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Mustafa HJ, Kalafat E, Prasad S, Heydari M, Nunge RN, Khalil A. Prediction of hypertension and diabetes in twin pregnancy using machine learning model based on characteristics at first prenatal visit: national registry study. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2025; 65:613-623. [PMID: 38805609 PMCID: PMC12047682 DOI: 10.1002/uog.27710] [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: 12/10/2023] [Revised: 03/27/2024] [Accepted: 05/18/2024] [Indexed: 05/30/2024]
Abstract
OBJECTIVE To develop a prediction model for hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) in twin pregnancy using characteristics obtained at the first prenatal visit. METHODS This was a cross-sectional study using national live-birth data in the USA between 2016 and 2021. The association of all prenatal candidate variables with HDP and GDM was tested on univariable and multivariable logistic regression analyses. Prediction models were built with generalized linear models using the logit link function and classification and regression tree (XGboost) machine learning algorithm. Performance was assessed with repeated 2-fold cross-validation and the area under the receiver-operating-characteristics curve (AUC) was calculated. A P value < 0.001 was considered statistically significant. RESULTS A total of 707 198 twin pregnancies were included in the HDP analysis and 723 882 twin pregnancies were included in the GDM analysis. The incidence of HDP and GDM increased significantly from 12.6% and 8.1%, respectively, in 2016 to 16.0% and 10.7%, respectively, in 2021. Factors associated with increased odds of HDP in twin pregnancy were maternal age < 20 years or ≥ 35 years, infertility treatment, prepregnancy diabetes mellitus, non-Hispanic Black race, overweight prepregnancy BMI, prepregnancy obesity and Medicaid as the payment source for delivery (P < 0.001 for all). Obesity Class II and III more than doubled the odds of HDP. Factors associated with increased odds of GDM in twin pregnancy were maternal age ≤ 24 years or ≥ 30 years, infertility treatment, prepregnancy hypertension, non-Hispanic Asian race, maternal birthplace outside the USA and prepregnancy obesity (P < 0.001 for all). Maternal age ≥ 30 years, non-Hispanic Asian race and obesity Class I, II and III more than doubled the odds of GDM. For both HDP and GDM, the performances of the machine learning model and logistic regression model were mostly similar, with negligible differences in the performance domains tested. The mean ± SD AUCs of the final machine learning models for HDP and GDM were 0.620 ± 0.001 and 0.671 ± 0.001, respectively. CONCLUSIONS The incidence of HDP and GDM in twin pregnancies in the USA is increasing. The predictive accuracy of the machine learning models for HDP and GDM in twin pregnancies was similar to that of the logistic regression models. The models for HDP and GDM had modest predictive performance, were well calibrated and did not have poor fit. © 2024 The Author(s). 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)
- H. J. Mustafa
- Department of Obstetrics and Gynecology, Division of Maternal–Fetal MedicineIndiana University School of MedicineIndianapolisINUSA
- Riley Children and Indiana University Health Fetal CenterIndianapolisINUSA
| | - E. Kalafat
- Department of Obstetrics and GynecologyKoc University School of MedicineIstanbulTurkey
| | - S. Prasad
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
| | - M.‐H. Heydari
- Non‐Communicable Diseases Research Center, Endocrinology and Metabolism Population Sciences InstituteTehran University of Medical SciencesTehranIran
| | - R. N. Nunge
- Indiana University School of MedicineIndianapolisINUSA
| | - A. Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation TrustUniversity of LondonLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George's University of LondonLondonUK
- Fetal Medicine UnitLiverpool Women's HospitalLiverpoolUK
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He Y, Xie J, Guo Y, Ma J, Wang X, Lv Y, Wu S, Wei S, Xie X, Wang B. The potential of repeated mean arterial pressure measurements for predicting early- and late-onset pre-eclampsia in twin pregnancies: Prediction model study. Int J Gynaecol Obstet 2025; 168:196-204. [PMID: 39072715 DOI: 10.1002/ijgo.15825] [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: 05/08/2024] [Revised: 07/12/2024] [Accepted: 07/16/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVE To investigate the contribution of longitudinal mean arterial pressure (MAP) measurement during the first, second, and third trimesters of twin pregnancies to the prediction of pre-eclampsia. METHODS A retrospective cohort study was conducted on women with twin pregnancies. Historical data between 2019 and 2021 were analyzed, including maternal characteristics and mean artery pressure measurements were obtained at 11-13, 22-24, and 28-33 weeks of gestation. The outcome measures included pre-eclampsia with delivery <34 and ≥34 weeks of gestation. Models were developed using logistic regression, and predictive performance was evaluated using the area under the curve, detection rate at a given false-positive rate of 10%, and calibration plots. Internal validation was conducted via bootstrapping. RESULTS A total of 943 twin pregnancies, including 36 (3.82%) women who experienced early-onset pre-eclampsia and 93 (9.86%) who developed late-onset pre-eclampsia, were included in this study. To forecast pre-eclampsia during the third trimester, the most accurate prediction for early-onset pre-eclampsia resulted from a combination of maternal factors and MAP measured during this trimester. The optimal predictive model for late-onset pre-eclampsia includes maternal factors and MAP data collected during the second and third trimesters. The areas under the curve were 0.937 (95% confidence interval [CI] 0.894-0.981) and 0.887 (95% CI 0.852-0.921), respectively. The corresponding detection rates were 83.33% (95% CI 66.53%-93.04%) for early-onset pre-eclampsia and 68.82% (95% CI 58.26%-77.80%) for late-onset pre-eclampsia. CONCLUSION Repeated measurements of MAP during pregnancy significantly improved the accuracy of late-onset pre-eclampsia prediction in twin pregnancies. The integration of longitudinal data into pre-eclampsia screening may be an effective and valuable strategy.
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Affiliation(s)
- Yunjiang He
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinliang Xie
- Department of Biostatistics, Clinical Research Institute, School of Public Health, Shanghai Sixth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yuna Guo
- International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jue Ma
- International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaojin Wang
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yao Lv
- International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siqi Wu
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Siying Wei
- School of Public Health, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xianjing Xie
- International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Bingshun Wang
- Department of Biostatistics, Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
- International Peace Maternity and Child Health Hospital of China Welfare Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Wu H, Yu L, Xie Z, Cai H, Wen C. The impact of maternal serum biomarkers on maternal and neonatal outcomes in twin pregnancies: a retrospective cohort study conducted at a tertiary hospital. PeerJ 2024; 12:e18415. [PMID: 39484218 PMCID: PMC11526785 DOI: 10.7717/peerj.18415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 10/07/2024] [Indexed: 11/03/2024] Open
Abstract
Background Prior prediction models used for screening preeclampsia (PE) in twin pregnancies were found to be inadequate. In singleton pregnancies, various maternal biomarkers have been shown to be correlated with negative pregnancy outcomes. However, the impact of these biomarkers in twin pregnancies remained uncertain. Methods A retrospective cohort study was carried out on 736 twin pregnancies at a tertiary hospital in Hangzhou, China. Multivariable logistic models were employed to examine the association between levels of serological markers and the likelihood of adverse pregnancy outcomes. The final logistic model was formulated as a user-friendly nomogram. The primary outcome assessed was the occurrence of PE. Results were presented as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Results The prevalence of PE in the study was 10.3%. When comparing women diagnosed with PE to those without, it was evident that the former group experienced a significantly higher risk of unfavorable maternal and neonatal outcomes. A multivariable logistic regression analysis revealed notable associations between various factors including maternal age, parity, gestational weight gain, a family history of hypertension, as well as levels of cholesterol, albumin, and creatinine and the risk of developing PE, with a significance level of P < 0.05. The concordance index for the constructed nomogram was determined to be 0.792 (95% CI: [0.739-0.844]). Furthermore, an increment of 1 * 1012/L in red blood cell (RBC) count was associated with more than a two-fold increase in the odds of experiencing adverse maternal outcomes (OR 2.247, 95% CI: [1.229-4.107]). However, no significant correlations were identified between any of the examined variables and neonatal outcomes. Conclusions In this study, we developed a user-friendly predictive model that achieves notable detection rates by incorporating maternal serum biomarker levels alongside maternal characteristics and medical history. Our findings indicate that the probability of adverse maternal outcomes increases with elevated levels of RBCs. Obstetricians should consider intensifying surveillance for these women in clinical practice.
