Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222

Outcomes of hyperglycaemia in pregnancy in Africa: systematic review study protocol

INTRODUCTION

The prevalence of diabetes mellitus globally has increased considerably over the past decades with a resultant increase in the incidence of diabetes-complicated pregnancies. Hyperglycaemia in pregnancy is the most common metabolic complication encountered during pregnancy and is associated with adverse maternal and fetal outcomes. This systematic review aims to examine maternal, fetal, neonatal, childhood and long-term maternal outcomes of hyperglycaemia in pregnancy in Africa.

METHODS AND ANALYSIS

A systematic review of all studies that investigated hyperglycaemia in pregnancy outcomes, carried out in Africa from 1998 to 2019. A comprehensive search of all published articles indexed in PubMed-MEDLINE, Cochrane Library, Scopus, CINAHL (EBSCOhost), Embase and Web of Science databases will be performed. Studies will be screened for eligibility by title, abstract and full text in duplicate by two independent reviewers. For data where meta-analysis is not possible, narrative analysis will be carried out using themes from data. For data where meta-analysis is possible, random effects meta-analysis will be conducted. This systematic review will be reported according to the Meta-analyses of Observational Studies in Epidemiology.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study considering this is a systematic review protocol that uses only published data. The findings of this study will be disseminated through peer-reviewed publications and conference presentations.

PROSPERO REGISTRATION NUMBER

CRD42020184573.

Inherited thrombophilia is significantly associated with severe preeclampsia

Methods to prevent the development of pathologies due to placental dysfunctions, such as gestational hypertension and preeclampsia, are the main approaches for obtaining the best maternal and fetal antepartum and postpartum prognosis. During 5 years of study (January, 2015 to December, 2019), the cases of pregnancy and puerperium complicated with pathology due to placental dysfunction were analyzed. The main objective was to determine the magnitude of the impact of thrombophilia on the development of an entity of gestational hypertension disorder. We compared the impact of thrombophilia and its associated complications in patients with gestational hypertension with moderate and severe preeclampsia. Thus, we found obesity, thrombophilia, and underlying cardiac pathology to be significant risk factors for severe preeclampsia. Regarding the comparative analysis of the risk factors and complications associated with patients with mild preeclampsia compared with those with severe preeclampsia, the presence in severe preeclampsia of thrombophilia, endocrine, liver, and cardiac pathology was higher and, a higher rate of complications was observed; complications included fetal death, intrauterine growth restriction (IUGR), prematurity, fetal arrhythmia with acute fetal distress, HELLP syndrome, and placental abruption. Thrombophilia has a significant effect on the development of severe preeclampsia, and oligohydramnios as specific complication of mild preeclampsia. Factors indicating an increased risk of progression from mild preeclampsia to severe preeclampsia are in addition to inherited thrombophilia the underlying pathologies, namely cardiac, hepatic, and endocrine factors.

Postpartum microvascular functional alterations following severe preeclampsia

Preeclampsia is associated with adverse maternal health outcomes later in life. Vascular endothelial dysfunction has been previously described following preeclampsia. We hypothesized that microvascular endothelial dysfunction associated with preeclampsia persists postpartum and may identify those at greatest risk of future cardiovascular disease. The objective of this study was to examine postpartum microvascular endothelial function in women after a pregnancy complicated by preeclampsia. Women with previous preeclampsia (n = 30) and normotensive controls (n = 30) between 6 mo and 5 yr postpartum were recruited. Severity of preeclampsia [severe (n = 16) and mild (n = 14)] was determined by standardized chart review. Microvascular reactivity in the forearm was measured with laser speckle contrast imaging, coupled with iontophoresis; endothelium-dependent and endothelium-independent vasodilation was induced with 1% acetylcholine and sodium nitroprusside solutions, respectively. A postocclusive reactive hyperemia test assessed vasodilatory response following three minutes of suprasystolic (200 mmHg) occlusion with a mechanized cuff. Women with prior severe preeclampsia exhibited significantly higher vasodilation to acetylcholine and sodium nitroprusside compared to controls (P < 0.01; P = 0.03) and prior mild preeclampsia (P = 0.03; P < 0.01). Neither the degree of postocclusive reactive hyperemia (P = 0.98), nor time to return halfway to baseline [OR = 1.026 (0.612, 1.72); P = 0.92], differed between preeclampsia and controls. In conclusion, severe preeclampsia is associated with heightened postpartum microvascular endothelium-dependent and endothelium-independent vasoreactivity. These changes, or a common antecedent, may be linked to postpartum alterations in vascular function that predispose women to disease after preeclampsia. Further investigation should identify the contributing mechanism and the degree to which it could be amenable to medical intervention.NEW & NOTEWORTHY We examine maternal microvascular function after preeclampsia, identifying heightened endothelium-dependent and endothelium-independent microvascular reactivity following severe disease. Our study represents a noteworthy addition to the existing literature with the use of a novel imaging modality, vascular perturbation, postpartum time point, and patient population with differentiation of preeclampsia into severe and nonsevere subtypes. These results represent a novel addition to the growing clinical and academic understanding of maternal health outcomes following preeclampsia.

