A historical overview of preeclampsia-eclampsia

FIRST TRIMESTER SCREENING FOR PREECLAMPSIA - A SYSTEMATIC REVIEW

Objective: To increase the detection rate of preterm preeclampsia (PE) first trimester combined screening tests are being developed. The aim of this review is to create an overview of the currently investigated screening markers, algorithms and their validations.Methods: Comprehensive review of the literature concerning first trimester screening for PEResults and conclusions: Studies investigating a total of 160 biochemical, 6 biophysical and 14 ultrasound markers could be identified. Of the 21 algorithms published, mainly the algorithm published by the Fetal Medicine Foundation London has been validated. This algorithm performes significantly better than screening by anamnestic risk factors only.

Birthing life and death: women's reproductive health in early twentieth-century Rio de Janeiro

This article explores women's reproductive health in early twentieth-century Rio de Janeiro, showing that elevated and sustained stillbirth and maternal mortality rates marked women's reproductive years. Syphilis and obstetric complications during childbirth were the main causes of stillbirths, while puerperal fever led maternal death rates. Utilizing traditional sources such as medical dissertations and lesser-used sources including criminal investigations, this article argues that despite official efforts to medicalize childbirth and increase access to clinical healthcare, no real improvements were made to women's reproductive health in the first half of the twentieth century. This, of course, did not make pregnancy and childbirth any easier for the women who embodied these statistics in their reproductive lives.

Asprosin in umbilical cord of newborns and maternal blood of gestational diabetes, preeclampsia, severe preeclampsia, intrauterine growth retardation and macrosemic fetus

Pathological pregnancies, such as gestational diabetes, preeclampsia, severe preeclampsia, intrauterine growth retardation and macrosomic fetuses, are among the most fundamental problems of obstetrics clinics that are risk factors for both mother and child. Our main goal here is to compare maternal blood and newborn venous-arterial cord blood asprosin levels in pathological and healthy pregnancies. The study included 30 pregnant women with gestational diabetes, 30 with preeclampsia, 30 with severe preeclampsia, 30 with intrauterine growth retardation, 29 with macrosomic fetuses and 30 healthy pregnant women. All mothers were voluntary participants. Arteries and venous blood samples from both mothers and newborns were taken, in which asprosin levels were measured by ELISA. There was a statistically significant increase in asprosin levels in pregnant women with gestational diabetes, preeclampsia, severe preeclampsia and macrosemic fetuses compared with the control group, whereas in those with intrauterine growth retardation a significant decrease was observed. Venous and arterial cord blood asprosin levels were also close to maternal asprosin levels. Regarding the asprosin levels in venous and arterial cord blood in all newborns, the former was higher, but was not statistically significant.

[Posterior reversible encephalopathy syndrome: a case report]

L'encéphalopathie postérieure réversible (EPR) est une entité radio-clinique associant une atteinte réversible du système nerveux central à une imagerie encéphalique typique. Il existe une grande variabilité dans la présentation clinique de ce syndrome et des aspects en imagerie parfois atypiques. L'EPR est une complication neurologique inhabituelle survenant au cours de la grossesse ou en post-partum, en dehors de toute pathologie préexistante de la grossesse dont l'œdème vasogénique par rupture de la barrière hémato encéphalique paraît être l'acteur principal. Nous rapportons l'observation d'une patiente primipare présentant des crises convulsives généralisées tonico-cloniques associées à un pic hypertensif, survenant au cours du troisième trimestre de grossesse. L'imagerie par résonance magnétique (IRM) cérébrale était en faveur d'une encéphalopathie postérieure réversible. L'EPR doit être évoqué devant tout signe d'appel neurologique, vu l'évolution favorable sans séquelles sous un traitement précoce et rapide.

It Takes a System: Magnesium Sulfate for Prevention of Eclampsia in a Resource-Limited Community Setting

Magnesium sulfate is not a silver bullet to reduce maternal mortality associated with preeclampsia/eclampsia. We believe a well-functioning health care system, especially at the hospital level, with competent well-trained providers, adequate equipment, and medications will likely be necessary.

Learning from experience: cellular and molecular bases for improved outcome in subsequent pregnancies

The frequencies of preeclampsia, fetal growth restriction, fetal demise, and low birthweight are lower in subsequent pregnancies. Enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation also have been observed in subsequent as compared with first pregnancies. We sought to investigate the cellular and molecular bases for better outcomes in subsequent pregnancies. Based on the knowledge that specialized immune cells at the maternal-fetal interface, decidual natural killer cells, promote development of the placental bed and conversion of the spiral arteries by secreting a myriad of angiogenic and growth factors, we asked whether decidual natural killer cells differ in subsequent as compared with first pregnancies. This idea stemmed from recent studies suggesting that natural killer cells, although part of the innate immune system, possess some features of adaptive immunity, including a certain type of immune cell memory, termed trained immunity. We found that decidual natural killer cells from parous women "remember pregnancy" and differ from decidual natural killer cells of primigravidae. Compared with the decidual natural killer cells of first pregnancy, these cells, that we termed pregnancy-trained decidual natural killer cells, express greater levels of the natural killer receptors NKG2C and leukocyte immunoglobulin-like receptor B1, which interact with ligands expressed on invasive trophoblasts. Furthermore, they secrete greater levels of several growth factors, including vascular endothelial growth factor α as well as interferon-γ, augmenting remodeling of the placental bed. We propose that this pregnancy-trained memory dwells in the epigenome, where memory of stimuli is known to persist even when the stimulus is no longer present. This epigenetic memory apparently resides in endometrial natural killer cells between pregnancies. We suggest that this trained memory, which we coined pregnancy-trained decidual natural killer cells, may be the missing link in the immune basis for enhanced subsequent pregnancy. Epigenetic memory (chromatin modification) also may afford a global explanation for additional findings of enhanced maternal cardiovascular adaptation, shorter first and second stages of labor, and more robust lactation. Understanding the molecular and cellular bases of improved outcomes of subsequent pregnancy may lead to the development of treatment modalities designed for women at high risk for pregnancy disorders originating at the maternal-fetal interface.

