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Englund Ögge L, Dotevall A, Elfvin A, Sandgren U, Linden K, Bohlin L, Wallstersson B, Sjödell M, Augustinsson J, Hagman A. Glycemic control assessed by continuous glucose monitoring during pregnancy in women with type 1 diabetes and its association with preeclampsia, an observational Swedish cohort study. Acta Obstet Gynecol Scand 2024; 103:1426-1436. [PMID: 38725185 PMCID: PMC11168267 DOI: 10.1111/aogs.14856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 06/13/2024]
Abstract
INTRODUCTION Women with type 1 diabetes have an increased risk of preeclampsia (PE), but it is not fully understood if degree of glycemic control is associated with this risk. The aim of this study was to assess glycemic control during pregnancy analyzed by continuous glucose monitoring (CGM) in women with and without PE and to investigate if glycemic control is associated with increased risk of PE. MATERIAL AND METHODS A total of 120 pregnant Swedish women with type 1 diabetes using CGM were included. Background factors and pregnancy outcomes were collected from medical records. CGM data were collected via the internet-based platform Diasend. Mean glucose, standard deviation of mean glucose, percentage of time in target, time below target, and time above target were presented for each trimester in women who did or did not develop PE. Associations between CGM-derived metrics and PE were analyzed with logistic regression and adjusted for confounders. RESULTS Twenty-two women (18.3%) developed PE. There were no significant differences in maternal characteristics between women with and without PE. Glycemic control improved in each trimester but was suboptimal in both groups. Time in target increased from 59% in the non-PE group and 54% in the PE group in the first trimester to 65% in both groups in the third trimester. There were no significant associations between glycemic control and PE after adjustment for confounders. CONCLUSIONS Degree of glycemic control during pregnancy assessed by CGM was not associated with development of PE in women with type 1 diabetes. However, more research is needed to understand the role of glycemic control in relation to development of PE.
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Affiliation(s)
- Linda Englund Ögge
- Department of Obstetrics and GynecologySahlgrenska University Hospital/ÖstraGothenburgSweden
- Department of Obstetrics and GynecologyInstitute of Clinical Sciences, University of GothenburgGothenburgSweden
| | - Annika Dotevall
- Department of MedicineSahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Anders Elfvin
- Department of PediatricsInstitute of Clinical Sciences, Sahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Ulrika Sandgren
- Department of Obstetrics and GynecologySahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Karolina Linden
- Institute of Health and Care Sciences, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Linnea Bohlin
- Regionhälsan Health Care, Gynecology and Obstetrics ClinicGothenburgSweden
| | - Bernadette Wallstersson
- Department of Obstetrics and GynecologySahlgrenska University Hospital/ÖstraGothenburgSweden
| | - Mårten Sjödell
- Department of Obstetrics and GynecologySkaraborg HospitalSkövdeSweden
| | - Jaine Augustinsson
- Regionhälsan Health Care, Gynecology and Obstetrics ClinicGothenburgSweden
| | - Anna Hagman
- Regionhälsan Health Care, Gynecology and Obstetrics ClinicGothenburgSweden
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Guerby P, Audibert F, Johnson JA, Okun N, Giguère Y, Forest JC, Chaillet N, Mâsse B, Wright D, Ghesquiere L, Bujold E. Prospective Validation of First-Trimester Screening for Preterm Preeclampsia in Nulliparous Women (PREDICTION Study). Hypertension 2024; 81:1574-1582. [PMID: 38708601 DOI: 10.1161/hypertensionaha.123.22584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/05/2024] [Indexed: 05/07/2024]
Abstract
BACKGROUND Fetal Medicine Foundation (FMF) studies suggest that preterm preeclampsia can be predicted in the first trimester by combining biophysical, biochemical, and ultrasound markers and prevented using aspirin. We aimed to evaluate the FMF preterm preeclampsia screening test in nulliparous women. METHODS We conducted a prospective multicenter cohort study of nulliparous women recruited at 11 to 14 weeks. Maternal characteristics, mean arterial blood pressure, PAPP-A (pregnancy-associated plasma protein A), PlGF (placental growth factor) in maternal blood, and uterine artery pulsatility index were collected at recruitment. The risk of preterm preeclampsia was calculated by a third party blinded to pregnancy outcomes. Receiver operating characteristic curves were used to estimate the detection rate (sensitivity) and the false-positive rate (1-specificity) for preterm (<37 weeks) and for early-onset (<34 weeks) preeclampsia according to the FMF screening test and according to the American College of Obstetricians and Gynecologists criteria. RESULTS We recruited 7554 participants including 7325 (97%) who remained eligible after 20 weeks of which 65 (0.9%) developed preterm preeclampsia, and 22 (0.3%) developed early-onset preeclampsia. Using the FMF algorithm (cutoff of ≥1 in 110 for preterm preeclampsia), the detection rate was 63.1% for preterm preeclampsia and 77.3% for early-onset preeclampsia at a false-positive rate of 15.8%. Using the American College of Obstetricians and Gynecologists criteria, the equivalent detection rates would have been 61.5% and 59.1%, respectively, for a false-positive rate of 34.3%. CONCLUSIONS The first-trimester FMF preeclampsia screening test predicts two-thirds of preterm preeclampsia and three-quarters of early-onset preeclampsia in nulliparous women, with a false-positive rate of ≈16%. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02189148.
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Affiliation(s)
- Paul Guerby
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
- Department of Gynecology and Obstetrics, Infinity CNRS, Inserm UMR 1291, CHU Toulouse, France (P.G.)
| | - Francois Audibert
- Department of Obstetrics and Gynecology, CHU Ste-Justine Research Center, Université de Montréal, Canada (F.A.)
| | - Jo-Ann Johnson
- Department of Obstetrics and Gynaecology, University of Calgary, AB, Canada (J.-A.J.)
| | - Nanette Okun
- Department of Obstetrics and Gynaecology, University of Toronto, ON, Canada (N.O.)
| | - Yves Giguère
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology (Y.G., J.-C.F.), Université Laval, Canada
| | - Jean-Claude Forest
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
- Department of Molecular Biology, Medical Biochemistry and Pathology (Y.G., J.-C.F.), Université Laval, Canada
| | - Nils Chaillet
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
| | - Benoit Mâsse
- École de Santé Publique de l'Université de Montréal, QC, Canada (B.M.)
| | - David Wright
- École de Santé Publique de l'Université de Montréal, QC, Canada (B.M.)
- Institute of Health Research, University of Exeter, United Kingdom (D.W.)
| | - Louise Ghesquiere
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
- Department of Obstetrics, Université de Lille, CHU de Lille, France (L.G.)
| | - Emmanuel Bujold
- Reproduction, Mother and Child Health Unit, CHU De Québec-Université Laval Research Center (P.G., Y.G., J.-C.F., N.C., L.G., E.B.), Université Laval, Canada
- Department of Gynecology, Obstetrics and Reproduction (E.B.), Université Laval, Canada
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Shaaban M, Shepelak ZD, Stanford JB, Silver RM, Mumford SL, Schisterman EF, Hinkle SN, Nkoy FL, Theilen L, Page J, Woo JG, Brown BH, Varner MW, Schliep KC. Low-dose aspirin, maternal cardiometabolic health, and offspring respiratory health 9 to 14 years after delivery: Findings from the EAGeR Follow-up Study. Paediatr Perinat Epidemiol 2024. [PMID: 38886184 DOI: 10.1111/ppe.13097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 05/16/2024] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Accumulating evidence shows that peri-conceptional and in-utero exposures have lifetime health impacts for mothers and their offspring. OBJECTIVES We conducted a Follow-Up Study of the Effects of Aspirin in Gestation and Reproduction (EAGeR) trial with two objectives. First, we determined if women who enrolled at the Utah site (N = 1001) of the EAGeR trial (2007-2011, N = 1228) could successfully be contacted and agree to complete an online questionnaire on their reproductive, cardio-metabolic, and offspring respiratory health 9-14 years after original enrollment. Second, we evaluated if maternal exposure to low-dose aspirin (LDA) during pregnancy was associated with maternal cardio-metabolic health and offspring respiratory health. METHODS The original EAGeR study population included women, 18-40 years of age, who had 1-2 prior pregnancy losses, and who were trying to become pregnant. At follow-up (2020-2021), participants from the Utah cohort completed a 13-item online questionnaire on reproductive and cardio-metabolic health, and those who had a live birth during EAGeR additionally completed a 7-item questionnaire on the index child's respiratory health. Primary maternal outcomes included hypertension and hypercholesterolemia; primary offspring outcomes included wheezing and asthma. RESULTS Sixty-eight percent (n = 678) of participants enrolled in the follow-up study, with 10% and 15% reporting maternal hypertension and hypercholesterolemia, respectively; and 18% and 10% reporting offspring wheezing and asthma. We found no association between maternal LDA exposure and hypertension (risk difference [RD] -0.001, 95% confidence interval [CI] -0.05, 0.04) or hypercholesterolemia (RD -0.01, 95% CI -0.06, 0.05) at 9-14 years follow-up. Maternal LDA exposure was not associated with offspring wheezing (RD -0.002, 95% CI -0.08, 0.08) or asthma (RD 0.13, 95% CI 0.11, 0.37) at follow-up. Findings remained robust after considering potential confounding and selection bias. CONCLUSIONS We observed no association between LDA exposure during pregnancy and maternal cardiometabolic or offspring respiratory health.
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Affiliation(s)
- May Shaaban
- Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Zachary D Shepelak
- Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Joseph B Stanford
- Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Sunni L Mumford
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Enrique F Schisterman
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Stefanie N Hinkle
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Flory L Nkoy
- Department of Pediatrics, University of Utah Health, Salt Lake City, Utah, USA
| | - Lauren Theilen
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Jessica Page
- Department of Obstetrics and Gynecology, Intermountain Healthcare, Salt Lake City, Utah, USA
| | - Jessica G Woo
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Benjamin H Brown
- Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, Utah, USA
| | - Michael W Varner
- Department of Obstetrics and Gynecology, University of Utah Health, Salt Lake City, Utah, USA
| | - Karen C Schliep
- Department of Family and Preventive Medicine, University of Utah Health, Salt Lake City, Utah, USA
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Ramesh P, Countouris M, Hauspurg A. Interpregnancy Care After Preeclampsia: A Call to Action for Primary Care and Maternal Subspecialty Clinicians. Am J Hypertens 2024; 37:452-454. [PMID: 38652469 PMCID: PMC11176271 DOI: 10.1093/ajh/hpae042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/07/2024] [Indexed: 04/25/2024] Open
Affiliation(s)
- Praveen Ramesh
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Malamo Countouris
- Department of Medicine, Division of Cardiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Alisse Hauspurg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Magee-Womens Research Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Goulart H, Masarova L, Mesa R, Harrison C, Kiladjian JJ, Pemmaraju N. Myeloproliferative neoplasms in the adolescent and young adult population: A comprehensive review of the literature. Br J Haematol 2024. [PMID: 38853641 DOI: 10.1111/bjh.19557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 05/14/2024] [Indexed: 06/11/2024]
Abstract
Myeloproliferative neoplasms (MPN) are characterized by a clonal proliferation of myeloid lineage cells within the bone marrow. The classical BCR-ABL negative MPNs are comprised of polycythaemia vera, essential thrombocythaemia and primary myelofibrosis. Historically, the majority of MPNs are diagnosed in adults older than 60 years of age; however, in recent years, there has been recognition of MPNs in the adolescent and young adult (AYA) population. AYAs with MPN, typically defined as between the ages of 15 and 39 years old, may comprise up to 20% of patients diagnosed with MPN. They demonstrate unique patterns of driver mutations and thrombotic events and remain at risk for progression to more aggressive disease states. Given the likely long length of time they will live with their disease, there is a significant unmet need in identifying well-tolerated and effective treatment options for these patients, particularly with the advent of disease modification. In this review, we provide a comprehensive overview of the clinical features, disease course and management of AYA patients with MPN and, in doing so, highlight key characteristics that distinguish them from their older counterparts.
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Affiliation(s)
- Hannah Goulart
- Division of Cancer Medicine, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Lucia Masarova
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
| | - Ruben Mesa
- Atrium Health Wake Forest Baptist Comprehensive Cancer Center, Winston-Salem, North Carolina, USA
| | - Claire Harrison
- Department of Haematology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | - Naveen Pemmaraju
- Department of Leukemia, University of Texas, MD Anderson Cancer Center, Houston, Texas, USA
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Rodrigues-Martins D, Andrade S, Pereira SS, Braga J, Nunes I, Monteiro MP. Gestational Diabetes Risk and Low Birth Weight After Metabolic Bariatric Surgery: a Complex Interplay to be Balanced. Obes Surg 2024:10.1007/s11695-024-07314-1. [PMID: 38833131 DOI: 10.1007/s11695-024-07314-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/06/2024]
Abstract
INTRODUCTION Metabolic bariatric surgery (MBS) is known to improve the obstetric outcomes of women with obesity and to prevent gestational diabetes (GD). To what extent does MBS decreases GD, without incurring at additional risks is a matter of concern. METHODS A retrospective case-control study to compare the pregnancy outcomes of women previously submitted to MBS to those of age and preconception body mass index (PC BMI) matched non-operated controls. RESULTS Pregnancies of women after MBS (n = 79) and matched controls (n = 79) were included. GD was significantly less frequent after MBS (7.6% vs. 19%; p = 0.03). Fasting blood glucose (76.90 ± 0.77 vs 80.37 ± 1.15 mg/dl, p < 0.05; 70.08 ± 1.34 vs. 76.35 ± 0.95 mg/dl; p < 0.05, first and second trimesters respectively) and birth weight (2953.67 ± 489.51 g vs. 3229.11 ± 476.21 g; p < 0.01) were significantly lower after MBS when compared to controls. The occurrence of small-for-gestational-age (SGA) was more frequent after MBS (22.8% vs. 6.3%; p < 0.01), but no longer significant after controlling for smoking habits (15.5% vs. 6%, p = 0.14). There were no significant differences in gestational weight gain, prematurity rate nor mode of delivery between groups. CONCLUSION MBS was associated with a lower prevalence of GD than observed in non-operated women with the same age and BMI. After controlling for smoking, this occurred at the expense of a lower birth weight. Our data reinforces the hypothesis that MBS has body weight independent effects on glucose kinetics during pregnancy with distinctive impacts for mother and offspring, which need to be balanced.
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Affiliation(s)
- Diana Rodrigues-Martins
- Centro Materno-Infantil do Norte - Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal
- Endocrine and Metabolic Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Sara Andrade
- Endocrine and Metabolic Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Sofia S Pereira
- Endocrine and Metabolic Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Jorge Braga
- Centro Materno-Infantil do Norte - Centro Hospitalar Universitário de Santo António (CMIN-CHUdSA), Porto, Portugal
| | - Inês Nunes
- Obstetrics and Gynecology, Centro Hospitalar Vila Nova de Gaia/ Espinho, Porto, Portugal
- CINTESIS - Centro de Investigação Em Tecnologias E Serviços de Saúde, University of Porto, Porto, Portugal
| | - Mariana P Monteiro
- Endocrine and Metabolic Research, UMIB - Unit for Multidisciplinary Research in Biomedicine, ICBAS - School of Medicine and Biomedical Sciences, University of Porto, Porto, Portugal.
