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Minckas N, Swarray-Deen A, Fawcus S, Ndiema RC, McDougall A, Scott J, Oppong SA, Osman A, Osoti AO, Eddy K, Matjila M, Gwako GN, Vogel JP, Gülmezoglu AMA, Nwameme AU, Bohren MA. Formative research to optimize pre-eclampsia risk-screening and prevention (PEARLS): study protocol. Reprod Health 2025; 22:44. [PMID: 40128812 PMCID: PMC11934789 DOI: 10.1186/s12978-025-01980-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2025] [Accepted: 03/03/2025] [Indexed: 03/26/2025] Open
Abstract
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).
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Affiliation(s)
- Nicole Minckas
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
| | - Alim Swarray-Deen
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, College of Health Sciences, Accra, Ghana
| | - Sue Fawcus
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Rosa Chemwey Ndiema
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
- Obstetrics and Gynecology Department, Kenyatta National Hospital, Nairobi, Kenya
| | - Annie McDougall
- Women's, Children's and Adolescents' Health Program, Burnet Institute, Melbourne, Australia
| | - Jennifer Scott
- Concept Foundation, Geneva, Switzerland
- Department of Obstetrics, Gynecology & Reproductive Biology, Harvard Medical School, Boston, USA
| | - Samuel Antwi Oppong
- Department of Obstetrics and Gynaecology, University of Ghana Medical School, College of Health Sciences, Accra, Ghana
| | - Ayesha Osman
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - Alfred Onyango Osoti
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Katherine Eddy
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
- Women's, Children's and Adolescents' Health Program, Burnet Institute, Melbourne, Australia
| | - Mushi Matjila
- Department of Obstetrics and Gynaecology, University of Cape Town, Cape Town, South Africa
| | - George Nyakundi Gwako
- Department of Obstetrics and Gynaecology, Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Joshua P Vogel
- Women's, Children's and Adolescents' Health Program, Burnet Institute, Melbourne, Australia
| | | | - Adanna Uloaku Nwameme
- Department of Social and Behavioural Sciences, School of Public Health, University of Ghana, College of Health Sciences, Accra, Ghana
| | - Meghan A Bohren
- Nossal Institute for Global Health, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.
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Raphael K, Wiles K, Iliodromiti S, Greco E. A review of ethnic disparities in preeclampsia. Curr Opin Obstet Gynecol 2024; 36:450-456. [PMID: 39361440 DOI: 10.1097/gco.0000000000000996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2024]
Abstract
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.
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Affiliation(s)
- Katie Raphael
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London
- Barts Health NHS Trust, London, UK
| | - Kate Wiles
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London
- Barts Health NHS Trust, London, UK
| | - Stamatina Iliodromiti
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London
- Barts Health NHS Trust, London, UK
| | - Elena Greco
- Women's Health Research Unit, Wolfson Institute of Population Health, Queen Mary University of London
- Barts Health NHS Trust, London, UK
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Kongprayoon P, Phupong V. Serum macrophage stimulating protein α-chain and uterine artery Doppler ultrasound in the first trimester for the prediction of preeclampsia. Sci Rep 2024; 14:21905. [PMID: 39300215 PMCID: PMC11413173 DOI: 10.1038/s41598-024-72304-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2024] [Accepted: 09/05/2024] [Indexed: 09/22/2024] Open
Abstract
To assess how effective macrophage stimulating protein α-chain (MSP-α) combined with uterine artery Doppler is in predicting preeclampsia in singleton pregnancies during 11-13+6 weeks of gestation. This prospective observational study included singleton pregnant women who attended antenatal care at King Chulalongkorn Memorial Hospital, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University between December 2021 and April 2023, during 11-13+6 weeks of gestation. Serum MSP-α levels were collected and uterine artery Doppler ultrasound was performed. Pregnancy outcomes were recorded, and the predictive values of these tests were determined to predict preeclampsia. A total of 365 patients, with 21 cases of preeclampsia (5.8%), were analyzed. Serum MSP-α levels were higher in pregnant women who developed preeclampsia than those who did not (899.7 ± 550.1 ng/ml vs 642.5 ± 466.1 ng/ml, p = 0.016). The mean pulsatility index of the uterine artery and the presence of diastolic notching were not significantly different between the groups. As a cut-off value for predicting preeclampsia, using serum MSP-α levels higher than 1.0 multiple of median for gestational age, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 71.4%, 50.3%, 8.1%, and 96.7%, respectively. Additionally, when abnormal serum MSP-α levels were combined with a uterine artery Doppler pulsatility index above the 95th percentile and bilateral notching as predictive values for preeclampsia, the sensitivity was 85.7%, specificity was 18.3%, PPV was 6.0%, and NPV was 95.5%. Serum MSP-α alone at 11-13+6 weeks of gestation was effective in predicting preeclampsia. However, the use of serum MSP-α in combination with uterine artery Doppler increased sensitivity but reduced specificity for the prediction of preeclampsia.
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Grants
- GA65/15 Ratchadapiseksompotch Fund, Faculty of Medicine, Chulalongkorn University, study grant number GA65/15 and Grant for International Research Integration: Research Pyramid, Ratchadaphiseksomphot Endowment Fund, Chulalongkorn University, and Placental Related Disease Research Unit, Chulalongkorn University.
- GA65/15 Ratchadapiseksompotch Fund, Faculty of Medicine, Chulalongkorn University, study grant number GA65/15 and Grant for International Research Integration: Research Pyramid, Ratchadaphiseksomphot Endowment Fund, Chulalongkorn University, and Placental Related Disease Research Unit, Chulalongkorn University.
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Affiliation(s)
- Pimon Kongprayoon
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Vorapong Phupong
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
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Sugulle M, Fiskå BS, Jacobsen DP, Fjeldstad HE, Staff AC. Placental Senescence and the Two-Stage Model of Preeclampsia. Am J Reprod Immunol 2024; 92:e13904. [PMID: 39049670 DOI: 10.1111/aji.13904] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Revised: 06/07/2024] [Accepted: 07/03/2024] [Indexed: 07/27/2024] Open
Abstract
In this review, we summarize how an increasingly stressed and aging placenta contributes to the maternal clinical signs of preeclampsia, a potentially lethal pregnancy complication. The pathophysiology of preeclampsia has been conceptualized in the two-stage model. Originally, highlighting the importance of poor placentation for early-onset preeclampsia, the revised two-stage model explains late-onset preeclampsia as well, which is often preceded by normal placentation. We discuss how cellular senescence in the placenta may fit with the framework of the revised two-stage model of preeclampsia pathophysiology and summarize potential cellular and molecular mechanisms, including effects on placental and maternal endothelial function. Cellular senescence may occur in response to inflammatory processes and oxidative, mitochondrial, or endoplasmic reticulum stress and chronic stress induce accelerated, premature placental senescence. In preeclampsia, both circulating and tissue-based senescence markers are present. We suggest that aspirin prophylaxis, commonly recommended from the first trimester onward for women at risk of preeclampsia, may affect placentation and possibly mechanisms of placental senescence, thus attenuating the risk of preeclampsia developing clinically. We propose that biomarkers of placental dysfunction and senescence may contribute to altered preventive strategies, including discontinuation of aspirin at week 24-28 depending on placenta-associated biomarker risk stratification.
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Affiliation(s)
- Meryam Sugulle
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Bendik S Fiskå
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Daniel Pitz Jacobsen
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Heidi Elisabeth Fjeldstad
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
| | - Anne Cathrine Staff
- Faculty of Medicine, University of Oslo, Oslo, Norway
- Division of Obstetrics and Gynaecology, Oslo University Hospital, Oslo, Norway
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Staff AC, Costa ML, Dechend R, Jacobsen DP, Sugulle M. Hypertensive disorders of pregnancy and long-term maternal cardiovascular risk: Bridging epidemiological knowledge into personalized postpartum care and follow-up. Pregnancy Hypertens 2024; 36:101127. [PMID: 38643570 DOI: 10.1016/j.preghy.2024.101127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/31/2024] [Accepted: 04/16/2024] [Indexed: 04/23/2024]
Abstract
Cardiovascular disease (CVD) is globally the leading cause of death and disability. Sex-specific causes of female CVD are under-investigated. Pregnancy remains an underinvestigated sex-specific stress test for future CVD and a hitherto missed opportunity to initiate prevention of CVD at a young age. Population-based studies show a strong association between female CVD and hypertensive disorders of pregnancy. This association is also present after other pregnancy complications that are associated with placental dysfunction, including fetal growth restriction, preterm delivery and gestational diabetes mellitus. Few women are, however, offered systematic cardio-preventive follow-up after such pregnancy complications. These women typically seek help from the health system at first clinical symptom of CVD, which may be decades later. By this time, morbidity is established and years of preventive opportunities have been missed out. Early identification of modifiable risk factors starting postpartum followed by systematic preventive measures could improve maternal cardiovascular health trajectories, promoting healthier societies. In this non-systematic review we briefly summarize the epidemiological associations and pathophysiological hypotheses for the associations. We summarize current clinical follow-up strategies, including some proposed by international and national guidelines as well as user support groups. We address modifiable factors that may be underexploited in the postpartum period, including breastfeeding and blood pressure management. We suggest a way forward and discuss the remaining knowledge gaps and barriers for securing the best evidence-based follow-up, relative to available resources after a hypertensive pregnancy complication in order to prevent or delay onset of premature CVD.
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Affiliation(s)
- Anne Cathrine Staff
- Faculty of Medicine, University of Oslo, PB 1171, Blindern, 0381 Oslo, Norway; Division of Obstetrics and Gynaecology, Oslo University Hospital, PB 4956 Nydalen, 0424 Oslo, Norway.
| | - Maria Laura Costa
- Department of Obstetrics and Gynecology, Universidade Estadual de Campinas (UNICAMP), Campinas/SP, Brazil
| | - Ralf Dechend
- HELIOS Clinic, Berlin, Germany; Experimental and Clinical Research Center, Charité Medical Faculty and Max-Delbrueck Center for Molecular Medicine, and HELIOS Clinic Berlin, Germany
| | - Daniel P Jacobsen
- Faculty of Medicine, University of Oslo, PB 1171, Blindern, 0381 Oslo, Norway; Division of Obstetrics and Gynaecology, Oslo University Hospital, PB 4956 Nydalen, 0424 Oslo, Norway
| | - Meryam Sugulle
- Faculty of Medicine, University of Oslo, PB 1171, Blindern, 0381 Oslo, Norway; Division of Obstetrics and Gynaecology, Oslo University Hospital, PB 4956 Nydalen, 0424 Oslo, Norway
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Kupka E, Roberts JM, Mahdy ZA, Escudero C, Bergman L, De Oliveira L, Global Pregnancy Collaboration. Aspirin for preeclampsia prevention in low- and middle-income countries: mind the gaps. AJOG GLOBAL REPORTS 2024; 4:100352. [PMID: 38694484 PMCID: PMC11061325 DOI: 10.1016/j.xagr.2024.100352] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/04/2024] Open
Abstract
Preeclampsia is a syndrome that continues to be a major contributor to maternal and neonatal mortality, especially in low-income countries. Low-dose aspirin reduces the risk of preeclampsia, but the mechanism is still unknown. Risk factors to identify women at risk of preeclampsia are based on clinical characteristics. Women identified as high-risk would benefit from aspirin treatment initiated, preferably at the end of the first trimester. Current efforts have largely focused on developing screening algorithms that incorporate clinical risk factors, maternal biomarkers, and uterine artery Doppler evaluated in the first trimester. However, most studies on preeclampsia are conducted in high-income settings, raising uncertainties about whether the information gained can be totally applied in low-resource settings. In low- and middle-income countries, lack of adequate antenatal care and late commencement of antenatal care visits pose significant challenges for both screening for preeclampsia and initiating aspirin treatment. Furthermore, the preventive effect of first-trimester screening based on algorithms and subsequent aspirin treatment is primarily seen for preterm preeclampsia, and reviews indicate minimal or no impact on reducing the risk of term preeclampsia. The lack of evidence regarding the effectiveness of aspirin in preventing term preeclampsia is a crucial concern, as 75% of women will develop this subtype of the syndrome. Regarding adverse outcomes, low-dose aspirin has been linked to a possible higher risk of postpartum hemorrhage, a condition as deadly as preeclampsia in many low- and middle-income countries. The increased risk of postpartum hemorrhage among women in low-income settings should be taken into consideration when discussing which pregnant women would benefit from the use of aspirin and the ideal aspirin dosage for preventing preeclampsia. In addition, women's adherence to aspirin during pregnancy is crucial for determining its effectiveness and complications, an aspect often overlooked in trials. In this review, we analyze the knowledge gaps that must be addressed to safely increase low-dose aspirin use in low- and middle-income countries, and we propose directions for future research.
