of EPCs in vitro and in vivo placental vasculogenesis. The results of the present study provide a new insight into microRNA regulation of vessel homeostasis and angiogenesis, and a basis for alternative treatments for patients with pre-eclampsia.

Prenatal Exposure to Preeclampsia and Long-Term Ophthalmic Morbidity of the Offspring

The aim of this population-based study was to evaluate whether prenatal exposure to preeclampsia poses a risk for long-term ophthalmic morbidity. A population-based cohort analysis compared the risk of long-term ophthalmic morbidity among children who were prenatally exposed to preeclampsia and those who were not. The study population was composed of children who were born between the years 1991 and 2014 at a single tertiary medical center. Total ophthalmic hospitalization and time-to-event were both evaluated. A Kaplan-Meier survival curve was conducted to compare cumulative ophthalmic hospitalization incidence based on the severity of preeclampsia. Confounders were controlled using a Cox regression model. A total of 242,342 deliveries met the inclusion criteria, of which 7279 (3%) were diagnosed with mild preeclampsia and 2222 (0.92%) with severe preeclampsia or eclampsia. A significant association was found between severe preeclampsia or eclampsia and the risk of long-term vascular-associated ophthalmic morbidity in the offspring (no preeclampsia 0.3%, mild preeclampsia 0.2% and severe preeclampsia or eclampsia 0.5%, p = 0.008). This association persisted after controlling for maternal age and ethnicity (adjusted hazard ratio (HR) 1.861, 95% CI 1.051-3.295). In conclusion, within our population, prenatal exposure to severe preeclampsia or eclampsia was found to be a risk factor for long-term vascular-associated ophthalmic morbidity in the offspring.

Placental pathology in pregnancies complicated by fetal growth restriction: recurrence vs. new onset

OBJECTIVE

In an attempt to shed new light on the pathogenesis of fetal growth restriction (FGR), we aimed to study pregnancy characteristics, neonatal outcomes, and placental histopathological lesions of FGR pregnancies in two different subgroups: when developed after appropriate for gestational age (AGA) pregnancy and when developed after previous pregnancy with FGR.

STUDY DESIGN

Pregnancy and placental reports of all singleton pregnancies complicated by FGR (defined as actual birthweight below the 10th percentile according to local birthweight nomograms) between 2008 and 2018 were reviewed. Included were only cases with previous delivery. Maternal background, neonatal outcomes, and placental histopathology were compared between FGR that occurred after FGR (recurrent FGR group) and FGR that occurred after an AGA pregnancy (FGR after AGA group). Placental lesions were classified according to the current "Amsterdam" criteria. Continuous variables were compared using the Student's t test or the Mann-Whitney test as appropriate. Categorical variables were compared using Chi-square or Fisher's exact test as appropriate.

RESULTS

A total of 334 FGR cases with a previous delivery were included in the study. Of them, 111 cases constituted the recurrent FGR group and 223 constituted the FGR after AGA group. The recurrent FGR group was characterized by higher rates of maternal diabetes during pregnancy and hypertensive diseases (9% versus 2.7%, p = 0.01 and 19.8% versus 11.6%, p = 0.04). The FGR after AGA group was characterized by a higher rate of fetal vascular malperfusion (FVM) lesions (29.6% versus 18.0%, p = 0.02), and by lower mean birthweight (1842 ± 424.9 versus 1977.4 ± 412.2, p = 0.005), as compared to the recurrent FGR group.

CONCLUSION

Recurrent FGR was associated with maternal background morbidities during pregnancy which represents a chronic repeated insult, while "new" FGR cases (those followed an AGA pregnancy) were characterized by a higher rate of FVM lesions and lower birthweight which probably represent an "accident" in placentation. These findings may suggest that different mechanisms of placental dysfunction exist in the two subgroups of FGR.

Effect of blood pressure control in early pregnancy and clinical outcomes in African American women with chronic hypertension

OBJECTIVE

Chronic hypertension (cHTN) affects 3-5% of all pregnancies and is twice as prevalent in African American (AA) women. AA women develop more severe HTN at an earlier onset and have higher rates of adverse pregnancy outcomes. Blood pressure control during pregnancy is controversial.

STUDY DESIGN

This retrospective cohort included AA women with cHTN and singleton pregnancies delivering between January 2013 and December 2016. Patients were classified as not receiving antihypertensives in the first 20 weeks (Group A), on antihypertensives in the first 20 weeks but with an average BP <140/90 during pregnancy (Group B) and on antihypertensives in the first 20 weeks but with average BP during pregnancy ≥140/90 (Group C). Adverse outcomes including severe HTN and preterm delivery <35 weeks was compared between groups.

RESULTS

Of the 198 patients included, 68 received at least one AHT before 20 weeks including 45 patients with average BP <140/90 and 23 with average BP ≥140/90 during pregnancy. The incidence of superimposed PE and preterm birth was significantly higher among women with elevated BPs on AHT (39.1% vs 8.9% vs 17.7%, p = 0.01; preterm birth 52.2%, 8.9% and 9.2%, p < 0.001 for Groups C, B and A, respectively). A significantly higher proportion of adverse neonatal outcomes were observed in Group C (78.3%) as opposed to those in Group B (53.3%) or Group A (50.0%; p = 0.04).

