ASPRE trial: performance of screening for preterm pre-eclampsia

Preeclampsia pathogenesis and prediction - where are we now: the focus on the role of galectins and miRNAs

Preeclampsia is a complex, progressive multisystem hypertensive disorder during pregnancy that significantly contributes to increased maternal and perinatal morbidity and mortality. Two screening algorithms are in clinical use for detecting preeclampsia: first-trimester screening, which has been developed and validated for predicting early-onset preeclampsia but is less effective for late-onset disease; and the sFlt-1:PlGF biomarker ratio (soluble tyrosine kinase and placental growth factor) used in suspected cases of preeclampsia. This ratio has a high negative predictive value, allowing for the reliable exclusion of the disease. Both of these screening tests have not met expectations. This review attempts to summarize the current knowledge on the pathogenesis and prediction of preeclampsia and to draw attention to novel biomarkers with a focus on microRNAs and galectins. Although these molecules belong to two distinct biological classes, they functionally converge in regulating placental and immune pathways. Ample evidence supports their involvement in the molecular mechanisms underlying preeclampsia. Based on current knowledge, galectin-13, C19MC members, and miRNA-210 are associated with the trophoblast/placenta and conditions of placental ischemia or hypoxia. Their levels differ significantly in pregnant women at risk of preeclampsia as early as the late first and early second trimester, making them potential markers for predicting preeclampsia.

Carrier screening for Alport syndrome: The clinical importance of heterozygosity for pathogenic or likely pathogenetic variants

Reproductive carrier screening aims to identify individuals at an increased chance of having children affected by genetic conditions. However, testing can also reveal health implications for autosomal or X-chromosome heterozygotes. One such example is screening for Alport syndrome (COL4A3-5-related disease) which is one of the most common causes of inherited chronic kidney disease. Alport syndrome heterozygotes have an increased chance for chronic kidney disease. Monitoring and providing early treatment can slow kidney disease progression and delay the onset of kidney failure. We provide information on Alport syndrome and propose a simple management algorithm for individuals found on carrier screening to have a pathogenic or likely pathogenic variant in one or more of the Alport syndrome genes. We emphasize the importance of genetic counseling, partner screening, and cascade testing to identify at-risk family members, including existing children. Clinical management includes baseline evaluation for kidney disease, nephrology referral when needed, enhanced pregnancy surveillance for proteinuria and hypertension, and long-term follow-up. The proposed management plan serves as an example for other conditions where screening identifies heterozygotes with a variable chance for disease in the individual tested.

Implementation of the new S2e guideline "first-trimester diagnostics and therapy @ 11-13 + 6 weeks of pregnancy": a survey in outpatient practices

PURPOSE

The objective of this study was to ascertain the awareness of the guideline since its publication, its impact on outpatient approaches, implementation, and any alterations to daily practices.

METHODS

A questionnaire containing 36 items pertaining to first-trimester diagnostics and therapy was distributed to certificated gynecologists specializing in screening in Lower Saxony and East Westphalia. The questionnaire contained both multiple choice and open questions. The questions addressed information about the structure of the study population, the presentation of mandatory and optionally recommended settings for early structured fetal malformation diagnostics and echocardiography, the basic treatment regimens for first-trimester screening, and the utilization and management of non-invasive fetal test systems.

RESULTS

92.1% of the 38 respondents were familiar with the guideline at the time of the survey. The mandatory recommended structures are consistently displayed by 92.1-100% of participants, the remaining optional settings are displayed ranging from 7.9 to 55.3%. The majority of participants consider the combination of biochemistry and ultrasound markers as an indication for invasive diagnostics. 71.1% offer a non-invasive prenatal test in parallel with the first-trimester screening, while 65.8% of participants offer screening for preeclampsia. It was indicated by the participants that the publication of the guideline tended to have an impact on the outpatient approach to first-trimester screening. On average, the participants have modified their practice in first-trimester screening since the guideline was published.

CONCLUSION

The recommendations outlined in the guideline have achieved a high level of awareness among most outpatient specialists, thereby exerting a notable influence on the formulation of treatment algorithms. In the contemporary context of patient-centered medicine and rapidly evolving healthcare, guidelines have emerged as a pivotal instrument for the effective aggregation of information.

Maternal cell-free DNA in early pregnancy for preeclampsia screening: a systematic review

PURPOSE

To quantify the separation between maternal blood cell-free (cf)DNA markers in preeclampsia and unaffected pregnancies and compare with existing markers. This approach has not been used in previous studies.

METHODS

Comprehensive systematic literature search of PubMed to identify studies measuring total cfDNA, fetal cf(f)DNA or the fetal fraction (FF) in pregnant women. Included-studies of asymptomatic pregnancies with subsequent preeclampsia (cases) and unaffected pregnancies (controls) tested in the first or second trimester and before the clinical onset of preeclampsia. Excluded-studies not reporting the median or mean, standard deviation, inter-quartile range or range in cases and controls. Information from 26 eligible studies was entered into a meta-analysis to estimate, for each marker, the Mahalanobis distance, a measure of separation between the overlapping distributions in preeclampsia and unaffected pregnancies. This was compared with estimates for mean arterial pressure (MAP), uterine artery Doppler pulsatility index (UtA-PI), pregnancy associated plasma protein (PAPP)-A and placental growth factor (PlGF).

RESULTS

The mean Mahalanobis distance for total cfDNA was 0.44 (95% CI 0.12-0.76), which fell between UtA-PI (0.53) and the absolute value of PAPP-A (- 0.36). For cffDNA the distance was 1.03 (0.37-1.69), which is superior to MAP (0.74), UtA-PI, PlGF (- 0.57) and PAPP-A. The distance for FF was - 0.34 (- 0.56 to - 0.12), similar to PAPP-A.

CONCLUSION

All three markers have a potential preeclampsia screening role, particularly cffDNA. However, to estimate the screening performance in combination with existing markers further large studies are needed. The current analysis will help in the power calculation for such studies.

First-trimester uterine artery pulsatility index and preeclampsia risk in pregnancies after artificial frozen embryo transfer: analysis of over 27,000 pregnancies

BACKGROUND

Accumulating evidence indicates that pregnancies after artificial cycle frozen embryo transfer are associated with an increased risk of preeclampsia. Uterine artery Doppler, along with maternal factors and serum biomarkers, is a crucial biomarker for first-trimester preeclampsia screening, aiding in identifying "high-risk" patients. Guidelines strongly recommend administering aspirin (150 mg/d) in these women, owing to robust evidence demonstrating a 62% reduction in the incidence of preeclampsia. Although previous studies suggested lower uterine artery pulsatility index after frozen embryo transfer, no previous studies explored the impact of the type of endometrial preparation in Uterine Artery Doppler or its influence on estimating first-trimester preeclampsia risk.

OBJECTIVE

The study aims to evaluate the possible impact of endometrial preparation for frozen embryo transfer on the uterine artery pulsatility index during the first-trimester preeclampsia screening.

STUDY DESIGN

This is a retrospective single-center study including 27,289 singleton pregnancies (naturally conceived or after assisted reproductive treatment) who underwent the first-trimester ultrasound screening at our University Hospital between January 2010 and May 2023. Overall, 27,289 pregnancies were included: 23,410 naturally conceived and 3879 following assisted reproductive technologies including 391 after ovulation induction and intrauterine insemination, 888 in vitro fertilization and fresh embryo transfer, and 2600 natural or artificial frozen embryo transfer cycles. An analysis of covariance was conducted to assess if there is an association between the uterine artery pulsatility index value and the mode of conception, adjusting for confounding factors (age, weight, smoking, and oocyte donation).

RESULTS

Overall, pregnancies after artificial frozen embryo transfer demonstrated significantly lower first-trimester uterine artery pulsatility index as compared with all other modes of conception in a multivariable regression analysis adjusted for age, weight, smoking, and oocyte donation. The percent difference was 22.6 [confidence interval, CI 95%: 20.6; 24.5] compared to naturally conceived pregnancy, 24.5 [CI 95%: 20.7; 28.1] to ovulation induction or intrauterine insemination, 24.8 [CI 95%: 22.9; 27.6] to fresh embryo transfer and 21.7 [CI 95%: 17.6; 25.5] compared to natural cycle frozen embryo transfer. When calculating the risk for initiating preventive aspirin administration, the number of patients with increased risk (>1/100) who initiated prophylactic aspirin was significantly lower in the artificial cycle frozen embryo transfer group (7.8% vs 16.0% in natural cycle P<.001 vs 11.0% in Fresh embryo transfer P=.01 vs 10.5% in ovulation induction or intrauterine insemination P=.14 vs 9.3% in naturally conceived pregnancy P=.03). Surprisingly although significantly fewer patients were considered at high risk for preeclampsia in the artificial cycle frozen embryo transfer group, analysis of the actual incidence of preeclampsia demonstrated 3 times higher preeclampsia incidence in artificial cycle group 5.3% (122/2284) as compared with naturally conceived 1.4% (321/23,410), ovulation induction and intrauterine insemination 1.3% (5/391) or natural cycle pregnancies 1.6% (5/316) and more than 2 times higher when compared to fresh embryo transfer pregnancies 2.3% (20/888), P<.001.

CONCLUSION

Pregnancies following frozen embryo transfer in artificial cycle are associated with significantly lower uterine artery pulsatility index during first-trimester preeclampsia screening. This results in a significantly lower number of patients being classified as high-risk for developing preeclampsia, despite accumulating evidence that artificial cycles are linked to an increased risk of preeclampsia. Therefore, the first-trimester preeclampsia risk algorithm should be adjusted to accurately assess risk for those patients undergoing artificial cycle frozen embryo transfer, to prevent the undertreatment of patients who are at very high risk of developing preeclampsia and may benefit from prophylactic aspirin.

The role of second trimester uterine artery doppler using uterine artery score in routine prenatal care in Switzerland

OBJECTIVE

The role of 2nd trimester uterine artery Doppler (UtAd) remains unclear and its implementation varies greatly. Aim of this study was to determine whether 2nd trimester UtAd interpreted with uterine artery score (UAS), a score combining PI and notching in both UtA, is useful in an unselected population in routine care.

METHODS

We retrospectively calculated the UAS in 503 unselected singleton pregnancies with 2nd trimester scan at 20-24 weeks between 09/2021 and 08/2023 and later delivery in our department and analysed its relationship with perinatal outcome.

RESULTS

With UAS > 2 there was a significant increase in adverse perinatal outcome such as hypertension/PE (OR 7.88), SGA (OR 6.82), preterm birth (OR 5.51) and placental abruption (OR 6.89). In contrast, no significant difference was found when comparing UAS 0, 1 and 2. In general, NPV for adverse outcomes were high while PPV were low. In 50 % of SGA-fetuses and 33 % of cases with hypertension/PE in UAS 3-4, the woman had no risk factor.