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Affiliation(s)
| | - James M. Roberts
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Zaleha A. Mahdy
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Carlos Escudero
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Lina Bergman
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Leandro De Oliveira
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
| | - Global Pregnancy Collaboration
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg (Drs Kupka and Bergman), Sweden
- Department of Research and Higher Education, Center for Clinical Research Dalarna, Uppsala University, Region Dalarna (Dr Kupka), Falun, Sweden
- Magee-Womens Research Institute (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynecology, Epidemiology and Clinical and Translational Research, University of Pittsburgh (Dr Roberts), Pittsburgh, PA
- Department of Obstetrics and Gynaecology, University Kebangsaan Malaysia Medical Center (Dr Mahdy), Cheras, Malaysia
- Vascular Physiology Laboratory, Basic Sciences Department, Faculty of Sciences, Universidad del Bio-Bio (Dr Escudero), Chillan, Chile
- Group of Research and Innovation in Vascular Health (GRIVAS Health) (Dr Escudero), Chillan, Chile
- Department of Women's and Children's Health, Uppsala University (Dr Bergman), Uppsala, Sweden
- Department of Obstetrics and Gynecology, Stellenbosch University (Dr Bergman), Cape Town, South Africa
- São Paulo State University (UNESP), Medical School (Dr Oliveira), Botucatu
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Fu R, Li Y, Li X, Jiang W. Hypertensive Disorders in Pregnancy: Global Burden From 1990 to 2019, Current Research Hotspots and Emerging Trends. Curr Probl Cardiol 2023; 48:101982. [PMID: 37479005 DOI: 10.1016/j.cpcardiol.2023.101982] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 07/16/2023] [Indexed: 07/23/2023]
Abstract
Hypertensive disorders in pregnancy (HDP) constitute a worldwide health problem for pregnant women and their infants. This study provided HDP burden over 1990 to 2019 by region and age distribution, and predicted changes in related values for the next 25 years. We then conducted an econometric analysis of the author distribution, collaborative networks, keyword burst clustering, and spatio-temporal analysis of HDP-related publications from 2012 to 2022 to access current scientific developments and hotspots. The number of pregnant women with HDP has been increasing over the past 30 years, with regional and age-stratified differences in the burden of disease. Additionally, projections suggest an increase of deaths due to maternal HDP among adolescents younger than 20 years. Current research is mostly centered on pre-eclampsia, with hot keywords including trophoblast, immune tolerance, frozen-thawed embryo transfer, aspirin, gestational diabetes association, and biomarkers. Researches on the pathological mechanism, classification, and subtypes of HDP need to be further advanced.
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Affiliation(s)
- Ru Fu
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yihui Li
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Xiaogang Li
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Weihong Jiang
- Department of Cardiology, The Third Xiangya Hospital, Central South University, Changsha, China.
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Mosimann B, Amylidi-Mohr S, Surbek D, Förger F, Raio L. Use of Polynomial Reference Ranges for Atrioventricular Intervals Assessed by Fetal Echocardiography in Anti-Ro/SSA Antibody-Positive Pregnancies to Exclude Fetal Heart Blocks: A Pilot Study. Fetal Diagn Ther 2023; 50:422-429. [PMID: 37497922 DOI: 10.1159/000531780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/21/2023] [Indexed: 07/28/2023]
Abstract
INTRODUCTION Maternal anti-Ro/SSA antibodies can cause fetal atrioventricular blocks (AVB). This pilot study aims to apply previously published echocardiographic reference ranges of the fetal atrioventricular (AV) intervals in the setting of anti-Ro/SSA antibody-positive pregnancies in order to exclude a 1° AVB. MATERIALS AND METHODS Between January 2018 and September 2022, we included all women with known anti-Ro/SSA antibodies followed up at the prenatal ultrasound department of the University Hospital of Bern. AV intervals were serially measured by two previously reported methods and plotted against previously created reference ranges. RESULTS We included 23 pregnancies from 17 anti-Ro/SSA antibody-positive women with connective tissue diseases. 443 AV interval measurements were recorded between 16+3 and 38+4 weeks of gestation. 14 (3.2%) AV-intervals measured >150 ms, none measured >170 ms and 8 (1.8%) were found to be >95th percentile. In none of the pregnancies, serial AV-prolongations were noted. The postnatal electrocardiograms demonstrated normal sinus rhythm without AVB in all children. CONCLUSION AV intervals of pregnancies followed up for anti-Ro/SSA antibodies without neonatal AVB lie within our published polynomial reference ranges. While diagnosing a 1° AVB remains controversial, more data are needed to prove that our reference ranges are helpful exclude a 1° AVB.
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Affiliation(s)
- Beatrice Mosimann
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Sofia Amylidi-Mohr
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
| | - Frauke Förger
- Department of Rheumatology and Immunology, University Hospital, University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Gynaecology, University Hospital, University of Bern, Bern, Switzerland
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Berlinska L, Marichereda V, Rohachevskyi O, Volyanska A, Lavrynenko G. The model of screening for preeclampsia in the second and third trimesters of gestation. ELECTRONIC JOURNAL OF GENERAL MEDICINE 2023. [DOI: 10.29333/ejgm/12992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
<b>Purpose:</b> Preeclampsia (PE) is a specific syndrome of multiple organ insufficiency in case of pregnancy, which is included in the panel of major obstetric syndromes and is among the main causes of maternal morbidity and mortality in the whole world.<br />
<b>Material and methods</b>: We conducted a prospective cohort study of 91 pregnant women to evaluate the effectiveness of integrated use of maternal risk factors (2019 International Federation of Gynecology and Obstetrics recommendations), placenta location (ultrasound at 18-20 weeks of gestation), and serum cystatin C (at 18-36 weeks of gestation) in screening for pe in the second and third trimesters of gestation.<br />
<b>Results: </b>In the subgroup of pregnant women with cystatin C levels greater than 1.0 mg/L (27 women), PE developed in 26 women, which is 96.29% in percentage terms. When calculating GFR for cystatin C in a group with PE there was a significant violation of the renal filtration system -52.46±2.08 (95% CI, 48.39-56.54), while in healthy group the indicator is within normal limits -97.6±1.64 (95% CI, 94.38-100.82). In the analysis of the ratio of cystatin C levels more than 1.0 mg / l and the development of PE, a sensitivity of 98.46%, specificity of 100% and accuracy of 98.9%, p<0.001.<br />
<b>Conclusions: </b>The data show that the combined model of maternal factors, ultrasound of the placenta and serum cystatin C, is prognostically effective in pregnant women in the second and third trimesters of gestation and is a reliable marker for the development of pe.
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Affiliation(s)
- Liudmyla Berlinska
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Valerie Marichereda
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Oleksandr Rohachevskyi
- Department of Simulation Medical Technologies, Odessa National Medical University, Odesa, UKRAINE
| | - Alla Volyanska
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
| | - Ganna Lavrynenko
- Department of Obstetrics and Gynecology, Odesa National Medical University, Odesa, UKRAINE
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10
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von Dadelszen P, Syngelaki A, Akolekar R, Magee LA, Nicolaides KH. Preterm and term pre-eclampsia: Relative burdens of maternal and perinatal complications. BJOG 2023; 130:524-530. [PMID: 36562190 DOI: 10.1111/1471-0528.17370] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/10/2022] [Accepted: 12/06/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To determine the relative burdens of maternal and perinatal complications for preterm and term pre-eclampsia. DESIGN Prospective observational cohort study. SETTING Two English maternity units. POPULATION Unselected women with singleton pregnancies who developed pre-eclampsia (International Society for the Study of Hypertension in Pregnancy definition). METHODS Outcomes were ascertained by health record review and compared between pregnancies with preterm (versus term) pre-eclampsia. MAIN OUTCOME MEASURES Severe maternal hypertension, maternal mortality or major maternal morbidity, perinatal mortality or major neonatal morbidity, neonatal unit (NNU) admission ≥48 hours, and birthweight <3rd percentile. RESULTS Among 40 241 singleton pregnancies, 298 (0.7%, 95% confidence interval [CI] 0.66-0.83) and 1194 (3.0%, 95% CI 2.8-3.1) developed preterm and term pre-eclampsia, respectively. Women with preterm (versus term) pre-eclampsia more commonly experienced adverse maternal or perinatal events: severe hypertension 18.5% (95% CI 14.5-23.3) versus 13.6% (95% CI 11.7-15.6); maternal mortality/major morbidity 7.4% (95% CI 4.9-10.9) versus 2.2% (95% CI 1.5-3.2); perinatal mortality/major neonatal morbidity 29.5% (95% CI 24.6-34.9) versus 2.2% (95% CI 1.5-3.2); and birthweight <3rd percentile 54.4% (95% CI 48.7-59.9) versus 14.2% (95% CI 12.4-16.3). However, in absolute terms, most maternal complications occurred in women with term pre-eclampsia, as did a large proportion of perinatal complications: severe hypertension 74.7% (95% CI 68.5-80.0); maternal mortality/major morbidity 54.2% (95% CI 40.3-67.4); perinatal mortality/major neonatal morbidity 22.8% (95% CI 16.1-31.3); NNU admission ≥48 hours 38.1% (95% CI 32.4-44.1); and birthweight <3rd percentile 51.2% (95% CI 45.8-56.5). CONCLUSIONS Although adverse event risks are greater with preterm (versus term) pre-eclampsia, term disease is associated with at least equivalent total numbers of maternal, and a significant proportion of perinatal, adverse events. Increased efforts should be made to decrease the incidence of term pre-eclampsia.
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Affiliation(s)
- Peter von Dadelszen
- School of Life Course and Population Sciences, King's College London, Institute of Women and Children's Health, London, UK
| | - Argyro Syngelaki
- School of Life Course and Population Sciences, King's College London, Institute of Women and Children's Health, London, UK.,Fetal Medicine Research Institute, King's College Hospital, London, UK
| | - Ranjit Akolekar
- Fetal Medicine Unit, Medway Maritime Hospital, Gillingham, UK.,Institute of Medical Sciences, Canterbury Christ Church University, Chatham, UK
| | - Laura A Magee
- School of Life Course and Population Sciences, King's College London, Institute of Women and Children's Health, London, UK
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11
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Abstract
Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.
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12
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Ormesher L, Vause S, Higson S, Roberts A, Clarke B, Curtis S, Ordonez V, Ansari F, Everett TR, Hordern C, Mackillop L, Stern V, Bonnett T, Reid A, Wallace S, Oyekan E, Douglas H, Cauldwell M, Reddy M, Palmer K, Simpson M, Brennand J, Minns L, Freeman L, Murray S, Mary N, Castleman J, Morris KR, Haslett E, Cassidy C, Johnstone ED, Myers JE. Prevalence of pre-eclampsia and adverse pregnancy outcomes in women with pre-existing cardiomyopathy: a multi-centre retrospective cohort study. Sci Rep 2023; 13:153. [PMID: 36599871 DOI: 10.1038/s41598-022-26606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 12/16/2022] [Indexed: 01/05/2023] Open
Abstract
Pre-eclampsia is associated with postnatal cardiac dysfunction; however, the nature of this relationship remains uncertain. This multicentre retrospective cohort study aimed to determine the prevalence of pre-eclampsia in women with pre-existing cardiac dysfunction (left ventricular ejection fraction < 55%) and explore the relationship between pregnancy outcome and pre-pregnancy cardiac phenotype. In this cohort of 282 pregnancies, pre-eclampsia prevalence was not significantly increased (4.6% [95% C.I 2.2-7.0%] vs. population prevalence of 4.6% [95% C.I. 2.7-8.2], p = 0.99); 12/13 women had concurrent obstetric/medical risk factors for pre-eclampsia. The prevalence of preterm pre-eclampsia (< 37 weeks) and fetal growth restriction (FGR) was increased (1.8% vs. 0.7%, p = 0.03; 15.2% vs. 5.5%, p < 0.001, respectively). Neither systolic nor diastolic function correlated with pregnancy outcome. Antenatal ß blockers (n = 116) were associated with lower birthweight Z score (adjusted difference - 0.31 [95% C.I. - 0.61 to - 0.01], p = 0.04). To conclude, this study demonstrated a modest increase in preterm pre-eclampsia and significant increase in FGR in women with pre-existing cardiac dysfunction. Our results do not necessarily support a causal relationship between cardiac dysfunction and pre-eclampsia, especially given the population's background risk status. The mechanism underpinning the relationship between cardiac dysfunction and FGR merits further research but could be influenced by concomitant ß blocker use.
