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Velazquez-Cervantes MA, López-Ortega O, Cruz-Holguín VJ, Herrera Moro-Huitron L, Flores-Pliego A, Lara-Hernandez I, Comas-García M, Villavicencio-Carrisoza O, Helguera-Reppeto AC, Arévalo-Romero H, Vázquez-Martínez ER, León-Juárez M. Metformin Inhibits Zika Virus Infection in Trophoblast Cell Line. Curr Microbiol 2024; 81:133. [PMID: 38592489 DOI: 10.1007/s00284-024-03651-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 02/26/2024] [Indexed: 04/10/2024]
Abstract
Zika virus (ZIKV) infections have been associated with severe clinical outcomes, which may include neurological manifestations, especially in newborns with intrauterine infection. However, licensed vaccines and specific antiviral agents are not yet available. Therefore, a safe and low-cost therapy is required, especially for pregnant women. In this regard, metformin, an FDA-approved drug used to treat gestational diabetes, has previously exhibited an anti-ZIKA effect in vitro in HUVEC cells by activating AMPK. In this study, we evaluated metformin treatment during ZIKV infection in vitro in a JEG3-permissive trophoblast cell line. Our results demonstrate that metformin affects viral replication and protein synthesis and reverses cytoskeletal changes promoted by ZIKV infection. In addition, it reduces lipid droplet formation, which is associated with lipogenic activation of infection. Taken together, our results indicate that metformin has potential as an antiviral agent against ZIKV infection in vitro in trophoblast cells.
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Affiliation(s)
- Manuel Adrían Velazquez-Cervantes
- Laboratorio de Virología Perinatal y Diseño Molecular de Antigenos y Biomarcadores, Departamento de Inmunobioquimica, Instituto Nacional de Perinatología, 11000, Mexico City, Mexico
| | - Orestes López-Ortega
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, Institut Necker Enfants Malades, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Victor Javier Cruz-Holguín
- Laboratorio de Virología Perinatal y Diseño Molecular de Antigenos y Biomarcadores, Departamento de Inmunobioquimica, Instituto Nacional de Perinatología, 11000, Mexico City, Mexico
| | - Luis Herrera Moro-Huitron
- Laboratorio de Virología Perinatal y Diseño Molecular de Antigenos y Biomarcadores, Departamento de Inmunobioquimica, Instituto Nacional de Perinatología, 11000, Mexico City, Mexico
| | - Arturo Flores-Pliego
- Departamento de Inmunobioquimica, Instituto Nacional de Perinatología, 11000, Mexico City, Mexico
| | - Ignacio Lara-Hernandez
- Sección de Microscopía de Alta Resolución, Centro de Investigación en Ciencias de la Salud y Biomedicina, Universidad Atunóma de San Luis Potrosí, San Luis Potosí, SLP, Mexico
- Facultad de Ciencias, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, Mexico
| | - Mauricio Comas-García
- Sección de Microscopía de Alta Resolución, Centro de Investigación en Ciencias de la Salud y Biomedicina, Universidad Atunóma de San Luis Potrosí, San Luis Potosí, SLP, Mexico
- Facultad de Ciencias, Universidad Autónoma de San Luis Potosí, San Luis Potosí, SLP, Mexico
| | | | - Addy Cecilia Helguera-Reppeto
- Institut National de la Santé et de la Recherche Médicale (INSERM) U1151, Institut Necker Enfants Malades, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Haruki Arévalo-Romero
- Laboratorio de Inmunología y Microbiología Molecular, División Académica Multidisciplinaria de Jalpa de Méndez, Universidad Juárez Autónoma de Tabasco, Jalpa de Méndez, Mexico
| | - Edgar Ricardo Vázquez-Martínez
- Unidad de Investigación en Reproducción Humana, Instituto Nacional de Perinatología-Universidad Nacional Autónoma de México, 11000, Mexico City, Mexico
| | - Moises León-Juárez
- Laboratorio de Virología Perinatal y Diseño Molecular de Antigenos y Biomarcadores, Departamento de Inmunobioquimica, Instituto Nacional de Perinatología, 11000, Mexico City, Mexico.
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Bramante CT, Buse JB, Liebovitz DM, Nicklas JM, Puskarich MA, Cohen K, Belani HK, Anderson BJ, Huling JD, Tignanelli CJ, Thompson JL, Pullen M, Wirtz EL, Siegel LK, Proper JL, Odde DJ, Klatt NR, Sherwood NE, Lindberg SM, Karger AB, Beckman KB, Erickson SM, Fenno SL, Hartman KM, Rose MR, Mehta T, Patel B, Griffiths G, Bhat NS, Murray TA, Boulware DR. Outpatient treatment of COVID-19 and incidence of post-COVID-19 condition over 10 months (COVID-OUT): a multicentre, randomised, quadruple-blind, parallel-group, phase 3 trial. THE LANCET. INFECTIOUS DISEASES 2023; 23:1119-1129. [PMID: 37302406 DOI: 10.1016/s1473-3099(23)00299-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 03/30/2023] [Accepted: 05/02/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Post-COVID-19 condition (also known as long COVID) is an emerging chronic illness potentially affecting millions of people. We aimed to evaluate whether outpatient COVID-19 treatment with metformin, ivermectin, or fluvoxamine soon after SARS-CoV-2 infection could reduce the risk of long COVID. METHODS We conducted a decentralised, randomised, quadruple-blind, parallel-group, phase 3 trial (COVID-OUT) at six sites in the USA. We included adults aged 30-85 years with overweight or obesity who had COVID-19 symptoms for fewer than 7 days and a documented SARS-CoV-2 positive PCR or antigen test within 3 days before enrolment. Participants were randomly assigned via 2 × 3 parallel factorial randomisation (1:1:1:1:1:1) to receive metformin plus ivermectin, metformin plus fluvoxamine, metformin plus placebo, ivermectin plus placebo, fluvoxamine plus placebo, or placebo plus placebo. Participants, investigators, care providers, and outcomes assessors were masked to study group assignment. The primary outcome was severe COVID-19 by day 14, and those data have been published previously. Because the trial was delivered remotely nationwide, the a priori primary sample was a modified intention-to-treat sample, meaning that participants who did not receive any dose of study treatment were excluded. Long COVID diagnosis by a medical provider was a prespecified, long-term secondary outcome. This trial is complete and is registered with ClinicalTrials.gov, NCT04510194. FINDINGS Between Dec 30, 2020, and Jan 28, 2022, 6602 people were assessed for eligibility and 1431 were enrolled and randomly assigned. Of 1323 participants who received a dose of study treatment and were included in the modified intention-to-treat population, 1126 consented for long-term follow-up and completed at least one survey after the assessment for long COVID at day 180 (564 received metformin and 562 received matched placebo; a subset of participants in the metformin vs placebo trial were also randomly assigned to receive ivermectin or fluvoxamine). 1074 (95%) of 1126 participants completed at least 9 months of follow-up. 632 (56·1%) of 1126 participants were female and 494 (43·9%) were male; 44 (7·0%) of 632 women were pregnant. The median age was 45 years (IQR 37-54) and median BMI was 29·8 kg/m2 (IQR 27·0-34·2). Overall, 93 (8·3%) of 1126 participants reported receipt of a long COVID diagnosis by day 300. The cumulative incidence of long COVID by day 300 was 6·3% (95% CI 4·2-8·2) in participants who received metformin and 10·4% (7·8-12·9) in those who received identical metformin placebo (hazard ratio [HR] 0·59, 95% CI 0·39-0·89; p=0·012). The metformin beneficial effect was consistent across prespecified subgroups. When metformin was started within 3 days of symptom onset, the HR was 0·37 (95% CI 0·15-0·95). There was no effect on cumulative incidence of long COVID with ivermectin (HR 0·99, 95% CI 0·59-1·64) or fluvoxamine (1·36, 0·78-2·34) compared with placebo. INTERPRETATION Outpatient treatment with metformin reduced long COVID incidence by about 41%, with an absolute reduction of 4·1%, compared with placebo. Metformin has clinical benefits when used as outpatient treatment for COVID-19 and is globally available, low-cost, and safe. FUNDING Parsemus Foundation; Rainwater Charitable Foundation; Fast Grants; UnitedHealth Group Foundation; National Institute of Diabetes, Digestive and Kidney Diseases; National Institutes of Health; and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Carolyn T Bramante
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA.
