The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis

Pregnancy-associated plasma protein A (PAPP-A) as a first trimester serum biomarker for preeclampsia screening: a systematic review and meta-analysis

OBJECTIVE

The aim of this study is to systematically examine the role of the pregnancy-associated plasma protein A (PAPP-A) serum biomarker in the first trimester screening of preeclampsia (PE).

MATERIALS AND METHODS

A systematic search of the literature was conducted on PubMed via Medline, and Cochrane Library up to 8 November 2022, for prospective studies evaluating PAPP-A serum levels in first trimester pregnant women as a screening biomarker for PE. Eligible were all prospectively designed case-control or cohort studies, published in English. Two investigators independently examined the studies and the studies' characteristics were extracted. Newcastle-Ottawa Scale (NOS) for case-control and cohort studies were applied to assess the risk of bias. For the quantitative analysis of the studies, a meta-analysis was also performed.

RESULTS

A total of 22 studies including 33,651 pregnant women were assessed, of whom, 2001 were diagnosed with PE. A meta-analysis was performed, showing that PAPP-A levels in the first trimester were significantly lower in early onset preeclamptic women (MD: -0.24, 95% CI: -0.37, -0.11, p = .0002), late onset (MD: -0.15, 95% CI: -0.25, -0.05, p = .03), and total preeclamptic cases (MD = -0.17, 95% CI = -0.23, -0.11, p < .00001) when compared with controls.

CONCLUSIONS

Our results suggest that PAPP-A can be a promising predictor in early screening for PE; hence, women at risk can be diagnosed early in their pregnancy stage and benefit from individualized PE treatment before it progresses.

Biology and Pathophysiology of Placenta Accreta Spectrum Disorder

Placenta accreta spectrum (PAS) disorders present a significant clinical challenge, characterized by abnormal placental adherence to the uterine wall secondary to uterine scarring. With the rising global cesarean delivery rates, the incidence of this iatrogenic disorder has increased, underscoring the critical need for an understanding of its pathophysiology to inform management and prevention strategies. Normal placentation depends on tightly regulated extravillous trophoblast invasion into the decidua, spiral artery remodeling, interactions with the extracellular matrix, and immune modulation. Uterine scarring disrupts this balance, creating an environment deficient in key regulatory signals required for coordinated implantation and decidualization. In PAS, the loss of inhibitory decidual cues and deficient boundary limits permits unrestrained trophoblast into the abnormal decidual environment. Dysregulated signaling, along with an inflammatory milieu in scarred tissues, exacerbates abnormal placental development. Current prenatal imaging focuses on the appearance of excessive fibrinoid deposition, extracellular matrix remodeling, and incomplete spiral artery transformation as surrogates of PAS risk stratification. Emerging single-cell RNA sequencing and proteomic profiling offer insights into biomarkers and pathways that enable targeted interventions. Preventive efforts should prioritize reducing cesarean delivery rates to limit uterine scarring. Advances in regenerative medicine and bioengineering, including extracellular matrix-modulating biomaterials, growth factor therapies, and antifibrotic interventions, hold promise for improving scar healing and reducing PAS risk. This review bridges foundational science and clinical application, emphasizing the importance of the underlying placental biology and pathophysiology to make a clinical difference in detecting, treating, and preventing PAS. Addressing drivers of abnormal placentation is critical for improving maternal and neonatal outcomes with this increasingly prevalent iatrogenic condition.

Postpartum maternal thrombophilia workup value in pregnancies with severe small for gestational age

INTRODUCTION

In the absence of prenatal etiology explaining small for gestational age (SGA), a blood workup may be performed postpartum to look for maternal thrombophilia if a newborn is confirmed to be growth-restricted at birth. The literature regarding thrombophilia factors and fetal growth restriction is discordant. The main objective was to assess the prevalence and type of maternal thrombophilia among women delivering newborns of birthweight below the 3rd percentile and undergoing a postpartum thrombophilia workup and placental analysis.

