Mechanisms and management of hypertension in pregnant women

Detection of hypertension and blood pressure phenotypes using ambulatory blood pressure monitoring in women with past hypertensive disorders of pregnancies

OBJECTIVE

To evaluate the incidence of hypertension and blood pressure (BP) phenotypes using 24-hour ambulatory BP (24hr-ABP) in women with past pregnancy complications who were recruited into a Women's Heart Clinic (WHC).

STUDY DESIGN

We recruited 156 women aged 30-55 years with past hypertensive disorders of pregnancy (HDP) and/or gestational diabetes (GDM) to a multidisciplinary six-month WHC that provided cardiovascular risk management in Melbourne, Australia. Women were referred for 24 hr-ABP monitoring if clinic BP was ≥130/80 mmHg.

MAIN OUTCOME MEASURES

Primary outcome was incident hypertension, defined by 24 hr-ABP monitoring as daytime hypertension ≥135/85 mmHg, nocturnal hypertension ≥120/70 mmHg, and/or 24hr-average hypertension ≥130/80 mmHg.

RESULTS

From 156 women, 54 women underwent 24hr-ABP monitoring (mean age 41.3 ± 4.5 years; 3.9 ± 2.6 years post-partum), with 64.8 % HDP and 45.2 % GDM. Incidence of hypertension was 61.1 % [95 % CI 48.2 %-74.0 %]. Higher proportion of women with past HDP had daytime hypertension compared to those with GDM only (57.1 % vs. 26.3 %; p = 0.05) and higher nocturnal mean systolic-BP [116.0 ± 11.2 mmHg vs. 109.6 ± 8.7 mmHg; p = 0.04]. Women with HDP had increased odds of hypertension [adjusted-OR 5.26 95 % CI (1.07-32.76); p = 0.05]. Following management at the WHC, women diagnosed with hypertension had significantly improved BP control (6.1 % at baseline vs. 75.8 % at six-month follow-up; p < 0.001).

CONCLUSION

Women with past HDP had five-fold increased incidence of hypertension, with higher daytime hypertension and nocturnal systolic-BP, compared to women with GDM. After attending WHC, BP control significantly improved. Our findings suggest routine postpartum follow-up with 24hr-ABP monitoring, through a WHC, may be useful in early detection and management of hypertension in these women.

Pregnancy and placental outcomes according to maternal BMI in women with preeclampsia: a retrospective cohort study

PURPOSE

Obesity and preeclampsia share similar patho-mechanisms and can both affect placental pathology. We aimed to investigate pregnancy outcomes in correlation with placental pathology among pregnancies complicated by preeclampsia in three different maternal body mass index (BMI, kg/m2) groups.

METHODS

In this retrospective cohort study, medical and pathological records of patients with preeclampsia and a singleton pregnancy delivered between 2008 and 2021 at a single tertiary medical center were reviewed. Study population was divided into three BMI groups: BMI < 22.6 kg/m2 (low BMI group), 22.7 ≤ BMI ≤ 28.0 kg/m2 (middle-range BMI group), and BMI > 28.0 kg/m2 (high BMI group). Data regarding maternal characteristics, neonatal outcomes, and placental histopathological lesions were compared.

RESULTS

The study groups included a total of 295 patients diagnosed with preeclampsia-98, 99, and 98 in the low, middle-range, and high BMI groups respectively. Neonatal birth weight was significantly decreased in the low maternal BMI group compared to both middle and high BMI groups (p = 0.04) with a similar trend seen in placental weight (p = 0.03). Villous changes related to maternal malperfusion were more prevalent in the low and high BMI groups compared to middle-range BMI group (p < 0.01) and composite maternal vascular malperfusion lesions were also more prevalent in the groups of BMI extremities compared to the middle-range BMI group (p < 0.01).

CONCLUSION

Maternal BMI might influence neonatal outcomes and placental pathology in pregnancies complicated by preeclampsia. Both extremes of BMI were associated with higher rates of placental maternal vascular malperfusion. Balanced BMI in women at risk for preeclampsia may reduce the incidence of placental lesions.

The Impact of Secondary Hypertension in Pregnancy on Maternal and Fetal Outcomes: A 42-Month Observational Study from South India

Objectives

To examine the prevalence, etiology, and clinical outcomes of secondary hypertension in pregnancy in a high-risk tertiary care hospital.

Study Design

This retrospective study used data from patient records between January 2015 and July 2018. Of 52,293 pregnant women admitted during this period, those with hypertension were included. Patient demographics, diagnosis of secondary hypertension, investigations, suspected etiologies of secondary hypertension, maternal and neonatal outcomes and discharge conditions were included.

Main Outcome Measures

The prevalence of secondary hypertension and causes were measured. Univariate followed by multivariate analyses were done to look for associated maternal and neonatal outcomes.

Results

Among patients with chronic hypertension in pregnancy, 13.7% had secondary causes, of which renal and cardiac causes were the commonest. The incidence of severe pre-eclampsia (40.5%) among patients with secondary hypertension was higher in patients with systolic blood pressures more than 140 mm of Hg than in those with systolic blood pressures lower than 140 mm of Hg (odds ratio [OR]: 4.92, confidence interval [CI]: 1.7-14.16, p: 0.002) irrespective of etiology. Pre-eclampsia predisposed to maternal acute kidney injury (OR: 1.23, CI: 1.04-1.45, p: 0.003), low birthweight (OR: 4.69, CI: 1.44-11.9, p: 0.006), preterm delivery (OR: 4.69, CI: 1.78-12.34, p: 0.001), and neonatal death (OR: 5.19, CI: 0.97-27.6, p: 0.04).

Conclusion

The prevalence of hypertension in pregnancy was 10.3%; among them, the prevalence of secondary hypertension was 1.46%. Uncontrolled secondary hypertension was associated with poor maternal and neonatal outcomes. Strict control of blood pressure in secondary hypertension in pregnancy ensured better outcomes.