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, NC, USA
| | - David M Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL, USA
| | | | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN, USA
| | - Hrishikesh K Belani
- Department of Medicine, Olive View, University of California, Los Angeles, CA, USA
| | - Blake J Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, GA, USA; Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | | | - Jennifer L Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew Pullen
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Lianne K Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer L Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David J Odde
- Department of Biomedical Engineering, University of Minnesota, Minneapolis, MN, USA
| | - Nichole R Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN, USA
| | - Nancy E Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Sarah M Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Amy B Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN, USA
| | | | - Spencer M Erickson
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Sarah L Fenno
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Katrina M Hartman
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Michael R Rose
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Tanvi Mehta
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - Barkha Patel
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Gwendolyn Griffiths
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Neeta S Bhat
- Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN, USA
| | - David R Boulware
- Division of Infectious Diseases and International Medicine, Department of Medicine, Medical School, University of Minnesota, Minneapolis, MN, USA
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Anness AR, Nath M, Osman MW, Webb D, Robinson T, Khalil A, Mousa HA. Does treatment modality affect measures of arterial stiffness in women with gestational diabetes? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:422-429. [PMID: 37099764 DOI: 10.1002/uog.26234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/10/2023] [Accepted: 03/29/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVE To investigate whether arterial stiffness (AS) differs between healthy women and women with gestational diabetes mellitus (GDM) managed by different treatment modalities. METHODS This was a prospective longitudinal cohort study comparing AS in pregnancies complicated by GDM and low-risk controls. AS was assessed by recording aortic pulse-wave velocity (AoPWV), brachial augmentation index (BrAIx) and aortic augmentation index (AoAIx) using the Arteriograph® at four gestational-age windows: 24 + 0 to 27 + 6 weeks (W1); 28 + 0 to 31 + 6 weeks (W2); 32 + 0 to 35 + 6 weeks (W3) and ≥ 36 + 0 weeks (W4). Women with GDM were considered both as a single group and as subgroups stratified by treatment modality. Data were analyzed using a linear mixed model on each AS variable (log-transformed) with group, gestational-age window, maternal age, ethnicity, parity, body mass index, mean arterial pressure and heart rate as fixed effects and individual as a random effect. We compared the group means including relevant contrasts and adjusted the P-values using Bonferroni correction. RESULTS The study population comprised 155 low-risk controls and 127 women with GDM, of whom 59 were treated with dietary intervention, 47 were treated with metformin only and 21 were treated with metformin + insulin. The two-way interaction term of study group and gestational age was significant for BrAIx and AoAIx (P < 0.001), but there was no evidence that mean AoPWV was different between the study groups (P = 0.729). Women in the control group demonstrated significantly lower BrAIx and AoAIx compared with the combined GDM group at W1-W3, but not at W4. The mean difference in log-transformed BrAIx was -0.37 (95% CI, -0.52 to -0.22), -0.23 (95% CI, -0.35 to -0.12) and -0.29 (95% CI, -0.40 to -0.18) at W1, W2 and W3, respectively. The mean difference in log-transformed AoAIx was -0.49 (95% CI, -0.69 to -0.30), -0.32 (95% CI, -0.47 to -0.18) and -0.38 (95% CI -0.52 to -0.24) at W1, W2 and W3, respectively. Similarly, women in the control group also demonstrated significantly lower BrAIx and AoAIx compared with each of the GDM treatment subgroups (diet, metformin only and metformin + insulin) at W1-W3. The increase in mean BrAIx and AoAIx seen between W2 and W3 in women with GDM treated with dietary management was attenuated in the metformin-only and metformin + insulin groups. However, the mean differences in BrAIx and AoAIx between these treatment groups were not statistically significant at any gestational-age window. CONCLUSIONS Pregnancies complicated by GDM demonstrate significantly higher AS compared with low-risk pregnancies regardless of treatment modality. Our data provide the basis for further investigation into the association of metformin therapy with changes in AS and risk of placenta-mediated diseases. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A R Anness
- Maternal and Fetal Medicine Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
- University of Leicester, Leicester, UK
| | - M Nath
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - M W Osman
- Maternal and Fetal Medicine Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - D Webb
- Diabetes Research Centre, College of Life Sciences, University of Leicester, Leicester, UK
| | - T Robinson
- College of Life Sciences, University of Leicester, Leicester, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Fetal Medicine Unit, Liverpool Women's Hospital, University of Liverpool, Liverpool, UK
| | - H A Mousa
- Maternal and Fetal Medicine Unit, University Hospitals of Leicester NHS Trust, Leicester, UK
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Lopian M, Kashani-Ligumsky L, Many A. A Balancing Act: Navigating Hypertensive Disorders of Pregnancy at Very Advanced Maternal Age, from Preconception to Postpartum. J Clin Med 2023; 12:4701. [PMID: 37510816 PMCID: PMC10380965 DOI: 10.3390/jcm12144701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Revised: 05/31/2023] [Accepted: 07/12/2023] [Indexed: 07/30/2023] Open
Abstract
The decision to postpone parenting has gained momentum in recent years, a shift driven by evolving social dynamics and improved access to fertility treatments. Despite their increasing prevalence, pregnancies at advanced maternal ages are associated with increased risks of adverse maternal and neonatal outcomes. This article addresses the association between advanced maternal age and hypertensive disorders of pregnancies (HDPs), which are more prevalent and a significant cause of maternal morbidity and mortality in this population. This review explores the biological mechanisms and age-related risk factors that underpin this increased susceptibility and offers practical management strategies that can be implemented prior to, as well as during, each stage of pregnancy to mitigate the incidence and severity of HDPs in this group. Lastly, this review acknowledges both the short-term and long-term postpartum implications of HDPs in women of advanced maternal age.
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Affiliation(s)
- Miriam Lopian
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Lior Kashani-Ligumsky
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
| | - Ariel Many
- Department of Obstetrics and Gynecology, Mayanei Hayeshua Medical Center, Bnei Brak 51544, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv 69978, Israel
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Semertzidou A, Grout-Smith H, Kalliala I, Garg A, Terzidou V, Marchesi J, MacIntyre D, Bennett P, Tsilidis K, Kyrgiou M. Diabetes and anti-diabetic interventions and the risk of gynaecological and obstetric morbidity: an umbrella review of the literature. BMC Med 2023; 21:152. [PMID: 37072764 PMCID: PMC10114404 DOI: 10.1186/s12916-023-02758-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 01/27/2023] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Diabetes has reached epidemic proportions in recent years with serious health ramifications. The aim of this study was to evaluate the strength and validity of associations between diabetes and anti-diabetic interventions and the risk of any type of gynaecological or obstetric conditions. METHODS Design: Umbrella review of systematic reviews and meta-analyses. DATA SOURCES PubMed, Medline, Embase, Cochrane Database of Systematic Reviews, manual screening of references. ELIGIBILITY CRITERIA Systematic reviews and meta-analyses of observational and interventional studies investigating the relationship between diabetes and anti-diabetic interventions with gynaecological or obstetric outcomes. Meta-analyses that did not include complete data from individual studies, such as relative risk, 95% confidence intervals, number of cases/controls, or total population were excluded. DATA ANALYSIS The evidence from meta-analyses of observational studies was graded as strong, highly suggestive, suggestive or weak according to criteria comprising the random effects estimate of meta-analyses and their largest study, the number of cases, 95% prediction intervals, I2 heterogeneity index between studies, excess significance bias, small study effect and sensitivity analysis using credibility ceilings. Interventional meta-analyses of randomised controlled trials were assessed separately based on the statistical significance of reported associations, the risk of bias and quality of evidence (GRADE) of included meta-analyses. RESULTS A total of 117 meta-analyses of observational cohort studies and 200 meta-analyses of randomised clinical trials that evaluated 317 outcomes were included. Strong or highly suggestive evidence only supported a positive association between gestational diabetes and caesarean section, large for gestational age babies, major congenital malformations and heart defects and an inverse relationship between metformin use and ovarian cancer incidence. Only a fifth of the randomised controlled trials investigating the effect of anti-diabetic interventions on women's health reached statistical significance and highlighted metformin as a more effective agent than insulin on risk reduction of adverse obstetric outcomes in both gestational and pre-gestational diabetes. CONCLUSIONS Gestational diabetes appears to be strongly associated with a high risk of caesarean section and large for gestational age babies. Weaker associations were demonstrated between diabetes and anti-diabetic interventions with other obstetric and gynaecological outcomes. TRIAL REGISTRATION Open Science Framework (OSF) (Registration https://doi.org/10.17605/OSF.IO/9G6AB ).
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Affiliation(s)
- Anita Semertzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Harriet Grout-Smith
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Ilkka Kalliala
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Department of Obstetrics and Gynaecology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Akanksha Garg
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Vasso Terzidou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Julian Marchesi
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- School of Biosciences, Cardiff University, Cardiff, UK
| | - David MacIntyre
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Phillip Bennett
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Konstantinos Tsilidis
- Department of Hygiene and Epidemiology, University of Ioannina School of Medicine, Ioannina, Greece
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Maria Kyrgiou
- Department of Metabolism, Digestion and Reproduction - Surgery and Cancer, Faculty of Medicine, Imperial College London, London, UK.
- Queen Charlotte's and Chelsea - Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK.
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Vatish M, Powys VR, Cerdeira AS. Novel therapeutic and diagnostic approaches for preeclampsia. Curr Opin Nephrol Hypertens 2023; 32:124-133. [PMID: 36683536 DOI: 10.1097/mnh.0000000000000870] [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: 01/24/2023]
Abstract
PURPOSE OF REVIEW This review will summarize recent findings relating to the diagnostic approach to preeclampsia and current avenues of research aimed at modifying the underlying disease process. RECENT FINDINGS Growing international consensus supports a broad preeclampsia definition that incorporates maternal end-organ and uteroplacental dysfunction. Recent evidence demonstrates that this definition better identifies women and babies at risk of adverse outcomes compared to the traditional definition of hypertension and proteinuria. Multiple studies have demonstrated the usefulness and cost-effectiveness of angiogenic biomarkers such as soluble fms-like tyrosine kinase-1 and placental growth factor as a clinical adjunct to diagnose and predict severity of preeclampsia associated outcomes. Current novel therapeutic approaches to preeclampsia target pathogenic pathways (e.g. antiangiogenesis) or downstream effects such as oxidative stress and nitric oxide. Recent findings relating to these promising candidates are discussed. Multicenter clinical trials are needed to evaluate their effectiveness and ability to improve fetal and maternal outcomes. SUMMARY We provide an updated framework of the current approaches to define and diagnose preeclampsia. Disease modifying therapies (in particular, targeting the angiogenic pathway) are being developed for the first time and promise to revolutionize the way we manage preeclampsia.
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Affiliation(s)
- Manu Vatish
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
| | | | - Ana Sofia Cerdeira
- Nuffield Department of Women's Health and Reproductive Research, University of Oxford, Oxford
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GRADE Use in Evidence Syntheses Published in High-Impact-Factor Gynecology and Obstetrics Journals: A Methodological Survey. J Clin Med 2023; 12:jcm12020446. [PMID: 36675377 PMCID: PMC9866985 DOI: 10.3390/jcm12020446] [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: 11/07/2022] [Revised: 12/24/2022] [Accepted: 12/27/2022] [Indexed: 01/09/2023] Open
Abstract
Objective: To identify and describe the certainty of evidence of gynecology and obstetrics systematic reviews (SRs) using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Method: Database searches of SRs using GRADE, published between 1 January 2016 to 31 December 2020, in the 10 "gynecology and obstetrics" journals with the highest impact factor, according to the Journal Citation Report 2019. Selected studies included those SRs using the GRADE approach, used to determine the certainty of evidence. Results: Out of 952 SRs, ninety-six SRs of randomized control trials (RCTs) and/or nonrandomized studies (NRSs) used GRADE. Sixty-seven SRs (7.04%) rated the certainty of evidence for specific outcomes. In total, we identified 946 certainty of evidence outcome ratings (n = 614 RCT ratings), ranging from very-low (42.28%) to low (28.44%), moderate (17.65%), and high (11.63%). High and very low certainty of evidence ratings accounted for 2.16% and 71.60% in the SRs of NRSs, respectively, compared with 16.78% and 26.55% in the SRs of RCTs. In the SRs of RCTs and NRSs, certainty of evidence was mainly downgraded due to imprecision and bias risks. Conclusions: More attention needs to be paid to strengthening GRADE acceptance and building knowledge of GRADE methods in gynecology and obstetrics evidence synthesis.