Pre-eclampsia: pathogenesis, novel diagnostics and therapies

Pre-eclampsia is a complication of pregnancy that is associated with substantial maternal and fetal morbidity and mortality. The disease presents with new-onset hypertension and often proteinuria in the mother, which can progress to multi-organ dysfunction, including hepatic, renal and cerebral disease, if the fetus and placenta are not delivered. Maternal endothelial dysfunction due to circulating factors of fetal origin from the placenta is a hallmark of pre-eclampsia. Risk factors for the disease include maternal comorbidities, such as chronic kidney disease, hypertension and obesity; a family history of pre-eclampsia, nulliparity or multiple pregnancies; and previous pre-eclampsia or intrauterine fetal growth restriction. In the past decade, the discovery and characterization of novel antiangiogenic pathways have been particularly impactful both in increasing understanding of the disease pathophysiology and in directing predictive and therapeutic efforts. In this Review, we discuss the pathogenic role of antiangiogenic proteins released by the placenta in the development of pre-eclampsia and review novel therapeutic strategies directed at restoring the angiogenic imbalance observed during pre-eclampsia. We also highlight other notable advances in the field, including the identification of long-term maternal and fetal risks conferred by pre-eclampsia.

Direct laboratory evidence that pregnancy-induced hypertension might be associated with increased catecholamines and decreased renalase concentrations in the umbilical cord and mother’s blood

Background

Renalase (RNL) is a controversial enzyme as to whether it oxidizes catecholamines (CAs) (as is generally accepted) in the blood or not. CAs (dopamine [DPMN], epinephrine [EPI] and norepinephrine [NEPI]) are associated with hypertension, including pregnancy-induced hypertension, which occurs in 8–10% of all pregnancies. Therefore, the aim of the study was to compare CAs and renalase concentration in (i) normotensive controls (C), (ii) patients with preeclampsia (PE) and (iii) patients with severe preeclampsia (SPE), which is one of the well-known symptoms of hypertension.

Methods

This case-control study involved 90 women divided into three groups – 30 C, 30 PE and 30 SPE – whose age and body mass indexes (BMIs) were similar. A total of 270 blood samples (90 maternal samples, 90 umbilical cord artery samples and 90 umbilical cord vein samples) were obtained. CAs and RNL concentrations of the biological samples were measured by enzyme-linked immunosorbent assay (ELISA).

Results

Comparing the amounts of CAs, RNL and systolic blood pressure (SBP)/diastolic blood pressure (DBP) between healthy control pregnant women and pregnant women with PE and SPE (SBP/DBP was 120/80 mm Hg for C, above 140/90 mm Hg for PE and above 160/110 mm Hg for SPE), the levels of CAs were significantly increased whereas RNL was reduced. The correlation between SBP/DBP and the amount of RNL in pregnant women with PE and SPE was negative.

Conclusions

These novel results are evidence that hypertension seen in PE and SPE is directly related to increased levels of CAs and reduced RNL concentrations. The use of RNL preparations may be preferred in future to prevent maternal and perinatal morbidity and mortality due to pregnancy-induced hypertension.

The role of the erythrocyte in the outcome of pregnancy with preeclampsia

The objective of this study was to analyze the relationships of osmotic and mechanical stability of erythrocytes with anthropometric, biochemical, hematologic and hemodynamic variables in pregnant women with preeclampsia (PE). The studied population consisted of 20 normotensive patients and 16 patients with PE. Patients with PE presented worse gestational outcome, greater hematologic impairment, erythrocytes osmotically more stable in vitro, but in conditions of isotonicity with the in vivo medium, in addition to hyperflow in orbital territory, when compared to normotensive patients. The correlation analysis between anthropometric, hematologic and hemodynamic variables in patients with PE indicated that erythrocytes with lower volumes and lower levels of hemoglobin favor the occurrence of a better gestational outcome, because they are more stable and because they are associated with a decrease in the hemodynamic changes present in the disease. This should mean that the tendency to microcytosis, probably due to a mechanism of compensatory mechanical selection, is a desirable characteristic in the disease.

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.

Interrelationship Between Markers of Oxidative Stress, Inflammation and Hematological Parameters Among Preeclamptic Nigerian Women

BACKGROUND Preeclampsia is a multifaceted pregnancy-related disorder affecting women and fetuses. A link between preeclampsia, oxidative stress, and inflammation has been suggested. This study evaluated the interrelationship between biomarkers of oxidative stress, inflammation, and hematological parameters among preeclamptic Nigerian women. MATERIAL AND METHODS A cross-sectional study was conducted among 49 preeclamptic and 50 normotensive healthy pregnant women. Blood samples were obtained after 20-week gestation in all participants. Levels of superoxide dismutase (SOD), catalase, glutathione (GSH), malonaldehyde (MDA), total protein, high-sensitivity C-reactive protein (hs-CRP), and cardiac-specific troponin I (cTnI) were determined by spectrophotometric and ELISA techniques. FBC, prothrombin time, and activated partial thromboplastin time were determined using an auto-analyzer, Quick's one-stage, and Proctor's and Rappaport's modification methods, respectively. RESULTS The mean SOD (0.051±0.050 vs. 0.073±0.047, p 0.029), catalase (2.62±1.93 vs. 8.48±4.40, p<0.001), GSH (49.05±17.57 vs. 187.10±56.07 p<0.001), platelet (127.63±89.75 vs. 267.16±212.82, p<0.001 were lower in preeclampsia. MDA (7.16±5.00 vs. 2.91±2.66, p<0.001), cTnI (0.46±0.31 vs. 0.13±0.14 p<0.001), PT (19.36±4.06 vs. 13.45±1.97 p<0.001), APTT (45.53±2.92 vs. 37.49±4.99; p<0.001) were higher in preeclampsia. Negative associations between SOD and MDA (r -0.527 p<0.001), CAT and MDA (r -0.469, p 0.001) and positive associations between catalase and hs-CRP (r 0.844, p 0.029), RBC and HB (r 0.442, p 0.001), platelet, and SOD (r 0.353, p 0.013) were observed among preeclamptic volunteers. CONCLUSIONS Preeclampsia is associated with oxidative stress, derangement of hematological and coagulation homeostasis, as well as deleterious effects on the cardiovascular system.

