Prediction of preterm pre-eclampsia according to NICE and ACOG criteria: descriptive study of 597 492 Danish births from 2008 to 2017

Exploring new predictors for hypertensive disorders of pregnancy

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

Occupational noise exposure and maternal pregnancy complications: register-based cohort from urban areas in four Nordic countries

OBJECTIVE

To assess the role of occupational noise exposure on pregnancy complications in urban Nordic populations.

METHODS

A study population covering five metropolitan areas in Denmark, Finland, Norway and Sweden was generated using national birth registries linked with occupational and residential environmental exposures and sociodemographic variables. The data covered all pregnancies during 5-11 year periods in 2004‒2016, resulting in 373 184 pregnancies. Occupational noise exposure was based on a Swedish-developed job-exposure-matrix, containing measured A-weighted annual 8 hour noise levels (LAeq8h), and linked with person-specific job-history. Outcomes included diagnosed gestational diabetes, gestational hypertension, mild pre-eclampsia and severe pre-eclampsia. The data were analysed with logistic regression models separately in each country, adjusting for maternal (age, parity, birth year, education and marital status) and residential environmental factors (low neighbourhood income, NO2 and green and blue space). The results were combined by meta-analysis.

RESULTS

Occupational noise exceeding 80 dB, compared with less than 70 dB, was associated with an increased odds of gestational diabetes in all countries, with a combined OR of 1.26 (95% CI 1.04 to 1.51), and mild pre-eclampsia in all countries except Finland, resulting in a combined OR of 1.22 (95% CI 0.99 to 1.51). Further adjustment by maternal body-mass index attenuated these associations. No association with gestational hypertension or severe pre-eclampsia was found.

CONCLUSIONS

Register data from four nationalities show that gestational diabetes and, tentatively, mild pre-eclampsia was increased among pregnant workers working in occupations where noise levels exceed 80 dB LAeq8h but not in occupations with lower noise levels.

Association of epidural labor analgesia with maternal and neonatal outcomes in women with preeclampsia: a propensity score-matched single-center retrospective cohort study

BACKGROUND

Epidural labor analgesia (ELA) is widely and safely used for labor pain relief. However, it remains unclear whether ELA affects maternal and neonatal outcomes in women suffering from preeclampsia.

METHODS

This study reviewed the medical records of women with preeclampsia at ≥ 28 weeks of gestation between January 2015 and December 2020. The medical records of women were divided into ELA and no analgesia (NA) groups. The primary endpoint was the cesarean section (CS) rate. Secondary endpoints included hypotension, operative vaginal delivery, fetal distress, neonatal intensive care unit admission, and complications. Using multivariate logistic regression analysis and propensity score matching (PSM), the association between ELA and maternal and neonatal outcomes was examined.

RESULTS

A total of medical records of 686 women were enrolled, with 242 (35.3%) receiving ELA. Of these, 126 (18.4%) had a higher incidence of CS in the ELA group than in the NA group (22.7% vs. 16.0%, P = 0.020). Multivariable analysis indicated greater risks of CS [adjusted Odds Ratio (aOR) = 1.71; 95% CI, 1.07-2.74; P = 0.025] and operative vaginal delivery (aOR = 2.810; 95% CI, 1.379-5.725; P = 0.004) in the ELA group than that of NA group. In the PSM, ELA did not increase the risk of CS (aOR = 1.56; 95% CI, 0.97-2.52; P = 0.067) and OVD (aOR = 2.048; 95% CI, 0.936-4.484; P = 0.073). The secondary endpoints showed no significant differences between the two groups.

CONCLUSION

The study indicates an association between ELA and maternal and neonatal outcomes, supporting the safety of ELA in this population.

In utero aspirin exposure and child neurocognitive development: A propensity score-matched analysis

OBJECTIVE

To evaluate the association between a short-period, high-dose in utero aspirin exposure and child neurocognitive development.

DESIGN

A propensity score-matched analysis of a multicentre prospective cohort study.

SETTING

The US Collaborative Perinatal Project (1959-1976).

POPULATION

A total of 50 565 singleton live births with maternal information.

METHODS

We performed a propensity score matching to balance maternal characteristics between women with and without aspirin exposure. Inverse probability-weighted marginal structural models were used to estimate associations between aspirin exposure and child neurocognitive assessments.

MAIN OUTCOME MEASURES

Child neurocognitive development was assessed using the Bayley Scales at 8 months, the Stanford Binet Intelligence Scale at 4 years, and the Wechsler Intelligence Scale and Wide-Range Achievement Test (WRAT) at 7 years.