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal.
- Institute of Biomedical Sciences Abel Salazar - University of Porto, Rua Jorge Viterbo Ferreira 228, Building 1.3, 4050-313, Porto, Portugal.
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Gholizadeh Ghozloujeh Z, Singh T, Jhaveri KD, Shah S, Lerma E, Abdipour A, Norouzi S. Lupus nephritis: management challenges during pregnancy. FRONTIERS IN NEPHROLOGY 2024; 4:1390783. [PMID: 38895665 PMCID: PMC11183321 DOI: 10.3389/fneph.2024.1390783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/15/2024] [Indexed: 06/21/2024]
Abstract
Lupus nephritis (LN), a severe complication of systemic lupus erythematosus (SLE), leads to significant kidney inflammation and damage and drastically increases mortality risk. Predominantly impacting women in their reproductive years, LN poses specific risks during pregnancy, including pre-eclampsia, growth restrictions, stillbirth, and preterm delivery, exacerbated by lupus activity, specific antibodies, and pre-existing conditions like hypertension. Effective management of LN during pregnancy is crucial and involves carefully balancing disease control with the safety of the fetus. This includes pre-conception counseling and a multidisciplinary approach among specialists to navigate the complexities LN patients face during pregnancy, such as distinguishing LN flare-ups from pregnancy-induced conditions. This review focuses on exploring the complex dynamics between pregnancy and LN, emphasizing the management difficulties and the heightened risks pregnant women with LN encounter.
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Affiliation(s)
- Zohreh Gholizadeh Ghozloujeh
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Tripti Singh
- Department of Medicine, Division of Nephrology, University of Wisconsin, Madison, WI, United States
| | - Kenar D. Jhaveri
- Department of Medicine, Division of Kidney Diseases and Hypertension, Zucker School of Medicine at Hofstra/Northwell, Northwell Health, Great Neck, NY, United States
| | - Silvi Shah
- Department of Medicine, Division of Nephrology, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Edgar Lerma
- Department of Medicine, Division of Nephrology, Advocate Christ Medical Center, University of Illinois at Chicago, Oak Lawn, IL, United States
| | - Amir Abdipour
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
| | - Sayna Norouzi
- Department of Medicine, Division of Nephrology, Loma Linda University School of Medicine, Loma Linda, CA, United States
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Roberts JM. Preeclampsia epidemiology(ies) and pathophysiology(ies). Best Pract Res Clin Obstet Gynaecol 2024; 94:102480. [PMID: 38490067 DOI: 10.1016/j.bpobgyn.2024.102480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/14/2023] [Accepted: 02/05/2024] [Indexed: 03/17/2024]
Abstract
Preeclampsia/eclampsia was first described 2000 years ago. Concepts guiding diagnosis have changed over time making longitudinal studies challenging. Similarly, concepts of pathophysiology have evolved from eclampsia as a pregnancy seizure disorder to preeclampsia as a hypertensive and renal disorder to our current concept of a preeclampsia as a pregnancy specific, multisystemic inflammatory disorder. Although preeclampsia is pregnancy specific and many pathophysiologic findings begin to resolve with delivery, its impact extends beyond pregnancy. The risk of cardiovascular and neurological disease is increased after pregnancy in women who have had preeclampsia. The disorder is not a disease, but a syndrome and emerging data indicate multiple pathways to the syndrome. It is likely that our failure to have a major impact on prediction and prevention despite a large increase in understanding is due to the existence of multiple subtypes of preeclampsia. This concept should guide future research.
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Affiliation(s)
- James M Roberts
- Obstetrics Gynecology and Reproductive Sciences, Epidemiology and Clinical and Translational Research University of Pittsburgh, 10 Georgian Place, Pittsburgh, PA, 15215, United States.
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Ngene NC, Moodley J. Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries. Best Pract Res Clin Obstet Gynaecol 2024; 94:102473. [PMID: 38513504 DOI: 10.1016/j.bpobgyn.2024.102473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 03/23/2024]
Abstract
Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, Rahima Moosa Mother and Child Hospital, Johannesburg, Gauteng, South Africa; Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, Gauteng, South Africa.
| | - Jagidesa Moodley
- Women's Health and HIV Research Group, Department of Obstetrics and Gynecology, School of Clinical Medicine, Faculty of Health Sciences, University of Kwa Zulu-Natal, Durban, South Africa.
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Agarwala A, Dixon DL, Gianos E, Kirkpatrick CF, Michos ED, Satish P, Birtcher KK, Braun LT, Pillai P, Watson K, Wild R, Mehta LS. Dyslipidemia management in women of reproductive potential: An expert clinical consensus from the national lipid association. J Clin Lipidol 2024:S1933-2874(24)00188-0. [PMID: 38824114 DOI: 10.1016/j.jacl.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
Cardiovascular disease (CVD) is the leading cause of death among women and its incidence has been increasing recently, particularly among younger women. Across major professional society guidelines, dyslipidemia management remains a central tenet for atherosclerotic CVD prevention for both women and men. Despite this, women, particularly young women, who are candidates for statin therapy are less likely to be treated and less likely to achieve their recommended therapeutic objectives for low-density lipoprotein cholesterol (LDL-C) levels. Elevated LDL-C and triglycerides are the two most common dyslipidemias that should be addressed during pregnancy due to the increased risk for adverse pregnancy outcomes, such as preeclampsia, gestational diabetes mellitus, and pre-term delivery, as well as pancreatitis in the presence of severe hypertriglyceridemia. In this National Lipid Association Expert Clinical Consensus, we review the roles of nutrition, physical activity, and pharmacotherapy as strategies to address elevated levels of LDL-C and/or triglycerides among women of reproductive age. We include a special focus on points to consider during the shared decision-making discussion regarding pharmacotherapy for dyslipidemia during preconception planning, pregnancy, and lactation.
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Affiliation(s)
- Anandita Agarwala
- Center for Cardiovascular Disease Prevention Cardiovascular Division, Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Agarwala).
| | - Dave L Dixon
- Department of Pharmacotherapy & Outcomes Science, Virginia Commonwealth University School of Pharmacy, Richmond, Virginia, USA (Dr Dixon); Center for Pharmacy Practice Innovation, Virginia Commonwealth University, Richmond, Virginia, USA (Dr Dixon)
| | - Eugenia Gianos
- Department of Cardiology, Northwell Health, New Hyde Park, Cardiovascular Institute, Lenox Hill Hospital Northwell, New York, NY, USA (Dr Gianos)
| | - Carol F Kirkpatrick
- Midwest Biomedical Research, Addison, IL, USA (Dr Kirkpatrick); Kasiska Division of Health Sciences, Idaho State University, Pocatello, ID, USA (Dr Kirkpatrick)
| | - Erin D Michos
- Division of Cardiology, Department of Medicine Johns Hopkins University School of Medicine Baltimore, MD, USA (Dr Michos)
| | - Priyanka Satish
- The University of Texas at Austin Dell School of Medicine, Ascension Texas Cardiovascular, Austin, TX, USA (Dr Satish)
| | - Kim K Birtcher
- University of Houston College of Pharmacy, Houston, TX, USA (Dr Birtcher)
| | - Lynne T Braun
- Rush University College of Nursing, Rush Heart Center for Women, Chicago, IL, USA (Dr Braun)
| | - Priyamvada Pillai
- Baylor Scott and White Health Heart Hospital Baylor Plano, Plano, TX, USA (Dr Pillai)
| | - Karol Watson
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA (Dr Watson)
| | - Robert Wild
- Oklahoma University Health Sciences Center, Oklahoma City, OK, USA (Dr Wild)
| | - Laxmi S Mehta
- Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA (Dr Mehta)
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11
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Hoi A, Igel T, Mok CC, Arnaud L. Systemic lupus erythematosus. Lancet 2024; 403:2326-2338. [PMID: 38642569 DOI: 10.1016/s0140-6736(24)00398-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/28/2023] [Accepted: 02/25/2024] [Indexed: 04/22/2024]
Abstract
Systemic lupus erythematosus (SLE) is a multisystemic autoimmune disease characterised by the presence of autoantibodies towards nuclear antigens, immune complex deposition, and chronic inflammation at classic target organs such as skin, joints, and kidneys. Despite substantial advances in the diagnosis and management of SLE, the burden of disease remains high. It is important to appreciate the typical presentations and the diagnostic process to facilitate early referral and diagnosis for patients. In most patients, constitutional, mucocutaneous, and musculoskeletal symptoms represent the earliest complaints; these symptoms can include fatigue, lupus-specific rash, mouth ulcers, alopecia, joint pain, and myalgia. In this Seminar we will discuss a diagnostic approach to symptoms in light of the latest classification criteria, which include a systematic evaluation of clinical manifestations (weighted within each domain) and autoantibody profiles (such as anti-double-stranded DNA, anti-Sm, hypocomplementaemia, or antiphospholipid antibodies). Non-pharmacotherapy management is tailored to the individual, with specific lifestyle interventions and patient education to improve quality of life and medication (such as hydroxychloroquine or immunosuppressant) adherence. In the last decade, there have been a few major breakthroughs in approved treatments for SLE and lupus nephritis, such as belimumab, anifrolumab, and voclosporin. However the disease course remains variable and mortality unacceptably high. Access to these expensive medications has also been restricted across different regions of the world. Nonetheless, understanding of treatment goals and strategies has improved. We recognise that the main goal of treatment is the achievement of remission or low disease activity. Comorbidities due to both disease activity and treatment adverse effects, especially infections, osteoporosis, and cardiovascular disease, necessitate vigilant prevention and management strategies. Tailoring treatment options to achieve remission, while balancing treatment-related comorbidities, are priority areas of SLE management.
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Affiliation(s)
- Alberta Hoi
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia.
| | - Talia Igel
- Department of Rheumatology, Monash Health, School of Clinical Sciences, Monash University, Melbourne, VIC, Australia
| | - Chi Chiu Mok
- Department of Medicine, Tuen Mun Hospital, Hong Kong Special Administrative Region, China
| | - Laurent Arnaud
- Department of Rheumatology, National Reference Center for Autoimmune Diseases, INSERM UMR-S 1109, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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12
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Pimentel VM, Larrea ADA, Renaud SJ, Sloan S, Figueroa R, Wakefield D, Crowell R. Feasibility of Universal Screening for Preeclampsia Risk and Aspirin Recommendation in the Ultrasound Unit. Am J Perinatol 2024; 41:e3187-e3195. [PMID: 38101442 DOI: 10.1055/s-0043-1777445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2023]
Abstract
OBJECTIVE To evaluate the feasibility and impact of using the first-trimester ultrasound visit to identify and counsel women at increased risk of preeclampsia about the benefits of low-dose aspirin (LDA) for preventing preeclampsia. We also assessed patient-reported utilization of LDA, perceived risk for preeclampsia, and clinical outcomes. STUDY DESIGN Women presenting for routine first-trimester nuchal-translucency (NT) ultrasounds were screened for clinical preeclampsia risks using a self-administered risk assessment. Women at moderate or high risk for preeclampsia were counseled to take LDA, if not already taking it. LDA utilization and perceived risk for preeclampsia were assessed during the second-trimester ultrasound. Factors associated with LDA utilization were analyzed. Pregnancy outcomes were compared between those who used LDA and those who did not. RESULTS Slightly more than 20% of patients (765/3,669) screened at increased risk for developing preeclampsia. Of those, 67.8% (519/765) had not received LDA recommendations from their referring obstetrician and 97 had not been taking LDA despite being advised to do so. Combined, 94.6% (583/616) of these patients eligible to start LDA prophylaxis received the indicated counseling during the ultrasound visit. A total of 61.4% (358/583) of women completed the follow-up form and of those 77.9% (279/358) reported taking LDA. Screening at increased risk for preeclampsia and perception of increased risk were positively associated with LDA utilization, whereas concerns for LDA safety were negatively associated with use. African American/Black patients and Medicaid recipients were less likely to use LDA. Pregnancy outcomes were similar between those who used LDA and those who did not. CONCLUSION Assessing preeclampsia risk and counseling patients about LDA at the time of the NT ultrasound are feasible in the ultrasound unit and led to good LDA utilization among women at increased risk for preeclampsia. This intervention may standardize patient care and help close the disparity in maternal health. KEY POINTS · A simple intervention captured 2/3 of eligible patients.. · Aspirin utilization rate was good after the intervention.. · Screening high risk for preeclampsia and self-perception of risk correlated with aspirin use..
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Affiliation(s)
- Verónica Maria Pimentel
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford Connecticut
- Department of Obstetrics and Gynecology, Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
- Department of Obstetrics and Gynecology, University of Connecticut School of Medicine, Farmington, Connecticut
| | - Alexander D Almeida Larrea
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford Connecticut
| | - Sophie J Renaud
- Department of Obstetrics and Gynecology, Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - Sophie Sloan
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford Connecticut
| | - Reinaldo Figueroa
- Department of Obstetrics and Gynecology, Saint Francis Hospital and Medical Center, Hartford Connecticut
- Department of Obstetrics and Gynecology, Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut
| | - Dorothy Wakefield
- Department of Research, Saint Francis Hospital and Medical Center, Hartford, Connecticut
| | - Rebecca Crowell
- Department of Research, Saint Francis Hospital and Medical Center, Hartford, Connecticut
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13
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Ilizaliturri AO, Jimenez K, Trejo R, Serpas S. A Quality Improvement Project in Family Medicine Residency Training: Improving Preeclampsia Prevention Through Risk Factor Screening and Low-Dose Aspirin. Am J Public Health 2024; 114:S318-S321. [PMID: 38748955 PMCID: PMC11096769 DOI: 10.2105/ajph.2024.307667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2024] [Indexed: 05/18/2024]
Abstract
Providing aspirin during pregnancy is a critical intervention proven to reduce the rates of preeclampsia in patients at risk. This quality improvement project prepared family medicine residents to use public health strategies to improve screening of pregnant patients at risk for preeclampsia in an underserved population. A preeclampsia awareness campaign was launched utilizing a publicly available toolkit, while a multidisciplinary team implemented systemic clinical changes to increase the rates of preeclampsia risk factor screening and aspirin prescription to prevent preeclampsia. (Am J Public Health. 2024;114(S4):S318-S321. https://doi.org/10.2105/AJPH.2024.307667).