Maternal long chain polyunsaturated fatty acid status and pregnancy complications

Maternal nutrition plays a crucial role in influencing fetal growth and birth outcome. Any nutritional insult starting several weeks before pregnancy and during critical periods of gestation is known to influence fetal development and increase the risk for diseases during later life. Literature suggests that chronic adult diseases may have their origin during early life - a concept referred to as Developmental Origins of Health and Disease (DOHaD) which states that adverse exposures early in life "program" risks for later chronic disorders. Long chain polyunsaturated fatty acids (LCPUFA), mainly omega-6 and omega-3 fatty acids are known to have an effect on fetal programming. The placental supply of optimal levels of LCPUFA to the fetus during early life is extremely important for the normal growth and development of both placenta and fetus. Any alteration in placental development will result in adverse pregnancy outcome such as gestational diabetes mellitus (GDM), preeclampsia, and intrauterine growth restriction (IUGR). A disturbed materno-fetal LCPUFA supply is known to be linked with each of these pathologies. Further, a disturbed LCPUFA metabolism is reported to be associated with a number of metabolic disorders. It is likely that LCPUFA supplementation during early pregnancy may be beneficial in improving the health of the mother, improving birth outcome and thereby reducing the risk of diseases in later life.

Preeclampsia and Related Cardiovascular Risk: Common Genetic Background

PURPOSE OF REVIEW

Preeclampsia (PE) is a hypertensive disorder exclusive for pregnancy. It affects women all over the world and poses a great threat to life, both for mother and child. No definitive treatment exists and placenta delivery comprises the only known cure for PE. One of the most severe complications observed in preeclamptic women is the occurrence of cardiovascular diseases (CVDs) later in life.

RECENT FINDINGS

Both PE and CVDs share some of their pathogenic pathways and gene variations. Thus far, a number of publications have examined those relationships; however, almost all of them focus only on common risk factors. The precise pathomechanism and genetic basis of PE and its associated cardiovascular complications remain unknown. Therefore, the aim of this review is to unify and clarify the current state of knowledge and provide direction for future studies, especially those regarding the genetic aspect.

Gestational Weight Gain: Historical Evolution of a Contested Health Outcome

The history of research on gestational weight gain (GWG) in the United States and United Kingdom provides a context for current clinical practice. We trace the evolution of research on GWG in scientific literature from the 19th century to the present and examine its implications for contemporary clinical and public health practice. Obstetricians, beginning in the late 1800s, recommended dieting during pregnancy in order to limit GWG to 20 lb or less, driven by a belief that excessive weight gain was a cause of toxemia. Beginning in the 1930s, a burgeoning focus on nutrition and health allowed a better understanding of the effect of GWG on the health of the fetus and the newborn. Increased awareness of disparities in infant mortality in the 1960s, followed by systematic review of the literature, produced further refinements in GWG recommendations in the 1970s, which continue today. Current research focuses on epigenetic influences over the life course and has emphasized individualized recommendations. The complex historical perspective that this article provides serves as a reminder of both the interplay and the gaps between research and practice. These gaps result from the fact that clinical guidelines often reflect a specific point in a perpetually evolving state of knowledge that is influenced not only by advances in bench research, but also by refinements in statistical and epidemiologic methods, as well as by the political realities of the time in which they are drafted.

Importance

Gestational weight gain and its relationship to maternal, fetal, and infant health are areas of active inquiry.

Objective

We critically review evolution of scientific understanding of GWG from the 19th century to the present, and examine its implications for contemporary obstetric practice.

Evidence Acquisition

We reviewed all English-language medical studies related to GWG published through 1930s as well as widely cited influential works from 1940s through present time.

Results

During the past century, recommendations for GWG have reversed from emphasizing dieting during pregnancy to the importance of proper nutrition during pregnancy. Obstetricians' focus has also evolved from being exclusively on the newborn to include the health of mothers. Contemporary obstetric practice seeks to achieve a balance between mothers' and infants' risk of adverse outcomes.

Conclusions

Historical and social contexts of the United States and the United Kingdom led to distinct GWG policies in the 2 countries. Changes in GWG recommendations over the past century reflect developments in the allied fields, such as epidemiology and nutrition, as much as progress in obstetrics and gynecology.

Relevance

The complex historical perspective that this article provides serves as a reminder of both the interplay and the gaps between research and practice. These gaps result from the fact that clinical guidelines often reflect a specific point in a perpetually evolving state of knowledge that is influenced not only by advances in bench research, but also by refinements in statistical and epidemiologic methods, as well as by the political realities of the time in which they are drafted.

Eclampsia in rural Nigeria: The unmitigating catastrophe

Introduction:

Eclampsia is one of the most dreaded causes of adverse outcomes of pregnancy worldwide. It is one of the greatest causes of maternal and perinatal morbidity and mortality world over. We do not know the prevalence, management outcome, and the devastation caused by this dreaded disease in our center hence the need for this work.

Materials and Methods:

This is a 7-year retrospective review of all cases of eclampsia managed in Mater Misericordiae Hospital Afikpo, a rural secondary cum referral Catholic Mission Hospital in Afikpo, Ebonyi State in Southeastern Nigeria.

Results:

The prevalence of eclampsia in our center is 1.12% or one case of eclampsia for every 89 women that delivered in our facility. The majority of the women that had eclampsia in our center 56 (71.8%) were primigravidae. Seventeen women (21.8%) had various antenatal complications with 4 or 23.6% presenting with intrauterine fetal deaths and two (11.8%) each with intrauterine growth restriction, and domestic violence, respectively. Thirty-five or 44.9% of the women were delivered by emergency lower segment cesarean section. Fifteen or 17.9% babies were dead giving a perinatal mortality rate of 174 per 1,000After delivery, and 3 (3.8%) of the women had postpartum hemorrhage. Two women (2.6%) died giving a maternal mortality ratio of 2564 per 100,000 deliveries.

