Gestational Hypertension and Preeclampsia: ACOG Practice Bulletin, Number 222

Pregnancy and the liver

Some of the physiological changes that occur in pregnancy manifest in the liver. These alterations might exacerbate or improve some pre-existent liver diseases, while many conditions remain unaffected. Some hepatic manifestations during pregnancy are secondary to disorders unique to pregnancy. Due to improved management of chronic conditions and assisted conception methods, pregnancies in people with cirrhosis or after liver transplantation are increasingly common. With pregnancy also becoming more common in older people and with the rising prevalence of comorbidities, such as obesity, diabetes, and metabolic syndrome, hypertensive disorders of pregnancy and gestational diabetes are increasing in prevalance. Thus, a broad range of specialists might encounter liver abnormalities in pregnancy, necessitating an understanding of how the liver changes during pregnancy and the importance of multi-disciplinary input to mitigate maternal-fetal risks. From a global health perspective, pregnancy also offers a unique opportunity to influence disease management and initiate interventions that might influence the life course of pregnant people and their families. In this Review, we describe the challenges of diagnosing, risk stratifying, and managing liver disease in pregnancy, and explore factors that might affect future maternal health.

A comprehensive review of the roles of T-cell immunity in preeclampsia

Preeclampsia (PE) is an obstetrical disorder that occurs after the 20th week of gestation. It is recognized as one of the "Great Obstetrical Syndromes" and principally contributes to maternal morbidity and mortality. PE has been associated with a range of immune disorders, including a preponderance of T helper (Th) 1 over Th2 cells and imbalanced levels of Th17 and T regulatory cells (Tregs). During pregnancy, T cells safeguard the placenta against immune rejection and aid embryo implantation while involved in pregnancy complications, such as PE. Promoting alloantigen-specific Treg cells is a potential preventive and therapeutic strategy for PE. However, ensuring the safety of mothers and infants is of the utmost importance since the risk-benefit ratio of reproductive and obstetric conditions differs significantly from that of immune diseases that pose a life-threatening risk. In this review, we systematically summarize the roles of T-cell immunity in the peripheral blood, reproductive tissues, and at the maternal-fetal interface of PE patients. Furthermore, the recent therapeutic approaches centered on targeting T cell immunity in PE are critically appraised.

Identification of genes involved in energy metabolism in preeclampsia and discovery of early biomarkers

Background

Preeclampsia is a complex pregnancy condition marked by hypertension and organ dysfunction, posing significant risks to maternal and fetal health. This study investigates the role of energy metabolism-associated genes in preeclampsia development and identifies potential early diagnostic biomarkers.

Methods

Preeclampsia datasets from Gene Expression Omnibus were analyzed for batch correction, normalization, and differential expression. Enrichment analyses using gene ontology, Kyoto Encyclopedia of Genes and Genomes, and gene set enrichment were performed. Protein-protein interaction networks were constructed to identify key genes, and regulatory networks involving transcription factors, miRNAs, and RNA-binding proteins were established. Differential expression was validated with receiver operating characteristic curve analyses, and immune infiltration was assessed.

Results

Six energy metabolism-related genes were identified. Enrichment analyses revealed their involvement in glycolysis, gluconeogenesis, lipid transport, bone remodeling, and glucagon secretion. Key differentially expressed genes included CRH(Corticotropin-Releasing Hormone), LEP(Leptin), PDK4(Pyruvate Dehydrogenase Kinase Isozyme 4), SPP1(Secreted Phosphoprotein 1), and SST(Somatostatin). PDK4 exhibited moderate accuracy in receiver operating characteristic analysis. Immune infiltration analysis indicated significant differences between preeclampsia and control samples. qRT-PCR confirmed LEP and CRH increased, while SPP1 expression in preeclampsia samples.

Conclusion

Dysregulated energy metabolism-related genes may contribute to preeclampsia through metabolic and immune changes. Identifying these genes aids in understanding preeclampsia's molecular basis and early diagnosis. Future studies should validate these markers in larger cohorts and explore targeted treatments.

Enhanced Recovery Canada Clinical Pathway for Cesarean Delivery

Enhanced recovery after surgery is a process to promote optimal recovery after a variety of operations utilized by many surgical specialties. This evidence-based series of interventions was developed to decrease the physiological stress and risks associated with surgery. In April of 2023, Enhanced Recovery Canada released its new Clinical Pathway for Cesarean Delivery. This has been endorsed by the Society of Obstetricians and Gynaecologists of Canada. This manuscript will introduce the Clinical Pathway, emphasize its unique features specific to cesarean delivery, and detail how to incorporate guidance into routine practice.

Racism and Postpartum Blood Pressure in a Multiethnic Prospective Cohort

BACKGROUND

Postpartum hypertension is a key factor in racial-ethnic inequities in maternal mortality. Emerging evidence suggests that experiences of racism, both structural and interpersonal, may contribute to disparities. We examined associations between gendered racial microaggressions (GRMs) during obstetric care with postpartum blood pressure (BP).

METHODS

We conducted a prospective postpartum cohort of 373 Asian, Black, and Hispanic people in New York City and Philadelphia. At delivery, we administered the GRM in obstetrics scale. We measured BP for 3 months using text-based monitoring. We estimated place-based structural racism with the Structural Racism Effect Index. We used mixed models to estimate associations between GRM and mean postpartum systolic BP and diastolic BP. We adjusted for race-ethnicity, education, body mass index, chronic hypertension (diagnosed at <20 weeks of gestation), age, and the Structural Racism Effect Index. We examined effect modification by hypertensive disorder of pregnancy and place-based structural racism.

RESULTS

A total of 4.6% of participants had chronic hypertension, 20.9% had pregnancy hypertension, and 13.4% had preeclampsia, comprising a hypertensive disorder of pregnancy subgroup (n=117). A total of 37.5% of participants experienced ≥1 GRM. Participants who experienced ≥1 GRM versus none had 1.88 mm Hg higher systolic BP from days 1 to 10 (95% CI, -0.19 to 3.95) and 2.19 mm Hg higher systolic BP from days 11 to 85 (95% CI, 0.17-4.22). Associations followed a similar pattern for diastolic BP and were stronger among the hypertensive disorder of pregnancy subgroup. Participants experiencing GRM and a high Structural Racism Effect Index had systolic BP 7.55 mm Hg (95% CI, 3.41-11.69) and diastolic BP 6.03 mm Hg (95% CI, 2.66-9.41) higher than those with neither.

CONCLUSIONS

Structural racism and interpersonal racism are associated with increased postpartum BP, potentially contributing to inequities in postpartum morbidity and mortality and lifecourse cardiovascular disease.

Preeclampsia and fetal growth restriction: does novel proteomics reveal immunological possible candidate biomarkers?

PURPOSE OF REVIEW

The aim of this review is to explore a possible link between immunological candidate proteins, identified through modern proteomic techniques, and preeclampsia (PE) and fetal growth restriction (FGR).

RECENT FINDINGS

Proteomics has become a promising tool in the search for disease pathways, drug targets, and biomarkers. PE and FGR are adverse pregnancy complications with supposed immunological involvement in their pathogenesis, but no circulating immunological biomarkers are currently established for diagnosis and risk stratification. Several proteomic studies have aimed to identify PE and FGR biomarkers - often with varying results across studies. However, proteomics has revealed altered expression of human leukocyte antigen-I in PE cases, which is supported in Genome-wide association study (GWAS) studies. Proteomic results support the heterogeneous nature of PE by identification of molecular subgroups - including subgroups characterized by immune-related proteins e.g. CXCL10. No specific immunological markers are found on FGR, but differences in overall plasma proteomic signature have been suggested.

SUMMARY

Proteomics certainly holds great potential. The immunological component in PE and FGR are still unclarified, but improvements in proteomic technologies may provide both definition of disease subgroups and subsequent discovery of biomarkers and targeted analysis within each subgroup.

Safety of labor, Valsalva maneuver, and neuraxial anesthesia for pregnant women after decompressive craniectomy: Case series and review of the literature

Decompressive craniectomies are a neurosurgical operation aimed at normalizing intracranial pressure (ICP). Occasionally, there is delayed replacement of the skull resulting in an acquired skull defect. When managing laboring patients with an acquired skull defect there is often fear associated with traditional labor involving the Valsalva maneuver and with neuraxial anesthesia. These fears typically stem from potential ICP changes and risk of herniation. In reviewing the literature, only 15 cases are described detailing labor management after decompressive craniectomy (DC), mostly with incomplete labor histories. We aim to expand that literature by reporting two cases of safe labor with epidural anesthesia in patients with large skull defects. The first described patient underwent a cranioplasty during pregnancy because of trauma. Later, because of concerns for pre-eclampsia, induction of labor was initiated and she received neuraxial anesthesia via epidural. The patient ultimately underwent cesarean delivery 48 h after induction began due to nonreassuring fetal heart tones. The second patient underwent a cranioplasty because of infection prior to pregnancy. Once in labor, she was cleared by neurosurgery and the anesthesia team placed her epidural. She later underwent an uncomplicated standard vaginal delivery. The existing literature on labor following DC is sparse. Retrospective review of case reports can advance discussion and standardization regarding care for laboring women with a history of DC. We advocate that the Valsalva maneuver and epidural anesthesia is safe for pregnant women who are neurologically asymptomatic.

Preterm preeclampsia as an independent risk factor for thromboembolism in a large national cohort

BACKGROUND

Preterm preeclampsia, a product of vascular dysfunction, is associated with prolonged hospital admission and proteinuria, significant risk factors for thromboembolism in pregnancy. The risk of thromboembolism in preterm preeclampsia warrants further investigation.

OBJECTIVE

To determine the relationship between preterm preeclampsia and thromboembolic risk. We hypothesize that preterm preeclampsia is an independent risk factor for thromboembolism in pregnancy.

STUDY DESIGN

This is a retrospective cohort study using the National Inpatient Sample database via Healthcare Cost and Utilization Project-Agency for Healthcare Cost and Utilization Project from 2017-2019. All subjects with an International Classification of Diseases, Tenth Revision code for pregnancy or peripartum encounter were included. Subjects were excluded if the gestational age at delivery was <20 weeks or if they had a history of thromboembolism, inherited thrombophilia, or antiphospholipid syndrome. Patients with preterm (delivered <37 weeks) preeclampsia and term (delivered ≥37 weeks) preeclampsia were compared with those without preeclampsia. The primary outcome was a composite of any thromboembolic event, including pulmonary embolism, deep vein thrombosis, cerebral thrombosis or transient ischemic attack, or other thromboses. The secondary outcomes were rates of each type of thromboembolic event. The groups were compared via variance analysis, chi-square, and logistic regression analyses. The logistic regression included those variables that differed between groups with P<.05.