The Xi'an longitudinal mother-child cohort study: design, study population and methods

The large-scale Xi'an longitudinal mother-child cohort study has started to enroll pregnant women who attended Northwest Women's and Children's Hospital (NWCH) for antenatal care in early pregnancy (less than 20 weeks' gestation) from January 2013 and the enrollment will be ended in January 2023. We aimed to investigate the role of external factors (i.e., diet and environment) and internal (i.e., biological, genetic and epigenetic) on the short- and long-term outcomes of mothers and children up to at least 12 years. Mothers completed all routine prenatal care during pregnancy and four times of follow-up at 42 days, 3, 6 and 12 years after delivery, respectively. For children, birth information were obtained from routine medical records and the follow-up information were obtained from child health care clinics of NWCH at age 42 days, 6, 12 and 24 months, then by interviewing mothers every two years until 12 years old. A range of data (including biological, demographic, birth outcomes/birth defects and nutritional factors from both maternal and off-spring) were collected by both interviews and laboratory tests. By June 30th 2019, a total of 114,946 mothers and 124,454 live births had been recruited.

Non-communicable Diseases in Pregnant and Postpartum Women Living with HIV: Implications for Health Throughout the Life Course

PURPOSE OF REVIEW

The development of non-communicable diseases (NCDs) in pregnant women living with HIV can be a harbinger of future NCD-related morbidity and mortality. This review focuses on the NCDs that complicate pregnancy and the postpartum period, including hypertensive complications, hyperglycemic disorders, excessive gestational weight gain, and bone mineral density losses. For each disease process, we explore the role of HIV as a possible driver of excess risk, the immediate consequences of these complications on pregnancy outcomes and maternal and infant health, and possible implications for long-term women's health.

RECENT FINDINGS

Countries with the highest burden of HIV also shoulder a high burden of NCDs that complicate pregnancy, including hypertensive disorders, hyperglycemic disorders, weight gain, and osteopenia. This double burden of disease is a significant public health threat for reproductive-age women, with the potential for serious short- and long-term consequences for both women and their infants. Additionally, as the global first-line antiretroviral therapy regimens increasingly include integrase inhibitors, unhealthy weight gain associated with this drug class poses additional risk for NCD-related pregnancy complications and their persistence postpartum. Further research is needed to better define prevalence of NCD complications in pregnancy, elucidate HIV-specific and traditional factors associated with poor outcomes, and to develop interventions to reduce risk and avoid downstream complications in those at highest risk.

Decreased Endometrial Thickness Is Associated With Higher Risk of Neonatal Complications in Women With Polycystic Ovary Syndrome

PURPOSE

To evaluate the association of endometrial thickness (EMT) with obstetric and neonatal outcomes in women with polycystic ovary syndrome (PCOS).

METHODS

A total of 1755 subfertile PCOS women with singleton livebirths after frozen-thawed embryo transfer were included between January 2009 and September 2019. Main obstetric outcomes were hypertensive disorders in pregnancy and abnormal placentation. Main neonatal outcomes were preterm birth (PTB), low birthweight (LBW) and small-for-gestational age (SGA). Crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were estimated by univariate and multivariate logistic regression analyses.

RESULTS

Each millimeter decrease in EMT was related to a 9% (adjusted OR 1.09, 95% CI 1.00-1.19; P = 0.053), 14% (adjusted OR 1.14, 95% CI 1.02-1.28; P = 0.002) and 22% (adjusted OR 1.22, 95% CI 1.07-1.38; P = 0.003) higher risk of PTB, LBW and SGA, respectively. Compared to women with EMT >13 mm, women with EMT ≤8 mm also had significantly higher risk of PTB (adjusted OR 3.79, 95% CI 1.53-9.39; P = 0.004), LBW (adjusted OR 4.33, 95% CI 1.39-13.50; P = 0.012) and SGA (adjusted OR 6.38, 95% CI 1.78-22.83; P = 0.004). These associations remained consistent in further subgroup analysis by endometrial preparation regimen and in sensitivity analyses among nulligravida women or women without adverse obstetric outcomes. No significant differences were found in the incidence of several pregnancy complications across EMT categories.

CONCLUSION

Decreased EMT was independently associated with increased risk of PTB, LBW and SGA in women with PCOS.

Magnesium: The recent research and developments

Magnesium is the fourth most abundant mineral in the human body, which facilitates more than 300 enzymatic reactions. Magnesium is essential for nucleic material and protein synthesis, neuromuscular conduction, cardiac contractility, energy metabolism, and immune system function. Gastrointestinal system and kidneys closely regulate magnesium absorption and elimination to maintain adequate storage of magnesium. Magnesium deficiency has been linked to many diseases and poor health outcomes. Magnesium has also been proven to be an effective therapeutic agent in many diseases, such as bronchial asthma, cardiac arrhythmia, and pre-eclampsia.

Association Between Menstrual Patterns and Adverse Pregnancy Outcomes in Patients With Polycystic Ovary Syndrome

OBJECTIVE

To investigate the results of in vitro fertilization among polycystic ovary syndrome (PCOS) patients using the long-acting long protocol regarding the relationship between menstrual patterns and adverse pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

University-affiliated reproductive medical center.

BACKGROUND

The menstrual patterns of patients with PCOS is considered related to metabolism; however, no study has analyzed the outcome of in vitro fertilization/intracytoplasmic sperm injection (IVF/ICSI) in patients with PCOS who have different menstrual patterns. This study aimed to observe the outcomes of IVF/ICSI in patients with PCOS with different menstrual patterns who used the long-acting long protocol.

METHODS

This was a retrospective analysis in the first cycle of IVF/ICSI at the Reproductive Medicine Center of the First Affiliated Hospital of Zhengzhou University from January 2017 to December 2019. In total, 1834 patients with PCOS were classified into the regular menstruation group (n=214), the oligomenorrhea group (n=1402), and the amenorrhea group (n=218).