Conclusion:

Eclampsia is a dreaded obstetric disease with adverse fetal and maternal consequences that are not mitigating, and no effort should be spared in managing it effectively including public enlightenment.

Are There Differences in the Anthropometric, Hemodynamic, Hematologic, and Biochemical Profiles between Late- and Early-Onset Preeclampsia?

Preeclampsia (PE) is classified as early-onset PE (EOPE) and late-onset PE (LOPE) when present before or after 34 weeks of gestation, respectively. This transversal study aimed to investigate the differences and possible associations existing in the anthropometric, hemodynamic, hematologic, and biochemical profiles of late- and early-onset preeclampsia. The study included 65 volunteers admitted to a tertiary hospital in Brazil: 29 normotensive and 36 with preeclampsia (13 with EOPE and 23 with LOPE). Pregnant women with LOPE presented greater weight gain and borderline increase in body mass index at the end of gestation in relation to the other groups, which is compatible with the metabolic origin, associated with obesity, attributed to this form of the disease. Pregnant women with EOPE presented a borderline reduction in the number of erythrocytes and a significant decrease in the number of platelets, in addition to a significant increase in reticulocytes, serum iron, and ferritin when compared to normotensive pregnant women and pregnant women with LOPE. A significant increase in osmotic stability of erythrocytes was observed in the EOPE group in relation to other groups. Hemodynamic analysis by Doppler ultrasonography of the ophthalmic artery showed that both groups of pregnant women with PE presented alterations compatible with the occurrence of hyperflow in the orbital territory. These hemodynamic changes were associated with changes in hematimetric indices.

Selective inhibition of 20-hydroxyeicosatetraenoic acid lowers blood pressure in a rat model of preeclampsia

Little is currently known of the role(s) of the vasoconstrictor 20-hydroxyeicosatetraenoic acid (20-HETE) in hypertensive pregnancies. We hypothesized that specific inhibition of 20-HETE would attenuate increases in blood pressure in the reduced uterine perfusion pressure (RUPP) rat model of preeclampsia. Specific 20-HETE synthesis inhibitor HET0016 (1mg/kg) was administered daily to RUPP rats from gestational days 14-18. Blood pressure (BP) increased in RUPP rats and was decreased with HET0016 administration. BP was unchanged in NP+HET0016 rats. Fetal death greatly increased in RUPP rats and was reduced in RUPP+HET0016 rats. 20-HETE levels increased modestly in RUPP rats compared to NP and was reduced in both NP+HET0016 and RUPP+HET0016 rats. Furthermore, circulating levels of HETEs, EET, and DHETE were significantly altered between groups. HET0016 shifted CYP metabolism toward EETs, as indicated by a decrease in plasma 20-HETE:EETs in RUPP+HET0016 rats compared to RUPP. In conclusion, 20-HETE inhibition in RUPP rats reduces BP and fetal death, and is associated with an increase in EET/20-HETE ratio.

Historical evolution of ideas on eclampsia/preeclampsia: A proposed optimistic view of preeclampsia

Eclampsia (together with epilepsy) being the first disease ever written down since the beginning of writings in mankind 5000 years ago, we will make a brief presentation of the different major steps in comprehension of Pre-eclampsia. 1) 1840. Rayer, description of proteinuria in eclampsia, 2) 1897 Vaquez, discovery of gestational hypertension in eclamptic women, 3) In the 1970's, description of the "double" trophoblastic invasion existing only in humans (Brosens & Pijnenborg,), 4) between the 1970's and the 1990's, description of preeclampsia being a couple disease. The "paternity problem" (and therefore irruption of immunology), 5) at the end of the 1980's, a major step forward: Preeclampsia being a global endothelial cell disease (glomeruloendotheliosis, hepatic or cerebral endotheliosis, HELLP, eclampsia), inflammation (J.Roberts.C Redman, R Taylor), 6) End of the 1990's: Consensus for a distinction between early onset preeclampsia EOP and late onset LOP (34 weeks gestation), EOP being rather a problem of implantation of the trophoblast (and the placenta), LOP being rather a pre-existing maternal problem (obesity, diabetes, coagulopathies etc…). LOP is predominant everywhere on this planet, but enormously predominant in developed countries: 90% of cases. This feature is very different in countries where women have their first child very young (88% of world births), where the fatal EOP (early onset) occurs in more than 30% of cases. 7) What could be the common factor which could explain the maternal global endotheliosis in EOP and LOP? Discussion about the inositol phospho glycans P type.

Spectrum of Factors Triggering Endothelial Dysfunction in PIH

INTRODUCTION

Pre-eclampsia (PE) is a major cause of maternal and fetal/neonatal mortality and morbidity. The aetiology and pathogenesis of PE is yet to be completely understood. Evidence shows that, Endothelial Dysfunction (ED) plays a pivotal role in the genesis of this multi-system disorder that develops in PE and eclampsia.

AIM

To determine the circulating levels of factors Malondialdehyde (MDA), Ferric Reducing Ability of Plasma-α (FRAP), Tumour Necrosis Factor (TNF-α), sFlt-1, VEGF, PlGF, Nitric Oxide (NO) that influence the ED.

MATERIALS AND METHODS

Study groups consisted of Normotensive pregnant women (N), preeclamptic women (PE) and eclamptic women (E) with 100 subjects in each group in the 3^rd trimester of pregnancy. They were investigated for MDA, FRAP, TNF-α, sFlt-1, VEGF, PlGF, NO. Statistical analysis was done using Analysis of Variance (ANOVA).