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Bramante CT, Buse JB, Liebovitz D, Nicklas J, Puskarich MA, Cohen K, Belani H, Anderson B, Huling JD, Tignanelli C, Thompson J, Pullen M, Siegel L, Proper J, Odde DJ, Klatt N, Sherwood N, Lindberg S, Wirtz EL, Karger A, Beckman K, Erickson S, Fenno S, Hartman K, Rose M, Patel B, Griffiths G, Bhat N, Murray TA, Boulware DR. Outpatient treatment of Covid-19 with metformin, ivermectin, and fluvoxamine and the development of Long Covid over 10-month follow-up. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.12.21.22283753. [PMID: 36597543 PMCID: PMC9810227 DOI: 10.1101/2022.12.21.22283753] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background Long Covid is an emerging chronic illness potentially affecting millions, sometimes preventing the ability to work or participate in normal daily activities. COVID-OUT was an investigator-initiated, multi-site, phase 3, randomized, quadruple-blinded placebo-controlled clinical trial (NCT04510194). The design simultaneously assessed three oral medications (metformin, ivermectin, fluvoxamine) using two by three parallel treatment factorial assignment to efficiently share placebo controls and assessed Long Covid outcomes for 10 months to understand whether early outpatient treatment of SARS-CoV-2 with metformin, ivermectin, or fluvoxamine prevents Long Covid. Methods This was a decentralized, remotely delivered trial in the US of 1,125 adults age 30 to 85 with overweight or obesity, fewer than 7 days of symptoms, and enrolled within three days of a documented SARS-CoV-2 infection. Immediate release metformin titrated over 6 days to 1,500mg per day 14 days total; ivermectin 430mcg/kg/day for 3 days; fluvoxamine, 50mg on day one then 50mg twice daily through 14 days. Medical-provider diagnosis of Long Covid, reported by participant by day 300 after randomization was a pre-specified secondary outcome; the primary outcome of the trial was severe Covid by day 14. Result The median age was 45 years (IQR 37 to 54), 56% female of whom 7% were pregnant. Two percent identified as Native American; 3.7% as Asian; 7.4% as Black/African American; 82.8% as white; and 12.7% as Hispanic/Latino. The median BMI was 29.8 kg/m2 (IQR 27 to 34); 51% had a BMI >30kg/m2. Overall, 8.4% reported having received a diagnosis of Long Covid from a medical provider: 6.3% in the metformin group and 10.6% in the metformin control; 8.0% in the ivermectin group and 8.1% in the ivermectin control; and 10.1% in the fluvoxamine group and 7.5% in the fluvoxamine control. The Hazard Ratio (HR) for Long Covid in the metformin group versus control was 0.58 (95% CI 0.38 to 0.88); 0.99 (95% CI 0.592 to 1.643) in the ivermectin group; and 1.36 in the fluvoxamine group (95% CI 0.785 to 2.385). Conclusions There was a 42% relative decrease in the incidence of Long Covid in the metformin group compared to its blinded control in a secondary outcome of this randomized phase 3 trial.
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Affiliation(s)
| | - John B Buse
- Endocrinology, University of North Carolina, Chapel Hill, ND
| | - David Liebovitz
- General Internal Medicine, Northwestern University, Chicago, IL
| | - Jacinda Nicklas
- General Internal Medicine, University of Colorado, Denver, CO
| | | | - Ken Cohen
- UnitedHealth Group, Optum Labs, Minnetonka, MN
| | - Hrishikesh Belani
- Department of Medicine, Olive View - University of California, Los Angeles, CA
| | - Blake Anderson
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia; Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Jared D Huling
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | | | - Jennifer Thompson
- Department of Obstetrics and Gynecology, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew Pullen
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
| | - Lianne Siegel
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Jennifer Proper
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David J Odde
- Department of Biomedical Engineering University of Minnesota, Minneapolis, MN
| | - Nichole Klatt
- Department of Surgery, Medical School, University of Minnesota, Minneapolis, MN
| | - Nancy Sherwood
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Sarah Lindberg
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Esteban Lemus Wirtz
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Amy Karger
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Kenny Beckman
- Department of Laboratory Medicine and Pathology, Medical School, University of Minnesota, Minneapolis, MN
| | - Spencer Erickson
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Sarah Fenno
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Katrina Hartman
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Michael Rose
- General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Barkha Patel
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | | | - Neeta Bhat
- General Internal Medicine, University of Minnesota, Minneapolis, MN
| | - Thomas A Murray
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
| | - David R Boulware
- Infectious Diseases, University of Minnesota Medical School, Minneapolis, MN
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9
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Bramante CT, Johnson SG, Garcia V, Evans MD, Harper J, Wilkins KJ, Huling JD, Mehta H, Alexander C, Tronieri J, Hong S, Kahkoska A, Alamgir J, Koraishy F, Hartman K, Yang K, Abrahamsen T, Stürmer T, Buse JB. Diabetes medications and associations with Covid-19 outcomes in the N3C database: A national retrospective cohort study. PLoS One 2022; 17:e0271574. [PMID: 36395143 PMCID: PMC9671347 DOI: 10.1371/journal.pone.0271574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 07/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND While vaccination is the most important way to combat the SARS-CoV-2 pandemic, there may still be a need for early outpatient treatment that is safe, inexpensive, and currently widely available in parts of the world that do not have access to the vaccine. There are in-silico, in-vitro, and in-tissue data suggesting that metformin inhibits the viral life cycle, as well as observational data suggesting that metformin use before infection with SARS-CoV2 is associated with less severe COVID-19. Previous observational analyses from single-center cohorts have been limited by size. METHODS Conducted a retrospective cohort analysis in adults with type 2 diabetes (T2DM) for associations between metformin use and COVID-19 outcomes with an active comparator design of prevalent users of therapeutically equivalent diabetes monotherapy: metformin versus dipeptidyl-peptidase-4-inhibitors (DPP4i) and sulfonylureas (SU). This took place in the National COVID Cohort Collaborative (N3C) longitudinal U.S. cohort of adults with +SARS-CoV-2 result between January 1 2020 to June 1 2021. Findings included hospitalization or ventilation or mortality from COVID-19. Back pain was assessed as a negative control outcome. RESULTS 6,626 adults with T2DM and +SARS-CoV-2 from 36 sites. Mean age was 60.7 +/- 12.0 years; 48.7% male; 56.7% White, 21.9% Black, 3.5% Asian, and 16.7% Latinx. Mean BMI was 34.1 +/- 7.8kg/m2. Overall 14.5% of the sample was hospitalized; 1.5% received mechanical ventilation; and 1.8% died. In adjusted outcomes, compared to DPP4i, metformin had non-significant associations with reduced need for ventilation (RR 0.68, 0.32-1.44), and mortality (RR 0.82, 0.41-1.64). Compared to SU, metformin was associated with a lower risk of ventilation (RR 0.5, 95% CI 0.28-0.98, p = 0.044) and mortality (RR 0.56, 95%CI 0.33-0.97, p = 0.037). There was no difference in unadjusted or adjusted results of the negative control. CONCLUSIONS There were clinically significant associations between metformin use and less severe COVID-19 compared to SU, but not compared to DPP4i. New-user studies and randomized trials are needed to assess early outpatient treatment and post-exposure prophylaxis with therapeutics that are safe in adults, children, pregnancy and available worldwide.
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Affiliation(s)
- Carolyn T. Bramante
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Steven G. Johnson
- Institute for Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Victor Garcia
- Department of Biomedical Informatics, Stony Brook University Hospital, Stony Brook, New York, United States of America
| | - Michael D. Evans
- Biostatistical Design and Analysis Center, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Jeremy Harper
- Owl HealthWorks, Indianapolis, IN, United States of America
| | - Kenneth J. Wilkins
- Biostatistics Program, Office of the Director, National Institute of Diabetes and Digestive and Kidney Disease, Bethesda, Maryland, United States of America
| | - Jared D. Huling
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America
| | - Hemalkumar Mehta
- Division of Epidemiology and Methodology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Caleb Alexander
- Division of General Internal Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America
| | - Jena Tronieri
- Department of Psychiatry, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Stephenie Hong
- Division of Epidemiology and Methodology, Johns Hopkins School of Public Health, Baltimore, Maryland, United States of America
| | - Anna Kahkoska
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Joy Alamgir
- ARIScience, Boston, Massachusetts, United States of America
| | - Farrukh Koraishy
- Division of Nephrology, Stony Brook University Hospital, Stony Brook, New York, United States of America
| | - Katrina Hartman
- Division of General Internal Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, Minnesota, United States of America
| | - Kaifeng Yang
- Division of Biostatistics, University of Minnesota School of Public Health, Minneapolis, Minnesota, United States of America
| | | | - Til Stürmer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - John B. Buse
- Division of Endocrinology, Department of Medicine, University of North Carolina Medical School, Chapel Hill, North Carolina, United States of America
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10
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Zhang X, Chen Y, Sun D, Zhu X, Ying X, Yao Y, Fei W, Zheng C. Emerging pharmacologic interventions for pre-eclampsia treatment. Expert Opin Ther Targets 2022; 26:739-759. [PMID: 36223503 DOI: 10.1080/14728222.2022.2134779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Pre-eclampsia is a serious pregnancy complication and a major global concern for the mortality of both mother and fetus. Existing symptomatic treatments do not delay disease progression; thus, timely delivery of the baby is the most effective measure. However, the risk of various maternal and fetal injuries remains. AREAS COVERED In this review, we summarize the potential strategies for pharmacologic interventions in pre-eclamptic therapy. Specifically, we discuss the pathophysiological process of various effective candidate therapeutics that act on potential pathways and molecular targets to inhibit key stages of the disease. We refer to this pathogenesis-focused drug discovery model as a pathogenesis-target-drug (P-T-D) strategy. Finally, we discuss the introduction of nanotechnologies to improve the safety and efficacy of therapeutics via their specific placental targeting ability and placental retention effects. EXPERT OPINION Despite the active development of novel pharmacological treatments based on our current knowledge of pre-eclamptic pathogenesis, investigations are still in the early phase. Thus, further exploration of the pathological mechanisms, integrated with the P-T-D strategy and novel nanosystems, could encourage the development of more effective and safer strategies. Such advances could lead to a shift from expectant management to mechanistic-based therapy for pre-eclampsia.