Hypoxia induced-disruption of lncRNA TUG1/PRC2 interaction impairs human trophoblast invasion through epigenetically activating Nodal/ALK7 signalling

Inadequate trophoblastic invasion is considered as one of hallmarks of preeclampsia (PE), which is characterized by newly onset of hypertension (>140/90 mmHg) and proteinuria (>300 mg in a 24‐h urine) after 20 weeks of gestation. Accumulating evidence has indicated that long noncoding RNAs are aberrantly expressed in PE, whereas detailed mechanisms are unknown. In the present study, we showed that lncRNA Taurine upregulated 1 (TUG1) were downregulated in preeclamptic placenta and in HTR8/SVneo cells under hypoxic conditions, together with reduced enhancer of zeste homolog2 (EZH2) and embryonic ectoderm development (EED) expression, major components of polycomb repressive complex 2 (PRC2), as well as activation of Nodal/ALK7 signalling pathway. Mechanistically, we found that TUG1 bound to PRC2 (EZH2/EED) in HTR8/SVneo cells and weakened TUG1/PRC2 interplay was correlated with upregulation of Nodal expression via decreasing H3K27me3 mark at the promoter region of Nodal gene under hypoxic conditions. And activation of Nodal signalling prohibited trophoblast invasion via reducing MMP2 levels. Overexpression of TUG1 or EZH2 significantly attenuated hypoxia‐induced reduction of trophoblastic invasiveness via negative modulating Nodal/ALK7 signalling and rescuing expression of its downstream target MMP2. These investigations might provide some evidence for novel mechanisms responsible for inadequate trophoblastic invasion and might shed some light on identifying future therapeutic targets for PE.

South African medicinal plants displaying angiotensin-converting enzyme inhibition: Potential use in the management of preeclampsia

In resource-limited settings, such as South Africa, hypertensive disorders of pregnancy such as preeclampsia, is the most common direct cause of maternal deaths. Current management strategies of preeclampsia primarily involve the use of pharmaceutical drugs, which are frequently associated with undesirable side-effects. Moreover, these drugs are often not easily accessible due to financial and economic constraints. Consequently, many patients rely on traditional medicine obtained from medicinal plants to manage health-related conditions. Angiotensin-converting enzyme inhibitors are widely used drugs for the management of preeclampsia. This narrative review aims to highlight the use of indigenous medicinal plants from South Africa with Angiotensin-converting enzyme inhibitory activity whilst also evaluating their potential use in the treatment of hypertension in pregnancy. This information will influence traditional healers and sangomas in their patient management. Furthermore, the antihypertensive potential of these plants will be unraveled thus facilitating the development of new naturally occurring pharmaceutical products to reduce maternal and neonatal mortality and morbidity.

Associations between residential proximity to oil and gas extraction and hypertensive conditions during pregnancy: a difference-in-differences analysis in Texas, 1996-2009

BACKGROUND

Oil and gas extraction produces air pollutants that are associated with increased risks of hypertension. To date, no study has examined residential proximity to oil and gas extraction and hypertensive conditions during pregnancy. This study quantifies associations between residential proximity to oil and gas development on gestational hypertension and eclampsia.

METHODS

We utilized a population-based retrospective birth cohort in Texas (1996-2009), where mothers reside <10 km from an active or future drilling site (n = 2 845 144.) Using full-address data, we linked each maternal residence at delivery to assign exposure and evaluate this exposure with respect to gestational hypertension and eclampsia. In a difference-in-differences framework, we model the interaction between maternal health before (unexposed) or after (exposed) the start of drilling activity (exposed) and residential proximity near (0-1, >1-2 or >2-3 km) or far (≥3-10 km) from an active or future drilling site.

RESULTS

Among pregnant women residing 0-1 km from an active oil or gas extraction site, we estimate 5% increased odds of gestational hypertension [95% confidence interval (CI): 1.00, 1.10] and 26% increased odds of eclampsia (95% CI: 1.05, 1.51) in adjusted models. This association dissipates in the 1- to 3-km buffer zones. In restricted models, we find elevated odds ratios among maternal ages ≤35 years at delivery, maternal non-Hispanic White race, ≥30 lbs gained during pregnancy, nulliparous mothers and maternal educational attainment beyond high school.

CONCLUSIONS

Living within 1 km of an oil or gas extraction site during pregnancy is associated with increased odds of hypertensive conditions during pregnancy.

Comparison of nitric oxide levels, roll over test value, and body mass index in preeclampsia and normotension

OBJECTIVE

The study aims to compare levels NO, the ROT, and BMI values in preeclampsia and normotension.

METHOD

This study was an observational analytical study that combined the draft case-control study and a cross-sectional study (hybrid method) conducted in February-June 2020. This study was conducted in the Hospital Dr. Wahidin Sudirohusodo Makasar, Antang Health Center, Barabaraya Health Center, and Mamajang Health Center. Respondents in this study were pregnant women divided into two groups, 108 mothers with normal pregnancies and 42 mothers with preeclampsia. The criteria of the study respondents were single pregnancies, pregnancy of more than 20 weeks, and the gestational age of 20-35 years old. Data collected includes age, parity, gestational age, pregnancy interval, body mass index (BMI), and education. In addition, Nitric oxide levels are determined using Elisa Kit, and roll over test is collected by performing blood pressure measurements at two different positions.

RESULTS

The mean serum NO levels in the preeclampsia 176.43±50.8 and 152.75±51.3 in normotension, and there is a meaningful relationship p=0.012. Mean value of ROT in preeclampsia 23.21±8.54 and 19.63±8.85 in normotension p=0.026. There is a meaningful difference in IMT with preeclampsia p=0.003.

CONCLUSION

NO, ROT and BMI are significantly higher in pregnant mothers with preeclampsia than in normal pregnancies.