MATERIAL AND METHODS

This was a single-center retrospective observational cohort study in a tertiary care French maternity. The study population included all women delivering a liveborn infant with severe SGA, defined as a birthweight below the 3rd percentile according to French charts between January 2014 and December 2018. Data from thrombophilia workups (antiphospholipid antibodies, protein C assay, protein S assay, antithrombin assay, factor V Leiden mutation, and factor II G 20210A mutation search) were collected from medical records. Placental pathology analysis, if available, was also collected. The primary endpoint was the prevalence of positive expanded thrombophilia workup (inherited or acquired).

RESULTS

A total of 733 patients were included in our study, 401 of whom (54.7%) underwent a postpartum thrombophilia workup. The overall prevalence of hereditary thrombophilia was 6.7%, 95% confidence interval (4.3 to 9.2) and of acquired thrombophilia was 2.0%, 95% confidence interval (0.6 to 3.4). Among hereditary anomalies, heterozygous factor V mutation and heterozygous factor II mutation were the most frequently observed, respectively, 4% and 1.7%. Concerning the presence of antiphospholipid antibodies, triple positivity was present in one patient (0.2%). The presence of a single antiphospholipid antibody was more frequently observed in 3 patients (0.7%).

CONCLUSIONS

Among patients with a severe SGA infant and postpartum investigation of maternal thrombophilia, an extensive workup of postpartum thrombophilia contributed to a low proportion of positive findings. This suggests that the prescription of such a workup should be targeted, based on personal and family medical history. In fact, testing for inherited thrombophilia should be reserved for patients with a personal or family history of thrombosis. Testing for antiphospholipid antibodies should follow ACR/EULAR criteria.

Delayed villous maturation with and without fetal demise: A case report of three successive pregnancies

This case study examined three subsequent pregnancies with delayed villous maturation (DVM) resulting in infants either large for gestational age (LGA) or appropriate for gestational age. A perinatal pathologist histopathologically reviewed the placentas using the Amsterdam Consensus Criteria. The first pregnancy ended in a term fetal demise of an LGA infant due to severe asphyxia associated with idiopathic DVM. Due to the history of stillbirth and DVM, labor was induced at 36 weeks of gestation in the second and third pregnancies. The second and third pregnancies resulted in liveborn infants with varying weight profiles despite similar placental lesions. All three placentas showed DVM with positive CD15 immunostaining. Additionally, the second and third placentas exhibited villitis of unknown etiology. This case report underscores the importance of structured histologic placental examination following complicated pregnancies by a perinatal pathologist.

Association between migraine, migraine subtype, and adverse pregnancy outcomes: A systematic review and meta-analysis

INTRODUCTION

Migraine is one of the most prevalent conditions worldwide. This systematic review aimed to evaluate the association between migraine, its subtypes, and adverse pregnancy outcomes.

MATERIAL AND METHODS

Eligible cohort and retrospective case-control studies were included from PubMed and Embase databases from their inception to May 2024. Adverse pregnancy outcomes of interest were preeclampsia, preterm birth, low birthweight, small for gestational age, and placental abruption. Study quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses of the outcomes with their odds ratios (ORs) and adjusted ORs (aOR), including a 95% confidence interval (CI), were performed using RevMan. Outcomes were pooled using random effects models, with separate analyses for cohort and retrospective case-control studies. The protocol was registered with PROSPERO (no. CRD42023404759).