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Affiliation(s)
- Ana Ortiz Ilizaliturri
- All authors are with the Scripps Mercy Family Medicine Residency Program, Chula Vista, CA
| | - Krystal Jimenez
- All authors are with the Scripps Mercy Family Medicine Residency Program, Chula Vista, CA
| | - Raul Trejo
- All authors are with the Scripps Mercy Family Medicine Residency Program, Chula Vista, CA
| | - Shaila Serpas
- All authors are with the Scripps Mercy Family Medicine Residency Program, Chula Vista, CA
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14
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Kupka E, Roberts JM, Mahdy ZA, Escudero C, Bergman L, De Oliveira L. Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps. AJOG GLOBAL REPORTS 2024; 4:100352. [PMID: 38694484 PMCID: PMC11061325 DOI: 10.1016/j.xagr.2024.100352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated, preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Furthermore, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. In addition, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries, and we propose directions for future research.
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Affiliation(s)
| | - James M. Roberts
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Zaleha A. Mahdy
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Carlos Escudero
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Lina Bergman
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Leandro De Oliveira
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Global Pregnancy Collaboration
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
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15
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Myers SO, Luke S, Ramey-Collier KL, Truong T, Weaver K, Swamy GK, Wheeler SM. Factors Associated with Guideline Concordant Clinician Counseling about Low-Dose Aspirin to Prevent Preeclampsia in Nulliparous Patients. Am J Perinatol 2024; 41:e2004-e2009. [PMID: 37207675 PMCID: PMC10764634 DOI: 10.1055/a-2096-3466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
OBJECTIVE The primary aim of this study was to examine the United States Preventative Services Task Force (USPSTF) guidelines concordant low-dose aspirin (LDA) counseling and factors associated with counseling in nulliparous birthing individuals. STUDY DESIGN We conducted a retrospective cohort study of nulliparous birthing individuals who delivered between January 1, 2019 and June 30, 2020 and received prenatal care at the Duke High Risk Obstetrical Clinics (HROB). All nulliparous patients over 18 years old who established or transferred care to HROB by 16 weeks, 6 days were included in the analysis. We excluded patients with more than two previous first-trimester pregnancy losses, multiple gestation, a known contraindication to LDA, initiation of LDA prior to their prenatal care, or documented medical history of coagulation disorder. Bivariate associations between demographic/medical characteristics and our primary outcome, receipt of counseling (yes/no), were assessed using two-sample t-tests for continuous variables and chi-square or Fisher's exact test for categorical variables. Factors significantly associated with the primary outcome (p < 0.05) were entered into the multivariable logistic regression model. RESULTS Among 391 birthing individuals included in the final analysis cohort, 51.7% of eligible patients received guideline consistent LDA counseling. Factors associated with increased odds of LDA counseling were advanced maternal age (adjusted odds ratio [aOR]: 1.05, 95% confidence interval [CI]: 1.01-1.09), Black race compared with White race (aOR:1.75, 95% CI: 1.03-2.98), chronic hypertension (aOR: 4.17, 95% CI: 1.82-9.55), and obesity (aOR: 5.02, 95% CI: 3.12-8.08). CONCLUSION Approximately half of all nulliparous birthing individuals had appropriately documented LDA counseling. The USPSTF guidelines on LDA for preeclampsia risk reduction are complex, which may lead to ineffective provider adherence. Efforts to simplify guidelines and improve LDA counseling are vital to ensuring this low-cost, evidence-based preeclampsia prevention is used in a consistent and equitable manner. KEY POINTS · A total of 51.7% of eligible patients received guideline consistent LDA counseling.. · Advanced maternal age , body mass index > 30, Black race, and chronic hypertension associated with increased odds of counseling.. · Among patients most likely to be counseled, high numbers did not receive LDA counseling..
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Affiliation(s)
| | - Shauntell Luke
- Duke University School of Medicine, Durham, North Carolina
| | | | - Tracy Truong
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kristin Weaver
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Geeta K. Swamy
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Sarahn M. Wheeler
- Department of Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, Duke University School of Medicine, Durham, North Carolina
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16
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Martinez-King LC, Machiorlatti M, Ogburn T, Salcedo J. Physician's Knowledge and Practices Surrounding Low-Dose Aspirin for Preeclampsia Risk Reduction. Am J Perinatol 2024; 41:e1120-e1125. [PMID: 36452971 DOI: 10.1055/a-1990-2728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
OBJECTIVE Preeclampsia is a leading cause of pregnancy-related deaths. Up to 60% of maternal deaths associated with preeclampsia may be prevented. Clinical trials have shown that low-dose aspirin reduces preeclampsia up to 30% among women at increased risk. Since 2014, multiple professional societies and the U.S. Preventive Services Task Force have released guidelines on the use of low-dose aspirin to reduce the risk of preeclampsia. We aimed to evaluate physician's knowledge and practices surrounding low-dose aspirin for preeclampsia risk reduction. STUDY DESIGN We distributed an anonymous electronic survey to licensed physicians in the Rio Grande Valley of Texas who provide prenatal care, including general obstetrician-gynecologists, maternal fetal medicine subspecialists, and family medicine physicians. The survey consisted of 20 items assessing demographics, provider practices, and knowledge on the use of low-dose aspirin for preeclampsia risk reduction. RESULTS We received 48 surveys with a response rate of 55%. More than 90% of physicians reported recommending low-dose aspirin for preeclampsia risk reduction, of which 98% correctly identified the dose. Of the physicians recommending aspirin, 83% initiate dosing between 12 and 16 weeks, but only 52% continue it until the day of delivery. Nearly 80% of respondents identified that one high-risk factor for preeclampsia is an indication for prophylaxis, but only 56% identified that two or more moderate risk factors should prompt aspirin recommendation. CONCLUSION Despite clear professional guidelines, physicians demonstrated gaps in knowledge and differences in practices. Enhancing screening tools to assess patient's risk of developing preeclampsia and tailored medical education on moderate risk factors are needed to identify patients who may benefit from this intervention. Increasing the use of aspirin in patients at risk is critical given the benefits of low-dose aspirin in the reduction of poor maternal and neonatal outcomes related to preeclampsia. KEY POINTS · Low-dose aspirin reduces preeclampsia in patients up to 30%.. · Physicians have gaps in knowledge despite guidelines.. · Following guidelines reduces poor outcomes associated with preeclampsia..
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Affiliation(s)
- L Carolina Martinez-King
- Department of Obstetrics and Gynecology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
| | - Michael Machiorlatti
- Department of Population Health and Biostatistics, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
| | - Tony Ogburn
- Department of Obstetrics and Gynecology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
| | - Jennifer Salcedo
- Department of Obstetrics and Gynecology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas
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17
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Paiboonborirak C, Phupong V. Serum fatty acid binding protein 4 and Doppler of uterine artery ultrasound in the first trimester for the prediction of preeclampsia. Hypertens Res 2024; 47:1208-1215. [PMID: 38182901 DOI: 10.1038/s41440-023-01553-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 11/27/2023] [Accepted: 12/02/2023] [Indexed: 01/07/2024]
Abstract
The objective of this study was to determine the predictive value of serum fatty acid binding protein 4 (FABP4) combined with Doppler of the uterine artery in singleton pregnancy at gestational age (GA) 11-13+6 weeks for prediction of preeclampsia. A prospective observational study included singleton pregnant women at GA 11-13+6 weeks and was conducted at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, between December 2020 and April 2022. Serum FABP4 levels and Doppler of the uterine artery were performed. Pregnancy outcomes were recorded. The predictive values of these combined tests at the optimal cut-off values were determined to predict preeclampsia. A total of 330 participants with 15 cases of preeclampsia (4.5%) and 6 cases of them had preterm preeclampsia (GA < 37 weeks) (1.8%) were analyzed. Women with preeclampsia had significantly higher serum FABP4 levels than normal pregnant women (12.9 ± 6.5 ng/ml vs 10.1 ± 4.8 ng/ml, p = 0.034) but no difference in the mean pulsatility index (PI) of the uterine artery and the presence of an early diastolic notch. When using serum FABP4 levels greater than 1.0 multiple of the median of GA as a cut-off value to predict preeclampsia, combined with abnormal Doppler PI of the uterine artery, the sensitivity, specificity, positive predictive value, and negative predictive value were 73.3%, 47.3%, 6.2%, and 97.4%, respectively. This study demonstrated that serum FABP4 levels combined with Doppler of the uterine artery at GA 11-13+6 weeks were effective in predicting preeclampsia.
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Affiliation(s)
- Chaiyawut Paiboonborirak
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Vorapong Phupong
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
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18
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DeBolt CA, Gottlieb ZS, Rao MG, Johnson S, Rekawek P, Deshpande R, Meislin R, Berkin J, Bianco A, Mella MT, Dubinsky MC. Low-Dose Aspirin Use Does Not Increase Disease Activity in Pregnant Patients with Inflammatory Bowel Disease. Dig Dis Sci 2024; 69:1803-1807. [PMID: 38493274 DOI: 10.1007/s10620-024-08364-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 02/19/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND The adverse effects of non-steroidal anti-inflammatory (NSAID) drugs on the gastrointestinal system are well recognized, but the effect of NSAID use on disease activity patients with inflammatory bowel disease (IBD) remains unresolved. Low-dose aspirin (LDA) is recommended for all pregnant patients with risk factors for developing preeclampsia, including autoimmune conditions. As recognition of risk factors for preeclampsia improves, the preventative use of LDA is likely to increase. AIMS To investigate if LDA use for prevention of preeclampsia increases the risk of disease activity in pregnant women with IBD. METHODS Single-center retrospective cohort study of pregnant patients with IBD who delivered from 2012 to 2020, comparing those with and without LDA use. Primary outcome was odds of clinical IBD activity in patients in remission at time of conception. Secondary outcomes were rate of elevated inflammatory biomarkers, defined as C-reactive protein > 5 ug/mL or fecal calprotectin > 250 ug/g, and rate of preeclampsia. Univariate analyses tested for associations. RESULTS Patients taking LDA were older (p = 0.003) and more likely to have chronic hypertension (p = 0.002), to have undergone in vitro fertilization (p < 0.001), and to be on biologics (p = 0.03). Among patients in remission at conception, there was no difference in clinical disease activity or biomarker elevation during pregnancy based on LDA use (OR 1.27, 95% CI [0.55-2.94], p = 0.6). Rates of preeclampsia were similar between groups. CONCLUSION LDA use for preeclampsia prevention did not increase the incidence of disease activity in pregnant patients with IBD.
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Affiliation(s)
- Chelsea A DeBolt
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Zoë S Gottlieb
- Departments of Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, Susan and Leonard Feinstein Inflammatory Bowel Diseases Clinical Center, 1 Gustave Levy Place, Annenberg 5, New York, NY, 10029, USA.
| | - Manasa G Rao
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shaelyn Johnson
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Patricia Rekawek
- Department of Obstetrics and Gynecology, NYU Langone Health, NYU Langone Hospital Long Island, NYU Long Island School of Medicine, Mineola, NY, USA
| | - Richa Deshpande
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Rachel Meislin
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jill Berkin
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Angela Bianco
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Maria Teresa Mella
- Department of Obstetrics, Gynecology and Reproductive Science, Mount Sinai Health System & Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Marla C Dubinsky
- Departments of Medicine and Pediatrics, Icahn School of Medicine at Mount Sinai, Susan and Leonard Feinstein Inflammatory Bowel Diseases Clinical Center, 1 Gustave Levy Place, Annenberg 5, New York, NY, 10029, USA
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Yan X, Zheng W, Wang J, Yuan X, Li G. Low-dose aspirin for the prevention of preterm birth in nulliparous women: systematic review and meta-analysis. BMC Pregnancy Childbirth 2024; 24:260. [PMID: 38605330 PMCID: PMC11008052 DOI: 10.1186/s12884-024-06413-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/12/2024] [Indexed: 04/13/2024] Open
Abstract
OBJECTIVE The objective was to assess the efficacy and safety of low-dose aspirin for the prevention of preterm birth in nulliparous women. DATA SOURCES We searched PubMed, Embase and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to June 2022. STUDY ELIGIBILITY CRITERIA Randomized controlled trials that compared aspirin to placebo in nulliparous women were eligible. METHODS This study was reported in accordance with the PRISMA 2020 checklist. The primary outcomes of this study were the rates of preterm birth at less than 37 weeks and less than 34 weeks of gestation. The secondary outcomes included postpartum hemorrhage, placental abruption, cesarean section, any hypertensive disorder of pregnancy and small for gestational age. Relative risks with their 95% confidence intervals were calculated for analysis. Heterogeneity was assessed by Cochran's Q test and Higgins's I2. A random-effects model was used when I2 was > 50% to generate the RR and 95% CI; otherwise, a fixed-effects model was used. The risk of publication bias was assessed by funnel plots. We performed sensitivity analysis by sequentially omitting each included study to confirm the robustness of the analysis. RESULTS Seven studies with a total of 29,029 participants were included in this review. Six studies were assessed as having a low risk of bias or an unclear risk of bias, and one study was judged as having a high risk of bias. In nulliparous women, low-dose aspirin was associated with a significant reduction in the rate of preterm birth at less than 34 weeks of gestational age (RR 0.84,95% CI: 0.71-0.99; I2 = 0%; P = 0.04), but we did not observe a significant difference in the rate of preterm birth at less than 37 weeks of gestation (RR 0.96,95% CI: 0.90-1.02; I2 = 31%; P = 0.18). Low-dose aspirin was associated with a significant increase in the rates of postpartum hemorrhage (RR 1.32,95% CI: 1.14-1.54; I2 = 0%; P = 0.0003), placental abruption (RR 2.18,95% CI: 1.10-4.32; I2 = 16%; P = 0.02) and cesarean section (RR 1.053, 95% CI: 1.001-1.108; I2 = 0%; P = 0.05) in nulliparous women. We also did not observe a significant effect of low-dose aspirin on the rates of any hypertensive disorder of pregnancy (RR 1.05, 95% CI: 0.96-1.14; I2 = 9%; P = 0.28) or small for gestational age (RR 0.96, 95% CI: 0.91-1.02; I2 = 0%; P = 0.16) in nulliparous women. Funnel plots indicated that no significant publication bias existed in this meta-analysis. Except for preterm birth at less than 34 weeks of gestation, placental abruption and cesarean section, the sensitivity analysis showed similar results, which confirmed the robustness of this meta-analysis. CONCLUSIONS Low-dose aspirin might reduce the risk of preterm birth at less than 34 weeks of gestation in nulliparous women. The use of low-dose aspirin in nulliparous women increased the risk of postpartum hemorrhage and might increase the risk of placental abruption and cesarean section.
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Affiliation(s)
- Xin Yan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Wei Zheng
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Jia Wang
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Xianxian Yuan
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China
| | - Guanghui Li
- Division of Endocrinology and Metabolism, Department of Obstetrics, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing Maternal and Child Health Care Hospital, No.251, Yaojiayuan Road, Chaoyang District, Beijing, 100026, China.