RESULTS

PCOS patients who used the long-acting long protocol of IVF/ICSI had similar clinical pregnancy rates and live birth rates despite having different menstrual patterns. The overall incidence of adverse pregnancy outcomes, including abortion, spontaneous preterm birth (sPTB), gestational diabetes(GDM), hypertensive disorder inpregnancy (HDP), and premature rupture of membranes(PROM, was significantly higher in the amenorrhea group than in the regular menstrual and oligomenorrhea groups (25.88% vs. 30.41% vs. 43.69%; P = 0.013). Additionally, the rates of GDM (2.35% vs. 6.10% vs. 13.79%; P=0.015) and macrosomia (5.26% vs. 10.94% vs. 18.39%; P=0.026) in the amenorrhea group were significantly higher than those in the other two groups. Correction for confounding factors showed that menstrual patterns are related to the occurrence of adverse pregnancy outcomes. Amenorrhea is an independent risk factor for adverse pregnancy outcome (OR [odds ratio]: 2.039, 95% CI [confidence interval]: 1.087-3.822), GDM (OR: 5.023, 95% CI: 1.083-23.289), and macrosomia (OR: 4.918, 95% CI: 1.516-15.954).

CONCLUSIONS

IVF/ICSI can achieve similar pregnancy and live birth rates in PCOS patients with different menstrual patterns. However, the overall incidence of adverse pregnancy outcomes in PCOS patients with amenorrhea is higher than that in patients with regular menstruation or oligomenorrhea.

Congo red test for identification of preeclampsia: Results of a prospective diagnostic case-control study in Bangladesh and Mexico

BACKGROUND

Misfolded proteins in the urine of women with preeclampsia bind to Congo Red dye (urine congophilia). We evaluated a beta prototype of a point-of-care test for the identification of urine congophilia in preeclamptic women.

METHODS

Prospective diagnostic case-control study conducted in 409 pregnant women (n = 204 preeclampsia; n = 205 uncomplicated pregnancies) presenting for delivery in two tertiary level hospitals located in Bangladesh and Mexico. The GV-005, a beta prototype of a point-of-care test for detecting congophilia, was performed on fresh and refrigerated urine samples. The primary outcome was the prevalence of urine congophilia in each of the two groups. Secondary outcome was the likelihood of the GV-005 (index test) to confirm and rule-out preeclampsia based on an adjudicated diagnosis (reference standard).

FINDINGS

The GV-005 was positive in 85% of clinical cases (83/98) and negative in 81% of clinical controls (79/98) in the Bangladesh cohort. In the Mexico cohort, the GV-005 test was positive in 48% of clinical cases (51/106) and negative in 77% of clinical controls (82/107). Adjudication confirmed preeclampsia in 92% of Bangladesh clinical cases (90/98) and 61% of Mexico clinical cases (65/106). The odds ratio of a urine congophilia in adjudicated cases versus controls in the Bangladesh cohort was 34^.5 (14^.7 - 81^.1) (p<0^.001) compared to 4^.2 (2^.1 - 8^.4; p<0^.001) in the Mexico cohort.

INTERPRETATION

The GV-005, a beta prototype of a point-of-care test for detection of urine congophilia, is a promising tool for rapid identification of preeclampsia.

FUNDING

Saving Lives at Birth.

Collagen I Induces Preeclampsia-Like Symptoms by Suppressing Proliferation and Invasion of Trophoblasts

Preeclampsia is a common obstetric disorder affecting 2-8% of pregnancy worldwide. Fibrosis is an important histological change occurring in preeclamptic placenta, and might depend on the excess deposition of collagen I. However, the role of fibrotic placenta and collagen I in the pathogenesis of preeclampsia remains unclear. Therefore, we analyzed the collagen deposition and the expression of Collagen I in human placenta by Masson staining, Sirius red staining and western blotting. Further, the role of collagen I in preeclampsia pathogenesis was studied in C57BL/6 mice. HTR-8/SVneo cells were used to investigate the mechanisms underlying the effects of collagen I in trophoblasts by transcriptome sequencing and pharmacological agonists. Human preeclamptic placenta exhibited a significantly higher degree of fibrosis in stem villi and terminal villi than normal placenta, and was characterized by collagen I deposition. In vivo, a single injection of collagen I on gestational day 0.5 led to an increase in systolic pressure of pregnant mice from gestational days 4.5-17.5, to a decrease in weight and number of embryos, and to enhanced placental collagen I expression and degree of fibrosis compared with control mice. In vitro, collagen I attenuated the proliferation and invasion of HTR-8SV/neo cells. This effect could be reversed by treatment with agonists of ERK and β-catenin. Moreover, transcriptome sequencing demonstrated that signaling pathways related to cell proliferation and invasion were significantly downregulated in HTR-8SV/neo cells. Thus, we propose that collagen I induced preeclampsia-like symptoms by suppressing the proliferation and invasion of trophoblasts through inhibition of the ERK phosphorylation and WNT/β-catenin signaling pathways. Our findings could pave the way to the discovery of small-molecule inhibitors for preeclampsia treatment and future studies with larger sample size are required.