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Affiliation(s)
- Hanglin Wu
- Department of Obstetrics and Gynecology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Liming Yu
- Department of Obstetrics and Gynecology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Zhen Xie
- Department of Obstetrics and Gynecology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Hongxia Cai
- Department of Obstetrics and Gynecology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
| | - Caihe Wen
- Department of Obstetrics and Gynecology, Hangzhou Women’s Hospital, Hangzhou, Zhejiang, China
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Yang M, Bai Y, Li M, Lin X, Duan X, Zhang X. Predictive value of the soluble fms-like tyrosine kinase 1 to placental growth factor ratio for preeclampsia in twin pregnancies: a systematic review and meta-analysis. Am J Obstet Gynecol MFM 2024; 6:101290. [PMID: 38401234 DOI: 10.1016/j.ajogmf.2024.101290] [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: 10/31/2023] [Revised: 01/04/2024] [Accepted: 01/11/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE In recent years, the ratio of soluble fms-like tyrosine kinase 1 to placental growth factor for use in predicting preeclampsia has been explored extensively. Despite extensive research, available data on its effectiveness in predicting preeclampsia in twin pregnancies are limited and conflicting. This meta-analysis aimed to assess the diagnostic accuracy of the soluble fms-like tyrosine kinase 1 to placental growth factor ratio in distinguishing cases with preeclampsia in twin pregnancies from healthy controls. DATA SOURCES Studies that evaluated the use of the soluble fms-like tyrosine kinase 1 to placental growth factor ratio in predicting preeclampsia were searched in PubMed, Embase, and Cochrane databases from inception to August 6, 2023, without language restriction. STUDY ELIGIBILITY CRITERIA The following population, exposure, comparators, outcomes, and study designs were included: women with twin pregnancies; an increased soluble fms-like tyrosine kinase 1 to placental growth factor ratio with preeclampsia as the outcome; women without preeclampsia; a 2 × 2 diagnostic table, diagnostic accuracy data, and the incidence of preeclampsia; and prospective cohort studies and observational comparative studies, respectively. STUDY APPRAISAL AND SYNTHESIS METHODS The quality of the included studies was evaluated. Key parameters, including the specificity, sensitivity, positive likelihood ratio, negative likelihood ratio, and diagnostic odds ratio, were calculated using the random- and fixed-effects models. In addition, the area under the receiver operating characteristic curve and the summary receiver operating characteristic curve were evaluated. RESULTS A total of 7 studies were included, including 442 women with twin pregnancies (115 patients with preeclampsia and 327 controls without preeclampsia). The results highlighted the promising effectiveness of the soluble fms-like tyrosine kinase 1 to placental growth factor ratio in predicting preeclampsia in twin pregnancies with a pooled specificity of 0.89 (95% confidence interval, 0.80-0.95), a sensitivity of 0.84 (95% confidence interval, 0.73-0.93), a positive likelihood ratio of 32.76 (95% confidence interval, 12.82-83.74), and a negative likelihood ratio of 0.03 (95% confidence interval, 0.01-0.08). The combined diagnostic odds ratio was 35.72 (95% confidence interval, 12.92-98.76), and the area under the receiver operating characteristic curve was 0.92. CONCLUSION These collective findings underscore the potential of the soluble fms-like tyrosine kinase 1 to placental growth factor ratio as an accurate marker for identifying preeclampsia among women with twin pregnancies.
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Affiliation(s)
- Meilin Yang
- Department of Obstetrics, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China (Drs Yang, Lin, Duan, and Zhang); Xiamen Key Laboratory of Basic and Clinical Research on Major Obstetric Diseases and Department of Obstetrics, Women and Children's Hospital, Xiamen University, Xiamen, China (Drs Yang, Lin, Duan, and Zhang)
| | - Yuci Bai
- Department of Obstetrics and Gynecology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China (Drs Bai and Li)
| | - Min Li
- Department of Obstetrics and Gynecology, Xiamen Chang Gung Hospital, Xiamen, Fujian, China (Drs Bai and Li)
| | - Xueyan Lin
- Department of Obstetrics, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China (Drs Yang, Lin, Duan, and Zhang); Xiamen Key Laboratory of Basic and Clinical Research on Major Obstetric Diseases and Department of Obstetrics, Women and Children's Hospital, Xiamen University, Xiamen, China (Drs Yang, Lin, Duan, and Zhang)
| | - Xiaoyu Duan
- Department of Obstetrics, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China (Drs Yang, Lin, Duan, and Zhang); Xiamen Key Laboratory of Basic and Clinical Research on Major Obstetric Diseases and Department of Obstetrics, Women and Children's Hospital, Xiamen University, Xiamen, China (Drs Yang, Lin, Duan, and Zhang)
| | - Xueqin Zhang
- Department of Obstetrics, Women and Children's Hospital, School of Medicine, Xiamen University, Xiamen, Fujian, China (Drs Yang, Lin, Duan, and Zhang); Xiamen Key Laboratory of Basic and Clinical Research on Major Obstetric Diseases and Department of Obstetrics, Women and Children's Hospital, Xiamen University, Xiamen, China (Drs Yang, Lin, Duan, and Zhang).
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Jiang Y, Du Y, Su R, Zhou X, Wei L, Zhang J, Zhu S, Zhang H, Fang C, Chen Y, Gao P, Zhang L, Wang S, Yu J, He M, Ding W, Feng L. Long-term outcomes of offspring from multiple gestations: a two-sample Mendelian randomization study on multi-system diseases using UK Biobank and FinnGen databases. J Transl Med 2023; 21:608. [PMID: 37684631 PMCID: PMC10492369 DOI: 10.1186/s12967-023-04423-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 08/05/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND Assisted reproductive technologies (ART) have increased the incidence of multiple births, which can have a negative impact on maternal and offspring health. The study aimed to investigate the association between genetically predicted multiple birth and the risk of 42 common diseases of the nervous, psychiatric, cardiovascular, respiratory, digestive, and endocrine systems. METHODS The study utilized two-sample Mendelian randomization (MR) analysis to explore the potential causal relationship between genetically predicted multiple birth and the genetically predicted risk of diseases. The study used the FinnGen and UK Biobank datasets for analysis. RESULTS The study found no significant causal relationship between multiple birth and psychiatric disorders. However, the lower limits of the 95% confidence intervals for bipolar affective disorder and anxiety disorders were not robust, indicating a need for further investigation. The study found that multiple birth may be a strong risk factor for infantile cerebral palsy, and caution is necessary in both natural and ART multiple births. The study revealed a potential causal relationship between multiple birth and coronary heart disease, ischemic heart disease, and deep vein thrombosis, which may be related to abnormal intrauterine environments in multiple pregnancies. Surprisingly, multiple birth appears to have a protective effect against some respiratory diseases, such as chronic obstructive pulmonary disease and asthma. CONCLUSIONS The study highlights the need for caution regarding the risk of infantile cerebral palsy, cardiovascular diseases, and psychiatric disorders in multiple birth. Our study can lead to the development of preventive strategies and improved clinical management for affected infants.
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Affiliation(s)
- Yi Jiang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Yuanyuan Du
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Rui Su
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Xuan Zhou
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Lijie Wei
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Jingyi Zhang
- Department of Obstetrics and Gynecology Ultrasound, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Shenglan Zhu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Huiting Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Chenyun Fang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Yuting Chen
- Department of Obstetrics and Gynecology Ultrasound, Zhongnan Hospital of Wuhan University, Wuhan, 430071, China
| | - Peng Gao
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Liangnan Zhang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Shaoshuai Wang
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Jun Yu
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Mengzhou He
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China
| | - Wencheng Ding
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China.
| | - Ling Feng
- Department of Obstetrics and Gynecology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095, Jiefang Avenue, Wuhan, 430030, Hubei, China.