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Affiliation(s)
- Xiao Zhang
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Yue Chen
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Dongli Sun
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xiaojun Zhu
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Xia Ying
- Department of Obstetrics, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Yao Yao
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Weidong Fei
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
| | - Caihong Zheng
- Department of Pharmacy, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, China
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11
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van Hoorn EGM, van Dijk PR, Prins JR, Lutgers HL, Hoogenberg K, Erwich JJHM, Kooy A. Pregnancy Outcomes: Effects of Metformin (POEM) study: a protocol for a long-term, multicentre, open-label, randomised controlled trial in gestational diabetes mellitus. BMJ Open 2022; 12:e056282. [PMID: 35354633 PMCID: PMC8968576 DOI: 10.1136/bmjopen-2021-056282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Gestational diabetes mellitus (GDM) is a common disorder of pregnancy with health risks for mother and child during pregnancy, delivery and further lifetime, possibly leading to type 2 diabetes mellitus (T2DM). Current treatment is focused on reducing hyperglycaemia, by dietary and lifestyle intervention and, if glycaemic targets are not reached, insulin. Metformin is an oral blood glucose lowering drug and considered safe during pregnancy. It improves insulin sensitivity and has shown advantages, specifically regarding pregnancy-related outcomes and patient satisfaction, compared with insulin therapy. However, the role of metformin in addition to usual care is inconclusive and long-term outcome of metformin exposure in utero are lacking. The primary aim of this study is to investigate the early addition of metformin on pregnancy and long-term outcomes in GDM. METHODS AND ANALYSIS The Pregnancy Outcomes: Effects of Metformin study is a multicentre, open-label, randomised, controlled trial. Participants include women with GDM, between 16 and 32 weeks of gestation, who are randomised to either usual care or metformin added to usual care, with insulin rescue in both groups. Metformin is given up to 1 year after delivery. The study consists of three phases (A-C): A-until 6 weeks after delivery; B-until 1 year after delivery; C-observational study until 20 years after delivery. During phase A, the primary outcome is a composite score consisting of: (1) pregnancy-related hypertension, (2) large for gestational age neonate, (3) preterm delivery, (4) instrumental delivery, (5) caesarean delivery, (6) birth trauma, (7) neonatal hypoglycaemia, (8) neonatal intensive care admission. During phase B and C the primary outcome is the incidence of T2DM and (weight) development in mother and child. ETHICS AND DISSEMINATION The study was approved by the Central Committee on Research Involving Human Subjects in the Netherlands. Results will be submitted for publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02947503.
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Affiliation(s)
- Eline G M van Hoorn
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Peter R van Dijk
- Department of Endocrinology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Jelmer R Prins
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Helen L Lutgers
- Department of Internal Medicine, Medical Centre Leeuwarden, Leeuwarden, Netherlands
| | - Klaas Hoogenberg
- Department of Internal Medicine, Martini Hospital, Groningen, Netherlands
| | - Jan Jaap H M Erwich
- Department of Obstetrics and Gynaecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan Kooy
- Department of Internal Medicine, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Bethesda Diabetes Research Center, Hoogeveen, Netherlands
- Department of Internal Medicine, Treant Care Group, Hoogeveen, Netherlands
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12
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The etiology of preeclampsia. Am J Obstet Gynecol 2022; 226:S844-S866. [PMID: 35177222 PMCID: PMC8988238 DOI: 10.1016/j.ajog.2021.11.1356] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/17/2021] [Accepted: 11/18/2021] [Indexed: 02/08/2023]
Abstract
Preeclampsia is one of the "great obstetrical syndromes" in which multiple and sometimes overlapping pathologic processes activate a common pathway consisting of endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. This article reviews the potential etiologies of preeclampsia. The role of uteroplacental ischemia is well-established on the basis of a solid body of clinical and experimental evidence. A causal role for microorganisms has gained recognition through the realization that periodontal disease and maternal gut dysbiosis are linked to atherosclerosis, thus possibly to a subset of patients with preeclampsia. The recent reports indicating that SARS-CoV-2 infection might be causally linked to preeclampsia are reviewed along with the potential mechanisms involved. Particular etiologic factors, such as the breakdown of maternal-fetal immune tolerance (thought to account for the excess of preeclampsia in primipaternity and egg donation), may operate, in part, through uteroplacental ischemia, whereas other factors such as placental aging may operate largely through syncytiotrophoblast stress. This article also examines the association between gestational diabetes mellitus and maternal obesity with preeclampsia. The role of autoimmunity, fetal diseases, and endocrine disorders is discussed. A greater understanding of the etiologic factors of preeclampsia is essential to improve treatment and prevention.
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13
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Bidhendi Yarandi R, Amiri M, Ramezani Tehrani F, Behboudi‐Gandevani S. Effectiveness of antidiabetic agents for treatment of gestational diabetes: A methodological quality assessment of meta-analyses and network meta-analysis. J Diabetes Investig 2021; 12:2247-2258. [PMID: 34042261 PMCID: PMC8668072 DOI: 10.1111/jdi.13603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 05/02/2021] [Accepted: 05/16/2021] [Indexed: 01/08/2023] Open
Abstract
AIMS/INTRODUCTION Despite there being several meta-analyses on the effects of antidiabetic agents in patients with gestational diabetes mellitus, the reliability of their findings is a concern, mainly due to undetermined methodological quality of these studies. This study aimed to assess the methodological quality of available meta-analyses and provide a summary estimation of the effectiveness of treatments modalities. MATERIALS AND METHODS PubMed, Web of Science and Scopus databases were comprehensively searched for retrieving relevant meta-analyses published in English up to May 2020. A Measurement Tool to Assess Systematic Reviews (AMSTAR-2) was applied to evaluate methodological quality of eligible meta-analyses. A network meta-analysis was used to calculate the pooled odds ratio of maternal and neonatal outcomes in gestational diabetes mellitus patients treated with metformin or glyburide compared with those treated with insulin. The rank network analysis was carried out for ranking of the treatments and reporting the most efficient treatment. RESULTS A total of 27 and 17 studies were included for qualitative and quantitative syntheses, respectively; of these, just four studies were classified as high quality. The results showed that metformin had the highest probability of being the best treatment, compared with insulin and glyburide, for the majority of adverse neonatal outcomes, whereas glyburide was the best treatment in reducing the risk of adverse maternal outcomes. The results were not significantly changed after excluding low-quality studies. CONCLUSIONS This review study of available literature shows that metformin can be a superior option in most neonatal and maternal adverse pregnancy outcomes in women with gestational diabetes mellitus; the results need to be further updated by including future more qualified studies.
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Affiliation(s)
- Razieh Bidhendi Yarandi
- Reproductive Endocrinology Research CenterResearch Institute for Endocrine SciencesShahid Beheshti University of Medical SciencesTehranIran
| | - Mina Amiri
- Reproductive Endocrinology Research CenterResearch Institute for Endocrine SciencesShahid Beheshti University of Medical SciencesTehranIran
| | - Fahimeh Ramezani Tehrani
- Reproductive Endocrinology Research CenterResearch Institute for Endocrine SciencesShahid Beheshti University of Medical SciencesTehranIran
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14
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Anthoulakis C, Mamopoulos A, Rousso D, Karagiannis A, Athanasiadis A, Grimbizis G, Athyros V. Arterial Stiffness as a Cardiovascular Risk Factor for the Development of Preeclampsia and Pharmacopreventive Options. Curr Vasc Pharmacol 2021; 20:52-61. [PMID: 34615450 DOI: 10.2174/1570161119666211006114258] [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: 05/20/2021] [Revised: 08/08/2021] [Accepted: 08/18/2021] [Indexed: 11/22/2022]
Abstract
Arterial stiffness (AS) describes the rigidity of the arterial walls. Epidemiological studies have shown that increased AS is an independent predictive marker of cardiovascular (CV) morbidity and mortality in both pregnant and non-pregnant women. Preeclampsia (PE), a form of pregnancy-induced hypertension, affects approximately 5% of pregnancies worldwide. Preeclamptic women have a higher risk of CV disease (CVD), mainly because PE damages the heart's ability to relax between contractions. Different pharmacological approaches for the prevention of PE have been tested in clinical trials (e.g. aspirin, enoxaparin, metformin, pravastatin, and sildenafil citrate). In current clinical practice, only low-dose aspirin is used for PE pharmacoprevention. However, low-dose aspirin does not prevent term PE, which is the most common form of PE. Compromised vascular integrity precedes the onset of PE and therefore, AS assessment may constitute a promising predictive marker of PE. Several non-invasive techniques have been developed to assess AS. Compared with normotensive pregnancies, both carotid-femoral pulse wave velocity (cfPWV) and augmentation index (AIx) are increased in PE. In view of simplicity, reliability, and reproducibility, there is an interest in oscillometric AS measurements in pregnancies complicated by PE.
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Affiliation(s)
- Christos Anthoulakis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Mamopoulos
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - David Rousso
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Asterios Karagiannis
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Apostolos Athanasiadis
- Third Department of Obstetrics & Gynecology, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Grigoris Grimbizis
- First Department of Obstetrics & Gynecology, "Papageorgiou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
| | - Vasilios Athyros
- Second Propaedeutic Department of Internal Medicine, Hippokration General Hospital, Aristotle University of Thessaloniki, Thessaloniki. Greece
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15
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Acar Sirinoglu H, Uysal G, Nazik H, Destegul E, Okmen F, Pekin O. Comparison of elasticity values in normal and gestational diabetic pregnancies in the third trimester. J OBSTET GYNAECOL 2021; 42:842-847. [PMID: 34553652 DOI: 10.1080/01443615.2021.1945012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Placental elasticity was compared by using Shear wave elastography (SWE) in patients with gestational diabetes mellitus (GDM) with and without insulin to non-diabetic controls. Three groups were created as follows: Group 1 (n = 79, GDM with insulin therapy), Group 2 (n = 90, GDM with only diet) and Group 3 (n = 150, healthy controls) All patients were above 36 gestational weeks with anterior placenta. Clinical trial number was also received (NCT04455880). Group 1 had higher BMI while group 3 had lowest rate of C/S. Birthweight in GDM groups was statistically significantly higher than controls (p = .001). Although there was no significant difference between APGAR scores, Group 1 had higher rates of neonatal intensive care unit (NICU) admission. SWE values were significantly higher in GDM patients treated with insulin or diet than controls. SWE may be an alternatively supplementary management modality in GDM.IMPACT STATEMENTWhat is already known on this subject? Shear wave elastography (SWE), is one of the types of sono elastography methods that are used to measure the stiffness and elasticity of soft tissues. Recently, it became popular for screening the stiffness and elasticity of the placenta in high-risk pregnancies like preeclampsia, intrauterine growth restriction (IUGR), and placental dysfunction.What the results of this study add? All SWE velocities on the maternal side were statistically significantly different between groups. Regarding foetal side velocities, GDM groups had statistically significantly higher values (stiffer tissue) compared to controls.What the implications are of these findings for clinical practice and/or further research? SWE may be a Supplementary method in the diagnosis and management of GDM. Placental SWE should be measured at 24-28 weeks of gestation in patients with GDM and diagnosis confirmation and their responses to the treatment should be examined.