RESULTS

Of individuals in the database, >2.2 million met the inclusion criteria. A total of 56,446 (2.7%) had preterm preeclampsia, and 86,152 (6.7%) had term preeclampsia. Those with preterm preeclampsia were more likely to be older, identify as non-Hispanic black, have obesity, have chronic hypertension among other chronic diseases, and be in the lowest quartile of income (P<.001). Among patients with preterm preeclampsia, 0.32% experienced thromboembolism, whereas those with term preeclampsia and without preeclampsia experienced thromboembolism at 0.10% and 0.09%, respectively. After controlling for confounders that differed between groups with P<.05, preterm preeclampsia remained independently associated with any thromboembolic event (adjusted odds ratio, 2.21 [95% confidence interval, 1.84-2.65]), and each type of thromboembolism. Term preeclampsia was not associated with an increased risk of thromboembolism (adjusted odds ratio, 1.18 [95% confidence interval, 0.94-1.48]).

CONCLUSION

Preterm preeclampsia is independently associated with an increased risk of thromboembolic events.

Clinical presentations, management, and outcomes of trauma in pregnancy: A retrospective observational study

BACKGROUND

Trauma poses significant risks during pregnancy, leading to adverse outcomes. We aimed to evaluate the impact of trauma during pregnancy on maternal and fetal outcomes.

MATERIAL AND METHODS

A retrospective observational study was performed involving all pregnant women presented to a national trauma center (2015- 2021). Univariate and multivariate analyses were done to assess the trauma-related variables and to identify predictors of adverse outcomes (birthweight <2.5 kg, premature delivery, and neonatal death).

RESULTS

A total of 566 pregnant women with trauma were included in the analysis. The patients mean age was 29.6 (SD 5.4) years, and motor vehicle collisions (MVCs) were the most frequent mechanism of injury (60.1 %). Approximately 41 % of the MVC victims (139/342) were wearing protective devices. Extremity injuries were the most common type of injury (25.7 %). The mean gestational age at the time of injury was 23.3 (9.4) weeks. Fetal distress, fetal death, and neonatal death occurred infrequently, ranging from 0.2 % to 4.6 %. Overall, 12.9 % of pregnancies resulted in adverse outcomes. In the multivariable model, hypertension (OR= 9.1, p = 0.001), diabetes mellitus (OR= 5.7, p = 0.006), placental abruption (OR = 23.4, p = 0.001), a history of previous C-section (OR = 3.4, p = 0.008) and gestational age at the time of injury (OR = 2.6, p = 0.001) were associated with an increased likelihood of adverse pregnancy outcomes.

CONCLUSION

This study revealed that trauma during pregnancy is associated with adverse pregnancy outcomes, therefore, these patients should be monitored carefully. Further research is needed to explore how trauma impacts pregnancy progression and fetal well-being, and public health interventions/awareness campaigns highlighting the importance of preventive measures should target pregnant women.

Evaluating the proteinuria/creatininuria ratio as a rapid prognostic tool for complications of preeclampsia: A comparison with 24-hour proteinuria

INTRODUCTION

This study aimed to evaluate the agreement between the proteinuria/creatinuria (P/C) ratio and the traditional 24-hour proteinuria measurement for proteinuria levels above 3 g/24h in pregnant patients with preeclampsia. Additionally, we assessed whether high levels of each measurement are predictive of adverse maternal and neonatal outcomes.

MATERIAL AND METHODS

We conducted a monocentric retrospective study of pregnant patients hospitalized for preeclampsia between January 1, 2019, and November 11, 2020. The primary outcome was a composite measure of adverse maternal outcomes associated with preeclampsia, and the secondary outcome focused on adverse neonatal outcomes. Agreement between high levels of 24-hour proteinuria and the P/C ratio was evaluated using Cohen's Kappa. Maternal and neonatal outcomes were compared across three groups: those with neither, one, or both high proteinuria levels (24-hour proteinuria ≥ 3 g/24h and/or P/C ratio ≥ 300 mg/mmol). Logistic regression, adjusted for confounders, analyzed associations between measures and outcomes, with ROC curves and AUC calculated for predictive models.

RESULTS

We found a strong correlation between 24-hour proteinuria and P/C ratio, with 95.1% agreement at the threshold of 3 g/24h and 300 mg/mmol, respectively (Kappa = 0.87, p < 0.01). Both measurements were associated with an increased risk of adverse maternal (aOR 6.78 [2.47-18.63]) and neonatal (aOR 7.00 [1.56-31.31]) outcomes.

DISCUSSION

This study demonstrated a strong agreement between the P/C ratio ≥ 300 mg/mmol and 24-hour proteinuria ≥ 3 g/24h, both associated with an increased risk of adverse perinatal outcomes, with the P/C ratio offering a quicker, simpler alternative for managing preeclampsia.

Expectant management of preeclampsia with severe features diagnosed at less than 24 weeks

BACKGROUND

The recent American College of Obstetricians and Gynecologists Practice Bulletin offers no guidance on the management of preeclampsia with severe features at <24 weeks of gestation. Historically, immediate delivery was recommended because of poor perinatal outcomes and high maternal morbidity. Recently, advances in neonatal resuscitation have led to increased survival at periviable gestational ages.

OBJECTIVE

This study aimed to report perinatal and maternal outcomes after expectant management of preeclampsia with severe features at <24 weeks of gestation.

STUDY DESIGN

This was a retrospective case series of preeclampsia with severe features at <24 weeks of gestation at a level 4 center between 2017 and 2023. Individuals requiring delivery within 24 hours of diagnosis were excluded. Perinatal and maternal outcomes were analyzed. Categorical variables from our database were compared with previously published data using chi-square tests.

RESULTS

A total of 41 individuals were diagnosed with preeclampsia with severe features at <24 weeks of gestation. After the exclusion of delivery within 24 hours, 30 individuals (73%) were evaluated. The median gestational age at diagnosis was 22 weeks (interquartile range, 22-23). Moreover, 16% of individuals had assisted reproductive technology, 27% of individuals had chronic hypertension, 13% of individuals had pregestational diabetes mellitus, 30% of individuals had previous preeclampsia, and 73% of individuals had a body mass index of >30 kg/m2. The median latency periods at 22 and 23 weeks of gestation were 7 days (interquartile range, 4-23) and 8 days (interquartile range, 4-13). In preeclampsia with severe features, neonatal survival rates were 44% (95% confidence interval, 3%-85%) at 22 weeks of gestation and 29% (95% confidence interval, 1%-56%) at 23 weeks of gestation. There were 2 cases of acute kidney injury (7%) and 2 cases of pericardial or pleural effusions (7%). Overall perinatal survival at <24 weeks of gestation was 30% in our current study vs 7% in previous reports (P=.02).

CONCLUSION

For cases of expectant management of preeclampsia with severe features at <24 weeks of gestation, our findings showed an increased perinatal survival rate with decreased maternal morbidity compared with previously published data. This information may be used when counseling on expectant management of preeclampsia with severe features at <24 weeks of gestation.

Platelet indices in preeclampsia: comparative analysis with normotensive pregnant women

BACKGROUND

To compare platelet count (PC), mean platelet volume (MPV), and platelet distribution width (PDW) between women with preeclampsia (PE) and normotensive pregnant women, and evaluate their effectiveness as predictors of PE.

RESEARCH DESIGN AND METHODS

This cross-sectional study at Nishtar Hospital, Multan, included 141 women: 74 normotensive and 67 preeclamptic. Data was collected using an automated hematology analyzer and analyzed with SPSS version 26 and ROC curves.

RESULTS

Mean age was 27.45 ± 5.18 years for cases and 28.41 ± 5.28 years for controls (p = 0.280). Gestational age was lower in the preeclamptic group (31.97 ± 4.07 weeks) compared to controls (33.92 ± 3.30 weeks) (p = 0.002). Blood pressures were higher in preeclamptic women (p < 0.001). Platelet count was lower in preeclamptic women (183.42 ± 95.69) vs. controls (256.42 ± 77.98) (p < 0.001). MPV (10.98 ± 1.55 vs. 9.79 ± 1.59, p < 0.001) and PDW (16.82 ± 5.70vs. 14.20 ± 2.40, p < 0.001) were higher in preeclamptic women. ROC analysis showed PDW had an AUC of 0.73 and MPV an AUC of 0.71.

CONCLUSIONS

PDW and MPV are significantly altered in preeclamptic women and can aid in early detection, potentially enhancing management.

Blood Pressure in Pregnancy and Hypertension 10-14 Years After Delivery

We examined the association between blood pressure (BP) in the early third trimester and hypertension 10-14 years after delivery per American College of Cardiology and American Heart Association recommendations. We conducted a secondary analysis using the prospective HAPO FUS (Hyperglycemia and Adverse Pregnancy Outcome Follow-up Study) in patients without a chronic hypertension diagnosis. The exposure and outcome were systolic and diastolic BP measured in the early third trimester and 10-14 years after delivery, respectively. Among 4,697 participants in the HAPO FUS, at 10-14 years after delivery (median age 41.6 years), 8.3% had elevated BP, 14.1% had stage 1 hypertension, and 6.1% had stage 2 hypertension. Compared with normal BP, elevated BP in the early third trimester was associated with an increased risk of stage 1 hypertension (adjusted odds ratio [aOR] 2.76; 95% CI, 1.91-4.00) and stage 2 hypertension (aOR 3.76; 95% CI, 2.28-6.19). Stage 1 hypertension was associated with an increased risk of stage 2 hypertension (aOR 6.16; 4.24, 8.94). Pregnant individuals with high BP in the third trimester were at increased risk of developing hypertension 10-14 years after delivery.

Multi-omics-based mapping of decidualization resistance in patients with a history of severe preeclampsia

Endometrial decidualization resistance (DR) is implicated in various gynecological and obstetric conditions. Here, using a multi-omic strategy, we unraveled the cellular and molecular characteristics of DR in patients who have suffered severe preeclampsia (sPE). Morphological analysis unveiled significant glandular anatomical abnormalities, confirmed histologically and quantified by the digitization of hematoxylin and eosin-stained tissue sections. Single-cell RNA sequencing (scRNA-seq) of endometrial samples from patients with sPE (n = 11) and controls (n = 12) revealed sPE-associated shifts in cell composition, manifesting as a stromal mosaic state characterized by proliferative stromal cells (MMP11 and SFRP4) alongside IGFBP1+ decidualized cells, with concurrent epithelial mosaicism and a dearth of epithelial-stromal transition associated with decidualization. Cell-cell communication network mapping underscored aberrant crosstalk among specific cell types, implicating crucial pathways such as endoglin, WNT and SPP1. Spatial transcriptomics in a replication cohort validated DR-associated features. Laser capture microdissection/mass spectrometry in a second replication cohort corroborated several scRNA-seq findings, notably the absence of stromal to epithelial transition at a pathway level, indicating a disrupted response to steroid hormones, particularly estrogens. These insights shed light on potential molecular mechanisms underpinning DR pathogenesis in the context of sPE.