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Malone SL, Haj Yahya R, Kane SC. Reviewing Accuracy of First Trimester Screening for Preeclampsia Using Maternal Factors and Biomarkers. Int J Womens Health 2022; 14:1371-1384. [PMID: 36161188 PMCID: PMC9507456 DOI: 10.2147/ijwh.s283239] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 08/25/2022] [Indexed: 11/23/2022] Open
Abstract
Preeclampsia is a common and important complication of pregnancy, one with potentially significant morbidity and even mortality to both mother and baby. Identifying those at high risk of developing the condition is helpful as there is evidence that the incidence of preeclampsia can be reduced with low dose aspirin taken in pregnancy. Accurately predicting the risk of preeclampsia allows for more targeted aspirin prophylaxis and a greater opportunity for early detection of maternal and/or fetal complications associated with impaired placentation through a schedule of enhanced antenatal surveillance. Traditional preeclampsia prediction models use maternal characteristics and risk factors and have been shown to be of low predictive value. Multiparametric screening tests combine patient characteristics with serum biomarkers and ultrasound Doppler indices and have been shown to be more effective at detecting those at high risk of preeclampsia - more specifically, early-onset preeclampsia (onset of preeclampsia <34 weeks' gestation). Multiparametric screening has now been validated in different populations. The true cost effectiveness of a multiparametric screening model for preeclampsia screening is not yet fully known and will vary depending on the clinical setting. Despite the growing body of evidence for its improved detection rates, first trimester preeclampsia screening using multiparametric models is not widely implemented and is not part of the recommendations for antenatal screening from most international bodies. The International Federation of Gynecology and Obstetrics has advised universal preeclampsia screening using maternal risk factors and biomarkers and has strongly encouraged its promotion worldwide. Various barriers to implementation must be considered such as the immediate cost of equipment and training, the need for audit and quality control, and the expected benefit to the population. Low to middle income settings may require a pragmatic approach to the implementation of multiparametric screening given limited resources.
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Affiliation(s)
- Sarah L Malone
- Department of Maternal Fetal Medicine, the Royal Women’s Hospital, Parkville, Victoria, Australia
| | - Rani Haj Yahya
- Department of Maternal Fetal Medicine, the Royal Women’s Hospital, Parkville, Victoria, Australia
| | - Stefan C Kane
- Department of Maternal Fetal Medicine, the Royal Women’s Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Department of Obstetrics and Gynaecology, Parkville, Victoria, Australia
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Single Intrauterine Death in Twin Pregnancy: Evidenced-based Counselling and Management. Best Pract Res Clin Obstet Gynaecol 2022; 84:205-217. [DOI: 10.1016/j.bpobgyn.2022.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 08/31/2022] [Indexed: 11/22/2022]
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8
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Routine Doppler Ultrasound in Twin Pregnancy. Best Pract Res Clin Obstet Gynaecol 2022; 84:43-54. [DOI: 10.1016/j.bpobgyn.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/14/2022] [Indexed: 11/15/2022]
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Francisco C, Gamito M, Reddy M, Rolnik DL. Screening for preeclampsia in twin pregnancies. Best Pract Res Clin Obstet Gynaecol 2022; 84:55-65. [PMID: 35450774 DOI: 10.1016/j.bpobgyn.2022.03.008] [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: 01/04/2022] [Accepted: 03/13/2022] [Indexed: 11/02/2022]
Abstract
Twin pregnancies are an important risk factor for preeclampsia, a hypertensive disorder of pregnancy that is associated with a significant risk of maternal and perinatal morbidity. Given the burden of preeclampsia, the identification of women at high risk in early pregnancy is essential to allow for preventive strategies and close monitoring. In singleton pregnancies, the risk factors for preeclampsia are well established, and a combined first-trimester prediction model has been shown to adequately predict preterm disease. Furthermore, intervention with low-dose aspirin at 150 mg/day in those identified as high-risk reduces the rate of preterm preeclampsia by 62%. In contrast, risk factors for preeclampsia in twin pregnancies are less established, the proposed screening models have shown poor performance with high false-positive rates, and the benefit of aspirin for the prevention of preeclampsia is not clearly demonstrated. In this review, we examine the literature assessing prediction and prevention of preeclampsia in twin pregnancies.
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Affiliation(s)
- Carla Francisco
- Department of Obstetrics and Gynaecology, Hospital Beatriz Ângelo, Avenida Carlos, Teixeira 3, 2674-514 Loures, Portugal.
| | - Mariana Gamito
- Department of Obstetrics and Gynaecology, Hospital Beatriz Ângelo, Avenida Carlos, Teixeira 3, 2674-514 Loures, Portugal.
| | - Maya Reddy
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia.
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, 246 Clayton Road, Clayton, Melbourne, Victoria, Australia.
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Tian Y, Yang X. A Review of Roles of Uterine Artery Doppler in Pregnancy Complications. Front Med (Lausanne) 2022; 9:813343. [PMID: 35308523 PMCID: PMC8927888 DOI: 10.3389/fmed.2022.813343] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 02/10/2022] [Indexed: 11/22/2022] Open
Abstract
The invasion of trophoblasts into the uterine decidua and decidual vessels is critical for the formation of placenta. The defects of placentation are related to the etiologies of preeclampsia (PE), fetal growth restriction (FGR), and small-for-gestational age (SGA) neonates. It is possible to predict significant vascular events during pregnancy through uterine artery Doppler (UAD). From the implantation stage to the end of pregnancy, detecting changes in uterine and placental blood vessels can provide a favorable diagnostic instrument for pregnancy complications. This review aims to collect literature about the roles of UAD in pregnancy complications. We consider all relevant articles in English from January 1, 1983 to October 30, 2021. Predicting pregnancy complications in advance allows practitioners to carry out timely interventions to avoid or lessen the harm to mothers and neonates. Administering low-dose aspirin daily before 16 weeks of pregnancy can significantly reduce the incidence of pregnancy complications. From early pregnancy to late pregnancy, UAD can combine with other maternal factors, biochemical indicators, and fetal measurement data to identify high-risk population. The identification of high-risk groups can also lessen maternal mortality. Besides, through moderate risk stratification, stringent monitoring for high-risk pregnant women can be implemented, decreasing the incidence of adversities.