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Affiliation(s)
- Hicran Acar Sirinoglu
- Division of Perinatology, Department of Obstetrics and Gynecology, Cemil Taşçıoğlu City Hospital, Istanbul, Turkey
| | - Gulsum Uysal
- Department of Obstetrics and Gynecology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
| | - Hakan Nazik
- Department of Obstetrics and Gynecology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
| | - Emre Destegul
- Department of Obstetrics and Gynecology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
| | - Fırat Okmen
- Department of Obstetrics and Gynecology, University of Health Sciences, Adana City Training and Research Hospital, Adana, Turkey
| | - Oya Pekin
- Department of Obstetrics and Gynecology, Zeynep Kamil Women and Children Disease Training and Research Hospital, Istanbul, Turkey
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Cluver CA, Hiscock R, Decloedt EH, Hall DR, Schell S, Mol BW, Brownfoot F, Kaitu'u-Lino TJ, Walker SP, Tong S. Use of metformin to prolong gestation in preterm pre-eclampsia: randomised, double blind, placebo controlled trial. BMJ 2021; 374:n2103. [PMID: 34551918 PMCID: PMC8457042 DOI: 10.1136/bmj.n2103] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate whether extended release metformin could be used to prolong gestation in women being expectantly managed for preterm pre-eclampsia. DESIGN Randomised, double blind, placebo controlled trial. SETTING Referral hospital in Cape Town, South Africa. PARTICIPANTS 180 women with preterm pre-eclampsia between 26+0 to 31+6 weeks' gestation undergoing expectant management: 90 were randomised to extended release metformin and 90 to placebo. INTERVENTION 3 g of oral extended release metformin or placebo daily, in divided doses, until delivery. MAIN OUTCOME MEASURE The primary outcome was prolongation of gestation. RESULTS Of 180 participants, one woman delivered before taking any trial drug. The median time from randomisation to delivery was 17.7 days (interquartile range 5.4-29.4 days; n=89) in the metformin arm and 10.1 (3.7-24.1; n=90) days in the placebo arm, a median difference of 7.6 days (geometric mean ratio 1.39, 95% confidence interval 0.99 to 1.95; P=0.057). Among those who continued to take the trial drug at any dose, the median prolongation of gestation in the metformin arm was 17.5 (interquartile range 5.4-28.7; n=76) days compared with 7.9 (3.0-22.2; n=74) days in the placebo arm, a median difference of 9.6 days (geometric mean ratio 1.67, 95% confidence interval 1.16 to 2.42). Among those who took the full dosage, the median prolongation of gestation in the metformin arm was 16.3 (interquartile range 4.8-28.8; n=40) days compared with 4.8 (2.5-15.4; n=61) days in the placebo arm, a median difference of 11.5 days (geometric mean ratio 1.85, 95% confidence interval 1.14 to 2.88). Composite maternal, fetal, and neonatal outcomes and circulating concentrations of soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin did not differ. In the metformin arm, birth weight increased non-significantly and length of stay decreased in the neonatal nursery. No serious adverse events related to trial drugs were observed, although diarrhoea was more common in the metformin arm. CONCLUSIONS This trial suggests that extended release metformin can prolong gestation in women with preterm pre-eclampsia, although further trials are needed. It provides proof of concept that treatment of preterm pre-eclampsia is possible. TRIAL REGISTRATION Pan African Clinical Trial Registry PACTR201608001752102 https://pactr.samrc.ac.za/.
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Affiliation(s)
- Catherine A Cluver
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Richard Hiscock
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
| | - Eric H Decloedt
- Department of Medicine, Division of Clinical Pharmacology, Stellenbosch University, Tygerberg Hospital, Cape Town, South Africa
| | - David R Hall
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Sonja Schell
- Department of Obstetrics and Gynaecology, Stellenbosch University, Tygerberg Hospital, 7505, Cape Town, South Africa
| | - Ben W Mol
- Department of Obstetrics and Gynaecology, Monash School of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Brownfoot
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Tu'uhevaha J Kaitu'u-Lino
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Susan P Walker
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - Stephen Tong
- Translational Obstetrics Group, Department of Obstetrics and Gynaecology, University of Melbourne, Victoria, Australia
- Mercy Perinatal, Mercy Hospital for Women, Heidelberg, Victoria, Australia
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Pascual-Morena C, Cavero-Redondo I, Álvarez-Bueno C, Lucerón-Lucas-Torres M, Sanabria-Martínez G, Poyatos-León R, Rodríguez-Martín B, Martínez-Vizcaíno V. Exercise versus Metformin to Improve Pregnancy Outcomes among Overweight Pregnant Women: A Systematic Review and Network Meta-Analysis. J Clin Med 2021; 10:jcm10163490. [PMID: 34441786 PMCID: PMC8397096 DOI: 10.3390/jcm10163490] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/03/2021] [Accepted: 08/05/2021] [Indexed: 12/16/2022] Open
Abstract
Being overweight is associated with pregnancy-related disorders such as gestational diabetes mellitus (GDM), hypertensive disorders of pregnancy (HDP), and excessive maternal weight gain (MWG). Exercise and metformin reduce the risk of these disorders. This network meta-analysis (NMA) aims to compare the effect of metformin and different types of exercise (aerobic, resistance and combined) on the risk of GDM, HDP, and MWG among overweight/obese pregnant women. Medline, EMBASE, Web of Science and Cochrane Library were searched from inception to June 2021. Meta-analyses and NMAs were performed. Sixteen randomized controlled trials were included. In the NMA, aerobic exercise showed an effect on GDM (RR = 0.51, 95% CI = 0.26, 0.97), and metformin a reduction in MWG (MWG = -2.93 kg, 95% CI = -4.98, -0.87). No intervention showed any effect on the reduction of HDP. Our study suggests that aerobic exercise may have the greatest effect in reducing the risk of GDM, and perhaps, the MWG. Strategies should be developed to increase adherence to this type of intervention among overweight women without contraindications. Although metformin could reduce MWG, medicalization of pregnancy in healthy women is not justified with the present results. More research is needed on the effect of the intensity and frequency of exercise sessions and the length of interventions.
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Affiliation(s)
- Carlos Pascual-Morena
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
| | - Iván Cavero-Redondo
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
- Rehabilitation in Health Research Center (CIRES), Universidad de las Américas, Santiago 72819, Chile
- Correspondence:
| | - Celia Álvarez-Bueno
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
- Universidad Politécnica y Artística del Paraguay, Asunción 001518, Paraguay
| | - Maribel Lucerón-Lucas-Torres
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
| | - Gema Sanabria-Martínez
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
| | - Raquel Poyatos-León
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
| | - Beatriz Rodríguez-Martín
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
| | - Vicente Martínez-Vizcaíno
- Health and Social Research Center, Universidad de Castilla—La Mancha, 16071 Cuenca, Spain; (C.P.-M.); (C.Á.-B.); (M.L.-L.-T.); (G.S.-M.); (R.P.-L.); (B.R.-M.); (V.M.-V.)
- Facultad de Ciencias de la Salud, Universidad Autónoma de Chile, Talca 3460000, Chile
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18
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The Role of Metformin in Treating Preeclampsia. MATERNAL-FETAL MEDICINE 2021. [DOI: 10.1097/fm9.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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19
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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: 1.3] [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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20
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Tarry-Adkins JL, Ozanne SE, Aiken CE. Impact of metformin treatment during pregnancy on maternal outcomes: a systematic review/meta-analysis. Sci Rep 2021; 11:9240. [PMID: 33927270 PMCID: PMC8085032 DOI: 10.1038/s41598-021-88650-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 04/09/2021] [Indexed: 02/02/2023] Open
Abstract
We systematically assessed the impact of metformin treatment on maternal pregnancy outcomes. PubMed, Ovid Embase, Medline, Web of Science, ClinicalTrials.gov and Cochrane databases were systematically searched (inception-1st February 2021). Randomised controlled trials reporting pregnancy outcomes in women randomised to metformin versus any other treatment for any indication were included. Outcomes included gestational weight gain (GWG), pre-eclampsia, gestational hypertension, preterm birth, gestational age at delivery, caesarean section, gestational diabetes, glycaemic control, and gastrointestinal side-effects. Two independent reviewers conducted screening, with a third available to evaluate disagreements. Risk-of-bias and GRADE assessments were conducted using Cochrane Risk-of-Bias and GRADE-pro software. Thirty-five studies (n = 8033 pregnancies) met eligibility criteria. GWG was lower in pregnancies randomised to metformin versus other treatments (1.57 kg ± 0.60 kg; I2 = 86%, p < 0.0001), as was likelihood of pre-eclampsia (OR 0.69, 95% CI 0.50-0.95; I2 = 55%, p = 0.02). The risk of gastrointestinal side-effects was greater in metformin-exposed versus other treatment groups (OR 2.43, 95% CI 1.53-3.84; I2 = 76%, p = 0.0002). The risk of other maternal outcomes assessed was not significantly different between metformin-exposed versus other treatment groups. Metformin for any indication during pregnancy is associated with lower GWG and a modest reduced risk of pre-eclampsia, but increased gastrointestinal side-effects compared to other treatments.
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Affiliation(s)
- Jane L. Tarry-Adkins
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Obstetrics and Gynaecology, The Rosie Hospital and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
| | - Susan E. Ozanne
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Catherine E. Aiken
- grid.5335.00000000121885934Metabolic Research Laboratories and MRC Metabolic Diseases Unit, Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK ,grid.5335.00000000121885934Department of Obstetrics and Gynaecology, The Rosie Hospital and NIHR Cambridge Biomedical Research Centre, University of Cambridge, Cambridge, UK
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21
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Anness AR, Baldo A, Webb DR, Khalil A, Robinson TG, Mousa HA. Effect of metformin on biomarkers of placental- mediated disease: A systematic review and meta-analysis. Placenta 2021; 107:51-58. [PMID: 33798839 DOI: 10.1016/j.placenta.2021.02.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2020] [Revised: 02/16/2021] [Accepted: 02/25/2021] [Indexed: 12/13/2022]
Abstract
Metformin reduces the incidence of placental-mediated disease (PMD) in pregnancies with and without diabetes, but the mechanism through which it exerts these effects is not yet fully understood. We performed a systematic review and meta-analysis to examine the effect of metformin on biomarkers implicated in the pathogenesis of PMD. We searched Medline, Embase and the Cochrane Library for studies of metformin and biomarkers of PMD in pregnancy. Meta-analysis was undertaken where comparable data were obtained from two or more studies. 12 studies were included in the final review. Meta-analysis of 2 studies including 323 pregnant women showed significantly reduced CRP levels following treatment with metformin compared to placebo [mean difference = -1.72, 95% CI (-2.97; -0.48); p = 0.007]. Metformin exposure was also associated with decreased levels of the inflammatory cytokines TNFα, IL-1a, IL-1b and IL-6 in serum, placenta and omental tissue taken from pregnant women. Metformin significantly decreased the release of anti-angiogenic factors sFlt-1 and sEng from ex-vivo placental and umbilical vein tissue, and increased maternal serum levels of non-phosphorylated IGFBP-1. Overall, our findings show that metformin mediates several molecular pathways implicated in the pathogenesis of pre-eclampsia and intrauterine growth retardation. Metformin therefore has exciting potential as a therapeutic, as well as preventative, agent in the treatment of PMD, which warrants further investigation.
