WITHDRAWN: Antiplatelet agents for preventing and treating pre-eclampsia

RhoGDI1 interacts with PHLDA2, suppresses the proliferation, migration, and invasion of trophoblast cells, and participates in the pathogenesis of preeclampsia

Preeclampsia (PE) is a pregnancy-associated disease, which is the major cause of mortality on maternity and perinatal infants. It is hypothesized that PE is a consequence of the dysfunction of the trophoblast cells. Pleckstrin homology-like domain, family A, member 2 (PHLDA2) was shown to inhibit the proliferation, migration, and invasion of trophoblast cells in our previous studies. However, the mechanism by which PHLDA2 affects trophoblast cell function has not been clarified. In the current study, co-immunoprecipitation (Co-IP) with mass spectroscopy analysis was used to explore the proteins that interacted with PHLDA2. A total of 291 candidate proteins were found to be associated with PHLDA2. The interaction between PHLDA2 and Rho guanine nucleotide dissociation inhibitor (RhoGDI) 1 was identified by Co-IP and immunofluorescence staining. Western blot analysis indicated that overexpression of PHLDA2 resulted in upregulation of the RhoGDI1 protein levels, which were stabilized in the presence of cycloheximide. Similarly, overexpression of RhoGDI1 promoted PHLDA2 expression and its stability. Furthermore, pull-down and Co-IP results indicated that PHLDA2 repressed the activity of Rho guanosine triphosphate hydrolase family proteins by regulating RhoGDI1 expression. In addition, RhoGDI1 expression was upregulated in the placental tissues of patients with PE. The effects of the suppression of PHLDA2 expression on proliferation, migration, and invasion of trophoblast cells were partly abrogated following knockdown of RhoGDI1. Taken together, the data indicated that RhoGDI1 mediated regulation of PHLDA2 on the biological behavior of trophoblast cells and may participate in the pathophysiology of PE.

A best practice position statement on pregnancy in chronic kidney disease: the Italian Study Group on Kidney and Pregnancy

Pregnancy is increasingly undertaken in patients with chronic kidney disease (CKD) and, conversely, CKD is increasingly diagnosed in pregnancy: up to 3 % of pregnancies are estimated to be complicated by CKD. The heterogeneity of CKD (accounting for stage, hypertension and proteinuria) and the rarity of several kidney diseases make risk assessment difficult and therapeutic strategies are often based upon scattered experiences and small series. In this setting, the aim of this position statement of the Kidney and Pregnancy Study Group of the Italian Society of Nephrology is to review the literature, and discuss the experience in the clinical management of CKD in pregnancy. CKD is associated with an increased risk for adverse pregnancy-related outcomes since its early stage, also in the absence of hypertension and proteinuria, thus supporting the need for a multidisciplinary follow-up in all CKD patients. CKD stage, hypertension and proteinuria are interrelated, but they are also independent risk factors for adverse pregnancy-related outcomes. Among the different kidney diseases, patients with glomerulonephritis and immunologic diseases are at higher risk of developing or increasing proteinuria and hypertension, a picture often difficult to differentiate from preeclampsia. The risk is higher in active immunologic diseases, and in those cases that are detected or flare up during pregnancy. Referral to tertiary care centres for multidisciplinary follow-up and tailored approaches are warranted. The risk of maternal death is, almost exclusively, reported in systemic lupus erythematosus and vasculitis, which share with diabetic nephropathy an increased risk for perinatal death of the babies. Conversely, patients with kidney malformation, autosomal-dominant polycystic kidney disease, stone disease, and previous upper urinary tract infections are at higher risk for urinary tract infections, in turn associated with prematurity. No risk for malformations other than those related to familiar urinary tract malformations is reported in CKD patients, with the possible exception of diabetic nephropathy. Risks of worsening of the renal function are differently reported, but are higher in advanced CKD. Strict follow-up is needed, also to identify the best balance between maternal and foetal risks. The need for further multicentre studies is underlined.