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Affiliation(s)
- Yingying Tian
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
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Petca A, Sinescu R, Sandru F, Petca RC, Dumitrascu M, Mehedintu C, Zvanca M. New approaches in predicting and diagnosing preeclampsia: Congo Red Dot Paper Test (Review). Exp Ther Med 2022; 23:270. [DOI: 10.3892/etm.2022.11196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 12/07/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Aida Petca
- Deparment of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Ruxandra Sinescu
- Department of Plastic Surgery and Reconstructive Microsurgery, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Florica Sandru
- Department of Dermatology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Razvan-Cosmin Petca
- Department of Urology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mihai Dumitrascu
- Deparment of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Claudia Mehedintu
- Deparment of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Mona Zvanca
- Deparment of Obstetrics and Gynecology, ‘Carol Davila’ University of Medicine and Pharmacy, 050474 Bucharest, Romania
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12
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Rolnik DL, Nicolaides KH, Poon LC. Prevention of preeclampsia with aspirin. Am J Obstet Gynecol 2022; 226:S1108-S1119. [PMID: 32835720 DOI: 10.1016/j.ajog.2020.08.045] [Citation(s) in RCA: 179] [Impact Index Per Article: 59.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 01/02/2023]
Abstract
Preeclampsia is defined as hypertension arising after 20 weeks of gestational age with proteinuria or other signs of end-organ damage and is an important cause of maternal and perinatal morbidity and mortality, particularly when of early onset. Although a significant amount of research has been dedicated in identifying preventive measures for preeclampsia, the incidence of the condition has been relatively unchanged in the last decades. This could be attributed to the fact that the underlying pathophysiology of preeclampsia is not entirely understood. There is increasing evidence suggesting that suboptimal trophoblastic invasion leads to an imbalance of angiogenic and antiangiogenic proteins, ultimately causing widespread inflammation and endothelial damage, increased platelet aggregation, and thrombotic events with placental infarcts. Aspirin at doses below 300 mg selectively and irreversibly inactivates the cyclooxygenase-1 enzyme, suppressing the production of prostaglandins and thromboxane and inhibiting inflammation and platelet aggregation. Such an effect has led to the hypothesis that aspirin could be useful for preventing preeclampsia. The first possible link between the use of aspirin and the prevention of preeclampsia was suggested by a case report published in 1978, followed by the first randomized controlled trial published in 1985. Since then, numerous randomized trials have been published, reporting the safety of the use of aspirin in pregnancy and the inconsistent effects of aspirin on the rates of preeclampsia. These inconsistencies, however, can be largely explained by a high degree of heterogeneity regarding the selection of trial participants, baseline risk of the included women, dosage of aspirin, gestational age of prophylaxis initiation, and preeclampsia definition. An individual patient data meta-analysis has indicated a modest 10% reduction in preeclampsia rates with the use of aspirin, but later meta-analyses of aggregate data have revealed a dose-response effect of aspirin on preeclampsia rates, which is maximized when the medication is initiated before 16 weeks of gestational age. Recently, the Aspirin for Evidence-Based Preeclampsia Prevention trial has revealed that aspirin at a daily dosage of 150 mg, initiated before 16 weeks of gestational age, and given at night to a high-risk population, identified by a combined first trimester screening test, reduces the incidence of preterm preeclampsia by 62%. A secondary analysis of the Aspirin for Evidence-Based Preeclampsia Prevention trial data also indicated a reduction in the length of stay in the neonatal intensive care unit by 68% compared with placebo, mainly because of a reduction in births before 32 weeks of gestational age with preeclampsia. The beneficial effect of aspirin has been found to be similar in subgroups according to different maternal characteristics, except for the presence of chronic hypertension, where no beneficial effect is evident. In addition, the effect size of aspirin has been found to be more pronounced in women with good compliance to treatment. In general, randomized trials are underpowered to investigate the treatment effect of aspirin on the rates of other placental-associated adverse outcomes such as fetal growth restriction and stillbirth. This article summarizes the evidence around aspirin for the prevention of preeclampsia and its complications.
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Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines. Obstet Gynecol Surv 2021; 76:613-633. [PMID: 34724074 DOI: 10.1097/ogx.0000000000000942] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Importance Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons. Objective The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications. Evidence Acquisition A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out. Results There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring. Conclusions The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.
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Filipecka-Tyczka D, Pokropek A, Kajdy A, Modzelewski J, Rabijewski M. Uterine Artery Doppler Reference Ranges in a Twin Caucasian Population Followed Longitudinally From 17 to 37 Weeks Gestation Compared to That of Singletons. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2021; 40:2421-2429. [PMID: 33438788 DOI: 10.1002/jum.15627] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 12/28/2020] [Accepted: 12/29/2020] [Indexed: 06/12/2023]
Abstract
OBJECTIVES The primary aim was to measure uterine artery (UtA) indices in twin pregnancies of Polish Caucasian women and compare it with a previously published study by Geipel et al for DC twins (2011). The secondary aim was to find differences in UtA indices in MC, DC twins, and singletons. METHODS A prospective longitudinal evaluation of UtA Doppler indices in 1462 examinations of twins and 5766 examinations of singletons between 17 and 37 gestational age (GA). Pulsatility index (PI) and resistance index (RI) were calculated. RESULTS UtA PI and RI are lower in the twins than singletons but the analyzed mean values throughout gestation are higher than the study presented by Geipel et al. Obtained curves for DC twins and singletons had the same form as Geipel's curves. In MC twins, curves are flatter and characterized by lower differences throughout pregnancy than Geipel's curves for DC twins. They tend to be more similar about 32 weeks of gestations, resulting from different placenta structure in MC than DC twin pregnancies. CONCLUSIONS UtA Doppler indices in twin pregnancies are lower than in singletons. Obtained data have higher values for twins than reference charts proposed by Geipel's for dichorionic twins. We observed some differences between monochorionic and dichorionic twins' curves throughout pregnancy, but they were not significant.
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Affiliation(s)
| | - Artur Pokropek
- Institute of Philosophy and Sociology of the Polish Academy of Sciences, Warsaw, Poland
| | - Anna Kajdy
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Jan Modzelewski
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Michał Rabijewski
- Department of Reproductive Health, Centre of Postgraduate Medical Education, Warsaw, Poland
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sFlt-1, Not PlGF, Is Related to Twin Gestation Choronicity in the First and Third Trimesters of Pregnancy. Diagnostics (Basel) 2021; 11:diagnostics11071181. [PMID: 34209832 PMCID: PMC8305523 DOI: 10.3390/diagnostics11071181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 06/22/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Background: Preeclampsia occurs more often in dichorionic than in monochorionic twin pregnancy. We hypothesize that serum concentrations of biomarkers: placental growth factor (PlGF), serum soluble fms-like tyrosine kinase-1 (sFlt-1), and endoglin (Eng) differ between monochorionic and dichorionic twin pregnancies. Methods: A prospective observational study including 43 monochorionic and 36 dichorionic twin gestation was conducted. Blood samples were collected twice from all participants: between 11 + 0 and 13 + 6 and between 32 + 0 and 34 + 0 weeks of gestation. PlGF, sFlt-1 and Eng were measured using immnunoenzymatic assays. Results: We found a significantly higher concentration of sFlt-1 in dichorionic in comparison to monochorionic pregnancies in both the first and third trimesters. PlGF and sEng levels did not differ between mono- and dichorionic gestation in both study periods. sFlt-1 level was related to twin gestation chorionicity, while PlGF expression was not. PlGF, sFlt-1 and sEng concentrations increased significantly during gestation and were much higher in the third trimester compared to the values measured in the first trimester. Conclusions: Angiogenic biomarkers expression differ between dichorionic and monochorionic twin pregnancy. The sFlt-1 level is related to chorionicity of a twin gestation.