CONCLUSION

Routine 2nd trimester UtAd is useful in all pregnancies as it can identify additional patients without a pre-existing risk who generally would not be eligible for intense surveillance but still develop PE or SGA later. Further, due to the high NPV, UtAd qualifies as a rule-out tool for adverse outcome even in high-risk pregnancies. To standardise its interpretation, UAS with a cut-off at 2 seems to be a suitable tool for an unselected population. In case of UAS 3-4 a more intense surveillance program should be offered.

Prediction of small-for-gestational age and fetal growth restriction at routine ultrasound examination at 35-37 weeks' gestation

OBJECTIVE

To evaluate the performance of sonographic fetal biometry and Doppler parameters assessed at routine third-trimester ultrasound examination for predicting small-for-gestational age (SGA) and fetal growth restriction (FGR).

METHODS

This was a retrospective cohort study of low-risk singleton pregnancies undergoing routine ultrasound examination between 35 + 0 and 37 + 6 weeks' gestation and delivered at St George's University Hospital, London, UK, between December 2019 and February 2024. The study outcomes were SGA (birth weight < 5th centile) and FGR (birth weight < 3rd centile or birth weight < 10th centile with composite adverse perinatal outcome). Composite adverse perinatal outcome comprised intrauterine death, neonatal death or admission to the neonatal intensive care unit. Demographic characteristics, estimated fetal weight (EFW) and abdominal circumference centiles, as well as Doppler indices, including pulsatility indices (PI) of the umbilical artery (UA), middle cerebral artery (MCA) and uterine artery (UtA) were evaluated. The cerebroplacental ratio (CPR) was calculated, and all indices were converted to multiples of the median (MoM). Multivariable logistic regression analysis was performed to identify and adjust for confounders. The area under the receiver-operating-characteristics curve (AUC) was used to evaluate the model's performance for predicting small neonates.

RESULTS

A total of 14 161 pregnancies were included in the study. The prevalence of SGA and FGR neonates was 3.1% and 1.5%, respectively. Independent predictors of SGA and FGR, respectively, were: EFW centile (adjusted odds ratio (aOR) 0.91 (95% CI, 0.90-0.92); P < 0.001 and aOR 0.90 (95% CI, 0.89-0.91); P < 0.001); AC centile (aOR 0.91 (95% CI, 0.90-0.92); P < 0.001 and aOR 0.91 (95% CI, 0.90-0.92); P <0.001); UA-PI MoM (aOR 4.60 (95% CI, 2.19-9.64); P < 0.001 and aOR 2.53 (95% CI, 1.05-6.10); P = 0.038); MCA-PI MoM (aOR 0.37 (95% CI, 0.20-0.70); P = 0.002 and aOR 0.26 (95% CI, 0.12-0.59); P = 0.001); CPR MoM (aOR 0.23 (95% CI, 0.13-0.42); P < 0.001 and aOR 0.25 (95% CI, 0.12-0.53); P < 0.001); and UtA-PI MoM (aOR 2.54 (95% CI, 1.68-3.83); P < 0.001 and aOR 2.16 (95% CI, 1.31-3.58); P = 0.003). The EFW centile alone was associated with an AUC of 0.917 (95% CI, 0.907-0.929) for the prediction of SGA and 0.925 (95% CI, 0.908-0.939) for the prediction of FGR. This was similar to AUCs of around 0.92 for the prediction of SGA and AUCs of around 0.93 for the prediction of FGR when the EFW centile was combined with any Doppler parameters.

CONCLUSIONS

Sonographic fetal biometry evaluation in the late third trimester can predict delivery of a neonate affected by SGA or FGR, including those at risk for adverse perinatal outcomes. In an unselected population, fetal arterial Doppler parameters were independent predictors of SGA and FGR, but the addition of Doppler parameters to fetal biometry did not improve prediction of the incidence of small neonates. © 2025 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Increase of augmentation index (AIx@75): a promising tool for screening hypertensive pregnancy disorders

BACKGROUND

Screening tools in the first trimester of pregnancy for hypertensive pregnancy disorders need to be determined.

OBJECTIVES

To compare cardiovascular parameters between pregnant (PG) and non-pregnant women (NPG) and to evaluate the sensitivity and specificity of arterial stiffness indices in screening for hypertensive pregnancy disorders and their possible association with the mean uterine artery pulsatility index (MUA-PI).

METHODS

This study included 77 pregnant women (11-13.6 gestational weeks) and 77 age-matched non-pregnant women. Cardiovascular parameters were non-invasively measured using Mobil- O-Graph®, a cuff-based oscillometric device. The Doppler Ultrasonographic was used to evaluate the MUA-PI.

RESULTS

Augmentation index (AIx@75) was significantly higher in PG compared to NPG. ROC curve of AIx@75 showed area under curve (AUC): 0.7303, Sensitivity: 74.03% and Specificity: 64.94% and Cutoff: 22.50%. The systolic volume index was lower and the heart rate was higher in PG compared to NPG. Of the 77 pregnant women, 12 had an unfavorable outcome with hypertensive changes. Central systolic blood pressure (109.1 ± 8.84mmHg) and AIx@75 (31.97 ± 5.47%) were significantly higher in the group of pregnant women with outcome compared to the group without outcome (103.0 ± 8.53mmHg and 26.80 ± 8.71%). ROC curve showed better performance of the AIx@75 [AUC: 0.7179, Sensitivity: 83.33% and Specificity: 60.00%, Cutoff: 27.67%] compared to MUA-PI [AUC: 0.5098, Sensitivity: 8.333% and Specificity 98.44%].

CONCLUSIONS

AIx@75 was significantly higher in PG compared to NPG. We compared the AIx@75 of PG with and without outcomes. ROC curve analysis showed that this index could discriminate between PG with and without an outcome. Differently, the MUA-PI did not differ between PG with and without outcome, suggesting the superiority of AIx@75 in relation to MUA-PI as a method of screening in the first trimester for hypertensive disease of pregnancy. AIx@75 did not assotiate with MUA-PI. Prospective studies will be needed to confirm these findings.

Serial evaluation of morphological and biophysical placental attributes in women with normal outcome and preeclampsia

OBJECTIVE

The study's aim was to perform serial placental biometry and Doppler assessments in antenatal women and compare the characteristics of preeclampsia (PE) and normal outcome.

METHODS

This prospective cohort study was carried out after ethical clearance. Placental length (PL), thickness, and plavental volume (PV), along with the uterine artery (Ut), middle cerebral artery (MCA), and umbilical artery (UA) blood flow were evaluated serially at 11-14, 20-24, and 28-32 weeks of gestation. The women were followed until delivery, those with PE were considered cases, and those with no other adverse outcome were controls. The placental attributes between cases and controls were compared.

RESULTS

A total of 135/1008 (13.4%) had hypertensive disorders of pregnancy (HDP) and 44/1008 (4.4%) had PE, and no maternal or fetal adverse outcomes were seen in 600 (59.5%) women. The PL and PV were significantly less in those with PE (P = 0.005) than in controls. The ratios of PL/Ut A PI and PV/Ut A PI were significantly lower in cases than in controls in all trimesters (P <0.001). In the first trimester, the area under the curve (AUC), sensitivity, and specificity of PV/Ut A PI for PE prediction were 0.801, 81.8%, and 70.5%, respectively. The sensitivity and specificity of the PL/Ut PI ratio was 81.8% and 70.5%, whereas that at 28-32 weeks was 73.3% & 70.7%.

CONCLUSION

Placental parameters were significantly lower in PE than in normal outcome, and the ratios of PL/Ut A PI and PV/Ut A PI proved to be promising markers.

Prevention of maternal mortality with interventions in primary care services: What can we do?

Despite global progress and a marked reduction in maternal mortality ratio worldwide, the burden of maternal death and morbidity remains a huge challenge, especially among low- and middle-income settings. Maternal mortality is determined by multiple components. As a result, sustainable strategies require not only the implementation of effective health policies but also social development. In this narrative review, we discuss strategies to improve the maternal mortality ratio based on recent advances in public health. Primary care plays a key role in identifying background conditions, risk factors and early signs of some major causes of maternal mortality and morbidity. Antenatal care also addresses other conditions that influence outcomes: unwanted pregnancies, nutrition, sexually transmitted illnesses, family planning, immunization, and child health. Therefore, awareness about major causes of maternal mortality, direct and indirect targeted interventions to adequately identify risk factors, implement prophylactic interventions when available and guarantee early diagnosis, can certainly impact outcomes.

Exploring new predictors for hypertensive disorders of pregnancy

The best performing predicting Bayesian algorithm for preeclampsia, endorsed by FIGO, identifies high-risk women at first trimester screening who benefits of a closer monitoring and possibly preventive measures. Unfortunately, the most frequent late term and term preeclampsia are less efficiently predicted. This algorithm is based on statistical assumptions at odds with the physiopathology: preeclampsia is a disease and not a syndrome, as we know it is, and the contingent time-based criteria according to which all pregnancies if not terminated by nature should develop this "disease". In addition to this, we know that gestational hypertension might cause in fifty percent of cases severe outcome, comparable to preeclampsia. The very definition of preeclampsia as proteinuric hypertension is now extended to hypertension associated with other end-organ damage, including fetal growth restriction (FGR), this latter condition proceeding, in early onset cases, hypertension. Predicting phenotypes of hypertensive Disorders of pregnancy (HDP) could better help clinical practice. This study reports exploratory observations in women resulted at high and low risk at first trimester screening followed up at second and third trimester, to term. The co-variates interrogated were sFlt1/PlGF ratio, the uterine arteries PI, the systemic vascular resistances (SVR), maternal total body water and visceral fat. Women were classified as HDP-AGA, HDP-FGR, normotensive-FGR and uneventful pregnancies (controls). We performed a longitudinal Bayesian multivariate mixed-effects model corrected both for pre-gestational BMI and trimester of analysis. The sFlt-1/PlGF ratio and SVR confirmed their significant difference in HDP-AGA, in normotensive FGR, and HDP-FGR along the three trimesters from controls, but with different strength along the three trimesters. The bioimpedance analysis of total body water and visceral fat confirmed the association of these co-factors with women who will develop HDP-AGA. The strength of longitudinal changes observed, even on a limited number of cases, provide evidence that Bayesian algorithms applied at screening tests at different gestational ages, should be based on co-variates significantly associated either with HDP-FGR or with HDP-AGA provided that the main causative co-factors involved are adopted by predictive models aimed at these distinct diseases.