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Ding Y, Yao M, Liu J, Fu W, Zhu X, He Y, Ma Q, Zhang C, Yin J. Association between human blood metabolome and the risk of pre-eclampsia. Hypertens Res 2024; 47:1063-1072. [PMID: 38332312 DOI: 10.1038/s41440-024-01586-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/23/2023] [Accepted: 12/26/2023] [Indexed: 02/10/2024]
Abstract
Pre-eclampsia is a complex multi-system pregnancy disorder with limited treatment options. Therefore, we aimed to screen for metabolites that have causal associations with preeclampsia and to predict target-mediated side effects based on Mendelian randomization (MR) analysis. A two-sample MR analysis was firstly conducted to systematically assess causal associations of blood metabolites with pre-eclampsia, by using metabolites related large-scale genome-wide association studies (GWASs) involving 147,827 European participants, as well as GWASs summary data about pre-eclampsia from the FinnGen consortium R8 release data that included 182,035 Finnish adult female subjects (5922 cases and 176,113 controls). Subsequently, a phenome-wide MR (Phe-MR) analysis was applied to assess the potential on-target side effects associated with hypothetical interventions that reduced the burden of pre-eclampsia by targeting identified metabolites. Four metabolites were identified as potential causal mediators for pre-eclampsia by using the inverse-variance weighted method, including cholesterol in large HDL (L-HDL-C) [odds ratio (OR): 0.88; 95% confidence interval (95% CI): 0.83-0.93; P = 2.14 × 10-5), cholesteryl esters in large HDL (L-HDL-CE) (OR: 0.88; 95% CI: 0.83-0.94; P = 5.93 × 10-5), free cholesterol in very large HDL (XL-HDL-FC) (OR: 0.88; 95% CI: 0.82-0.94; P = 1.10 × 10-4) and free cholesterol in large HDL (L-HDL-FC) (OR: 0.89; 95% CI: 0.84-0.95; P = 1.45 × 10-4). Phe-MR analysis showed that targeting L-HDL-CE had beneficial effects on the risk of 24 diseases from seven disease chapters. Based on this systematic MR analysis, L-HDL-C, L-HDL-CE, XL-HDL-FC, and L-HDL-FC were inversely associated with the risk of pre-eclampsia. Interestingly, L-HDL-CE may be a promising drug target for preventing pre-eclampsia with no predicted detrimental side effects. The study consists of a two-stage design that conducts MR at both stages. First, we assessed the causality for the associations between 194 blood metabolites and the risk of pre-eclampsia. Second, we investigated a broad spectrum of side effects associated with the targeting identified metabolites in 693 non-preeclampsia diseases. Our results suggested that Cholesteryl esters in large HDL may serve as a promising drug target for the prevention or treatment of pre-eclampsia with no predicted detrimental side effects.
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Affiliation(s)
- Yaling Ding
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China
| | - Mengxin Yao
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China
| | - Jiafeng Liu
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China
| | - Wanyi Fu
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China
| | - Xiaoyan Zhu
- Suzhou Center for Disease Prevention and Control, Suzhou, Jiangsu, China
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yelin He
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China
| | - Qiuping Ma
- Taicang Affiliated Hospital of Soochow University, The First People's Hospital of Taicang, 58 Changsheng Road, Suzhou, Jiangsu, 215413, China
| | - Chunhua Zhang
- The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Gusu School, Nanjing Medical University, Suzhou, Jiangsu, 215000, China
| | - Jieyun Yin
- Department of Epidemiology and Health Statistic, School of Public Health, Jiangsu Key Laboratory of Preventive and Translational Medicine for Geriatric Diseases, MOE Key Laboratory of Geriatric Diseases and Immunology, Suzhou Medical College of Soochow University, Suzhou, Jiangsu, 215123, P. R. China.
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Souter VL, Painter I, Khalil A. Reply. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:572-573. [PMID: 38561978 DOI: 10.1002/uog.27631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/28/2024] [Indexed: 04/04/2024]
Affiliation(s)
- V L Souter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - I Painter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Ghesquière L, Bujold E, Dubé E, Chaillet N. Comparison of National Factor-based Models for Preeclampsia Screening. Am J Perinatol 2024. [PMID: 38490251 DOI: 10.1055/s-0044-1782676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
OBJECTIVE This study aimed to compare the predictive values of the American College of Obstetricians and Gynecologists (ACOG), the National Institute for Health and Care Excellence (NICE), and the Society of Obstetricians and Gynecologists of Canada (SOGC) factor-based models for preeclampsia (PE) screening. STUDY DESIGN We conducted a secondary analysis of maternal and birth data from 32 hospitals. For each delivery, we calculated the risk of PE according to the ACOG, the NICE, and the SOGC models. Our primary outcomes were PE and preterm PE (PE combined with preterm birth) using the ACOG criteria. We calculated the detection rate (DR or sensitivity), the false positive rate (FPR or 1 - specificity), the positive (PPV) and negative (NPV) predictive values of each model for PE and for preterm PE using receiver operator characteristic (ROC) curves. RESULTS We used 130,939 deliveries including 4,635 (3.5%) cases of PE and 823 (0.6%) cases of preterm PE. The ACOG model had a DR of 43.6% for PE and 50.3% for preterm PE with FPR of 15.6%; the NICE model had a DR of 36.2% for PE and 41.3% for preterm PE with FPR of 12.8%; and the SOGC model had a DR of 49.1% for PE and 51.6% for preterm PE with FPR of 22.2%. The PPV for PE of the ACOG (9.3%) and NICE (9.4%) models were both superior than the SOGC model (7.6%; p < 0.001), with a similar trend for the PPV for preterm PE (1.9 vs. 1.9 vs. 1.4%, respectively; p < 0.01). The area under the ROC curves suggested that the ACOG model is superior to the NICE for the prediction of PE and preterm PE and superior to the SOGC models for the prediction of preterm PE (all with p < 0.001). CONCLUSION The current ACOG factor-based model for the prediction of PE and preterm PE, without considering race, is superior to the NICE and SOGC models. KEY POINTS · Clinical factor-based model can predict PE in approximately 44% of the cases for a 16% false positive.. · The ACOG model is superior to the NICE and SOGC models to predict PE.. · Clinical factor-based models are better to predict PE in parous than in nulliparous..
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Affiliation(s)
- Louise Ghesquière
- Reproduction, Mother and Child Health Unit, Research Center of the CHU de Québec, Université Laval, Québec City, QC, Canada
- Department of Obstetrics, Université de Lille, CHU de Lille, Lille, France
| | - Emmanuel Bujold
- Reproduction, Mother and Child Health Unit, Research Center of the CHU de Québec, Université Laval, Québec City, QC, Canada
- Department of Obstetrics, Gynecology and Reproduction, CHU de Québec-Université Laval, Québec City, QC, Canada
| | - Eric Dubé
- Reproduction, Mother and Child Health Unit, Research Center of the CHU de Québec, Université Laval, Québec City, QC, Canada
| | - Nils Chaillet
- Reproduction, Mother and Child Health Unit, Research Center of the CHU de Québec, Université Laval, Québec City, QC, Canada
- Department of Obstetrics, Gynecology and Reproduction, CHU de Québec-Université Laval, Québec City, QC, Canada
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Cowan A, Haverty C, MacDonald R, Khodursky A. Impact of early preeclampsia prediction on medication adherence and behavior change: a survey of pregnant and recently-delivered individuals. BMC Pregnancy Childbirth 2024; 24:196. [PMID: 38481154 PMCID: PMC10935975 DOI: 10.1186/s12884-024-06397-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Behavior change and medication adherence represent potential barriers to optimal prevention of pregnancy complications including preeclampsia. We sought to evaluate baseline sentiments on pregnancy care and medication amenability, and how these measures would be impacted by early predictive testing for preeclampsia. METHODS We developed a digital survey to query participants' baseline sentiments on pregnancy care, knowledge about pregnancy complications, and views on a hypothetical test to predict preeclampsia. The survey was administered online to pregnant and recently-delivered individuals in the United States. Survey data were analyzed using pooled two-sample proportion z-tests with adjustment for multiple comparisons. RESULTS One thousand and twenty-two people completed the survey. 84% reported they were satisfied with their pregnancy care. Self-assessed knowledge about preeclampsia was high, with 75% of respondents reporting they have a "good understanding" of preeclampsia, but measured knowledge was low, with only 10% able to identify five common signs/symptoms of preeclampsia. Notably, 40% of participants with prior preeclampsia believed they were at average or below-average risk for recurrence. 91% of participants desired early pregnancy predictive testing for preeclampsia. If found to be at high risk for preeclampsia, 88% reported they would be more motivated to follow their provider's medication recommendations and 94% reported they would desire home blood pressure monitoring. Increased motivation to follow clinicians' medication and monitoring recommendations was observed across the full spectrum of medication amenability. Individuals who are more medication-hesitant still reported high rates of motivation to change behavior and adhere to medication recommendations if predictive testing showed a high risk of preeclampsia. Importantly, a high proportion of medication-hesitant individuals reported that if a predictive test demonstrated they were at high risk of preeclampsia, they would feel more motivated to take medications (83.0%) and aspirin (75.9%) if recommended. CONCLUSION While satisfaction with care is high, participants desire more information about their pregnancy health, would value predictive testing for preeclampsia, and report they would act on this information. Improved detection of at-risk individuals through objective testing combined with increased adherence to their recommended care plan may be an important step to remedy the growing gap in prevention.
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Affiliation(s)
- Alison Cowan
- Mirvie, Inc., 820 Dubuque Ave, South San Francisco, CA, 94080, USA.
| | - Carrie Haverty
- Mirvie, Inc., 820 Dubuque Ave, South San Francisco, CA, 94080, USA
| | - Reece MacDonald
- Mirvie, Inc., 820 Dubuque Ave, South San Francisco, CA, 94080, USA
| | - Arkady Khodursky
- Mirvie, Inc., 820 Dubuque Ave, South San Francisco, CA, 94080, USA
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Demuth B, Pellan A, Boutin A, Bujold E, Ghesquière L. Aspirin at 75 to 81 mg Daily for the Prevention of Preterm Pre-Eclampsia: Systematic Review and Meta-Analysis. J Clin Med 2024; 13:1022. [PMID: 38398335 PMCID: PMC10888723 DOI: 10.3390/jcm13041022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Revised: 02/04/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
Background: Aspirin at 150 mg daily, initiated in the 1st trimester of pregnancy, prevents preterm pre-eclampsia. We aimed to estimate whether a dose of 75 to 81 mg daily can help to prevent preterm pre-eclampsia as well. Methods: A systematic search was conducted using multiple databases and meta-analyses of randomized controlled trials (RCTs) that compared aspirin initiated in the first trimester of pregnancy to placebo or no treatment, following the PRISMA guidelines and the Cochrane risk of bias tool. Results: We retrieved 11 RCTs involving 13,981 participants. Five RCTs had a low risk of bias, one at unclear risk, and fiver had a high risk of bias. A pooled analysis demonstrated that doses of 75 to 81 mg of aspirin, compared to a placebo or no treatment, was not associated with a significant reduction in preterm pre-eclampsia (8 studies; 12,391 participants; relative risk, 0.66; 95% confidence interval: 0.27 to 1.62; p = 0.36), but there was a significant heterogeneity across the studies (I2 = 61%, p = 0.02). Conclusion: It cannot be concluded that taking 75 to 81 mg of aspirin daily reduces the risk of preterm pre-eclampsia. However, given the significant heterogeneity between the studies, the true effect that such a dose of aspirin would have on pregnancy outcomes could not be properly estimated.
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Affiliation(s)
- Brielle Demuth
- Centre de Recherche du CHU de Québec, Université Laval, Québec, QC G1V 0A6, Canada; (B.D.); (A.B.); (L.G.)
| | - Ariane Pellan
- Centre de Recherche du CHU de Québec, Université Laval, Québec, QC G1V 0A6, Canada; (B.D.); (A.B.); (L.G.)
| | - Amélie Boutin
- Centre de Recherche du CHU de Québec, Université Laval, Québec, QC G1V 0A6, Canada; (B.D.); (A.B.); (L.G.)
- Department of Pediatry, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Emmanuel Bujold
- Centre de Recherche du CHU de Québec, Université Laval, Québec, QC G1V 0A6, Canada; (B.D.); (A.B.); (L.G.)
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Québec, QC G1V 0A6, Canada
| | - Louise Ghesquière
- Centre de Recherche du CHU de Québec, Université Laval, Québec, QC G1V 0A6, Canada; (B.D.); (A.B.); (L.G.)
- Department of Obstetrics, Centre Hospitalier Universitaire de Lille, 59000 Lille, France
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Bekele D, Gudu W, Tolu LB, Birara M, Sium AF. Preeclampsia prevention: a survey study on knowledge and practice among prenatal care providers in Ethiopia. AJOG GLOBAL REPORTS 2024; 4:100300. [PMID: 38318266 PMCID: PMC10839527 DOI: 10.1016/j.xagr.2023.100300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Knowledge and practice gaps among providers have been cited as factors behind the underuse of aspirin for preeclampsia prevention globally. OBJECTIVE This study aimed to determine the knowledge and practice levels of prenatal care providers at a national tertiary referral hospital in Ethiopia and its catchment health institutions. STUDY DESIGN This was a cross-sectional survey on the knowledge and practice of preeclampsia prevention through aspirin prophylaxis among prenatal care providers at St. Paul's Hospital Millennium Medical College (Ethiopia) and its catchment health institutions. Data were collected prospectively using a structured questionnaire on ODK (Get ODK Inc, San Diego, CA). The primary objective of our study was to determine the knowledge and practice levels among prenatal care providers. Data were analyzed using SPSS software (version 23; IBM, Chicago, IL). Simple descriptive analyses were performed to analyze the data. Proportions and percentages were used to present the results. RESULTS A total of 92 prenatal care providers working at 17 health institutions were approached, and 80 of them agreed to participate in the study, constituting a response rate of 87%. The mean scores of knowledge and practice of preeclampsia prevention using aspirin were 42.90 (±0.13) and 45.8 (±0.07), respectively. Most of the providers had poor knowledge (score of <50%) and poor practice (score of <50%). Among the 80 prenatal care providers, only 19 (23.8%) had good knowledge, and only 29 (36.3%) had good practice. More than half of the respondents (49/80 [61.3%]) mentioned "lack of national guidelines for use of aspirin in pregnancy" as the main factor that affected their practice of aspirin prophylaxis for preeclampsia prevention in pregnant women. Among the resources used as a reference for the practice of aspirin prophylaxis for preeclampsia prevention, International Federation of Gynecology and Obstetrics or World Health Organization guidelines (45/80 [56.3%]) were the most frequently used resources, followed by American College of Obstetricians and Gynecologists guidelines (36/80 [45.0%]) and clinical judgment (36/80 [45.0%]). CONCLUSION Our results support previous reports of significant knowledge-to-practice gaps in the use of aspirin prophylaxis for preeclampsia prevention among prenatal care providers. Moreover, the results underscore the need for immediate action in narrowing this gap among providers by availing practical national guidelines for preeclampsia prevention and in-service trainings.