RESULTS

Children exposed to aspirin in utero were associated with an 8%-16% reduced risk of having suspect/abnormal or below-average scores in most neurocognitive assessments. A trend of lower risks of having suspect/abnormal or below-average scores was further observed in children with in utero aspirin exposure for more than 7 days, particularly on Bayley Mental (relative risk [RR] 0.82, 95% CI 0.74-0.92), WRAT Reading (RR 0.88, 95% CI 0.78-0.98) and WRAT Arithmetic tests (RR 0.76, 95% CI 0.66-0.86). This association was mainly observed in the second trimester of pregnancy.

CONCLUSIONS

In utero aspirin exposure was associated with improved child neurocognitive development in a prospective cohort study. Further studies are warranted to evaluate the impact of long-period and low-dose in utero aspirin exposure on child short- and long-term neurodevelopment.

Maternal blood endometase level as a predictive biomarker for hypertensive disorders during pregnancy: a prospective cohort study

Preeclampsia (PE) occurs due to inadequate spiral artery/trophoblast remodeling in early pregnancy. Endometases are involved in the remodeling of spiral arteries and placental trophoblasts. This study aimed to investigate differences in blood endometase levels between pregnant women with hypertensive disorders (PE and gestational hypertension [GHT]) and healthy pregnant women and to evaluate whether plasma endometase values ​​could play a predictive role in PE or GHT diagnosis. A total of 90 pregnant women (n(PE) = 30, n(GHT) = 30, n(healthy pregnant) = 30) who presented at the hospital between December 2023 and May 2024 and were 26-32 years of age and > 20 weeks pregnant were included in the study. The endometase levels in all pregnant women were determined in maternal blood plasma via enzyme-linked immunosorbent assay. The endometase values were recalculated according to albumin values, and corrected endometase (cEndo) values were determined. No significant differences in blood endometase levels were observed between the groups (p > 0.05). The cEndo value was significantly lower in the PE and GHT groups than in the control group (p < 0.05). There was no statistically significant difference in the cEndo values between the PE and GHT groups (p > 0.05). A statistically significant negative linear relationship was detected between cEndo values and mean systolic blood pressure and mean diastolic blood pressure (p < 0.05). The cEndo values in the PE and GHT groups at early (≤ 32 weeks 3 days) and late pregnancy were compared, and no statistically significant difference was detected (p > 0.05). Maternal blood cEndo values may play a successful role in distinguishing hypertensive diseases of pregnancy (PE + GHT) from healthy pregnant women. cEndo does not play an effective role in the differential diagnosis between pregnant women with PE and those with GHT. Studies with larger patient populations are needed.

Screening for pre-eclampsia with competing-risks model using placental growth factor measurement in blood samples collected before 11 weeks' gestation

OBJECTIVES

To describe the distributional properties and assess the performance of placental growth factor (PlGF) measured in blood samples collected before 11 weeks' gestation in the prediction of pre-eclampsia (PE).

METHODS

The study population consisted of pregnant women included in the Pre-eclampsia Screening in Denmark (PRESIDE) study with a PlGF measurement from the routine combined first-trimester screening (cFTS) blood sample collected at 8-14 weeks' gestation. PRESIDE was a prospective multicenter study investigating the predictive performance of the Fetal Medicine Foundation (FMF) first-trimester screening algorithm for PE in a Danish population. In the current study, serum concentration of PlGF in the cFTS blood samples was analyzed in batches between January and June 2021.

RESULTS

A total of 8386 pregnant women were included. The incidence of PE was 0.7% at < 37 weeks' gestation and 3.0% at ≥ 37 weeks. In blood samples collected at 10 weeks' gestation, PlGF multiples of the median (MoM) were significantly lower in pregnancies with preterm PE < 37 weeks compared to unaffected pregnancies. However, PlGF MoM did not differ significantly between pregnancies with PE and unaffected pregnancies in samples collected before 10 weeks' gestation.

CONCLUSIONS

The gestational-age range for PlGF sampling may be expanded from 11-14 to 10-14 weeks when assessing the risk for PE using the FMF first-trimester screening model. There is little evidence to support the use of PlGF in blood samples collected before 10 weeks' gestation. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Pre-eclampsia screening in Denmark (PRESIDE): national validation study

OBJECTIVES

To investigate the predictive performance of the Fetal Medicine Foundation (FMF) first-trimester screening algorithm for pre-eclampsia in a Danish population and compare screening performance with that of the current Danish strategy, which is based on maternal risk factors.

METHODS

This was a prospective study of women with a singleton pregnancy attending for their first-trimester ultrasound scan and screening for aneuploidies at six Danish university hospitals between May 2019 and December 2020. Prenatal data on maternal characteristics and medical history were recorded, and measurements of mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), serum pregnancy-associated plasma protein-A (PAPP-A) and serum placental growth factor (PlGF) were collected without performing a risk assessment for pre-eclampsia. Information on acetylsalicylic acid use was recorded. After delivery, pregnancy outcome, including gestational age at delivery and pre-eclampsia diagnosis, was recorded. Pre-eclampsia risk assessment for each woman was calculated blinded to outcome using the FMF screening algorithm following adjustment to the Danish population. Detection rates (DRs) of the FMF algorithm were calculated for a fixed screen-positive rate (SPR) of 10% and for the SPR achieved in the current Danish screening.