Formative research to optimize pre-eclampsia risk-screening and prevention (PEARLS): study protocol

BACKGROUND

Pre-eclampsia is a leading cause of maternal and neonatal mortality, affecting nearly 5% of pregnant women worldwide. Accurate and timely risk-screening of pregnant women is essential to start preventive therapies as early as possible, including low-dose aspirin and calcium supplementation. In the formative phase for the "Preventing pre-eclampsia: Evaluating AspiRin Low-dose regimens following risk Screening" (PEARLS) trial, we aim to validate and implement a pre-eclampsia risk-screening algorithm, and validate an artificial intelligence (AI) ultrasound for gestational age estimation. In the trial phase, we will compare different daily aspirin doses (75 mg v 150 mg) for pre-eclampsia prevention and postpartum bleeding. This study protocol outlines the mixed-methods formative phase of PEARLS, which will identify challenges and the feasibility of implementing these activities in participating facilities in Ghana, Kenya, and South Africa.

METHODS

We will employ qualitative and quantitative methods to identify factors that may influence trial implementation. In-depth interviews and focus group discussions with policy stakeholders, research midwives, health workers, and pregnant women will explore the barriers, facilitators, and acceptability of pre-eclampsia risk screening, AI ultrasound, and aspirin uptake. A cross-sectional survey of antenatal care and maternity health workers will assess current clinical practices around pre-eclampsia and willingness to participate in the trial activities. Data will be analyzed using thematic analysis and triangulated across sources and participant groups. The findings will inform trial design and help optimize implementation.

DISCUSSION

The research will provide critical insights into the feasibility of pre-eclampsia risk screening and AI ultrasound for gestational age estimation in resource-limited settings. By identifying factors that can influence implementation of pre-eclampsia prevention and care pathways, the findings will inform successful execution of the PEARLS trial, and post-research scale-up activities. This, in turn, can help reduce the prevalence of pre-eclampsia, and improve maternal and newborn outcomes in high-burden settings.

TRIAL REGISTRATION

PACTR202403785563823 || pactr.samrc.ac.za (Date of registration: 12 March 2024).

Optimal Aspirin Dosage for the Prevention of Preeclampsia and Other Adverse Pregnancy Outcomes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Objectives: This systematic review and meta-analysis aimed to determine the effectiveness of different aspirin dosages in preventing preeclampsia and its effect on other pregnancy-associated conditions. Methods: A comprehensive search of three databases (Pubmed, Embase, and Cochrane Library) was conducted for randomized controlled trials without time interval criteria, comparing aspirin at various doses with placebo or no specific preeclampsia prophylaxis. Eligible randomized controlled trials (RCTs) examined pregnant women receiving aspirin at any dose and time during their pregnancy, while the control group received a placebo, or placebo and a different dose of aspirin, or no specific preeclampsia prevention. No exclusion criteria were established regarding the population, study size, study site, or length of aspirin prophylaxis. Studies examining additional preventive medication (such as low-molecular-weight heparin) compared to aspirin without a placebo group were excluded. For all outcomes, the risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated. Meta-regression was performed to examine the relation between aspirin dosage and preeclampsia. Results: Based on the analysis of 31 studies involving 28,318 pregnancies and 20 studies involving 26,551 pregnancies, the early initiation of aspirin significantly reduced the overall incidence of preeclampsia (RR = 0.63, CI: 0.47-0.84) and perinatal death risk (RR = 0.82, CI: 0.72-0.93), respectively. Based on our meta-regression model, we could not establish a dose-dependent correlation between aspirin dosage and the risk of preeclampsia. Conclusions: Early-initiated aspirin prophylaxis is effective in preventing preeclampsia, without raising the incidence of placental abruption or increasing the amount of peripartum bleeding. No specific dose was superior to others; thus, further research should explore higher doses and focus on preterm preeclampsia, maternal-fetal complications, and bleeding.

Pathophysiology of Maternal Obesity and Hypertension in Pregnancy

Obesity is one of the biggest health problems in the 21st century and the leading health disorder amongst women of fertile age. Maternal obesity is associated with several adverse maternal and fetal outcomes. In this group of women, the risk for the development of hypertensive disorders of pregnancy (HDPs), such as gestational hypertension (GH) and pre-eclampsia (PE), is increased. In fact, there is a linear association between an increase in pre-pregnancy body mass index (BMI) and PE. Excessive weight gain during pregnancy is also related to the development of PE and GH. The role of obesity in the pathophysiology of HDP is complex and is most likely due to an interaction between several factors that cause a state of poor maternal cardiometabolic health. Adipokines seem to have a central role in HDP development, especially for PE. Hypoadiponectinemia, hyperleptinemia, insulin resistance (IR), and a proinflammatory state are metabolic disturbances related to PE pathogenesis, contributing to its development by inducing a state of maternal endothelial dysfunction. Hypertriglyceridemia is suggested to also be a part of the disease mechanisms of HDP. Therefore, this review seeks to explore the scientific literature to assess the complications of maternal obesity and its association with the development of HDP.

Aspirin dosage for preeclampsia prophylaxis: an argument for 81-mg dosing

Research conducted over the past few decades has shown that low-dose aspirin can effectively reduce the risk of developing preeclampsia. Consequently, numerous prominent organizations have adopted the recommendation to use low-dose aspirin during pregnancy to prevent preeclampsia. However, the optimal dosage of low-dose aspirin (81mg versus 162mg) remains a subject of debate. Currently, there is insufficient high-quality data to justify the use of a higher dosage of low-dose aspirin. In this review, we review the existing evidence that supports the continued use of 81mg of aspirin over a higher dose and emphasize the need for high-quality research to alter current recommendations.

Aspirin dosage for preeclampsia prophylaxis: an argument for 162-mg dosing

The optimal aspirin dose for preeclampsia prevention remains controversial, with international guidelines lacking consensus on the most effective regimen. Aspirin is a proven intervention for reducing the risk of preeclampsia, particularly when initiated early in pregnancy. Its benefits stem from the selective inhibition of cyclooxygenase-1 (COX-1), reducing thromboxane A2 synthesis while preserving prostacyclin production, thereby restoring the vascular balance essential for placental health. A dose-response relationship has been established, with doses ≥100 mg showing significantly greater efficacy than lower doses. Furthermore, aspirin's pharmacological effects remain highly specific to COX-1 at the 162 mg dose, minimizing concerns about broader prostaglandin inhibition. Emerging evidence suggests that certain patient factors, such as altered pharmacokinetics during pregnancy or obesity, may reduce aspirin's effectiveness at lower doses (e.g., 81 mg). In these studies, aspirin resistance was successfully overcome with a 162 mg dose. While concerns regarding safety at this dose have been raised, contemporary randomized controlled trials utilizing a 150 mg dose have shown no increase in adverse effects compared to placebo. As such, current evidence increasingly supports 162 mg as the optimal dose for preeclampsia prevention, offering greater effectiveness than the commonly used 81 mg dose, without significant evidence of increased risk.

Maternal Thyroid Function and Biochemical Markers of Placental Function in Early Pregnancy

OBJECTIVE

A link between maternal thyroid function and the placental biomarkers, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF), has been brought forward. This study aimed to describe their association in early pregnancy.

DESIGN

Retrospective cohort study.

PARTICIPANTS

Eight hundred and fifty-eight pregnant women from the North Denmark Region, 2013, with blood samples drawn in early pregnancy.

MEASUREMENTS

Thyroid-stimulating hormone (TSH), free thyroxine (fT4), thyroid-peroxidase antibodies (TPO-Ab), thyroglobulin antibodies (Tg-Ab) (ADVIA Centaur XPT, Siemens Healthineers), sFlt-1 and PlGF (Kryptor Compact, ThermoFisher Scientific) were measured. The association between maternal TSH and fT4 and percentile (pc) levels of sFlt-1 and PlGF (< 25th pc, 25-75th pc, > 75th pc) was evaluated using regression analysis and reported as adjusted beta coefficient (aβ). The frequency of maternal thyroid autoantibodies (TPO-Ab > 60 U/mL or Tg-Ab > 33 U/mL) by pc levels of sFlt-1 and PlGF was compared using chi-squared test.

RESULTS

Higher levels (> 75th pc) of sFlt-1 associated with lower TSH (aβ 0.62, 95% CI: 0.51-0.76) and higher fT4 (aβ 1.03, 95% CI: 1.01-1.05). Higher levels of PlGF associated with lower TSH (aβ 0.82, 95% CI: 0.69-0.98), but not with levels of fT4 (aβ 1.00, 95% CI: 0.97-1.02). No association with maternal thyroid autoantibodies was found (TPO-Ab: sFlt-1: p-value 0.5 and PlGF: p-value 0.1; Tg-Ab: sFlt-1: p-value 0.7 and PlGF: p-value 0.1).

CONCLUSIONS

In a large cohort of Danish pregnant women, higher levels of sFlt-1 and PlGF associated with maternal thyroid function in early pregnancy, while there was no association with maternal thyroid autoantibodies.

Massively elevated sFlt1/PlGF in a pregnant patient with fetal growth restriction and perinatal death in the context of a systemic lupus erythematosus

We report a case of confusingly high soluble fms-like tyrosine kinase 1/placental growth factor (sFlt1/PlGF) ratio in a pregnant patient with underlying systemic lupus erythematosus and antiphospholipid syndrome without superimposed pre-eclampsia.

Risk and decision-making: Communication between health professionals and pregnant women at risk of preeclampsia in Catalonia

The biomedical model of attention focuses on preventive risk assessment to mitigate the apparition of future diseases. In the event of a pregnancy classified "at risk" of preeclampsia, screening undertaken in first-term ultrasound controls determines which patients receive preventive treatment. This article examines women's narratives on the communication dynamics with health professionals by drawing on an eight-month ethnographic fieldwork, between 2022 and 2023, in a Barcelona hospital's obstetrics department and 24 semi-structured interviews with women in the postpartum period. The participants of this study had been classified at high risk of developing preeclampsia, which is determined through a screening undertaken during the first trimester of pregnancy, or had a diagnosis of preeclampsia. The results suggest that risk classification significantly impacts the decision-making process and the technical parameters. As we contend, participants experienced difficulties receiving quality information and communicating with professionals, making shared decision-making challenging. As we conclude, doctor-patient dialogue and shared decisions are increasingly replaced by institutional protocols where patients feel their knowledge and experiences have little room.

Comparison of two aspirin doses for the prophylaxis of pre-eclampsia in twin pregnancy: a multicentre retrospective study with propensity score matching

BACKGROUND

Aspirin has proved its efficacy in reducing the rate of preeclampsia in singleton pregnancy; however, there is discrepancy about the efficient dosage that should be used. While some societies recommend daily 75 to 81 mg, others recommend higher dosage (160 mg). This discrepancy is due to the lack of randomized controlled studies that compare these 2 dosages. Moreover, there remains a considerable gap in our knowledge concerning the appropriate prophylactic aspirin dosage for twin pregnancies.

OBJECTIVE

This study aimed to assess the efficacy of various aspirin prophylaxis dosages in the prevention of preeclampsia and hypertensive disorders of pregnancy (HDP) in twin pregnancies.