CONCLUSIONS

Among AA women with cHTN, use of antihypertensives prior to 20 weeks and lower antenatal BP was associated with a decreased risk of adverse maternal and neonatal outcomes.

Heart rate variability in hypertensive pregnancy disorders: A systematic review

BACKGROUND

Hypertensive pregnancy disorders (HPD) are associated with dysfunction of the autonomic nervous system. Cardiac autonomic functions can be assessed by heart rate variability (HRV) measurements.

OBJECTIVE

To study whether HRV detects differences in the function of the autonomic nervous system between pregnant women with HPD compared to normotensive pregnant women and between women with a history of a pregnancy complicated by HPD compared to women with a history of an uncomplicated pregnancy.

METHODS

A systematic search was performed in Medline, EMBASE, and CENTRAL to identify studies comparing HRV between pregnant women with HPD or women with a history of HPD to women with (a history of) normotensive pregnancies.

RESULTS

The search identified 523 articles of which 24 were included in this review, including 850 women with (a history of) HPD and 1205 normotensive controls. The included studies showed a large heterogenicity. A decrease in overall HRV was found in preeclampsia (PE), compared to normotensive pregnant controls. A trend is seen towards increased low frequency/high frequency-ratio in women with PE compared to normotensive pregnant controls.

CONCLUSION

Our systematic review supports the hypothesis a sympathetic overdrive is found in HPD which is associated with a parasympathetic withdrawal. However, the included studies in our review showed a large diversity in the methods applied and their results.

Blood pressure after PREeclampsia/HELLP by SELF monitoring (BP-PRESELF): rationale and design of a multicenter randomized controlled trial

Background

Hypertensive disorders of pregnancy (HDP), such as preeclampsia (PE) or the Hemolysis Elevated Liver enzymes and Low Platelets (HELLP) syndrome are associated with elevated cardiovascular disease (CVD) risks, but standardized prevention guidelines after such pregnancies are lacking. Hypertension is the first emerging risk factor after PE/HELLP pregnancies and is a major risk factor for CVD. Hypertension before the age of 55 years may lead to various manifestations of end-organ damage at relatively young age. Therefore, timely treatment of elevated blood pressure is mandatory, but many of these high-risk women have long-term undetected and untreated hypertension before adequate treatment is initiated.

Aim

The aim of our study is to assess whether home blood pressure monitoring (HBPM) in women with a previous PE/HELLP pregnancy is a valuable tool for the early detection of hypertension.

Methods

Women with a history of both early and late PE/HELLP syndrome aged 40–60 years are invited to participate. Patients with a history of CVD, known hypertension and/or use of antihypertensive medication are excluded. Women are randomized between HPBM or ‘usual care’. The primary outcome is feasibility and usability of HBPM after 1 year of follow-up.

Secondary outcomes will be the effectiveness of HPBM to detect hypertension, the efficacy of BP treatment, quality of life, health-related symptoms, work ability, and life-style behaviour.

The results of this study will provide better strategies for timely detection and prevention of hypertension in women after PE/HELLP.

Trial registration

ClinicalTrials.gov, NCT03228082. Registered June 15, 2017.

Cardiovascular Disease-Related Pregnancy Complications Are Associated with Increased Maternal Levels and Trajectories of Cardiovascular Disease Biomarkers During and After Pregnancy

Background: Having a pregnancy complicated by hypertensive disorders of pregnancy (HDP) and/or having a small or preterm baby put a woman at risk for later cardiovascular disease (CVD). It is uncertain if higher maternal CVD risk factors (reflected by increased peripartum CVD biomarker levels) account for this risk, or if experiencing a complicated pregnancy itself increases a woman's CVD risk (reflected by an increase in biomarker trajectories from early pregnancy to postpartum). Methods: We conducted a secondary analysis of an 8-week mindful eating and stress reduction intervention in 110 pregnant women. We used mixed linear regression analysis to compare CVD biomarker levels and trajectories, between women with and without a CVD-related pregnancy complication (including HDP [gestational hypertension or preeclampsia] or having a small for gestational age [<10th percentile] or preterm [<37 weeks] baby), at three times: (1) 12-20 weeks of gestation, (2) 3 months postpartum, and (3) 9 months postpartum. CVD biomarkers studied included serum glucose, insulin, homeostasis model assessment of insulin resistance (HOMA-IR), body mass index (BMI), blood pressure (BP), interleukin-6 (IL-6), tumor necrosis factor, and lipids. We adjusted for age, maternal smoking, prepregnancy BMI, BP, age × time, and BMI × time. Results: Women had a mean age of 28 years (standard deviation [SD] 6), mean prior pregnancies of 0.8 (SD 1.0), and 22 women had one or more CVD-related pregnancy complications. HOMA-IR, diastolic BP, triglyceride, high-density lipoprotein cholesterol, and IL-6 average levels, but not trajectories, differed among women with complicated versus normal pregnancy (all p values were ≤0.04). Peripartum glucose and systolic BP trajectories were statistically greater in complicated versus normal pregnancies (p values were 0.008 and 0.01, respectively). Conclusion: We conclude that the experience of a complicated pregnancy in addition to elevated CVD risk factor levels may both increase a woman's risk of future CVD. ClinicalTrials.gov Identifier: NCT01307683.