RESULTS

A total of 8783 pregnant women were included, with a median age of 30.8 (interquartile range (IQR), 28.1-33.9) years. The majority were white (95%), naturally conceiving (90%), non-smokers (97%) and had no family history of pre-eclampsia (96%). The median body mass index was 23.4 (IQR, 21.2-26.6) kg/m2 . A complete risk assessment including maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A was available for 8156 women (92.9%). In these women, UtA-PI was measured bilaterally with a median value of 1.58 (IQR, 1.27-1.94) and the median resting MAP of 80.5 (IQR, 76.1-85.4) mmHg in two consecutive measurements. Among these, 303 (3.7%) developed pre-eclampsia, including 55 (0.7%) cases of pre-eclampsia with delivery < 37 weeks of gestation and 16 (0.2%) cases of pre-eclampsia with delivery < 34 weeks. At a SPR of 10%, combined screening using the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A had a DR of 77.4% (95% CI, 57.6-97.2%) for pre-eclampsia with delivery < 34 weeks, 66.8% (95% CI, 54.4-79.1%) for pre-eclampsia with delivery < 37 weeks and 44.1% (95% CI, 38.5-49.7%) for pre-eclampsia with delivery at any gestational age. The current Danish screening strategy using maternal risk factors detected 25.0% of women with pre-eclampsia with delivery < 34 weeks and 19.6% of women with pre-eclampsia with delivery < 37 weeks at a SPR of 3.4%. When applying the FMF algorithm including maternal characteristics, MAP, UtA-PI and PlGF at the fixed SPR of 3.4%, the DRs were 60.5% (95% CI, 36.9-84.1%) for PE with delivery < 34 weeks and 45.2% (95% CI, 32.0-58.5%) for PE with delivery < 37 weeks.

CONCLUSION

In this large Danish multicenter study, the FMF algorithm based on maternal characteristics, MAP, UtA-PI, PlGF and PAPP-A predicted 77.4% of cases with pre-eclampsia with delivery < 34 weeks and 66.8% of cases with pre-eclampsia with delivery < 37 weeks of gestation at a SPR of 10%, suggesting that the performance of the algorithm in a Danish cohort matches that in other populations. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

First-trimester prediction of preterm prelabour rupture of membranes incorporating cervical length measurement

OBJECTIVES

To examine early pregnancy risk factors for preterm prelabour rupture of membranes (PPROM) and develop a predictive model.

STUDY DESIGN

Retrospective analysis of a cohort of mixed-risk singleton pregnancies screened in the first and second trimesters in three Danish tertiary fetal medicine centres, including a cervical length measurement at 11-14 weeks, at 19-21 weeks and at 23-24 weeks of gestation. Univariable and multivariable logistic regression analyses were employed to identify predictive maternal characteristics, biochemical and sonographic factors. Receiver operating characteristic (ROC) curve analysis was used to determine predictors for the most accurate model.

RESULTS

Of 3477 screened women, 77 (2.2%) had PPROM. Maternal factors predictive of PPROM in univariable analysis were nulliparity (OR 2.0 (95% CI 1.2-3.3)), PAPP-A < 0.5 MoM (OR 2.6 (1.1-6.2)), previous preterm birth (OR 4.2 (1.9-8.9)), previous cervical conization (OR 3.6 (2.0-6.4)) and cervical length ≤ 25 mm on transvaginal imaging (first-trimester OR 15.9 (4.3-59.3)). These factors all remained statistically significant in a multivariable adjusted model with an AUC of 0.72 in the most discriminatory first-trimester model. The detection rate using this model would be approximately 30% at a false-positive rate of 10%. Potential predictors such as bleeding in early pregnancy and pre-existing diabetes mellitus affected very few cases and could not be formally assessed.

CONCLUSIONS

Several maternal characteristics, placental biochemical and sonographic features are predictive of PPROM with moderate discrimination. Larger numbers are required to validate this algorithm and additional biomarkers, not currently used for first-trimester screening, may improve model performance.

Risk of pre-eclampsia and impact of disease activity and antirheumatic treatment in women with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis: a collaborative matched cohort study from Sweden and Denmark

Objective

To explore the risk of pre-eclampsia in rheumatoid arthritis (RA), axial spondyloarthritis (AxSpA) and psoriatic arthritis (PsA), focusing on the impact of treatment and disease activity.

Methods

We identified RA, AxSpA and PsA singleton pregnancies (2006–2018) by linking medical birth registers to Swedish (SRQ) and Danish (DANBIO) rheumatology registers. Control pregnancies from the medical birth registers were matched 1:10 on maternal age, parity and birth year.