Alpha-1 Antitrypsin-Induced Endoplasmic Reticulum Stress Promotes Invasion by Extravillous Trophoblasts

Alpha-1 antitrypsin (A1AT) is a glycoprotein that has been shown to protect tissues from proteolytic damage under various inflammatory conditions. Several studies show that A1AT may be associated with pre-eclampsia. However, the role of A1AT expression in placental physiology is not fully understood. In the present study, we aim to characterize the expression and function of placental A1AT. A1AT knockdown is found to reduce the expression of the serine protease HTRA1 in a trophoblast cell line. In addition, A1AT overexpression (A1AT-OE) increases the expression of HTRA1, IL6, CXCL8, and several markers of endoplasmic reticulum (ER) stress. Treatment with tunicamycin or thapsigargin, which induces ER stress, increases HTRA1 expression. Furthermore, immunohistochemistry reveals that HTRA1 is expressed in trophoblasts and the endometrial decidual cells of human placentas. An invasion assay shows that A1AT and HTRA1 stimulate cell invasion, but treatment with the ER stress inhibitors reduces the expression of HTRA1 and ER stress markers and prevents cell invasion in A1AT-OE trophoblasts. These results suggest that endogenous A1AT regulates inflammatory cytokine expression and HTRA1-induced trophoblast invasion via the induction of ER stress. It is concluded that an imbalance in the functional link between A1AT and ER stress at the maternal-fetal interface might cause abnormal placental development.

Fetal High-Density Lipoproteins: Current Knowledge on Particle Metabolism, Composition and Function in Health and Disease

Cholesterol and other lipids carried by lipoproteins play an indispensable role in fetal development. Recent evidence suggests that maternally derived high-density lipoprotein (HDL) differs from fetal HDL with respect to its proteome, size, and function. Compared to the HDL of adults, fetal HDL is the major carrier of cholesterol and has a unique composition that implies other physiological functions. Fetal HDL is enriched in apolipoprotein E, which binds with high affinity to the low-density lipoprotein receptor. Thus, it appears that a primary function of fetal HDL is the transport of cholesterol to tissues as is accomplished by low-density lipoproteins in adults. The fetal HDL-associated bioactive sphingolipid sphingosine-1-phosphate shows strong vasoprotective effects at the fetoplacental vasculature. Moreover, lipoprotein-associated phospholipase A2 carried by fetal-HDL exerts anti-oxidative and athero-protective functions on the fetoplacental endothelium. Notably, the mass and activity of HDL-associated paraoxonase 1 are about 5-fold lower in the fetus, accompanied by an attenuation of anti-oxidative activity of fetal HDL. Cholesteryl ester transfer protein activity is reduced in fetal circulation despite similar amounts of the enzyme in maternal and fetal serum. This review summarizes the current knowledge on fetal HDL as a potential vasoprotective lipoprotein during fetal development. We also provide an overview of whether and how the protective functionalities of HDL are impaired in pregnancy-related syndromes such as pre-eclampsia or gestational diabetes mellitus.

Hypertensive Disorders of Pregnancy in Relation to Coffee and Tea Consumption: The Japan Environment and Children's Study

Background: The association between coffee/tea intake and hypertensive disorders of pregnancy (HDP) remains unclear. This study aimed to investigate the association of caffeine, coffee, and tea intake during pregnancy with the risk of HDP. Methods: We assessed this association in 85,533 singleton pregnant women with live births in the Japan Environment and Children’s Study, a prospective cohort in Japan that included women from early pregnancy onward. Caffeinated and decaffeinated coffee and tea (green, oolong, and black) consumption during pregnancy was assessed using a validated food frequency questionnaire conducted at mid-pregnancy, and caffeine intake was calculated based on coffee and tea consumption. Multivariable logistic regression was used to assess the association with the risk of HDP. Results: HDP developed in 2222 women (2.6%). Caffeine intake was weakly associated with increased risk of HDP; the multivariable odds ratio of HDP for the highest versus the lowest quartile was 1.26 (95% confidence interval: 1.11, 1.43). Coffee drinkers of two or more cups per day showed a decreased risk compared with non-drinkers (multivariable odds ratio 0.79; 0.62, 0.99) even after adjustment for total caffeine intake. Tea consumption was not associated with the risk of HDP. Conclusions: Our study suggests that higher caffeine intake may increase HDP risk, while coffee drinkers had a lower risk. Further high-quality studies are needed to replicate these findings, and to elucidate if other substances in coffee may be protective against HDP.

Soluble endoglin in urine as an early-pregnancy preeclampsia marker: antenatal longitudinal feasibility study

This study aimed to evaluate soluble endoglin (sEng) in urine as a preeclampsia predictor. Ninety-three pregnant women at risk for preeclampsia were followed. Spot urine sample ELISA analysis before 20 weeks of gestation was done to assess protein levels. Logistic regression analysis evaluated associations between preeclampsia with sEng/creatinine ratio, pg/mg, adjusted for risk factors. Preeclampsia incidence was 22.8% (20/92). Urinary sEng/creatinine (pg/mg) 0.001 (95% CI 0.001-0.136) was associated, adjusted for body mass index > 28 kg/m² OR 6.44 (95% CI 1.11-37.47) and mean arterial pressure OR 1.20 (1.07-1.35). During the first half of gestation sEng urinary excretion was lower in pregnant women developing preeclampsia.Impact statementWhat is already known on this subject? The angiogenesis factors present in the plasma of pregnant women have shown good preclinical predictors of preeclampsia. Studies on urinary markers in pregnancy are infrequent, despite the ease of obtaining urine specimens.What do the results of this study add? Values of the sEng/creatinine ratio during the first half of pregnancy were related to a higher chance of preeclampsia occurring when it was evaluated alone or adjusted by body mass index and mean arterial pressure values.What are the implications of these findings for clinical practice and/or further research? The potential benefits of a urinary test compared to one of the blood levels include its non-invasive nature and ease of performing the test, even during prenatal care. Future research is expected to evaluate the sEng/creatinine ratio relevance to improve clinical scores of preeclampsia prediction for the identification of women at risk for this disease.