STUDY DESIGN

This was an international multicentre retrospective cohort study that was conducted in 3 European centers. We included all twin pregnancies with 2 live fetuses at 13 weeks of gestation (WG). We excluded fetal malformations, twin-twin transfusion syndrome, twin anemia polycythemia sequence, twin reversed arterial perfusion sequence, twin pregnancies at onset but continued as singletons (vanishing twin/arrest before 13 WG), and loss of follow-up. Patients were categorized into 3 groups: no aspirin, daily 80 to 100 mg aspirin, and daily 160 mg aspirin. Primary outcomes were the incidence of preeclampsia and HDP, whereas secondary outcomes were small-for-gestational age, postpartum hemorrhage >1000 mL, antenatal bleeding of obstetrical origin, thrombocytopenia, miscarriage, intrauterine fetal demise, neonatal death, and gastritis. Propensity score matching and multivariate analyses were conducted to assess outcomes including pre-eclampsia, gestational hypertension, maternal complications, and gastritis. Propensity score matching was used to balance the 3 groups of study. Cox regression models were done for each outcome after matching to compare the 3 groups. A P-value<.05 was considered statistically significant.

RESULTS

A total of 1907 twin pregnancies were included: 1423 (74.62%) received no aspirin, 212 (11.12%) received 80 to 100 mg, and 272 (14.26%) received 160 mg. After using propensity score matching for maternal age, body mass index, race, parity, history of preeclampsia, chronic hypertension, diabetes mellitus, thrombophilia, spontaneous conception, and type of twin pregnancy, the 3 groups were adequately balanced (absolute standardized difference [ASD] <15%), except for age and thrombophilia (ASD 22.1% and 16.4%, respectively). The administration of aspirin 160 mg decreased the hazard ratio (HR) for preeclampsia to 0.63 and for HDP to 0.56, whereas the administration of aspirin 80 to 100 mg failed to decrease both HR below 1. In addition, aspirin 160 mg decreased the risk for preeclampsia <34 WG. No significant increase for aspirin-related complications, such as bleeding or thrombocytopenia, or other obstetrical outcomes was observed with the higher dose of aspirin.

CONCLUSION

The use of 160 mg aspirin for the prevention of hypertensive disorders of pregnancy may offer superior outcomes in twin pregnancies, with no discernible rise in complications when compared to aspirin doses ranging from 80 to 100 mg. Further research should explore long-term impacts and refine dosage strategies for optimal outcomes in twin pregnancies.

Association of Circulating Neprilysin with BMI, Cardiovascular Health, and Kidney Function in High-Risk Pregnancies: A Pilot Study

BACKGROUND/OBJECTIVES

Inadequate cardiovascular adaptation during pregnancy impairs endothelial function and vascular resistance, contributing to complications such as pre-eclampsia (PE) and gestational hypertension (GH). Neprilysin (NEP), a protease involved in vascular regulation, has been linked to PE, but its role in endothelial function and vascular adaptation remains unclear. This pilot study investigates the associations between soluble neprilysin (sNEP) and markers of vascular and renal function in high-risk pregnancies without PE.

METHODS

Observed parameters were analyzed in 29 high-risk pregnant women across early, mid-, and late pregnancy. sNEP levels were analyzed alongside body mass index (BMI), endothelial dysfunction (ADMA), arterial stiffness (pulse wave velocity, PWV), retinal microvasculature (central retinal arteriolar and venular equivalents, CRAE and CRVE), and kidney function markers. The impact of gestational hypertension (GH) and prior smoking on sNEP levels was also evaluated.

RESULTS

In early and mid-pregnancy, sNEP was inversely associated with BMI. During mid-pregnancy, sNEP showed a positive correlation with CRAE and an inverse correlation with PWV, suggesting reduced arterial stiffness. By late pregnancy, sNEP was positively associated with glomerular filtration rate and inversely correlated with creatinine and protein levels, reflecting improved kidney function. Women with GH exhibited elevated sNEP, while former smokers had lower sNEP levels in early pregnancy.

CONCLUSIONS

These findings suggest that sNEP plays a role in vascular and renal adaption during pregnancy, offering new perspectives on vascular tone regulation in high-risk pregnancies. Further research is needed to clarify these mechanisms and their clinical relevance.

Plasma acute phase proteins as potential predictors of intra-amniotic inflammation and infection in preterm premature rupture of membranes

BACKGROUND

We aimed to investigate the potential of altered levels of various acute phase proteins (APPs) in the plasma, either used alone or in combination with ultrasound-, clinical-, and conventional blood-based tests, for predicting the risk of intra-amniotic inflammation (IAI), microbial invasion of the amniotic cavity (MIAC), histologic chorioamnionitis (HCA), and funisitis in women with preterm premature rupture of membranes (PPROM).

METHODS

A total of 195 consecutive pregnancies involving singleton women with PPROM (at 23 + 0-34 + 0 weeks) who underwent amniocentesis and from whom plasma samples were obtained at amniocentesis were retrospectively included in this study. Amniotic fluid (AF) was cultured to assess the MIAC and analyzed for interleukin (IL)-6 levels to define IAI (AF IL-6 level of ≥2.6 ng/mL). The plasma concentrations of hepcidin, mannose-binding lectin (MBL), pentraxin-2, retinol-binding protein 4 (RBP4), serum amyloid A1 (SAA1), and serpin A1 were determined using ELISA. Ultrasonographic cervical length (CL), neutrophil-to-lymphocyte ratio (NLR), and C-reactive protein levels were measured. IAI/MIAC was defined as IAI, MIAC, or both.

RESULTS

Multivariate logistic regression analyses showed the following: (1) elevated plasma levels of hepcidin and SAA1 and decreased levels of RBP4 in the plasma were independently associated with IAI/MIAC and (2) decreased plasma RBP4 levels were independently associated with funisitis; however, (3) none of the plasma APPs investigated were associated with acute HCA when adjusted for baseline covariates. Using stepwise regression analysis, noninvasive prediction models comprising plasma RBP4 levels, CL, NLR, and gestational age at sampling were proposed, which provided a good prediction of IAI/MIAC and funisitis (area under the curve: 0.80 and 0.72, respectively).

CONCLUSIONS

Hepcidin, RBP4, and SAA1 were identified as potential APP biomarkers in the plasma predictive of IAI/MIAC or funisitis in patients with PPROM. In particular, combination of these APP biomarkers with ultrasound-, clinical-, and conventional blood-based markers can significantly support the diagnosis of IAI/MIAC and funisitis.

Chronic Inflammation Offers Hints About Viable Therapeutic Targets for Preeclampsia and Potentially Related Offspring Sequelae

The combination of hypertension with systemic inflammation during pregnancy is a hallmark of preeclampsia, but both processes also convey dynamic information about its antecedents and correlates (e.g., fetal growth restriction) and potentially related offspring sequelae. Causal inferences are further complicated by the increasingly frequent overlap of preeclampsia, fetal growth restriction, and multiple indicators of acute and chronic inflammation, with decreased gestational length and its correlates (e.g., social vulnerability). This complexity prompted our group to summarize information from mechanistic studies, integrated with key clinical evidence, to discuss the possibility that sustained or intermittent systemic inflammation-related phenomena offer hints about viable therapeutic targets, not only for the prevention of preeclampsia, but also the neurobehavioral and other developmental deficits that appear to be overrepresented in surviving offspring. Importantly, we feel that carefully designed hypothesis-driven observational studies are necessary if we are to translate the mechanistic evidence into child health benefits, namely because multiple pregnancy disorders might contribute to heightened risks of neuroinflammation, arrested brain development, or dysconnectivity in survivors who exhibit developmental problems later in life.

Impact of Sonographer Experience, Insonation Angle, and Bladder Filling on Uterine Artery Doppler Measurements in the First Trimester of Pregnancy

OBJECTIVE

To investigate the influence of different measurement conditions and ultrasound training level on uterine artery pulsatility index (UtA-PI) measurements as required for combined first trimester preeclampsia (PE) screening.

METHODS

This was a prospective study of consecutive patients with singleton pregnancies presenting for an ultrasound examination between 11 and 14 weeks' gestation. UtA-PI measurements were conducted by residents in training and repeated by experienced sonographers thereafter. UtA-PI measurements were conducted under different examination conditions. First, the trainee sonographers performed transabdominal sagittal and transverse UtA-PI measurements without bladder filling. These measurements were then repeated by the expert sonographers. Additionally, the expert sonographers also performed transvaginal UtA-PI measurements and transabdominal measurements with bladder filling. Statistical analysis was conducted with the statistical software R and included descriptive statistics as well as 2-sided paired t tests.

RESULTS

A total of 100 women were included in the study. Mean age was 31.7 ± 4.92 years and mean gestational week was 12.5 ± 0.53 weeks. A total of 56% were nulliparous and 44% were parous. UtA-PI was significantly lower if performed by a sonographer in training versus an experienced sonographer (P = .031). No significant difference was observed in comparing transverse and sagittal techniques (P = .241). There was also no significant difference in transabominal versus transvaginal measurements (P = .806) and with an empty versus full bladder (P = .444).

CONCLUSION

Experience of sonographer has a significant impact on UtA-PI. Supervised onsite training is necessary to improve reliability and consistency of UtA-PI measurements and make PE screening reliable for implementation in a universal screening setting.

A review of ethnic disparities in preeclampsia

PURPOSE OF REVIEW

Recent reports have reiterated the inequities in maternal morbidity and mortality for minority ethnic groups, with preeclampsia being a significant concern. Females of Black and South Asian ethnicity have an increased risk of preeclampsia with disproportionately higher adverse outcomes compared to white females.

RECENT FINDINGS

This review will explore ethnic disparities in preeclampsia outcomes, prediction, diagnosis, prevention and management. Recent evidence has demonstrated that biochemical and biophysical markers that are used for preeclampsia prediction and diagnosis vary for females of different ethnic groups. This needs careful consideration given the current need for accurate prediction models. Furthermore, recent reports have highlighted the disparity in maternal morbidity for those of minority ethnic groups. The reasons for this are multifactorial but underlying biases and racism have been attributed as major contributors to poor care and adverse outcomes.

SUMMARY

Exploring disparities in preeclampsia care is essential to address ethnic inequities that lead to increased adverse outcomes. We must alter current clinical practice to break down the barriers that result in substandard care for females from minority ethnic backgrounds.

Placental lesions in stillbirth following the Amsterdam consensus: A systematic review and meta-analysis

Placental disorders remain one of the main causes of stillbirth. However, the lack of standardised nomenclature has significantly limited the clinical utility of placental histology. Following the Amsterdam consensus classification, which now allows proper comparisons of placenta histology across the world, we conducted the first systematic review and meta-analysis (Prospero CRD42023410469) to assess the commonest stillbirth-associated placental lesions worldwide. Eighteen studies with 3082 placentas were included. Maternal vascular malperfusion and fetal vascular malperfusion were the most prevalent placental lesions in stillbirth, and significantly more frequent in stillbirths than livebirths [OR 3.0 (95 % CI 2.0-4.5), p < 0.001 and OR 5.12 (95 % CI 3.09-8.47), p < 0.001, respectively]. However, when adjusting for gestational age, only maternal vascular malperfusion remained significant at term. Better understanding of the pathophysiology underlying placental lesions is needed to inform timely risk assessment and therapeutic interventions capable of reducing placental-related stillbirths.