Functional Evaluation of STOX1 (STORKHEAD-BOX PROTEIN 1) in Placentation, Preeclampsia, and Preterm Birth

Revaluation of the association of the STOX1 (STORKHEAD_BOX1 PROTEIN 1) transcription factor mutation (Y153H, C allele) with the early utero-vascular origins of placental pathology is warranted. To investigate if placental STOX1 Y153H genotype affects utero-vascular remodeling-compromised in both preterm birth and preeclampsia-we utilized extravillous trophoblast (EVT) explant and placental decidual coculture models, transfection of STOX1 wild-type and mutant plasmids into EVT-like trophoblast cell lines, and a cohort of 75 placentas from obstetric pathologies. Primary EVT and HTR8/SVneo cells carrying STOX1 Y153H secreted lower levels of IL (interleukin) 6, and IL-8, and higher CXCL16 (chemokine [C-X-C motif] ligand 16) and TRAIL (tumor necrosis factor-related apoptosis-inducing ligand) than wild-type EVT and Swan71 cells. Media from wild-type EVT or Swan71 cells transfected with wild-type STOX1 stimulated: endothelial chemokine expression, angiogenesis, and decidual natural killer cell and monocyte migration. In contrast, Y153H EVT conditioned medium, Swan71 transfected with the Y153H plasmid, or HTR8/SVneo media had no effect. Genotyping of placental decidual cocultures demonstrated association of the placental STOX1 CC allele with failed vascular remodeling. Decidual GG NODAL R165H increased in failed cocultures carrying the placental CC alleles of STOX1. Multivariate analysis of the placental cohort showed that the STOX1 C allele correlated with premature birth, with or without severe early-onset preeclampsia, and small for gestational age babies. In conclusion, placental STOX1 Y153H is a precipitating factor in preterm birth and placental preeclampsia due to defects in early utero-placental development.

Polycystic Ovarian Syndrome: Impact on Adult and Fetal Health

Women with the polycystic ovarian syndrome (PCOS) may have an increased risk for complications in pregnancy including miscarriage, gestational diabetes mellitus, hypertensive disorders of pregnancy, higher rates of cesarean delivery, and abnormalities in fetal growth. In addition, PCOS has been associated with the development of type II diabetes mellitus, hypertension, cardiovascular disease, obstructive sleep apnea, endometrial cancer, depression and anxiety, and nonalcoholic fatty liver disease. In understanding that PCOS is a disease impacting more than just a woman's fertility, prevention and early identification of risk factors for affiliated conditions is essential.

Maternal Morbidity and Mortality: Are We Getting to the "Heart" of the Matter?

Cardiovascular disease (CVD), including hypertensive disorders of pregnancy (HDP) and peripartum cardiomyopathy, is a leading cause of pregnancy-related death in the United States. Women who are African American or American Indian/Alaskan Native, have HDP, are medically underserved, are older, or are obese have a major risk for the onset and/or progression of CVD during and after pregnancy. Paradoxically, women with no preexisting chronic conditions or risk factors also experience significant pregnancy-related cardiovascular (CV) complications. The question remains whether substantial physiologic stress on the CV system during pregnancy reflected in hemodynamic, hematological, and metabolic changes uncovers subclinical prepregnancy CVD in these otherwise healthy women. Equally important and similarly understudied is the concept that women's long-term CV health could be detrimentally affected by adverse pregnancy outcomes, such as preeclampsia, gestational hypertension, and diabetes, and preterm birth. Thus, a critical life span perspective in the assessment of women's CV risk factors is needed to help women and health care providers recognize and appreciate not only optimal CV health but also risk factors present before, during, and after pregnancy. In this review article, we highlight new advancements in understanding adverse, pregnancy-related CV conditions and will discuss promising strategies or interventions for their prevention, diagnosis, and treatment.

Obstetric and Perinatal Outcomes in Pregnancies Conceived After Preimplantation Genetic Testing for Monogenetic Diseases

OBJECTIVE

To investigate whether the addition of embryo biopsy performed during preimplantation genetic testing for monogenic diseases is associated with a higher risk of obstetric and neonatal complications compared with in vitro fertilization (IVF) without preimplantation genetic testing or spontaneously conceived pregnancies.

METHODS

This is a cohort study of all pregnancies conceived after preimplantation genetic testing for monogenic diseases (PGT-M group) from 2006 to 2018 at Sheba Medical Center, Israel. The control groups included patients who had conceived spontaneously (spontaneous conception group) or by IVF without preimplantation genetic testing (IVF group) and delivered at Sheba Medical Center. The obstetrics outcomes were compared among the groups. Multivariable regression modeling was performed, focusing on the relationship between preimplantation genetic testing and adverse outcomes.

RESULTS

Final analysis included 345 singleton and 76 twin deliveries in the PGT-M group. The spontaneous conception group included 5,290 singleton and 92 twin deliveries. The IVF group included 422 singleton and 101 twin deliveries. Among singleton pregnancies, patients in the PGT-M group had a higher rate of hypertensive disorders (6.9%) compared with those in the spontaneous conception group (2.3%; odds ratio [OR] 3.3; 95% CI 1.9-4.8; adjusted odds ratio [aOR] 14.8; 95% CI 7.4-29.8) and the IVF group (4.7%; OR 1.5; 95% CI 0.8-2.7; aOR 5.9; 95% CI 1.9-18.2). Likewise, patients in the PGT-M group had a higher rate of small-for-gestational age neonates (12.4%) compared with those in the spontaneous conception group (3.9%; OR 3.4; 95% CI 2.4-4.9; aOR 2.3; 95% CI 1.5-3.4) and the IVF group (4.5%; OR 3; 95% CI 1.7-5.2; aOR 2.5; 95% CI 1.7-5.2). Among twin pregnancies, patients in the PGT-M group also had an increased rate of hypertensive disorders compared with those in the spontaneous conception group (4.3%; OR 4.1; 95% CI 1.2-13.3; aOR 10.9; 95% CI 2.3-50) and the IVF group (4%; OR 4.5; 95% CI 1.4-14.7; aOR 3.7; 95% CI 1.1-12.8).

CONCLUSION

Pregnancies conceived after preimplantation genetic testing for monogenic disorders were associated with an increased risk of obstetric complications compared with pregnancies conceived spontaneously or by IVF without preimplantation genetic testing.