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Affiliation(s)
| | | | - David R Webb
- Diabetes Research Centre, University of Leicester, UK
| | - Asma Khalil
- St. George's University Hospital (University of London), UK
| | | | - Hatem A Mousa
- University Hospitals of Leicester NHS Trust, Leicester, UK
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22
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Valent AM, Barbour LA. Management of Women with Polycystic Ovary Syndrome During Pregnancy. Endocrinol Metab Clin North Am 2021; 50:57-69. [PMID: 33518186 DOI: 10.1016/j.ecl.2020.10.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Polycystic ovary syndrome (PCOS) is the most common endocrinopathy among reproductive age women and is associated with subfertility and adverse perinatal outcomes, which may include early pregnancy loss, gestational diabetes mellitus, hypertensive spectrum disorder, preterm birth, fetal growth disorders, and cesarean deliveries. The phenotypic heterogeneity, different diagnostic criteria, and PCOS-related conditions that women enter pregnancy with have limited evidenced-based studies and guidelines to reduce pregnancy complications among this high-risk population. This review summarizes the available evidence on the approach and management of women with PCOS preconception, prenatal, and postpartum.
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Affiliation(s)
- Amy M Valent
- Department of Obstetrics and Gynecology, Oregon Health and Science University, 3181 Southwest Sam Jackson Park Road, Mail Location L-458, Portland, OR 97239, USA.
| | - Linda A Barbour
- Department of Medicine, University of Colorado Anschutz Medical Campus, 12801 East 17th Avenue, RC1 South Room 7103, Aurora, CO 80045, USA; Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, 12801 East 17th Avenue, RC1 South Room 7103, Aurora, CO 80045, USA
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23
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Wu P, Park K, Gulati M. The Fourth Trimester: Pregnancy as a Predictor of Cardiovascular Disease. Eur Cardiol 2021; 16:e31. [PMID: 34603511 PMCID: PMC8478146 DOI: 10.15420/ecr.2021.18] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 07/10/2021] [Indexed: 12/20/2022] Open
Abstract
Pregnancy identifies women who may be at a greater risk of cardiovascular disease (CVD), based on the development of adverse pregnancy outcomes (APOs), and may identify women who may benefit from atherosclerotic CVD (ASCVD) risk reduction efforts. APOs are common and although they are separate diagnoses, all these disorders seem to share an underlying pathogenesis. What is not clear is whether the APO itself initiates a pathway that results in CVD or whether the APO uncovers a woman's predisposition to CVD. Regardless, APOs have immediate risks to maternal and foetal health, in addition to longer-term CVD consequences. CVD risk assessment and stratification in women remains complex and, historically, has underestimated risk, especially in young women. Further research is needed into the role of ASCVD risk assessment and the effect of aggressive ASCVD risk modification on CVD outcomes in women with a history of APOs.
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Affiliation(s)
- Pensée Wu
- School of Medicine, Keele UniversityStaffordshire, UK
| | - Ki Park
- University of FloridaGainesville, FL, US
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24
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Shpakov AO. Improvement Effect of Metformin on Female and Male Reproduction in Endocrine Pathologies and Its Mechanisms. Pharmaceuticals (Basel) 2021; 14:ph14010042. [PMID: 33429918 PMCID: PMC7826885 DOI: 10.3390/ph14010042] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 01/02/2021] [Accepted: 01/06/2021] [Indexed: 02/07/2023] Open
Abstract
Metformin (MF), a first-line drug to treat type 2 diabetes mellitus (T2DM), alone and in combination with other drugs, restores the ovarian function in women with polycystic ovary syndrome (PCOS) and improves fetal development, pregnancy outcomes and offspring health in gestational diabetes mellitus (GDM) and T2DM. MF treatment is demonstrated to improve the efficiency of in vitro fertilization and is considered a supplementary drug in assisted reproductive technologies. MF administration shows positive effect on steroidogenesis and spermatogenesis in men with metabolic disorders, thus MF treatment indicates prospective use for improvement of male reproductive functions and fertility. MF lacks teratogenic effects and has positive health effect in newborns. The review is focused on use of MF therapy for restoration of female and male reproductive functions and improvement of pregnancy outcomes in metabolic and endocrine disorders. The mechanisms of MF action are discussed, including normalization of metabolic and hormonal status in PCOS, GDM, T2DM and metabolic syndrome and restoration of functional activity and hormonal regulation of the gonadal axis.
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Affiliation(s)
- Alexander O Shpakov
- I.M. Sechenov Institute of Evolutionary Physiology and Biochemistry of Russian Academy of Sciences, 194223 Saint Petersburg, Russia
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25
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Ibrahim S, Lowe JR, Bramante CT, Shah S, Klatt NR, Sherwood N, Aronne L, Puskarich M, Tamariz L, Palacio A, Bomberg E, Usher M, King S, Benson B, Vojta D, Tignanelli C, Ingraham N. Metformin and Covid-19: Focused Review of Mechanisms and Current Literature Suggesting Benefit. Front Endocrinol (Lausanne) 2021; 12:587801. [PMID: 34367059 PMCID: PMC8342037 DOI: 10.3389/fendo.2021.587801] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Accepted: 05/11/2021] [Indexed: 01/08/2023] Open
Abstract
Metformin is the first-line medication for type 2 diabetes, but it also has a long history of improved outcomes in infectious diseases, such as influenza, hepatitis C, and in-vitro assays of zika. In the current Covid-19 pandemic, which has rapidly spread throughout the world, 4 observational studies have been published showing reduced mortality among individuals with home metformin use. There are several potential overlapping mechanisms by which metformin may reduce mortality from Covid-19. Metformin's past anti-infectious benefits have been both against the infectious agent directly, as well as by improving the underlying health of the human host. It is unknown if the lower mortality suggested by observational studies in patients infected with Covid-19 who are on home metformin is due to direct activity against the virus itself, improved host substrate, or both.
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Affiliation(s)
- Sherehan Ibrahim
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Jamie R. Lowe
- MPH Program, Dartmouth College, Hanover, NH, United States
| | - Carolyn T. Bramante
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
- *Correspondence: Carolyn T. Bramante,
| | - Surbhi Shah
- Department of Medicine, Division of Hematology, Oncology and Transplant, University of Minnesota, Minneapolis, MN, United States
| | - Nichole R. Klatt
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Nancy Sherwood
- Department of Epidemiology, University of Minnesota, Minneapolis, MN, United States
| | - Louis Aronne
- Division of Endocrinology, Cornell Weill College of Medicine, New York, NY, United States
| | - Michael Puskarich
- Department of Emergency Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Leonardo Tamariz
- Division of Cardiology and Miami VA Healthcare Administration, University of Miami, Miami, FL, United States
| | - Ana Palacio
- Division of Cardiology and Miami VA Healthcare Administration, University of Miami, Miami, FL, United States
| | - Eric Bomberg
- Department of Pediatrics, Division of Pediatric Endocrinology, University of Minnesota, Minneapolis, MN, United States
| | - Michael Usher
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Samantha King
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Brad Benson
- Department of Medicine, Division of General Internal Medicine, University of Minnesota, Minneapolis, MN, United States
| | - Deneen Vojta
- UnitedHealth Group, Research and Development, Plymouth, MN, United States
| | - Chris Tignanelli
- Department of Surgery, University of Minnesota, Minneapolis, MN, United States
| | - Nicholas Ingraham
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Minnesota, Minneapolis, MN, United States
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Cavalcanti D, Bujold E. Commentary: In Utero Exposure to Metformin Reduces the Fertility of Male Offspring in Adulthood. Front Endocrinol (Lausanne) 2021; 12:815532. [PMID: 35046904 PMCID: PMC8761974 DOI: 10.3389/fendo.2021.815532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 12/08/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Deborah Cavalcanti
- Research Center of the Centre Hospitalier Universitaire (CHU) de Quebec – Université Laval, Quebec City, QC, Canada
| | - Emmanuel Bujold
- Research Center of the Centre Hospitalier Universitaire (CHU) de Quebec – Université Laval, Quebec City, QC, Canada
- Department of Obstetrics and Gynecology, Faculty of Medicine, Université Laval, Quebec City, QC, Canada
- *Correspondence: Emmanuel Bujold,
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27
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Minhas AS, Ying W, Ogunwole SM, Miller M, Zakaria S, Vaught AJ, Hays AG, Creanga AA, Cedars A, Michos ED, Blumenthal RS, Sharma G. The Association of Adverse Pregnancy Outcomes and Cardiovascular Disease: Current Knowledge and Future Directions. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22. [DOI: 10.1007/s11936-020-00862-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Novel approaches to combat preeclampsia: from new drugs to innovative delivery. Placenta 2020; 102:10-16. [PMID: 32980138 DOI: 10.1016/j.placenta.2020.08.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 08/30/2020] [Accepted: 08/31/2020] [Indexed: 12/22/2022]
Abstract
Preeclampsia is a complex disease affecting 2-8% of pregnancies worldwide. It poses significant risk of maternal and perinatal morbidity and mortality. Despite the rising research interest to discover new therapeutic approaches to prevent and treat preeclampsia, options remain limited. Identifying the important pathological stages in the progression of this disease allows us to evaluate effective candidate therapeutics. Three important stages in the pathophysiology are: 1) placental hypoxia and oxidative stress, 2) excess release of anti-angiogenic and pro-inflammatory factors, and 3) widespread systemic endothelial dysfunction and vasoconstriction. Repurposing drugs already safe for use in pregnancy is an attractive option for discovery of novel therapeutics. There are many drugs currently being assessed to treat preeclampsia, including proton pump inhibitors (PPIs), metformin, statins, sulfasalazine, sofalcone, resveratrol, melatonin, and sildenafil citrate. These drugs show positive effects in preclinical studies, targeting placental and endothelial dysfunction. However, using novel therapeutics can raise safety concerns for the developing fetus. Therefore, innovative targeted delivery systems are being developed to safely administer these therapeutics directly to the placenta and/or endothelium. These include nanoparticle delivery systems, developed and used by the oncology field, now being adapted for obstetrics. This technology is currently being assessed in animal models and shows promise for treating preeclampsia. Combining effective therapeutics with targeted drug delivery could be the future of preeclampsia treatment.