RESULTS

When compared to controls MDA, TNF-α, sFlt-1 levels were found to be significantly high and FRAP, VEGF, PIGF and NO levels were significantly low in PE and E group. E showed a significantly high level of MDA, TNF-α, sFlt-1 and low levels of FRAP, VEGF, PIGF, NO when compared to PE group.

CONCLUSION

Our study substantiated the fact, that oxidative stress, imbalance between anti-angiogenic factors and pro- angiogenic factors exists in Pregnancy Induced Hypertension (PIH) condition. This imbalance is directly related to the ED, the hallmark of PE. So oxidative stress, VEGF, PlGF and sFlt-1 can be used as markers to analyze the onset and progression of the disease.

Pre-eclampsia: Molecular events to biomarkers

Pre-eclampsia is a hypertensive disorder in pregnancy, which accounts for 10-15% of the maternal and perinatal mortality worldwide. Abnormal placental development and tissue hypoxia are its main etiologic factors. The present diagnostic methods of blood pressure monitoring and renal function evaluation are insufficient in the early detection of pre-eclampsia. Since molecular events portent well ahead of the disease onset, biomarker research for the early diagnosis of pre-eclampsia has recently generated ambitious clinical targets. However, no clinically validated biomarker has so far been reported for the prediction of pre-eclampsia. Therefore, this review takes stock of the current understanding of pre-eclampsia from a molecular biology perspective and critically evaluates the following diagnostic potentials claimed for the biomarkers: placental proteins, angiogenic markers, and cell-free fetal DNA (cffDNA) in maternal circulation. Though the emerging evidences in favor of the fetal-specific epigenetic marker, hypermethylated RASSF1A of cffDNA, are highlighted, it pitches for a broader strategy of 'combination biomarker approach' for the reliable forecasting and triaging of pre-eclampsia.

Prospective assessment of neurodevelopment in children following a pregnancy complicated by severe pre-eclampsia

OBJECTIVE

To prospectively examine whether children of women with a pregnancy affected by severe pre-eclampsia (PE), compared to children of women without a PE-affected pregnancy, have differences in neurodevelopmental performance up to 5 years of age.

DESIGN

Prospective cohort study.

SETTING

Tertiary care centre.

PARTICIPANTS

Women were recruited following a PE-affected pregnancy. After each PE participant was recruited, the next normotensive woman without a prior history of PE and matched by parity, maternal age and race was invited to participate. Women with a history of chronic hypertension, diabetes or renal disease were excluded. Total enrolment included 129 PE-affected and 140 normotensive mothers.

OUTCOME MEASURES

The primary outcome measure was failure of the Ages and Stages Questionnaire (ASQ). The ASQ was completed yearly, until age 5.

RESULTS

A significant difference was found in the proportion of ASQ categories failed in year 3 (p<0.05), and this approached significance in years 1 and 4 (p<0.10 and p<0.15, respectively). At year 1, the number of ASQ categories failed was significantly greater among children born to PE mothers. A subgroup analysis revealed that a significant proportion of PE children born preterm (<37 weeks) failed the ASQ in years 3 and 4 (p<0.05), and when failed, those who were preterm failed significantly more categories (p<0.05). A trend towards increased failure in the gross motor category was found. There was a significant positive correlation between maternal lifetime CVD risk score and number of ASQ categories failed at years 1 and 3 (p<0.05).

CONCLUSIONS

Severe PE is associated with other adverse pregnancy outcomes, including intrauterine growth restriction and preterm birth, all of which are associated with increased neurodevelopment delays. Thus, PE indicates a need for early screening and intervention at the neurodevelopmental level to improve children's long-term health, with larger studies required to tease out contributing factors.

Preeclampsia, of mice and women

Preeclampsia (PE) is a devastating disorder of pregnancy that affects up to 8% of pregnant women in the United States. The diagnosis of PE is made by the presentation of new-onset hypertension, ≥140 mmHg systolic blood pressure (BP) or ≥90 mmHg diastolic BP, and either proteinuria or another accompanying sign/symptom, such as renal insufficiency, thrombocytopenia, hepatic dysfunction, pulmonary edema, or cerebral/visual. These signs can occur suddenly and without warning. PE that presents before 34 wk of gestation is considered early onset and carries a greater risk for perinatal morbidity/mortality than late-onset PE that occurs at or after 34 wk of gestation. At this time there is no cure for PE, and the only effective treatment is delivery of the baby and placenta. If allowed to progress to eclampsia (PE with neurologic involvement), seizures will occur and possibly death through stroke. PE also carries the risk of significant fetal and neonatal morbidity/mortality in addition to long-term health risks for mother and child. Despite significant research efforts to accurately predict, diagnose, and treat PE, a cure eludes us. Elucidating the pathophysiological mechanisms that can cause PE will aid in our ability to accurately prevent, manage, and treat PE to avoid maternal and fetal losses. Intense research efforts are focused on PE, and the mouse has proven to be a useful animal model for investigating molecular mechanisms that may hold the key to unraveling the mysteries of PE in women.

Hypertensive disorders during pregnancy and health outcomes in the offspring: a systematic review

The hypertensive disorders of pregnancy complicate up to 10% of pregnancies worldwide and are a leading cause of maternal, foetal, and neonatal morbidity and mortality. The aim of this study was to present an overview of recent studies addressing offspring's medium and long-term health outcomes after intrauterine exposure to maternal hypertension. A search on PubMed/MEDLINE and Bireme databases was conducted to identify observational studies that reported any offspring outcome measured after the 6th month of life. The search was limited to studies published after May 2008. Forty-five articles were included and categorized into four groups of outcomes: cardiovascular, immune, metabolic and behavioural/neurological effects. According to our findings, hypertensive disorders of pregnancy had an overall negative impact on offspring's cardiovascular, immune and neurological health, although not all parameters analysed in each group had consistent results among studies. The most prominent and reliable associations were verified between gestational hypertension and higher offspring's blood pressure and between preeclampsia and offspring's lower cognitive functioning. In the metabolic outcomes, body composition had conflicting results among papers, while all studies that examined blood biomarkers showed no evidence that preeclampsia or gestational hypertension could be associated with an alteration of this metabolic outcomes. Most included studies were highly heterogeneous regarding the measure of outcomes and covariables used for adjustments. Future studies should consider using the same protocols and cut-off points already published so that results can be better compared and summarized. This review was registered in PROSPERO.