RESULTS

This meta-analysis included 19 studies (11 cohort and 8 retrospective case-control) encompassing 1 420 690 deliveries. Significant associations were observed between migraine and increased risk of preeclampsia (cohort: aOR 1.28 [95% CI: 1.11-1.47], I2 = 0%), (retrospective case-control: aOR 3.4 [95% CI: 1.81-6.4], I2 = 83%) and preterm birth (cohort: aOR 1.30 [95% CI: 1.17-1.44], I2 = 11%). The meta-analyses of adjusted data on low birthweight and small for gestational age were inconsistent with respect to statistical significance (cohort: aOR 1.27 [95% CI: 0.89-1.82], I2 = 36% and cohort: aOR 1.07 [95% CI: 1.03-1.12], I2 = 0%, respectively). In addition, migraine without aura (MO) (cohort: OR 1.62 [95% CI: 1.30-2.01], I2 = 0%; retrospective case-control: aOR 4.91 [95% CI: 2.78-8.67], I2 = 0%) and migraine with aura (MA) (cohort: OR 2.06 [95% CI: 1-4.27], I2 = 29%) were significantly associated with the risk of preeclampsia. Similarly, MO (cohort: OR 1.28 [95% CI: 1.11-1.49], I2 = 0%) and MA (cohort: OR 1.25 [95% CI: 1.07-1.47], I2 = 0%) were associated with preterm birth risk.

CONCLUSIONS

Pregnant women with migraines have a higher risk of preeclampsia and preterm birth compared with those without migraines. Migraine could be associated with an increased risk of low birth weight and small for gestational age. Sub-analyses indicate an elevated risk of preeclampsia and preterm birth across migraine subtypes. Notably, no previous meta-analyses have differentiated between migraine subtypes. Additional studies are needed to strengthen these findings.

NFĸB and its inhibitors in preeclampsia: mechanisms and potential interventions

Preeclampsia (PE), which affects between 2 and 15% of pregnancies, is one of the most often reported prenatal problems. It is defined as gestational hypertension beyond 20 weeks of pregnancy, along with widespread edema or proteinuria and specific types of organ damage. PE is characterized by increased levels and activation of nuclear factor kappa B (NF-κB) in the mother's blood and placental cells. This factor controls over 400 genes linked to inflammatory, apoptotic, angiogenesis, and cellular responses to hypoxia and oxidative stress. In the final stages of physiological pregnancy, NF-κB levels need to be lowered to favor maternal immunosuppressive events and continue gestation to prevent hypoxia and inflammation, which are advantageous for implantation. Pharmacotherapy is thought to be a potential treatment for PE by downregulating NF-κB activation. NF-κB activity has been discovered to be regulated by several medications used for both prevention and treatment of PE. However, in order to guarantee treatment safety and effectiveness, additional creativity is desperately required. This article provides an overview of the current understanding of the defined function of NF-κB in PE progression. According to their effect on the cellular control of NF-κB pathways, newly proposed compounds for preventing and treating PE have also been emphasized.

Effect of Continuous Positive Airway Pressure or Positional Therapy Compared to Control for Treatment of Obstructive Sleep Apnea on the Development of Gestational Diabetes Mellitus in Pregnancy: Protocol for Feasibility Randomized Controlled Trial

BACKGROUND

Obstructive sleep apnea (OSA) is a common sleep disorder, and in pregnancy, it is associated with an increased risk of complications, including gestational diabetes mellitus and preeclampsia. Supine sleep may worsen OSA, and in pregnancy, it is associated with an increased risk of stillbirth due to effects on fetomaternal blood flow. Continuous positive airway pressure (CPAP) therapy is considered the gold-standard treatment for moderate to severe OSA, although compliance is frequently poor; positional therapy (PT) is generally less effective than CPAP in nonpregnant patients but may be better tolerated and more accessible during pregnancy. There is limited data on whether widespread, early screening for sleep disorders in pregnant women with symptoms of sleep-disordered breathing or at high risk of metabolic complications and subsequent early intervention with CPAP or PT attenuates fetomaternal risks.

OBJECTIVE

This study aims to determine the feasibility of conducting a randomized controlled trial to assess improved fetomaternal outcomes in a high-risk pregnant population with OSA, using CPAP or PT, initiated by the 16th week of gestation.