Preliminary study on the role of human defensins, interleukins and PCSK9 in early and late preeclampsia

The lack of reliable methods for preeclampsia (PE) early diagnosis limits the opportunities for timely prevention, diagnosis and treatment. This study aims to identify the alterations of biochemical parameters and the immune system activity to build a panel of markers that can support preeclampsia diagnosis. For this study, we recruited 30 pregnant women: 10 healthy pregnant women (CTR); 10 pregnant women with early preeclampsia (EP); 10 pregnant women with late preeclampsia (LP). We evaluated lipid profile and, by gene expression, we assessed PCSK9, IL-2, IL-6, IL-8, IL-10, TNF-α and TGF-β. Moreover, we evaluated both the serum and gene levels of the defensins HBD-1, HBD-2, HBD-4 and HNP-1. Our results showed an increase in gene expression levels of IL-6 and IL-8 in EP compared to LP (IL-6: median 11.7 vs 3.3, p = 0.005; IL-8: median 634.1 vs 214.1, p = 0.013) and to CTR (IL-6: median 11.7 vs 0.5, p < 0.001; IL-8: median 634.1 vs 225.6, p = 0.012), highlighting a massive activation of immune system in case of more severe preeclampsia. Furthermore, higher serum levels of HBD1 in LP compared to CTR (median: 278.8 vs 67.8, p = 0.005) and to EP (median: 278.8 vs 68.6, p = 0.001) might indicate that the same immune system puts in action protective actions to prevent adverse outcome in these cases. Finally, gene expression levels of PCSK9 decreased significantly in women with EP compared to controls and to LP (median: 0.2 vs 0.9, p = 0.010; median: 0.2 vs 1.2, p = 0.012), causing a decrease in circulating LDL-c necessary for the synthesis of placental hormones.

Anti-hypertensive therapy for preeclampsia: a network meta-analysis and systematic review

BACKGROUND

Preeclampsia (PE) is a pregnancy disorder that represents a major cause of maternal and perinatal morbidity and mortality.

METHODS

This network meta-analysis was registered with PROSPERO. We searched the PubMed, ClinicalTrials.gov. and Embase databases for studies published from inception to the 31st of March 2023. RevMan5.3 software provided by the Cochrane Collaboration was used for direct meta-analysis (DMA) statistical analysis. Funnel maps, network meta-analysis (NMA), the surface under the cumulative ranking curve (SUCRA) to rank the different interventions and publication bias were generated by STATA 17.0 software.

RESULTS

We included eight randomized controlled trials (RCTs) involving a total of 1192 women with PE; two studies were of high quality and six were of moderate quality. Eight interventions were addressed in the NMA. In the DMA, we found that blood pressure in the Ketanserin group were significantly higher than those in the Nicardipine group. NMA showed that blood pressure in the Dihydralazine group was significantly higher than that in the Methyldopa, Labetalol, Nicardipine and Diltiazem groups. And the blood pressure in the Labetalol group was significantly lower than that in the Nicardipine group. SUCRA values showed that Diltiazem was more effective in lowering blood pressure than other drugs looked at in this study.

CONCLUSION

According to the eight RCTs included in this study, Diltiazem was the most effective in reducing blood pressure in PE patients; Labetalol and Nicardipine also had good effects. Diltiazem is preferred for the treatment of patients with severe PE and high blood pressure.

Validation of urinary Congo Red preeclampsia detection point-of-care devise

OBJECTIVES

To evaluate a commercial a Congo Red urine devise for assessing preeclampsia risk.

STUDY DESIGN

Prospective non-intervention study among women presenting with clinical suspicion of preeclampsia. The devise was used at the time of enrolment and, depending on gestation, on 1-3 later occasions.

OUTCOME MEASURES

Abnormal diffusion patterns classified as positive or negative, in relation to subsequent confirmation of preeclampsia (detection and false-positive rates, and predictive value) and the probability of diagnosis within a fixed time period (rule-in and rule-out).

RESULTS

600 women were enrolled in the study and follow-up information was available on 538, of whom 95 had preeclampsia at delivery and 443 did not. At enrolment the detection rate was 18 % and the false-positive rate 3.2 %; positive predictive value - probability of positive result being associated with preeclampsia - was 55 % and negative predictive value - probability of negative result not being preeclampsia - was 85 %. A positive test ruled-in delivery with preeclampsia within 28 days among 35 % and ruled-out preeclampsia with 7 days among 98 %. Repeat testing after enrolment yielded similar results to the initial sample.

CONCLUSION

The test has screening potential although published studies differ in the observed detection rate. Using the test to rule-out preeclampsia within 7 days can provide a significant management advantage especially for triaging patients and selecting those who can be managed at the peripheral centres.

Aspirin dose for preeclampsia prophylaxis: an argument for 162-mg dosing

The optimal aspirin dose for preeclampsia prevention remains controversial, with international guidelines lacking consensus on the most effective regimen. Aspirin is a proven intervention for reducing the risk of preeclampsia, particularly when initiated early in pregnancy. Its benefits stem from the selective inhibition of cyclooxygenase-1 (COX-1), reducing thromboxane A2 synthesis while preserving prostacyclin production, thereby restoring the vascular balance essential for placental health. A dose-response relationship has been established, with doses ≥100 mg showing significantly greater efficacy than lower doses. Furthermore, aspirin's pharmacological effects remain highly specific to COX-1 at the 162 mg dose, minimizing concerns about broader prostaglandin inhibition. Emerging evidence suggests that certain patient factors, such as altered pharmacokinetics during pregnancy or obesity, may reduce aspirin's effectiveness at lower doses (e.g., 81 mg). In these studies, aspirin resistance was successfully overcome with a 162 mg dose. While concerns regarding safety at this dose have been raised, contemporary randomized controlled trials utilizing a 150 mg dose have shown no increase in adverse effects compared to placebo. As such, current evidence increasingly supports 162 mg as the optimal dose for preeclampsia prevention, offering greater effectiveness than the commonly used 81 mg dose, without significant evidence of increased risk.

The role of cell-free DNA biomarkers and patient data in the early prediction of preeclampsia: an artificial intelligence model

BACKGROUND

Accurate individualized assessment of preeclampsia risk enables the identification of patients most likely to benefit from initiation of low-dose aspirin at 12 to 16 weeks of gestation when there is evidence for its effectiveness, and enables the guidance of appropriate pregnancy care pathways and surveillance.

OBJECTIVE

The primary objective of this study was to evaluate the performance of artificial neural network models for the prediction of preterm preeclampsia (<37 weeks' gestation) using patient characteristics available at the first antenatal visit and data from prenatal cell-free DNA screening. Secondary outcomes were prediction of early-onset preeclampsia (<34 weeks' gestation) and term preeclampsia (≥37 weeks' gestation).

METHODS

This secondary analysis of a prospective, multicenter, observational prenatal cell-free DNA screening study (SMART) included singleton pregnancies with known pregnancy outcomes. Thirteen patient characteristics that are routinely collected at the first prenatal visit and 2 characteristics of cell-free DNA (total cell-free DNA and fetal fraction) were used to develop predictive models for early-onset (<34 weeks), preterm (<37 weeks), and term (≥37 weeks) preeclampsia. For the models, the "reference" classifier was a shallow logistic regression model. We also explored several feedforward (nonlinear) neural network architectures with ≥1 hidden layers, and compared their performance with the logistic regression model. We selected a simple neural network model built with 1 hidden layer and made up of 15 units.

RESULTS

Of the 17,520 participants included in the final analysis, 72 (0.4%) developed early-onset, 251 (1.4%) preterm, and 420 (2.4%) term preeclampsia. Median gestational age at cell-free DNA measurement was 12.6 weeks, and 2155 (12.3%) had their cell-free DNA measurement at ≥16 weeks' gestation. Preeclampsia was associated with higher total cell-free DNA (median, 362.3 vs 339.0 copies/mL cell-free DNA; P<.001) and lower fetal fraction (median, 7.5% vs 9.4%; P<.001). The expected, cross-validated area under the curve scores for early-onset, preterm, and term preeclampsia were 0.782, 0.801, and 0.712, respectively, for the logistic regression model, and 0.797, 0.800, and 0.713, respectively, for the neural network model. At a screen-positive rate of 15%, sensitivity for preterm preeclampsia was 58.4% (95% confidence interval, 0.569-0.599) for the logistic regression model and 59.3% (95% confidence interval, 0.578-0.608) for the neural network model. The contribution of both total cell-free DNA and fetal fraction to the prediction of term and preterm preeclampsia was negligible. For early-onset preeclampsia, removal of the total cell-free DNA and fetal fraction features from the neural network model was associated with a 6.9% decrease in sensitivity at a 15% screen-positive rate, from 54.9% (95% confidence interval, 52.9-56.9) to 48.0% (95% confidence interval, 45.0-51.0).

CONCLUSION

Routinely available patient characteristics and cell-free DNA markers can be used to predict preeclampsia with performance comparable to that of other patient characteristic models for the prediction of preterm preeclampsia. Logistic regression and neural network models showed similar performance.

Effect of low-dose aspirin intervention on pre-eclampsia prevention in high-risk pregnant women and its impact on postpartum hemorrhage

Background

Pre-eclampsia, characterized by hypertension and organ dysfunction during pregnancy, poses significant risks to both maternal and fetal health. Aspirin, known for its antiplatelet properties, has been extensively utilized to mitigate pregnancy-related complications. However, the efficacy of low-dose aspirin in managing pre-eclampsia among high-risk pregnant women and its potential impact on postpartum hemorrhage remain contentious topics.

Methods

A retrospective analysis was conducted on 344 pregnant women diagnosed with high-risk factors for pre-eclampsia. Among them, 152 received intervention with low-dose aspirin, while the rest did not receive it. The incidence of pre-eclampsia, as well as related complications and outcomes associated with bleeding, were compared and evaluated between the two groups.

Results

The study findings indicate a significant reduction in the incidence of pre-eclampsia among pregnant women receiving low-dose aspirin intervention, along with a significantly reduced risk of complications. Additionally, there was no significant statistical difference in postpartum hemorrhage between the two groups (p > 0.05). The safety profile of aspirin usage was found to be favorable.

Conclusion

Low-dose aspirin demonstrates promising efficacy as an intervention strategy for high-risk preeclamptic women. It does not increase the risk of postpartum hemorrhage and reduces the occurrence of complications associated with preeclampsia. Therefore, low-dose aspirin presents a potential preventive measure against adverse outcomes associated with high-risk pregnancies related to preeclampsia. Further research is necessary to validate and elucidate the optimal dosage and timing of administration for maximal benefits.