Clinical Experiences of Intravenous Hydralazine and Labetalol for Acute Treatment of Severe Hypertension in Pregnant Thai Women

Response to acute treatment of severe hypertension during pregnancy in Asian women was not known. Labor and delivery checklists of Thai women treated with intravenous hydralazine or labetalol for systolic blood pressure (SBP) ≥ 160 or diastolic blood pressure (DBP) ≥ 110 mm Hg from January 2011 to December 2013 were reviewed as parts of an audit. Primary outcome was prompt achievement of SBP 140-150 and DBP 90-100 mm Hg after the first bolus. Secondary outcomes were medication-related undesired effects. The mean ± standard deviation age and prevalence of chronic hypertension in hydralazine (n = 62) versus labetalol (n = 64) groups were 32.5 ± 6 versus 29.9 ± 6.8 years and 50% versus 21.9%, respectively (P < .05). Magnesium sulfate was promptly administered on admission to every woman to prevent seizure. Targeted blood pressure was timely achieved in 41.9% and 67.2% of the hydralazine and labetalol groups, respectively (P < .05). Nonreassuring fetal heart rate occurred in 51.6% and 32.8% of the hydralazine and labetalol groups, respectively (P = .05). The prevalence of cesarean section and Apgar score < 7 were not significantly different (P > .05). Real-life clinical experiences suggested significant advantages of intravenous labetalol over hydralazine in pregnant women with severe hypertension.

A mushroom diet reduced the risk of pregnancy-induced hypertension and macrosomia: a randomized clinical trial

Background

Pregnancy-induced hypertension (PIH) is a disease characterized by high blood pressure detected after 20 weeks of pregnancy, affecting approximately 10% of pregnant women worldwide. Effective strategies are imperatively needed to prevent and treat PIH.

Methods

Subjects were required to consume 100 g mushroom daily from pre-pregnancy to the 20th week of gestation. The gestational hypertension and related primary and secondary outcomes of the mushroom diet (MD) group and placebo group were investigated to compare the intervention of a MD on the PIH and preeclampsia-associated maternal and child health conditions.

Results

A total of 582 and 580 subjects belonging to the MD group and placebo group were included for the analysis, respectively. Compared to the placebo, the MD significantly reduced the incidence of gestational hypertension (P = 0.023), preeclampsia (P = 0.014), gestational weight gain (P = 0.017), excessive gestational weight gain (P = 0.032) and gestational diabetes (P = 0.047). Stratified analysis showed that the MD lowered the risk of PIH for overweighed women (P = 0.036), along with the percentage of macrosomia (P = 0.007).

Conclusion

An MD could serve as a preventative strategy for lowering the risk of PIH and could control newborn birthweight while reducing comorbidities including gestational weight gain, diabetes etc.

Blood pressure changes during twin pregnancies: the Japan Environment and Children's Study

OBJECTIVES

Although a twin pregnancy is a risk factor for hypertensive disorders of pregnancy, studies investigating longitudinal blood pressure changes during twin pregnancies are uncommon. The aims of this study were to evaluate the longitudinal blood pressure changes during twin pregnancies and to compare blood pressure levels between twin and singleton pregnancies.

METHODS

Five hundred dichorionic diamniotic twin, 240 monochorionic diamniotic twin, and 80 775 singleton pregnancies were included in this Japanese prospective birth cohort study. A marginal model was applied to evaluate the SBP, DBP, and mean arterial pressure levels during early gestation, mid-gestation, and late gestation.

RESULTS

The blood pressure levels fell from early-to-mid-gestation and rose after mid-gestation in the dichorionic and monochorionic diamniotic twin pregnancies. The SBP and mean arterial pressure levels during early gestation and the DBP and mean arterial pressure levels during late gestation were higher in the dichorionic diamniotic twin pregnancies than those in the singleton pregnancies. The blood pressure levels in the monochorionic diamniotic twin pregnancies were higher than those in the singleton pregnancies at each gestational stage, except for the SBP during late gestation.

CONCLUSION

Although the longitudinal blood pressure changes during twin pregnancies were similar to those during singleton pregnancies, the blood pressure levels during twin pregnancies were higher. Further studies that examine the associations between the longitudinal blood pressure changes during pregnancy and the perinatal outcomes in twin pregnancies are necessary.

Direct laboratory evidence that pregnancy-induced hypertension might be associated with increased catecholamines and decreased renalase concentrations in the umbilical cord and mother’s blood

Background

Renalase (RNL) is a controversial enzyme as to whether it oxidizes catecholamines (CAs) (as is generally accepted) in the blood or not. CAs (dopamine [DPMN], epinephrine [EPI] and norepinephrine [NEPI]) are associated with hypertension, including pregnancy-induced hypertension, which occurs in 8–10% of all pregnancies. Therefore, the aim of the study was to compare CAs and renalase concentration in (i) normotensive controls (C), (ii) patients with preeclampsia (PE) and (iii) patients with severe preeclampsia (SPE), which is one of the well-known symptoms of hypertension.

Methods

This case-control study involved 90 women divided into three groups – 30 C, 30 PE and 30 SPE – whose age and body mass indexes (BMIs) were similar. A total of 270 blood samples (90 maternal samples, 90 umbilical cord artery samples and 90 umbilical cord vein samples) were obtained. CAs and RNL concentrations of the biological samples were measured by enzyme-linked immunosorbent assay (ELISA).

Results

Comparing the amounts of CAs, RNL and systolic blood pressure (SBP)/diastolic blood pressure (DBP) between healthy control pregnant women and pregnant women with PE and SPE (SBP/DBP was 120/80 mm Hg for C, above 140/90 mm Hg for PE and above 160/110 mm Hg for SPE), the levels of CAs were significantly increased whereas RNL was reduced. The correlation between SBP/DBP and the amount of RNL in pregnant women with PE and SPE was negative.

Conclusions

These novel results are evidence that hypertension seen in PE and SPE is directly related to increased levels of CAs and reduced RNL concentrations. The use of RNL preparations may be preferred in future to prevent maternal and perinatal morbidity and mortality due to pregnancy-induced hypertension.

The management of hypertension in women planning for pregnancy

INTRODUCTION OR BACKGROUND

Poorly-controlled hypertension in the first trimester significantly increases maternal and fetal morbidity and mortality. The majority of guidelines and clinical trials focus on the management and treatments for hypertension during pregnancy and breast-feeding, while limited evidence could be applied to the management for hypertension before pregnancy. In this review, we summarized the existing guidelines and treatments of pre-pregnancy treatment of hypertension.

SOURCES OF DATA

PubMed.