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Affiliation(s)
- Laura Ormesher
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK. .,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK.
| | - Sarah Vause
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Suzanne Higson
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK
| | - Anna Roberts
- Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Bernard Clarke
- Manchester Heart Centre, Manchester University NHS Foundation Trust, Manchester, UK.,Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | | | | | | | | | - Claire Hordern
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Lucy Mackillop
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Victoria Stern
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Tessa Bonnett
- Academic Unit of Developmental and Reproductive Medicine, University of Sheffield, Sheffield, UK
| | - Alice Reid
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Suzanne Wallace
- Department of Obstetrics, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ebruba Oyekan
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | - Maya Reddy
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Kirsten Palmer
- Monash Women's, Monash Health, Monash University, Melbourne, Australia
| | - Maggie Simpson
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK
| | - Janet Brennand
- Scottish Adult Congenital Cardiac Service, Golden Jubilee National Hospital, Glasgow, UK.,Queen Elizabeth University Hospital, NHS Greater Glasgow & Clyde, Glasgow, UK
| | - Laura Minns
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Leisa Freeman
- Department of Cardiology, Norfolk& Norwich University Hospital Foundation Trust, Norwich, UK
| | - Sarah Murray
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - Nirmala Mary
- Royal Infirmary of Edinburgh, NHS Lothian University Hospitals Division, Edinburgh, UK
| | - James Castleman
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK
| | - Katie R Morris
- Birmingham Women's and Children's Hospital NHS Foundation Trust, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | | | | | - Edward D Johnstone
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Jenny E Myers
- Maternal & Fetal Health Research Centre, Division of Developmental Biology and Medicine, University of Manchester, Manchester, UK.,Saint Mary's Hospital, Manchester University NHS Foundation Trust, Manchester, UK
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13
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Trilla C, Mora J, Ginjaume N, Nan MN, Alejos O, Domínguez C, Vega C, Godínez Y, Cruz-Lemini M, Parra J, Llurba E. Reduction in Preterm Preeclampsia after Contingent First-Trimester Screening and Aspirin Prophylaxis in a Routine Care Setting. Diagnostics (Basel) 2022; 12:diagnostics12081814. [PMID: 36010165 PMCID: PMC9406877 DOI: 10.3390/diagnostics12081814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/17/2022] [Accepted: 07/25/2022] [Indexed: 12/01/2022] Open
Abstract
Objectives: Several multivariate algorithms for preeclampsia (PE) screening in the first trimester have been developed over the past few years. These models include maternal factors, mean arterial pressure (MAP), uterine artery Doppler (UtA-PI), and biochemical markers (pregnancy-associated plasma protein-A (PAPP-A) or placental growth factor (PlGF)). Treatment with low-dose aspirin (LDA) has shown a reduction in the incidence of preterm PE in women with a high-risk assessment in the first trimester. An important barrier to the implementation of first-trimester screening is the cost of performing tests for biochemical markers in the whole population. Theoretical contingent strategies suggest that two-stage screening models could also achieve high detection rates for preterm PE with lower costs. However, no data derived from routine care settings are currently available. This study was conducted to validate and assess the performance of a first-trimester contingent screening process using PlGF for PE, with prophylactic LDA, for decreasing the incidence of preterm PE. Methods: This was a two-phase study. In phase one, a contingent screening model for PE was developed using a multivariate validated model and a historical cohort participating in a non-interventional PE screening study (n = 525). First-stage risk assessment included maternal factors, MAP, UtA-PI, and PAPP-A. Several cut-off levels were tested to determine the best screening performance, and three groups were then defined (high-, medium-, and low-risk groups). PlGF was determined in the medium-risk group to calculate the final risk. Phase two included a validation cohort of 847 singleton pregnancies prospectively undergoing first-trimester PE screening using this approach. Women at high risk of PE received prophylactic treatment with 150 mg of LDA. The clinical impact of the model was evaluated by comparing the incidence of early-onset (<34 weeks) and preterm (<37 weeks) PE between groups. Results: Cut-off levels for the contingent screening model were chosen in the first and second stages of screening to achieve a performance with sensitivities of 100% and 80% for early-onset and preterm PE detection, respectively, with a 15% false positive rate. In the development phase, 21.5% (n = 113) of the women had a medium risk of PE and required second-stage screening. In the prospective validation phase, 15.3% (n = 130) of the women required second-stage screening for PlGF, yielding an overall screen-positive rate of 14.9% (n = 126). The incidence of preterm PE was reduced by 68.4% (1.9% vs. 0.6%, p = 0.031) after one year of screening implementation. Conclusions: Implementation of contingent screening for PE using PlGF in a routine care setting led to a significant reduction (68.4%) in preterm PE, suggesting that contingent screening can achieve similar results to protocols using PlGF in the whole population. This could have financial benefits, with a similar reduction in the rate of preterm PE.
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Affiliation(s)
- Cristina Trilla
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS, RD21/0012/0001), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Josefina Mora
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS, RD21/0012/0001), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Biochemistry Department, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Nuria Ginjaume
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
| | - Madalina Nicoleta Nan
- Biochemistry Department, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain;
| | - Obdulia Alejos
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
| | - Carla Domínguez
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
| | - Carmen Vega
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
| | - Yessenia Godínez
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
| | - Monica Cruz-Lemini
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS, RD21/0012/0001), Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Juan Parra
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
| | - Elisa Llurba
- Department of Obstetrics and Gynaecology, Institut d’Investigació Biomèdica Sant Pau-IIB Sant Pau, Hospital de la Santa Creu i Sant Pau, 08025 Barcelona, Spain; (C.T.); (N.G.); (O.A.); (C.D.); (C.V.); (Y.G.); (M.C.-L.); (J.P.)
- Department of Medicine, Universitat Autònoma de Barcelona, 08193 Barcelona, Spain;
- Primary Care Interventions to Prevent Maternal and Child Chronic Diseases of Perinatal and Developmental Origin Network (RICORS, RD21/0012/0001), Instituto de Salud Carlos III, 28029 Madrid, Spain
- Correspondence: ; Tel.: +34-935-337-041
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14
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Trottmann F, Mollet AE, Amylidi-Mohr S, Surbek D, Raio L, Mosimann B. Integrating Combined First Trimester Screening for Preeclampsia into Routine Ultrasound Examination. Geburtshilfe Frauenheilkd 2022; 82:333-340. [PMID: 35250382 PMCID: PMC8893983 DOI: 10.1055/a-1534-2599] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 06/22/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction
The Fetal Medicine Foundation (FMF) London has developed a first trimester screening algorithm for preeclampsia (PE), based on maternal characteristics and past risk
factors, mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and placental growth factor (PlGF). The aim of this study was to determine the feasibility of integrating PE
screening into routine practice.
Material and Methods
All pregnancies with a fetal crown-rump length of 45 – 84 mm presenting to our ultrasound department between January 2014 and September 2020 were included in
this analysis. Screening for PE was offered to singleton pregnancies only. The number of screening tests performed in the eligible population was assessed and the reasons for missed
screenings identified with the help of the electronic clinical database. SPSS Statistics 25 and GraphPad version 8.0 for Windows were used for statistical analysis.
Results
6535 pregnancies were included, 4510 (69.0%) of which were screened for PE. The percentage of patients being offered PE screening increased over the years from 63.1 to 96.7%
(r
s
= 0.96; p = 0.003), while the rate of screenings performed in eligible patients remained stable at a median [range] of 86.2% [78.0 – 91.8%] (p = ns). 2025 (31.0%)
pregnancies were not screened for PE, 1306 (64.5%) because they were not eligible for screening. 145 (2.2%) women explicitly declined PE screening; their background risk was lower than that
of women who accepted screening.
Conclusion
Our study shows that integration of PE screening into the routine first trimester ultrasound scan is feasible and widely accepted by pregnant women and health care
providers.
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Affiliation(s)
- Fabienne Trottmann
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
| | - Anne Elena Mollet
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
| | - Sofia Amylidi-Mohr
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
| | - Daniel Surbek
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
| | - Luigi Raio
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
| | - Beatrice Mosimann
- Department of Obstetrics and Feto-maternal Medicine, University Hospital Insel Bern, University of Bern, Bern, Switzerland
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15
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Magee LA, Brown MA, Hall DR, Gupte S, Hennessy A, Karumanchi SA, Kenny LC, McCarthy F, Myers J, Poon LC, Rana S, Saito S, Staff AC, Tsigas E, von Dadelszen P. The 2021 International Society for the Study of Hypertension in Pregnancy classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2022; 27:148-169. [DOI: 10.1016/j.preghy.2021.09.008] [Citation(s) in RCA: 412] [Impact Index Per Article: 137.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 09/30/2021] [Indexed: 12/13/2022]
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16
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Magee LA, Khalil A, Kametas N, von Dadelszen P. Toward personalized management of chronic hypertension in pregnancy. Am J Obstet Gynecol 2022; 226:S1196-S1210. [PMID: 32687817 PMCID: PMC7367795 DOI: 10.1016/j.ajog.2020.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/27/2020] [Accepted: 07/15/2020] [Indexed: 12/15/2022]
Abstract
Chronic hypertension complicates 1% to 2% of pregnancies, and it is increasingly common. Women with chronic hypertension are an easily recognized group who are in touch with a wide variety of healthcare providers before, during, and after pregnancy, mandating that chronic hypertension in pregnancy be within the scope of many practitioners. We reviewed recent data on management to inform current care and future research. This study is a narrative review of published literature. Compared with normotensive women, women with chronic hypertension are at an increased risk of maternal and perinatal complications. Women with chronic hypertension who wish to be involved in their care can do by measuring blood pressure at home. Accurate devices for home blood pressure monitoring are now readily available. The diagnostic criteria for superimposed preeclampsia remain problematic because most guidelines continue to include deteriorating blood pressure control in the definition. It has not been established how angiogenic markers may aid in confirmation of the diagnosis of superimposed preeclampsia when suspected, over and above information provided by routinely available clinical data and laboratory results. Although chronic hypertension is a strong risk factor for preeclampsia, and aspirin decreases preeclampsia risk, the effectiveness specifically among women with chronic hypertension has been questioned. It is unclear whether calcium has an independent effect in preeclampsia prevention in such women. Treating hypertension with antihypertensive therapy halves the risk of progression to severe hypertension, thrombocytopenia, and elevated liver enzymes, but a reduction in preeclampsia or serious maternal complications has not been observed; however, the lack of evidence for the latter is possibly owing to few events. In addition, treating chronic hypertension neither reduces nor increases fetal or newborn death or morbidity, regardless of the gestational age at which the antihypertensive treatment is started. Antihypertensive agents are not teratogenic, but there may be an increase in malformations associated with chronic hypertension itself. At present, blood pressure treatment targets used in clinics are the same as those used at home, although blood pressure values tend to be inconsistently lower at home among women with hypertension. Although starting all women on the same antihypertensive medication is usually effective in reducing blood pressure, it remains unclear whether there is an optimal agent for such an approach or how best to use combinations of antihypertensive medications. An alternative approach is to individualize care, using maternal characteristics and blood pressure features beyond blood pressure level (eg, variability) that are of prognostic value. Outcomes may be improved by timed birth between 38 0/7 and 39 6/7 weeks' gestation based on observational literature; of note, confirmatory trial evidence is pending. Postnatal care is facilitated by the acceptability of most antihypertensives (including angiotensin-converting enzymes inhibitors) for use in breastfeeding. The evidence base to guide the care of pregnant women with chronic hypertension is growing and aligning with international guidelines. Addressing outstanding research questions would inform personalized care of chronic hypertension in pregnancy.
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Affiliation(s)
- Laura A Magee
- Department of Women and Children's Health, King's College London, London, United Kingdom.
| | - Asma Khalil
- Department of Obstetrics and Gynecology, St. George's, University of London, London, United Kingdom
| | - Nikos Kametas
- Harris Birthright Centre, King's College Hospital, London, United Kingdom
| | - Peter von Dadelszen
- Department of Women and Children's Health, King's College London, London, United Kingdom
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17
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Chaemsaithong P, Sahota DS, Poon LC. First trimester preeclampsia screening and prediction. Am J Obstet Gynecol 2022; 226:S1071-S1097.e2. [PMID: 32682859 DOI: 10.1016/j.ajog.2020.07.020] [Citation(s) in RCA: 130] [Impact Index Per Article: 43.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/30/2020] [Accepted: 07/14/2020] [Indexed: 12/16/2022]
Abstract
Preeclampsia is a major cause of maternal and perinatal morbidity and mortality. Early-onset disease requiring preterm delivery is associated with a higher risk of complications in both mothers and babies. Evidence suggests that the administration of low-dose aspirin initiated before 16 weeks' gestation significantly reduces the rate of preterm preeclampsia. Therefore, it is important to identify pregnant women at risk of developing preeclampsia during the first trimester of pregnancy, thus allowing timely therapeutic intervention. Several professional organizations such as the American College of Obstetricians and Gynecologists (ACOG) and National Institute for Health and Care Excellence (NICE) have proposed screening for preeclampsia based on maternal risk factors. The approach recommended by ACOG and NICE essentially treats each risk factor as a separate screening test with additive detection rate and screen-positive rate. Evidence has shown that preeclampsia screening based on the NICE and ACOG approach has suboptimal performance, as the NICE recommendation only achieves detection rates of 41% and 34%, with a 10% false-positive rate, for preterm and term preeclampsia, respectively. Screening based on the 2013 ACOG recommendation can only achieve detection rates of 5% and 2% for preterm and term preeclampsia, respectively, with a 0.2% false-positive rate. Various first trimester prediction models have been developed. Most of them have not undergone or failed external validation. However, it is worthy of note that the Fetal Medicine Foundation (FMF) first trimester prediction model (namely the triple test), which consists of a combination of maternal factors and measurements of mean arterial pressure, uterine artery pulsatility index, and serum placental growth factor, has undergone successful internal and external validation. The FMF triple test has detection rates of 90% and 75% for the prediction of early and preterm preeclampsia, respectively, with a 10% false-positive rate. Such performance of screening is superior to that of the traditional method by maternal risk factors alone. The use of the FMF prediction model, followed by the administration of low-dose aspirin, has been shown to reduce the rate of preterm preeclampsia by 62%. The number needed to screen to prevent 1 case of preterm preeclampsia by the FMF triple test is 250. The key to maintaining optimal screening performance is to establish standardized protocols for biomarker measurements and regular biomarker quality assessment, as inaccurate measurement can affect screening performance. Tools frequently used to assess quality control include the cumulative sum and target plot. Cumulative sum is a sensitive method to detect small shifts over time, and point of shift can be easily identified. Target plot is a tool to evaluate deviation from the expected multiple of median and the expected median of standard deviation. Target plot is easy to interpret and visualize. However, it is insensitive to detecting small deviations. Adherence to well-defined protocols for the measurements of mean arterial pressure, uterine artery pulsatility index, and placental growth factor is required. This article summarizes the existing literature on the different methods, recommendations by professional organizations, quality assessment of different components of risk assessment, and clinical implementation of the first trimester screening for preeclampsia.