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Khalil A, Liu B. Controversies in the management of twin pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:888-902. [PMID: 32799348 DOI: 10.1002/uog.22181] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 07/18/2020] [Accepted: 07/30/2020] [Indexed: 06/11/2023]
Abstract
Despite many advances in antenatal care, twin pregnancies still experience more adverse outcomes, in particular perinatal morbidity and mortality. They also pose a multitude of challenges and controversies, as outlined in this Review. Moreover, they are less likely to be included in clinical trials. Many issues on classification and management remain under debate. Efforts at standardizing diagnostic criteria, monitoring protocols, management and outcome reporting are likely to reduce their perinatal risks. The top 10 most important research uncertainties related to multiple pregnancies have been identified by both clinicians and patients. More robust research in the form of randomized trials and large well-conducted prospective cohort studies is needed to address these controversies. © 2020 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)
- A Khalil
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Liu
- Twins Trust Centre for Research and Clinical Excellence, St George's University Hospitals NHS Foundation Trust, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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17
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Benkő Z, Wright A, Rehal A, Cimpoca B, Syngelaki A, Delgado JL, Tsokaki T, De Alvarado M, Vojtassakova D, Malligiannis Ntalianis K, Chaveeva P, Del Campo A, De Ganzo T, Resta C, Atanasova V, Accurti V, Villalain C, Aguilera J, Dojcinovska D, O'Gorman N, Plasencia W, Zingler E, Dutemeyer V, Alvar B, Casanova MC, Nicolaides KH. Prediction of pre-eclampsia in twin pregnancy by maternal factors and biomarkers at 11-13 weeks' gestation: data from EVENTS trial. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:257-265. [PMID: 33142361 DOI: 10.1002/uog.23531] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/16/2020] [Accepted: 10/20/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES First, to validate a previously developed model for screening for pre-eclampsia (PE) by maternal characteristics and medical history in twin pregnancies; second, to compare the distributions of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum placental growth factor (PlGF) and serum pregnancy-associated plasma protein-A (PAPP-A) in twin pregnancies that delivered with PE to those in singleton pregnancies and to develop new models based on these results; and, third, to examine the predictive performance of these models in screening for PE with delivery at < 32 and < 37 weeks' gestation. METHODS Two datasets of prospective non-intervention multicenter screening studies for PE in twin pregnancies at 11 + 0 to 13 + 6 weeks' gestation were used. The first dataset was from the EVENTS (Early vaginal progesterone for the preVention of spontaneous prEterm birth iN TwinS) trial and the second was from a previously reported study that examined the distributions of biomarkers in twin pregnancies. Maternal demographic characteristics and medical history from the EVENTS-trial dataset were used to assess the validity of risks from our previously developed model. The combined data from the first and second datasets were used to compare the distributional properties of log10 multiples of the median (MoM) values of UtA-PI, MAP, PlGF and PAPP-A in twin pregnancies that delivered with PE to those in singleton pregnancies and develop new models based on these results. The competing-risks model was used to estimate the individual patient-specific risks of delivery with PE at < 32 and < 37 weeks' gestation. Screening performance was measured by detection rates (DR) and areas under the receiver-operating-characteristics curve. RESULTS The EVENTS-trial dataset comprised 1798 pregnancies, including 168 (9.3%) that developed PE. In the validation of the prior model based on maternal characteristics and medical history, calibration plots demonstrated very good agreement between the predicted risks and the observed incidence of PE (calibration slope and intercept for PE < 32 weeks were 0.827 and 0.009, respectively, and for PE < 37 weeks they were 0.942 and -0.207, respectively). In the combined data, there were 3938 pregnancies, including 339 (8.6%) that developed PE and 253 (6.4%) that delivered with PE at < 37 weeks' gestation. In twin pregnancies that delivered with PE, MAP, UtA-PI and PlGF were, at earlier gestational ages, more discriminative than in singleton pregnancies and at later gestational ages they were less so. For PAPP-A, there was little difference between PE and unaffected pregnancies. The best performance of screening for PE was achieved by a combination of maternal factors, MAP, UtA-PI and PlGF. In screening by maternal factors alone, the DR, at a 10% false-positive rate, was 30.6% for delivery with PE at < 32 weeks' gestation and this increased to 86.4% when screening by the combined test; the respective values for PE < 37 weeks were 24.9% and 41.1%. CONCLUSIONS In the assessment of risk for PE in twin pregnancy, we can use the same prior model based on maternal characteristics and medical history as reported previously, but in the calculation of posterior risks it is necessary to use the new distributions of log10 MoM values of UtA-PI, MAP and PlGF according to gestational age at delivery with PE. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Z Benkő
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Wright
- University of Exeter, Exeter, UK
| | - A Rehal
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - B Cimpoca
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - A Syngelaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - J L Delgado
- Hospital Clínico Universitario Virgen de la Arrixaca and Institute for Biomedical Research of Murcia, IMIB-Arrixaca, Murcia, Spain
| | - T Tsokaki
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- North Middlesex University Hospital, London, UK
| | - M De Alvarado
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Homerton University Hospital, London, UK
| | | | - K Malligiannis Ntalianis
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Southend University Hospital, Westcliff-on-Sea, UK
| | | | - A Del Campo
- Hospital Universitario Cruces, Biocruces Bizkaia Health Research Institute, UPV/EHU, Bizkaia, Spain
| | - T De Ganzo
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Hospital Universitario San Cecilio, Instituto de Investigación Biosanitaria (IBS) Granada, Spain
| | - C Resta
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Chelsea and Westminster Hospital, Imperial College London, UK
| | - V Atanasova
- Hospital Universitario La Paz, Madrid, Spain
| | - V Accurti
- Ospedale Maggiore Policlinico, Milan and Department of Clinical Sciences and Community Health, University of Milan, Italy
| | - C Villalain
- Hospital Universitario "12 De Octubre", Madrid, Spain
| | - J Aguilera
- University Hospital Lewisham, London, UK
| | - D Dojcinovska
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Royal London Hospital, London, UK
| | - N O'Gorman
- Hospital Necker Enfants Malades, Paris, France
| | | | - E Zingler
- Fetal Medicine Research Institute, King's College Hospital, London, UK
- Kingston Hospital, Kingston upon Thames, UK
| | - V Dutemeyer
- University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - B Alvar
- University Hospital A Coruña, Spain
| | - M C Casanova
- Hospital Universitario de Torrejón and School of Medicine, Universidad Francisco de Vitoria, Madrid, Spain
| | - K H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital, London, UK
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Stevenson DK, Wong RJ, Aghaeepour N, Maric I, Angst MS, Contrepois K, Darmstadt GL, Druzin ML, Eisenberg ML, Gaudilliere B, Gibbs RS, Gotlib IH, Gould JB, Lee HC, Ling XB, Mayo JA, Moufarrej MN, Quaintance CC, Quake SR, Relman DA, Sirota M, Snyder MP, Sylvester KG, Hao S, Wise PH, Shaw GM, Katz M. Towards personalized medicine in maternal and child health: integrating biologic and social determinants. Pediatr Res 2021; 89:252-258. [PMID: 32454518 PMCID: PMC8061757 DOI: 10.1038/s41390-020-0981-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 05/13/2020] [Accepted: 05/14/2020] [Indexed: 12/16/2022]
Affiliation(s)
- David K Stevenson
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Ronald J Wong
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA.
| | - Nima Aghaeepour
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Ivana Maric
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Martin S Angst
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Kevin Contrepois
- Stanford Center for Genomics and Personalized Medicine, Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Gary L Darmstadt
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Maurice L Druzin
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Michael L Eisenberg
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Department of Urology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Brice Gaudilliere
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Ronald S Gibbs
- Department of Obstetrics and Gynecology, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Ian H Gotlib
- Department of Psychology, Stanford University School of Humanities and Science, Stanford, CA, 94305, USA
| | - Jeffrey B Gould
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Henry C Lee
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Xuefeng B Ling
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, 94306, USA
| | - Jonathan A Mayo
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Mira N Moufarrej
- Departments of Bioengineering and Applied Physics, Stanford University, and Chan Zuckerberg Biohub, Stanford, CA, 94305, USA
| | - Cecele C Quaintance
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Stephen R Quake
- Departments of Bioengineering and Applied Physics, Stanford University, and Chan Zuckerberg Biohub, Stanford, CA, 94305, USA
| | - David A Relman
- Department of Medicine, Stanford University School of Medicine, Stanford, CA, 94305, USA
- Infectious Diseases Section, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, 94306, USA
| | - Marina Sirota
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, CA, USA
- Department of Pediatrics, University of California, San Francisco, San Francisco, CA, USA
| | - Michael P Snyder
- Stanford Center for Genomics and Personalized Medicine, Department of Genetics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Karl G Sylvester
- Department of Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Shiying Hao
- Clinical and Translational Research Program, Betty Irene Moore Children's Heart Center, Lucile Packard Children's Hospital, Palo Alto, CA, 94306, USA
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Paul H Wise
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Gary M Shaw
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
| | - Michael Katz
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA, 94305, USA
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19
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Springer S, Polterauer M, Stammler-Safar M, Zeisler H, Leipold H, Worda C, Worda K. Notching and Pulsatility Index of the Uterine Arteries and Preeclampsia in Twin Pregnancies. J Clin Med 2020; 9:jcm9082653. [PMID: 32824222 PMCID: PMC7465290 DOI: 10.3390/jcm9082653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/02/2022] Open
Abstract
Increased uterine artery Doppler indices have been shown to be associated with preeclampsia and adverse pregnancy outcomes in singleton and twin pregnancies. At 20–22 weeks of gestation, we assessed the use of notching, the highest, lowest, and mean pulsatility index (PI), and the combination of notching and PI of the uterine arteries to screen for preeclampsia. This was done in a cohort of 380 twin pregnancies. The results showed that the combination of notching and the highest PI above the 95th centile of the uterine arteries gives the best screening characteristics for preeclampsia in twin pregnancies. We calculated sensitivities for preeclampsia for notching, highest PI, and the combination of notching and the highest PI of 50%, 45% and 91%, with specificities of 96%, 96% and 93%, respectively. The present findings demonstrate that notching, increased highest PI, and the combination of notching and the highest PI of the uterine arteries is associated with an increased risk of preeclampsia in twin pregnancies. We observed the highest sensitivity and specificity by using the combination of notching and the highest PI of the uterine arteries.