AREAS OF AGREEMENT

Methyldopa and labetalol are considered the first choice, but angiotensin-converting enzyme (ACE) inhibitors and angiotensin receptor blockers (ARBs) need to be withdrawn if a hypertensive woman wishes to become pregnant. In women with chronic hypertension, it is very important to make an assessment before conception to exclude secondary causes of hypertension, evaluate their hypertensive control to ensure that it is optimal, discuss the increased risks of pre-eclampsia, and provide education regarding any drug alterations before they become pregnant.

AREAS OF CONTROVERSY

There is increasing debate regarding discouraging the use of diuretics. There is also controversy regarding the use of supplementations such as calcium, antioxidants and low-dose aspirin.

GROWING POINTS

A less restricted blood-pressure goal could be set for hypertensive women planning for pregnancy. A healthy body weight before pregnancy could lower the risk of pregnancy-related hypertensive disorders. Recent guidelines also encourage women with chronic hypertension to keep their dietary sodium intake low, either by reducing or substituting sodium salt before pregnancy.

TIMELY AREAS FOR DEVELOPING RESEARCH

Large, worldwide, randomized trials should be conducted to see the outcomes for hypertensive women who take antioxidants/physical activity before pregnancy.

Association between alcohol consumption during pregnancy and hypertensive disorders of pregnancy in Japan: the Japan Environment and Children's Study

This study examined the association between maternal alcohol consumption during pregnancy and hypertensive disorders of pregnancy in the Japan Environment and Children's Study, a nationwide birth cohort study. A total of 76 940 pregnant women were included in the analysis. Information about alcohol consumption during pregnancy was obtained using two questionnaires: T1 and T2. The mean (standard deviation) gestational age in the T1 and T2 questionnaires were 16.5 (5.8) and 27.9 (3.7) weeks, respectively. Alcohol consumption was considered as an exposure, hypertensive disorders of pregnancy as an outcome, and possible confounding factors were included in a generalized linear mixed-effects model with a logit link function. Among the study subjects, 2 348 (3.1%) women developed hypertensive disorders of pregnancy. Compared with 25 300 women who never drank alcohol, 43 women who drank alcohol according to the T1 questionnaire and continued to drink ≥150 g ethanol/week according to the T2 questionnaire had significantly higher odds of hypertensive disorders of pregnancy. The adjusted odds ratio was 3.98 (95% confidence interval [CI], 1.33-11.9). In conclusion, alcohol consumption of ≥150 g ethanol/week during pregnancy is better avoided because of the high odds of developing hypertensive disorders of pregnancy. It may be meaningful that healthcare providers confirm information about alcohol consumption during pregnancy. Moreover, discontinuation of alcohol consumption is recommended to prevent the onset of hypertensive disorders of pregnancy in Japan.

Air Pollutant Exposure Within a Few Days of Delivery and Placental Abruption in Japan

BACKGROUND

Placental abruption is an emergency obstetric complication. Although the etiology of abruption is not fully understood, acute stimuli, such as ischemia and/or inflammation, are associated with rupture of the decidual artery, resulting in placental separation. Ischemia and inflammation are acute biologic effects of air pollution. Using a case-crossover design, we tested the hypothesis that a short-term increase in exposure to air pollutants is a potential trigger of placental abruption.

METHODS

We received data for western Japan (Kyushu-Okinawa Districts) from the Japan Perinatal Registry Network database. From 2005 to 2010, 821 singleton pregnant women with placental abruption were identified. We assigned daily concentrations of air pollutants, including nitrogen dioxide (NO2), suspended particulate matter, ozone, and sulfur dioxide (SO2), from the nearest monitoring station to the respective delivery hospital of each woman. Because information on the onset day of abruption was not obtained, we assumed the case day to be 1 day before the day of delivery.

RESULTS

Exposure to NO2 at 2 days' lag was associated with placental abruption (temperature adjusted odds ratio per 10 ppb increase = 1.4; 95% confidence interval = 1.1, 1.8). The association patterns were similar, when we restricted to participants who delivered by emergency cesarean (1.4, 1.1, 1.9), or who delivered after 35 weeks of gestation (1.4, 1.0, 2.0). There was no association with suspended particulate matter, ozone, or SO2.

CONCLUSIONS

We observed an association between NO2 exposure at 2 days before the day of delivery and placental abruption in pregnant Japanese women.

Dysregulated placental microRNAs in Early and Late onset Preeclampsia

INTRODUCTION

To determine the miRNA expression profile in placentas complicated by Preeclampsia (PE) and compare it to uncomplicated pregnancies.

METHODS

Sixteen placentas from women with PE, [11 with early onset PE (EOPE) and 5 with late onset PE (LOPE)], as well as 8 placentas from uncomplicated pregnancies were analyzed using miRNA microarrays. For statistical analyses the MATLAB^® simulation environment was applied. The over-expression of miR-518a-5p was verified using Quantitative Real-Time Polymerase Chain Reaction.

RESULTS

Forty four miRNAs were found dysregulated in PE complicated placentas. Statistical analysis revealed that miR-431, miR-518a-5p and miR-124* were over-expressed in EOPE complicated placentas as compared to controls, whereas miR-544 and miR-3942 were down-regulated in EOPE. When comparing the miRNA expression profile in cases with PE and PE-growth restricted fetuses (FGR), miR-431 and miR-518a-5p were found over-expressed in pregnancies complicated by FGR.

DISCUSSION

Since specific miRNAs can differentiate EOPE and LOPE from uncomplicated placentas, they may be considered as putative PE-specific biomarkers. MiR-518a-5p emerged as a potential diagnostic indicator for EOPE cases as well as for PE-FGR complicated placentas, indicating a potential link to the severity of the disease.

Moderately elevated blood pressure during pregnancy and odds of hypertension later in life: the POUCHmoms longitudinal study

OBJECTIVE

Hypertensive disorders in pregnancy signal an increased risk of cardiovascular disease for women. However, future hypertension risk among pregnant women with moderately elevated blood pressure (BP) is unknown. We examined associations among moderately elevated BP or hypertensive disorders during pregnancy and later prehypertension or hypertension.

DESIGN

Longitudinal cohort study.

SETTING

Five communities in Michigan, USA.