None, One, or Both Placentas Involved with Malperfusion Lesions in Twin Pregnancies Complicated by Preeclampsia-Does It Matter?

We aimed to study the association between the number of placentas with vascular malperfusion lesions in dichorionic twin pregnancies complicated by preeclampsia and the severity of the disease and pregnancy outcomes. Dichorionic twin pregnancies with preeclampsia (n = 125), from January 2007-June 2018, were reviewed. Affected placenta was defined as the presence of maternal/fetal vascular malperfusion lesions. Maternal demographics, pregnancy characteristics, and neonatal outcomes were compared between three groups: no pathological placentas, one pathological placenta, and two pathological placentas. Composite adverse neonatal outcome was defined as ≥ 1 early neonatal complication. Regression analysis models were used to recognize independent associations with the number of involved placentas. The two pathological placenta group (n = 57 pregnancies), the one pathological placenta group (n = 40 pregnancies), and the no pathological placenta group (n = 28 pregnancies) differed in terms of gestational age (GA) at delivery (p < 0.001, p = 0.008) and the rates of severe features (p = 0.028, p = 0.047). Neonates born to the two pathological placenta group (n = 114), the one pathological placenta group (n = 80), and the no pathological placenta group (n = 56) were characterized by lower birth weights (p < 0.001, p = 0.031), higher rates of small for gestational age (SGA) (p = 0.017, p = 0.748), neonatal intensive care unit admission (p = 0.004, p = 0.013), and composite adverse neonatal outcome (p < 0.001, p = 0.025). By regression analyses, the presence of two pathological placentas was found to be independently associated with severe features (aOR = 5.1), GA at delivery < 32 weeks (aOR = 2.0), SGA (aOR = 2.5), and composite adverse neonatal outcome (aOR = 2.7). In dichorionic twin pregnancies, there is an association between the presences of placental vascular malperfusion lesions in none, one, or both placentas and the development of early and severe preeclampsia, as well as with SGA and adverse neonatal outcome.

Influence of maternal characteristics and gestational age on hemodynamic indices: NICOM device-specific reference ranges

OBJECTIVES

To construct reference ranges for stroke volume, cardiac output and systemic vascular resistance (SVR) in normal pregnancy for the NICOM® device, and to explore associations between maternal characteristics and these hemodynamic variables.

METHODS

This was a prospective cohort study of healthy singleton pregnancies between 10 and 40 weeks' gestation attending a tertiary referral hospital between September 2012 and May 2018. Measurements of stroke volume, cardiac output and SVR were obtained throughout pregnancy using NICOM, a non-invasive device based on bioreactance technology. NICOM device-specific reference ranges were created with respect to gestational age and maternal characteristics. Once the distribution of the data had been determined with respect to the gestational age, patient characteristics were added to the model to test whether they provided a significant improvement in prediction of the median value. The effect was assessed of maternal weight, height, smoking status, conception using assisted reproductive technology, nulliparity and ethnicity.

RESULTS

We included 411 women in this study. The relationships between cardiac variables and gestational age observed in the NICOM-specific reference ranges are consistent with previous findings, with increasing cardiac output values until around 35 weeks and a decrease thereafter until term, and decreasing SVR until around 36 weeks, followed by an increase towards 40 weeks. Stroke volume showed a small linear increase across gestation with lower variability in observations close to term. Maternal weight, height and age were associated with cardiac output (all P < 0.05) and SVR (all P < 0.01), whilst maternal weight and height were associated with stroke volume (both P < 0.001). Ethnicity was significantly associated with stroke volume (P = 0.001) but not with cardiac output or SVR.

CONCLUSIONS

This study presents device-specific reference ranges for stroke volume, cardiac output and SVR for the NICOM device in healthy pregnancy and describes the maternal characteristics that are associated with the values of these hemodynamic measurements. Studies using NICOM in pregnancy can use these ranges in order to evaluate observations relative to those expected in uncomplicated pregnancy conditional on maternal characteristics. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

MicroRNAs in Uteroplacental Vascular Dysfunction

Pregnancy complications of preeclampsia and intrauterine growth restriction (IUGR) are major causes of maternal and perinatal/neonatal morbidity and mortality. Although their etiologies remain elusive, it is generally accepted that they are secondary to placental insufficiency conferred by both failure in spiral artery remodeling and uteroplacental vascular malfunction. MicroRNAs (miRNAs) are small no-coding RNA molecules that regulate gene expression at the post-transcriptional level. Increasing evidence suggests that miRNAs participate in virtually all biological processes and are involved in numerous human diseases. Differentially expressed miRNAs in the placenta are typical features of both preeclampsia and IUGR. Dysregulated miRNAs target genes of various signaling pathways in uteroplacental tissues, contributing to the development of both complications. In this review, we provide an overview of how aberrant miRNA expression in preeclampsia and IUGR impacts the expression of genes involved in trophoblast invasion and uteroplacental vascular adaptation.