Hyperbaric index in the primary prevention of hypertensive complications in high-risk pregnancy

INTRODUCTION

Preeclampsia (PE) is a major cause of fetal morbidity and mortality. In the Western World, PE affects 2-7% of pregnancies and is responsible for 50,000 deaths annually. Early detection is a priority as it can change the clinical course, but there are no biomarkers or instrumental methods with high sensitivity and specificity. Only the hyperbaric index has a sensitivity and specificity of 99% for early identification of pregnant women at risk of developing PE, but its use is not widespread.

OBJECTIVE

To assess the usefulness of the hyperbaric index in the primary prevention of hypertensive pregnancy complications in a public healthcare area.

MATERIAL AND METHODS

This is a retrospective study of pregnancies that occurred in our area during the period 2007-2012 (N=11,784). The diagnosis was established by the hyperbaric index and pregnant women at risk were treated with ASA at night.

RESULTS

In pregnant patients referred to the nephrology clinic (38.2%), diagnosed as high-risk for PE, and treated with 100mg ASA/night (from week 17), the incidence of PE episodes was reduced by 96.94.

Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period

BACKGROUND

Venous thromboembolism (VTE), although rare, is a major cause of maternal mortality and morbidity, and methods of prophylaxis are therefore often used for women considered to be at risk. This may include women who have given birth by caesarean section, those with a personal or family history of VTE and women with inherited or acquired thrombophilias (conditions that predispose people to thrombosis). Many methods of prophylaxis carry risks of adverse effects, and as the risk of VTE is often low, it is possible that the benefits of thromboprophylaxis may be outweighed by harms. Guidelines for clinical practice have been based on expert opinion rather than high-quality evidence from randomised trials.

OBJECTIVES

To assess the effects of thromboprophylaxis in women who are pregnant or have recently given birth and are at increased risk of VTE on the incidence of VTE and adverse effects of treatment.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (27 November 2013). 

SELECTION CRITERIA

Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, and randomised trials comparing two (or more) methods of thromboprophylaxis.

DATA COLLECTION AND ANALYSIS

At least two review authors assessed trial eligibility and quality and extracted the data.

MAIN RESULTS

Nineteen trials, at an overall moderate risk of bias, met the inclusion criteria for the review. Only 16 trials, involving 2592 women, assessing a range of methods of thromboprophylaxis, contributed data to the review. Six trials compared methods of antenatal prophylaxis: heparin versus no treatment/placebo (two trials), and low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) (four trials). Nine trials assessed prophylaxis after caesarean section: four compared heparin with placebo; three compared LMWH with UFH; one compared hydroxyethyl starch (HES) with UFH; and one compared five-day versus 10-day LMWH. One study examined prophylaxis with UFH in the postnatal period (including following vaginal births).For antenatal prophylaxis, none of the included trials reported on maternal mortality, and no differences were detected for the other primary outcomes of symptomatic thromboembolic events, symptomatic pulmonary embolism (PE) and symptomatic deep venous thrombosis (DVT) when LMWH or UFH was compared with no treatment/placebo or when LMWH was compared with UFH. The risk ratios (RR) for symptomatic thromboembolic events were: antenatal LMWH/UFH versus no heparin, RR 0.33; 95% confidence interval (CI) 0.04 to 2.99 (two trials, 56 women); and antenatal LMWH versus UFH, RR 0.47; 95% CI 0.09 to 2.49 (four trials, 404 women). No differences were shown when antenatal LMWH or UFH was compared with no treatment/placebo for any secondary outcomes. Antenatal LMWH was associated with fewer adverse effects sufficient to stop treatment (RR 0.07; 95% CI 0.01 to 0.54; two trials, 226 women), and fewer fetal losses (RR 0.47; 95% CI 0.23 to 0.95; three trials, 343 women) when compared with UFH. In two trials, antenatal LMWH compared with UFH was associated with fewer bleeding episodes (defined in one trial of 121 women as bruises > 1 inch (RR 0.18, 95% CI 0.09 to 0.36); and in one trial of 105 women as injection site haematomas of ≥ 2 cm, bleeding during delivery or other bleeding (RR 0.28; 95% CI 0.15 to 0.53)), however in a further trial of 117 women no difference between groups was shown for bleeding at delivery. The results for these secondary outcomes should be interpreted with caution, being derived from small trials that were not of high methodological quality.For post-caesarean/postnatal prophylaxis, only one trial comparing five-day versus 10-day LMWH after caesarean section reported on maternal mortality, observing no deaths. No differences were seen across any of the comparisons for the other primary outcomes (symptomatic thromboembolic events, symptomatic PE and symptomatic DVT). The RRs for symptomatic thromboembolic events were: post-caesarean LMWH/UFH versus no heparin, RR 1.30; 95% CI 0.39 to 4.27 (four trials, 840 women); post-caesarean LMWH versus UFH, RR 0.33; 95% CI 0.01 to 7.99 (three trials, 217 women); post-caesarean five-day versus 10-day LMWH, RR 0.36; 95% CI 0.01 to 8.78 (one trial, 646 women); postnatal UFH versus no heparin, RR 0.16; 95% CI 0.02 to 1.36 (one trial, 210 women). For prophylaxis after caesarean section, in one trial (of 580 women), women receiving UFH and physiotherapy were more likely to have bleeding complications ('complications hémorragiques') than women receiving physiotherapy alone (RR 5.03; 95% CI 2.49 to 10.18). In two additional trials, that compared LMWH with placebo, no difference between groups in bleeding episodes (major bleeding; major bruising; bleeding/bruising reported at discharge) were detected. No other differences in secondary outcomes were shown when LMWH was compared with UFH post-caesarean, nor when post-caesarean HES was compared with UFH, post-caesarean five-day LMWH was compared with 10-day LMWH, or when UFH was compared to no heparin postnatally.