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Verlohren S, Brennecke SP, Galindo A, Karumanchi SA, Mirkovic LB, Schlembach D, Stepan H, Vatish M, Zeisler H, Rana S. Clinical interpretation and implementation of the sFlt-1/PlGF ratio in the prediction, diagnosis and management of preeclampsia. Pregnancy Hypertens 2021; 27:42-50. [PMID: 34915395 DOI: 10.1016/j.preghy.2021.12.003] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 11/12/2021] [Accepted: 12/03/2021] [Indexed: 11/16/2022]
Abstract
Preeclampsia is associated with significant morbidity and mortality for mother and baby. Although around 30% of all pregnancies are evaluated for preeclampsia, diagnosis is difficult, especially in patients who have overlying symptoms from other diseases. Discovery of circulating angiogenic factors in the pathogenesis of preeclampsia has been a major advance for both diagnosis and prognosis. The anti-angiogenic factor, soluble fms-like tyrosine kinase 1 (sFlt-1) and the pro-angiogenic factor, placental growth factor (PlGF), can be measured in plasma and serum and are usually reported as a ratio, which specifically relates to the onset and severity of preeclampsia. The sFlt-1/PlGF ratio has a very high negative predictive value in ruling out the development of preeclampsia within 7 days among women with suspected preeclampsia. Currently, there is no clear consensus on the practical use of angiogenic biomarkers in the detection and management of preeclampsia in routine clinical practice. While major international clinical guidelines exist, they do not define which specific parameters signal patient admission, or outpatient evaluation of suspected preeclampsia, and most clinicians follow local practices. Better guidance is needed on risk stratification among women with suspected preeclampsia, as well as among women at high risk for preeclampsia. Prediction of adverse outcomes in women, after the clinical diagnosis of preeclampsia, is also important. This report has been developed following a meeting of international experts and aims to guide clinicians in the management of pregnant women at risk of preeclampsia using the sFlt-1/PlGF ratio test.
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Affiliation(s)
| | - Shaun P Brennecke
- University of Melbourne/Royal Women's Hospital, Melbourne, Australia
| | - Alberto Galindo
- Department of Obstetrics and Gynecology, University Hospital 12 de Octubre, Research Institute (imas12), Complutense University, Madrid, Spain
| | | | | | - Dietmar Schlembach
- Vivantes Network of Health GmbH, Clinicum Berlin-Neukoelln, Clinic of Obstetric Medicine, Berlin, Germany
| | | | - Manu Vatish
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | | | - Sarosh Rana
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Chicago, Chicago, IL, USA.
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Rezende KBDC, Bornia RG, Rolnik DL, Amim J, Pritsivelis C, Cardoso MIMP, Gama LB, Crespo RA, L' Hotellier MCMP, da Cunha AJLA. External validation of first trimester combined screening for pre-eclampsia in Brazil: An observational study. Pregnancy Hypertens 2021; 26:110-115. [PMID: 34739940 DOI: 10.1016/j.preghy.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 10/22/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To validate a combined algorithm for early prediction of pre-eclampsia (PE) in the Brazilian population. STUDY DESIGN This is an unplanned secondary analysis of a cohort study. Consecutive singleton pregnancies undergoing first-trimester screening for PE involving examination of maternal characteristics, medical history, and biophysical markers were considered eligible. Women were classified as low-or high-risk using a cutoff of 1/200, but the individual risk was not used to dictate management, as aspirin prophylaxis was given to women based solely on clinical risk factors. Receiver-operating characteristics (ROC) curves for PE, preterm PE(PE < 37) and early 34(PE < 34) were constructed and detection rates(DR) and false-positive rates(FPR) were calculated, adjusting for the effect of aspirin. Propensity score analysis was utilized to account for possible confounding by indication. MAIN OUTCOME MEASURES Screening performance and PE rates. RESULTS Among 1695 women, 323(19.1%) were classified as high-risk for PE and 1372(80.9%) were considered low-risk. Aspirin use was registered in 62(3.7%) in the high-risk group and 33(1.9%) in the low-risk group. There were 164(9.7%) women who developed PE, including 41(2.4%) with PE < 37 and 18(1.1%) PE < 34.Subgroups with aspirin had higher incidence of PE, suggest confounding by indication. The algorithm had an AUC of 0.87, DR of 72% for PE < 34; an AUC of 0.8, DR of 59% for PE < 37, both with FPR of 18%. Accounting for effect of aspirin, we observed an improvement in DR of PE < 37 to 67%. CONCLUSION Using combined predictive algorithm for preterm PE prediction is feasible in clinical practice in low/middle-income countries. Aspirin use needs to be accounted for when evaluating the performance of screening.
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Affiliation(s)
- Karina B de C Rezende
- Clinical Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Multidisciplinary Laboratory of Epidemiology and Health - LAMPES, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil.
| | - Rita G Bornia
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Program in Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Australia
| | - Joffre Amim
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Program in Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Cristos Pritsivelis
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Maria Isabel M P Cardoso
- Maternity School, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Professional Master Program in Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Luiza B Gama
- Professional Master Program in Perinatal Health, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Raquel A Crespo
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Maria Carolina M P L' Hotellier
- Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
| | - Antônio José L A da Cunha
- Clinical Medicine Postgraduate Program, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Multidisciplinary Laboratory of Epidemiology and Health - LAMPES, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil; Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, Brasil
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Rode L, Ekelund CK, Riishede I, Rasmussen S, Lidegaard Ø, Tabor A. Prediction of preterm pre-eclampsia according to NICE and ACOG criteria: descriptive study of 597 492 Danish births from 2008 to 2017. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 58:561-567. [PMID: 34021947 DOI: 10.1002/uog.23693] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/31/2021] [Accepted: 05/10/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE The aim of this national study was to examine the incidence of preterm pre-eclampsia (PE) and the proportion of women with risk factors for PE, according to the criteria suggested by the National Institute for Health and Care Excellence (NICE) and the American College of Obstetricians and Gynecologists (ACOG), during a 10-year period in Denmark. METHODS Data from The Danish National Patient Registry and the Danish Medical Birth Registry were used to obtain the incidence of preterm PE with delivery < 37 weeks' gestation and risk factors for PE for all deliveries in Denmark from 1 January 2008 to 31 December 2017. The proportion of women with at least one high-risk factor and/or at least two moderate-risk factors for PE, according to the NICE and ACOG criteria, and the detection rate for preterm PE were examined. Race, socioeconomic status and the woman's weight at birth were not available from the registries used, and information on Type-2 diabetes was found to be invalid. RESULTS Of the 597 492 deliveries during the study period, any PE was registered in 3.2%, preterm PE < 37 weeks in 0.7% and early-onset PE < 34 weeks' gestation in 0.3%. These proportions remained largely unchanged from 2008 to 2017. Overall, the NICE criteria were fulfilled in 7.5% of deliveries and the ACOG criteria in 17.3%. In the total population, the NICE criteria identified 47.6% of those with preterm PE and the ACOG criteria identified 60.5%. The current criteria for offering aspirin treatment in Denmark largely correspond to having at least one NICE high-risk factor. In 2017, a total of 3.5% of deliveries had at least one NICE high-risk factor, which identified 28.4% of cases that later developed preterm PE. CONCLUSIONS The incidence of preterm PE remained largely unchanged in Denmark from 2008 to 2017. Prediction of PE according to high-risk maternal factors could be improved by addition of moderate-risk factors. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Rode
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Biochemistry, Copenhagen University Hospital Rigshospitalet, Glostrup, Denmark
| | - C K Ekelund
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - I Riishede
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - S Rasmussen
- Department of Gynecology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Ø Lidegaard
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Gynecology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - A Tabor
- Center of Fetal Medicine and Pregnancy, Department of Obstetrics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Low Molecular Weight Heparins (LMWH) and Implications along Pregnancy: a Focus on the Placenta. Reprod Sci 2021; 29:1414-1423. [PMID: 34231172 DOI: 10.1007/s43032-021-00678-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Abstract
Low molecular weight heparins (LMWH) have been largely studied for their use during pregnancy. The biology and the pharmacology of these molecules are well known and may be summarized in three main mechanisms of action: anti-coagulant, anti-inflammatory, and immunomodulant. The clinical implications of these drugs during pregnancy are mainly related to their action on the placenta, because of the presence of specific molecular and cellular targets, particularly at the trophoblast-endometrial interface. As well as for the prevention and treatment of thromboembolism, LMWH have been largely investigated for the improvement of embryo implantation and for the prevention of placenta-related complications such as preeclampsia, fetal growth restriction, and intrauterine fetal death. However, data on this topic are still unclear. The present review discusses the biological features, the mechanisms of action, and the possible contribution of LMWH to the success of placentation along pregnancy, pointing out the need for future basic science and clinical researches in this important field with the final aim to improve clinical practice in high-risk pregnancies.
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Poniedziałek-Czajkowska E, Mierzyński R, Dłuski D, Leszczyńska-Gorzelak B. Prevention of Hypertensive Disorders of Pregnancy-Is There a Place for Metformin? J Clin Med 2021; 10:jcm10132805. [PMID: 34202343 PMCID: PMC8268471 DOI: 10.3390/jcm10132805] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 06/20/2021] [Accepted: 06/23/2021] [Indexed: 12/13/2022] Open
Abstract
The possibility of prophylaxis of hypertensive disorders of pregnancy (HDPs) such as preeclampsia (PE) and pregnancy-induced hypertension is of interest due to the unpredictable course of these diseases and the risks they carry for both mother and fetus. It has been proven that their development is associated with the presence of the placenta, and the processes that initiate it begin at the time of the abnormal invasion of the trophoblast in early pregnancy. The ideal HDP prophylaxis should alleviate the influence of risk factors and, at the same time, promote physiological trophoblast invasion and maintain the physiologic endothelium function without any harm to both mother and fetus. So far, aspirin is the only effective and recommended pharmacological agent for the prevention of HDPs in high-risk groups. Metformin is a hypoglycemic drug with a proven protective effect on the cardiovascular system. Respecting the anti-inflammatory properties of metformin and its favorable impact on the endothelium, it seems to be an interesting option for HDP prophylaxis. The results of previous studies on such use of metformin are ambiguous, although they indicate that in a certain group of pregnant women, it might be effective in preventing hypertensive complications. The aim of this study is to present the possibility of metformin in the prevention of hypertensive disorders of pregnancy with respect to its impact on the pathogenic elements of development
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Cordisco A, Periti E, Antoniolli N, Lozza V, Conticini S, Vannucci G, Masini G, Pasquini L. Clinical implementation of pre-eclampsia screening in the first trimester of pregnancy. Pregnancy Hypertens 2021; 25:34-38. [PMID: 34051436 DOI: 10.1016/j.preghy.2021.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 05/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES Early identification of preeclampia in the first trimester of pregnancy represents one of the major challenges of modern fetal medicine. The primary aim of our study was to evaluate the effectiveness of implementation of preeclampsia screening in Tuscany, Italy. The secondary aim was to evaluate pregnancy/neonatal outcome in the positive screening group compared with the negative screening group. STUDY DESIGN Retrospective study including singleton pregnancies undergoing screening for preeclampsia. The screening test was a multiparametric algorithm based on maternal history, biochemical and biophysical parameters (Fetal Medicine Foundation algorithm). MAIN OUTCOME MEASURES The overall performance of the test was calculated, in terms of sensitivity, specificity, positive and negative predictive value and in relation to gestational age at onset (primary aim). Pregnancy and neonatal outcomes were then compared between the positive and negative population at preeclampsia screening test (secondary aim). RESULTS Of the 5719 patients enrolled, 4797 were included in the analysis. The sensitivity for early onset of preeclampsia (≤34 weeks) was 0.75 (CI:0.41-0.93) and specificity 0.93 (CI:0.92-0.94) for a false positive rate of 7%. The population that tested positive for preeclampsia screening showed a higher incidence of deliveries at lower gestational ages (p < 0.001), preeclampsia onset despite prophylaxis with aspirin (p < 0.001), emergency caesarean section (p < 0.001), low fetal birth weight (p < 0.001) and neonatal admission in intensive care unit (p < 0.001). CONCLUSIONS Our data confirm the validity of first trimester screening test in identifying a category of patients at greatest risk for preeclampsia even in the presence of a post-test pharmacological prophylaxis.
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Affiliation(s)
- Adalgisa Cordisco
- Division of Prenatal Diagnosis, Piero Palagi Hospital, Florence, Italy
| | - Enrico Periti
- Division of Prenatal Diagnosis, Piero Palagi Hospital, Florence, Italy
| | - Nicole Antoniolli
- Fetal Medicine Unit, Department for Women and Children Health, Careggi University Hospital, Florence, Italy
| | - Virginia Lozza
- Division of Prenatal Diagnosis, Piero Palagi Hospital, Florence, Italy
| | - Silvia Conticini
- Division of Prenatal Diagnosis, Piero Palagi Hospital, Florence, Italy
| | - Giulia Vannucci
- Fetal Medicine Unit, Department for Women and Children Health, Careggi University Hospital, Florence, Italy
| | - Giulia Masini
- Fetal Medicine Unit, Department for Women and Children Health, Careggi University Hospital, Florence, Italy
| | - Lucia Pasquini
- Fetal Medicine Unit, Department for Women and Children Health, Careggi University Hospital, Florence, Italy.