Biomarkers and point of care screening approaches for the management of preeclampsia

Preeclampsia is a multi-organ pregnancy complication, that is primarily detected when pregnant people have high blood pressure, and is confirmed by testing for the presence of protein in the urine. While more specific and accurate diagnostic and imaging tests are becoming available, they are still in the process of undergoing widespread regulatory adoption, and so are not yet the standard of care. Since biochemical processes are a precursor to the systemic progression of disease, we review some established, emerging, and promising biomarkers that are proposed to be associated with preeclampsia, and newly developed approaches for screening them at the point of care, to reduce the burden of the disease.

Comparison of 75 mg versus 150 mg aspirin for the prevention of preterm preeclampsia in high-risk women at a tertiary level hospital: study protocol for a randomized double-blind clinical trial

BACKGROUND

Hypertensive disorders of pregnancy (HDP) pose significant risks to maternal and fetal health, with substantial mortality and morbidity rates globally, particularly in developing countries. Pre-eclampsia (PE) accounts for a notable portion of maternal morbidity and mortality, with varied prevalence across regions within countries like India. Despite advancements, disparities in healthcare access persist, influencing outcomes. PE not only affects maternal health during pregnancy but also predisposes women to long-term cardiovascular complications, emphasizing the need for early screening and preventive measures.

METHODS

This prospective randomized double-blind clinical trial aims to compare the efficacy and safety of 75 mg versus 150 mg aspirin for preventing preterm pre-eclampsia in high-risk women. Screen-positive women aged 18-45 years with singleton pregnancies between 12 and 16 weeks of gestational age will be enrolled. They will be randomized in a 1:1 ratio to receive either 75 mg or 150 mg of aspirin nightly until 37 weeks of pregnancy or earlier if preterm pre-eclampsia develops. Feto-maternal outcomes, including preterm pre-eclampsia incidence and neonatal and maternal complications, will be assessed. The sample size calculation based on expected proportions of preterm pre-eclampsia in both groups indicates a total of 370 participants (185 per group) accounting for 20% attrition.

DISCUSSION

This prospective randomized double-blind clinical trial aims to compare the effectiveness and safety of two doses of aspirin (75 mg vs 150 mg) in preventing preterm pre-eclampsia in high-risk women. The potential implications of this study are significant, including the optimization of aspirin prophylaxis, the development of evidence-based guidelines, and comprehensive assessment of maternal and fetal outcomes. In conclusion, the results of this study have the potential to significantly impact clinical practice by enhancing maternal and perinatal health outcomes and contributing to evidence-based obstetric care.

TRIAL REGISTRATION

Clinical Trials Registry-India CTRI/2023/12/060983. Trial was registered prospectively on 29 December 2023. Acknowledgement Number REF/2023/12/076358. https://acrobat.adobe.com/id/urn:aaid:sc:AP:15870322-f1f4-4460-900c-6e056ab83a44 .

Examining postpartum anticoagulation practices: An international survey of healthcare providers

BACKGROUND

The risk of venous thromboembolism (VTE) is 15 to 35-fold higher in the postpartum period compared to non-pregnant individuals. Clinical practice guidelines recommend the use of postpartum thromboprophylaxis with low molecular weight heparin (LMWH) for 6 weeks in individuals at high risk of developing VTE. However, a marked reduction in the risk of VTE risk occurs beyond the third week of the postpartum period.

OBJECTIVE

We sought to characterize practice patterns of clinicians who manage postpartum individuals at high risk of VTE.

METHODS

We conducted a cross-sectional study using a self-administered electronic questionnaire. The survey explored the use of postpartum thromboprophylaxis in high-risk individuals. Descriptive statistics were used to summarize survey responses.

RESULTS

Of the 113 participants that responded to the initial invitation, 78 completed the survey (Europe (53.9 %); North America (23.2 %); Australia and New Zealand (19.0 %)). For individuals with a prior unprovoked or provoked deep venous thrombosis or pulmonary embolism, cerebral vein thrombosis and splanchnic vein thrombosis, 97.4 %, 93.5 %, 91.0 % and 88.5 % of the respondents recommended six weeks of postpartum thromboprophylaxis using LMWH, respectively. The recommendation for 6 weeks of thromboprophylaxis in patients with sickle cell disease and obstetric APS was comparatively lower (70.5 and 78.2 % respectively). Respondents with higher practice volumes and more years of experience in clinical practice were more likely to recommend a shorter duration of thromboprophylaxis.

CONCLUSION

Our study highlights the variability in clinician recommendations and the acceptability of treatment durations for postpartum thromboprophylaxis in high-risk conditions. Prospective studies are needed to determine optimal duration and establish evidence-based management.

Aspirin therapy is associated with a lower risk of pregnancy loss in both JAK2- and CALR-mutated essential thrombocythemia-A Mayo Clinic study of 200 pregnancies

Two-hundred pregnancies involving 100 women with essential thrombocythemia (ET) were accessed from Mayo Clinic databases (1990-2023). Median platelet count displayed a decline during pregnancy, nadiring at 48% of baseline, in the third trimester: 704-369 × 109/L. Live birth rate was 72%. Of 53 (27%) unintentional pregnancy losses, 48 (24%) occurred in the first trimester. Other fetal complications included preterm birth 3%, intrauterine growth retardation 3%, and stillbirth 1%. Maternal complications included major hemorrhage (7%), preeclampsia (6%), thrombosis (1%), and placental abruption (0.5%). Antepartum management included no specific therapy in 52 (26%), aspirin alone in 112 (56%), aspirin combined with cytoreductive drugs or systemic anticoagulants in 23 (12%), and other permutations in the remaining. Postpartum systemic anticoagulation was documented in 29 (15%) pregnancies. Unintentional first-trimester loss was predicted by prior fetal loss (43% vs. 18%; p < .01), diabetes mellitus (DM; 67% vs. 23%; p = .02), and absence of aspirin therapy (45% vs. 14%; p < .01); the salutary effect of aspirin therapy was independent of the other two risk factors and apparent in both high (presence of ≥1 risk factor; 33% vs. 61%; p = .07) and low (absence of both risk factors; 10% vs. 34%; p < .01) risk scenarios. The benefit of aspirin therapy, in preventing first-trimester loss, was significant in both JAK2-mutated (18% vs. 50%; p < .01) and CALR-mutated (8% vs. 43%; p < .01) cases. Aspirin use was also associated with a lower risk of venous thrombosis (0% vs. 3%; p = .03). By contrast, the use of systemic anticoagulation, antepartum or postpartum, did not influence fetal or maternal complication rates. CALR mutation and DM predicted maternal hemorrhage (13% vs. 4%; p = .05) and preeclampsia (33% vs. 5%; p = .03), respectively. The current study demonstrates the protective role of aspirin in preventing first-trimester loss in ET, independent of driver mutation status or other risk factors.

Validation of the first-trimester machine learning model for predicting pre-eclampsia in an Asian population

OBJECTIVES

To evaluate the performance of an artificial intelligence (AI) and machine learning (ML) model for first-trimester screening for pre-eclampsia in a large Asian population.

METHODS

This was a secondary analysis of a multicenter prospective cohort study in 10 935 participants with singleton pregnancies attending for routine pregnancy care at 11-13+6 weeks of gestation in seven regions in Asia between December 2016 and June 2018. We applied the AI+ML model for the first-trimester prediction of preterm pre-eclampsia (<37 weeks), term pre-eclampsia (≥37 weeks), and any pre-eclampsia, which was derived and tested in a cohort of pregnant participants in the UK (Model 1). This model comprises maternal factors with measurements of mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor (PlGF). The model was further retrained with adjustments for analyzers used for biochemical testing (Model 2). Discrimination was assessed by area under the receiver operating characteristic curve (AUC). The Delong test was used to compare the AUC of Model 1, Model 2, and the Fetal Medicine Foundation (FMF) competing risk model.

RESULTS

The predictive performance of Model 1 was significantly lower than that of the FMF competing risk model in the prediction of preterm pre-eclampsia (0.82, 95% confidence interval [CI] 0.77-0.87 vs. 0.86, 95% CI 0.811-0.91, P = 0.019), term pre-eclampsia (0.75, 95% CI 0.71-0.80 vs. 0.79, 95% CI 0.75-0.83, P = 0.006), and any pre-eclampsia (0.78, 95% CI 0.74-0.81 vs. 0.82, 95% CI 0.79-0.84, P < 0.001). Following the retraining of the data with adjustments for the PlGF analyzers, the performance of Model 2 for predicting preterm pre-eclampsia, term pre-eclampsia, and any pre-eclampsia was improved with the AUC values increased to 0.84 (95% CI 0.80-0.89), 0.77 (95% CI 0.73-0.81), and 0.80 (95% CI 0.76-0.83), respectively. There were no differences in AUCs between Model 2 and the FMF competing risk model in the prediction of preterm pre-eclampsia (P = 0.135) and term pre-eclampsia (P = 0.084). However, Model 2 was inferior to the FMF competing risk model in predicting any pre-eclampsia (P = 0.024).

CONCLUSION

This study has demonstrated that following adjustment for the biochemical marker analyzers, the predictive performance of the AI+ML prediction model for pre-eclampsia in the first trimester was comparable to that of the FMF competing risk model in an Asian population.

Metformin use and preeclampsia risk in women with diabetes: a two-country cohort analysis

BACKGROUND

Metformin is a hypoglycaemic medication that has been proposed to treat or prevent preeclampsia. Combining national birth data from Scotland and Sweden, we investigated whether metformin used during pregnancy was associated with an altered risk of developing a hypertensive disorder of pregnancy.

METHODS

We utilised data from two population-based cohorts: Scotland (2012-2018) and Sweden (2007-2019). Nulliparous women with gestational diabetes or type 2 diabetes who had birth outcome data linked with medications prescribed during pregnancy were included. The association between metformin prescription and hypertensive disorders of pregnancy was characterised using inverse probability weighted regression analysis, adjusting for variables that predict metformin use and potential confounders. Adverse neonatal outcomes were included as secondary outcomes. Results from both countries were then combined in a meta-analysis using a random effects model.