Congenital Heart Disease and Women's Health Across the Life Span: Focus on Reproductive Issues

From adolescence to older age, women with congenital heart disease (CHD) face unique challenges. In this review we explore the ways in which CHD affects women's sexual and reproductive health and, in turn, how their sexual and reproductive history affects the course of their CHD. In adolescence, special attention must be paid to menstrual irregularities and concerns of developing sexuality and self-image. Discussions about sexuality and reproduction are an important part of transition planning and must be done with an awareness of the adolescent's developing understanding and maturity. Pregnancy imposes a hemodynamic load on the heart which may lead to cardiac, obstetric, and fetal/neonatal complications in women with CHD. Prepregnancy counselling must include an assessment of maternal and fetal risk according to several well developed models. Counselling should also include discussions about fertility and alternatives to pregnancy when appropriate. Recommendations for contraception must be made according to the patient's cardiac lesion. In caring for women with CHD during pregnancy, a multidisciplinary cardio-obstetrics team is recommended to optimize care. More research is needed into the long-term impact of pregnancy on the prognosis of patients with CHD. As women with CHD increasingly survive into old age, more attention will need to be directed toward the treatment of menopause and acquired heart disease in this population.

Expectant management of early-onset severe preeclampsia: a principal component analysis

Background

Preeclampsia is a multisystem disorder that is characterized by hypertension with either proteinuria or end-organ dysfunction in both previously normotensive women and chronically hypertensive women. To identify the important influencing factors for early-onset severe preeclampsia, this study undertook to explore the associations between preeclampsia characteristics, along with the decreased latency and poor neonatal outcomes during expectant management of severe preeclampsia before 34 weeks of gestation.

Methods

A total of 213 patients were retrospectively studied. Pregnancy outcomes in terms of maternal complications and neonatal outcomes were determined. Statistical analysis was performed by principal component analysis, Student's t-test, and Pearson correlation analysis.

Results

Neonatal mortality was influenced by gestational age at delivery and birth weight. The main factors that influenced pregnancy outcome were gestational age at diagnosis, the 24-h urine protein level, the plasma albumin level, and hydrothorax plus ascites. When the gestational age at diagnosis was 25 weeks, and 4/7 days, the probability that the pregnancy would be classified into group 2 with 79.3% neonatal survival was almost 50%. Only the plasma albumin level and hydrothorax plus ascites affected prolongation.

Conclusions

Plasma albumin level and hydrothorax plus ascites should be considered seriously, as they may be a reason to terminate the expectant management of early-onset severe preeclampsia. Given its unsatisfactory pregnancy outcomes, expectant management should be reconsidered before 25 weeks and 4/7 days.

Longitudinal changes in placental biomarkers in women with early versus late placental dysfunction

Objective: To evaluate longitudinal changes of angiogenic biomarkers in early- (EO-PD) versus late-onset (LO-PD) placental dysfunction. Methods: Serum PlGF and sFlt-1 measured at different intervals in EO-PD (n= 43), LO-PD (n= 31) and controls (n = 133). Results: sFlt-1/PlGF ratio was higher at 16 weeks (30.6 vs 17.5), 20 weeks (29.3 vs 8.9) and 30 weeks (16.6 vs 6.7) in EO-PD vs controls (all p< 0.05), but not in LO-PD. Longitudinal changes for all intervals had higher AUC than single measurements. Conclusion: Longitudinal biomarker change between 12 and 30 weeks could improve prediction of EO-PD compared to single measurements.

Preeclampsia: a gestational cardiorenal syndrome

It is generally accepted today that there are two different types of preeclampsia: an early-onset or placental type and a late-onset or maternal type. In the latent phase, the first one presents with a low output/high resistance circulation eventually leading in the late second or early third trimester to an intense and acutely aggravating systemic disorder with an important impact on maternal and neonatal mortality and morbidity; the other type presents initially as a high volume/low resistance circulation, gradually evolving to a state of circulatory decompensation usually in the later stages of pregnancy, with a less severe impact on maternal and neonatal outcome. For both processes, numerous dysfunctions of the heart, kidneys, arteries, veins and interconnecting systems are reported, most of them presenting earlier and more severely in early- than in late-onset preeclampsia; however, some very specific dysfunctions exist for either type. Experimental, clinical and epidemiological observations before, during and after pregnancy are consistent with gestation-induced worsening of subclinical pre-existing chronic cardiovascular dysfunction in early-onset preeclampsia, and thus sharing the pathophysiology of cardiorenal syndrome type II, and with acute volume overload decompensation of the maternal circulation in late-onset preeclampsia, thus sharing the pathophysiology of cardiorenal syndrome type 1. Cardiorenal syndrome type V is consistent with the process of preeclampsia superimposed upon clinical cardiovascular and/or renal disease, alone or as part of a systemic disorder. This review focuses on the specific differences in haemodynamic dysfunctions between the two types of preeclampsia, with special emphasis on the interorgan interactions between heart and kidneys, introducing the theoretical concept that the pathophysiological processes of preeclampsia can be regarded as the gestational manifestations of cardiorenal syndromes.