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Chaparro A, Monckeberg M, Realini O, Hernández M, Param F, Albers D, Ramírez V, Kusanovic JP, Romero R, Rice G, Illanes SE. Gingival Crevicular Placental Alkaline Phosphatase Is an Early Pregnancy Biomarker for Pre-Eclampsia. Diagnostics (Basel) 2021; 11:diagnostics11040661. [PMID: 33916883 PMCID: PMC8067553 DOI: 10.3390/diagnostics11040661] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/15/2021] [Accepted: 03/22/2021] [Indexed: 12/20/2022] Open
Abstract
Early and innovative diagnostic strategies are required to predict the risk of developing pre-eclampsia (PE). The purpose of this study was to evaluate the performance of gingival crevicular fluid (GCF) placental alkaline phosphatase (PLAP) concentrations to correctly classify women at risk of PE. A prospectively collected, retrospectively stratified cohort study was conducted, with 412 pregnant women recruited at 11–14 weeks of gestation. Physical, obstetrical, and periodontal data were recorded. GCF and blood samples were collected for PLAP determination by ELISA assay. A multiple logistic regression classification model was developed, and the classification efficiency of the model was established. Within the study cohort, 4.3% of pregnancies developed PE. GCF-PLAP concentration was 3- to 6-fold higher than in plasma samples. GCF-PLAP concentrations and systolic blood pressure were greater in women who developed PE (p = 0.015 and p < 0.001, respectively). The performance of the multiparametric model that combines GCF-PLAP concentration and the levels of systolic blood pressure (at 11–14 weeks gestation) showed an association of systolic blood pressure and GCF-PLAP concentrations with the likelihood of developing PE (OR:1.07; 95% CI 1.01–1.11; p = 0.004 and OR:1.008, 95% CI 1.000–1.015; p = 0.034, respectively). The model had a sensitivity of 83%, a specificity of 72%, and positive and negative predictive values of 12% and 99%, respectively. The area under the receiver operating characteristic (AUC-ROC) curve was 0.77 and correctly classified 72% of PE pregnancies. In conclusion, the multivariate classification model developed may be of utility as an aid in identifying pre-symptomatic women who subsequently develop PE.
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Affiliation(s)
- Alejandra Chaparro
- Centre for Biomedical and Innovation Research, Department of Periodontology, Faculty of Dentistry, Universidad de Los Andes, Santiago 7620001, Chile; (O.R.); (F.P.)
- Correspondence: ; Tel.: +56-9983-76593
| | - Maximiliano Monckeberg
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (S.E.I.)
| | - Ornella Realini
- Centre for Biomedical and Innovation Research, Department of Periodontology, Faculty of Dentistry, Universidad de Los Andes, Santiago 7620001, Chile; (O.R.); (F.P.)
| | - Marcela Hernández
- Laboratory of Periodontal Biology, Department of Pathology, Faculty of Dentistry, Universidad de Chile, Santiago 8330015, Chile;
| | - Fernanda Param
- Centre for Biomedical and Innovation Research, Department of Periodontology, Faculty of Dentistry, Universidad de Los Andes, Santiago 7620001, Chile; (O.R.); (F.P.)
| | - Daniela Albers
- Department of Statistics, Faculty of Dentistry, Universidad Mayor, Santiago 8580745, Chile;
| | - Valeria Ramírez
- Department of Public Health and Epidemiology, Faculty of Dentistry, Universidad de los Andes, Santiago 7620001, Chile;
| | - Juan Pedro Kusanovic
- Department of Obstetrics and Gynecology, Hospital Sótero del Río, Santiago 13201, Chile;
- Division of Obstetrics and Gynecology, Faculty of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI 48201, USA;
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI 48109, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, MI 48824, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, MI 48201, USA
- Detroit Medical Center, Detroit, MI 48201, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, FL 33199, USA
| | - Gregory Rice
- Center for Research and Medical Innovation, Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile;
- UQ Centre for Clinical Research, University of Queensland, Brisbane, QLD 4072, Australia
| | - Sebastián E. Illanes
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (S.E.I.)
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago 7620001, Chile
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Tianthong W, Phupong V. Serum hypoxia-inducible factor-1α and uterine artery Doppler ultrasound during the first trimester for prediction of preeclampsia. Sci Rep 2021; 11:6674. [PMID: 33758274 PMCID: PMC7988168 DOI: 10.1038/s41598-021-86073-w] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/23/2021] [Indexed: 11/09/2022] Open
Abstract
The objective of this study was to determine the predictive value of serum hypoxia-inducible factor-1α (HIF-1α) combined with uterine artery Doppler in singleton pregnancy during 11-13+6 weeks of gestation for preeclampsia. This prospective observational study was conducted in singleton pregnant women at 11-13+6 weeks of gestation who visited the King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University for antenatal care between February 2019 and May 2020. Serum HIF-1α levels and uterine artery Doppler ultrasound were performed. Pregnancy outcomes were recorded. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of these tests at the optimal cut-off values were determined to predict preeclampsia. A total of 385 participants were analyzed. Of these, 31 cases had preeclampsia (8.1%), and 6 cases of them had early-onset preeclampsia (1.6%). Preeclamptic women had significantly higher serum HIF-1α levels than normal pregnant women (median 1315.2 pg/ml vs. 699.5 pg/ml, p < 0.001). There was no difference in the mean pulsatility (PI) of the uterine artery. Serum HIF-1α levels were higher than 1.45 multiple of median for the gestational age as a cut-off value for predicting preeclampsia; the sensitivity, specificity, PPV, and NPV were 66.7%, 71.5%, 17.2%, and 96.2%, respectively. When a combination of abnormal serum HIF-1α levels and abnormal uterine artery Doppler PI (above the 95th percentile) were used as a predictive value to predict preeclampsia, the sensitivity, specificity, PPV, and NPV were 74.2%, 67.2%, 16.6%, and 96.8%, respectively. This study showed that the serum HIF-1α levels with or without uterine artery Doppler at 11-13+6 weeks of gestation were effective in predicting preeclampsia.
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Affiliation(s)
- Wasinee Tianthong
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand
| | - Vorapong Phupong
- Placental Related Diseases Research Unit, Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
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Nagalla SR, Janaki V, Vijayalakshmi AR, Chayadevi K, Pratibha D, Rao PV, Sage KM, Nair‐Schaef D, Bean E, Roberts CT, Gravett MG. Glycosylated fibronectin point-of-care test for diagnosis of pre-eclampsia in a low-resource setting: a prospective Southeast Asian population study. BJOG 2020; 127:1687-1694. [PMID: 32426899 PMCID: PMC7687275 DOI: 10.1111/1471-0528.16323] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine the performance of a glycosylated fibronectin (GlyFn) point-of-care (POC) test for pre-eclampsia (PE) in a large Southeast Asian cohort (India) in comparison to previously described biomarkers. DESIGN A total of 798 pregnant women at ≥20 weeks of gestation were enrolled in a prospective case-control study. Study participants included 469 normotensive women with urinary mg protein/mmol creatinine ratio <0.3, 135 with PE (hypertension with urinary mg protein/mmol creatinine ratio ≥0.3) and 194 with gestational hypertension (hypertension with urinary mg protein/mmol creatinine ratio <0.3). METHODS GlyFn levels were determined using a POC device and PIGF, sFlt-1 and PAPPA2 levels were determined by immunoassay. Performance was assessed using logistic regression modelling and receiver-operating characteristic (ROC) curves. Classification performance and positive and negative predictive values are reported at specific thresholds. RESULTS Increased levels of GlyFn, soluble fms-like tyrosine kinase-1 (sFlt-1) and pregnancy-associated placental protein A2 (PAPPA2), and decreased levels of placental growth factor (PlGF) were significantly associated (P < 0.01) with clinically defined PE. Area under the ROC (AUROC) values with 95% confidence intervals were: GlyFn, 0.99 (0.98-0.99); PlGF, 0.96 (0.94-0.98); sFlt-1, 0.86 (0.83-0.89); and PAPPA2, 0.96 (0.94-0.97). Of subjects with GH, 48% were positive for more than two PE biomarkers, and 70% of these delivered preterm. CONCLUSIONS The Lumella™ GlyFn POC test has been validated in a low/middle-income country setting for PE diagnosis and may be a useful adjunctive tool for early identification, appropriate triage, and improved outcomes. TWEETABLE ABSTRACT The Lumella™ point-of-care test had excellent performance in diagnosing PE in a large Southeast Asian cohort.
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Affiliation(s)
| | - V Janaki
- Department of Obstetrics and GynaecologyOsmania Medical CollegeHyderabadIndia
| | - AR Vijayalakshmi
- Department of Obstetrics and GynaecologyMallareddy Institute of Medical SciencesHyderabadIndia
| | | | - D Pratibha
- Department of Obstetrics and GynaecologyOsmania Medical CollegeHyderabadIndia
| | - PV Rao
- DiabetOmics, Inc.HillsboroORUSA
| | - KM Sage
- DiabetOmics, Inc.HillsboroORUSA
| | | | - E Bean
- DiabetOmics, Inc.HillsboroORUSA
| | | | - MG Gravett
- Department of Obstetrics and GynecologyUniversity of WashingtonSeattleWAUSA
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Nkamba DM, Vangu R, Elongi M, Magee LA, Wembodinga G, Bernard P, Ditekemena J, Robert A. Health facility readiness and provider knowledge as correlates of adequate diagnosis and management of pre-eclampsia in Kinshasa, Democratic Republic of Congo. BMC Health Serv Res 2020; 20:926. [PMID: 33028310 PMCID: PMC7542875 DOI: 10.1186/s12913-020-05795-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/01/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hypertensive disorders in pregnancy are the second most common cause of maternal mortality in the Democratic Republic of Congo (DRC), accounting for 23% of maternal deaths. This study aimed to assess facility readiness, and providers' knowledge to prevent, diagnose, and treat pre-eclampsia. METHODS A facility-based cross-sectional study was conducted in 30 primary health centres (PHCs) and 28 referral facilities (hospitals) randomly selected in Kinshasa, DRC. In each facility, all midwives and physicians involved in maternal care provision (n = 197) were included. Data on facility infrastructure and providers' knowledge about pre-eclampsia were collected using facility checklists and a knowledge questionnaire. Facility readiness score was defined as the sum of 13 health commodities needed to manage pre-eclampsia. A knowledge score was defined as the sum of 24 items about the diagnosis, management, and prevention of pre-eclampsia. The score ranges from 0 to 24, with higher values reflecting a better knowledge. The Mann-Witney U test was used to compare median readiness scores by facility type and ownership; and median knowledge scores between midwives in hospitals and in PHCs, and between physicians in hospitals and in PHCs. RESULTS Overall, health facilities had 7 of the 13 commodities, yielding a median readiness score of 53.8%(IQR: 46.2 to 69.2%). Although all provider groups had significant knowledge gaps about pre-eclampsia, providers in hospitals demonstrated slightly more knowledge than those in PHCs. Midwives in public facilities scored higher than those in private facilities (median(IQR): 8(5 to 12) vs 7(4 to 8), p = 0.03). Of the 197 providers, 91.4% correctly diagnosed severe pre-eclampsia. However, 43.9 and 82.2% would administer magnesium sulfate and anti-hypertensive drugs to manage severe pre-eclampsia, respectively. Merely 14.2 and 7.1% of providers were aware of prophylactic use of aspirin and calcium to prevent pre-eclampsia, respectively. CONCLUSION Our study showed poor availability of supplies to diagnose, prevent and treat pre-eclampsia in Kinshasa. While providers demonstrated good knowledge regarding the diagnosis of pre-eclampsia, they have poor knowledge regarding its prevention and management. The study highlights the need for strengthening knowledge of providers toward the prevention and management of pre-eclampsia, and enhancing the availability of supplies needed to address this disease.
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Affiliation(s)
- Dalau Mukadi Nkamba
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo.
- Pôle d'Épidémiologie et Biostatistique, Université catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Clos Chapelle-aux-champs, 30 bte B1.30.13, 1200, Brussels, Belgium.
| | - Roland Vangu
- Department of Gynecology and Obstetrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Moyene Elongi
- Department of Gynecology and Obstetrics, University Clinics of Kinshasa, Kinshasa, Democratic Republic of Congo
- Department of Gynecology and Obstetrics, Provincial General Hospital of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Laura A Magee
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK
| | - Gilbert Wembodinga
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Pierre Bernard
- Pôle de Gynécologie et Obstétrique, Université Catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Brussels, Belgium
| | - John Ditekemena
- Kinshasa School of Public Health, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of Congo
| | - Annie Robert
- Pôle d'Épidémiologie et Biostatistique, Université catholique de Louvain (UCLouvain), Institut de Recherche Expérimentale et Clinique (IREC), Clos Chapelle-aux-champs, 30 bte B1.30.13, 1200, Brussels, Belgium
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Springer S, Polterauer M, Stammler-Safar M, Zeisler H, Leipold H, Worda C, Worda K. Notching and Pulsatility Index of the Uterine Arteries and Preeclampsia in Twin Pregnancies. J Clin Med 2020; 9:jcm9082653. [PMID: 32824222 PMCID: PMC7465290 DOI: 10.3390/jcm9082653] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 08/04/2020] [Accepted: 08/10/2020] [Indexed: 12/02/2022] Open
Abstract
Increased uterine artery Doppler indices have been shown to be associated with preeclampsia and adverse pregnancy outcomes in singleton and twin pregnancies. At 20–22 weeks of gestation, we assessed the use of notching, the highest, lowest, and mean pulsatility index (PI), and the combination of notching and PI of the uterine arteries to screen for preeclampsia. This was done in a cohort of 380 twin pregnancies. The results showed that the combination of notching and the highest PI above the 95th centile of the uterine arteries gives the best screening characteristics for preeclampsia in twin pregnancies. We calculated sensitivities for preeclampsia for notching, highest PI, and the combination of notching and the highest PI of 50%, 45% and 91%, with specificities of 96%, 96% and 93%, respectively. The present findings demonstrate that notching, increased highest PI, and the combination of notching and the highest PI of the uterine arteries is associated with an increased risk of preeclampsia in twin pregnancies. We observed the highest sensitivity and specificity by using the combination of notching and the highest PI of the uterine arteries.