Mechanisms of Homoarginine: Looking Beyond Clinical Outcomes

PURPOSE

Homoarginine (hArg) is an arginine metabolite that has been known for years, but its physiological role in the body remains poorly understood. For instance, it is well known that high hArg concentrations in the blood are protective against several disease states, yet the mechanisms behind these health benefits are unclear. This review compiles what is known about hArg, namely its synthetic pathways, its role in different diseases and conditions, and its proposed mechanisms of action in humans and experimental animals.

FINDINGS

Previous work has identified multiple pathways that control hArg synthesis and degradation in the body. Furthermore, endogenous hArg can modulate the cardiovascular system, with decreased hArg being associated with cardiovascular complications and increased mortality. Studies also suggest that hArg could serve as a diagnostic biomarker for a variety of immune, pancreatic, renal, and hepatic dysfunctions. Finally, in women, hArg concentrations rapidly increase throughout pregnancy and there are suggestions that alterations in hArg could indicate pregnancy complications like pre-eclampsia.

SUMMARY

Homoarginine is an under-appreciated amino acid with potential wide-ranging roles in systemic health, pregnancy, and pathophysiology. Although recent research has focused on its health or disease associations, there is a need for more investigations into understanding the mechanistic pathways by which hArg may operate. This could be aided using metabolomics, which provides a comprehensive approach to correlating multiple metabolites and metabolic pathways with physiological effects. Increasing our knowledge of hArg's roles in the body could pave the way for its routine use as both a diagnostic and therapeutic molecule.

Platelet aggregation and thromboelastometry monitoring in women with preeclampsia: a prospective observational study

BACKGROUND

Thrombocytopenia affects 12-20% of women with preeclampsia and a low platelet count impairs coagulation. Women with preeclampsia have an increased risk of both cerebral hemorrhage, thromboembolism, and postpartum hemorrhage. Studies of platelet function and coagulation in women with preeclampsia show conflicting results. Therefore, we aimed to study platelet aggregation and coagulation in women with preeclampsia.

METHOD

Women with preeclampsia and women with normotensive pregnancies were included prior to delivery in a prospective observational study as a part of the Gothenburg Preeclampsia Adverse Event (GoPROVE) Biobank and Database. Sampling and analyses were performed shortly before delivery. Platelet count was analyzed and impedance aggregometry was used for examining platelet adhesion and aggregation. Thromboelastometry was used to assess coagulation.

RESULTS

Ninety-three women with preeclampsia and 45 normotensive pregnant control patients were included. There was no difference in platelet aggregation (adenosine diphosphate, ADP-test), (arachidonic acid, ASPI-test) or (thrombin receptor-activating peptide, TRAP-test) between women with preeclampsia and women with normotensive pregnancies. Women with preeclampsia had lower platelet counts, shorter clotting (EXTEM-CT and INTEM-CT) and clot formation (EXTEM-CFT and INTEM-CFT) times than women with normotensive pregnancies. Platelet aggregation and coagulation were hyperactivated in women with preeclampsia and normal platelet counts. In women with preeclampsia and thrombocytopenia, platelet aggregation and thromboelastic tests of coagulation were impaired compared with normotensive pregnancies.

CONCLUSION

Platelet aggregation and thromboelastic tests of coagulation are dependent on platelet counts in women with preeclampsia. At normal platelet counts, women with preeclampsia have hyperactivated tests of coagulation. In contrast, women with thrombocytopenia demonstrated lower coagulation test values.

Blood pressure cutoffs at 11-13 weeks of gestation and risk of preeclampsia

BACKGROUND

A parallel has been drawn between first-trimester placental vascular maturation and maternal cardiovascular adaptations, including blood pressure. Although 140/90 mm Hg is well-accepted as the threshold for chronic hypertension in the general obstetric population in early pregnancy, a different threshold could apply to stratify the risk of adverse outcomes, such as preeclampsia. This could have implications for interventions, such as the threshold for initiation of antihypertensive therapy and the target blood pressure level.

OBJECTIVE

We evaluated the relationship between various blood pressure cutoffs at 11-13 weeks of gestation and the development of preeclampsia, overall and according to key maternal characteristics.

STUDY DESIGN

This secondary analysis was of data from a prospective nonintervention cohort study of singleton pregnancies delivering at ≥24 weeks, without major anomalies, at 2 United Kingdom maternity hospitals, 2006-2020. Blood pressure at 11-13 weeks of gestation was classified according to American College of Cardiology/American Heart Association categories (mm Hg) as (1) normal blood pressure (systolic <120 and diastolic <80), (2) elevated blood pressure (systolic ≥120 and diastolic <80), stage 1 hypertension (systolic ≥130 or diastolic 80-89), and stage 2 hypertension (systolic ≥140 or diastolic ≥90). For blood pressure category thresholds and the outcome of preeclampsia, the following were calculated overall and across maternal age, body mass index, ethnicity, method of conception, and previous pregnancy history: detection rate, screen-positive rate, and positive and negative likelihood ratios, with 95% confidence intervals. A P value of <.05 was considered significant.

RESULTS

There were 137,458 pregnancies screened at 11-13 weeks of gestation. The population was ethnically diverse, with 15.9% of Black ethnicity, 6.7% of South or East Asian ethnicity, and 2.7% of mixed ethnicity, with the remainder of White ethnicity. Compared with normal blood pressure, stage 2 hypertension was associated with both preterm preeclampsia (0.3% to 4.9%) and term preeclampsia (1.0% to 8.3%). A blood pressure threshold of 140/90 mm Hg was good at identifying women at increased risk of preeclampsia overall (positive likelihood ratio, 5.61 [95% confidence interval, 5.14-6.11]) and across maternal characteristics, compared with elevated blood pressure (positive likelihood ratio, 1.70 [95% confidence interval, 1.63-1.77]) and stage 1 hypertension (positive likelihood ratio, 2.68 [95% confidence interval, 2.58-2.77]). There were 2 exceptions: a blood pressure threshold of 130/80 mm Hg was better for the 2.1% of women with body mass index <18.5 kg/m2 (positive likelihood ratio, 5.13 [95% confidence interval, 3.22-8.16]), and a threshold of 135/85 mm Hg better for the 50.4% of parous women without a history of preeclampsia (positive likelihood ratio, 5.24, [95% confidence interval, 4.77-5.77]). There was no blood pressure threshold below which reassurance could be provided against the development of preeclampsia (all-negative likelihood ratios ≥0.20).

CONCLUSION

The traditional blood pressure threshold of 140/90 mm Hg performs well to identify women at increased risk of preeclampsia. Women who are underweight or parous with no prior history of preeclampsia may be better identified by lower thresholds; however, a randomized trial would be necessary to determine any benefits of such an approach if antihypertensive therapy were also administered at this threshold. No blood pressure threshold is reassured against the development of preeclampsia, regardless of maternal characteristics.

Pharmacological treatment of pregnancy complications in adults: An overview of phase IV clinical trials

The aim of this review was to provide a review of the pharmacological treatments for pregnancy complications in adults. This review analyzed medications used for pregnancy complications in phase IV clinical trials based on the ClinicalTrials.gov database. The search included completed trials only. As of September 1, 2023, a total of 29,654 phase IV clinical trials were identified, of which 298 were related to pregnancy complications. Of these, 24 clinical trials met the inclusion criteria for the current study. In the 24 included clinical trials, we found 9 trials for overactive bladder with 5005 participants in total, 236 of which had adverse effects from the drugs used. Six trials for preeclampsia were conducted on 663 participants, with only 1 adverse drug effect reported. Three trials each were conducted on urinary tract infections and gestational diabetes mellitus (115 and 656 participants, respectively) without any adverse drug effects reported. One trial each focused on anemia, dystocia, and placentation disorders (80, 1003, and 14 participants, respectively) without any adverse drug effects reported. The trials reported minimal adverse drug effects, suggesting potential effectiveness and safety in managing these complications. While the trials mentioned minimal adverse effects, close monitoring and individualized patient care are essential, as are evaluating the risk-benefit ratio and the specific circumstances of each patient.

Vascular health and exercise in females throughout the lifespan: Exploring puberty, pregnancy and menopause

This narrative review highlights the impact of exercise on vascular health in females over the lifespan with an emphasis on puberty, pregnancy and menopause. These events encompass substantial changes in sex hormone levels, particularly oestrogens and progesterone. They are also accompanied by distinct adaptations of the central, peripheral and cerebral vasculature. Regular exercise is an effective mechanism to reduce vascular risk in females of all ages, especially for those at higher risk for vascular disorders. However, there are large variabilities in the vascular adaptations to exercise in females that may be related to circulating sex hormone levels. In addition, exogenous hormones, such as oral contraceptives taken after puberty or hormonal replacement therapy taken to mitigate symptoms of menopause, may interact with exercise-induced changes in vascular function. We highlight how more research is needed to understand the optimal exercise interventions to promote vascular health in females across the lifespan, especially during times of hormonal transition.

The early COVID-19 pandemic period and associated gestational weight gain

OBJECTIVES

The aim of this study was to investigate if gestational weight gain was altered during the early COVID-19 pandemic period.

METHODS

This a retrospective cohort study evaluating gestational weight gain among individuals delivering during the early COVID-19 pandemic epoch (March 10-December 31, 2020) compared to temporally matched pre-pandemic (matched months in 2018 and 2019) controls using electronic medical record data from a large tertiary care hospital. The primary outcome was gestational weight gain defined as a categorical measure representing below, meeting, or above Institute of Medicine (IOM) criteria with further adjustment for gestational age at delivery. The early-pandemic exposure group was also categorized by gestational age at the start period (<14 weeks' and 14-20 weeks') to assess if duration of exposure affected gestational weight gain risks with the use of multinominal logistic regression.

RESULTS

Among 5,377 individuals 3,619 (67.3 %) and 1,758 (32.7 %) were in the pre and early pandemic epochs respectively. Overall, 934 (17.4 %) individuals gained below recommended, 1,280 (23.8 %) met recommendations, and 3,163 (58.8 %) gained above IOM recommended gestational weight gain. Compared to the pre-pandemic epoch, the early pandemic period was not associated with weight gain below (OR 1.06, 95 % Cl 0.89-1.27) or above (OR 1.03, 95 % Cl 0.89-1.19) IOM recommendations. This was also true when the early pandemic group was stratified based on gestational age at the start of the early pandemic period (<14 weeks' and 14-20 weeks').