AUTHORS' CONCLUSIONS

There is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period, with the small number of differences detected in this review being largely derived from trials that were not of high methodological quality. Large scale, high-quality randomised trials of currently used interventions are warranted.

Prophylaxis for venous thromboembolic disease in pregnancy and the early postnatal period

BACKGROUND

Venous thromboembolic disease (TED), although rare, is a major cause of maternal mortality and morbidity, hence methods of prophylaxis are often used for women at risk. This may include women delivered by caesarean section, those with a personal or family history of TED and women with inherited or acquired thrombophilias (conditions that predispose people to thrombosis). Many methods of prophylaxis carry a risk of side effects, and as the risk of TED is low, it is possible that the benefits of thromboprophylaxis may be outweighed by harm. Current guidelines for clinical practice are based on expert opinion only, rather than high quality evidence from randomised trials.

OBJECTIVES

To determine the effects of thromboprophylaxis in women who are pregnant or have recently delivered and are at increased risk of TED on the incidence of venous TED and side effects of treatment.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2009).

SELECTION CRITERIA

Randomised trials comparing one method of thromboprophylaxis with placebo or no treatment, and randomised trials comparing two (or more) methods of thromboprophylaxis.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data independently and resolved any discrepancies by discussion.

MAIN RESULTS

Sixteen trials met the inclusion criteria but only 13 trials, involving 1774 women, examining a range of methods of thromboprophylaxis, contributed data for the outcomes of interest. Four of them compared methods of antenatal prophylaxis: low molecular weight heparin (LMWH) versus unfractionated heparin (UFH) (two studies), and heparin versus no treatment (two studies). Eight studies assessed postnatal prophylaxis after caesarean section; one compared hydroxyethyl starch with unfractionated heparin; four compared heparin with placebo; and the other three compared UFH with LMWH. One study examined prophylaxis in the postnatal period.The small number of statistically significant findings in this review are largely derived from trials which are not of high methodological quality. It was not possible to assess the effects of any of these interventions on most outcomes, and especially on rare outcomes such as death, TED and osteoporosis, because of small sample sizes and the small number of trials making the same comparisons.There was some evidence of side effects associated with thromboprophylaxis.

AUTHORS' CONCLUSIONS

There is insufficient evidence on which to base recommendations for thromboprophylaxis during pregnancy and the early postnatal period. Large scale randomised trials of currently-used interventions should be conducted.