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Affiliation(s)
- Stephanie Springer
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Mariella Polterauer
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Maria Stammler-Safar
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Harald Zeisler
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Heinz Leipold
- Department of Obstetrics and Gynecology, Landeskrankenhaus Klagenfurt, 9020 Klagenfurt am Wörthersee, Austria;
| | - Christof Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
- Correspondence: ; Tel.: +43-1-40400-28220
| | - Katharina Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
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Tskhay V, Schindler A, Shestakova M, Klimova O, Narkevich А. The role of progestogen supplementation (dydrogesterone) in the prevention of preeclampsia. Gynecol Endocrinol 2020; 36:698-701. [PMID: 31876197 DOI: 10.1080/09513590.2019.1706085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Our goal was determine the effects of dydrogesterone supplementation to reduce the incidence of preeclampsia (PE) in early pregnancy (from 6 to 20 weeks of gestation). A total of 406 pregnant women were involved into the study. The Study group enrolled 169 women, supplemented with dydrogesterone at a dose of 30 mg/d 6-20 weeks of gestation compared with the control group (237 subjects) - without dydrogesterone supplementation. The women were randomized by age, race, obstetrics complications, and their somatic history. The use of dydrogesterone in early pregnancy - before 20 weeks of gestation (at a dose of 30 mg/d) with high-risk factors of PE contributed to a statistically significant reduction in the frequency of this complication (13.1% and 71.4%, p < .001). It was seen, that women who took dydrogesterone developed significantly less such disorders like hypertension (3.2% and 71.2%, p < .001), proteinuria (0.0% and 66.18%, p < .001), fetal growth retardation syndrome (2.2% and 21.58%, p < .001), destroy of uteri-placenta velocity (3.2% and 21.58%, p < .001), preterm labor (8.6% and 53.95%, p < .001). Dydrogesterone supplementation in the first and second period of pregnancy (from 6 to 20 weeks of gestation) significantly reduced the incidence of PE in women with higher risk pregnancy.
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Affiliation(s)
- V Tskhay
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - A Schindler
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
- Institute for Medical Research and Education, Essen, Germany
| | - M Shestakova
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - O Klimova
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - А Narkevich
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
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21
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Vikraman SK, Elayedatt RA. Pre-eclampsia screening in the first trimester - preemptive action to prevent the peril. J Matern Fetal Neonatal Med 2020; 35:1808-1816. [PMID: 32434399 DOI: 10.1080/14767058.2020.1767059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Pre-eclampsia complicating 2-5% of pregnancies is an obstetrical syndrome associated with deleterious short-and long-term consequences to the gravid women, the fetus and the neonate. Majority of the obstetrical complications occur in early pre-eclampsia (requiring delivery <34 weeks). The risk factor based approach recommended by the professional organizations for pre-eclampsia screening has shown suboptimal clinical performance. The combined multimarker screening for pre-eclampsia encompassing documentation of maternal medical history, measurement of mean arterial pressure, estimation of the maternal serum levels of placental growth factor, pregnancy associated plasma protein-A, and recording the Uterine artery mean pulsatility index, performed in the first trimester between 11 and 13 + 6 weeks has proven to be an effective screening strategy. The a-priori risk is determined by multivariate analysis of the factors from history, while the other parameters are converted to log 10 transformed multiple of median values. Bayes' theorem is used to calculate the final risk. The above model has shown to detect 77% of preterm pre-eclampsia (<37 weeks), 96% of early preterm pre-eclampsia (<34 weeks), 38% of term pre-eclampsia and 54% of all pre-eclampsia, at a false positive rate of 10%. Uterine artery Doppler is key to pre-eclampsia screening. Currently a risk of >1:100 for pre-eclampsia developing before 37 weeks (preterm pre-eclampsia) is regarded as screen positive. Aspirin at a dose of 150 mg at bedtime given to screen positive subjects is associated with a significant reduction of preterm pre-eclampsia and early pre-eclampsia. The intervention is now supported by a well conducted randomized trial and metanalysis data. Aspirin acts by diminishing stores of constitutive cyclooxygenase enzyme in the non-nucleated platelets without disturbing systemic prostaglandin production. Selective use of aspirin in screen positive women is associated with a very low incidence of adverse maternal, fetal and neonatal side effects. The screening protocol can be applied to twin pregnancies albeit minor differences. Hence, screening for pre-eclampsia in first trimester, which is now endorsed by the federation of international obstetrical and gynecological societies, should be offered universally to all women at 11 to 13 + 6 weeks of gestation, followed by the administration of aspirin and serial maternal-fetal surveillance in the screen positive woman.
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Affiliation(s)
- Seneesh Kumar Vikraman
- Center for Prenatal diagnosis and Fetal therapy, ARMC AEGIS Hospital, Perinthalmana, Kerala, India.,Department of Fetal Medicine, Almas Hospital, Malappuram, Kerala, India
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Chen J, Zhao D, Liu Y, Zhou J, Zou G, Zhang Y, Guo M, Duan T, Van Mieghem T, Sun L. Screening for preeclampsia in low-risk twin pregnancies at early gestation. Acta Obstet Gynecol Scand 2020; 99:1346-1353. [PMID: 32356359 DOI: 10.1111/aogs.13890] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 04/15/2020] [Accepted: 04/22/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Preeclampsia affects about 10% of twin pregnancies and significantly increases the risk of adverse pregnancy outcomes. However, screening models for preeclampsia in twin pregnancies remain elusive. The present study aimed to evaluate the performance of a multi-marker first trimester preeclampsia screening model in low-risk twin pregnancies. MATERIAL AND METHODS Between 2014 and 2017, we prospectively assessed first trimester biomarkers for preeclampsia in a 'low-risk' twin pregnancy cohort at a single center. Multiple logistic regression was used to determine significant predictors for early preeclampsia (occurring prior to 34 weeks) and late preeclampsia (occurring after 34 weeks). The performance of the screening models fitted using the significant predictors was calculated using receiver operating characteristics curves, and internal validation was performed using bootstrapping. RESULTS A total of 769 twin pregnancies were included in the study. Early preeclampsia and late preeclampsia developed in 27 (3.5%) and 59 (7.7%) cases, respectively. Logistic regression analyses showed that maternal age, body mass index, mean artery pressure and placental growth factor were significant predictors for early preeclampsia. Maternal age, body mass index, mean artery pressure and pregnancy-associated plasma protein A were significant for late preeclampsia. Uterine artery pulsatility index was not predictive of either early or late preeclampsia. For the fitted screening model of early and late preeclampsia, the areas under receiver operating characteristics curves were 0.82 (95% confidence interval [CI] 0.76-0.88) and 0.66 (95% CI 0.59-0.73), which were expected to decrease to 0.77 and 0.60, respectively, based on bootstrapping; the positive predictive values were 10.2% and 12.5%; and the estimated detection rates were 40.7% and 22.0%, respectively, at a false-positive rate of 10%. CONCLUSIONS A multi-marker screening model for preeclampsia in low-risk twin pregnancies, using a modified version of Fetal Medicine Foundation predictors in singletons, does not perform well. Uterine artery pulsatility index is of little value in screening for preeclampsia in low-risk twin pregnancies.