Oxidative Stress and Preeclampsia-Associated Prothrombotic State

Preeclampsia (PE) is a common obstetric disease characterized by hypertension, proteinuria, and multi-system dysfunction. It endangers both maternal and fetal health. Although hemostasis is critical for preventing bleeding complications during pregnancy, delivery, and post-partum, PE patients often develop a severe prothrombotic state, potentially resulting in life-threatening thrombosis and thromboembolism. The cause of this thrombotic complication is multi-factorial, involving endothelial cells, platelets, adhesive ligands, coagulation, and fibrinolysis. Increasing evidence has shown that hemostatic cells and factors undergo oxidative modifications during the systemic inflammation found in PE patients. However, it is largely unknown how these oxidative modifications of hemostasis contribute to development of the PE-associated prothrombotic state. This knowledge gap has significantly hindered the development of predictive markers, preventive measures, and therapeutic agents to protect women during pregnancy. Here we summarize reports in the literature regarding the effects of oxidative stress and antioxidants on systemic hemostasis, with emphasis on the condition of PE.

Risk factors associated with adverse maternal outcomes following intrapartum cesarean birth: a secondary analysis of the WHO global survey on maternal and perinatal health, 2004-2008

BACKGROUND

To identify risk factors associated with a composite adverse maternal outcomes in women undergoing intrapartum cesarean birth.

METHODS

We used the facility-based, multi-country, cross-sectional WHO Global Survey of Maternal and Perinatal Health (2004-2008) to examine associations between woman-, labor/obstetric-, and facility-level characteristics and a composite adverse maternal outcome of postpartum morbidity and mortality. This analysis was performed among women who underwent intrapartum cesarean birth during the course of labor.

RESULTS

We analyzed outcomes of 29,516 women from low- and middle-income countries who underwent intrapartum cesarean birth between the gestational ages of 24 and 43 weeks, 3.5% (1040) of whom experienced the composite adverse maternal outcome. In adjusted analyses, factors associated with a decreased risk of the adverse maternal outcome associated with intrapartum cesarean birth included having four or more antenatal visits (AOR 0.60; 95% CI: 0.43-0.84; p = 0.003), delivering in a medium- or high-human development index country (vs. low-human development index country: AOR 0.07; 95% CI: 0.01-0.85 and AOR 0.02; 95% CI: 0.001-0.39, respectively; p = 0.03), and malpresentation (vs. cephalic: breech AOR 0.52; CI: 0.31-0.87; p = 0.04). Women who were medically high risk (vs. not medically high risk: AOR 1.81; CI: 1.30-2.51, p < 0.0004), had less education (0-6 years) (vs. 13+ years; AOR 1.64; CI: 1.03-2.63; p = 0.01), were obstetrically high risk (vs. not high risk; AOR 3.67; CI: 2.58-5.23; p < 0.0001), or had a maternal or obstetric indication (vs. elective: AOR 4.74; CI: 2.36-9.50; p < 0.0001) had increased odds of the adverse outcome.

CONCLUSION

We found reduced adverse maternal outcomes of intrapartum cesarean birth in women with ≥ 4 antenatal visits, those who delivered in a medium or high human development index country, and those with malpresenting fetuses. Maternal adverse outcomes associated with intrapartum cesarean birth were medically and obstetrically high risk women, those with less education, and those with a maternal or obstetric indication for intrapartum cesarean birth.

Hypoxaemia during tracheal intubation in patients with hypertensive disorders of pregnancy: analysis of data from an obstetric airway management registry

BACKGROUND

In South Africa, hypertensive disorders of pregnancy are the leading cause of maternal mortality. More than 50% of anaesthesia-related maternal deaths are attributed to complications of airway management. We compared the prevalence and risk factors for hypoxaemia during induction of general anaesthesia in parturients with and without hypertensive disorders of pregnancy. We hypothesised that hypertensive disorders of pregnancy are associated with desaturation during tracheal intubation.

METHODS

Data from 402 cases in a multicentre obstetric airway management registry were analysed. The prevalence of peri-induction hypoxaemia (SpO₂ <90%) was compared in patients with and without hypertensive disorders of pregnancy. Quantile regression of SpO₂ nadir was performed to identify confounding variables associated with, and mediators of, hypoxaemia.

RESULTS

In the cohort of 402 cases, hypoxaemia occurred in 19% with and 9% without hypertension (estimated risk difference, 10%; 95% CI 2% to 17%; P=0.005). Quantile regression demonstrated a lower SpO₂ nadir associated with hypertensive disorders of pregnancy as body mass index increased. Room-air oxygen saturation, Mallampati grade, and number of intubation attempts were associated with the relationship.

CONCLUSIONS

Clinically significant oxygen desaturation during airway management occurred twice as often in patients with hypertensive disorders of pregnancy, compounded by increasing body mass index. Intermediary factors in the pathway from hypertension to hypoxaemia were also identified.

Association of placenta-derived extracellular vesicles with pre-eclampsia and associated hypercoagulability: a clinical observational study

OBJECTIVE

Pre-eclampsia (PE) is a pregnancy-associated condition initiated by placental factors. We have demonstrated that placental extracellular vesicles (pcEVs) cause hypertension and proteinuria in pregnant and non-pregnant mice.

STUDY DESIGN

An observational study with both case-control and longitudinal designs.

SETTING

A single centre at the Department of Obstetrics and Gynaecology, Tianjin Medical University.

POPULATION

We collected blood samples and clinical information from 54 PE patients, 33 normally pregnant women at 30-36 gestational weeks and on postpartum days 1 and 4 for the cross-sectional study, and at 22-31, 32-35 and 36-40 weeks for the longitudinal study. Non-pregnant women were also recruited.