REGISTRATION NUMBER

CRD42015020838.

Preeclampsia: Short-term and Long-term Implications

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

No Hypertensive Disorder of Pregnancy; No Preeclampsia-eclampsia; No Gestational Hypertension; No Hellp Syndrome. Vascular Disorder of Pregnancy Speaks for All

Hypertensive disorders complicate 5%-10% of pregnancies with increasing incidence mainly due to upward trends in obesity globally. In the last century, several terminologies have been introduced to describe the spectrum of this disease. The current and widely used classification of hypertensive pregnancy disorders was introduced in 1972 and in 1982, but has not been free of controversy and confusion. Unlike other diseases, the existing terminology combines signs and symptoms, but does not describe the underlying pathology of the disease itself. In this commentary, a detailed account is given to vascular disorder of pregnancy (VDP) as an inclusive terminology taking into account the underlying pathology of the disease on affected organs and systems. A simple and uniform classification scheme for VDP is proposed.

Preeclampsia and future cardiovascular risk: A point of view from the clearance of plasma vasoactive amines

OBJECTIVE

To summarize the reported evidence on the relationship between vasoactive amines and preeclampsia.

METHODS

A literature search was conducted in MEDLINE/PubMed and EMBASE.

RESULTS

The summarized results are as follows: (1) Menstruation can effectively eliminate vasoactive amines norepinephrine, serotonin and histamine. (2) Pregnancy increases norepinephrine production due to fetal brain development and decreases vasoactive-amine elimination due to amenorrhea. (3) Preeclampsia is associated with a low renal and/or sweating capacity, or in rare cases, with increased norepinephrine production due to maternal pheochromocytoma and fetal neuroblastoma.

CONCLUSION

Preeclampsia is mainly due to decreased excretion of norepinephrine and other vasoactive amines.

Prognostic Value of Cardiovascular Disease Risk Factors Measured in the First-Trimester on the Severity of Preeclampsia

Recent studies have suggested that preeclampsia and cardiovascular disease may share common mechanisms. The purpose of this prospective nested case-controlled study was to characterize a variety of cardiovascular disease risk factors measured during the first trimester of pregnancy in predicting subsequent outcomes and the severity of preeclampsia.We ascertained the severity of preeclampsia at the onset of the disease, and the presence of intrauterine growth restriction (IUGR). We compared first trimester maternal serum cardiovascular disease risk factors in preeclampsia subjects versus normal pregnancies, early-onset versus late-onset preeclampsia, and preeclampsia with IUGR versus without IUGR. To identify the prognostic value of independent predictors on the severity of preeclampsia, we calculated the area under the receiver operating characteristics curve (AUC) using logistic regression analysis.There were 134 cases of preeclampsia and 150 uncomplicated pregnancies, and preeclampsia cases were classified as early-onset (53 cases) or late-onset (81 cases), or as with IUGR (44 cases) or without IUGR (90 cases). Among the cardiovascular disease risk factors, maternal serum high-sensitive C-reactive protein (hsCRP) and homocysteine were predictors of both early-onset preeclampsia and preeclampsia with IUGR. For the detection of early onset preeclampsia or preeclampsia with IUGR, the AUC for the combination model (0.943 and 0.952, respectively) was significantly higher than with serum hsCRP or serum homocysteine only.Patients with preeclampsia can be subdivided into different severities according to time of onset and fetal weight. Cardiovascular risk factors distinguish a subgroup of these patients.

Evidence-Based Revised View of the Pathophysiology of Preeclampsia

Preeclampsia is a life-threatening vascular disorder of pregnancy due to a failing stressed placenta. Millions of women risk death to give birth each year and globally each year, almost 300,000 lose their life in this process and over 500,000 babies die as a consequence of preeclampsia. Despite decades of research, we lack pharmacological agents to treat it. Maternal endothelial oxidative stress is a central phenomenon responsible for the preeclampsia phenotype of high maternal blood pressure and proteinuria. In 1997, it was proposed that preeclampsia arises due to the loss of VEGF activity, possibly due to elevation in anti-angiogenic factor, soluble Flt-1 (sFlt-1). Researchers showed that high sFlt-1 and soluble endoglin (sEng) elicit the severe preeclampsia phenotype in pregnant rodents. We demonstrated that heme oxygenase-1 (HO-1)/carbon monoxide (CO) pathway prevents placental stress and suppresses sFlt-1 and sEng release. Likewise, hydrogen sulphide (H₂S)/cystathionine-γ-lyase (Cth) systems limit sFlt-1 and sEng and protect against the preeclampsia phenotype in mice. Importantly, H₂S restores placental vasculature, and in doing so improves lagging fetal growth. These molecules act as the inhibitor systems in pregnancy and when they fail, preeclampsia is triggered. In this review, we discuss what are the hypotheses and models for the pathophysiology of preeclampsia on the basis of Bradford Hill causation criteria for disease causation and how further in vivo experimentation is needed to establish 'proof of principle'. Hypotheses that fail to meet the Bradford Hill causation criteria include abnormal spiral artery remodelling and inflammation and should be considered associated or consequential to the disorder. In contrast, the protection against cellular stress hypothesis that states that the protective pathways mitigate cellular stress by limiting elevation of anti-angiogenic factors or oxidative stress and the subsequent clinical signs of preeclampsia appear to fulfil most of Bradford Hill causation criteria. Identifying the candidates on the roadmap to this pathway is essential in developing diagnostics and therapeutics to target the pathogenesis of preeclampsia.