CONCLUSIONS

This study demonstrated no significant difference in maternal weight gain between pre and early COVID-19 pandemic periods.

Evaluation of placental growth factor, Vitamin D, and systemic inflammatory index as predictive biomarkers for preeclampsia severity: a retrospective cohort study

AIM

Our study aimed to evaluate the predictive value of Placental growth factor (PlGF), Vitamin D, and systemic inflammatory index for assessing preeclampsia risk and severity.

MATERIALS AND METHODS

This retrospective cohort study included 457 pregnant individuals who delivered at our hospital between March 2023 and October 2024. Participants were divided into three groups: control (n = 217), mild preeclampsia (n = 101), and severe preeclampsia (n = 67). A separate validation cohort (n = 72) was used to test model performance. Data on demographic, clinical, and laboratory characteristics, including PlGF, Vitamin D, neutrophil, lymphocyte, and monocyte counts, were collected between 16 and 20 weeks of gestation. Logistic regression analysis was performed to identify independent risk factors, and receiver operating characteristic (ROC) curve analysis was used to assess the predictive power of PlGF, Vitamin D, lymphocyte count, and Pan-immune-inflammation value (PIV). The regression models adjusted for potential confounders, including maternal age, body mass index (BMI), and parity.

RESULTS

In the training cohort, significant differences were observed among control, mild, and severe preeclampsia groups, with severe cases showing elevated PIV (515.8 ± 126.7) and reduced levels of PlGF (12.5 ± 5.8 pg/mL) and Vitamin D (8.4 ± 1.9 ng/mL) compared to controls (P < 0.001). Logistic regression identified lower levels of PlGF (P < 0.001) and Vitamin D (P < 0.001) as significant independent risk factors for severe preeclampsia. PIV was also a strong predictor, showing a high hazard ratio (P < 0.001). In the training and validation cohorts, ROC analysis showed AUC values of 0.774 and 0.751 for PlGF, 0.805 and 0.796 for Vitamin D, 0.688 and 0.675 for Lymphocyte, and 0.724 and 0.752 for PIV, respectively, indicating strong predictive value for PlGF, Vitamin D, and PIV in assessing preeclampsia risk.

CONCLUSION

Lower levels of PlGF and Vitamin D, along with higher PIV, were independently associated with an increased risk of severe preeclampsia. These findings suggest that PlGF, Vitamin D, and PIV are valuable biomarkers for early identification of high-risk preeclampsia patients, potentially aiding in timely intervention and improved outcomes.

Placental mitochondrial metabolic adaptation maintains cellular energy balance in pregnancy complicated by gestational hypoxia

The mechanisms that drive placental dysfunction in pregnancies complicated by hypoxia and fetal growth restriction remain poorly understood. Changes to mitochondrial respiration contribute to cellular dysfunction in conditions of hypoxia and have been implicated in the pathoaetiology of pregnancy complications, such as pre-eclampsia. We used bespoke isobaric hypoxic chambers and a combination of functional, molecular and imaging techniques to study cellular metabolism and mitochondrial dynamics in sheep undergoing hypoxic pregnancy. We show that hypoxic pregnancy in sheep triggers a shift in capacity away from β-oxidation and complex I-mediated respiration, while maintaining total oxidative phosphorylation capacity. There are also complex-specific changes to electron transport chain composition and a switch in mitochondrial dynamics towards fission. Hypoxic placentas show increased activation of the non-canonical mitochondrial unfolded protein response pathway and enhanced insulin like growth factor 2 signalling. Combined, therefore, the data show that the hypoxic placenta undergoes significant metabolic and morphological adaptations to maintain cellular energy balance. Chronic hypoxia during pregnancy in sheep activated placental mitochondrial stress pathways, leading to alterations in mitochondrial respiration, mitochondrial energy metabolism and mitochondrial dynamics, as seen in the placenta of women with pre-eclampsia. KEY POINTS: Hypoxia shifts mitochondrial respiration away from β-oxidation and complex I. Complex-specific changes occur in the electron transport chain composition. Activation of the non-canonical mitochondrial unfolded protein response pathway is heightened in hypoxic placentas. Enhanced insulin like growth factor 2 signalling is observed in hypoxic placentas. Hypoxic placentas undergo significant functional adaptations for energy balance.

Impact of blastocyst biopsy for preimplantation genetic testing on maternal and neonatal outcomes following single frozen embryo transfer cycles

BACKGROUND

Up to now, a number of studies have explored the influence of blastocyst biopsy on maternal and neonatal outcomes, and the results have been somewhat inconsistent. Therefore, the aim of this study was to investigate whether blastocyst biopsy is associated with an elevated risk of hypertensive disorders of pregnancy (HDP) and other adverse perinatal outcomes during frozen embryo transfer (FET) cycles in singleton live births resulting from intracytoplasmic sperm injection (ICSI) in women aged ≤ 35 years.

METHODS

A total of 1,008 women were involved in this study from January 2020 to June 2022, who underwent ICSI cycles and received single FET, leading to the birth of a live singleton newborn. The study population were categorized into two groups: the preimplantation genetic testing (PGT) group, comprising 269 women whose blastocysts underwent trophectoderm biopsy, and the control group, consisting of 739 women whose blastocysts did not undergo biopsy. The primary outcome assessed in this study was HDP. Additionally, various relevant perinatal outcomes related to both maternal and neonatal health were also evaluated.

RESULTS

In comparison to the control group, notable disparities were observed between the groups in relation to infertility duration, EMT, infertility type, infertility cause and endometrial preparation protocol (P < 0.05, for all). The percentage of female gender significantly increased in the PGT group in comparison with the control group (P < 0.05). However, the risk of HDP, other maternal and neonatal outcomes exhibited comparable results between the two groups (P > 0.05, for all). Moreover, univariate regression analyses further revealed that PGT had no influence on maternal and neonatal outcomes, except for gender (aOR 1.44; 95% CI, 1.03-2.01; P = 0.031).

CONCLUSIONS

In the short-term perspective, it could be inferred that blastocyst biopsy may not increase the risks associated with HDP or other unfavorable maternal and neonatal outcomes. However, despite the limited sample size, our findings may not be applicable to those aged 35 or over; therefore, larger cohort studies are imperative for the validation of our results.

Traditional and Non-Traditional Risk Factors of Acute Coronary Syndrome in Young Women: Evidence from the ANCORS-YW Study

Purpose

Young women are at risk of acute coronary syndrome (ACS). They represent a unique population exposed to traditional cardiovascular risk factors and female sex-specific, non-traditional risk factors. The current study aimed to describe traditional and non-traditional risk factors of ACS in young women from the Middle East.

Patients and Methods

The present study used data from the Jordanian, nationwide, multicenter, case-control study, ANCORS-YW. Bivariate analyses and logistic regression models were used to predict independent risk factors of ACS using adjusted odds ratios (AOR) and 95% confidence intervals (CI).

Results

The study included 572 young women (≤50-years) with a median age of 45-years, divided into an ACS group (n=154, 26.9%) and a control group with no atherosclerotic cardiovascular disease (n=418, 73.1%). The most common presentation of ACS was non-ST-elevation ACS (n=98, 64%). The ACS group, compared to control group, had higher proportions of type-2 diabetes (41.6%vs.11.7%, p<0.001), hypertension (53.9%vs.23.4%, p<0.001), tobacco use (37.7%vs.24.2%, p=0.001), family history of cardiovascular disease (53.2%vs.23.4%, p<0.001), metabolic syndrome (14.3%vs.2.4%, p<0.001), and preterm delivery (24.7%vs.16.7%, p=0.032). ACS group had nonsignificantly greater proportions of hypertensive disorders of pregnancy (29.2%vs.22.7%, p=0.109) and gestational diabetes (15.6%vs.10.3%, p=0.081). Multivariable logistic regression analyses identified five independent predictors of ACS: type-2 diabetes (AOR, 95% CI: 3.45, 1.98─5.99), family history of cardiovascular disease (3.33, 2.15─5.17), tobacco use (2.01, 1.26─3.21), hypertension (1.72, 1.07─2.78), and metabolic syndrome (4.35, 1.72─11.03).

Conclusion

Modifiable risk factors play an important role in ACS risk among young women. Efforts should be made to improve primordial and primary prevention in this population.

Association of epidural labor analgesia with maternal and neonatal outcomes in women with preeclampsia: a propensity score-matched single-center retrospective cohort study

BACKGROUND

Epidural labor analgesia (ELA) is widely and safely used for labor pain relief. However, it remains unclear whether ELA affects maternal and neonatal outcomes in women suffering from preeclampsia.

METHODS

This study reviewed the medical records of women with preeclampsia at ≥ 28 weeks of gestation between January 2015 and December 2020. The medical records of women were divided into ELA and no analgesia (NA) groups. The primary endpoint was the cesarean section (CS) rate. Secondary endpoints included hypotension, operative vaginal delivery, fetal distress, neonatal intensive care unit admission, and complications. Using multivariate logistic regression analysis and propensity score matching (PSM), the association between ELA and maternal and neonatal outcomes was examined.

RESULTS

A total of medical records of 686 women were enrolled, with 242 (35.3%) receiving ELA. Of these, 126 (18.4%) had a higher incidence of CS in the ELA group than in the NA group (22.7% vs. 16.0%, P = 0.020). Multivariable analysis indicated greater risks of CS [adjusted Odds Ratio (aOR) = 1.71; 95% CI, 1.07-2.74; P = 0.025] and operative vaginal delivery (aOR = 2.810; 95% CI, 1.379-5.725; P = 0.004) in the ELA group than that of NA group. In the PSM, ELA did not increase the risk of CS (aOR = 1.56; 95% CI, 0.97-2.52; P = 0.067) and OVD (aOR = 2.048; 95% CI, 0.936-4.484; P = 0.073). The secondary endpoints showed no significant differences between the two groups.

CONCLUSION

The study indicates an association between ELA and maternal and neonatal outcomes, supporting the safety of ELA in this population.

Effects of pregnancy-induced hypertension on early-onset neonatal thrombocytopenia

BACKGROUND

Gestational hypertension and preeclampsia are potentially linked to similar pathophysiological processes. Maternal preeclampsia increases the occurrence of early-onset neonatal thrombocytopenia. We hypothesized that maternal gestational hypertension may impact the incident early-onset neonatal thrombocytopenia.