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Virtanen A, Huttala O, Tihtonen K, Toimela T, Heinonen T, Laivuori H, Uotila J. Therapeutic doses of metformin do not have impact on angiogenesis in presence of sera from pre-eclamptic, IUGR and healthy pregnancies. Pregnancy Hypertens 2020; 22:7-13. [PMID: 32682321 DOI: 10.1016/j.preghy.2020.06.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 06/25/2020] [Accepted: 06/30/2020] [Indexed: 01/15/2023]
Abstract
Recent evidence suggests that metformin may prevent pre-eclampsia by reverting the angiogenic imbalance in maternal sera. In this study, we investigated effect of metformin on angiogenesis by quantifying tubule formation in a human-based in vitro test with co-culture of human adipose stromal cell (hASC) and human umbilical vein endothelial cell (HUVEC). A total of 20 pregnant women were recruited in the study. Serum samples were obtained from women with early- and late-onset pre-eclampsia and from women with pregnancies complicated by intrauterine growth restriction (IUGR) without pre-eclampsia (N = 5 in each of the three groups). Serum samples from women with healthy pregnancies served as controls (N = 5). The direct effect of metformin on angiogenesis was first assessed without maternal sera. Secondly, we investigated the impact of metformin on angiogenesis in the present of maternal sera. Metformin was used at 5, 50 and 600 µg/ml concentrations. Angiogenic and inflammatory biomarkers in maternal sera were analyzed by immunoassays. When the direct effect of metformin was studied, the two lowest concentrations of metformin did not affect tubule formation (angiogenesis), but the highest concentration inhibited angiogenesis. When metformin was supplemented at therapeutic concentrations of 5 and 50 µg/ml along with serum samples, there was no change in tubule formation in comparison to maternal sera alone. However, strong inhibitory effect on tubule formation was observed in all groups with the highest, non-therapeutic (600 µg/ml), concentration of metformin.
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Affiliation(s)
- Anita Virtanen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland.
| | - Outi Huttala
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Kati Tihtonen
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
| | - Tarja Toimela
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Tuula Heinonen
- FICAM, Finnish Centre for Alternative Methods, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Hannele Laivuori
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Jukka Uotila
- Department of Obstetrics and Gynaecology, Tampere University Hospital, Tampere, Finland
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Can Endothelial Glycocalyx Be a Major Morphological Substrate in Pre-Eclampsia? Int J Mol Sci 2020; 21:ijms21093048. [PMID: 32357469 PMCID: PMC7246531 DOI: 10.3390/ijms21093048] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 04/21/2020] [Accepted: 04/23/2020] [Indexed: 02/06/2023] Open
Abstract
Today pre-eclampsia (PE) is considered as a disease of various theories; still all of them agree that endothelial dysfunction is the leading pathogenic factor. Endothelial dysfunction is a sequence of permanent immune activation, resulting in the change of both the phenotype and the functions of an endothelial cell and of the extracellular layer associated with the cell membrane—endothelial glycocalyx (eGC). Numerous studies demonstrate that eGC mediates and regulates the key functions of endothelial cells including regulation of vascular tone and thromboresistance; and these functions are disrupted during PE. Taking into account that eGC and its components undergo alterations under pathological conditions leading to endothelial activation, it is supposed that eGC plays a certain role in pathogenesis of PE. Envisaging the eGC damage as a key factor of PE, might be a new approach to prevention, treatment, and rehabilitation of patients with PE. This approach could include the development of drugs protecting eGC and promoting regeneration of this structure. Since the issue of PE is far from being solved, any effort in this direction might be valuable.
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Phipps EA, Thadhani R, Benzing T, Karumanchi SA. Pre-eclampsia: pathogenesis, novel diagnostics and therapies. Nat Rev Nephrol 2019; 15:275-289. [PMID: 30792480 DOI: 10.1038/s41581-019-0119-6] [Citation(s) in RCA: 513] [Impact Index Per Article: 102.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Pre-eclampsia is a complication of pregnancy that is associated with substantial maternal and fetal morbidity and mortality. The disease presents with new-onset hypertension and often proteinuria in the mother, which can progress to multi-organ dysfunction, including hepatic, renal and cerebral disease, if the fetus and placenta are not delivered. Maternal endothelial dysfunction due to circulating factors of fetal origin from the placenta is a hallmark of pre-eclampsia. Risk factors for the disease include maternal comorbidities, such as chronic kidney disease, hypertension and obesity; a family history of pre-eclampsia, nulliparity or multiple pregnancies; and previous pre-eclampsia or intrauterine fetal growth restriction. In the past decade, the discovery and characterization of novel antiangiogenic pathways have been particularly impactful both in increasing understanding of the disease pathophysiology and in directing predictive and therapeutic efforts. In this Review, we discuss the pathogenic role of antiangiogenic proteins released by the placenta in the development of pre-eclampsia and review novel therapeutic strategies directed at restoring the angiogenic imbalance observed during pre-eclampsia. We also highlight other notable advances in the field, including the identification of long-term maternal and fetal risks conferred by pre-eclampsia.
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Affiliation(s)
- Elizabeth A Phipps
- Nephrology Division, Brigham and Women's Hospital, Boston, MA, USA.,Nephrology Division, Massachusetts General Hospital, Boston, MA, USA
| | - Ravi Thadhani
- Nephrology Division, Massachusetts General Hospital, Boston, MA, USA.,Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Thomas Benzing
- Department II of Internal Medicine and Center for Molecular Medicine Cologne, University of Cologne, Cologne, Germany
| | - S Ananth Karumanchi
- Departments of Medicine and Biomedical Sciences, Cedars-Sinai Medical Center, Los Angeles, CA, USA. .,Nephrology Division, Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Maric-Bilkan C, Abrahams VM, Arteaga SS, Bourjeily G, Conrad KP, Catov JM, Costantine MM, Cox B, Garovic V, George EM, Gernand AD, Jeyabalan A, Karumanchi SA, Laposky AD, Miodovnik M, Mitchell M, Pemberton VL, Reddy UM, Santillan MK, Tsigas E, Thornburg KLR, Ward K, Myatt L, Roberts JM. Research Recommendations From the National Institutes of Health Workshop on Predicting, Preventing, and Treating Preeclampsia. Hypertension 2019; 73:757-766. [PMID: 30686084 DOI: 10.1161/hypertensionaha.118.11644] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Christine Maric-Bilkan
- From the Division of Cardiovascular Sciences (C.M.-B., S.S.A., V.L.P.), National Institutes of Health, Bethesda, MD
| | - Vikki M Abrahams
- Department of Ob/Gyn and Reproductive Sciences, Yale University School of Medicine, New Haven, CT (V.M.A.)
| | - S Sonia Arteaga
- From the Division of Cardiovascular Sciences (C.M.-B., S.S.A., V.L.P.), National Institutes of Health, Bethesda, MD
| | - Ghada Bourjeily
- Department of Medicine, Warren Alpert Medical School, Brown University, Providence, RI (G.B.)
| | - Kirk P Conrad
- Department of Physiology and Functional Genomics and Ob/Gyn, University of Florida College of Medicine, Gainesville (K.P.C.)
| | - Janet M Catov
- Department of Ob/Gyn and Reproductive Sciences, Magee-Women's Research Institute and Clinical and Translational Sciences Research Institute, University of Pittsburgh, PA (J.M.C., A.J., J.M.R.)
| | - Maged M Costantine
- Department of Ob/Gyn, University of Texas Medical Branch, Galveston (M.M.C.)
| | - Brian Cox
- Department of Physiology and Ob/Gyn, University of Toronto, ON, Canada (B.C.)
| | - Vesna Garovic
- Department of Internal Medicine and Division of Nephrology and Hypertension, Department of Ob/Gyn, Mayo Clinic, Rochester, MN (V.G.)
| | - Eric M George
- Department of Physiology and Biophysics and Cell and Molecular Biology, University of Mississippi Medical Center, Jackson (E.M.G.)
| | - Alison D Gernand
- Department of Nutritional Sciences, The Pennsylvania State University (A.D.G.)
| | - Arun Jeyabalan
- Department of Ob/Gyn and Reproductive Sciences, Magee-Women's Research Institute and Clinical and Translational Sciences Research Institute, University of Pittsburgh, PA (J.M.C., A.J., J.M.R.)
| | - S Ananth Karumanchi
- Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA (S.A.K.)
| | - Aaron D Laposky
- Division of Lung Diseases, National Center on Sleep Disorders Research (A.D.L.), National Institutes of Health, Bethesda, MD
| | - Menachem Miodovnik
- National Heart, Lung, and Blood Institute and Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (M. Miodovnik, U.M.R.), National Institutes of Health, Bethesda, MD
| | - Megan Mitchell
- Division of Extramural Research Activities (M. Mitchell), National Institutes of Health, Bethesda, MD
| | - Victoria L Pemberton
- From the Division of Cardiovascular Sciences (C.M.-B., S.S.A., V.L.P.), National Institutes of Health, Bethesda, MD
| | - Uma M Reddy
- National Heart, Lung, and Blood Institute and Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development (M. Miodovnik, U.M.R.), National Institutes of Health, Bethesda, MD
| | - Mark K Santillan
- Department of Ob/Gyn, University of Iowa Carver College of Medicine (M.K.S.)
| | | | - Kent L R Thornburg
- Bob & Charlee Moore Institute for Nutrition & Wellness, Oregon Health and Science University, Portland (K.L.R.T.)
| | | | - Leslie Myatt
- Bob & Charlee Moore Institute for Nutrition & Wellness and Department of Ob/Gyn, Oregon Health and Science University, Portland (L.M.)
| | - James M Roberts
- Department of Ob/Gyn and Reproductive Sciences, Magee-Women's Research Institute and Clinical and Translational Sciences Research Institute, University of Pittsburgh, PA (J.M.C., A.J., J.M.R.)