SAMPLE

Data are from pregnant women enrolled in the Pregnancy Outcomes and Community Health Study. We included 667 women with gestational BP measurements who participated in the POUCHmoms Study follow-up 7-15 years later.

METHODS

Moderately elevated BP was defined as two measures of systolic BP ≥ 120 mmHg or diastolic BP ≥80 mmHg among women without a hypertensive disorder. Weighted multinomial logistic regression models estimated odds of prehypertension or hypertension at follow-up, adjusted for maternal confounders and time to follow-up.

MAIN OUTCOME MEASURES

Prehypertension or hypertension.

RESULTS

Women meeting the moderately elevated BP criteria (64%) had significantly higher odds of hypertension at follow-up (adjusted odds ratio 2.6; 95% confidence interval 1.2-5.5). These increased odds were observed for moderately elevated BP first identified before or after 20 weeks of gestation, and for elevated systolic BP alone or combined with elevated diastolic BP.

CONCLUSIONS

Moderately elevated BP in pregnancy may be a risk factor for future hypertension. Pregnancy offers an opportunity to identify women at risk for hypertension who may not have been identified otherwise.

TWEETABLE ABSTRACT

Moderately elevated blood pressure in pregnancy may be associated with hypertension later in life.

Delivery Outcomes of Patients with Acute Migraine in Pregnancy: A Retrospective Study

OBJECTIVE

To describe labor and delivery outcomes in pregnant patients presenting to the hospital setting with an acute severe migraine headache attack earlier in the same gestation.

METHODS

We retrospectively reviewed pregnancy and delivery records from a database of consecutive inpatient neurology consultations for acute headache in pregnant women over a 5 year period.

RESULTS

We identified 86 pregnant women with acute migraine. The mean age was 29.3 (±6.4) years. Nearly half had migraine with aura (35/86 [40.7%]), 12.8% (12/86) had chronic migraine, and 31.4% (27/86) presented in status migrainosus. Complication rates included 54.7%([41/75], 95% CI 29.87, 52.13) for at least one adverse outcome, 28.0% ([21/75], 95% CI 11.78, 30.22) for preterm delivery, 21.3% ([16/75], 95% CI 7.7, 24.3) for preeclampsia, 30.6% ([23/75] 95% CI 13.48, 32.52) for cesarean delivery, and 18.7% ([14/75] 95% CI 6.15, 21.85) for low birthweight.

CONCLUSIONS

Pregnant women seeking treatment for acute migraine headache experienced a higher rate of preterm delivery, preeclampsia, and low birthweight but a lower rate of cesarean delivery than the local and general populations. More than half (54.7% [41/75] 95% CI 29.87, 52.13) of the study patients experienced some type of adverse birth outcome, suggesting that pregnancies in migraine patients presenting to an acute care setting may benefit from more intense surveillance.

HELLP Syndrome

The hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is frequently observed in mothers whose offspring have long-chain fatty acid oxidation defects. We previously found that fatty acid oxidation is compromised not only in these inborn errors of metabolism but also in human umbilical vein endothelial cells (HUVECs) from all pregnancies complicated by the HELLP syndrome. Sirtuins are oxidized nicotinamide adenine dinucleotide (NAD⁺)dependent deacetylases linked to the metabolic status of the cell. SIRT 4 is known to have regulatory functions in fatty acid oxidation. The HELLP syndrome is often associated with short-term hypoxia. We studied sirtuins (SIRT 1, SIRT 3, and SIRT 4) in HUVECs from pregnancies complicated by the HELLP syndrome and uncomplicated pregnancies exposed to hypoxia (n = 7 controls, 7 HELLP; 0, 10, 60, or 120 minutes of 2% O₂). Protein levels of SIRT 4 were significantly higher in HUVECs from HELLP compared to control after 60 and 120 minutes of hypoxia. The NAD⁺ levels increased in a time-dependent manner.

Exercise during pregnancy protects against hypertension and macrosomia: randomized clinical trial

BACKGROUND

The prevalence of all pregnancies with some form of hypertension can be up to 10%, with the rates of diagnosis varying according to the country and population studied and the criteria used to establish the diagnosis. Prepregnancy obesity and excessive gestational weight gain (GWG) of all body mass index (BMI) categories have been associated with maternal hypertensive disorders and linked to macrosomia (>4000 g) and low birthweight (<2500 g). No large randomized controlled trial with high adherence to an exercise program has examined pregnancy-induced hypertension and these associated issues. We investigated whether women adherent (≥80% attendance) to an exercise program initiated early showed a reduction in pregnancy-induced hypertension and excessive GWG in all prepregnancy BMI categories, and determined if maternal exercise protected against macrosomia and low birthweight.

OBJECTIVE

We sought to examine the impact of a program of supervised exercise throughout pregnancy on the incidence of pregnancy-induced hypertension.

STUDY DESIGN

A randomized controlled trial was used. Women were randomized into an exercise group (N = 382) or a control group (N = 383) receiving standard care. The exercise group trained 3 d/wk (50-55 min/session) from gestational weeks 9-11 until weeks 38-39. The 85 training sessions involved aerobic exercise, muscular strength, and flexibility.

RESULTS

High attendance to the exercise program regardless of BMI showed that pregnant women who did not exercise are 3 times more likely to develop hypertension (odds ratio [OR], 2.96; 95% confidence interval [CI], 1.29-6.81, P = .01) and are 1.5 times more likely to gain excessive weight if they do not exercise (OR, 1.47; 95% CI, 1.06-2.03, P = .02). Pregnant women who do not exercise are also 2.5 times more likely to give birth to a macrosomic infant (OR, 2.53; 95% CI, 1.03-6.20, P = .04).

CONCLUSION

Maternal exercise may be a preventative tool for hypertension and excessive GWG, and may control offspring size at birth while reducing comorbidities related to chronic disease risk.