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Affiliation(s)
- Jianping Chen
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Depeng Zhao
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Reproductive Medicine, Affiliated Shenzhen Maternity & Child Healthcare Hospital, Southern Medical University, Shenzhen, China
| | - Yang Liu
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China.,Shanghai Putuo District Maternity and Infant Hospital Corporation, Shanghai, China
| | - Jia Zhou
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gang Zou
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yun Zhang
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Ming Guo
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tao Duan
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
| | - Tim Van Mieghem
- Department of Obstetrics and gynecology, Mount Sinai Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Luming Sun
- Department of Fetal Medicine and Prenatal Diagnosis Center, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, China
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23
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Early prediction of preeclampsia via machine learning. Am J Obstet Gynecol MFM 2020; 2:100100. [PMID: 33345966 DOI: 10.1016/j.ajogmf.2020.100100] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 03/04/2020] [Accepted: 03/07/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Early prediction of preeclampsia is challenging because of poorly understood causes, various risk factors, and likely multiple pathogenic phenotypes of preeclampsia. Statistical learning methods are well-equipped to deal with a large number of variables, such as patients' clinical and laboratory data, and to select the most informative features automatically. OBJECTIVE Our objective was to use statistical learning methods to analyze all available clinical and laboratory data that were obtained during routine prenatal visits in early pregnancy and to use them to develop a prediction model for preeclampsia. STUDY DESIGN This was a retrospective cohort study that used data from 16,370 births at Lucile Packard Children Hospital at Stanford, CA, from April 2014 to January 2018. Two statistical learning algorithms were used to build a predictive model: (1) elastic net and (2) gradient boosting algorithm. Models for all preeclampsia and early-onset preeclampsia (<34 weeks gestation) were fitted with the use of patient data that were available at <16 weeks gestational age. The 67 variables that were considered in the models included maternal characteristics, medical history, routine prenatal laboratory results, and medication intake. The area under the receiver operator curve, true-positive rate, and false-positive rate were assessed via cross-validation. RESULTS Using the elastic net algorithm, we developed a prediction model that contained a subset of the most informative features from all variables. The obtained prediction model for preeclampsia yielded an area under the curve of 0.79 (95% confidence interval, 0.75-0.83), sensitivity of 45.2%, and false-positive rate of 8.1%. The prediction model for early-onset preeclampsia achieved an area under the curve of 0.89 (95% confidence interval, 0.84-0.95), true-positive rate of 72.3%, and false-positive rate of 8.8%. CONCLUSION Statistical learning methods in a retrospective cohort study automatically identified a set of significant features for prediction and yielded high prediction performance for preeclampsia risk from routine early pregnancy information.
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Kosinska-Kaczynska K, Zgliczynska M, Kozlowski S, Wicherek L. Maternal Serum Placental Growth Factor, Soluble Fms-Like Tyrosine Kinase-1, and Soluble Endoglin in Twin Gestations and the Risk of Preeclampsia-A Systematic Review. J Clin Med 2020; 9:jcm9010183. [PMID: 31936659 PMCID: PMC7019581 DOI: 10.3390/jcm9010183] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/16/2019] [Accepted: 01/07/2020] [Indexed: 11/16/2022] Open
Abstract
Multiple gestation is one of the key risk factors for the occurrence of preeclampsia (PE). Soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin are molecules involved in the process of angiogenesis with a proven role in the pathogenesis of PE. The aim of the review was to summarize available data on maternal serum levels of the above-mentioned factors and their usefulness in predicting PE in twin pregnancies. Only original research articles written in English were considered eligible. Reviews, chapters, case studies, conference papers, experts’ opinions, editorials, and letters were excluded from the analysis. No publication date limitations were imposed. The systematic literature search using PubMed/MEDLINE, Scopus, Embase, and Cochrane Library databases identified 338 articles, 10 of which were included in the final qualitative analyses. The included studies showed significant differences in maternal serum levels of the discussed factors between women with twin pregnancies with PE and those who did not develop PE, and their promising performance in predicting PE, alone or in combination with other factors. The identification of the most effective algorithms, their prompt introduction to the clinical practice, and further assessment of the real-life performance should become a priority.
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Affiliation(s)
| | - Magdalena Zgliczynska
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-809 Warsaw, Poland
- Chair and Department of Experimental and Clinical Physiology, Laboratory of the Centre for Preclinical Research, Medical University of Warsaw, 02-106 Warsaw, Poland
- Correspondence:
| | - Szymon Kozlowski
- University Center for Woman and Newborn Health of the Medical University of Warsaw, 02-015 Warsaw, Poland
| | - Lukasz Wicherek
- Second Department of Obstetrics and Gynecology, Center of Postgraduate Medical Education, 01-809 Warsaw, Poland
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Wertaschnigg D, Reddy M, Mol BWJ, Rolnik DL, da Silva Costa F. Prenatal screening for pre-eclampsia: Frequently asked questions. Aust N Z J Obstet Gynaecol 2019; 59:477-483. [PMID: 31119729 PMCID: PMC6767595 DOI: 10.1111/ajo.12982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/22/2019] [Indexed: 12/29/2022]
Abstract
The current approach to screening for pre-eclampsia is based on guidelines that rely on medical and obstetric history in early pregnancy to select a high-risk group that might benefit from low-dose aspirin. However, combined screening tests with the addition of biophysical and biochemical measurements have shown significantly better detection rates for preterm pre-eclampsia. Furthermore, the administration of aspirin for the 10% screen-positive group can lead to a significant reduction in severe and preterm forms of pre-eclampsia. This review aims to answer frequently asked questions related to the clinical implementation of screening and the management of screening results.
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Affiliation(s)
- Dagmar Wertaschnigg
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Maya Reddy
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Ben W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Fabricio da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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26
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Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, McAuliffe F, da Silva Costa F, von Dadelszen P, McIntyre HD, Kihara AB, Di Renzo GC, Romero R, D’Alton M, Berghella V, Nicolaides KH, Hod M. The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention. Int J Gynaecol Obstet 2019; 145 Suppl 1:1-33. [PMID: 31111484 PMCID: PMC6944283 DOI: 10.1002/ijgo.12802] [Citation(s) in RCA: 676] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.
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Affiliation(s)
- Liona C. Poon
- Department of Obstetrics and Gynaecology, The Chinese
University of Hong Kong
| | - Andrew Shennan
- Department of Women and Children’s Health, FoLSM,
Kings College London
| | | | | | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Fionnuala McAuliffe
- Department of Obstetrics and Gynaecology, National
Maternity Hospital Dublin, Ireland
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão
Preto Medical School, University of São Paulo, Ribeirão Preto,
São Paulo, Brazil
| | | | | | - Anne B. Kihara
- African Federation of Obstetrics and Gynaecology,
Africa
| | - Gian Carlo Di Renzo
- Centre of Perinatal & Reproductive Medicine
Department of Obstetrics & Gynaecology University of Perugia, Perugia,
Italy
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and
Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy
Shriver National Institute of Child Health and Human Development,
National Institutes of Health, U. S. Department of Health and Human Services,
Bethesda, Maryland, and Detroit, Michigan, USA
| | - Mary D’Alton
- Society for Maternal-Fetal Medicine, Washington, DC,
USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson
University, Philadelphia, PA, USA
| | | | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Comparison of two "a priori" risk assessment algorithms for preeclampsia in Italy: a prospective multicenter study. Arch Gynecol Obstet 2019; 299:1587-1596. [PMID: 30953193 DOI: 10.1007/s00404-019-05146-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 03/28/2019] [Indexed: 10/27/2022]
Abstract
PURPOSE To compare the performance of the algorithms proposed by the Fetal Medicine Foundation in 2012 and BCNatal in 2013 in an Italian population. METHODS A multicentric prospective study was carried out which included pregnancies at 11-13 weeks' gestation from Jan 2014 through May 2017. Two previously published algorithms were used for the calculation of the "a priori" risk of preeclampsia (based on risk factors from medical history) in each individual. RESULTS In a study population of 11,632 cases, 67 (0.6%) developed early preeclampsia and 211 (1.8%) developed late preeclampsia. The detection rates (95% CI) for early and late preeclampsia were 58.2% (45.5-70.2) vs. 41.8% (29.6-54.5) (p value < 0.05) and 44.1% (37.3-51.1) vs. 38% (31.3-44.8) (p value < 0.05) for the Fetal Medicine Foundation and BCNatal, respectively (at a 10% false positive rate). The associated risk was 1:226 and 1:198 (p value ns) for early PE, and 1:17 and 1:24 (p value ns) for late PE for the Fetal Medicine Foundation and BCNatal, respectively. CONCLUSIONS The Fetal Medicine Foundation screening for preeclampsia at 11-13 weeks' gestation scored the highest detection rate for both early and late PE. At a fixed 10% false positive rate, the estimated "a priori" risks of both the Fetal Medicine Foundation and the BCNatal algorithms in an Italian population were quite similar, and both were reliable and consistent.