Integration of suboptimal health status evaluation as a criterion for prediction of preeclampsia is strongly recommended for healthcare management in pregnancy: a prospective cohort study in a Ghanaian population

Background

Normotensive pregnancy may develop into preeclampsia (PE) and other adverse pregnancy complications (APCs), for which the causes are still unknown. Suboptimal health status (SHS), a physical state between health and disease, might contribute to the development and progression of PE. By integration of a routine health measure in this Ghanaian Suboptimal Health Cohort Study, we explored the usefulness of a 25-question item SHS questionnaire (SHSQ-25) for early screening and prediction of normotensive pregnant women (NTN-PW) likely to develop PE.

Methods

We assessed the overall health status among a cohort of 593 NTN-PW at baseline (10-20 weeks gestation) and followed them at 21-31 weeks until 32-42 weeks. After an average of 20 weeks follow-up, 498 participants returned and were included in the final analysis. Hematobiochemical, clinical and sociodemographic data were obtained.

Results

Of the 498 participants, 49.8% (248/498) had 'high SHS' at baseline (61.7% (153/248) later developed PE) and 38.3% (95/248) were NTN-PW, whereas 50.2% (250/498) had 'optimal health' (17.6% (44/250) later developed PE) and 82.4% (206/250) were NTN-PW. At baseline, high SHS score yielded a significantly (p < 0.05) increased adjusted odds ratio, a wider area under the curve (AUC) and a higher sensitivity and specificity for the prediction of PE (3.67; 0.898; 91.9% and 87.8%), PE coexisting with intrauterine growth restriction (2.86, 0.838; 91.5% and 75.9%), stillbirth (2.52; 0.783; 96.6% and 60.0%), hemolysis elevated liver enzymes and low platelet count (HELLP) syndrome (2.08; 0.800; 97.2% and 63.8%), acute kidney injury (2.20; 0.825; 95.3% and 70.0%) and dyslipidaemia (2.80; 0.8205; 95.7% and 68.4%) at 32-42 weeks gestation.

Conclusions

High SHS score is associated with increased incidence of PE; hence, SHSQ-25 can be used independently as a risk stratification tool for adverse pregnancy outcomes thereby creating an opportunity for predictive, preventive and personalized medicine.

Maternal hemodynamics in screen-positive and screen-negative women of the ASPRE trial

OBJECTIVE

To compare maternal hemodynamics and perinatal outcome, in pregnancies that do not develop pre-eclampsia (PE) or deliver a small-for-gestational-age (SGA) neonate, between those identified at 11-13 weeks' gestation as being screen positive or negative for preterm PE, by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, serum placental growth factor and pregnancy associated plasma protein-A.

METHODS

This was a prospective longitudinal cohort study of maternal cardiovascular function, assessed using a bioreactance method, in women undergoing first-trimester screening for PE. Maternal hemodynamics and perinatal outcome were compared between screen-positive and screen-negative women who did not have a medical comorbidity, did not develop PE or pregnancy-induced hypertension and delivered at term a live neonate with birth weight between the 5^th and 95^th percentiles. A multilevel linear mixed-effects model was used to compare the repeated measures of cardiac variables, controlling for maternal characteristics.

RESULTS

The screen-negative group (n = 926) had normal cardiac function changes across gestation, whereas the screen-positive group (n = 170) demonstrated static or reduced cardiac output and stroke volume and higher mean arterial pressure and peripheral vascular resistance with advancing gestation. In the screen-positive group, compared with screen-negative women, birth-weight Z-score was shifted toward lower values, with prevalence of delivery of a neonate below the 35^th , 30^th or 25^th percentile being about 70% higher, and the rate of operative delivery for fetal distress in labor also being higher.

CONCLUSION

Women who were screen positive for impaired placentation, even though they did not develop PE or deliver a SGA neonate, had pathological cardiac adaptation in pregnancy and increased risk of adverse perinatal outcome. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Hypertensive Diseases of Pregnancy Increase Risk of Readmission With Heart Failure: A National Readmissions Database Study

OBJECTIVE

To study the association between hypertensive diseases of pregnancy and immediate postpartum development of heart failure in a large national database.