AISF position paper on liver disease and pregnancy

The relationship between liver disease and pregnancy is of great clinical impact. Severe liver disease in pregnancy is rare; however, pregnancy-related liver disease is the most frequent cause of liver dysfunction during pregnancy and represents a severe threat to foetal and maternal survival. A rapid differential diagnosis between liver disease related or unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. This report summarizes the recommendation of an expert panel established by the Italian Association for the Study of the Liver (AISF) on the management of liver disease during pregnancy. The article provides an overview of liver disease occurring in pregnancy, an update on the key mechanisms involved in its pathogenesis, and an assessment of the available treatment options. The report contains in three sections: (1) specific liver diseases of pregnancy; (2) liver disease occurring during pregnancy; and (3) pregnancy in patients with pre-existing chronic liver disease. Each topic is discussed considering the most relevant data available in literature; the final statements are formulated according to both scientific evidence and clinical expertise of the involved physicians, and the AISF expert panel recommendations are reported.

Physiological mechanisms of vascular response induced by shear stress and effect of exercise in systemic and placental circulation

Physiological vascular function regulation is essential for cardiovascular health and depends on adequate control of molecular mechanisms triggered by endothelial cells in response to mechanical and chemical stimuli induced by blood flow. Endothelial dysfunction is one of the main risk factors of cardiovascular pathology, where the imbalance between the synthesis of vasodilator and vasoconstrictor molecules is common in the development of vascular disorders in systemic and placental circulation. In the placenta, an organ without autonomic innervations, the local control of vascular tone is critical for maintenance of fetal growth and mechanisms that underlie shear stress response induced by blood flow are essential during pregnancy. In this field, shear stress induced by moderate exercise is one of the most important mechanisms to improve vascular function through nitric oxide synthesis and stimulation of mechanical response of endothelial cells triggered by ion channels, caveolae, endothelial NO synthase, and vascular endothelial growth factor, among others. The demand for oxygen and nutrients by tissues and organs, especially in placentation and pregnancy, determines blood flow parameters, and physiological adaptations of vascular beds for covering metabolic requirements. In this regard, moderate exercise versus sedentarism shows potential benefits for improving vascular function associated with the enhancement of molecular mechanisms induced by shear stress. In this review, we collect evidence about molecular bases of physiological response to shear stress in order to highlight the relevance of moderate exercise-training for vascular health in adult and fetal life.

Hypertension in pregnancy

Hypertensive disorders of pregnancy represent the second commonest cause of direct maternal death and complicate an estimated 5-10 % of pregnancies. Classification systems aim to separate hypertension similar to that seen outside pregnancy (chronic and gestational hypertension) from the potentially fatal pregnancy-specific conditions. Preeclampsia, HELLP syndrome, and eclampsia represent increasing severities of this disease spectrum. The American College of Obstetricians and Gynecologists' 2013 guidelines no longer require proteinuria as a diagnostic criterion, because of its variable appearance in the disease spectrum. The cause involves inadequate cytotrophoblastic invasion of the myometrium, resulting in placental hypoperfusion and diffuse maternal endothelial dysfunction. Changes in angiogenic and antiangiogentic peptide profiles precede the onset of clinical preeclampsia. Women with preeclampsia should be closely monitored and receive magnesium sulfate intravenously if severe features, HELLP syndrome, or eclampsia occur. Definitive therapy is delivery of the fetus. Hypertension in pregnancy increases future maternal risk of hypertension and cardiovascular disorders.

Drug treatment of hypertension in pregnancy

Hypertensive disorders represent major causes of pregnancy-related maternal mortality worldwide. Similar to the non-pregnant population, hypertension is the most common medical disorder encountered during pregnancy and is estimated to occur in about 6-8 % of pregnancies. A recent report highlighted hypertensive disorders as one of the major causes of pregnancy-related maternal deaths in the USA, accounting for 579 (12.3 %) of the 4,693 maternal deaths that occurred between 1998 and 2005. In low-income and middle-income countries, preeclampsia and its convulsive form, eclampsia, are associated with 10-15 % of direct maternal deaths. The optimal timing and choice of therapy for hypertensive pregnancy disorders involves carefully weighing the risk-versus-benefit ratio for each individual patient, with an overall goal of improving maternal and fetal outcomes. In this review, we have compared and contrasted the recommendations from different treatment guidelines and outlined some newer perspectives on management. We aim to provide a clinically oriented guide to the drug treatment of hypertension in pregnancy.

Effect of exercise training on eNOS expression, NO production and oxygen metabolism in human placenta

Objective

To determine the effects of combined aerobic and resistance exercise training during the second half of pregnancy on endothelial NOS expression (eNOS), nitric oxide (NO) production and oxygen metabolism in human placenta.

Methods

The study included 20 nulliparous in gestational week 16–20, attending prenatal care at three tertiary hospitals in Colombia who were randomly assigned into one of two groups: The exercise group (n = 10) took part in an exercise session three times a week for 12 weeks which consisted of: aerobic exercise at an intensity of 55–75% of their maximum heart rate for 60 min and 25 mins. Resistance exercise included 5 exercise groups circuit training (50 repetitions of each) using barbells (1–3 kg/exercise) and low-to-medium resistance bands. The control group (n = 10) undertook their usual physical activity. Mitochondrial and cytosol fractions were isolated from human placental tissue by differential centrifugation. A spectrophotometric assay was used to measure NO production in cytosolic samples from placental tissue and Western Blot technique to determine eNOS expression. Mitochondrial superoxide levels and hydrogen peroxide were measured to determine oxygen metabolism.

Results

Combined aerobic and resistance exercise training during pregnancy leads to a 2-fold increase in eNOS expression and 4-fold increase in NO production in placental cytosol (p = 0.05). Mitochondrial superoxide levels and hydrogen peroxide production rate were decreased by 8% and 37% respectively in the placental mitochondria of exercising women (p = 0.05).

Conclusion

Regular exercise training during the second half of pregnancy increases eNOS expression and NO production and decreases reactive oxygen species generation in human placenta. Collectively, these data demonstrate that chronic exercise increases eNOS/NO production, presumably by increasing endothelial shear stress. This adaptation may contribute to the beneficial effects of exercise on the vascular and antioxidant system and in turn reduce the risk of preeclampsia, diabetes or hypertension during pregnancy.