METHODS

We included 538 neonates, comprising 318 and 220 neonates born to healthy mothers and those with pregnancy-induced hypertension. The minimum platelet count within 72 h of birth was recorded for these neonates. The incidence of early-onset thrombocytopenia in neonates in relation to maternal gestational hypertension, preeclampsia, and health status was evaluated. Logistic regression analysis was conducted to assess the relationship between maternal gestational hypertension and the risk of early-onset neonatal thrombocytopenia.

RESULTS

The incidence of early-onset thrombocytopenia was significantly higher in neonates born to mothers with preeclampsia than in those born to mothers with gestational hypertension or healthy mothers. Significant differences were observed among the three groups (30.0% vs. 13.3% vs. 7.9%, p < 0.001). Maternal gestational hypertension (OR = 2.79, 95%CI 1.19-6.54) increased the risk of early-onset neonatal thrombocytopenia when compared to healthy mothers.

CONCLUSIONS

Maternal gestational hypertension increases the occurrence of early-onset neonatal thrombocytopenia. Therefore, we recommend conducting platelet count screening at the early stages of neonates of mothers with gestational hypertension.

Comparison of serum ischemia modified albumin levels between preeclamptic and healthy pregnant women

Objective

Our aims to compare level of serum ischemia modified albümin(IMA) between healthy and preeclamptic pregnancies and to evaluate the relationship of IMA with preeclampsia, preeclampsia severity and perinatal outcomes.

Methods

Our study is a prospective case-control study. A total of 134 pregnant women (66 preeclamptic and 68 healthy pregnant) between 18-45 years of age and between 24- 41 gestational weeks participated. Serum IMA levels were measured by the Albumin Cobalt Binding (ACB) test.

Results

The mean IMA values were found to be significantly higher in the preeclampsia group compared to the control group (p<0,001). Patients were divided into 3 groups; severe preeclampsia(n=29), non-severe preeclampsia(n=37) and healthy pregnant(n=68). Statistically significant difference was not found between severe preeclampsia and non-severe preeclampsia (p=0.505). The performance of IMA values in predicting the development of preeclampsia among all participants was evaluated with Receiver Operating Characteristic (ROC) analysis. According to the ROC analysis, the best cut-off value at which the maximum area under the curve (AUC) was obtained was found when IMA>0.98(AUC: 0.690 95% Confidence Interval (CI): 0.600-0.781 p<0.001). When IMA threshold value of >0.98 was taken to predict preeclampsia; the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated as 65.15%, 64.71%, 64.18%, and 65.67%, respectively.

Conclusion

IMA level may be a useful new marker in recognizing and predicting preeclampsia. However, despite the power of recognizing the disease, serum IMA levels do not give an idea about the severity of the disease. More comprehensive studies are needed in order to use IMA levels in the diagnosis of preeclampsia.

The role of 1-Deoxysphingolipids and Polyamines in the pathogenesis of placental syndrome

BACKGROUND

Placental syndrome, mainly composed of preeclampsia and fetal growth restriction, has an impact on the health of mother and baby dyads. While impaired placentation is central to their pathophysiology, the underlying molecular mechanisms remain incompletely understood. This study investigates the association between placental syndrome and metabolic alterations in 1-deoxysphingolipids (1-deoxySLs) and polyamines, along with their regulatory enzymes.

METHODS

This prospective case-control study involved 26 healthy pregnant women and 17 with placental syndrome. Blood samples were collected from maternal, uterine venous, and umbilical cord veins. Levels of 1-deoxySL, spermine, and spermidine, as well as related enzymes of polyamine metabolism such as ornithine decarboxylase (ODC), spermidine/spermine N1-acetyltransferase (SSAT), polyamine oxidase (PAO), and spermine oxidase (SMO), were measured using the techniques of LC-MS and ELISA, respectively.

RESULTS

Women with placental syndrome had significantly higher levels of 1-deoxySL, spermine, and spermidine in all blood samples compared to the healthy pregnancy group. Additionally, ODC and SSAT levels were reduced significantly in the placental syndrome group, while PAO and SMO levels showed no significant differences. Strong positive correlations were found between the studied enzymes and biomolecules in healthy pregnancies, which were notably weaker in the placental syndrome group.

CONCLUSION

This study demonstrates significantly altered levels of 1-deoxySL and polyamines, with corresponding enzyme activity changes, in placental syndrome compared to healthy pregnancies. The disrupted correlations between these biomolecules suggest alterations in their metabolic pathways and potential utility as biomarkers. Further mechanistic studies are warranted to elucidate their role in placental syndrome pathophysiology.

Maternal lipids in overweight and obesity: implications for pregnancy outcomes and offspring's body composition

Overweight and obesity (OWO) are linked to dyslipidemia and low-grade chronic inflammation, which is fueled by lipotoxicity and oxidative stress. In the context of pregnancy, maternal OWO has long been known to negatively impact on pregnancy outcomes and maternal health, as well as to imprint a higher risk for diseases in offspring later in life. Emerging research suggests that individual lipid metabolites, which collectively form the lipidome, may play a causal role in the pathogenesis of OWO-related diseases. This can be applied to the onset of pregnancy complications such as gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDP), which in fact occur more frequently in women affected by OWO. In this review, we summarize current knowledge on maternal lipid metabolites in pregnancy and highlight associations between the maternal lipidome and the risk to develop GDM, HDP and childhood OWO. Emerging data underpin that dysregulations in maternal triglyceride, phospholipid and polyunsaturated fatty acid (PUFA) metabolism may play a role in modulating the risk for adverse pregnancy outcomes and childhood OWO, but it is yet premature to convert currently available insights into clinical guidelines. Well-designed large-scale lipidomic studies, combined with translational approaches including animal models of obesity, will likely facilitate the recognition of underling pathways of OWO-related pregnancy complications and child's health outcomes, based on which clinical guidelines and recommendations can be updated.

tiRNA-Gln-CTG is Involved in the Regulation of Trophoblast Cell Function in Pre-eclampsia and Serves as a Potent Biomarker

BACKGROUND

Pre-eclampsia (PE) is a gestational disorder that significantly endangers maternal and fetal health. Transfer ribonucleic acid (tRNA)-derived small RNAs (tsRNAs) are important in the progression and diagnosis of various diseases. However, their role in the development of PE is unclear. Consequently, we detected the expression profiles of tsRNAs in the plasma of patients with PE as well as those in the plasma of the healthy control group, and a multiplicity of experiments were conducted with the aim of clarifying their roles in the occurrence and development of PE and the feasibility of serving as predictive biomarkers for this disorder.

METHODS

High-throughput sequencing of tsRNA in plasma from PE cases was performed to evaluate its potential as a diagnostic or therapeutic biomarker. The function of tsRNA in trophoblasts was explored using the HTR-8/SVneo cell line. Plasma from pregnant women with suspected PE was analyzed to assess the potential of tsRNA to act as a predictive marker of PE.

RESULTS

High-throughput sequencing of tsRNA was performed on plasma from pregnant women with PE and from healthy pregnant controls. Analysis revealed a significant reduction in the level of tRNA-derived stress-inducing RNA (tiRNA)-Gln-CTG in the plasma (p < 0.001) and placenta (p < 0.001) of pregnant women with PE, suggesting its potential involvement in the development of this condition. tiRNA-Gln-CTG was identified in the cytoplasm and nucleus of HTR-8/SVneo cells. In vitro experiments revealed that tiRNA-Gln-CTG influences the proliferation, cycling, migration, and invasion of HTR-8/SVneo cells, possibly by targeting the 3'UTR region of thrombospondin-2 messenger ribonucleic acid (mRNA) for degradation. Extracellular vesicle (EV) carriers may mediate the level of tiRNA-Gln-CTG in the circulation. Y-box binding protein-1 (YBX1) may be involved in loading tiRNA-Gln-CTG into EVs. The sensitivity of low tiRNA-Gln-CTG levels for predicting the onset of PE in suspected cases was 91.7% within 1 week of delivery, 85.7% within 4 weeks of delivery, and 89.3% before delivery, with corresponding specificities of 84.5%, 79.2%, and 73.4%, respectively.

CONCLUSIONS

tiRNA-Gln-CTG significantly influences trophoblast function and is associated with the development of PE. It can serve as an effective biomarker for predicting PE progression within one week of delivery in women with suspected PE.

Pregnancy Complications and Long-Term Atherosclerotic Cardiovascular Disease Risk

PURPOSE OF REVIEW

Discuss the relationship between pregnancy complications and long-term atherosclerotic cardiovascular disease (ASCVD) risk.

RECENT FINDINGS

A large body of research confirms an association between pregnancy complications and increased short and long-term ASCVD risk and seeks to understand mechanisms for these associations. Social determinants of health continue to have a critical impact on the prevalence of adverse pregnancy outcomes (APOs) and long term ASCVD risk. Of the APOs, hypertensive disorders of pregnancy (HDP) are associated with the highest ASCVD risk. Additionally, recent research shows an association between APOs and microvascular coronary heart disease. APOs are associated with increased risk of ASCVD, however there is conflicting evidence on whether there is a causal relationship between APOs and ASCVD or if APOs are simply a marker of ASCVD risk. Current ASCVD risk models do not incorporate a history of APOs, therefore it is imperative that healthcare providers take a reproductive health history and account for pregnancy complications when counseling patients on long-term cardiovascular risk. Non-invasive modalities such as coronary artery calcium scoring can be considered as an adjunct, but further research is warranted to determine which patients would benefit most.

The Impact of Gestational Diabetes Mellitus on the Development of Preeclampsia in Twin Pregnancies: A Retrospective Cohort Study Conducted at a Tertiary Hospital

Purpose

This study aimed to examine the effects of gestational diabetes mellitus (GDM) on the risk of pregnancy complications in twin pregnancies and to investigate the relationship between glycemic levels and the risk of preeclampsia (PE) and abnormal fetal growth.

Patients and Methods

A retrospective cohort study of 736 twin pregnancies was conducted at a tertiary hospital. Propensity score matching and multivariable logistic models were utilized to compare maternal and neonatal outcomes between twin pregnancies with GDM and those without GDM. Multivariable logistic regressions were performed to address the intertwin correlation between glycemic levels and the primary outcomes.

Results

There was no significant difference in the risk of PE between non-GDM and GDM pregnancies (OR, 0.70; 95% CI: 0.38-1.27; P = 0.238). No statistically significant differences were observed in the prevalence of small for gestational age and large for gestational age between the study groups. A comparative analysis of twin pregnancies affected by PE and GDM versus those without GDM revealed that the former group exhibited similar maternal and neonatal outcome risks. Women with fasting blood glucose levels from 5.1 mmol/L (92mg/dL) to less than 5.3 mmol/L (95.6mg/dL) had a significantly higher risk of PE compared with women without GDM (OR, 2.90; 95% CI: 1.12-7.51; P = 0.028). In subgroups of glycosylated hemoglobin (HbA1c), HbA1c ≥ 5.5% had the highest risk of PE in the second and third trimesters compared with women without GDM (OR, 4.90; 95% CI: 1.00-24.12; P = 0.05).