RESULTS

The Scottish cohort included 3859 women with gestational diabetes or type 2 diabetes. Of these women, 30.8% (n = 1187) received at least one metformin prescription during pregnancy. For Sweden, 7771 women with gestational diabetes were included where 19.3% (1498) used metformin during pregnancy. Metformin prescription was not associated with an altered risk of any hypertensive disorder of pregnancy (Scotland adjusted relative risk (aRR) 0.88 [95% confidence interval (CI) 0.66-1.19]; Sweden aRR 1.08 [95% CI 0.86-1.37]) or preeclampsia (Scotland aRR 1.02 [95% CI 0.66-1.60]; Sweden aRR 1.00 [95% CI 0.72-1.39]). Combining adjusted results in a meta-analysis produced similar findings, with a pooled RR of 0.98 (95% CI 0.79-1.18) for any hypertensive disorder and RR 1.01 ([95% CI 0.73-1.28]) for preeclampsia. For neonatal outcomes, metformin was associated with a reduced risk of birthweight > 4500 g in Scotland (aRR 0.39 [95% CI 0.21-0.71]) but not in Sweden. There was no association between metformin and preterm birth or birthweight < 3rd or < 10th percentiles. Pooling results from both countries, metformin was not associated with adverse neonatal outcomes, including preterm birth (RR 1.00 [95% CI 0.89-1.13]), and birthweight < 10th percentile (RR 0.82 [95% CI 0.60-1.13]) or < 3rd percentile (RR 0.78 [95% CI 0.41-1.48]).

CONCLUSIONS

In this two-country analysis, metformin use in pregnancy among women with diabetes was not associated with an altered risk of developing any hypertensive disorder of pregnancy. In the combined meta-analysis, metformin was not associated with an altered risk of adverse neonatal outcomes.

Experience Counts: Unveiling Patients' Willingness to Pay for Remote Monitoring and Patient Self-Measurement

OBJECTIVES

This study aimed to (1) estimate patients' willingness to pay (WTP) for remote monitoring (RM) and patient self-measurement (PSM) for pregnant women at risk of gestational hypertensive disorders, (2) assess the impact of experience with these technologies on WTP, and (3) determine their impact on health-related quality of life (HRQoL).

METHODS

Data collection was part of a multicentric randomized controlled trial, Pregnancy Remote Monitoring II, with 2 interventions: RM and PSM. A contingent valuation survey, combining a payment card and open-ended question, was completed twice by 199 participants. Two-part models analyze the impact of experience on WTP, regression models estimated using ordinary least squares the impact of RM and PSM on HRQoL.

RESULTS

The mean WTP amount was approximately €120 for RM and €80 for PSM. Compared with having no experience, WTP RM was €63 higher after a long-term exposure to RM (P = .01) and WTP PSM was €26 lower after a short-term exposure to RM (P = .07). No significant impact of RM or PSM on HRQoL was found.

CONCLUSIONS

This study contributes to the discussion on the impact of experience on WTP. Those who had a long-term experience with RM, were willing to pay more for RM than those without experience. This confirms our hypothesis that involving patients without experience with the valued treatment, possibly underestimates WTP. A long-term experience has, however, no impact on the WTP for technologies for which the potential benefits are apparent without experiencing them, such as PSM.

Assessing Severity and Need for Delivery in Early Onset Preeclampsia Before 32 Weeks of Gestation: a Delphi Consensus Procedure

Background

Preeclampsia is a potentially life-threatening hypertensive pregnancy disorder that carries an acute risk of an unfavorable outcome of the pregnancy but also has consequences for the long-term health of the mother. Women who develop the early form of pre-eclampsia before the 32nd week of pregnancy have the highest risk and are also the most difficult to treat. The severity of pre-eclampsia is not characterized uniformly in Germany, so that the indication for delivery is rather individualized. The aim of this study was to reach a consensus on parameters that could serve as criteria for describing the severity of pre-eclampsia based on the urgency of delivery. To this end, a Delphi procedure was used to present a scenario in which a woman was admitted for preeclampsia before 32 gestational weeks and after completion of antenatal steroid therapy.

Methods

Clinicians specialized in maternal-fetal medicine from German-speaking countries completed five rounds of a modified Delphi questionnaire. Presented parameters were selected by the section "Hypertensive Pregnancy Diseases and Fetal Growth Restriction" of the German Society of Gynecology and Obstetrics after reviewing the literature. These included objectifiable laboratory or clinical parameters as well as subjective symptoms of the patient. In addition, nine fetal parameters were taken into account. The clinicians were asked to rate presented parameters as an indication for delivery on a Likert scale from 0 to 4 (no indication to absolute indication without delay). For each item, the predefined cut-off for group consensus was ≥ 70% agreement.

Results

A total of 126 experts were approached. Sixty-nine experts (54.8%) took part in the first round; of those 50 completed the entire Delphi procedure. A consensus was reached on 14 parameters to be considered rapid preparation for delivery without delay (4 points on the Likert scale). These were among others hepatic hematoma or liver capsule rupture, acute liver failure with fulminant coagulation disorder or disseminated intravascular coagulation, eclampsia, pathologic findings in imaging (e.g. cMRI) or electrocardiogram arranged for new onset of headache or retrosternal pain, respectively. Twenty-six parameters were rated as factors that should be considered in the decision without being absolute (1 to 3 points), and 13 parameters should have no influence on the decision to deliver (0 points). No consensus on severe hypertension as an indication for delivery could be reached for blood pressure values below 220/140 mmHg.

Conclusion

A consensus was reached on whether to deliver in preeclampsia typic clinical findings and symptoms. The results can serve as guidance for current clinical practice and for the definition of clinical endpoints in intervention studies. Nevertheless, the isolated criteria are a theoretical construction since the combined deterioration or summation of several factors rather than a single factor most likely influences the decision to deliver and reflect the severity of preeclampsia. Moreover, the degree of hypertension as an indication for delivery remains controversial, unless the patient suffers additionally from complaints. Future research should be enforced to incorporate long-term risks for the mother into a decision aid.

Polymeric optical fiber biosensor with PAMAM dendrimer-based surface modification and PlGF detection for pre-eclampsia diagnosis

Pre-eclampsia (PE) is a life-threatening complication that occurs during pregnancy, affecting a large number of pregnant women and newborns worldwide. Rapid, on-site and affordable screening of PE at an early stage is necessary to ensure timely treatment and minimize both maternal and neonatal morbidity and mortality rates. Placental growth factor (PlGF) is an angiogenic blood biomarker used for PE diagnosis. Herein, we report the plasmonic fiber optic absorbance biosensor (P-FAB) strategy for detecting PlGF at femtomolar concentration using polymethyl methacrylate (PMMA) based U-bent polymeric optical fiber (POF) sensor probes. A novel poly(amidoamine) (PAMAM) dendrimer based PMMA surface modification is established to obtain a greater immobilization of the bioreceptors compared to a linear molecule like hexamethylenediamine (HMDA). Plasmonic sandwich immunoassay was realized by immobilizing the mouse anti-PlGF (3H1) on the U-bent POF sensor probe surface and gold nanoparticles (AuNP) labels conjugated with mouse anti-PlGF (6H9). The POF sensor probes could measure PlGF within 30 min using the P-FAB strategy. The limit-of-detection (LoD) was found to be 0.19 pg/mL and 0.57 pg/mL in phosphate-buffered saline and 10× diluted serum, respectively. The clinical sample testing, with eleven positive and eleven negative preeclamptic pregnancy samples, successfully confirmed the accuracy, reliability, specificity, and sensitivity of the P-FAB based POF sensor platform, thereby paving the way for cost-effective technology for PlGF detection and its potential for pre-eclampsia diagnosis.

Acceptability of data linkage to identify women at risk of postnatal complication for the development of digital risk prediction tools and interventions to better optimise postnatal care, a qualitative descriptive study design

BACKGROUND

Pregnancy acts as a cardiovascular stress test. Although many complications resolve following birth, women with hypertensive disorder of pregnancy have an increased risk of developing cardiovascular disease (CVD) long-term. Monitoring postnatal health can reduce this risk but requires better methods to identity high-risk women for timely interventions.

METHODS

Employing a qualitative descriptive study design, focus groups and/or interviews were conducted, separately engaging public contributors and clinical professionals. Diverse participants were recruited through social media convenience sampling. Semi-structured, facilitator-led discussions explored perspectives of current postnatal assessment and attitudes towards linking patient electronic healthcare data to develop digital tools for identifying postpartum women at risk of CVD. Participant perspectives were gathered using post-it notes or a facilitator scribe and analysed thematically.

RESULTS

From 27 public and seven clinical contributors, five themes regarding postnatal check expectations versus reality were developed, including 'limited resources', 'low maternal health priority', 'lack of knowledge', 'ineffective systems' and 'new mum syndrome'. Despite some concerns, all supported data linkage to identify women postnatally, targeting intervention to those at greater risk of CVD. Participants outlined potential benefits of digitalisation and risk prediction, highlighting design and communication needs for diverse communities.

CONCLUSIONS

Current health system constraints in England contribute to suboptimal postnatal care. Integrating data linkage and improving education on data and digital tools for maternal healthcare shows promise for enhanced monitoring and improved future health. Recognised for streamlining processes and risk prediction, digital tools may enable more person-centred care plans, addressing the gaps in current postnatal care practice.

Value of fetal echocardiographic examination in pregnancies complicated by preterm premature rupture of membranes

OBJECTIVES

Cardiopulmonary and infectious complications are more common in preterm newborns after preterm premature rupture of membranes (pPROM). Fetal echocardiography may be helpful in predicting neonatal condition. Our aim was to assess the cardiovascular changes in fetuses from pregnancies complicated by pPROM and possible utility in predicting the intrauterine or neonatal infection, and neonatal heart failure (HF).

METHODS

It was a prospective study enrolling 46 women with singleton pregnancies complicated by pPROM between 18+0 and 33+6 weeks of gestation and followed until delivery. 46 women with uncomplicated pregnancies served as a control group. Fetal echocardiographic examinations with the assessment of cardiac structure and function (including pulmonary circulation) were performed in all patients.

RESULTS

Mean gestational age of pPROM patients was 26 weeks. Parameters suggesting impaired cardiac function in fetuses from pPROM were: higher right ventricle Tei index (0.48 vs. 0.42 p<0.001), lower blood flow velocity in Ao z-score (0.14 vs. 0.84 p=0.005), lower cardiovascular profile score (CVPS), higher rate of tricuspid regurgitation (18.2 % vs. 4.4 % p=0.04) and pericardial effusion (32.6 vs. 0 %). Intrauterine infection was diagnosed in 18 patients (39 %). 4 (8.7 %) newborns met the criteria of early onset sepsis (EOS). HF was diagnosed in 9 newborns. In fetal echocardiographic examination HF group had shorter mitral valve inflow time and higher left ventricle Tei index (0.58 vs. 0.49 p=0.007).

CONCLUSIONS

Worse cardiac function was observed in fetuses from pPROM compared to fetuses from uncomplicated pregnancies.

Does Developing Interpregnancy Hypertension Affect the Recurrence Risk of Preeclampsia? A Population-Based Cohort Study

BACKGROUND

Preeclampsia in a first pregnancy is a strong risk factor for preeclampsia in a second pregnancy. Whether chronic hypertension developed after a first pregnancy (interpregnancy hypertension) affects the recurrence risk of preeclampsia is unknown.