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Affiliation(s)
- Delayehu Bekele
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Wondimu Gudu
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Lemi Belay Tolu
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Malede Birara
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
| | - Abraham Fessehaye Sium
- Department of Obstetrics and Gynecology, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia
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Zhang L, Wang W, Gong J, Wang X, Liang J, Gu S, Su M, Bi S, Sun M, Chen J, Zheng W, Wu J, Wang Z, Liu J, Li H, Chen D, Du L. Development, validation, and clinical utility of a risk prediction model for recurrent preeclampsia. J Hypertens 2024; 42:236-243. [PMID: 37796172 DOI: 10.1097/hjh.0000000000003580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES We aim to establish a predictive model for recurrent preeclampsia. METHODS A retrospective review of medical records from three hospitals between 2010 and 2021 was conducted. The study included women who had two consecutive singleton deliveries at the same hospital, with the first delivery complicated by preeclampsia. A multivariable logistic regression model was constructed using a training cohort, and subsequently cross-validated and tested using an independent cohort. The model's performance was assessed in terms of discrimination and calibration, and its clinical utility was evaluated using decision curve analysis (DCA). RESULTS Among 296 405 deliveries, 694 women met the inclusion criteria, with 151 (21.8%) experiencing recurrent preeclampsia. The predictive model incorporated 10 risk factors from previous preeclampsia, including gestational weeks with elevated blood pressure, gestational diabetes mellitus (GDM), pericardial effusion, heart failure, limb edema, serum creatinine, white blood cell count, low platelet counts within one week before delivery, SBP on the first postpartum day, and postpartum antihypertensive use. Additionally, one risk factor from the index pregnancy was included, which was antihypertensive use before 20 weeks. The model demonstrated better discrimination, calibration, and a net benefit across a wide range of recurrent preeclampsia risk thresholds. Furthermore, the model has been translated into a clinical risk calculator, enabling clinicians to calculate individualized risks of recurrent preeclampsia. CONCLUSION Our study demonstrates that a predictive tool utilizing routine clinical and laboratory factors can accurately estimate the risk of recurrent preeclampsia. This predictive model has the potential to facilitate shared decision-making by providing personalized and risk-stratified care.
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Affiliation(s)
- Lizi Zhang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weiwei Wang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Jingjin Gong
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Xinghe Wang
- Dongguan Maternal and Children Health Hospital
| | - Jingying Liang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shifeng Gu
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Minglian Su
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shilei Bi
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Manna Sun
- Dongguan Maternal and Children Health Hospital
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weitan Zheng
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Junwei Wu
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Jianmeng Liu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Hongtian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Lili Du
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
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Bank TC, Kline D, Costantine MM. Challenges in Conducting Clinical Trials for Preeclampsia. Curr Hypertens Rep 2024; 26:59-68. [PMID: 37971596 DOI: 10.1007/s11906-023-01276-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2023] [Indexed: 11/19/2023]
Abstract
PURPOSE OF REVIEW To review recent data describing the challenges and innovations in therapeutic research focused on the prevention and treatment of preeclampsia. RECENT FINDINGS Pregnant individuals have traditionally been excluded from therapeutic research, resulting in a paucity of innovation in therapeutics for pregnancy-specific medical conditions, especially preeclampsia. With the increased awareness of maternal morbidity and mortality, there is significant interest among researchers to expand therapeutic research in pregnancy. Several medications, including aspirin, pravastatin, metformin, and esomeprazole, which are commonly used in non-pregnant populations, are now being investigated for preeclampsia prevention. However, given the historic precedent of exclusion, along with the regulatory, ethical, and feasibility concerns that accompany this population, the study of these and novel medications has been complicated by numerous challenges. While complex, and laden with challenges, there is great ongoing need for therapeutic research to address preeclampsia. Aspirin, pravastatin, metformin, and esomeprazole have all shown promise as potential therapeutic agents; however, their use remains to be optimized, and innovative therapeutics need to be developed.
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Affiliation(s)
- T Caroline Bank
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA.
| | - Diana Kline
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Maged M Costantine
- Division of Maternal Fetal Medicine, Department of Obstetrics & Gynecology, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Zhao J, Duan R, Sun J, Chow RP, Lyons TJ, Yu JY. An Examination of the Effect of Aspirin and Salicylic Acid on Soluble Fms-like Tyrosine Kinase-1 Release from Human Placental Trophoblasts. Cells 2024; 13:113. [PMID: 38247805 PMCID: PMC10813906 DOI: 10.3390/cells13020113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 12/30/2023] [Accepted: 01/01/2024] [Indexed: 01/23/2024] Open
Abstract
Low-dose aspirin (LDA) is efficacious in preventing preeclampsia, but its mechanism of action is unclear. Conflicting evidence suggests that it may inhibit placental trophoblast release of soluble fms-like tyrosine kinase-1 (sFlt1), a key mediator of preeclampsia. We examined whether, and at what concentrations, aspirin and its principal metabolite, salicylic acid, modulate sFlt1 release and/or expression in trophoblasts. Human trophoblast lines BeWo and HTR-8/SVneo were cultured; BeWo cells were also treated with 1% oxygen vs. normoxia to mimic hypoxia in preeclamptic placentas. Cells were treated with aspirin or salicylic acid vs. vehicle for 24 h at concentrations relevant to LDA and at higher concentrations. Protein concentrations (ELISA) and mRNA expression (RT-PCR) of sFlt1 were determined. Under normoxia, LDA-relevant concentrations of aspirin (10-50 µmol/L) or salicylic acid (20-100 µmol/L) had no significant effect on sFlt1 protein release or mRNA expression in BeWo cells. However, inhibition was observed at higher concentrations (1 mmol/L for aspirin and ≥200 μmol/L for salicylic acid). Hypoxia enhanced sFlt1 protein release and mRNA expression in BeWo cells, but these responses were not significantly affected by either aspirin or salicylic acid at LDA concentrations. Similarly, neither drug altered sFlt1 protein secretion or mRNA expression in normoxic HTR-8/SVneo cells at LDA concentrations. We suggest that direct modulation of trophoblast release or expression of sFlt1 is unlikely to be a mechanism underlying the clinical efficacy of LDA in preeclampsia.
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Affiliation(s)
- Jiawu Zhao
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK; (J.Z.); (R.P.C.); (T.J.L.)
| | - Rui Duan
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA; (R.D.); (J.S.)
| | - Jinghui Sun
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA; (R.D.); (J.S.)
| | - Rebecca P. Chow
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK; (J.Z.); (R.P.C.); (T.J.L.)
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA; (R.D.); (J.S.)
| | - Timothy J. Lyons
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK; (J.Z.); (R.P.C.); (T.J.L.)
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA; (R.D.); (J.S.)
- Diabetes Free South Carolina, BlueCross BlueShield of South Carolina, Columbia, SC 29229, USA
| | - Jeremy Y. Yu
- Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast BT9 7BL, UK; (J.Z.); (R.P.C.); (T.J.L.)
- Division of Endocrinology, Diabetes and Metabolic Diseases, Department of Medicine, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC 29425, USA; (R.D.); (J.S.)
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Shree R, MacKinnon HJ, Hannan J, Kolarova TR, Reichel J, Lockwood CM. Anticoagulation use is associated with lower fetal fraction and more indeterminate results. Am J Obstet Gynecol 2024; 230:95.e1-95.e10. [PMID: 37429430 PMCID: PMC10772208 DOI: 10.1016/j.ajog.2023.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 06/30/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Maternal anticoagulation use may increase indeterminate result rates on cell-free DNA-based screening, but existing studies are confounded by inclusion of individuals with autoimmune disease, which alone is associated with indeterminate results. Changes in chromosome level Z-scores are proposed by others as a reason for indeterminate results, but the etiology of this is uncertain. OBJECTIVE This study aimed to evaluate differences in fetal fraction, indeterminate result rate, and total cell-free DNA concentration in individuals on anticoagulation without autoimmune disease compared with controls undergoing noninvasive prenatal screening. Secondly, using a nested case-control design, we evaluated differences in fragment size, GC-content, and Z-scores to evaluate laboratory-level test characteristics. STUDY DESIGN This was a retrospective single-institution study of pregnant individuals undergoing cell-free DNA-based noninvasive prenatal screening using low-pass whole-genome sequencing between 2017 and 2021. Individuals with autoimmune disease, suspected aneuploidy, and cases where fetal fraction was not reported were excluded. Anticoagulation included heparin-derived products (unfractionated heparin, low-molecular-weight heparin), clopidogrel, and fondaparinux, with a separate group for those on aspirin alone. An indeterminate result was defined as fetal fraction <4%. We evaluated the association between maternal anticoagulation or aspirin use, and fetal fraction, indeterminate results, and total cell-free DNA concentration using univariate and multivariate analyses, controlling for body mass index, gestational age at sample collection, and fetal sex. For the anticoagulation cohort, we compared laboratory-level test characteristics among cases (on anticoagulation) and a subset of controls. Lastly, we evaluated for differences in chromosome level Z-scores among those on anticoagulation with and without indeterminate results. RESULTS A total of 1707 pregnant individuals met the inclusion criteria. Of those, 29 were on anticoagulation and 81 were on aspirin alone. For those on anticoagulation, the fetal fraction was significantly lower (9.3% vs 11.7%; P<.01), the indeterminate result rate was significantly higher (17.2% vs 2.7%; P<.001), and the total cell-free DNA concentration was significantly higher (218 pg/μL vs 83.7 pg/μL; P<.001). Among those on aspirin alone, the fetal fraction was lower (10.6% vs 11.8%; P=.04); however, there were no differences in the rate of indeterminate results (3.7% vs 2.7%; P=.57) or total cell-free DNA concentration (90.1 pg/μL vs 83.8 pg/μL; P=.31). After controlling for maternal body mass index, gestational age at sample collection, and fetal sex, anticoagulation was associated with an >8-fold increase in the likelihood of an indeterminate result (adjusted odds ratio, 8.7; 95% confidence interval, 3.1-24.9; P<.001), but not aspirin (adjusted odds ratio, 1.2; 95% confidence interval, 0.3-4.1; P=.8). Anticoagulation was not associated with appreciable differences in cell-free DNA fragment size or GC-content. Although differences in chromosome 13 Z-scores were observed, none were observed for chromosomes 18 or 21, and this difference did not contribute to the indeterminate result call. CONCLUSION In the absence of autoimmune disease, anticoagulation use, but not aspirin, is associated with lower fetal fraction, higher total cell-free DNA concentration, and higher rates of indeterminate results. Anticoagulation use was not accompanied by differences in cell-free DNA fragment size or GC-content. Statistical differences in chromosome level Z-scores did not clinically affect aneuploidy detection. This suggests a likely dilutional effect by anticoagulation on cell-free DNA-based noninvasive prenatal screening assays contributing to low fetal fraction and indeterminate results, and not laboratory or sequencing-level changes.
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Affiliation(s)
- Raj Shree
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA.
| | - Hayley J MacKinnon
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Joely Hannan
- University of Washington School of Medicine, University of Washington, Seattle, WA
| | - Teodora R Kolarova
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA
| | - Jonathan Reichel
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
| | - Christina M Lockwood
- Department of Laboratory Medicine & Pathology, University of Washington, Seattle, WA
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Purohit A, Kim YJ, Michos ED. Cardiovascular disease prevention in women - the current state in 2023. Curr Opin Cardiol 2024; 39:54-60. [PMID: 37921758 DOI: 10.1097/hco.0000000000001099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
PURPOSE OF REVIEW Cardiovascular disease (CVD) remains a leading cause of morbidity and mortality for women globally. The purpose of this review is to provide an updated overview of CVD prevention in women, focusing on what is currently understood about female-specific or female-predominant CVD risk factors and the importance of tailored strategies for risk assessment and medical interventions. RECENT FINDINGS Recent studies have demonstrated the need to account for risk factors specific to women in current risk assessment models for CVD, including early menarche, polycystic ovary syndrome, adverse pregnancy outcomes, early menopause, and chronic inflammatory conditions. Incorporation of these findings has led to advancements in sex-specific guidelines, diagnostic tools, and treatment approaches that have led to improvement in the precision of CVD prevention strategies. At-risk women benefit similarly to lipid-lowering and other preventive therapies as men but are less likely to be treated. SUMMARY CVD prevention in women has made substantial progress over the past decade, marked by increasing awareness among clinicians, improved understanding of sex-specific risk-enhancing factors, and incorporation of sex-specific guidelines for management. However, there remain knowledge gaps that warrant ongoing efforts to optimize CVD prevention strategies in women, which will ultimately lead to improved cardiovascular health outcomes.
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Affiliation(s)
| | | | - Erin D Michos
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Okun N, Hoffman B, Johnson J, Biringer A, Shapiro J, Felix C, Van Mieghem T, Abbasi N, Metcalfe A, Maxey C, Snelgrove JW. Implementation of Multiple Marker Screening for Preterm Preeclampsia in a Single Tertiary Obstetric Centre. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2024; 46:102220. [PMID: 37726059 DOI: 10.1016/j.jogc.2023.102220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 09/05/2023] [Accepted: 09/05/2023] [Indexed: 09/21/2023]
Abstract
OBJECTIVES Early assessment of pregnant individuals for risk of preterm preeclampsia (PE) is possible at the 11-14 week ultrasound visit using a validated multiple marker algorithm, allowing timely use of preventative low-dose acetylsalicylic acid (LDA) in high-risk patients. With no established early screening program for preterm PE in Canada, our objectives were to assess the acceptability and operational impact of routine screening for preterm PE during the 11-14 week ultrasound visit, evaluate uptake and adherence to LDA when recommended, and assess screening performance. METHODS A prospective implementation study of preterm PE screening among pregnant patients at the ultrasound unit of a tertiary obstetric centre in Toronto, Canada. RESULTS A total of 1057 patients were screened, with an acceptance rate of 87.1%. First-trimester ultrasound appointment time increased by a median time of 7 minutes (Interquartile range 6-9). By 16 weeks gestation, 88.7% of high-risk patients had started LDA, with adherence of 88.7%‒94.6% from 16‒36 weeks. Satisfaction with counselling was ≥7/10 in more than 95% of patients. There were 7 cases of preterm PE (0.73%), 3 in the low-risk group (0.35%), and 4 in the high-risk group (4.1%). When accounting for LDA use, the treatment-adjusted detection rate was 78.6%. CONCLUSIONS We demonstrate successful implementation of a validated, effective screening and prevention program for preterm PE as a first step in the implementation of a broader program adaptable for cultural, access/equity considerations, and marker availability.