Conclusion

The risk of PE was not increased in twin pregnancies complicated with GDM, but significantly increased in women with an HbA1c ≥5.5%. No significant associations were observed between the co-occurrence of GDM and PE and the incidence of pregnancy complications in twin pregnancies. Strict glycemic control may decrease the risk of PE in twin pregnancies with GDM.

Evaluation of Conventional and Combined Doppler Parameters in Preeclampsia: Diagnostic and Prognostic Insights

Background: The aim of this study was to examine the relationship between conventional and novel Doppler parameters, including cerebroplacental ratio (CPR), cerebral-placental-uterine ratio (CPUR), umbilical-to-cerebral ratio (UCR), and amniotic-to-umbilical-cerebral ratio (AUCR), with the diagnosis of preeclampsia (PE) and adverse neonatal outcomes in PE cases. Methods: This prospective case-control study was conducted at the Ankara Etlik City Hospital Perinatology Clinic between November 2023 and May 2024. The study population was divided into two groups: Group 1, consisting of 74 patients diagnosed with preeclampsia, and Group 2, consisting of 80 healthy control patients. Composite adverse perinatal outcomes (CANOs) include presence of at least one adverse outcome: 5th-minute APGAR score < 7, transient tachypnea of the newborn (TTN), respiratory distress syndrome (RDS), need for continuous positive airway pressure (CPAP), need for mechanical ventilation, neonatal intensive care unit (NICU) admission, neonatal hypoglycemia, need for phototherapy, intraventricular hemorrhage (IVH), and neonatal sepsis. Results: The CPR, CPUR, and AUCR were significantly lower in the PE group compared to the control group, while the UCR was notably higher in the PE group. Among the combined ratios, the CPUR exhibited the highest diagnostic performance for both PE diagnosis and the prediction of CANOs. Additionally, while the UCR, CPR, and AUCR were significant for PE diagnosis, only AUCR demonstrated a significant association with the prediction of CANOs. Conclusions: Combined Doppler parameters, especially CPUR and AUCR, offer valuable insights into diagnosing PE and predicting CANOs. CPUR demonstrated the highest diagnostic accuracy, underscoring its potential utility in clinical settings.

Venous Endothelial Cell Transcriptomic Profiling Implicates METAP1 in Preeclampsia

BACKGROUND

Preeclampsia is a hypertensive disorder of pregnancy characterized by systemic endothelial dysfunction. The pathophysiology of preeclampsia remains incompletely understood. This study used human venous endothelial cell (EC) transcriptional profiling to investigate potential novel mechanisms underlying EC dysfunction in preeclampsia.

METHODS

Venous ECs were isolated from postpartum patients with severe preeclampsia and those with normotensive pregnancy using a J wire-based technique in the antecubital vein followed by CD144 (vascular endothelial cadherin) magnetic bead isolation. Venous EC transcriptomes were compared between preeclamptic and normotensive individuals. Differentially expressed genes were carried forward for genetic validation using expression quantitative trait loci from the Genotype-Tissue Expression project as exposures for vascular-specific Mendelian randomization. Functional validation of the top candidate was performed in human umbilical vein ECs using gain- and loss-of-function genetic approaches.

RESULTS

Seventeen individuals with preeclampsia and 7 normotensive controls were included. Pairwise analysis yielded 14 protein-coding genes nominally differentially expressed in participants with preeclampsia. Mendelian randomization revealed a significant association between higher genetically predicted METAP1 (methionyl aminopeptidase 1) expression in aortic and tibial arterial tissues and greater risk of preeclampsia. METAP1 overexpression in human umbilical vein ECs decreased angiogenesis, with a 66% decrease in tube formation (P=7.9×10-3) and 72% decrease in cell proliferation (P=2.9×10-2). Furthermore, METAP1 overexpression decreased VEGFA expression and increased expression of multiple preeclampsia-related genes, for example, FLT1, INHBA, and IL1B. Conversely, METAP1 knockdown produced opposite effects on tube formation, cell proliferation, and inflammation-related gene expression.

CONCLUSIONS

In a cohort of early postpartum individuals, we observed greater METAP1 expression in venous ECs of women with preeclampsia versus normotensive delivery. Mendelian randomization supported a causal relationship between greater vascular METAP1 expression and higher preeclampsia risk, and functional experiments demonstrated antiangiogenic and proinflammatory effects of METAP1 in human ECs consistent with alterations observed in preeclampsia. Ex vivo EC transcriptomics can identify novel mechanisms underlying preeclampsia pathophysiology, with implications for prevention and treatment.

Understanding barriers and facilitators to implementation of a patient safety bundle for pregnancy-related severe hypertension in 3 North Carolina outpatient clinics: a qualitative study

BACKGROUND

Pregnancy related hypertension is a leading cause of preventable maternal morbidity and mortality in the US, with consistently higher rates affecting racial minorities. Many complications are preventable with timely treatment, in alignment with the Alliance for Innovation on Maternal Health's Patient Safety Bundle ("Bundle"). The Bundle has been implemented successfully in inpatient settings, but 30% of preeclampsia-related morbidity occurs in outpatient settings in North Carolina. To address this, we have integrated community engagement and implementation science approaches to identify facilitators and barriers to Bundle implementation, which supports its adaptation for outpatient settings and identifies implementation strategies to be tested in a subsequent study.

METHODS

Eleven key informant interviews were conducted across three clinics to assess the implementation needs for effectively utilizing the Bundle. The interview guide was created using the Consolidated Framework for Implementation Research domains to identify facilitators and barriers to implementation. Additionally, three focus group discussions with patient participants were conducted to understand lived experiences and perceptions of respectful care. A coalition of community partners, patients, providers, those with lived experience, and the research team reviewed materials from the formative study design to dissemination and planning for future study.

RESULTS

Barriers included inadequate provider-patient interaction time, patients' lack of transportation to access care, limited protocols to inform/assess/treat/escalate patients, and workforce capacity (staff training and turnover). Facilitators included staff recognition of the importance of treating preeclampsia, champion buy-in of the Bundle's ability to improve outcomes, co-location of pharmacies for immediate treatment, and staff capacity. Respectful care principles were repeatedly identified as a facilitator for Bundle implementation, specifically for patient awareness of preeclampsia complications and treatment adherence.

CONCLUSIONS

Findings highlight the importance of community-engaged approaches. Further, clinic staff regarded Bundle implementation as crucial for the outpatient setting. Identified barriers suggest that strategies should address systemic social supports (i.e., transportation, childcare) and improve access to and use of home blood pressure monitoring. Identified facilitators support improving communication, increasing clinic champion engagement, enabling systems for identifying at-risk patients, and training staff on accurate blood pressure measurement. Successful Bundle implementation requires addressing systemic barriers to delivering respectful care, such as limited time with patients.

Association between exposure to environmental pollutants and increased oral health risks, a comprehensive review

The burden of disease and death attributable to environmental pollution is a growing public health challenge worldwide, particularly in developing countries. While the adverse effects of environmental pollution on oral health have garnered increasing attention, a comprehensive and systematic assessment remains lacking. This article delves into the intricate relationship between environmental pollution and oral health, highlighting significant impacts on various aspects such as dental caries, periodontal diseases, oral facial clefts, cancer, as well as other oral diseases. Our results suggested that secondhand smoke, particulate matters (PM) and heavy metals are the most important risk factors affecting oral health. Additional contributors, such as radiation pollutants, electronic cigarette, phthalates, gaseous air pollutants, pesticides, solvents, wood dust, formaldehyde and excessive fluoride were investigated, though evidence for their impacts remains limited and often inconclusive. The review also explores potential mechanisms underlying these impacts, including microorganism, inflammation, oxidative stress, genetic influences, and toxicant exposures from heavy metals and other pollutants. For instance, PM2.5 may contribute to dental caries by disrupting oral pH balance and absorbing heavy metals such as lead and cadmium which have been considered as caries promoting elements. It is also associated with adverse inflammatory responses and tissue damage in periodontal tissues by causing oxidative stress, potentially leading to periodontitis. Drawing on current evidence, it provides a comprehensive analysis of these associations, offering critical insights to guide the development of preventive strategies and public health interventions. The findings highlight the pressing need for future research to validate the causal links between environmental pollution and oral diseases and to unravel the underlying biological mechanisms. Ultimately, greater attention must be directed toward addressing the relationship between environmental pollution and oral diseases, with a focus on pollution control and the reduction of preventable environmental risks to safeguard oral health on a broader scale.

Severe Maternal Morbidity Associated With Chronic Hypertension, Preeclampsia, and Gestational Hypertension

Importance

Chronic hypertension and preeclampsia are leading risk enhancers for maternal-neonatal morbidity and mortality. Severe maternal morbidity (SMM) indicators include heart, kidney, and liver disease, but studies have not excluded patients with preexisting diseases that define SMM. Thus, SMM risks for uncomplicated chronic hypertension specific to preeclampsia remain unclear.

Objective

To determine SMM rates and estimate relative risks associated with hypertensive disorders of pregnancy among patients with and without chronic hypertension unencumbered by preexisting vascular or end organ diseases.

Design, Setting, and Participants

This retrospective cohort study used longitudinal health data from electronic health records from patients within a community-based, integrated health care system in northern California. The study cohort selected 263 518 pregnant patients without pregestational heart, kidney, or liver disease entering prenatal care at 14 weeks' gestation or earlier and delivering a singleton stillbirth or live birth in 2009 to 2019. The data were analyzed between February 2022 and March 2024.

Exposures

Five joint subgroups combining chronic hypertension status and the hypertensive disorders developing during pregnancy, defined as follows: (1) chronic hypertension with superimposed preeclampsia, (2) chronic hypertension and no preeclampsia, (3) no chronic hypertension with preeclampsia, (4) gestational hypertension, and (5) no chronic hypertension and no preeclampsia or gestational hypertension (reference group).

Main Outcomes and Measures

The main outcome was SMM rates at delivery hospitalization (cases per 10 000 births) using the Centers for Disease Control and Prevention criteria (≥1 of 21 indicators to define SMM) obtained from electronic health records. Modified Poisson regression models estimated crude and adjusted relative risks (aRRs) and 95% CIs of SMM associated with the chronic hypertension and developing hypertensive disorders of pregnancy groups vs the reference group (no chronic hypertension and no preeclampsia or gestational hypertension) adjusted for clinical, sociodemographic, social, and behavioral covariates.