METHODS

This is a population-based cohort study of 391,645 women with their first and second singleton births between 2006 and 2017. Exposure groups were women with preeclampsia in their first pregnancy, interpregnancy hypertension, or both risk factors. Women with neither risk factor were used as a reference group. We calculated the adjusted relative risk (aRR) with 95% confidence intervals (CIs) for overall preeclampsia in the second pregnancy as well as preterm (<37 gestational weeks) and term (≥37 gestational weeks) subgroups of the disease.

RESULTS

Women with preeclampsia in their first pregnancy who did or did not develop interpregnancy hypertension had rates of preeclampsia in their second pregnancy of 21.5% and 13.6%, respectively. In the same population, the corresponding rates of preterm preeclampsia were 5.5% and 2.6%, respectively. After adjusting for maternal factors, women with preeclampsia in their first pregnancy who developed interpregnancy hypertension and those who did not have almost the same risk of overall preeclampsia in their second pregnancy (aRRs with 95% CIs: 14.51; 11.77-17.89 and 12.83; 12.09-13.62, respectively). However, preeclampsia in the first pregnancy and interpregnancy hypertension had a synergistic interaction on the outcome of preterm preeclampsia (aRR with 95% CI 26.66; 17.44-40.80).

CONCLUSIONS

Women with previous preeclampsia who developed interpregnancy hypertension had a very high rate of preterm preeclampsia in a second pregnancy, and the two risk factors had a synergistic interaction.

Signs or symptoms of suspected preeclampsia - A retrospective national database study of prevalence, costs, and outcomes

BACKGROUND

Most patients with signs or symptoms (s/s) of suspected preeclampsia are not diagnosed with preeclampsia. We sought to determine and compare the prevalence of s/s, pregnancy outcomes, and costs between patients with and without diagnosed preeclampsia.

METHODS

This retrospective cohort study analyzed a large insurance research database. Pregnancies with s/s of preeclampsia versus a confirmed preeclampsia diagnosis were identified using International Classification of Diseases codes. S/s include hypertension, proteinuria, headache, visual symptoms, edema, abdominal pain, and nausea/vomiting. Pregnancies were classed as 1) s/s of preeclampsia without a confirmed preeclampsia diagnosis (suspicion only), 2) s/s with a confirmed diagnosis (preeclampsia with suspicion), 3) diagnosed preeclampsia without s/s recorded (preeclampsia only), and 4) no s/s, nor preeclampsia diagnosis (control).

RESULTS

Of 1,324,424 pregnancies, 29.2 % had ≥1 documented s/s of suspected preeclampsia, and 14.2 % received a preeclampsia diagnosis. Hypertension and headache were the most common s/s, leading 20.2 % and 9.2 % pregnancies developed to preeclampsia diagnosis, respectively. Preeclampsia, with or without suspicion, had the highest rates of hypertension-related severe maternal morbidity (HR [95 % CI]: 3.0 [2.7, 3.2] and 3.6 [3.3, 4.0], respectively) versus controls. A similar trend was seen in neonatal outcomes such as preterm delivery and low birth weight. Cases in which preeclampsia was suspected but not confirmed had the highest average total maternal care costs ($6096 [95 % CI: 602, 6170] over control).

CONCLUSION

There is a high prevalence but poor selectivity of traditional s/s of preeclampsia, highlighting a clinical need for improved screening method and cost-effectiveness disease management.

Poor Response to Gonadotropin Stimulation and Perinatal Outcomes in Fresh In Vitro Fertilization Embryo Transfer Cycles-A Retrospective Cohort Study

Objective: The objective was to examine the association between poor ovarian response to gonadotropin stimulation for in vitro fertilization (IVF) and adverse perinatal outcomes in singleton gestations in young patients. Methods: This was a retrospective cohort study including women aged 17-39 who underwent fresh embryo transfer and delivered a singleton neonate at a single center (pre-implantation genetic testing excluded) (2007-2022). Patients were classified as one of the following categories: poor responders-daily follicle-stimulating hormone (FSH) ≥ 150 IU yielding ≤ 3 retrieved oocytes; normal responders-4-15 oocytes; and high responders with ≥16 oocytes. The primary outcome was a composite of pre-eclampsia (mild or severe), small-for-gestational-age, gestational diabetes mellitus, and preterm birth (<37 weeks). We compared maternal and neonatal outcomes between the three groups. Multivariable logistic regression was used to control for confounders. Results: Overall, 507 women met the inclusion criteria. Of them, there were 44 (8.68%) poor responders, 342 (67.46%) normal responders, and 121 (23.87%) high responders. Poor responders, compared to normal and high responders, were characterized by a higher maternal age (34.64 ± 4.01 vs. 31.4 ± 5.04 vs. 30.01 ± 4.93, p < 0.001, respectively) and total FSH dosage (3028.41 ± 1792.05 IU vs. 2375.11 ± 1394.05 IU vs. 1869.31 ± 1089.63 IU, p < 0.001). The perinatal outcomes examined, including cesarean delivery (CD) rate and the composite outcome, were comparable between groups. Using multivariable logistic regression and adjusting for ovarian response group, maternal age, nulliparity, and estradiol level and endometrial thickness before ovulation triggering, poor response was not associated with CD rate or the composite outcome, with maternal age associated with CD (p = 0.005), and nulliparity with the composite outcome (p = 0.007). Similar results were obtained when comparing poor responders to each other group separately or to all other responders. Conclusions: Poor ovarian response is not associated with increased adverse maternal or neonatal outcomes.

First-trimester preterm preeclampsia prediction model for prevention with low-dose aspirin

INTRODUCTION

Preeclampsia (PE) is a major maternal and fetal threat. Previous risk-scoring methods in guidelines lacked precision. The Fetal Medicine Foundation (FMF) proposed a first-trimester PE screening model using Bayes' theorem.

PE PREDICTION MODEL

FMF prediction model combines maternal characteristics and medical/obstetrical history to determine prior risk and further incorporate maternal blood pressure, maternal serum biomarkers, and uterine Doppler pulsatility index expressed as multiples of the median (MoM) to estimate posterior risk.

LOW-DOSE ASPIRIN PREVENTION

Low-dose aspirin is one of the potential PE prevention strategies. Initiating it before 16 weeks is crucial. Aspirin's antiplatelet and anti-inflammatory properties align with PE's pathophysiology. Dosing and resistance warrant further study, but a standard regimen of 150 mg nightly, starting before 16 weeks, is widely supported.

PE PREVENTION IN PRACTICE

Clinical trials, including ASPRE, affirm aspirin's role in PE prevention. Starting aspirin based on FMF screening significantly reduces preterm PE and associated complications.

ADVANCEMENTS AND PROSPECTS

Emerging research explores predictors like maternal ophthalmic arterial waveform. Regional variations, especially in Asian populations, are considered. Machine learning and AI show promise, but examiner expertise remains essential for accurate prediction. In conclusion, integrating FMF's first-trimester PE screening with low-dose aspirin offers a promising strategy. Further advancements may enhance precision and broaden prevention efforts.

Serum fatty acid binding protein 4 and Doppler of uterine artery ultrasound in the first trimester for the prediction of preeclampsia

The objective of this study was to determine the predictive value of serum fatty acid binding protein 4 (FABP4) combined with Doppler of the uterine artery in singleton pregnancy at gestational age (GA) 11-13+6 weeks for prediction of preeclampsia. A prospective observational study included singleton pregnant women at GA 11-13+6 weeks and was conducted at the Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand, between December 2020 and April 2022. Serum FABP4 levels and Doppler of the uterine artery were performed. Pregnancy outcomes were recorded. The predictive values of these combined tests at the optimal cut-off values were determined to predict preeclampsia. A total of 330 participants with 15 cases of preeclampsia (4.5%) and 6 cases of them had preterm preeclampsia (GA < 37 weeks) (1.8%) were analyzed. Women with preeclampsia had significantly higher serum FABP4 levels than normal pregnant women (12.9 ± 6.5 ng/ml vs 10.1 ± 4.8 ng/ml, p = 0.034) but no difference in the mean pulsatility index (PI) of the uterine artery and the presence of an early diastolic notch. When using serum FABP4 levels greater than 1.0 multiple of the median of GA as a cut-off value to predict preeclampsia, combined with abnormal Doppler PI of the uterine artery, the sensitivity, specificity, positive predictive value, and negative predictive value were 73.3%, 47.3%, 6.2%, and 97.4%, respectively. This study demonstrated that serum FABP4 levels combined with Doppler of the uterine artery at GA 11-13+6 weeks were effective in predicting preeclampsia.

Detection of Urinary Misfolded Proteins for Imminent Prediction of Preeclampsia in Pregnant Women With Suspected Cases: Protocol for a Prospective Noninterventional Study

BACKGROUND

Preeclampsia (PE) is one of the most common hypertensive diseases, affecting 2%-8% of all pregnancies. The high maternal and fetal mortality rates of PE are due to a lack of early identification of affected pregnant women that would have led to closer monitoring and care. Recent data suggest that misfolded proteins might be a promising biomarker for PE prediction, which can be detected in urine samples of pregnant women according to their congophilia (aggregated) characteristic.

OBJECTIVE

The main purpose of this trial is to evaluate the value of the urine congophilia-based detection of misfolded proteins for the imminent prediction of PE in women presenting with suspected PE. The secondary objectives are to demonstrate that the presence of urine misfolded proteins correlates with PE-related maternal or neonatal adverse outcomes, and to establish an accurate PE prediction model by combining misfolded proteins with multiple indicators.

METHODS

At least 300 pregnant women with clinical suspicion of PE will be enrolled in this prospective cohort study. Participants should meet the following inclusion criteria in addition to a suspicion of PE: ≥18 years old, gestational week between 20+0 and 33+6, and single pregnancy. Consecutive urine samples will be collected, blinded, and tested for misfolded proteins and other PE-related biomarkers at enrollment and at 4 follow-up visits. Clinical assessments of PE status and related complications for all participants will be performed at regular intervals using strict diagnostic criteria. Investigators and participants will remain blinded to the results. Follow-up will be performed until 42 days postpartum. Data from medical records, including maternal and fetal outcomes, will be collected. The performance of urine misfolded proteins alone and combined with other biomarkers or clinical variables for the prediction of PE will be statistically analyzed.

RESULTS

Enrollment started in July 2023 and was still open upon manuscript submission. As of March 2024, a total of 251 eligible women have been enrolled in the study and enrollment is expected to continue until August 2024. Results analysis is scheduled to start after all participants reach the follow-up endpoint and complete clinical data are collected.

CONCLUSIONS

Upon completion of the study, we expect to derive an accurate PE prediction model, which will allow for proactive management of pregnant women with clinical suspicion of PE and possibly reduce the associated adverse pregnancy outcomes. The additional prognostic value of misfolded proteins is also expected to be confirmed.

TRIAL REGISTRATION

Chinese Clinical Trials Registry ChiCTR2300074878; https://www.chictr.org.cn/showproj.html?proj=202096.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/54026.