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Affiliation(s)
- Nanette Okun
- Sunnybrook Health Sciences Centre DAN Women and Babies Program and Maternal-Fetal Medicine, University of Toronto, Toronto, ON; Prenatal Screening Ontario, Toronto, ON.
| | - Barry Hoffman
- Laboratory Medicine and Pathobiology, Mount Sinai Hospital, University of Toronto, Toronto, ON
| | - JoAnn Johnson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Anne Biringer
- Department of Family Medicine, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Jodi Shapiro
- Department of Obstetrics and Gynecology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Carmen Felix
- Midwives Collective, and Mount Sinai Hospital, Toronto, ON
| | - Tim Van Mieghem
- Fetal Medicine Unit and Ontario Fetal Centre, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Nimrah Abbasi
- Fetal Medicine Unit and Ontario Fetal Centre, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, ON
| | - Amy Metcalfe
- Departments of Obstetrics and Gynecology, Medicine and Community Health Sciences, Maternal and Child Health Program, Alberta Children's Hospital Research Institute and University of Calgary, Calgary, AB
| | - Connor Maxey
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - John W Snelgrove
- Division of Maternal Fetal Medicine, Mount Sinai Hospital, University of Toronto, Toronto, ON
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Liabsuetrakul T, Yamamoto Y, Kongkamol C, Ota E, Mori R, Noma H. Maternal-neonatal events resulting from medications for preventing hypertensive disorders in high-risk pregnant women: A systematic review and network meta-analysis. Int J Gynaecol Obstet 2024; 164:19-32. [PMID: 37332168 DOI: 10.1002/ijgo.14910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/05/2023] [Accepted: 05/16/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND There have been few studies reporting on maternal and neonatal events in high-risk pregnant women receiving medications for preventing hypertensive disorders of pregnancy (HDP). OBJECTIVE To identify placental abruption, postpartum hemorrhage, neonatal intraventricular hemorrhage, and neonates with small for gestational age (SGA) or growth restriction resulting from medications for preventing HDP in high-risk pregnant women using a network meta-analysis. SEARCH STRATEGY All randomized controlled trials comparing the most commonly used medications (antiplatelet agents, anticoagulants, antioxidants, nitric oxide, and calcium) for preventing HDP in high-risk pregnant women were searched from the Cochrane Pregnancy and Childbirth's Specialized Register of Controlled Trials until July 31, 2020, without language restriction. SELECTION CRITERIA Two of the authors independently selected the eligible trials. DATA COLLECTION AND ANALYSIS Two authors independently extracted the data and assessed the methodological quality of the included trials. Pairwise and network meta-analyses were used to determine comparative risk ratios and 95% confidence intervals. MAIN RESULTS The 51 included trials involved 69 669 pregnant women. Compared with placebo/no treatment, antioxidants slightly reduced placental abruption with high-certainty evidence. Antiplatelet agents probably reduced SGA with low-certainty evidence and slightly increased neonatal intraventricular hemorrhage with moderate-certainty evidence. CONCLUSION Antiplatelet agents probably reduce SGA, but neonatal intraventricular hemorrhage should be monitored. SYSTEMATIC REVIEW REGISTRATION PROSPERO, CRD42018096276.
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Affiliation(s)
- Tippawan Liabsuetrakul
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Yoshiko Yamamoto
- Department of Health Policy, National Center for Child Health and Development, Setagaya-ku, Japan
| | - Chanon Kongkamol
- Department of Family and Preventive Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | - Rintaro Mori
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hisashi Noma
- Department of Data Science, The Institute of Statistical Mathematics, Tokyo, Japan
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Souter V, Painter I, Sitcov K, Khalil A. Propensity score analysis of low-dose aspirin and bleeding complications in pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:81-87. [PMID: 37674400 DOI: 10.1002/uog.27472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 09/08/2023]
Abstract
OBJECTIVE Low-dose aspirin (LDA) has been shown to reduce the risk of preterm pre-eclampsia and it has been suggested that it should be recommended for all pregnancies. However, some studies have reported an association between LDA and an increased risk of bleeding complications in pregnancy. Our aim was to evaluate the risk of placental abruption and postpartum hemorrhage (PPH) in patients for whom their healthcare provider had recommended prophylactic aspirin. METHODS This multicenter cohort study included 72 598 singleton births at 19 hospitals in the USA, between January 2019 and December 2021. Pregnancies complicated by placenta previa/accreta, birth occurring at less than 24 weeks' gestation, multiple pregnancy or those with data missing for aspirin recommendation were excluded. Propensity scores were calculated using 20 features spanning sociodemographic factors, medical history, year and hospital providing care. The association between LDA recommendation and placental abruption or PPH was estimated by inverse-probability treatment weighting using the propensity scores. RESULTS We included 71 627 pregnancies in the final analysis. Aspirin was recommended to 6677 (9.3%) and was more likely to be recommended for pregnant individuals who were 35 years or older (P < 0.001), had a body mass index of 30 kg/m2 or higher (P < 0.001), had prepregnancy hypertension (P < 0.001) and who had a Cesarean delivery (P < 0.001). Overall, 1.7% of the study cohort (1205 pregnancies) developed preterm pre-eclampsia: 1.3% in the no-aspirin and 5.8% in the aspirin group. After inverse-probability weighting with propensity scores, aspirin was associated with increased risk of placental abruption (adjusted odds ratio (aOR), 1.44 (95% CI, 1.04-2.00)) and PPH (aOR, 1.21 (95% CI, 1.05-1.39)). The aOR translated to a number needed to harm with LDA of 79 (95% CI, 43-330) for PPH and 287 (95% CI, 127-3151) for placental abruption. CONCLUSIONS LDA recommendation in pregnancy was associated with increased risk for placental abruption and for PPH. Our results support the need for more research into aspirin use and bleeding complications in pregnancy before recommending it beyond the highest-risk pregnancies. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- V Souter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - I Painter
- Foundation for Health Care Quality, Seattle, WA, USA
| | - K Sitcov
- Foundation for Health Care Quality, Seattle, WA, USA
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Boelig RC, Kaushal G, Rochani A, McKenzie SE, Kraft WK. Aspirin pharmacokinetics and pharmacodynamics through gestation. Am J Obstet Gynecol 2023:S0002-9378(23)02183-X. [PMID: 38145726 DOI: 10.1016/j.ajog.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Low dose aspirin is recommended for prevention of preeclampsia, however there is not consensus on the appropriate dose. Pregnancy specific changes have the potential to impact the pharmacology of aspirin in pregnancy, however there are very limited studies on aspirin pharmacokinetics in pregnancy and none linking pharmacokinetics (PK, drug dose and drug level) to pharmacodynamics (PD, drug dose and physiologic response) in pregnancy. As a result, we do not have a good understanding of the pharmacologic response to aspirin in pregnancy, which has important implications for clinical efficacy. We sought to describe the PK and PD of aspirin through pregnancy and to identify individual covariates that impacted aspirin PK/PD. OBJECTIVE We sought to describe the PK and PD of aspirin through pregnancy (first and third trimester), to identify covariates that significantly impact aspirin PK and to identify the relationship between aspirin PK and PD. STUDY DESIGN This is a prospective study of patients at high risk for preeclampsia recommended to take 81 mg aspirin daily. This study involved 3 visits as follows: (1) baseline, first trimester (10-16 weeks of gestation) 6-hour PK visit, done before initiation of aspirin; (2) follow-up 1: 2 to 4 weeks after aspirin initiation; and (3) follow-up 2: third trimester 6-hour PK visit (28-32 weeks of gestation). The following were assessed at each visit: weight or body mass index, platelet function analysis-100 (Siemens), urinary thromboxane B2, serum thromboxane B2, and plasma salicylic acid. The PK visits consisted of blood work done at baseline (predose), administration of 81 mg nonenteric coated aspirin, and then plasma blood level of salicylic acid assessed at 30 minutes and then hourly 1 to 6 hours after dose. Pearson correlation and multivariable regression were used to identify associations between parameters and identify relevant covariates. Log-adjusted values were used for regression analysis. P<.05 was considered statistically significant. RESULTS Nineteen participants were included with first trimester data, and 16 with third trimester data. There was no statistically significant change in mean PK parameters between the first and third trimester, although there was a trend to lower peak concentration in the third than in the first trimester (P=.08). In multivariable regression, baseline obesity and current body mass index as a continuous measures were negatively associated with log-adjusted peak salicylic acid concentration (-0.28 [-0.46 to -0.11], P=.003 and -0.02 [-0.03 to -0.009], P=.001, respectively) and log-adjusted plasma salicylic acid area under the curve 0 to 6 hours postdose (-0.25 [-0.45 to 0.05], P=.02, -0.04 [-0.07 to -0.01], P=.008 respectively). There was a significant decrease in urinary thromboxane 2 to 4 weeks after aspirin initiation compared with baseline, which correlated with a concomitant increase in platelet function analysis-100 closure time. In multivariable regression model, there was a strong association between plasma salicylic acid concentration (area under the curve 0-6 hours postdose) and urinary thromboxane (B=-3.12 [-5.38 to -1.04], P=.006), and with urinary thromboxane suppression and platelet inhibition, platelet function analysis-100 (-0.23 [-0.31 to -0.14], P<.001). With progressive thromboxane suppression, platelet inhibition (platelet function analysis-100 closure time) increased. Individual comorbidities, including weight, hypertension, and pregestational diabetes (Type I or II), also impacted aspirin response. CONCLUSION We have demonstrated the relationship between individual factors, plasma concentrations of salicylic acid, thromboxane suppression, and platelet inhibition at a single dose (81 mg) of aspirin taken through pregnancy. Our findings suggest that dose modification of aspirin in pregnancy may help to achieve the optimal response. Our results may be used to facilitate computational modeling to identify optimal dosing, taking into consideration individual factors.
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Gagan Kaushal
- College of Pharmacy, Thomas Jefferson University, Philadelphia, PA
| | - Ankit Rochani
- Wegmans School of Pharmacy, St. John Fisher University, Rochester, NY
| | - Steven E McKenzie
- Division of Hematology, Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Walter K Kraft
- Department of Pharmacology, Physiology, and Cancer Biology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
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Nissim OA, Haney A, Lazenby GB. Effect of tenofovir alafenamide in combination with and without integrase inhibitors on weight gain, diabetes, and hypertensive disorders of pregnancy. Pregnancy Hypertens 2023; 34:47-52. [PMID: 37804587 DOI: 10.1016/j.preghy.2023.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 09/18/2023] [Accepted: 09/23/2023] [Indexed: 10/09/2023]
Abstract
OBJECTIVES We sought to determine if tenofovir alafenamide (TAF) was associated with excessive weight gain, diabetes (DM), and hypertensive disorders of pregnancy (HDP) in persons with HIV. STUDY DESIGN This is a retrospective cohort study of pregnant persons with HIV prescribed antiretroviral therapy (ART) during the period of 01/01/2009 to 12/31/2020. MAIN OUTCOMES MEASURES χ2 tests were used to compare the proportion of persons with excessive weight gain, DM, and HDP according to ART regimens. Excess total gestational weight gain was calculated using BMI and Institute of Medicine recommendations for weight gain in pregnancy. HDP included gestational hypertension and preeclampsia. Logistic regression models were used to determine predictors of excessive weight gain, DM, and HDP. RESULTS We identified 189 pregnant persons prescribed ART with (30) and without TAF (159). The percentage of persons with excessive gestational weight gain was not significantly different in persons prescribed TAF (32 %) and other ART (17 %), p = 0.2. Persons prescribed TAF were more likely to have HDP (30 %) compared to other ART (9 %), p = 0.001. In the adjusted analysis, DM [aOR 6.2 (95 % CI 1.2-32.7)] and TAF exposure [aOR 3.2 (95 % CI 1.0-8.9)] were significantly associated with HDP. CONCLUSION Despite similar gestational weight gain, persons with HIV prescribed TAF were more likely to have HDP. Further understanding of the metabolic and cardiovascular impact of ART recommended for use during pregnancy is needed.
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Affiliation(s)
- Oriel A Nissim
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Haney
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA
| | - Gweneth Bratton Lazenby
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, SC, USA.
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Ishmail H, Khaliq OP, Ngene NC. The role of genetics in maternal susceptibility to preeclampsia in women of African ancestry. J Reprod Immunol 2023; 160:104139. [PMID: 37683532 DOI: 10.1016/j.jri.2023.104139] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023]
Abstract
Racial disparities exist in the prevalence of preeclampsia (PE), with women of African ancestry suffering the highest rates of morbidity and mortality. Genetic changes may play a role in the preponderance of PE among women of African ancestry. This review discusses 30 genes with variants that have been studied in PE in women of African ancestry. These studies found that a single gene is not responsible for PE susceptibility as 13 genes have been implicated. These genes subserve endothelial, immune, hemodynamic, homeostatic, thrombophilic, oxidative stress, and lipid metabolic pathways. Notably, maternal-fetal gene interactions also contribute to the susceptibility of the disease. For instance, the maternal KIR AA genotype and paternally inherited fetal HLA-C2 genotype confer risk for developing PE. Additionally, genetic changes such as epigenetic modulation of expression of the MTHFR gene through DNA methylation is also associated with the occurrence of PE. In contrast, some genes such as the KIR B centromeric region protect against development of PE in some women. The soluble fms-like tyrosine kinase 1 (sFlt-1) contributes to the development of PE and is a potential novel therapeutic option for targeted gene silencing of anti-angiogenic sFLT-1 gene. Additionally, NOS3 gene is an important target for pharmacogenomics because it is responsible for the production of endothelial nitric oxide. In conclusion, maternal genetic and epigenetic variants confer susceptibility to PE, indicating the need for further studies to develop a screening tool incorporating maternal genetic variants to identify women at high risk for PE and offer them a preventive therapy.
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Affiliation(s)
- Habiba Ishmail
- Department of Obstetrics and Gynecology, Leratong Hospital, Krugersdorp, South Africa.
| | - Olive Pearl Khaliq
- Department of Paediatrics, University of Free State, Bloemfontein, South Africa
| | - Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynecology, Leratong Hospital, Krugersdorp, South Africa; Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Jones Pullins M, Boggess K, Porter TF. Aspirin in Pregnancy. Obstet Gynecol 2023; 142:1333-1340. [PMID: 37917941 DOI: 10.1097/aog.0000000000005429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/31/2023] [Indexed: 11/04/2023]
Abstract
Preeclampsia is associated with significant perinatal morbidity and mortality. Aspirin has been long purported and extensively studied for prevention of preeclampsia. For this reason, the U.S. Preventive Services Task Force, the American College of Obstetricians and Gynecologists, and the Society for Maternal-Fetal Medicine recommend its use in pregnancy for preeclampsia prevention in those at high risk. Yet, much controversy exists regarding optimal use in pregnancy with guidelines across global organizations varying. In this narrative review, we summarize the published literature related to the safety, optimal dose, and timing and duration of use of aspirin, as well as other indications for which aspirin has been studied in pregnancy.