PATIENTS AND METHODS

Using the 2013 to 2014 National Readmissions Database, which covered admissions from January 1 through September 30 in years 2013 and 2014, we examined 90-day readmission rates in parturients with a diagnosis of hypertensive disease of pregnancy who were discharged after delivery. The primary outcome was the association between the presence of hypertensive disease of pregnancy and readmission with heart failure within 90 days of delivery discharge. Secondary outcomes included readmission mortality, time between delivery discharge and readmission, length of stay, and costs of readmission.

RESULTS

Women with hypertensive disease of pregnancy were more likely to be readmitted with heart failure (1809 of 25,908 readmissions (7.0%) vs 2622 of 89,660 readmissions (2.9%); P<.001). This difference persisted after adjustment for potential cofounders (6.3% vs 3.1%; odds ratio, 2.15; 95% CI, 1.92-2.40; P<.001). Women with a diagnosis of heart failure at readmission were readmitted sooner (11 days vs 23 days; P<.001) and had a longer length of stay (4 days vs 3 days; P<.001) and higher costs of readmission ($10,361 vs $6977; P<.001) than did women without a diagnosis of heart failure.

CONCLUSION

Parturients with hypertensive disease of pregnancy were more likely to be readmitted with heart failure within 90 days of delivery. Most patients readmitted with heart failure were readmitted within 2 weeks of discharge after delivery. Patients readmitted with heart failure had substantial health care expenditures.

Analysis of the Epigenome in Multiplex Pre-eclampsia Families Identifies SORD, DGKI, and ICA1 as Novel Candidate Risk Genes

Pre-eclampsia is a serious heritable disorder that affects 5-8% of pregnancies worldwide. While classical genetic studies have identified several susceptibility genes they do not fully explain the heritability of pre-eclampsia. An additional contribution to risk can be quantified by examining the epigenome, in particular the methylome, which is a representation of interactions between environmental and genetic influences on the phenotype. Current array-based epigenetic studies only examine 2-5% of the methylome. Here, we used whole-genome bisulfite sequencing (WGBS) to determine the entire methylome of 13 individuals from two multiplex pre-eclampsia families, comprising one woman with eclampsia, six women with pre-eclampsia, four women with uncomplicated normotensive pregnancies and two male relatives. The analysis of WGBS profiles using two bioinformatics platforms, BSmooth and Bismark, revealed 18,909 differentially methylated CpGs and 4157 differentially methylated regions (DMRs) concordant in females. The methylation patterns support the involvement of previously reported candidate genes, including COL4A1, SLC2A4, PER3, FLT1, GPI, LCT, DDAH1, TGFB3, DLX5, and LRP1B. Statistical analysis of DMRs revealed three novel genes significantly correlated with pre-eclampsia: sorbitol dehydrogenase (SORD, p = 9.98 × 10^-6), diacylglycerol kinase iota (DGKI, p = 2.52 × 10^-5), and islet cell autoantigen 1 (ICA1, 7.54 × 10^-3), demonstrating the potential of WGBS in families for elucidating the role of epigenome in pre-eclampsia and other complex diseases.

Mother's age at delivery and daughters' risk of preeclampsia

BACKGROUND

Some cardiovascular disease risk factors are associated with both risk of preeclampsia and having been born to a younger or older mother. We examined whether mother's age at delivery predicts a primiparous daughter's risk of preeclampsia.

METHODS

The analysis included 39 803 Sister Study participants (designated as "daughters") born between 1930 and 1974. Using log-binomial regression, we estimated relative risks (RR) of preeclampsia in the first pregnancy ending in birth ("primiparous preeclampsia") associated with mother's age at the daughter's birth. Models included: number of older full and maternal half-siblings, income level growing up, daughter's age at delivery, race/ethnicity, and 5-year birth cohort. We examined self-reported relative weight at age 10 (heavier than peers versus not) as a potential effect measure modifier.

RESULTS

Overall, 6.2% of daughters reported preeclampsia. Compared with those who had been born to 20-24-year old mothers, daughters of teenage mothers had a relative risk of 1.20 (95% confidence interval (CI) 1.01, 1.43) and daughters of mothers ≥25 had a ~10% lower risk. Relative weight at age 10 modified the association, with an inverse association between mother's age at delivery and preeclampsia seen only among daughters with low/normal childhood relative weight. In this subset, results were consistent across strata of daughter's age at menarche and age at first birth.

CONCLUSIONS

These findings, based on self-reported data, require replication. Nevertheless, as women increasingly delay childbearing, they provide some reassurance that having been born to an older mother is not, per se, a risk factor for primiparous preeclampsia.

Low-flow mediated constriction as a marker of endothelial function in healthy pregnancy and preeclampsia: A pilot study

OBJECTIVES

Overwhelming clinical evidence exists on disturbed vascular and endothelial function in the pathophysiology of preeclampsia (PE). In a non-pregnant (NP) population, L-FMC (low-flow mediated constriction) provides insight in the 'resting' endothelial capacity in contrast to the gold standard of flow mediated dilatation (FMD), reflecting endothelial nitric oxide bioavailability.