METHODS

Blood samples were analysed using flow cytometry, coagulation tests and ELISA.

MAIN OUTCOME MEASURES

The primary outcome was plasma pcEV and other extracellular vesicles (EVs), and their expressions of anionic phospholipids and von Willebrand factor (VWF). Secondary variables included coagulation, ADAMTS-13 and the anionic phospholipid-binding proteins.

RESULTS

Plasma pcEVs progressively increased from pregnant women during non-menstrual period (NW) to PE patients (interquartile range [IQR] for NW: 206/microlitre [116-255], normal pregnancy [NP]: 1108/microlitre [789-1969] and PE: 8487/microlitre [4991-16 752]) and predicted PE. EVs from endothelial cells, platelets and erythrocytes accounted for <10% of pcEVs. VWF became hyper-adhesive in PE patients and contributed to the pregnancy-associated hypercoagulability.

CONCLUSION

Placental, platelet- and endothelial cell-derived EVs were significantly elevated in PE patients, but only pcEVs predicted PE. These EVs played a causal role in the pregnancy-induced hypercoagulability.

TWEETABLE ABSTRACT

Placenta-derived extracellular vesicles predict pre-eclampsia and the associated hypercoagulability.

Correlations of spot urinary sodium and potassium with blood pressure in pregnant women: A longitudinal study in Southern Thailand

OBJECTIVE

To assess the changes of spot urinary sodium and potassium and blood pressure (BP) throughout pregnancy and their correlations in southern Thailand.

METHODS

A longitudinal study was conducted in southern Thailand from March 2018 to November 2019. Spot urinary excretion of sodium per creatinine (U[Na⁺ ]/[Cr]), potassium per creatinine (U[K⁺ ]/[Cr]) and U[Na⁺ ]/[K⁺ ] ratios, and BP were measured at four time points throughout pregnancy. A one-way analysis of variance with repeated measures and Bonferroni correction with post hoc analysis was used to identify significant differences between time points. The correlations were measured using Pearson's correlation coefficients.

RESULTS

A total of 327 pregnant women were included. Both systolic and diastolic BPs decreased gradually from up to 14 weeks of pregnancy to 18-22 weeks and then increased until 30-34 weeks. Mean spot U[Na⁺ ]/[Cr] ratios did not significantly change during the study period. Mean spot U[K⁺ ]/[Cr] ratios gradually increased, and spot U[Na⁺ ]/[K⁺ ] ratios gradually decreased. The correlation of spot U[Na⁺ ]/[Cr] and U[K⁺ ]/[Cr] ratios with BPs was weakly negative at all four time points.

CONCLUSIONS

Spot U[Na⁺ ]/[Cr] and U[K⁺ ]/[Cr] ratios are inversely correlated with BPs; weak correlations are found among pregnant women in southern Thailand. Further research in different populations is required to confirm its correlation and broader use.

Non-Criteria Antiphospholipid Antibodies: Risk Factors for Endothelial Dysfunction in Women with Pre-Eclampsia

The association between unconventional antiphospholipid antibodies and pre-eclampsia in patients without thrombotic manifestations and its relationship with endothelial dysfunction after delivery has been studied poorly. We included 157 pregnant women, 122 of them having developed pre-eclampsia (56 non-severe and 66 severe). The determination of classical and unconventional, as well as pulse wave velocity and ankle-brachial index were performed at three months after delivery. The prevalence of unconventional antiphospholipid antibodies was 22.9% and 54.9% in patients included in control and pre-eclampsia groups, respectively (p = 0.001). The most frequent antiphospholipid antibody was IgM anti-phosphatidylserine/prothrombin in both cohorts. The presence of IgM anti-phosphatidylserine/prothrombin showed an association with the development of pre-eclampsia (OR = 5.4; CI 95% (2.0-14.9), p = 0.001) with an AUC of 0.744 (p < 0.001). Likewise, IgM anti-phosphatidylserine/prothrombin exhibited a positive linear correlation with pulse wave velocity values (rho = 0.830; p < 0.001) and an association with the presence of pulse wave velocity altered values (OR = 1.33; CI95% (1.10-1.59), p = 0.002). With regard to ankle braquial index values, the presence of IgM anti-phosphatidylserine/prothrombin displayed a weak negative correlation (rho = -0.466; p < 0.001) and an association with altered ankle braquial index values (OR = 1.08; CI 95% (1.04-1.13), p < 0.001). In patients who developed preeclampsia, the presence of IgM anti-phosphatidylserine/prothrombin could be associated with endothelial dysfunction, causing alteration of cardiovascular parameters.

Coronavirus disease 2019 pregnancy outcomes in a racially and ethnically diverse population

Background

Older age and medical comorbidities are identified risk factors for developing severe coronavirus disease 2019. However, there are limited data on risk stratification, clinical and laboratory course, and optimal management of coronavirus disease 2019 in pregnancy.

Objective

Our study aimed to describe the clinical course of coronavirus disease 2019, effect of comorbidities on disease severity, laboratory trends, and pregnancy outcomes of symptomatic and asymptomatic severe acute respiratory syndrome coronavirus 2–positive pregnant women.

Study Design

This is a case series of pregnant and postpartum women who received positive test results for severe acute respiratory syndrome coronavirus 2 between March 3, 2020, and May 11, 2020, within 3 hospitals of the Yale New Haven Health delivery network. Charts were reviewed for basic sociodemographic and prepregnancy characteristics, coronavirus disease 2019 course, laboratory values, and pregnancy outcomes.