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Affiliation(s)
- Maura Jones Pullins
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; and the Division of Maternal-Fetal Medicine, Intermountain Healthcare, Salt Lake City, Utah
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Fitzgerald E, Shen M, Yong HEJ, Wang Z, Pokhvisneva I, Patel S, O'Toole N, Chan SY, Chong YS, Chen H, Gluckman PD, Chan J, Lee PKM, Meaney MJ. Hofbauer cell function in the term placenta associates with adult cardiovascular and depressive outcomes. Nat Commun 2023; 14:7120. [PMID: 37963865 PMCID: PMC10645763 DOI: 10.1038/s41467-023-42300-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/05/2023] [Indexed: 11/16/2023] Open
Abstract
Pathological placental inflammation increases the risk for several adult disorders, but these mediators are also expressed under homeostatic conditions, where their contribution to adult health outcomes is unknown. Here we define an inflammation-related expression signature, primarily expressed in Hofbauer cells of the term placenta and use expression quantitative trait loci to create a polygenic score (PGS) predictive of its expression. Using this PGS in the UK Biobank we conduct a phenome-wide association study, followed by Mendelian randomization and identify protective, sex-dependent effects of the placental module on cardiovascular and depressive outcomes. Genes differentially regulated by intra-amniotic infection and preterm birth are over-represented within the module. We also identify aspirin as a putative modulator of this inflammation-related signature. Our data support a model where disruption of placental Hofbauer cell function, due to preterm birth or prenatal infection, contributes to the increased risk of depression and cardiovascular disease observed in these individuals.
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Affiliation(s)
- Eamon Fitzgerald
- Sackler Program for Epigenetics and Psychobiology, McGill University, Montréal, Canada.
- Ludmer Centre for Neuroinformatics and Mental Health, McGill University, Montréal, Canada.
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada.
| | - Mojun Shen
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore
| | - Hannah Ee Juen Yong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore
| | - Zihan Wang
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada
| | - Irina Pokhvisneva
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada
| | - Sachin Patel
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada
| | - Nicholas O'Toole
- Sackler Program for Epigenetics and Psychobiology, McGill University, Montréal, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, McGill University, Montréal, Canada
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada
| | - Shiao-Yng Chan
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Yap Seng Chong
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Helen Chen
- KK Women's and Children's Hospital, Singapore, Singapore
- Duke-National University of Singapore, Singapore, Singapore
| | - Peter D Gluckman
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore
- The University of Auckland, Auckland, New Zealand
| | - Jerry Chan
- KK Women's and Children's Hospital, Singapore, Singapore
- Duke-National University of Singapore, Singapore, Singapore
| | - Patrick Kia Ming Lee
- Brain - Body Initiative, Agency for Science, Technology & Research, Singapore, Singapore
| | - Michael J Meaney
- Sackler Program for Epigenetics and Psychobiology, McGill University, Montréal, Canada.
- Douglas Mental Health University Institute, Department of Psychiatry, McGill University, Montréal, Canada.
- Singapore Institute for Clinical Sciences, Agency for Science, Technology & Research, Singapore, Singapore.
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.
- Brain - Body Initiative, Agency for Science, Technology & Research, Singapore, Singapore.
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Hughes ZH, Hughes LM, Khan SS. Genetic contributions to risk of adverse pregnancy outcomes. CURRENT CARDIOVASCULAR RISK REPORTS 2023; 17:185-193. [PMID: 38186860 PMCID: PMC10768680 DOI: 10.1007/s12170-023-00729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/01/2023] [Indexed: 01/09/2024]
Abstract
Purpose of Review Adverse pregnancy outcomes (APOs), including hypertensive disorders of pregnancy (HDP), low birthweight (LBW), and preterm birth (PTB), along with peripartum cardiomyopathy (PPCM) are associated with short- and long-term maternal and fetal cardiovascular risks. This review focuses on the genetic contributions to the risk of APOs and PPCM. Recent Findings The expansion of genome-wide association studies (GWAS) has led to better understanding of the biologic mechanisms underpinning APO, PPCM, and the predisposition to cardiovascular disease across the life course. Genetic loci known to be involved with the risk of hypertension (FTO, ZNF831) have been associated with the development of overall HDP and preeclampsia. Additionally, four loci significantly associated with type 2 diabetes have been associated with GDM (CDKAL1, MTNR1B, TCF7L2, CDK2NA-CDKN2B). Variants in loci known to affect genes coding for proteins involved in immune cell function and placental health (EBF1, EEFSEC, AGTR2, 2q13) have been implicated in the development of PTB and future cardiovascular risks for both the mother and the offspring. Genetic similarities in rare variants between PPCM and dilated cardiomyopathy have been described suggesting shared pathophysiologic origins as well as predisposition for future risk of heart failure, highlighting the need for the development PPCM genetic counseling guidelines. Summary Genetics may inform mechanisms, risk, and counseling for individuals after an APO or PPCM. Through recent advances in genetic techniques and analytic approaches, new insights into the underlying biologic mechanisms and genetic variants leading to these risks have been discovered.
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Affiliation(s)
- Zachary H. Hughes
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, UA
| | - Lydia M. Hughes
- Department of Obstetrics & Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, UA
| | - Sadiya S. Khan
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA
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Aslan K, Kasapoglu I, Cinar C, Cakir C, Avci B, Uncu G. Low Molecular Weight Heparin-Aspirin-Prednisolone Combination Does Not Increase the Live Birth Rate in Recurrent Implantation Failure: A Retrospective Cohort Study. Reprod Sci 2023; 30:3253-3260. [PMID: 37253934 DOI: 10.1007/s43032-023-01233-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 03/30/2023] [Indexed: 06/01/2023]
Abstract
This study investigates the triple combination of adjuvants (low molecular weight heparin (LMWH)-aspirin-prednisolone) whether it improves the live birth rates of IVF&ICSI patients with previous implantation failure. This retrospective study included 1095 patients with >2 failed either fresh or frozen single embryo transfer cycles between 2014 Jan and 2021 Jan. Patients were divided into two subgroups. Group A consisted of patients with only vaginal progesterone for luteal phase support. Group B consisted of patients with triple (daily subcutaneous LMWH, daily 150 mg aspirin, and daily 16 mg prednisolone) luteal phase supplementation to vaginal progesterone. Demographic parameters, cycle characteristics, embryology, and pregnancy outcomes were compared, and the study's primary outcome was the live birth rate. Demographic parameters were similar between the groups. Positive b-hCG, miscarriage, and live birth rates were similar between groups as Group A vs. Group B, positive b-hCG 30.8% (190/617) vs. 35.4% (169/478), miscarriage rates 4.4% (27/617) vs. 6.7% (32/478), and live birth rates 20.4% (126/617) vs. 23.8% (114/478), respectively. When patients were stratified according to previous failures, live birth rates were still similar. Pregnancy outcomes were significantly improved in only patients with diminished ovarian reserve (Group A vs. Group B, positive b-hCG 24.2% vs. 34.3%, live birth rate 12.1% vs. 21.9%, p < 0.01). Whether the embryo transfer was fresh or frozen-thawed did not affect the results. A combined supplementation of LMWH, aspirin, and prednisolone in the luteal phase does not improve live birth rates of IVF&ICSI patients with previous implantation failure except potentially for patients with diminished ovarian reserve.
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Affiliation(s)
- Kiper Aslan
- Faculty of Medicine, Department of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey
| | - Isil Kasapoglu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey
| | - Ceren Cinar
- Faculty of Medicine, Department of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey
| | - Cihan Cakir
- Faculty of Medicine, Department of Histology and Embryology, Bursa Uludag University, Bursa, Turkey
| | - Berrin Avci
- Faculty of Medicine, Department of Histology and Embryology, Bursa Uludag University, Bursa, Turkey
| | - Gurkan Uncu
- Faculty of Medicine, Department of Obstetrics and Gynecology, Bursa Uludag University, Bursa, Turkey.
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Tanacan A, Sakcak B, Ipek G, Agaoglu Z, Peker A, Haksever M, Kara O, Sahin D. The role of first trimester eosinophil count and eosinophil-based complete blood cell indices in the predictiction of preeclampsia: A case-control study. Placenta 2023; 143:16-21. [PMID: 37793323 DOI: 10.1016/j.placenta.2023.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/25/2023] [Accepted: 09/28/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION The importance of eosinophils in the pathogenesis of preeclampsia is an question of interest and there are recent studies in the literature indicating significantly lower eosinophil count values in pregnant women with preeclampsia. The present study aims to evaluate the utility of first-trimester eosinophil count and eosinophil-based complete blood cell count indices in the prediction of preeclampsia. METHODS Pregnant women diagnosed with preeclampsia (n = 281) were retrospectively compared with a control group (n = 307). The utility of first trimester eosinophil count, neutrophil to eosinophil ratio (NER) (neutrophil/eosinophil), leukocyte to eosinophil ratio (LER) (leukocyte/eosinophil), eosinophil to monocyte ratio (EMR) (eosinophil/monocyte) and, eosinophil to lymphocyte ratio (ELR) (eosinophil/lymphocyte) in the prediction of preeclampsia were evaluated. RESULTS Optimal cut-off values for eosinophil count, NER, LER, EMR and, ELR in predicting preeclampsia were 0.07 (AUC: 0.62, 58.7% sensitivity, 56.4% specificity), 90.9 (AUC: 0.65, 61.1% sensitivity, 59.4% specificity), 125.7 (AUC: 0.64, 61.4% sensitivity, 58.4% specificity), 0.15 (AUC: 0.63, 60.1% sensitivity, 59.6% specificity) and, 0.03 (AUC: 0.62, 60.9% sensitivity, 57% specificity), respectively. Mentioned values in predicting early-onset preeclampsia were 0.07 (AUC: 0.64, 60.5% sensitivity, 50.8% specificity), 102.1 (AUC: 0.64, 62.4% sensitivity, 58.8% specificity), 140.2 (AUC: 0.65, 63.5% sensitivity, 59.1% soecificity), 0.14 (AUC: 0.66, 66.3% sensitivity, 59.2% specificity), and, 0.03 (AUC: 0.63, 60.5% sensitivity, 57.4% specificity), respectively. The optimal cut-off value for EMR in the prediction of preeclampsia with severe features was 0.16 (AUC: 0.56, 56.9% sensitivity, 53.2% specificity). DISCUSSION Eosinophil-based complete blood count indices may be used to predict early-onset preeclampsia with relatively low sensitivity and specificity.
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Affiliation(s)
- Atakan Tanacan
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey; Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey.
| | - Bedri Sakcak
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Goksun Ipek
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Zahid Agaoglu
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ayca Peker
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Murat Haksever
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Ozgur Kara
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Dilek Sahin
- Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, University of Health Sciences, Ankara, Turkey; Department of Obstetrics and Gynecology, Turkish Ministry of Health Ankara City Hospital, Ankara, Turkey
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Suliburska J, Cholik RS. Risks and benefits of salicylates in food: a narrative review. Nutr Rev 2023:nuad136. [PMID: 37897072 DOI: 10.1093/nutrit/nuad136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/29/2023] Open
Abstract
Salicylates are generally present in plants as part of their defense system against pathogens and environmental stress. Major dietary sources of salicylates were found in spices and herbs, such as curry and paprika (hot powder). Several studies suggest that these natural salicylates offer health benefits in the human body, such as antidiabetic, anticancer, antiviral, and anti-inflammatory properties. However, despite their advantages, salicylates can be harmful to people with allergies, and high doses of salicylates may cause respiratory alkalosis and gastrointestinal bleeding. Additionally, salicylates can interact with certain drugs, such as nonsteroidal anti-inflammatory drugs and warfarin. This narrative review aimed to consolidate recent information on the content of salicylates in food based on the literature, while also highlighting the benefits and risks associated with salicylate consumption in humans. Based on the literature review and analysis of results, it can be concluded that the dietary intake of salicylates in vegetarians can be relatively high, resulting in concentrations of salicylic acid in the blood and urine that are comparable to those observed in patients taking a low dose of aspirin (75 mg). This suggests that a diet rich in salicylates may have potential benefits in preventing and treating some diseases that require low doses of aspirin.
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Affiliation(s)
- Joanna Suliburska
- Department of Human Nutrition and Dietetics, Faculty of Food Science and Nutrition, Poznan University of Life Sciences, Poznań, Poland
| | - Rafsan Syabani Cholik
- Department of Human Nutrition and Dietetics, Faculty of Food Science and Nutrition, Poznan University of Life Sciences, Poznań, Poland
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Singh N, Shuman S, Chiofalo J, Cabrera M, Smith A. Missed opportunities in aspirin prescribing for preeclampsia prevention. BMC Pregnancy Childbirth 2023; 23:717. [PMID: 37805449 PMCID: PMC10559409 DOI: 10.1186/s12884-023-06039-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 09/29/2023] [Indexed: 10/09/2023] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy, including preeclampsia, are a leading cause of perinatal morbidity and mortality in the United States, particularly among low-income and historically marginalized populations. Evidence suggests low-dose aspirin prophylaxis may help prevent preeclampsia in individuals at increased risk of developing the disease. This study examines associations between preeclampsia risk factors and aspirin prescribing practices among patients receiving prenatal care at a network of federally qualified health centers (FQHC). METHODS Researchers conducted retrospective chart reviews (n = 523) of pregnant individuals ages 18-50 who completed two or more prenatal visits at the FQHC between January 1, 2019 and December 31, 2020. Prescription patterns for patients at moderate and high risk for preeclampsia were analyzed using unadjusted and adjusted logistic regression models to identify the patients with the greatest risk of not receiving the recommended prophylactic treatment. RESULTS Of 249 total patients considered at risk for preeclampsia, only 39% received an aspirin prescription. 57.89% of patients with any high-risk factor were appropriately prescribed aspirin, but only 27.27% of patients with two or more moderate-risk factors without high-risk factors received a prescription. Clinicians most frequently prescribed aspirin for patients with a history of preeclampsia and history of hypertension. However, aspirin was prescribed a maximum of 78.79% of the time for patients with a prior history of hypertension. Among moderate-risk factors, patients with advanced maternal age, Black race, or nulliparity were significantly more likely in adjusted models to be prescribed aspirin. CONCLUSIONS Despite the documented benefits of aspirin prescribing and support from professional societies, there are still many missed opportunities for aspirin prophylaxis to prevent preeclampsia. Future interventions should focus on identifying patients who qualify for aspirin prophylaxis on the basis of having multiple moderate-risk factors without comorbid high-risk factors.
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Affiliation(s)
- Noreen Singh
- The Institute for Family Health, 230 W 17th St, New York, NY, 10011, USA.