Results

The analysis included a total of 263 518 pregnant patients (mean [SD] age at delivery, 31.0 [5.3] years), including 249 892 patients without chronic hypertension (4.7% developed preeclampsia) and 13 626 patients with chronic hypertension (31.5% developed superimposed preeclampsia). The highest SMM rates occurred in the no chronic hypertension with preeclampsia (934.3 [95% CI, 882.3-988.3] cases per 10 000 births) and the chronic hypertension with superimposed preeclampsia (898.3 [95% CI, 814.5-987.8] cases per 10,000 births) groups. Lower SMM rates occurred in the chronic hypertension and no preeclampsia (195.1 [95% CI, 168.0-225.2] cases per 10,000 births), gestational hypertension (312.7 [95% CI, 281.6-346.1] cases per 10,000 births), and no chronic hypertension and no preeclampsia or gestational hypertension (165.8 [95% CI, 160.6-171.2] cases per 10,000 births) groups (P < .001). Compared with the no chronic hypertension and no preeclampsia or gestational hypertension group, risks of SMM were significantly higher for the chronic hypertension with superimposed preeclampsia group (aRR, 4.97 [95% CI, 4.46-5.54]), no chronic hypertension with preeclampsia group (aRR, 5.12 [95% CI, 4.79-5.48]), chronic hypertension and no preeclampsia group (aRR, 1.17 [95% CI, 1.003-1.36]; P = .046), and the gestational hypertension group (aRR, 1.78 [95% CI 1.60-1.99]).

Conclusions and Relevance

This cohort study found that the highest SMM rates at delivery hospitalization occurred for preeclampsia superimposed on chronic hypertension and preeclampsia without chronic hypertension, while gestational hypertension had intermediate rates of SMM. The patients with chronic hypertension who did not develop preeclampsia had SMM rates that were nearly the same as the lowest-risk patients without chronic hypertension who did not develop preeclampsia or gestational hypertension. These findings provide evidence that prevention of preeclampsia among patients with uncomplicated chronic hypertension is paramount to mitigating maternal morbidity.

Food Insecurity in Pregnancy, Receipt of Food Assistance, and Perinatal Complications

Importance

Food insecurity is a growing public health concern, but its association with perinatal complications remains unclear.

Objective

To examine whether food insecurity in pregnancy was associated with the risk of perinatal complications and determine whether these potential associations differed by receipt of food assistance.

Design, Setting, and Participants

This cohort study used data from a pregnancy survey conducted between June 22, 2020, and September 9, 2022, at Kaiser Permanente Northern California, an integrated health care system serving a diverse population of 4.6 million. Participants included individuals who delivered singletons. Data were analyzed from December 2023 to June 2024.

Exposure

Food insecurity in pregnancy assessed using the validated 2-item Hunger Vital Sign screener.

Main Outcomes and Measures

Maternal (gestational diabetes, gestational hypertension, preeclampsia, cesarean delivery) and neonatal (preterm birth, neonatal intensive care unit [NICU] admission, small-for-gestational age [SGA], and large-for-gestational age [LGA]) complications extracted from the electronic health records, and a composite adverse perinatal outcome (APO) of maternal and neonatal complications. Modified Poisson regression models were adjusted for covariates and stratified by receipt of food assistance in pregnancy.

Results

Among 19 338 individuals, 2707 (14.0%) reported food insecurity in pregnancy. Individuals with food insecurity in pregnancy had a higher risk of gestational diabetes (adjusted relative risk [aRR], 1.13 [95% CI, 1.01-1.29]), preeclampsia (aRR, 1.28 [95% CI, 1.11-1.49]), preterm birth (aRR, 1.19 [95% CI, 1.02-1.38]), NICU admission (aRR, 1.23 [95% CI, 1.07-1.42]), and APO (aRR, 1.07 [95% CI, 1.02-1.13]) compared with individuals without food insecurity. Among 1471 individuals (7.6%) who received food assistance in pregnancy, associations of food insecurity in pregnancy with perinatal complications were attenuated to the null, except for preeclampsia (aRR, 1.64 [95% CI, 1.06-2.53]). On the contrary, the associations persisted among individuals who did not receive food assistance: gestational diabetes (aRR, 1.20 [95% CI, 1.04-1.37]), preeclampsia (aRR, 1.24 [95% CI, 1.06-1.46]), preterm birth (aRR, 1.23 [95% CI, 1.05-1.46]), NICU admission (aRR, 1.31 [95% CI, 1.12-1.52]), and APO (aRR, 1.12 [95% CI, 1.06-1.18]).

Conclusions and Relevance

In this cohort study, food insecurity in pregnancy was associated with a higher risk of perinatal complications, and these associations were overall attenuated to the null among individuals who received food assistance in pregnancy. These findings support clinical guidelines of screening for food insecurity in pregnancy and provide evidence to expand food assistance programs that may help improve maternal and neonatal outcomes.

Maternal PlGF and sFlt-1 are Associated with Low Birth Weight and/or Small-for-Gestational Age Neonates in Pregnancy with or without Preeclampsia

Objective

To evaluate the association of PIGF and sFlt-1 with low birth weight and/or small-for-gestational age neonates in pregnancy with or without preeclampsia.

Methods

Singleton pregnancies with sFlt-1/PlGF tested were included and set into four groups for case-control analysis. Distribution of sFlt-1/PlGF, sFlt-1, PlGF, and PGF% were evaluated, Kruskal-Wallis test and Mann-Whitney U test were adopted for significance analysis.

Results

Maternal sFlt-1/PlGF, PlGF, PlGF%, and sFlt-1 were statistically associated with low birth weight and/or small-for-gestational age in pregnancy complicated or uncomplicated with preeclampsia. A significant difference was shown on sFlt-1/PIGF ( p  = 0.0082), PIGF% ( p  = 0.0326), PIGF ( p  = 0.0128), and sFlt-1 ( p  = 0.0469) in pregnancy with small-for-gestational age and/or low birth weight neonates. A significantly higher median of sFlt-1/PlGF (448 vs. 61.6, p  < 0.0001) and sFlt-1 (15499 vs. 3226, p  < 0.0001), a significantly lower median of PlGF (33.92 vs. 115.2, p  < 0.0001) and PlGF% (-76.63 vs. -20.31, p  < 0.0001) were demonstrated, respectively, when preeclampsia with small-for-gestational age and/or low birth weight neonates was compared with preeclampsia with normal birth weight neonates. No significant difference was demonstrated between low birth weight and small-for-gestational age on sFlt-1/PlGF, PlGF, PlGF%, and sFlt-1.

Conclusion

sFlt-1/PlGF seems to be a promising biomarker in predicting low birth weight and/or small-for-gestational age neonates in pregnancy with or without preeclampsia.

Comparison of umbilical artery pulsatility index reference ranges

OBJECTIVE

To compare the accuracy of four published reference standards for the umbilical artery pulsatility index (UA-PI) in predicting small-for-gestational age (SGA), adverse neonatal outcomes and obstetric complications in pregnancies at risk for fetal growth restriction.

METHODS

This was a secondary analysis of a prospective study of singleton pregnancies that underwent fetal growth assessment by ultrasound between 26 and 36 weeks' gestation. Pregnancies with estimated fetal weight or abdominal circumference < 20th percentile with UA-PI measurements available were included. We excluded fetuses with chromosomal anomaly or congenital malformation and those without delivery information. The predictive ability of UA-PI > 95th percentile according to the reference standards of Acharya et al., the INTERGROWTH-21st Project, the Fetal Medicine Foundation and Parra-Cordero et al. for SGA, a composite of adverse neonatal outcomes and a composite of obstetric complications was compared using the area under the receiver-operating-characteristics curve (AUC). Sensitivity, specificity and positive and negative predictive values were calculated.

RESULTS

Of the 1054 pregnancies that underwent fetal growth evaluation by ultrasound, 207 were included in our analysis. SGA, adverse neonatal outcomes and obstetric complications were diagnosed in 94 (45.4%), 50 (24.2%) and 69 (33.3%) cases, respectively. All reference standards had similar and statistically significant but poor predictive accuracy for SGA (AUC of 0.55 to 0.56), adverse neonatal outcomes (AUC of 0.57 to 0.60) and obstetric complications (AUC of 0.55 for all).

CONCLUSIONS

The reference standards for UA-PI evaluated herein have poor predictive ability for SGA, adverse neonatal outcomes and obstetric complications. At present, no particular UA-PI reference standard can be recommended over others. Larger trials are needed to answer this research question. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Maternal Risk Conditions and Outcomes by Levels of Maternal Care

Objectives: To (1) determine associations between maternal risk conditions and severe adverse outcomes that may benefit from risk-appropriate care and (2) assess whether associations between risk conditions and outcomes vary by level of maternal care (LoMC). Methods: We used the 2017-2019 National Inpatient Sample (NIS) to calculate associations between maternal risk conditions and severe adverse outcomes. Risk conditions included severe preeclampsia, placenta accreta spectrum (PAS) conditions, and cardiac conditions. Outcomes included disseminated intravascular coagulation (DIC) with blood products transfusion or shock, pulmonary edema or acute respiratory distress syndrome (ARDS), stroke, acute renal failure, and a composite cardiac outcome. Then we used 2019 delivery hospitalization data from five states linked to hospital LoMC. We calculated associations between risk conditions and outcomes overall and stratified by LoMC and assessed for effect modification by LoMC. Results: We found positive measures of association between risk conditions and outcomes. Among patients with severe preeclampsia or PAS, the magnitudes of the associations with DIC with blood products transfusion or shock, pulmonary edema or ARDS, and acute renal failure were lower in Level III/IV compared with Collapse

Key Words

• maternal health
• maternal morbidity
• maternal severe morbidity and mortality
• pregnancy outcomes
• risk-appropriate care

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MESH Headings

• Humans
• Female
• Pregnancy
• Adult
• Pregnancy Complications/epidemiology
• Risk Factors
• Maternal Health Services/statistics & numerical data
• United States/epidemiology
• Pregnancy Outcome/epidemiology

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Affiliation(s)

Carla L DeSisto Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Alexander C Ewing Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Hafsatou Diop Division of MCH Research and Analysis, Massachusetts Department of Public Health, Boston, Massachusetts, USA
Sarah Rae Easter Division of Maternal-Fetal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
Elizabeth Harvey Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee, USA
Debra J Kane Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA Iowa Department of Health and Human Services, Division of Community Access, Wellness and Prevention Branch, Bureau of Family Health, Des Moines, Iowa, USA
Miriam Naiman-Sessions Early Childhood and Family Support Division, Montana Department of Public Health and Human Services, Helena, Montana, USA
Godwin Osei-Poku Betsy Lehman Center for Patient Safety, Boston, Massachusetts, USA
Melanie Riley West Virginia Perinatal Partnership, Charleston, West Virginia, USA
Birgit Shanholtzer West Virginia Health Statistics Center, Charleston, West Virginia, USA
Audrey M Stach Division of Family Health and Wellness, Tennessee Department of Health, Nashville, Tennessee, USA
Ramya Dronamraju Maternal and Infant Health, Association of State and Territorial Health Officials, Arlington, Virginia, USA
Andrea Catalano Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Elizabeth A Clark Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Sabrina A Madni Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Lindsay S Womack Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Elena V Kuklina Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
David A Goodman Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
Sarah J Kilpatrick Department of Obstetrics and Gynecology, Cedars-Sinai Medical Center, Los Angeles, California, USA
M Kathryn Menard Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA

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Hypertension Management in Pregnancy

Chronic hypertension and preeclampsia spectrum disorders in pregnancy are important contributors to long-term maternal morbidity and mortality. Due to physiologic changes during pregnancy and the postpartum period, blood pressure expectations differ between primary care providers and obstetricians. The goal of this article is to describe the pathophysiology and definitions of hypertension in the obstetric context and review current evidence for management during pregnancy and the postpartum period. Longitudinal follow-up with a primary care provider after delivery is crucial for long-term cardiovascular risk reduction in hypertensive patients.