Results

Of the 1567 tested pregnant and postpartum women between March 3, 2020, and May 11, 2020, 9% (n=141) had a positive severe acute respiratory syndrome coronavirus 2 result. Hispanic women were overrepresented in the severe acute respiratory syndrome coronavirus 2–positive group (n=61; 43.8%). In addition, Hispanic ethnicity was associated with a higher rate of moderate and severe diseases than non-Hispanic (18% [11/61] vs 3.8% [3/78], respectively; odds ratio, 5.5; 95% confidence interval, 1.46–20.7; P=.01). Of note, 44 women (31.2%) were asymptomatic, 37 of whom (26.2%) were diagnosed on universal screening upon admission for delivery. Moreover, 59% (n=83) were diagnosed before delivery, 36% (n=51) upon presentation for childbirth, and 5% (n=7) after delivery. Severe disease was diagnosed in 6 cases (4.3%), and there was 1 maternal death. Obese women were more likely to develop moderate and severe diseases than nonobese women (16.4% [9/55] vs 3.8% [3/79]; odds ratio, 4.96; 95% confidence interval, 1.28–19.25; P=.02). Hypertensive disorders of pregnancy were diagnosed in 22.3% of women (17/77) who delivered after 20 weeks’ gestation. Higher levels of C-reactive protein during antepartum coronavirus disease 2019–related admission were more common in women with worse clinical course; however, this association did not reach statistical significance.

Conclusion

Coronavirus disease 2019 in pregnancy may result in severe disease and death. Hispanic women were more likely to receive a positive test result for severe acute respiratory syndrome 2 than other ethnic groups. Obesity and Hispanic ethnicity represent risk factors for moderate and severe diseases.

Plane-Wave Ultrasound Doppler of the Eye in Preeclampsia

Purpose

Pre-eclampsia (PE) is a serious complication of pregnancy characterized by high blood pressure, proteinuria, compromised fetal blood supply, and potential organ damage. The superficial location of the eye makes it an ideal target for characterization hemodynamics. Our aim was to discern the impact of PE on ocular blood flow.

Methods

18 MHz plane-wave ophthalmic ultrasound scanning was performed on subjects with PE (n = 26), chronic or gestational hypertension (n = 8), and normal controls (n = 19) within 72 hours of delivery. Duplicate three-second long scans of the posterior pole including the optic nerve were acquired at 6000 images/sec for evaluation of the central retinal artery and vein and the short posterior ciliary arteries. The choroid was scanned at 1000 images/sec. Doppler analysis provided values of pulsatile flow velocity and resistance indexes.

Results

End diastolic velocity was higher, and pulsatility and resistive indexes were significantly lower in the choroid, central retinal artery and short posterior ciliary arteries in PE than in controls. Blood pressure was elevated in PE with respect to controls and was negatively correlated with resistance.

Conclusions

Although vasoconstriction is considered characteristic of PE, we found reduced resistance in the orbital vessels and choroidal arterioles, implying vasodilation at this level. Future studies incorporating optical coherence tomography angiography for characterization of the retina and choriocapillaris in conjunction with plane-wave ultrasound scanning, particularly in late pregnancy, might address this conundrum.

Translational Relevance

Use of plane-wave ultrasound scanning for evaluation ocular blood flow in women at risk for PE may offer an avenue towards early detection and clinical intervention.

Pre-Pregnancy Obesity vs. Other Risk Factors in Probability Models of Preeclampsia and Gestational Hypertension

In the face of the obesity epidemic around the world, attention should be focused on the role of maternal obesity in the development of pregnancy. The purpose of this analysis was to evaluate the prediction of preeclampsia (PE) and isolated gestational hypertension (GH) for a number of maternal factors, in order to investigate the importance of pre-pregnancy obesity (body mass index, BMI ≥ 30 kg/m²), compared to other risk factors (e.g., prior PE, pregnancy weight gain (GWG), infertility treatment, interpregnancy interval, family history, the lack of vitamin supplementation, urogenital infection, and socioeconomic factors). In total, 912 women without chronic diseases were examined in a Polish prospective cohort of women with a singleton pregnancy (recruited in 2015–2016). Separate analyses were performed for the women who developed GH (n = 113) vs. 775 women who remained normotensive, as well as for those who developed PE (n = 24) vs. 775 controls. The probability of each disease was assessed for the base prediction model (age + primiparity) and for the model extended by one (test) variable, using logistic regression. Three measures were used to assess the prediction: area under curve (AUC) of the base and extended model, integrated discrimination improvement (IDI) (the index shows the difference between the value of the mean change in the predicted probability between the group of sick and healthy women when a new factor is added to the model), and net reclassification improvement (NRI) (the index focuses on the reclassification table describing the number of women in whom an upward or downward shift in the disease probability value occurred after a new factor had been added, including results for healthy and sick women). In the GH prediction, AUC increased most strongly when we added BMI (kg/m²) as a continuous variable (AUC = 0.716, p < 0.001) to the base model. The highest IDI index was obtained for prior GH/PE (IDI = 0.068, p < 0.001). The addition of BMI as a continuous variable or BMI ≥ 25 kg/m² improved the classification for healthy and sick women the most (NRI = 0.571, p < 0.001). In the PE prediction, AUC increased most strongly when we added BMI categories (AUC = 0.726, p < 0.001) to the base model. The highest IDI index was obtained for prior GH/PE (IDI = 0.050, p = 0.080). The addition of BMI categories improved the classification for healthy and sick women the most (NRI = 0.688; p = 0.001). After summing up the results of three indexes, the probability of hypertension in pregnancy was most strongly improved by BMI, including BMI ≥ 25 kg/m² for the GH prediction, and BMI ≥ 30 kg/m² for the PE prediction. Main conclusions: Pre-pregnancy BMI was the most likely factor to increase the probability of developing hypertension in pregnancy, compared to other risk factors. Hierarchies of PE and GH risk factors may suggest different (or common) mechanisms of their development.