STUDY DESIGN

Longitudinal follow-up of 100 healthy pregnant (HP) women, 33 PE women and 16 NP controls with non-invasive vascular assessments. HP women were evaluated at 12 and 35 weeks of gestation and at 6 months postpartum. PE patients were assessed at diagnosis (mean 30 weeks) and 6 months postpartum.

MAIN OUTCOME MEASURES

Endothelial function (L-FMC, FMD, peripheral arterial tonometry (PAT)) and arterial stiffness (pulse wave velocity (PWV) and analysis (PWA)) were measured at the different visits and compared between groups.

RESULTS

Overall endothelial dysfunction is present in PE (FMD HP 9.09 ± 4.20 vs PE 5.21 ± 4.47, p = 0.0004; L-FMC HP -1.90 ± 2.66 vs PE -0.40 ± 2.09, p = 0.03). L-FMC gradually elevates during the course of a HP (1st trim -0.31 ± 1.75 vs 3rd trim -1.97 ± 3.02, p < 0.0001) and is present in 85% of women in the third trimester. In NP, only 27% of women has L-FMC. In PE, L-FMC is present in 50% of cases. Arterial stiffness is increased in PE (all p < 0.0001). There is no correlation between L-FMC and other markers of vascular function (p > 0.05).

CONCLUSION

PE is characterized by dysfunction of both resting and recruitable endothelial capacity. This study offers new insights in different aspects of endothelial function in pregnancy, since L-FMC reflects an adaptation in HP that is absent in PE.

Metformin for prevention of hypertensive disorders of pregnancy in women with gestational diabetes or obesity: systematic review and meta-analysis of randomized trials

OBJECTIVE

Metformin has been reported to reduce the risk of pre-eclampsia. It is also known to influence soluble fms-like tyrosine kinase-1 level, which correlates significantly with the gestational age at onset and severity of pre-eclampsia. The main aim of this systematic review and meta-analysis of randomized trials was to determine whether metformin use is associated with the incidence of hypertensive disorders of pregnancy (HDP).

METHODS

MEDLINE (1947 to September 2017), Scopus (1970 to September 2017) and the Cochrane Library (inception to September 2017) were searched for relevant citations in the English language. Only randomized controlled trials on metformin use, reporting the incidence of pre-eclampsia or pregnancy-induced hypertension, were included. Studies on populations with a high probability of metformin use prior to randomization (those with type II diabetes or polycystic ovary syndrome) were excluded. Random-effects models with the Mantel-Haenszel method were used for subgroup analyses. Bayesian random-effects meta-regression was used to summarize the evidence.

RESULTS

In total, 3337 citations matched the search criteria. After evaluating 2536 abstracts and performing full-text review of 52 studies, 15 were included in the review. In women with gestational diabetes, metformin use was associated with a reduced risk of pregnancy-induced hypertension when compared with insulin (relative risk (RR), 0.56; 95% CI, 0.37-0.85; I²  = 0%; 1260 women) and a non-significantly reduced risk of pre-eclampsia (RR, 0.83; 95% CI, 0.60-1.14; I²  = 0%; 1724 women). In obese women, when compared with placebo, metformin use was associated with a non-significant reduction in risk of pre-eclampsia (RR, 0.74; 95% CI, 0.09-6.28; I²  = 86%; 840 women). In women with gestational diabetes, metformin use was also associated with a non-significant reduction in risk of any HDP (RR, 0.71; 95% CI, 0.41-1.25; I²  = 0%; 556 women) when compared with glyburide. When studies were combined using Bayesian random-effects meta-regression, with treatment type as a covariate, the posterior probabilities of metformin having a beneficial effect on the prevention of pre-eclampsia, pregnancy-induced hypertension and any HDP were 92.7%, 92.8% and 99.2%, respectively, when compared with any other treatment or placebo.

CONCLUSIONS

There is a high probability that metformin use is associated with reduced HDP incidence when compared with other treatments or placebo. The small number of studies included in the analysis, the low quality of evidence and the clinical heterogeneity preclude generalization of these results to broader populations. Given the clinical importance of this topic and the magnitude of effect observed in this meta-analysis, further prospective trials are urgently needed. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Association of antepartum blood pressure levels and angiogenic profile among women with chronic hypertension

BACKGROUND

Angiogenic factors have been implicated in the pathogenesis of preeclampsia. This pilot study explored the association between antenatal blood pressure levels and angiogenic biomarkers (sFlt1 and PlGF) among women with chronic hypertension (cHTN).

METHODS

Blood samples were collected from women with cHTN (with/without superimposed preeclampsia) within 96 h prior to delivery. Subjects were stratified by mean outpatient BP as controlled (cBP < 140/90) or uncontrolled (uBP ≥ 140/90). Descriptive statistics were generated and assessed as appropriate. Logistic regression was employed to assess for adverse pregnancy outcomes between groups.