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Affiliation(s)
- Basky Thilaganathan
- From the Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, United Kingdom (B.T.).,Molecular and Clinical Sciences Research Institute, St George's University of London, United Kingdom (B.T.)
| | - Erkan Kalafat
- Faculty of Medicine, Department of Obstetrics and Gynecology, Ankara University, Turkey (E.K.)
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34
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Egan AM, Dunne FP. Optimal management of gestational diabetes. Br Med Bull 2019; 131:97-108. [PMID: 31504226 DOI: 10.1093/bmb/ldz025] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/11/2019] [Accepted: 07/17/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Gestational diabetes mellitus (GDM) is highly prevalent and has both short- and long-term implications for mother and infant. SOURCES OF DATA Literature search using PubMed with keywords 'Gestational diabetes' and 'diabetes in pregnancy' together with published papers known to the authors. AREAS OF AGREEMENT The cornerstone of management is medical nutrition therapy with regular self-monitoring of capillary blood glucose levels and intensification of therapy if glycaemic goals are not achieved. Post-partum, annual assessment for type 2 diabetes is recommended. AREAS OF CONTROVERSY Diagnostic criteria and new biomarkers for GDM and the clinical and economic benefits of treating women with milder levels of glucose intolerance during pregnancy. GROWING POINTS Women with GDM are a heterogeneous group with varying degrees of insulin resistance and beta cell dysfunction. AREAS TIMELY FOR DEVELOPING RESEARCH Development of alternative diagnostic markers and application of novel technologies for GDM management.
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Affiliation(s)
- Aoife M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN 55905, USA
| | - Fidelma P Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland, Galway H91 TK33, Ireland
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Bovbjerg ML, Pillai S. Current Resources for Evidence-Based Practice, September 2019. J Obstet Gynecol Neonatal Nurs 2019; 48:568-582. [PMID: 31442383 DOI: 10.1016/j.jogn.2019.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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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 DOI: 10.1002/ijgo.12802] [Citation(s) in RCA: 468] [Impact Index Per Article: 93.6] [Reference Citation Analysis] [Abstract] [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 Gynecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong SAR
| | - Andrew Shennan
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jonathan A Hyett
- Discipline of Obstetrics, Gynecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, NSW, Australia
| | - Anil Kapur
- World Diabetes Foundation, Bagsvaerd, Denmark
| | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Fionnuala McAuliffe
- Department of Obstetrics and Gynecology, The National Maternity Hospital, Dublin, Ireland
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, São Paulo, Brazil
| | - Peter von Dadelszen
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | | | - Anne B Kihara
- African Federation of Obstetrics and Gynaecology, Khartoum, Sudan
| | - Gian Carlo Di Renzo
- Center of Perinatal and Reproductive Medicine, Department of Obstetrics and Gynecology, 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, US Department of Health and Human Services, Bethesda, MD, Detroit, MI, 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
| | - Kypros H Nicolaides
- Fetal Medicine Research Institute, King's College Hospital London, London, UK
| | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center, Petah Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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38
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Affiliation(s)
- Sarosh Rana
- From the Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Chicago, IL (S.R.)
| | - Elizabeth Lemoine
- Harvard Medical School, Boston, MA (E.L.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
| | - Joey P. Granger
- Department of Physiology, University of Mississippi Medical Center, Jackson (J.P.G.)
| | - S. Ananth Karumanchi
- Departments of Medicine, Obstetrics and Gynecology, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (S.A.K.)
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA (E.L., S.A.K.)
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Abstract
PURPOSE OF REVIEW To evaluate recent developments in the management of hypertension in obese pregnant women. RECENT FINDINGS The mainstay of management targets prevention of hypertension with preconception counselling, entering pregnancy with a lower BMI, limiting weight gain, and taking low-dose aspirin to prevent pre-eclampsia from before 16 weeks' gestation. There are conflicting results regarding the use of metformin in reducing hypertensive disease, but there is a high probability that it has a role to play. Clinical trials are in progress examining the use of statins in preventing pre-eclampsia, with promising results from pre-clinical trials. Home blood pressure monitoring may be helpful in diagnosing and monitoring the control of hypertension. The most protective interventions against hypertensive disease in obese pregnant women are entering pregnancy at a lower BMI, avoiding inter-pregnancy weight gain, and taking low-dose aspirin during pregnancy. Further research is needed around the use of metformin, statins, and home blood pressure monitoring.
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Affiliation(s)
- Christina Coroyannakis
- Fetal Medicine Unit, St George's Hospital, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's Hospital, St George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.
- Fetal Medicine Unit, Department of Obstetrics & Gynaecology, St George's University Hospitals NHS Foundation Trust, Blackshaw Road, London, SW17 0QT, UK.
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Gu Y, Lu J, Li W, Liu H, Wang L, Leng J, Li W, Zhang S, Wang S, Tuomilehto J, Yu Z, Yang X, Baccarelli AA, Hou L, Hu G. Joint Associations of Maternal Gestational Diabetes and Hypertensive Disorders of Pregnancy With Overweight in Offspring. Front Endocrinol (Lausanne) 2019; 10:645. [PMID: 31616376 PMCID: PMC6763696 DOI: 10.3389/fendo.2019.00645] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 09/05/2019] [Indexed: 01/09/2023] Open
Abstract
Objectives: Either maternal gestational diabetes mellitus (GDM) or hypertensive disorder of pregnancy (HDP) is associated with an increased risk of obesity in the offspring. However, their joint associations with obesity in offspring remain unclear. We investigated the joint associations of maternal GDM and HDP with childhood overweight in offspring. Methods: We performed a large study in 1967 mother-child pairs. Maternal GDM was diagnosed according to the 1999 World Health Organization (WHO) criteria. HDP was defined as self-reported doctor-diagnosed hypertension or treatment of hypertension (including gestational hypertension, preeclampsia, sever preeclampsia or eclampsia) after 20 weeks of gestation on the questionnaire. Body mass index (BMI) for age Z-score and childhood overweight were evaluated according to WHO growth reference. We used the general linear models to compare children's Z score for BMI and logistic regression models to estimate odds ratios of childhood overweight according to maternal different status of GDM and HDP. Results: Offspring of mothers with both GDM and HDP had a higher BMI for age Z-score (0.63 vs. 0.03, P < 0.001) than children born to normotensive and normoglycemic pregnancy. After adjustment for maternal and children's major confounding factors, joint GDM and HDP were associated with increased odds ratios of offspring's overweight compared with normotensive and normoglycemic pregnancy (2.97, 95% confidence intervals [CIs] 1.65-5.34) and GDM alone (2.06, 95% CIs 1.20-3.54), respectively. After additional adjustment for maternal pre-pregnancy BMI and gestational weight gain, joint maternal GDM, and HDP was still associated with an increased risk of offspring's overweight compared with the maternal normotensive, and normoglycemic group but became to have a borderline increased risk compared with the maternal GDM alone group. Conclusions: Maternal GDM alone or joint GDM and HDP were associated with increased ratios of offspring's overweight.
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Affiliation(s)
- Yuying Gu
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA, United States
- Shanghai Business School, Shanghai, China
| | - Jun Lu
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA, United States
- Department of Endocrinology and Metabolism, Fengxian Hospital of Southern Medical University, Shanghai, China
| | - Weiqin Li
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Huikun Liu
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Leishen Wang
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Junhong Leng
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Wei Li
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Shuang Zhang
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Shuting Wang
- Tianjin Women's and Children's Health Center, Tianjin, China
| | - Jaakko Tuomilehto
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - Zhijie Yu
- Population Cancer Research Program, Dalhousie University, Halifax, NS, Canada
| | - Xilin Yang
- Department of Epidemiology, School of Public Health, Tianjin Medical University, Tianjin, China
| | - Andrea A. Baccarelli
- Department of Environmental Health Sciences, Columbia University Mailman School of Public Health, New York, NY, United States
| | - Lifang Hou
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Gang Hu
- Chronic Disease Epidemiology Laboratory, Pennington Biomedical Research Center, Baton Rouge, LA, United States
- *Correspondence: Gang Hu
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41
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Mayrink J, Costa ML, Cecatti JG. Preeclampsia in 2018: Revisiting Concepts, Physiopathology, and Prediction. ScientificWorldJournal 2018; 2018:6268276. [PMID: 30622442 PMCID: PMC6304478 DOI: 10.1155/2018/6268276] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 11/05/2018] [Accepted: 11/22/2018] [Indexed: 12/13/2022] Open
Abstract
Preeclampsia currently remains one of the leading causes of death and severe maternal morbidity. Although its prevalence is still underestimated in some places due to underreporting, preeclampsia is a disease that health professionals need to know how to deal with and take action. For this reason, the studies about the theme remain along with the advances in their understanding that often implies improvement and change of concepts and conducts. The complexity of its etiology is a challenge and requires further studies for its full understanding. Apparently, poor adaptation of the maternal organism to the conceptus, marked by the nonoccurrence of changes in the uterine spiral arteries, determines a series of systemic repercussions that compound the various forms of preeclampsia presentation. In recent years, the use of acetylsalicylic acid to prevent cases of early onset of the disease has been consolidated and, alongside, studies have advanced the development of accessible and effective methods of identifying women at risk of preeclampsia. The aim of this review is to discuss updates on the occurrence, concept, pathophysiology, repercussion, prevention, and prediction of preeclampsia.
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Affiliation(s)
- J. Mayrink
- Obstetric Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - M. L. Costa
- Obstetric Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
| | - J. G. Cecatti
- Obstetric Unit, Department of Obstetrics and Gynecology, School of Medical Sciences, University of Campinas, Campinas, Brazil
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Brosens I, Muter J, Ewington L, Puttemans P, Petraglia F, Brosens JJ, Benagiano G. Adolescent Preeclampsia: Pathological Drivers and Clinical Prevention. Reprod Sci 2018; 26:159-171. [DOI: 10.1177/1933719118804412] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Ivo Brosens
- Faculty of Medicine, KU Leuven, Leuven, Belgium
| | - Joanne Muter
- Division of Biomedical Sciences, Warwick Medical School, Coventry, United Kingdom
| | - Lauren Ewington
- Division of Biomedical Sciences, Warwick Medical School, Coventry, United Kingdom
| | | | - Felice Petraglia
- Department of Biomedical, Experimental and Clinical Sciences (Mario Serio), University of Florence, Florence, Italy
| | - Jan J. Brosens
- Division of Biomedical Sciences, Warwick Medical School, Coventry, United Kingdom
| | - Giuseppe Benagiano
- Department of Gynaecology, Obstetrics and Urology, “Sapienza” University, Rome, Italy
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