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Sotiriadis A, Hernandez-Andrade E, da Silva Costa F, Ghi T, Glanc P, Khalil A, Martins WP, Odibo AO, Papageorghiou AT, Salomon LJ, Thilaganathan B. ISUOG Practice Guidelines: role of ultrasound in screening for and follow-up of pre-eclampsia. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 53:7-22. [PMID: 30320479 DOI: 10.1002/uog.20105] [Citation(s) in RCA: 112] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/15/2018] [Accepted: 07/22/2018] [Indexed: 06/08/2023]
Affiliation(s)
- A Sotiriadis
- Second Department of Obstetrics and Gynecology, Faculty of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - E Hernandez-Andrade
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Hutzel Women Hospital, Wayne State University, Detroit, MI, USA
| | - F da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil; and Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - T Ghi
- Obstetrics and Gynecology Unit, University of Parma, Parma, Italy
| | - P Glanc
- Department of Radiology, University of Toronto, Toronto, Ontario, Canada
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - W P Martins
- SEMEAR Fertilidade, Reproductive Medicine and Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - A O Odibo
- Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - A T Papageorghiou
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Nuffield Department of Obstetrics and Gynecology, University of Oxford, Women's Center, John Radcliffe Hospital, Oxford, UK
| | - L J Salomon
- Department of Obstetrics and Fetal Medicine, Hopital Necker-Enfants Malades, Assistance Publique-Hopitaux de Paris, Paris Descartes University, Paris, France
| | - B Thilaganathan
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, London, UK; and Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
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Xiong ZH, Wei J, Lu MQ, Jin MY, Geng HL. Protective effect of human umbilical cord mesenchymal stem cell exosomes on preserving the morphology and angiogenesis of placenta in rats with preeclampsia. Biomed Pharmacother 2018; 105:1240-1247. [PMID: 30021360 DOI: 10.1016/j.biopha.2018.06.032] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 06/07/2018] [Accepted: 06/07/2018] [Indexed: 12/20/2022] Open
Abstract
AIM This study aims to investigate the effect of human umbilical cord mesenchymal stem cell exosomes (hucMSC-Ex) on placental tissue and angiogenesis in rats with preeclampsia (PE). METHOD The expression of MSC surface markers were identified by flow cytometry. Alizarin red staining and oil red O staining were used to examine osteogenic and adipogenic differentiation of hucMSCs. Western blotting was used to determine expressions of CD63 and CD81 in hucMSC-Ex. PE rat models were established using endothelial nitric oxide synthase, eNOS)NG-Nitro-l-arginine Methyl Ester, which were then treated with exosome (Exo) of low dosage (L-Exo), Exo of medium dosage (M-Exo) and Exo of high dosage (H-Exo). The blood pressure at the 15d, 17d and 19d of pregnancy and 24-h urinary protein were measured. TUNEL staining and immunohistochemistry were applied to detect the cell apoptosis and micro-vascular density (MVD) in placental tissues, respectively. Enzyme-linked immunosorbent assay (ELISA) was used to examine serum levels of vascular endothelial growth factor (VEGF) and soluble fms-like tyrosine kinase receptor-1 (sFlt1). RESULTS In vitro cultured hucMSCs showed expression of MSC surface markers (CD29, CD90 and CD105), and no expression of CD34 and CD45. Besides, the isolated exosomes expressed the exosome markers (CD63 and CD81). In response to the treatment of L-Exo, M-Exo and H-Exo, the blood pressure of PE rat models on the 17 d and the 19 d as well as the 24-h urinary protein were substantially decreased. Moreover, at the 21 d, PE rat models treated with L-Exo, M-Exo and H-Exo exhibited an increase in the number and quality of fetuses, placenta quality, MVD and VEGF expression, but substantial decreased cell apoptosis and expression of sFlt1. The influence of Exos was exerted in a dosage dependent manner. CONCLUSION hucMSC-Ex, in a dose-dependent manner, can improve the morphology of placental tissue in rats with PE, by inhibiting cell apoptosis and promoting angiogenesis in placental tissue.
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Affiliation(s)
- Zhi-Hui Xiong
- Department of Obstetrics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, PR China
| | - Jing Wei
- Department of Obstetrics, Hangzhou First People's Hospital, Hangzhou 310006, PR China
| | - Meng-Qi Lu
- Department of Obstetrics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, PR China
| | - Mei-Yuan Jin
- Department of Obstetrics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, PR China
| | - Hong-Ling Geng
- Department of Gynaecology, Guangdong Provincial Hospital of Chinese Medicine, The Second Affiliated Hospital of Guangzhou University of Chinese Medicine, No 111, Dade Road, Yuexiu District, Guangzhou 510120, PR China.
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Leigh MB, John-Cole V, Kamara M, Koroma AP, Koroma MM, Emuveyan EE, Bramlage P, Buschmann I. A Triple Obstetric Challenge of Thoracopagus-Type Conjoined Twins, Eclampsia, and Obstructed Labor: A Case Report from Sub-Saharan Africa. Case Rep Obstet Gynecol 2017; 2017:6815748. [PMID: 29359057 PMCID: PMC5735603 DOI: 10.1155/2017/6815748] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 10/15/2017] [Indexed: 11/26/2022] Open
Abstract
Conjoined twins are very rarely seen. We present a case of thoracopagus that was undiagnosed prior to delivery and combined with eclampsia and obstructed labor in a low-resource setting in sub-Saharan Africa. A 27-year-old pregnant woman was presented to the maternity emergency unit of Princess Christian Maternity Hospital (PCMH) in Freetown at term in labor. Upon admission, the patient was awake and orientated and presented a blood pressure of 180/120 mmHg and a protein value of 3+ on urine dipstick test. Clinical examination-ultrasound was not available-led to the admission diagnosis: obstructed labor with intrauterine fetal death and preeclampsia. Application of Hydralazine 5 mg (i.v.) under close blood pressure monitoring was performed. Under spontaneous progression of labor, one head of the yet unknown conjoined twin was born. The patient developed eclamptic fits. Ceasing of seizures was achieved after implementing the loading dose of the MgSO4 protocol. A vaginal examination led to the unexpected diagnosis of conjoined twins. An emergency cesarean section under general anesthesia via a longitudinal midline incision was performed immediately. The born head was repositioned vaginally. The stillborn conjoined twins presented a female thoracopagus type that seemed to involve the heart. After 8 weeks, the woman was clinically fully recovered.
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Affiliation(s)
- Mariatu Binta Leigh
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
- Center for Internal Medicine I, Department for Angiology, Medical School Brandenburg Theodor Fontane (MHB), Campus Brandenburg, Brandenburg, Germany
| | - Valerie John-Cole
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Mike Kamara
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Alimamy Philip Koroma
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Michael Momoh Koroma
- Department of Anesthesia, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
| | - Edward Ejiro Emuveyan
- Department of Obstetrics and Gynecology, Princess Christian Maternity Hospital (PCMH), University Teaching Hospitals Complex, University of Sierra Leone, Freetown, Sierra Leone
- Department of Obstetrics and Gynecology, College of Medicine, University of Lagos, Akoka, Lagos, Nigeria
| | - Peter Bramlage
- Center for Internal Medicine I, Department for Angiology, Medical School Brandenburg Theodor Fontane (MHB), Campus Brandenburg, Brandenburg, Germany
| | - Ivo Buschmann
- Center for Internal Medicine I, Department for Angiology, Medical School Brandenburg Theodor Fontane (MHB), Campus Brandenburg, Brandenburg, Germany
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