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Affiliation(s)
- Stephanie Springer
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Mariella Polterauer
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Maria Stammler-Safar
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Harald Zeisler
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
| | - Heinz Leipold
- Department of Obstetrics and Gynecology, Landeskrankenhaus Klagenfurt, 9020 Klagenfurt am Wörthersee, Austria;
| | - Christof Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
- Correspondence: ; Tel.: +43-1-40400-28220
| | - Katharina Worda
- Department of Obstetrics and Gynecology, Medical University of Vienna, 1090 Vienna, Austria; (S.S.); (M.P.); (M.S.-S.); (H.Z.); (K.W.)
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Wilson RD. The Real Maternal Risks in a Pregnancy: A Structured Review to Enhance Maternal Understanding and Education. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 42:1364-1378.e7. [PMID: 32712227 DOI: 10.1016/j.jogc.2019.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/04/2019] [Accepted: 12/06/2019] [Indexed: 10/23/2022]
Abstract
This review sought to use high-level published data sources for system knowledge translation, collaborative enhanced maternal education and understanding, and prospective maternal quality and safety care planning. The goal was to answer the following question: What are the short- and long-term maternal risks ("near misses," adverse events, severe morbidity and mortality) associated with pregnancy and childbirth? A structured analysis of the literature (systematic review, meta-analysis, observational case-control cohort), focusing on publications between 2016 and April 2019, was undertaken using the following key word search strategy: maternal, morbidity, mortality, co-morbidities (BMI, fertility, hypertension, cardiac, chronic renal disease, diabetes, mental health, stroke), preconception, antepartum, intrapartum, postpartum, "near miss," and adverse events. Only large cohort database sources with control comparison studies were accepted for inclusion because maternal mortality events are rare. Systematic review and meta-analysis were not undertaken because of the wide clinical scope and the goal of creating an education algorithm tool. For this educational tool, the results were presented in a counselling format that included a control group of common maternal morbidity from a regional maternity cohort (2017) of 54 000 births and published risk estimates for pre-conception, pregnancy-associated comorbidity, pregnancy-onset conditions, long-term maternal health associations, and maternal mortality scenarios. Because issues related to maternal comorbidities are increasing in prevalence, personalized pre-conception education on maternal pregnancy risk estimates needs to be encouraged and available to promote greater understanding. This maternal morbidity and mortality evaluation tool allows for patient-provider review and recognition of the possible leading factors associated with an increased risk of maternal morbidity: pre-conception risks (maternal age >45 years; pre-existing cardiac or hypertensive conditions) and pregnancy-obstetrical risks (gestational hypertension, preeclampsia, eclampsia; caesarean delivery, whether preterm or term; operative vaginal delivery; maternal sepsis; placenta accreta spectrum; and antepartum or postpartum hemorrhage).
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Affiliation(s)
- R Douglas Wilson
- Department of Obstetrics and Gynecology, Cumming School of Medicine, University of Calgary, Calgary, AB.
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Bij de Weg JM, Abheiden CNH, de Boer MA, de Groot C, de Vries JIP. Patients' perspective on aspirin during pregnancy: a survey. Hypertens Pregnancy 2020; 39:371-378. [PMID: 32564638 DOI: 10.1080/10641955.2020.1777299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE To elucidate patients' knowledge and counseling perspective on aspirin reducing the risk of hypertensive disorders of pregnancy (HDP). METHODS A quantitative survey was performed including women who are members of the patient orgasnization Dutch HELLP Foundation due to a history of HDP. RESULTS Awareness of the risk-reducing effect of aspirin on HDP was present in 51.9% of the 189 women. The majority was informed by their gynecologist (89.8%) and preferred to be informed by a gynecologist (79.4%), at the postpartum checkup (42.3%) or in the consecutive pregnancy (30.7%), both orally and written (62.4%). CONCLUSION Half of the women with a history of HDP were aware of the risk-reducing effect of aspirin in a consecutive pregnancy.
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Affiliation(s)
- Jeske M Bij de Weg
- Department of Obstetrics and Gynecology, Reproduction and Development, Amsterdam UMC, Location VUmc Amsterdam , Amsterdam, The Netherlands
| | - Carolien N H Abheiden
- Department of Obstetrics and Gynecology, Reproduction and Development, Amsterdam UMC, Location VUmc Amsterdam , Amsterdam, The Netherlands
| | - Marjon A de Boer
- Department of Obstetrics and Gynecology, Reproduction and Development, Amsterdam UMC, Location VUmc Amsterdam , Amsterdam, The Netherlands
| | | | - Johanna I P de Vries
- Department of Obstetrics and Gynecology, Reproduction and Development, Amsterdam UMC, Location VUmc Amsterdam , Amsterdam, The Netherlands
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Shub A, Lappas M. Pregestational diabetes in pregnancy: Complications, management, surveillance, and mechanisms of disease-A review. Prenat Diagn 2020; 40:1092-1098. [PMID: 32333803 DOI: 10.1002/pd.5718] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Revised: 03/12/2020] [Accepted: 04/20/2020] [Indexed: 12/16/2022]
Abstract
Diabetes is an increasingly common diagnosis among pregnant women. Pregestational diabetes is associated with an increase in many adverse pregnancy outcomes, which impact both on the woman and her fetus. The models of pregnancy care for women with diabetes are based largely on observational data or consensus opinion. Strategies for aneuploidy screening and monitoring for fetal well-being should be modified in women with diabetes. There is an increasing understanding of the mechanisms by which congenital anomalies and disorders of fetal growth occur, involving epigenetic modifications, changes in gene expression in critical developmental pathways, and oxidative stress. This knowledge may lead to pathways for improved care for these high-risk pregnancies.
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Affiliation(s)
- Alexis Shub
- Department of Obstetrics and Gynecology, University of Melbourne, Parkville, Australia.,Perinatal Department, Mercy Hospital for Women, Heidelberg, Australia
| | - Martha Lappas
- Department of Obstetrics and Gynecology, University of Melbourne, Parkville, Australia
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Gu W, Lin J, Hou YY, Lin N, Song MF, Zeng WJ, Shang J, Huang HF. Effects of low-dose aspirin on the prevention of preeclampsia and pregnancy outcomes: A randomized controlled trial from Shanghai, China. Eur J Obstet Gynecol Reprod Biol 2020; 248:156-163. [PMID: 32217429 DOI: 10.1016/j.ejogrb.2020.03.038] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To evaluate the preventive effects of low-dose aspirin on the incidence of preeclampsia and pregnancy outcomes of women at high-risk for preeclampsia. STUDY DESIGN This prospective randomized clinical trial was conducted at the Obstetrics Department of The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, China. It analyzed data from 1105 high-risk women who were divided into the control group (placebo group) and the aspirin group (including three subgroups: 25 mg, 50 mg and 75 mg). The aspirin group in this study was instructed to take aspirin daily before bedtime beginning in the 12th week of pregnancy. MAIN OUTCOME MEASURES The primary outcome is the occurrence of preeclampsia. The secondary outcomes included maternal and neonatal outcomes (such as premature delivery, FGR etc.), maternal serum biomarkers (including d-dimers, platelet aggregation rates, etc.) and uterine arterial blood flow resistance. The onset of preeclampsia and pregnancy outcomes were recorded after all participants delivered. RESULTS Low-dose aspirin significantly reduced the incidence of preeclampsia and early-onset preeclampsia. Aspirin also showed significant dose dependence in preeclampsia prevention. The results of Mantel-Haenszel trend test showed that there was a linear relationship between the dosage and the incidence of preeclampsia and early preeclampsia (P < 0.05). Pearson's results showed that the incidence of preeclampsia and early preeclampsia was negatively correlated with aspirin dosage. There was also a linear relationship between the dosage and the rates of postpartum hemorrhage, fetal growth restriction, premature births and cesarean section (P < 0.05). There was no evidence to suggest differences in the incidence of fetal distress, miscarriage and placental abruption among the four groups. The blood resistance S/D value of uterine artery in early pregnancy was the only independent factor affecting the efficacy of aspirin (OR = 1.405; 95 %CI,1.058-1.867; P = 0.019). CONCLUSION Low-dose aspirin can prevent preeclampsia and early-preeclampsia. Its efficacy is dose-dependent. It can reduce the rates of postpartum hemorrhage, fetal growth restriction, premature births and cesarean section. The prophylactic effect of aspirin on preeclampsia seemed to be greater in patients with higher blood resistance S/D value of uterine artery during early pregnancy.
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Affiliation(s)
- Wei Gu
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jing Lin
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yan-Yan Hou
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Nan Lin
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Meng-Fan Song
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Wei-Jian Zeng
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jing Shang
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - He-Feng Huang
- The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China; Shanghai Municipal Key Clinical Specialty, Shanghai, China.
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Schaller S, Knippel AJ, Verde PE, Kozlowski P. Concordance-analysis and evaluation of different diagnostic algorithms used in first trimester screening for late-onset preeclampsia. Hypertens Pregnancy 2020; 39:172-185. [PMID: 32306791 DOI: 10.1080/10641955.2020.1750627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Objective: Concordance-analysis and evaluation of existing algorithms detecting late-onset preeclampsia during first trimester screeningMethods: Retrospective cohort study investigating risk algorithms of late-onset preeclampsia during first trimester screening in a German prenatal center. Three previously developed algorithms including anamnestic factors (Apriori) and biophysical markers (BioM) were investigated by using detection rates (DR) with fixed FPR 10% and fixed cutoff >1:100. Furthermore, we set up a concordance-analysis of test results in late-onset preeclampsia cases to examine the effect of influencing factors and to detect potential weaknesses of the algorithms. Therefore, we modeled the probability of discordances as a function of the influencing factors based on a logistic regression, that was fitted using a Bayesian approach.Results: 6,113 pregnancies were considered, whereof 700 have been excluded and 5,413 pregnancies were analyzed. 98 (1.8%) patients developed preeclampsia (79 late-onsets, 19 early-onsets). The Apriori-algorithm reaches a DR of 34.2%, by adding BioM (MAP and UtA-PI) the DR improves to 57.0% (FPR of 10%). In concordance-analysis of Apriori algorithm and Apriori+BioM algorithms, influencing factor BMI<25 increases the chance of discordances sigificantly. Additional, in the subgroup of late-onset preeclampsias with BMI<25 the DR is higher in Apriori+BioM algorithms than in Apriori algorithm alone. If both compared algorithms include BioM, influencing factor MAP decreases the chance of discordances significantly. All other tested influencing factors do not have a statistically significant effect on discordancesConclusion: Normal-weight patients benefit more from the integration of MAP and UtA-PI compared to overweight/obese patients.
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Affiliation(s)
- Sabrina Schaller
- Praenatal-Medizin und Genetik Ärztliche Partnerschaftsgesellschaft Kozlowski und Partner, Düsseldorf
| | | | - Pablo Emilio Verde
- Coordination Center for Clinical Trials, Heinrich Heine University of Düsseldorf, Düsseldorf, Germany
| | - Peter Kozlowski
- Praenatal-Medizin und Genetik Ärztliche Partnerschaftsgesellschaft Kozlowski und Partner, Düsseldorf
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Gottesfeld-Hohler Memorial Foundation Risk Assessment for Early-Onset Preeclampsia in the United States: Think Tank Summary. Obstet Gynecol 2020; 135:36-45. [PMID: 31809427 DOI: 10.1097/aog.0000000000003582] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Preeclampsia is responsible for significant maternal and neonatal morbidity and is associated with a substantial economic burden. Aspirin has been shown to be effective in decreasing the risk of preterm preeclampsia; however, there is no consensus on the target population for aspirin prophylaxis. In May 2018, the Gottesfeld-Hohler Memorial Foundation organized a working group meeting with the goal of identifying the optimal preeclampsia risk-assessment strategy and consequent intervention in the United States. The meeting brought together experts from the leading professional societies. We discussed available literature and trends in preeclampsia risk assessment, current professional guidelines for identifying women at risk for preeclampsia, prophylactic use of aspirin in the United States and Europe, cost-effectiveness data, and feasibility of implementation of different assessment tools and preventive strategies in the United States. We identified specific knowledge gaps and future research directions in preeclampsia risk assessment and prevention that need to be addressed before practice change.
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Sleep Disordered Breathing, a Novel, Modifiable Risk Factor for Hypertensive Disorders of Pregnancy. Curr Hypertens Rep 2020; 22:28. [PMID: 32166454 DOI: 10.1007/s11906-020-1035-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Pathophysiology of hypertensive disorders of pregnancy (HDP), especially preeclampsia, has not been fully elucidated. Most trials aimed at the prevention of preeclampsia have failed to show significant benefit and investigation of novel, modifiable risk factors is sorely needed. Sleep disordered breathing (SDB), a group of disorders for which treatments are available, meets these criteria. SDB impacts about a third of all pregnancies and is associated with hypertension in the general non-pregnant population. RECENT FINDINGS Recent studies have shown a high prevalence of SDB, especially in complicated pregnancies. Several studies have shown that pregnant women with SDB have a higher risk for developing HDP, and these two disorders are associated with similar maternal long-term cardiovascular outcomes. Based on limited animal models of gestational intermittent hypoxia and human studies, SDB and HDP share similar risk factors and some pathophysiological mechanisms. However, there is paucity of studies addressing causality of this association and identifying therapeutic targets for intervention. Maternal SDB represents a novel and modifiable risk factor of HDP. Further studies are needed in order to establish the exact mechanisms underlying this association and to identify specific areas for clinical interventions.