Outcomes of labor induction at 39 weeks in pregnancies with a prior cesarean delivery

BACKGROUND

The optimal timing of induction for those undergoing a trial of labor after cesarean section has not been established. The little data which supports the consideration of induction at 39 weeks gestation excludes those with a history of prior cesarean section.

OBJECTIVE

To determine the risks and benefits of elective induction of labor (IOL) at 39 weeks compared with expectant management (EM) until 42 weeks in pregnancies complicated by one previous cesarean delivery.

STUDY DESIGN

This is a retrospective cohort analysis of singleton non-anomalous pregnancies in the United States between January 2015 and December 2017. Data was provided by the CDC National Center for Health Statistics, Division of Vital Statistics. Analyses included only pregnancies with a history of one previous cesarean delivery (CD). Perinatal outcomes of pregnancies electively induced at 39 weeks (IOL) were compared to pregnancies that were induced, augmented or underwent spontaneous labor between 40 and 42 weeks (EM). Unlabored cesarean deliveries were excluded. Outcomes of interest included: cesarean delivery, intra-amniotic infection, blood transfusion, adult intensive care unit (ICU) admission, uterine rupture, hysterectomy, 5-minute Apgar score ≤3, prolonged neonatal ventilation, neonatal ICU (NICU) admission, neonatal seizure, perinatal/neonatal death. Log-binomial regression analysis was performed to calculate the relative risk (RR) for each outcome of interest, adjusting for confounding variables.

RESULTS

There were 50,136 pregnancies included for analysis with 9,381 women in the IOL group. Compared with EM, IOL at 39 weeks decreased the risk of intra-amniotic infection (1.7% vs 3.0%, p < .001; aRR: 0.58, 95% CI: [0.49-0.68]), blood transfusion (0.3% vs. 0.5%, p = .03; aRR: 0.66, 95% CI: [0.45-0.98]), and low 5-minute Apgar score (0.31% vs 0.47%, p = .031; aRR: 0.66, 95% CI: [0.44-0.97]). Conversely, IOL increased the risk of cesarean delivery (49.0% vs 27.6%, p < .001; aRR: 1.72, 95% CI: [1.68-1.77]). Furthermore, in the EM group, 919 pregnancies developed preeclampsia and 42 progressed to eclampsia. There were no differences in other perinatal outcomes.

CONCLUSION

In pregnancies complicated by one previous cesarean delivery, elective induction of labor at 39 weeks reduced the risk of intra-amniotic infection, blood transfusion, and low 5-minute Apgar score while increased the risk of repeat cesarean delivery.

Prenatal Fine Particulate Matter (PM2.5) Exposure and Pregnancy Outcomes-Analysis of Term Pregnancies in Poland

Air pollution is currently one of the greatest threats to global health. Polish cities are among the most heavily polluted in Europe. Due to air pollution 43,100 people die prematurely in Poland every year. However, these data do not take into account the health consequences of air pollution for unborn children. Thus, the aim of this study was to evaluate the effects of the fine particulate matter air pollution (less than 2.5 μm in diameter) on pregnancy outcomes. An analysis of pregnant women and their children was made using a questionnaire survey from a nationwide study conducted in 2017. Questionnaires from 1095 pregnant women and data from their medical records were collected. An analysis of air pollution in Poland was conducted using the air quality database maintained by the Chief Inspectorate for Environmental Protection in Poland. A higher concentration of PM_2.5 was associated with a decrease in birth weight and a higher risk of low birthweight (i.e., <2500 g). We also observed lower APGAR scores. Thus, all possible efforts to reduce air pollution are critically needed.

Risk factors for third stage placental complications among primigravid women

INTRODUCTION

Third stage placental complications (TSPC) including partially or complete retained placenta, are a common obstetric complication. Previous studies have underlined risk factors for TSPC in heterogenous populations of women, whereas data regarding primigravid term women are scarce. We aimed to identify the factors associated with TSPC in this subset of parturients.

METHODS

A retrospective cohort study including all primigravid women who delivered vaginally a term, live-singleton neonate between 2011 and 2019. Women who underwent revision of the uterine cavity due to TSPC were compared with those who did not. Univariate and multivariate regression analyses were performed in order to identify the risk factors for TSPC.

RESULTS

Overall, 16,867 deliveries met the study inclusion criteria. Of those, 1097 (6.5%) deliveries were complicated by TSPC. Women with TSPC were older (p < 0.001) and with a higher proportion of lateral and fundal placental location (p < 0.001). In a multivariate regression analysis, the following factors were positively independently associated with TSPC: maternal age (aOR [95% CI] 1.26 (1.17-1.36), p < 0.001), the use of assisted reproduction technologies (aOR [95% CI] 1.26 (1.06-1.49), p = 0.007), preeclampsia (aOR [95% CI] 3.39 (1.89-6.10), p < 0.001), thrombocytopenia (aOR [95% CI] 1.83 (1.34-2.48), p < 0.001), oxytocin administration (aOR [95% CI] 1.29 (1.12-1.48), p < 0.001) and longer second stage duration (aOR [95% CI] 1.03 (1.003-1.05), p = 0.02). Fetal male gender was negatively associated with TSPC (aOR [95% CI] 0.80 (0.70-0.92), p = 0.002).

DISCUSSION

We have identified multiple independent risk factors for TSPC among primigravid women. This information can aid in patient counseling and delivery management in these subset of parturients.