METHODS

This study is a randomized, controlled, open-label feasibility study in which pregnant women with an apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) ≥5 are treated with CPAP (auto-titrating and fixed pressure) or positional therapy from early gestation (by 16 weeks) until delivery. The primary outcome is the feasibility of the study protocol and the development of gestational diabetes mellitus by the 28-week gestation period. Secondary outcomes include the development of hypertensive disorders of pregnancy (HDP), maternal weight gain, uterine artery blood flow, glycemic control during pregnancy (in participants who develop gestational diabetes), changes in maternal circulating biomarkers, and neonatal birthweight complications. Polysomnography at 28- to 32-week gestation period, postpartum polysomnography, therapy compliance, and patient acceptability are also assessed.

RESULTS

The trial commenced on September 30, 2019. The trial is ongoing as of August 6, 2024.

CONCLUSIONS

The trial intends to contribute to the growing evidence base to support the need for the identification and treatment of OSA occurring during pregnancy and to assess the feasibility of the study protocol. This will be the first trial to compare the early initiation of CPAP (auto-titrating and fixed pressure) and positional therapy in pregnant women from early gestation, providing alternative therapies for the treatment of OSA in this important population.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12619001530112; https://tinyurl.com/yctdzs4u.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/51434.

Hypertensive disorders of pregnancy trends in the United States post aspirin recommendation guidelines

OBJECTIVE

To evaluate changes in the rates of hypertensive disorders of pregnancy (HDP) in the US after the publication of aspirin (ASA) recommendation guidelines by the USPSTF and ACOG.

METHODS

A population-based retrospective cohort study was performed using the US Natality database. The pre-ASA group included births between 2010-2014. The post-ASA group were births between 2016-2021. Births in 2015 were excluded. Outcomes were rates of HDP. Univariate and multivariate analyses were performed. Using the 2010-2014 HDP trend, a projected trend was calculated and compared to the actual trend across the entire cohort.

RESULTS

There were 12,127,659 births in the pre-ASA group and 17,665,217 births in the post-ASA group. The post-ASA group had a significantly higher rate of overall HDP than the pre-ASA group (7.7 % vs 4.9 %; aOR 1.58, 95 % CI [1.57-1.59]). When stratified by gestational age at delivery, the post-ASA group had a significantly lower rate of preterm HDP prior to 37 weeks (21.6 % vs 23.7 %; aOR 0.90, 95 % CI [0.89-0.91]) and preterm HDP prior to 34 weeks (6.0 % vs 7.5 %; aOR 0.79, 95 % CI [0.78-0.81]). The actual HDP trend post-ASA recommendation was higher than projected for overall HDP and preterm HDP < 37 weeks but was not different for preterm HPD < 34 weeks.

CONCLUSION

While overall HDP is increasing, the rate of preterm births complicated by HDP has been decreasing. The actual trend for the overall HDP category and the two preterm HDP categories, however, remains either higher or no different compared to the projected trend post aspirin recommendation guidelines.

Vaginal miR-210-3p as a potential biomarker for pregnancies complicated by early fetal growth restriction: A proof-of-concept case-control study

INTRODUCTION

Fetal growth restriction (FGR) is associated with increased risk of neonatal morbidity and mortality or long-term adverse outcomes. We investigated the ability of hypoxia and angiogenesis-related miR-210-3p and miR-126-5p to identify early FGR cases and their correlations with neonatal outcomes.

METHODS

Twenty-nine women with pregnancies complicated by early FGR diagnosis and 25 controls matched for gestational age (GA) were enrolled and their vaginal fluid (VF) and plasma were collected. MiR-210-3p and miR-126-5p were measured by RT-qPCR and their targets were identified by in-silico analysis limited only to those already experimentally validated in other contexts.