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Al-Rubaie ZTA, Hudson HM, Jenkins G, Mahmoud I, Ray JG, Askie LM, Lord SJ. Prediction of pre-eclampsia in nulliparous women using routinely collected maternal characteristics: a model development and validation study. BMC Pregnancy Childbirth 2020; 20:23. [PMID: 31906891 PMCID: PMC6945640 DOI: 10.1186/s12884-019-2712-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Accepted: 12/30/2019] [Indexed: 12/17/2022] Open
Abstract
Background Guidelines recommend identifying in early pregnancy women at elevated risk of pre-eclampsia. The aim of this study was to develop and validate a pre-eclampsia risk prediction model for nulliparous women attending routine antenatal care “the Western Sydney (WS) model”; and to compare its performance with the National Institute of Health and Care Excellence (NICE) risk factor-list approach for classifying women as high-risk. Methods This retrospective cohort study included all nulliparous women who gave birth in three public hospitals in the Western-Sydney-Local-Health-District, Australia 2011–2014. Using births from 2011 to 2012, multivariable logistic regression incorporated established maternal risk factors to develop and internally validate the WS model. The WS model was then externally validated using births from 2013 to 2014, assessing its discrimination and calibration. We fitted the final WS model for all births from 2011 to 2014, and compared its accuracy in predicting pre-eclampsia with the NICE approach. Results Among 12,395 births to nulliparous women in 2011–2014, there were 293 (2.4%) pre-eclampsia events. The WS model included: maternal age, body mass index, ethnicity, multiple pregnancy, family history of pre-eclampsia, autoimmune disease, chronic hypertension and chronic renal disease. In the validation sample (6201 births), the model c-statistic was 0.70 (95% confidence interval 0.65–0.75). The observed:expected ratio for pre-eclampsia was 0.91, with a Hosmer-Lemeshow goodness-of-fit test p-value of 0.20. In the entire study sample of 12,395 births, 374 (3.0%) women had a WS model-estimated pre-eclampsia risk ≥8%, the pre-specified risk-threshold for considering aspirin prophylaxis. Of these, 54 (14.4%) developed pre-eclampsia (sensitivity 18% (14–23), specificity 97% (97–98)). Using the NICE approach, 1173 (9.5%) women were classified as high-risk, of which 107 (9.1%) developed pre-eclampsia (sensitivity 37% (31–42), specificity 91% (91–92)). The final model showed similar accuracy to the NICE approach when using lower risk-threshold of ≥4% to classify women as high-risk for pre-eclampsia. Conclusion The WS risk model that combines readily-available maternal characteristics achieved modest performance for prediction of pre-eclampsia in nulliparous women. The model did not outperform the NICE approach, but has the advantage of providing individualised absolute risk estimates, to assist with counselling, inform decisions for further testing, and consideration of aspirin prophylaxis.
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Affiliation(s)
- Ziad T A Al-Rubaie
- School of Medicine, The University of Notre Dame Australia, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia.
| | - H Malcolm Hudson
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Level 6 Medical Foundation Building, 92 Parramatta Road, Locked Bag 77, Camperdown, NSW, 2050, Australia.,Department of Statistics, Macquarie University, Level 6 Medical Foundation Building, 92 Parramatta Road, Camperdown, NSW, 2050, Australia
| | - Gregory Jenkins
- Department of Obstetrics, Westmead Hospital, Suite 110, 9 Norbrik Drive, Bella Vista, Westmead, NSW, 2153, Australia
| | - Imad Mahmoud
- Department of Obstetrics, Auburn and Mount-Druitt and Blacktown Hospitals, Suite 108, 9 Norbrik Drive, Bella Vista, NSW, 2153, Australia
| | - Joel G Ray
- Departments of Medicine, Health Policy Management and Evaluation, and Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario, M5B 1W8, Canada
| | - Lisa M Askie
- NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Level 6 Medical Foundation Building, 92 Parramatta Road, Locked Bag 77, Camperdown, NSW, 2050, Australia
| | - Sarah J Lord
- School of Medicine, The University of Notre Dame Australia, 160 Oxford Street, Darlinghurst, NSW, 2010, Australia.,NHMRC Clinical Trials Centre, Sydney Medical School, University of Sydney, Level 6 Medical Foundation Building, 92 Parramatta Road, Locked Bag 77, Camperdown, NSW, 2050, Australia
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Lakshmy S, Ziyaulla T, Rose N. The need for implementation of first trimester screening for preeclampsia and fetal growth restriction in low resource settings. J Matern Fetal Neonatal Med 2020; 34:4082-4089. [PMID: 31900014 DOI: 10.1080/14767058.2019.1704246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: Preeclampsia [PE] and fetal growth restriction [FGR] is a major cause of perinatal morbidity in both developed and developing countries but the disease leaves a severe impact in developing countries, due to the late presentation of cases where prevention and treatment becomes impossible. Routine antenatal ultrasound and health checkups in periphery are usually done in first trimester for dating and viability scan, in midtrimester for anomaly scan and in third trimester for safe confinement. Underlying disorder of deep placentation which is unidentified can lead to increased maternal morbidity and fetal compromise between 26 to 34 weeks of gestation The complications present at an irreversible stage where there is no sufficient time even for referral to tertiary care center. Frequent antenatal visits as suggested by WHO would definitely bring down maternal mortality but this increased surveillance when offered to all might be a huge burden to health care providers in low resource settings. An acceptable screening test should help in triaging the high risk group in first trimester itself targeting about only one third of the population for prophylactic therapy and increased antenatal surveillance.The objective of this study is to evaluate the performance and feasibility of different screening protocols in low resource settings.Methodology: Screening for PE and FGR was done at the 11-14 weeks aneuploidy scan as per FMF guidelines. Group I included 6289 women whose risk prediction was done with maternal characteristics [MC], mean arterial pressure [MAP] and Uterine artery Doppler [UAD]. Group II included 2067 women whose risk was predicted with MC, MAP, UAD and PAPP-A. Group III included 576 women whose risk prediction included all parameters with PLGF.Results: Two thousand five hundred fifty-seven cases were screen positive in group I and 602 were screen positive in group II. In group III which included PLGF, 24 were positive for early onset PE and 36 for late onset PE. The number needed to treat [NNT] was 35.9, 29.1 and 10% in Group I, II and III respectively. The detection rate [DR] for PE and FGR was 60% in Group I and DR for FGR in Group II was 85%. In Group III, for early onset PE the DR was 98% and 68% for late onset PE.Conclusion: Screening for PE with available resources in the periphery needs to be implemented to avoid its grave complications. Traditional screening for PE by NICE guidelines can be adopted but may have a detection rate of only 30-40%. Though screening by ACOG criteria may have good detection rates but more than two thirds of the population would become screen positive which nullifies this approach as a good screening methodology in low resource settings. Multiparametric approach for screening in first trimester serves as a better screening tool to enable higher detection rate of disease with least false positive rates. Uterine artery Doppler when combined with maternal characteristics and mean arterial pressure could achieve a detection rate of about 60% and would still target only one third of the population for increased antenatal surveillance. This requires training healthcare professionals in the periphery for this approach and this should be our prime focus in the current scenario. Inclusion of serum biochemistry would still bring down the target population to 10% and increase the DR and can be considered as an additional test in economically feasible population. In low resource settings a better screening approach to PE would be a combination of maternal history, biophysical or biochemical parameters whichever is feasible considering the economy and availability of resources.
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Affiliation(s)
| | | | - Nity Rose
- Shri Lakshmi Clinic and Scan Centre, Kaveripattinam, India
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Poon LC, Galindo A, Surbek D, Chantraine F, Stepan H, Hyett J, Tan KH, Verlohren S. From first-trimester screening to risk stratification of evolving pre-eclampsia in second and third trimesters of pregnancy: comprehensive approach. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:5-12. [PMID: 31503374 DOI: 10.1002/uog.21869] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 08/30/2019] [Indexed: 06/10/2023]
Affiliation(s)
- L C Poon
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - A Galindo
- Fetal Medicine Unit - Maternal and Child Health and Development Network, Department of Obstetrics and Gynaecology, University Hospital 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre, Universidad Complutense de Madrid, Madrid, Spain
| | - D Surbek
- Department of Obstetrics and Gynecology, Inselspital Bern University Hospital, University of Bern, Bern, Switzerland
| | - F Chantraine
- Department of Obstetrics and Gynecology, CHR Citadelle, CHU Liege, Liege, Belgium
| | - H Stepan
- Department of Obstetrics, University Hospital Leipzig, Leipzig, Germany
| | - J Hyett
- Department of Women and Babies, Royal Prince Alfred Hospital, Sydney, Australia
| | - K H Tan
- KK Women's and Children's Hospital, Singapore
| | - S Verlohren
- Department of Obstetrics, Charité - Universitätsmedizin Berlin, Berlin, Germany
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40
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Choorakuttil RM, Patel H, Bavaharan R, Devarajan P, Kanhirat S, Shenoy RS, Tiwari OP, Sodani RK, Sharma LK, Nirmalan PK. Samrakshan: An Indian Radiological and Imaging Association program to reduce perinatal mortality in India. Indian J Radiol Imaging 2019; 29:412-417. [PMID: 31949344 PMCID: PMC6958882 DOI: 10.4103/ijri.ijri_386_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 09/19/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022] Open
Abstract
Context: India has a high perinatal mortality rate. The Indian Radiological and Imaging Association (IRIA) is supplementing efforts to address perinatal mortality in India through the Samrakshan program. Aims: To describe various elements of the Samrakshan program that aims to reduce perinatal mortality in India. Methods: Samrakshan focuses on two priority areas, preeclampsia (PE) and fetal growth restriction (FGR). Samrakshan aims at technical skill upgradation, specifically focused on improved interpretative ability, prognostic and therapeutic efficacy using Doppler studies, a free online learning platform and offline continuous medical educations (CMEs), building an evidence base from the program to develop policy and guidelines, and improving synergy with the RAKSHA program of IRIA and other fetal care stakeholders. Results: Two courses on Doppler studies focused on first trimester and third trimester, supplemented by case discussions and journal articles, have started on the online platform with 230 registrants. The first statewide CME was held at Indore. Samrakshan screening identified 10 (17.24%, 95% CI: 8.59, 29.43) women at high risk for preterm PE and 29 (50.00%, 95% CI 36.58, 63.42) women at high risk for FGR in the first trimester. Ten fetuses (7.63%, 95% CI: 3.72, 13.59) including 9 with stage 1 FGR were identified in the third-trimester screening. Conclusions: Samrakshan is a flagship program of IRIA that aims to reduce perinatal mortality in India through a synergistic, holistic approach that complements and supplements existing efforts in India.
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Affiliation(s)
- Rijo M Choorakuttil
- National Coordinator for Samrakshan IRIA, AMMA Center for Diagnosis and Preventive Medicine, Kochi, Kerala, India
| | - Hemant Patel
- Indian Radiological and Imaging Association, Gujarat Imaging Center, Navrangpura, Ahmedabad, Gujarat, India
| | | | | | - Saneej Kanhirat
- Department of Radiology, Starcare Hospital, Kozhikode, Kerala, India
| | - Ramesh S Shenoy
- Consultant Radiologist, Lisie Hospital, Ernakulam, Kerala, India
| | - Om P Tiwari
- Consultant Radiologist and Director, Jyothi Hospital, Vijay Nagar, Indore, Madhya Pradesh, India
| | - Rajendra K Sodani
- Consultant Radiologist and Director, Sampurna Sodani Diagnostic Clinic, LG-1, Morya Center, Indore, Madhya Pradesh, India
| | - Lalit K Sharma
- Raj Sonography and X-Ray Clinic, Baiju Choraha, Nayapura, Guna, Madhya Pradesh, India
| | - Praveen K Nirmalan
- Chief Research Mentor, AMMA Education Research Foundation, Kochi, Kerala, India
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43
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Wertaschnigg D, Reddy M, Mol BWJ, Rolnik DL, da Silva Costa F. Prenatal screening for pre-eclampsia: Frequently asked questions. Aust N Z J Obstet Gynaecol 2019; 59:477-483. [PMID: 31119729 PMCID: PMC6767595 DOI: 10.1111/ajo.12982] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/22/2019] [Indexed: 12/29/2022]
Abstract
The current approach to screening for pre-eclampsia is based on guidelines that rely on medical and obstetric history in early pregnancy to select a high-risk group that might benefit from low-dose aspirin. However, combined screening tests with the addition of biophysical and biochemical measurements have shown significantly better detection rates for preterm pre-eclampsia. Furthermore, the administration of aspirin for the 10% screen-positive group can lead to a significant reduction in severe and preterm forms of pre-eclampsia. This review aims to answer frequently asked questions related to the clinical implementation of screening and the management of screening results.