- Mount Sinai Family Medicine Residency Program, New York, NY, USA.
| | - Saskia Shuman
- The Institute for Family Health, 230 W 17th St, New York, NY, 10011, USA
| | | | - Mariela Cabrera
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Boston University, Boston, MA, USA
| | - Aimee Smith
- The Institute for Family Health, Kingston, NY, USA
- Mid-Hudson Family Medicine Residency Program, Kingston, NY, USA
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Horgan R, Hage Diab Y, Waller J, Abuhamad A, Saade G. Low-dose aspirin therapy for the prevention of preeclampsia: time to reconsider our recommendations? Am J Obstet Gynecol 2023; 229:410-418. [PMID: 37120049 DOI: 10.1016/j.ajog.2023.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 04/21/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
The American College of Obstetricians and Gynecologists recommends initiation of 81 mg of aspirin daily for women at risk of preeclampsia between 12 and 28 weeks' gestation, optimally before 16 weeks, with continuation until delivery. The World Health Organization recommends that 75 mg of aspirin should be initiated before 20 weeks of gestation for women at high risk of preeclampsia. Both the Royal College of Obstetricians and Gynaecologists and the National Institute of Health and Care Excellence quality statement on "Antenatal Assessment of Pre-eclampsia Risk" request that healthcare providers prescribe low-dose aspirin to pregnant women at increased risk of preeclampsia daily from 12 weeks of gestation. The Royal College of Obstetricians and Gynaecologists recommends 150 mg of aspirin daily, and the National Institute of Health and Care Excellence guidelines suggest risk stratification with a dosage of 75 mg for those at moderate risk of preeclampsia and 150 mg for those at high risk of preeclampsia. The International Federation of Gynecology and Obstetrics initiative on preeclampsia recommends 150 mg of aspirin to be initiated at 11 to 14+6 week's gestation and also proposes that 2 tablets of 81 mg is an acceptable alternative. Review of the available evidence suggests that both the dosage and timing of aspirin initiation is key to its effectiveness at reducing the risk of preeclampsia. Doses of >100 mg of aspirin daily initiated before 16 weeks' gestation seem to be most effective at reducing the risk of preeclampsia and thus dosages recommended by most major societies and organizations may not be effective. Randomized control trials examining 81 mg vs 162 mg of aspirin daily for the prevention of preeclampsia are required to assess the safety and efficacy of aspirin dosages available in the United States.
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Affiliation(s)
- Rebecca Horgan
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA.
| | - Yara Hage Diab
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Jerri Waller
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - Alfred Abuhamad
- Division of Maternal-Fetal Medicine, Department of Obstetrics & Gynecology, Eastern Virginia Medical School, Norfolk, VA
| | - George Saade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The University of Texas Medical Branch, Galveston, TX
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Ledgerwood C, Angelides M, Idler J, Smith B, DuMont T, Cheema T, Barker B. Fetal and Maternal Monitoring. Crit Care Nurs Q 2023; 46:391-397. [PMID: 37684734 DOI: 10.1097/cnq.0000000000000474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Fetal monitoring in the intrapartum and peripartum periods is important for the well-being of both baby and mother. Electronic fetal monitoring was first designed over 50 years ago in an attempt to improve perinatal outcomes. Its purpose is to assess fetal oxygenation and acid-base status during the antepartum course when indicated and during labor. Maternal assessment begins early in gestation with blood pressure monitoring and urine protein excretion to diagnose potential complications, such as severe hypertension and preeclampsia/eclampsia.
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Affiliation(s)
- Chelsea Ledgerwood
- Division of Pulmonary and Critical Care Medicine, Allegheny Health Network Medicine Institute, Pittsburgh, Pennsylvania (Drs Ledgerwood, DuMont, Cheema, and Barker and Ms Smith); Allegheny Health Network Women's Institute, Pittsburgh, Pennsylvania (Dr Angelides); and Division of Maternal Fetal Medicine, Allegheny Health Network Women's Institute, Pittsburgh, Pennsylvania (Dr Idler)
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Shah A, Kapcin K, Deicke M, Pappan N, Holden K, Routray SK, Schmetzer A, DuMont T, Nashar K, Bajwa O, Ivanova V. Hypertension in Women and Pregnancy. Crit Care Nurs Q 2023; 46:377-390. [PMID: 37684733 DOI: 10.1097/cnq.0000000000000480] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/10/2023]
Abstract
Hypertension has been shown to have long-term cardiovascular effects if left untreated. Hypertension also has been shown to affect women during pregnancy, which can be detrimental not only to the patient but also to the fetus. Early identification and treatment are paramount to prevent adverse outcomes. This article details the epidemiology, clinical presentation, diagnosis, and treatment of essential hypertension in women, gestational hypertension, preeclampsia, and eclampsia.
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Affiliation(s)
- Aaisha Shah
- Divisions of Internal Medicine (Drs Shah, Kapcin, and Deicke), Pulmonary and Critical Care (Drs Holden, Schmetzer, and DuMont), Nephrology and Critical Care Medicine (Dr Routray), Nephrology (Dr Nashar), and Pulmonary and Critical Care Medicine (Dr Bajwa), Allegheny Health Network Medicine Institute, Pittsburgh, Pennsylvania; and Division of Cardiovascular Disease, Allegheny Health Network Cardiovascular Institute (Drs Pappan and Ivanova)
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White KJ, Son M, Lundsberg LS, Culhane JF, Partridge C, Reddy UM, Merriam AA. Low-Dose Aspirin during Pregnancy and Postpartum Bleeding. Am J Perinatol 2023; 40:1390-1397. [PMID: 37211010 DOI: 10.1055/a-2096-5199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVE This study aimed to investigate whether aspirin 81 mg daily for preeclampsia prevention is associated with increased risk of postpartum blood loss at the time of delivery. STUDY DESIGN This is a retrospective cohort study performed at a tertiary hospital from January 2018 to April 2021. Data were extracted from the electronic medical record. Patients prescribed low-dose aspirin (LDA) were compared with patients who were not. The primary outcome was a composite of postpartum blood loss, defined as: estimated blood loss (EBL) >1,000 mL, documentation of International Classification of Diseases-9/-10 codes for postpartum hemorrhage (PPH), or red blood cell (RBC) transfusion. Bivariate analysis, and unadjusted and adjusted logistic regression modeling were performed. RESULTS Among 16,980 deliveries, 1,922 (11.3%) were prescribed LDA. Patients prescribed LDA were more likely to be >35 years old, nulliparous, obese, taking other anticoagulants, or have diagnoses of diabetes, systemic lupus erythematosus, fibroids, or hypertensive disease of pregnancy. After adjusting for potential confounders, the significant association between LDA use and the composite did not persist (adjusted odds ratio [aOR]: 1.1, 95% confidence interval [CI]: 1.0-1.3) nor did the association between EBL > 1,000 mL (aOR: 1.0, 95% CI: 0.9-1.3) and RBC transfusion (aOR: 1.3, 95% CI: 0.9-1.7). The association between LDA and PPH remained significant (aOR: 1.3, 95% CI: 1.1-1.6). Patients who discontinued LDA <7 days prior to delivery had an increased risk of the postpartum blood loss composite compared discontinuation ≥7 days (15.0 vs. 9.3%; p = 0.03). CONCLUSION There may be an association between LDA use and increased risk of postpartum bleeding. This suggests that use of LDA outside the recommended guidelines should be cautioned and further investigation is needed to determine its ideal dosing and timing of discontinuation. KEY POINTS · There may be an association with LDA and an increased risk of postpartum bleeding.. · Patients who discontinued LDA less than 7 days prior to delivery had an increased rate of postpartum bleeding.. · Additional research is need to determine optimal LDA dose and timing of discontinuation..
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Affiliation(s)
- Kelsey J White
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Moeun Son
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Lisbet S Lundsberg
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Jennifer F Culhane
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Caitlin Partridge
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
| | - Uma M Reddy
- Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, New York
| | - Audrey A Merriam
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut
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Thomas G, Syngelaki A, Hamed K, Perez-Montaño A, Panigassi A, Tuytten R, Nicolaides KH. Preterm preeclampsia screening using biomarkers: combining phenotypic classifiers into robust prediction models. Am J Obstet Gynecol MFM 2023; 5:101110. [PMID: 37752025 DOI: 10.1016/j.ajogmf.2023.101110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/27/2023] [Indexed: 09/28/2023]
Abstract
BACKGROUND Preeclampsia screening is a critical component of antenatal care worldwide. Currently, the most developed screening test for preeclampsia at 11 to 13 weeks' gestation integrates maternal demographic characteristics and medical history with 3 biomarkers-serum placental growth factor, mean arterial pressure, and uterine artery pulsatility index-to identify approximately 75% of women who develop preterm preeclampsia with delivery before 37 weeks of gestation. It is generally accepted that further improvements to preeclampsia screening require the use of additional biomarkers. We recently reported that the levels of specific metabolites and metabolite ratios are associated with preterm preeclampsia. Notably, for several of these markers, preterm preeclampsia prediction varied according to maternal body mass index class. These findings motivated us to study whether patient classification allowed for combining metabolites with the current biomarkers more effectively to improve prediction of preterm preeclampsia. OBJECTIVE This study aimed to investigate whether metabolite biomarkers can improve biomarker-based preterm preeclampsia prediction in 3 screening resource scenarios according to the availability of: (1) placental growth factor, (2) placental growth factor+mean arterial pressure, and (3) placental growth factor+mean arterial pressure+uterine artery pulsatility index. STUDY DESIGN This was an observational case-control study, drawn from a large prospective screening study at 11 to 13 weeks' gestation on the prediction of pregnancy complications, conducted at King's College Hospital, London, United Kingdom. Maternal blood samples were also collected for subsequent research studies. We used liquid chromatography-mass spectrometry to quantify levels of 50 metabolites previously associated with pregnancy complications in plasma samples from singleton pregnancies. Biomarker data, normalized using multiples of medians, on 1635 control and 106 preterm preeclampsia pregnancies were available for model development. Modeling was performed using a methodology that generated a prediction model for preterm preeclampsia in 4 consecutive steps: (1) z-normalization of predictors, (2) combinatorial modeling of so-called (weak) classifiers in the unstratified patient set and in discrete patient strata based on body mass index and/or race, (3) selection of classifiers, and (4) aggregation of the selected classifiers (ie, bagging) into the final prediction model. The prediction performance of models was evaluated using the area under the receiver operating characteristic curve, and detection rate at 10% false-positive rate. RESULTS First, the predictor development methodology itself was evaluated. The patient set was split into a training set (2/3) and a test set (1/3) for predictor model development and internal validation. A prediction model was developed for each of the 3 different predictor panels, that is, placental growth factor+metabolites, placental growth factor+mean arterial pressure+metabolites, and placental growth factor+mean arterial pressure+uterine artery pulsatility index+metabolites. For all 3 models, the area under the receiver operating characteristic curve in the test set did not differ significantly from that of the training set. Next, a prediction model was developed using the complete data set for the 3 predictor panels. Among the 50 metabolites available for modeling, 26 were selected across the 3 prediction models; 21 contributed to at least 2 out of the 3 prediction models developed. Each time, area under the receiver operating characteristic curve and detection rate were significantly higher with the new prediction model than with the reference model. Markedly, the estimated detection rate with the placental growth factor+mean arterial pressure+metabolites prediction model in all patients was 0.58 (95% confidence interval, 0.49-0.70), a 15% increase (P<.001) over the detection rate of 0.43 (95% confidence interval, 0.33-0.55) estimated for the reference placental growth factor+mean arterial pressure. The same prediction model significantly improved detection in Black (14%) and White (19%) patients, and in the normal-weight group (18.5≤body mass index<25) and the obese group (body mass index≥30), with respectively 19% and 20% more cases detected, but not in the overweight group, when compared with the reference model. Similar improvement patterns in detection rates were found in the other 2 scenarios, but with smaller improvement amplitudes. CONCLUSION Metabolite biomarkers can be combined with the established biomarkers of placental growth factor, mean arterial pressure, and uterine artery pulsatility index to improve the biomarker component of early-pregnancy preterm preeclampsia prediction tests. Classification of the pregnant women according to the maternal characteristics of body mass index and/or race proved instrumental in achieving improved prediction. This suggests that maternal phenotyping can have a role in improving the prediction of obstetrical syndromes such as preeclampsia.
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Affiliation(s)
- Grégoire Thomas
- SQU4RE, Lokeren, Belgium (Dr Thomas); Metabolomic Diagnostics, Cork, Ireland (Drs Thomas, Panigassi, and Tuytten)
| | - Argyro Syngelaki
- The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom (Drs Syngelaki, Hamed, Perez-Montaño, and Nicolaides)
| | - Karam Hamed
- The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom (Drs Syngelaki, Hamed, Perez-Montaño, and Nicolaides)
| | - Anais Perez-Montaño
- The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom (Drs Syngelaki, Hamed, Perez-Montaño, and Nicolaides)
| | - Ana Panigassi
- Metabolomic Diagnostics, Cork, Ireland (Drs Thomas, Panigassi, and Tuytten)
| | - Robin Tuytten
- Metabolomic Diagnostics, Cork, Ireland (Drs Thomas, Panigassi, and Tuytten).
| | - Kypros H Nicolaides
- The Harris Birthright Research Centre for Fetal Medicine, King's College Hospital, London, United Kingdom (Drs Syngelaki, Hamed, Perez-Montaño, and Nicolaides)
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Filion KB, Grandi SM. Hypertensive Disorders of Pregnancy in Black Women - Where Do We Go from Here? NEJM EVIDENCE 2023; 2:EVIDe2300138. [PMID: 38320187 DOI: 10.1056/evide2300138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
In this issue of NEJM Evidence, Sheehy et al.1 report the results of a prospective cohort study that examined the association between hypertensive disorders of pregnancy (HDOP) and the risk of stroke among Black women in the United States. Using data from 42,924 participants in the Black Women's Health Study (BWHS) who were free of cardiovascular disease at baseline, they compared the rates of stroke between women with HDOP and those who did not have HDOP over a median follow-up of 22 years.
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Affiliation(s)
- Kristian B Filion
- Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal
- Department of Medicine, McGill University, Montreal
| | - Sonia M Grandi
- Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto
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Barry MJ, Nicholson WK, Silverstein M, Cabana MD, Chelmow D, Coker TR, Davis EM, Donahue KE, Jaén CR, Li L, Ogedegbe G, Rao G, Ruiz JM, Stevermer J, Tsevat J, Underwood SM, Wong JB. Screening for Hypertensive Disorders of Pregnancy: US Preventive Services Task Force Final Recommendation Statement. JAMA 2023; 330:1074-1082. [PMID: 37721605 DOI: 10.1001/jama.2023.16991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
Importance Hypertensive disorders of pregnancy are among the leading causes of maternal morbidity and mortality in the US. The rate of hypertensive disorders of pregnancy has been increasing from approximately 500 cases per 10 000 deliveries in 1993 to 1021 cases per 10 000 deliveries in 2016 to 2017. Objective The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertensive disorders of pregnancy. Population Pregnant persons without a known diagnosis of a hypertensive disorder of pregnancy or chronic hypertension. Evidence Assessment The USPSTF concludes with moderate certainty that screening for hypertensive disorders in pregnancy with blood pressure measurements has substantial net benefit. Recommendation The USPSTF recommends screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy. (B recommendation).
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Affiliation(s)
| | | | | | | | | | | | - Esa M Davis
- University of Maryland School of Medicine, Baltimore
| | | | | | - Li Li
- University of Virginia, Charlottesville
| | | | - Goutham Rao
- Case Western Reserve University, Cleveland, Ohio
| | | | | | - Joel Tsevat
- University of Texas Health Science Center, San Antonio
| | | | - John B Wong
- Tufts University School of Medicine, Boston, Massachusetts
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