[Pregnancy and vasculitides]

Systemic vasculitides, like Takayasu's arteritis, polyarteritis nodosa, Wegener's granulomatosis, Churg-Strauss syndrome, Henoch-Schönlein purpura, or Behçet's disease can affect women of child-bearing years. The rarity of these vasculitides, their frequent fatal outcomes until recent years, and the use of toxic immunosuppressants to treat patients, contra-indicating pregnancy and/or potentially inducing hypofertility or sterility, explain the few pregnancies reported in the literature so far. Notably, it does not seem that pregnancy has a major impact on vasculitis outcome, in contrast with systemic lupus erythematosus, but a specialized management of these pregnant patients is mandatory. There are some reported cases of vasculitis revealed during pregnancy. Even though some of these pregnant patients had a severe disease and died, most of them had a favourable outcome, and a living inborn, providing prompt care and adequate treatment. When vasculitis is already known and treated, pregnancy should at best be planned, when the disease is in sustained remission and all toxic immunosuppressants have been stopped for months. Vasculitis sequella, like hypertension, renal insufficiency, or asthma, must also be taken into account, monitored and appropriately managed throughout the pregnancy and a few weeks following delivery. In case of vasculitis' flare during pregnancy, potential treatments include corticosteroids, intravenous immunoglobulins, azathioprine, plasma exchanges, and, for limited skin manifestations or Behçet's disease, hydroxychloroquine or colchicine. Importantly, when the disease is severe, a delay in the prescription of a stronger, immunosuppressant, chiefly intravenous cyclophosphamide, can be more detrimental, although being potentially toxic, for both the mother and the foetus than an ineffective and/or inappropriate regimen with less active drugs. Safety data on biologics, like rituximab, for pregnant women are very sparse to date and their use is therefore not recommended, unless confronted with a severe and refractory disease, and after referring to a specialized center for vasculitides.

Antioxidants for preventing pre-eclampsia

BACKGROUND

Oxidative stress has been proposed as a key factor involved in the development of pre-eclampsia. Supplementing women with antioxidants during pregnancy may help to counteract oxidative stress and thereby prevent or delay the onset of pre-eclampsia.

OBJECTIVES

To determine the effectiveness and safety of any antioxidant supplementation during pregnancy and the risk of developing pre-eclampsia and its related complications.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (May 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2006, Issue 3), MEDLINE (1950 to October 2007) and Current Contents (1998 to August 2004).

SELECTION CRITERIA

All randomised trials comparing one or more antioxidants with either placebo or no antioxidants during pregnancy for the prevention of pre-eclampsia, and trials comparing one or more antioxidants with another, or with other interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and trial quality and extracted data.

MAIN RESULTS

Ten trials, involving 6533 women, were included in this review, five trials were rated high quality. For the majority of trials, the antioxidant assessed was combined vitamin C and E therapy. There was no significant difference between antioxidant and control groups for the relative risk (RR) of pre-eclampsia (RR 0.73, 95% confidence intervals (CI) 0.51 to 1.06; nine trials, 5446 women) or any other primary outcome: severe pre-eclampsia (RR 1.25, 95% CI 0.89 to 1.76; two trials, 2495 women), preterm birth (before 37 weeks) (RR 1.10, 95% CI 0.99 to 1.22; five trials, 5198 women), small-for-gestational-age infants (RR 0.83, 95% CI 0.62 to 1.11; five trials, 5271 babies) or any baby death (RR 1.12, 95% CI 0.81 to 1.53; four trials, 5144 babies). Women allocated antioxidants were more likely to self-report abdominal pain late in pregnancy (RR 1.61, 95% CI 1.11 to 2.34; one trial, 1745 women), require antihypertensive therapy (RR 1.77, 95% CI 1.22 to 2.57; two trials, 4272 women) and require an antenatal hospital admission for hypertension (RR 1.54, 95% CI 1.00 to 2.39; one trial, 1877 women). However, for the latter two outcomes, this was not clearly reflected in an increase in any other hypertensive complications.

AUTHORS' CONCLUSIONS

Evidence from this review does not support routine antioxidant supplementation during pregnancy to reduce the risk of pre-eclampsia and other serious complications in pregnancy.