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Affiliation(s)
- Dagmar Wertaschnigg
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynecology, Paracelsus Medical University, Salzburg, Austria
| | - Maya Reddy
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Ben W J Mol
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Daniel L Rolnik
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Fabricio da Silva Costa
- Department of Obstetrics and Gynaecology, Monash University, Melbourne, Victoria, Australia.,Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
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Rezende KBDC, Cunha AJLAD, Amim Junior J, Bornia RG. External validation of the Fetal Medicine Foundation algorithm for the prediction of preeclampsia in a Brazilian population. Pregnancy Hypertens 2019; 17:64-68. [PMID: 31487659 DOI: 10.1016/j.preghy.2019.05.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 02/18/2019] [Accepted: 05/08/2019] [Indexed: 01/27/2023]
Affiliation(s)
- Karina Bilda de Castro Rezende
- Maternidade Escola da Universidade Federal do Rio de Janeiro, Brazil; Professional Masters Program of Perinatal Health, Brazil; Faculdade de Medicina da, Universidade Federal do Rio de Janeiro, Brazil.
| | - Antônio José Ledo Alves da Cunha
- Faculdade de Medicina da, Universidade Federal do Rio de Janeiro, Brazil; Laboratório Multidisciplinar de Epidemiologia e Saúde-LAMPES, UFRJ, Brazil
| | - Joffre Amim Junior
- Maternidade Escola da Universidade Federal do Rio de Janeiro, Brazil; Professional Masters Program of Perinatal Health, Brazil; Faculdade de Medicina da, Universidade Federal do Rio de Janeiro, Brazil
| | - Rita Guérios Bornia
- Maternidade Escola da Universidade Federal do Rio de Janeiro, Brazil; Professional Masters Program of Perinatal Health, Brazil; Faculdade de Medicina da, Universidade Federal do Rio de Janeiro, Brazil
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Kadji C, Cannie MM, Resta S, Guez D, Abi-Khalil F, De Angelis R, Jani JC. Magnetic resonance imaging for prenatal estimation of birthweight in pregnancy: review of available data, techniques, and future perspectives. Am J Obstet Gynecol 2019; 220:428-439. [PMID: 30582928 DOI: 10.1016/j.ajog.2018.12.031] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 12/14/2018] [Accepted: 12/17/2018] [Indexed: 12/20/2022]
Abstract
Fetuses at the extremes of growth abnormalities carry a risk of perinatal morbidity and death. Their identification traditionally is done by 2-dimensional ultrasound imaging, the performance of which is not always optimal. Magnetic resonance imaging superbly depicts fetal anatomy and anomalies and has contributed largely to the evaluation of high-risk pregnancies. In 1994, magnetic resonance imaging was introduced for the estimation of fetal weight, which is done by measuring the fetal body volume and converting it through a formula to fetal weight. Approximately 10 studies have shown that magnetic resonance imaging is more accurate than 2-dimensional ultrasound imaging in the estimation of fetal weight. Yet, despite its promise, the magnetic resonance imaging technique currently is not implemented clinically. Over the last 5 years, this technique has evolved quite rapidly. Here, we review the literature data, provide details of the various measurement techniques and formulas, consider the application of the magnetic resonance imaging technique in specific populations such as patients with diabetes mellitus and twin pregnancies, and conclude with what we believe could be the future perspectives and clinical application of this challenging technique. The estimation of fetal weight by ultrasound imaging is based mainly on an algorithm that takes into account the measurement of biparietal diameter, head circumference, abdominal circumference, and femur length. The estimation of fetal weight by magnetic resonance imaging is based on one of the 2 formulas: (1) magnetic resonance imaging-the estimation of fetal weight (in kilograms)=1.031×fetal body volume (in liters)+0.12 or (2) magnetic resonance imaging-the estimation of fetal weight (in grams)=1.2083×fetal body volume (in milliliters)ˆ0.9815. Comparison of these 2 formulas for the detection of large-for-gestational age neonates showed similar performance for preterm (P=.479) and for term fetuses (P=1.000). Literature data show that the estimation of fetal weight with magnetic resonance imaging carries a mean or median relative error of 2.6 up to 3.7% when measurements were performed at <1 week from delivery; whereas for the same fetuses, the relative error at 2-dimensional ultrasound imaging varied between 6.3% and 11.4%. Further, in a series of 270 fetuses who were evaluated within 48 hours from birth and for a fixed false-positive rate of 10%, magnetic resonance imaging detected 98% of large-for-gestational age neonates (≥95th percentile for gestation) compared with 67% with ultrasound imaging estimates. For the same series, magnetic resonance imaging applied to the detection of small-for-gestational age neonates ≤10th percentile for gestation, for a fixed 10% false-positive rate, reached a detection rate of 100%, compared with only 78% for ultrasound imaging. Planimetric measurement has been 1 of the main limitations of magnetic resonance imaging for the estimation of fetal weight. Software programs that allow semiautomatic segmentation of the fetus are available from imaging manufacturers or are self-developed. We have shown that all of them perform equally well for the prediction of large-for-gestational age neonates, with the advantage of the semiautomatic methods being less time-consuming. Although many challenges remain for this technique to be generalized, a 2-step strategy after the selection of a group who are at high risk of the extremes of growth abnormalities is the most likely scenario. Results of ongoing studies are awaited (ClinicalTrials.gov Identifier # NCT02713568).
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Affiliation(s)
- Caroline Kadji
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - Mieke M Cannie
- Department of Radiology, University Hospital Brugmann, Brussels, Belgium; Department of Radiology, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium
| | - Serena Resta
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | - David Guez
- Advanced Technology Center, Sheba Tel Hashomer Hospital, Ramat Gan, Israel
| | - Fouad Abi-Khalil
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Jacques C Jani
- Department of Obstetrics and Gynecology, University Hospital Brugmann, Université Libre de Bruxelles, Brussels, Belgium.
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Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, McAuliffe F, da Silva Costa F, von Dadelszen P, McIntyre HD, Kihara AB, Di Renzo GC, Romero R, D’Alton M, Berghella V, Nicolaides KH, Hod M. The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention. Int J Gynaecol Obstet 2019; 145 Suppl 1:1-33. [PMID: 31111484 PMCID: PMC6944283 DOI: 10.1002/ijgo.12802] [Citation(s) in RCA: 676] [Impact Index Per Article: 112.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.
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Affiliation(s)
- Liona C. Poon
- Department of Obstetrics and Gynaecology, The Chinese
University of Hong Kong
| | - Andrew Shennan
- Department of Women and Children’s Health, FoLSM,
Kings College London
| | | | | | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Fionnuala McAuliffe
- Department of Obstetrics and Gynaecology, National
Maternity Hospital Dublin, Ireland
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão
Preto Medical School, University of São Paulo, Ribeirão Preto,
São Paulo, Brazil
| | | | | | - Anne B. Kihara
- African Federation of Obstetrics and Gynaecology,
Africa
| | - Gian Carlo Di Renzo
- Centre of Perinatal & Reproductive Medicine
Department of Obstetrics & Gynaecology University of Perugia, Perugia,
Italy
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and
Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy
Shriver National Institute of Child Health and Human Development,
National Institutes of Health, U. S. Department of Health and Human Services,
Bethesda, Maryland, and Detroit, Michigan, USA
| | - Mary D’Alton
- Society for Maternal-Fetal Medicine, Washington, DC,
USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson
University, Philadelphia, PA, USA
| | | | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Atallah A, Lecarpentier E, Goffinet F, Gaucherand P, Doret-Dion M, Tsatsaris V. [Aspirin and preeclampsia]. Presse Med 2019; 48:34-45. [PMID: 30665790 DOI: 10.1016/j.lpm.2018.11.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2018] [Revised: 08/02/2018] [Accepted: 11/27/2018] [Indexed: 10/27/2022] Open
Abstract
Indications for aspirin during pregnancy are a matter of debate and there is a recent trend to an extended prescription and an overuse of aspirin in pregnancy. Aspirin is efficient in secondary prevention of preeclampsia essentially in patients with a personal history of preeclampsia. The effect of aspirin on platelet aggregation and on the TXA2/PGI2 balance is dose-dependent. The optimum dosage, from 75mg/day to 150mg/day, needs to be determined. Fetal safety data at 150mg/day are still limited. The efficacy of aspirin seems to be subject to a chronobiological effect. It is recommended to prescribe an evening or bedtime intake. Aspirin, in primary prevention of preeclampsia, given to high-risk patients identified in the first trimester by screening tests, seems to reduce the occurrence of early-onset preeclampsia. Nevertheless, there are insufficient data for the implementation of such screening procedures in practice.
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Affiliation(s)
- Anthony Atallah
- Groupement hospitalier Est, centre hospitalier universitaire, département de gynécologie-obstétrique, maternité de l'hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69100 Bron, France; Université Claude-Bernard Lyon1, Lyon, France.
| | - Edouard Lecarpentier
- Centre hospitalier intercommunal de Créteil, centre hospitalier universitaire, université Paris Est Créteil, département de gynécologie-obstétrique, maternité de l'hôpital intercommunal de Créteil, 40, avenue de Verdun, 94000 Créteil, France
| | - François Goffinet
- Assistance publique-Hôpital de Paris, centre hospitalier universitaire Cochin Broca Hôtel-Dieu, groupe hospitalier universitaire Ouest, département de gynécologie-obstétrique, maternité de Port-Royal, 53, avenue de l'Observatoire, 75014 Paris, France; PRES Sorbonne Paris Cité, université Paris Descartes, Paris, France; Fondation PremUP, Paris, France; DHU Risques et grossesse, Paris, France
| | - Pascal Gaucherand
- Groupement hospitalier Est, centre hospitalier universitaire, département de gynécologie-obstétrique, maternité de l'hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69100 Bron, France; Université Claude-Bernard Lyon1, Lyon, France
| | - Muriel Doret-Dion
- Groupement hospitalier Est, centre hospitalier universitaire, département de gynécologie-obstétrique, maternité de l'hôpital Femme-Mère-Enfant, hospices civils de Lyon, 59, boulevard Pinel, 69100 Bron, France; Université Claude-Bernard Lyon1, Lyon, France
| | - Vassilis Tsatsaris
- Assistance publique-Hôpital de Paris, centre hospitalier universitaire Cochin Broca Hôtel-Dieu, groupe hospitalier universitaire Ouest, département de gynécologie-obstétrique, maternité de Port-Royal, 53, avenue de l'Observatoire, 75014 Paris, France; PRES Sorbonne Paris Cité, université Paris Descartes, Paris, France; Fondation PremUP, Paris, France; DHU Risques et grossesse, Paris, France
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Fleiss B, Wong F, Brownfoot F, Shearer IK, Baud O, Walker DW, Gressens P, Tolcos M. Knowledge Gaps and Emerging Research Areas in Intrauterine Growth Restriction-Associated Brain Injury. Front Endocrinol (Lausanne) 2019; 10:188. [PMID: 30984110 PMCID: PMC6449431 DOI: 10.3389/fendo.2019.00188] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Accepted: 03/06/2019] [Indexed: 12/16/2022] Open
Abstract
Intrauterine growth restriction (IUGR) is a complex global healthcare issue. Concerted research and clinical efforts have improved our knowledge of the neurodevelopmental sequelae of IUGR which has raised the profile of this complex problem. Nevertheless, there is still a lack of therapies to prevent the substantial rates of fetal demise or the constellation of permanent neurological deficits that arise from IUGR. The purpose of this article is to highlight the clinical and translational gaps in our knowledge that hamper our collective efforts to improve the neurological sequelae of IUGR. Also, we draw attention to cutting-edge tools and techniques that can provide novel insights into this disorder, and technologies that offer the potential for better drug design and delivery. We cover topics including: how we can improve our use of crib-side monitoring options, what we still need to know about inflammation in IUGR, the necessity for more human post-mortem studies, lessons from improved integrated histology-imaging analyses regarding the cell-specific nature of magnetic resonance imaging (MRI) signals, options to improve risk stratification with genomic analysis, and treatments mediated by nanoparticle delivery which are designed to modify specific cell functions.
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Affiliation(s)
- Bobbi Fleiss
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, United Kingdom
- *Correspondence: Bobbi Fleiss
| | - Flora Wong
- The Ritchie Centre, Hudson Institute of Medical Research, Clayton, VIC, Australia
- Department of Paediatrics, Monash University, Clayton, VIC, Australia
- Monash Newborn, Monash Children's Hospital, Clayton, VIC, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, Mercy Hospital for Women, University of Melbourne, Heidelberg, VIC, Australia
| | - Isabelle K. Shearer
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Olivier Baud
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Division of Neonatal Intensive Care, University Hospitals of Geneva, Children's Hospital, University of Geneva, Geneva, Switzerland
| | - David W. Walker
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
| | - Pierre Gressens
- NeuroDiderot, INSERM, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
- Centre for the Developing Brain, School of Biomedical Engineering and Imaging Sciences, King's College London, St Thomas' Hospital, London, United Kingdom
- PremUP, Paris, France
| | - Mary Tolcos
- School of Health and Biomedical Sciences, RMIT University, Bundoora, VIC, Australia
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Al-Rubaie ZT, Askie LM, Hudson HM, Ray JG, Jenkins G, Lord SJ. Assessment of NICE and USPSTF guidelines for identifying women at high risk of pre-eclampsia for tailoring aspirin prophylaxis in pregnancy: An individual participant data meta-analysis. Eur J Obstet Gynecol Reprod Biol 2018; 229:159-166. [DOI: 10.1016/j.ejogrb.2018.08.587] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2018] [Revised: 08/29/2018] [Accepted: 08/31/2018] [Indexed: 02/01/2023]
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50
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Reddy M, Springhall EA, Rolnik DL, da Silva Costa F. How to perform first trimester combined screening for pre-eclampsia. Australas J Ultrasound Med 2018; 21:191-197. [DOI: 10.1002/ajum.12111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Affiliation(s)
- Maya Reddy
- Perinatal Services; Monash Medical Centre; 246 Clayton Road Clayton Victoria Australia
- Department of Obstetrics and Gynaecology; Monash University; 246 Clayton Road Clayton Victoria Australia
| | | | - Daniel Lorber Rolnik
- Perinatal Services; Monash Medical Centre; 246 Clayton Road Clayton Victoria Australia
| | - Fabricio da Silva Costa
- Perinatal Services; Monash Medical Centre; 246 Clayton Road Clayton Victoria Australia
- Department of Obstetrics and Gynaecology; Monash University; 246 Clayton Road Clayton Victoria Australia
- Monash Ultrasound for Women; Melbourne Victoria Australia
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