RESULTS

Data from seventy-eight women were analyzed, of which 58 (74.4%) were African American. Fifty-six (71.8%) had cBP and 22 (28.2%) had uBP. Use of antepartum outpatient antihypertensive medications was more frequent in patients with uBP (46.4% vs. 13.6%, p = 0.01). Compared to women with cBP, women with uBP had higher levels of pre-delivery sFlt1 and sFlt1/PlGF ratio (sFlt: 4218.5 vs. 3056.0 pg/ml, p = 0.046; sFlt/PlGF: 62.5 vs. 25.0, p = 0.04). Additionally, more uBP patients had superimposed preeclampsia with severe features (54.6% vs. 25.0%; p = 0.01) and preterm delivery (defined as a gestational age <35 weeks (40.9% vs. 10.7%; p = 0.002)) than cBP patients. In the multivariable model, women with uBP had greater odds of preterm delivery (OR 6.78; p = 0.01), superimposed preeclampsia (OR 3.20; p = 0.03) and preeclampsia with severe features (OR 3.27; p = 0.04) than women with cBP.

CONCLUSION

In women with cHTN, elevated antepartum BP is associated with worsened outcomes and may be associated with abnormal angiogenic profile at delivery. Larger studies are needed to confirm these findings.

Increased maternal C1q/TNF-related protein-1 (CTRP-1) serum levels in pregnancies with preeclampsia

Objective: Metabolic changes and inflammation are involved in the pathogenesis of preeclampsia. Complement C1q tumor necrosis factor-related protein-1 (CTRP-1) is a pleiotropic molecule that possesses insulin-sensitizing effects and is also involved in lipid metabolism and inflammatory responses. The aim of the study was to investigate CTRP-1 levels in pregnancies with preeclampsia.Material and methods: Serum concentrations of CTRP-1 were measured in 29 pregnant women with early-onset preeclampsia (EOPE), 24 pregnant women with late-onset preeclampsia (LOPE), and 26 women with uncomplicated pregnancies using an enzyme-linked immunosorbent assay method.Results: Patients with both EOPE and LOPE had significantly higher serum concentrations of CTRP-1 compared to the healthy controls (p < .001). However, no significant difference was found between the EOPE and LOPE groups regarding CTRP-1 levels (p = 1.000). Correlation analysis showed that CTRP-1 levels were positively correlated with systolic blood pressure (p < .001), diastolic blood pressure (p < .001), and mean UtA PI (p < .001) but negatively correlated with gestational age at delivery (p = .001) and birth weight (p < .001).Conclusions: Serum CTRP-1 levels were significantly higher in patients with both EOPE and LOPE than in healthy pregnant women.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Activin A and Late Postpartum Cardiac Dysfunction Among Women With Hypertensive Disorders of Pregnancy

Women with hypertensive disorders of pregnancy have an increased risk of subsequent heart failure and cardiovascular disease when compared with women with normotensive pregnancies. Although the mechanisms underlying these findings are unclear, elevated levels of the biomarker activin A are associated with myocardial dysfunction and may have predictive value. We hypothesized that elevated levels of antepartum activin A levels would correlate with postpartum cardiac dysfunction in women with hypertensive disorders of pregnancy. We prospectively studied 85 women to determine whether increased antepartum activin A levels were associated with cardiac dysfunction at 1 year postpartum as measured by global longitudinal strain. Thirty-two patients were diagnosed with preeclampsia, 28 were diagnosed with gestational or chronic hypertension, and the remainder were nonhypertensive controls. Activin A levels were measured with ELISA both in the third antepartum trimester and at 1 year postpartum. Comprehensive echocardiograms including measurement of global longitudinal strain were also performed at enrollment and at 1 year postpartum. Antepartum activin A levels correlated with worsening antepartum global longitudinal strain (r=0.70; P=0.0001). Across the entire cohort, elevated antepartum activin A levels were associated with the development of abnormal global longitudinal strain at 1 year (C statistic 0.74; P=0.004). This association remained significant after multivariable adjustment for clinically relevant confounders (C statistic 0.93; P=0.01). Postpartum activin A levels also correlated with increasing left ventricular mass index (P=0.02), increasing mean arterial pressures (P=0.02), and decreasing E' values (P=0.01). Activin A may be a useful tool for identifying and monitoring patients at risk for postpartum development of cardiovascular disease.

Mechanisms and Clinical Significance of Endothelial Dysfunction in High-Risk Pregnancies

The maternal cardiovascular system undergoes critical anatomic and functional adaptations to achieve a successful pregnancy outcome which, if disrupted, can result in complications that significantly affect maternal and fetal health. Complications that involve the maternal cardiovascular system are among the most common disorders of pregnancy, including gestational hypertension, preeclampsia, gestational diabetes, and impaired fetal growth. As a central feature, maternal endothelial dysfunction is hypothesized to play a predominant role in mediating the pathogenesis of these high-risk pregnancies, and as such, might proceed and precipitate the clinical presentation of these pregnancy disorders. Improving or normalizing maternal endothelial function in high-risk pregnancies might be an effective therapeutic strategy to ameliorate maternal and fetal clinical outcomes.