Single-nuclei RNA-sequencing fails to detect molecular dysregulation in the preeclamptic placenta

INTRODUCTION

Single-cell RNA-seq (scRNA-seq) revolutionized our understanding of tissue complexity in health and disease and revealed massive transcriptional dysregulation across placental cell classes in early-onset, but not late-onset preeclampsia (PE). However, the multinucleated syncytium is largely inaccessible to cell dissociation. Nuclei isolation and single-nuclei RNA-seq may be preferable in the placenta; not least considering compatibility with long-term tissue storage. Yet, nuclei contain a subsample of the cells' transcriptional profile. Mature transcripts critical to cellular function and disease may be missed.

METHODS

We analyzed placenta from pregnancies using single-cell and single-nuclei RNA-seq. The datasets comprise 45,836 cells and 27,078 nuclei, from 10 to 7 early-onset preeclampsia (EPE) cases and 3 and 2 early idiopathic controls (ECT), respectively. We compared the methods' sensitivities, cell type detection, differential gene expression in PE, and performed histological validations.

RESULTS

Mature syncytiotrophoblast were sampled ∼50x more efficiently after nuclei extraction. Yet, scRNA-seq was more sensitive in detection of genes, molecules and mature transcripts. In snRNA-seq, nuclei of all placental cell classes suffered ambient trophoblast contamination. Transcripts from extravillous trophoblast, stroma, vasculature and immune cells were profiled less comprehensively by single-nuclei RNA-seq (snRNA-seq), restricting cell-type detection. In EPE, we found dysregulation of angiogenic actors FLT1/PGF both in prefused syncytiotrophoblast after cell extraction, and mature syncytiotrophoblast after nuclei isolation. Disease-related stress and inflammation were undetected from nuclei.

DISCUSSION

scRNA-seq has important advantages over snRNA-seq for comprehensive transcriptomics studies of the placenta, especially to understand cell-type resolved dysregulation in pathologies. Yet, to address the dilemma of an underrepresented syncytium, studies benefit from complementary nuclei extraction.

Reproductive and obstetric outcomes in TESE-ICSI cycles: A comparison between obstructive and non-obstructive azoospermia

PURPOSE

Comparison of intracytoplasmic sperm injection cycles with testicular sperm extraction in obstructive azoospermia and non-obstructive azoospermia are limited, and few studies have addressed obstetric and neonatal outcomes.

DESIGN

This study analyzed couples who underwent testicular sperm extraction-intracytoplasmic sperm injection cycles for obstructive azoospermia and non-obstructive azoospermia to determine whether impaired spermatogenesis in non-obstructive azoospermia patients would lead to worse reproductive outcomes and higher rates of pregnancy complications and fetal anomalies. This study is a retrospective, single-center analysis of all testicular sperm cycles performed between January 1, 2001 and December 31, 2020.

RESULTS

A total of 392 couples were considered in the study, leading to 1066 induction cycles, 620 (58.2%) from patients with obstructive azoospermia and 446 (41.8%) from non-obstructive azoospermia. The cumulative delivery rate did not significantly differ between the two groups (34% vs. 31%; p = 0.326). The miscarriage rate was similar between obstructive azoospermia and non-obstructive azoospermia patients. Fertilization rate instead showed a statistically significant difference (obstructive azoospermia: 66.1 ± 25.7 vs. non-obstructive azoospermia: 56.1 ± 27.0; p < 0.001). The overall maternal complication rate in the non-obstructive azoospermia group was higher (10.7% vs. 18.4%; p = 0.035), but there was no statistical significance for each pathology. There was no statistical difference in gestational age between the two groups for both single and twin pregnancies. Seven cases of congenital defects occurred in the obstructive azoospermia group, while two cases occurred in the non-obstructive azoospermia group.

CONCLUSIONS

Despite impaired spermatogenesis in non-obstructive azoospermia patients, there were no substantial differences in reproductive outcomes compared to patients with obstructive azoospermia, even in terms of obstetric safety and neonatal well-being.

Comparison of Characteristics Between Early-Onset and Late-Onset Severe Preeclampsia: A Retrospective Cohort Study from a Tertiary Hospital in China

This study aimed to explore the different characteristics between early-onset severe preeclampsia (ESPE) and late-onset severe preeclampsia (LSPE) to improve pregnancy outcomes. We performed a retrospective cohort study between January 2016 and December 2021. Eligible hospitalized pregnant women with severe preeclampsia were assigned into the early-onset or late-onset group, depending on the gestational age at the time of severe preeclampsia onset (< or ≥ 34 gestational weeks, respectively). The clinical characteristics, laboratory results, maternal complications, and fetal and neonatal outcomes were recorded and compared between the two groups. A total of 1,238 pregnant women were included, with 525 in the early-onset group and 713 in the late-onset group. The late-onset group had more cases of gestational diabetes, whereas the early-onset group had a higher blood pressure, showed more proteinuria, had more liver and renal damage, exhibited more serious adverse maternal, fetal, and neonatal outcomes, was more likely to be admitted to the intensive care unit, and required longer hospital stays (all P < 0.05). In addition, the early-onset group had fewer prenatal care appointments and was more often transferred from a primary or secondary care hospital. The logistic regression analysis showed that a weekly weight gain of > 100 g was a risk factor for ESPE and that fewer prenatal care appointments were a risk factor for ESPE in pregnant women with female fetuses. Moreover, logistic regression analysis indicated that nulliparity and gestational diabetes during the current pregnancy were risk factors for LSPE. In conclusion, compared with the women with LSPE, those with ESPE usually had worse maternal, fetal, and neonatal outcomes. More frequent prenatal screening and care should be provided for pregnant women with high-risk factors.

Ambulatory care utilization in the first 24 months' postpartum by rurality and pregnancy-related conditions: A prospective cohort study from Maine

PURPOSE

To estimate the rate of ambulatory care use among postpartum persons by rurality of residence and pregnancy-related conditions.

METHODS

We used Maine Health Data Organization's All Payer Claims Data for persons who delivered between 2007 and 2019 (N = 121,905). We estimated rates of ambulatory care (nonemergency department outpatient health care) utilization during the first 24 months' postpartum by level of rurality (urban, large rural, small rural, and isolated rural) and by pregnancy-related conditions (prenatal depression, hypertensive disorders of pregnancy, and gestational diabetes). To estimate rate ratios (RR), we used Poisson regression with an offset for population at risk, adjusting for potential confounders and restricting the analysis to those with continuous insurance (n = 70,431).

FINDINGS

The mean monthly rate per 100 deliveries of ambulatory care visits was 86.1; the median number of visits was 12 (interquartile range = 6, 25). Persons living in rural areas had lower monthly rates of visits than persons living in urban areas (adjusted RR ranged from 0.87 [95% CI: 0.85, 0.89] in isolated rural areas to 0.91 [95% CI: 0.90, 0.93] in large rural areas). Persons with prenatal depression (aRR = 2.07; 95% CI: 2.04, 2.11), hypertensive disorders of pregnancy (aRR = 1.07; 95% CI: 1.05, 1.10), and gestational diabetes (aRR = 1.11; 95% CI: 1.08, 1.14) had higher rates of visits than those without these conditions.

CONCLUSIONS

New practices and policies may be needed to improve postpartum ambulatory care access and utilization in rural areas. Postpartum persons with pregnancy-related conditions are accessing ambulatory care at higher rates after delivery, which may reduce their need for acute health care use.

Multidimensional Plasma Lipids Affect Preeclampsia/Eclampsia: A Mendelian Randomization Study

Circulating lipids play a crucial role during pregnancy and may impact various pregnancy-related diseases. This study employed a two-sample Mendelian randomization (MR) framework to investigate the causal relationship between alterations in multidimensional plasma lipid levels and the risk of preeclampsia or eclampsia, offering deeper insight into this association. The inverse variance weighted (IVW) method was utilized as the main analysis. Summary statistics from plasma lipidomics of 7174 Finnish individuals and summary data on preeclampsia/eclampsia from the FinnGen consortium involving 219 817 European participants were employed. Sensitivity analyses were conducted to evaluate heterogeneity and pleiotropy. The study identified 17 lipid species from a total of 179 lipid species associated with susceptibility to preeclampsia/eclampsia. Notably, ten species, including six triacylglycerols (TAGs) (50:1, 48:1, 56:4, 49:2, 48:2, 54:3), a diacylglycerol (DAG) (16:1_18:1), and three sphingomyelins (SMs) (d36:1, d34:1, d38:1), were found to increase the risk of preeclampsia/eclampsia. Conversely, seven species, including five phosphatidylcholines (PCs) (16:1_20:4, O-18:1_20:4, 18:1_20:4, 16:0_20:4, 17:0_20:4) and two phosphatidylethanolamines (PEAs) (18:0_20:4, 16:0_20:4), all containing arachidonic acid (ARA) in the sn-2 position, were associated with a reduced risk of preeclampsia/eclampsia (all p < 0.05). The results of the stratified analysis were consistent with these findings. Furthermore, reverse MR analysis indicated that preeclampsia/eclampsia does not causally affect plasma levels of these lipids. Our findings established a causal relationship between specific plasma lipid species and modulation of preeclampsia/eclampsia risk, providing improved resolution for risk assessment and potential therapeutic targets in the disease.