We obtained information on antirheumatic treatment before and during pregnancy and disease activity during pregnancy. Risks of pre-eclampsia in RA, AxSpA and PsA pregnancies, compared with control pregnancies, were estimated overall and by antirheumatic treatment (conventional synthetic disease-modifying antirheumatic drug (DMARD)/biological DMARD/corticosteroids, as monotherapy or combination therapy) and disease load (Health Assessment Questionnaire≥1/C-reactive protein≥10/Disease Activity Score in 28 joints≥3.2) through logistic regression (adjusted ORs (aORs) with 95% CI).

Results

We observed 69, 34, and 26 pre-eclampsia events among RA (n=1739), AxSpA (n=819) and PsA (n=489), resulting in a risk of pre-eclampsia of, respectively, aOR 1.27 (95% CI 0.96 to 1.67), 1.17 (0.76 to 1.78) and 1.85 (1.10 to 3.12), compared with controls.

For RA, maternal combination therapy before and during pregnancy was associated with increased risk (1.59; 1.07 to 2.37 and 1.53; 0.97 to 2.39, respectively). For PsA, maternal monotherapy before pregnancy was associated with pre-eclampsia (2.72; 1.4 to 5.13). In RA pregnancies with available information (43%), high disease load was associated with doubled risk of pre-eclampsia (aOR 1.96; 1.26 to 3.04).

Conclusion

PsA pregnancies, but not AxSpA pregnancies, were at increased risk of pre-eclampsia. For RA, combination therapy (potentially a surrogate for high disease activity both before and during pregnancy) and high disease load during pregnancy might be a risk factor for pre-eclampsia.

Fibrinolytic Changes in Women with Preeclampsia

Objectives

Preeclampsia (PE) is a serious complication of pregnancy. The fibrinolytic system play crucial roles regarding placentation and evolution of PE.

Aim

To study comprehensively components of the fibrinolytic system and fibrin lysability in women with PE.

Design and Methods

117 women with PE and matched controls were included. Tissue type plasminogen activator (t-PA), plasminogen, PAI-1, plasmin inhibitor (PI), D-dimer, the fibrinolytic potential of dextran sulphate euglobulin fraction (DEF), PAI-2, polymere PAI-2, fibrin clot lysability, thrombin activatable fibrinolysis inhibitor (TAFI) and fibrinogen were assessed.

Results

Women with PE had significantly increased concentrations of t-PA and PAI-1, whereas the plasma concentration of PAI-2 was significantly lower compared to controls, p < 0.0001. Polymere PAI-2 was detected in both groups. DEF, TAFI and fibrinogen were not different between the groups. D-dimer was significantly increased and plasminogen/PI together with fibrin clot lysability time decreased in the PE-group, p  =  0.0004 p  =  0.04, p  =  0.03, p < 0.0001 respectively.

Conclusion

This study demonstrates that PE is associated with an affected t-PA/PAI-1 system, decreased PAI-2 and increased fibrin lysability. Furthermore, PAI-2 has the potential to polymerize during pregnancy.

Depressed Kallikrein Generation in Women With Preeclampsia: A Matched Cross-Sectional Study

Objective

The pathophysiology of preeclampsia is not fully understood. Disturbances in the contact system are associated with preeclampsia. Few studies have investigated the association between preeclampsia and alterations in the contact system in plasma. This study aims to elucidate whether this basic biological system is affected in preeclampsia using new methods focusing on the dynamic interactions and total capacity of the contact system in blood.

Design

Cross-sectional study matching women with preeclampsia and controls without preeclampsia regarding age, pregestational body mass index, and gestational age at onset of the disease.

Setting

Two Danish University hospitals.

Sample

A cohort of 117 women with preeclampsia and 117 controls.

Methods

The turnover and capacity of the contact system were determined with new methods. Paired t-test, Wilcoxon signed-pairs signed rank test, Mann-Whitney or Chi²-test were applied, as appropriate.

Main Outcome Measurements

Kallikrein generation (peak kallikrein concentration and endogenous kallikrein potential), coagulation factor XII, prekallikrein, H-kininogen, cleaved H-kininogen, and complement C1 esterase inhibitor.

Results

The endogenous kallikrein potential, peak kallikrein concentration, prekallikrein and cleaved H-kininogen were significantly lower in women with preeclampsia compared to the controls, p ≤ 0.005, whereas the concentration of coagulation factor XII, H-kininogen and complement C1 esterase inhibitor was not significantly different, p > 0.05.

Conclusion

This study demonstrates significant reduction in kallikrein generating capacity, prekallikrein and cleaved H-kininogen indicating that the contact system is affected in preeclampsia suggesting a link to the pathophysiology of the disease.