Assessment of prevalence of preeclampsia from Dilla region of Ethiopia

Background

Preeclampsia is a multi-organ system disorder that occurs after the 20th week of gestation in pregnancy and is characterized by hypertension and proteinuria. In Africa more than 270,000 women die from maternal deaths, worldwide approximately 76,000 women and 500,000 babies die yearly due to preeclampsia. It affects about 8–10 % of all pregnancies. Studies have shown that up to 77 % women affected with preeclampsia lack knowledge about preeclampsia, and therefore cannot take preventative measures. The aim of study is to evaluate the outcomes and quality of care given to preeclamptic patients treated in Dilla University Referral Hospital.

Methods

The study is a retrospective, hospital based study. One hundred and seventy two records of women were retained for final study out of 7702 patients from January 2009 to December 2012.

Results

The incidence rate of preeclampsia in Dilla University Referral Hospital was found to be 2.23 %. The common mean ages found to be affected for preeclampsia were 19.2, 22.5 and 27.8 and 31.5 with a trend towards increasing severity with younger age population.

Conclusion

A guideline on the management and prevention of preeclampsia needs to be produced for Ehiopia.

Vitamin D supplementation improves pathophysiology in a rat model of preeclampsia

Deficiency of vitamin D (VD) is associated with preeclampsia (PE), a hypertensive disorder of pregnancy characterized by proinflammatory immune activation. We sought to determine whether VD supplementation would reduce the pathophysiology and hypertension associated with the reduced uterine perfusion pressure (RUPP) rat model of PE. Normal pregnant (NP) and RUPP rats were supplemented with VD2 or VD3 (270 IU and 15 IU/day, respectively) on gestation days 14-18 and mean arterial pressures (MAPs) measured on day 19. MAP increased in RUPP to 123 ± 2 mmHg compared with 102 ± 3 mmHg in NP and decreased to 113 ± 3 mmHg with VD2 and 115 ± 3 mmHg with VD3 in RUPP rats. Circulating CD4+ T cells increased in RUPP to 7.90 ± 1.36% lymphocytes compared with 2.04 ± 0.67% in NP but was lowered to 0.90 ± 0.19% with VD2 and 4.26 ± 1.55% with VD3 in RUPP rats. AT1-AA, measured by chronotropic assay, decreased from 19.5 ± 0.4 bpm in RUPPs to 8.3 ± 0.5 bpm with VD2 and to 15.4 ± 0.7 bpm with VD3. Renal cortex endothelin-1 (ET-1) expression was increased in RUPP rats (11.6 ± 2.1-fold change from NP) and decreased with both VD2 (3.3 ± 1.1-fold) and VD3 (3.1 ± 0.6-fold) supplementation in RUPP rats. Plasma-soluble FMS-like tyrosine kinase-1 (sFlt-1) was also reduced to 74.2 ± 6.6 pg/ml in VD2-treated and 91.0 ± 16.1 pg/ml in VD3-treated RUPP rats compared with 132.7 ± 19.9 pg/ml in RUPP rats. VD treatment reduced CD4+ T cells, AT1-AA, ET-1, sFlt-1, and blood pressure in the RUPP rat model of PE and could be an avenue to improve treatment of hypertension in response to placental ischemia.

Reduced Maternal Erythrocyte Long Chain Polyunsaturated Fatty Acids Exist in Early Pregnancy in Preeclampsia

The present prospective study examines proportions of maternal erythrocyte fatty acids across gestation and their association with cord erythrocyte fatty acids in normotensive control (NC) and preeclamptic pregnancies. We hypothesize that maternal fatty acid status in early pregnancy influences fetal fatty acid stores in preeclampsia. 137 NC women and 58 women with preeclampsia were included in this study. Maternal blood was collected at 3 time points during pregnancy (16-20th weeks, 26-30th weeks and at delivery). Cord blood was collected at delivery. Fatty acids were analyzed using gas chromatography. The proportions of maternal erythrocyte α-linolenic acid, docosahexaenoic acid, nervonic acid, and monounsaturated fatty acids (MUFA) (p < 0.05 for all) were lower while total n-6 fatty acids were higher (p < 0.05) at 16-20th weeks of gestation in preeclampsia as compared with NC. Cord 18:3n-3, 22:6n-3, 24:1n-9, MUFA, and total n-3 fatty acids (p < 0.05 for all) were also lower in preeclampsia as compared with NC. A positive association was observed between maternal erythrocyte 22:6n-3 and 24:1n-9 at 16-20th weeks with the same fatty acids in cord erythrocytes (p < 0.05 for both) in preeclampsia. Our study for the first time indicates alteration in maternal erythrocyte fatty acids at 16th weeks of gestation which is further reflected in cord erythrocytes at delivery in preeclampsia.

Increased homocysteine levels exist in women with preeclampsia from early pregnancy

OBJECTIVE

The present prospective study examines the levels of maternal plasma folate, vitamin B12 and homocysteine in normotensive control (NC) women and women with preeclampsia (PE) from early pregnancy till delivery.

METHODS

The present study includes 126 NC and 62 PE women. Maternal blood was collected at 3 time points during pregnancy (T1 = 16th-20th weeks, T2 = 26th-30th weeks and T3 = at delivery). Levels of folate, vitamin B12 and homocysteine were estimated by the chemiluminescent microparticle immunoassay technology.

RESULTS

Maternal plasma folate levels were similar between NC and PE women at all the time points across gestation. Maternal plasma vitamin B12 levels were significantly higher in PE (p < 0.05) as compared with NC at T2. Maternal plasma homocysteine levels were higher in PE as compared with NC at all the time points, i.e. T1, T2 (p < 0.05 for both) and T3 (p < 0.01).

CONCLUSION

Our results indicate that higher homocysteine levels exist in women with PE from early pregnancy and continue till delivery.