Diabetic nephropathy and microalbuminuria in pregnant women with type 1 and type 2 diabetes: prevalence, antihypertensive strategy, and pregnancy outcome

OBJECTIVE

To evaluate the prevalence of diabetic nephropathy and microalbuminuria in pregnant women with type 2 diabetes in comparison with type 1 diabetes and to describe pregnancy outcomes in these women following the same antihypertensive protocol.

RESEARCH DESIGN AND METHODS

Among 220 women with type 2 diabetes and 445 women with type 1 diabetes giving birth from 2007-2012, 41 women had diabetic nephropathy (albumin-creatinine ratio ≥300 mg/g) or microalbuminuria (albumin-creatinine ratio 30-299 mg/g) in early pregnancy. Antihypertensive therapy was initiated if blood pressure ≥135/85 mmHg or albumin-creatinine ratio ≥300 mg/g.

RESULTS

The prevalence of diabetic nephropathy was 2.3% (5 of 220) in women with type 2 diabetes and 2.5% (11 of 445) in women with type 1 diabetes (P = 1.00). The figures for microalbuminuria were 4.5 (10 of 220) vs. 3.4% (15 of 445) (P = 0.39). Baseline glycemic control was comparable between women with type 2 diabetes (n = 15) and type 1 diabetes (n = 26). Blood pressure at baseline was median 128 (range 100-164)/81 (68-91) vs. 132 (100-176)/80 (63-100) mmHg (not significant) and antihypertensive therapy in type 2 versus type 1 diabetes was used in 0 and 62%, respectively, at baseline, increasing to 33 and 96%, respectively, in late pregnancy. Pregnancy outcome was comparable regardless type of diabetes; gestational age at delivery: 259 days (221-276) vs. 257 (184-271) (P = 0.19); birth weight 3,304 g (1,278-3,914) vs. 2,850 (370-4,180) (P = 0.67).

CONCLUSIONS

The prevalence of diabetic nephropathy and microalbuminuria in early pregnancy was similar in type 2 and type 1 diabetes. Antihypertensive therapy was used more frequently in type 1 diabetes. Pregnancy outcome was comparable regardless type of diabetes.

Women, kidney disease, and pregnancy

Several glomerular diseases may occur in women of childbearing age. Pregnancy in such patients should be planned when the disease has been in remission for a minimum of 6 months to minimize maternal and fetal complications. Immunosuppressive agents should be optimized before conception to include those that are safe for pregnancy. The complexity of medical management when caring for these patients calls for a multidisciplinary team approach consisting of a nephrologist, rheumatologist, obstetrician, and pharmacist. This review will address the physiological changes of pregnancy that may affect glomerular disease presentation, activity, and diagnosis; specific glomerular diseases primary and secondary to systemic diseases in the context of pregnancy; fetal and maternal complications and long-term effects; diagnosis and differential diagnosis; and treatment strategies that are considered relatively safe with respect to fetal intrauterine exposure.

Hypertension in pregnancy after Escherichia coli O157:H7 gastroenteritis: a cohort study

BACKGROUND

Escherichia coli O157:H7 is a common cause of bacterial gastroenteritis and may increase the risk of hypertension. We studied the risk of hypertension in pregnancy following a large E. coli O157:H7 outbreak that occurred in Walkerton, Canada, in the year 2000.

METHODS

We linked data collected from Walkerton residents to provincial healthcare databases. We studied the pregnancies of three groups of women: two groups from Walkerton (those with and without acute gastroenteritis during outbreak) and a third group from neighboring rural communities unaffected by the outbreak. The primary outcome was a composite of gestational hypertension or preeclampsia. Secondary outcomes were gestational hypertension and preeclampsia examined separately.

RESULTS

The median time to pregnancy after cohort entry was five years. The composite outcome was not significantly higher among women with gastroenteritis during the outbreak compared with residents of neighboring communities (8 of 117 (6.8%) versus 96 of 2166 (4.4%) pregnancies, respectively; adjusted relative risk 1.5 (95% confidence interval (CI) 0.8 to 3.2)). When examined separately the risk of preeclampsia was significantly higher among women with gastroenteritis (4 of 117 (3.4%) versus 17 of 2166 (0.8%) pregnancies; adjusted relative risk 3.8 (95% CI 1.3 to 11.6)). However, the risk of preeclampsia was lower than expected in the referent group and overall there were a small number of events in all the groups.

CONCLUSION

There was no significant association between E. coli O157:H7 gastroenteritis and our primary assessment of hypertension in pregnancy.

A woman with GN presenting during pregnancy

The combination of kidney disease and pregnancy has long been recognized as a high-risk situation. When renal disease is recognized for the first time during pregnancy, it presents unique problems for both the obstetric and the renal teams. Particularly difficult can be distinguishing preeclampsia from preexisting kidney disease in women presenting for the first time with hypertension, proteinuria, and reduced GFR during pregnancy. Decision-making regarding performing a kidney biopsy and treatment of glomerular disease during pregnancy is often much more complicated by safety concerns for both the mother and the developing fetus.

The feto-placental endothelium in pregnancy pathologies

This review aims to provide a comprehensive summary of the aspects of endothelial and vascular dysfunction in the feto-placental vasculature occurring in pregnancy pathologies. This endothelium is continuous with the fetal circulation. Its function and potential dysfunction in pathologies will have a profound impact on fetal development. Gestational diabetes mellitus represents one of these pathologies, in which its associated metabolic derangements will alter feto-placental endothelial functions. These, in turn, may result in functional changes of the placenta, which may entail impaired fetal development. By contrast, changes in the feto-placental vasculature observed in cases of fetal growth restriction and preeclampsia may be causative (fetal growth restriction) or secondary (preeclampsia) for the pathology.

Hypertension in pregnancy

Hypertension in pregnancy is diagnosed on systolic blood pressure greater than or equal to 140 mm Hg and/or diastolic greater than or equal to 90 mm Hg. The classification systems separate chronic and gestational hypertension from preeclampsia. Significant uncertainty regarding optimal management is reflected in the differing major international society recommendations. Blood pressure treatment is designed to minimize maternal end-organ damage. Methyldopa, labetalol, hydralazine, and nifedipine are oral options; angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists are contraindicated. Women with preeclampsia should be closely monitored and receive intravenous magnesium sulfate.