Maternal hypertensive pregnancy disorders and cognitive functioning of the offspring: a systematic review

Hypertensive pregnancy disorders may affect the fetal developmental milieu and thus hint at mechanisms that link prenatal conditions with later developmental outcomes of the offspring. Here, we systematically review studies that have tested whether maternal pre-eclampsia, gestational hypertension, and hypertensive pregnancy disorders as a single diagnostic entity are associated with cognitive functioning of the offspring. Twenty-six studies were eligible for this review. Of them, 19 provided detailed methodological information deemed necessary to be included for a more detailed review. An overall conclusion is that, in the general population, maternal hypertensive disorders may be associated with lower cognitive ability of the offspring. Studies that extend to adulthood show the most consistent pattern of findings. It is possible that the associations arise during the lifetime or that the findings reflect improvements in management of these disorders. Evidence is, however, insufficient to conclude whether these associations are dissimilar in the offspring exposed to maternal pre-eclampsia and gestational hypertension, due to the varied criteria used across the different studies to distinguish between these conditions. The existing studies also vary in the definition of control groups, and very few have taken into account important confounding factors, including maternal pre-pregnancy obesity and lifestyle behaviors. Given the mixed pattern of findings and limitations related to internal and external validity, further studies are clearly warranted to clarify the associations.

First trimester screening can predict adverse pregnancy outcomes

There has been an increasing drive over the last two decades to push the detection of women at risk of adverse pregnancy outcomes into the first trimester. This has led to a plethora of techniques, risk assessments and biomarkers, both fascinating and bewildering in its breadth. Despite the vast amount of knowledge available, it is often difficult to determine what is practicable and valuable for clinical practice. This is especially true as earlier diagnosis does not necessarily equate to improved outcomes for mother and child. We suggest that, at least for preeclampsia, fetal growth restriction, spontaneous preterm birth and gestational diabetes, there are effective first trimester tests available to identify the women at risk of subsequently developing complications. Unfortunately, there are no currently reliable first trimester tests available for identifying women at risk of stillbirth. It is likely that this field will continue to develop over time, and we hope that new and better strategies will continue to emerge to target these clinically important pathologies.

Decreased seizure threshold in an eclampsia-like model induced in pregnant rats with lipopolysaccharide and pentylenetetrazol treatments

Objective

Eclampsia is a poorly understood but potentially fatal complication of pregnancy. Research to date on this disorder has been hampered by the lack of a suitable animal model. To correct this deficiency, this report describes the generation of a rat eclampsia-like model using pentylenetetrazol (PTZ) in a previously established rat preeclampsia model.

Method

Rats were administered lipopolysaccharide (1.0 µg/kg) by tail vein injection on gestational day 14 to establish preeclampsia (PE). PE and control rats (non-pregnant, NP; normal-pregnant, P) were injected intraperitoneally (i.p.) with PTZ (40 mg/kg) to induce seizures. In separate experiments, MgSO₄ (270 mg/kg IP) was injected in advance of PTZ into PE rats to observe its effect on PTZ-induced seizures.

Results

PE conditions were verified in rats after LPS administration by significantly higher blood pressure (P<0.01) and urinary albumin excretion (P<0.05), elevated sFlt-1 (P<0.05) and decreased PlGF serum levels (P<0.05), and evidence of hepatic dysfunction compared to control groups. PTZ successfully induced seizure activity in all groups studied. Latency to seizure was significantly (P<0.01) less in the PE-PTZ group (73.2±6.6 sec.) than in PTZ-treated controls (107.0±7.4 sec.). Pretreatment with MgSO₄ prolonged (P<0.05) latency to seizure, shortened seizure duration and decreased seizure rates. Significant increased (P<0.05) in the serum levels of the inflammatory cytokines TNF-α and IL-1β in PE and PE-PTZ groups, and decreased (P<0.05) in their levels following MgSO₄ administration.

Conclusion

This PTZ-induced eclampsia-like rat model is comparable to the human condition of eclampsia and may serve as a useful research tool for future studies of this disease. The increased inflammatory cytokines in preeclampsia are coincident with a decreased threshold for PTZ-induced seizures, suggesting that an inflammatory mechanism may contribute to the susceptibility to seizure activity and inflammation might have an important role in eclampsia.

THE EVIDENCE FOR LATE-ONSET PRE-ECLAMPSIA AS A MATERNOGENIC DISEASE OF PREGNANCY

It is our opinion that the evidence from epidemiological observations, clinical trials and biological studies is strong enough to support the view of different origin and phenotypes of pre-eclampsia: placental, which usually occurs (but not exclusively) early in pregnancy and is associated with poor early placentation of different severity with subsequent restriction of foetal growth, at different stages of gestation; and maternogenic, which generally occurs late in pregnancy and it is not related to placental insufficiency and foetal growth restriction.

Alterations of maternal serum and placental follistatin-like 3 and myostatin in pre-eclampsia

AIM

To clarify the alterations of myostatin, a member of the transforming growth factor-β superfamily, and follistatin-like 3 (FSTL3), a binding protein for myostatin, in pre-eclamptic women.

METHODS

Samples of blood and placenta were collected from 40 pre-eclamptic women and 40 controls. The serum level and placental expression of FSTL3 and myostatin were determined with enzyme-linked immunosorbent assay, real-time polymerized chain reaction and western blotting.

RESULTS

The serum levels of myostatin and FSTL3 were significantly higher in pre-eclamptic women than in the controls (P < 0.001 for both). Placental expression of myostatin and FSTL3 were also significantly increased in the pre-eclamptic placenta compared with that of the controls (P < 0.001 for both); however, there were no significant differences in myostatin or FSTL3 in either the maternal serum or the placenta in women with mild or severe pre-eclampsia (P > 0.05 for both).

CONCLUSION

The serum levels and placental expression of myostatin and FSTL3 are elevated in pre-eclampsia, suggesting the role of myostatin and its binding protein in pre-eclampsia.

Beneficial Effects of Magnesium Supplementation

Magnesium is an essential mineral necessary for optimal cellular health and well-being. Many adults in the United States fail to get recommended amounts of magnesium from their diets. Even so, symptoms of magnesium deficiency are rarely seen; however, maintaining normal body stores could be preventative against common diseases.