RESULTS

Overall, VF levels of miR-210-3p were lower in early FGR cases compared to controls (p < 0.05). miR-210-3p was lower in severe cases and in women who later developed preeclampsia (p < 0.05). VF miR-210-3p levels correlated with lower birth weight, premature birth and severe complications at birth (p < 0.05). miR-210-3p was not detected in plasma and no correlations were observed between miR-126-5p and FGR or neonatal outcomes. In silico analyses identified HIF-1α, HIF-3α, BDNF, IGFBP3, RAD52 and TWIST-1 as experimentally validated targets of miR-210-3p. Among the predicted biological pathways controlled by miR-210-3p, we found hypoxia-responsive signaling such as autophagy, oxidative stress and metabolic pathways.

DISCUSSION

Although validation is needed, these findings suggest that VF levels of miR-210-3p may potentially serve as biomarker for the diagnosis of early FGR; future mechanistic studies are also advisable to investigate whether pharmacological strategies based on miR-210-3p, or its downstream targets may be useful for FGR.

Widely accessible prognostication using medical history for fetal growth restriction and small for gestational age in nationwide insured women

Prevention of fetal growth restriction/small for gestational age (FGR/SGA) is adequate if screening is accurate. Ultrasound and biomarkers can achieve this goal; however, both are often inaccessible. This study aimed to develop, validate, and deploy a prognostic prediction model for screening FGR/SGA using only medical history. From a nationwide health insurance database (n = 1,697,452), we retrospectively selected visits to 22,024 healthcare providers of primary, secondary, and tertiary care. This study used machine learning (including deep learning) to develop prediction models using 54 medical-history predictors. After evaluating model calibration, clinical utility, and explainability, we selected the best by discrimination ability. We also externally validated the models using geographical and temporal splits of ~ 20% of the selected visits. The models were also compared with those from previous studies, which were rigorously selected by a systematic review of Pubmed, Scopus, and Web of Science. We selected 169,746 subjects with 507,319 visits for predictive modeling from the database, which were 12-to-55-year-old female insurance holders who used the healthcare services. The best prediction model was a deep-insight visible neural network. It had an area under the receiver operating characteristics curve of 0.742 (95% confidence interval 0.734 to 0.750) and a sensitivity of 49.09% (95% confidence interval 47.60-50.58% using a threshold with 95% specificity). The model was competitive against the previous models of 30 eligible studies of 381 records, including those using either ultrasound or biomarker measurements. We deployed a web application to apply the model. Our model used only medical history to improve accessibility for FGR/SGA screening. However, future studies are warranted to evaluate if this model's usage impacts patient outcomes.

Construction and evaluation of machine learning-based predictive models for early-onset preeclampsia

OBJECTIVE

To analyze the influencing factors of early-onset preeclampsia (EOPE). And to construct and validate the prediction model of EOPE using machine learning algorithm.

STUDY DESIGN

Based on Python system, the data profile of 1040 pregnant women was divided into 80% training set and 20% test set. Logistic regression algorithm, XGBoost algorithm, random forest algorithm, support vector machine algorithm and artificial neural network algorithm were used to construct the EOPE prediction model, respectively, and the resulting model was validated by resampling method. Accuracy, sensitivity, specificity, F1 score, and area under the ROC curve were used to evaluate the resulting models and screen the optimal models.

MAIN OUTCOME MEASURES

EOPE in pregnant women.

RESULTS

The results of binary logistic regression showed that the influencing factors of EOPE included six indicators: pre-pregnancy BMI, number of pregnancies, mean arterial pressure, smoking, alpha-fetoprotein, and methods of conception. Among them, the prediction model of EOPE constructed based on the XGBoost algorithm performed the best in the training and test sets, with an F1 score of 0.554 ± 0.068 and an AUC of 0.963 (95 % CI: 0.943 ∼ 0.983) in the training set, and an F1 score of 0.488 ± 0.082 and an AUC of 0.936 (95 % CI: 0.887 ∼ 0.983).

CONCLUSION

Our prediction model for EOPE constructed based on the XGBoost algorithm has superior disease prediction ability and can provide assistance in predicting the disease risk of EOPE.

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

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

Visualizing risk modification of hypertensive disorders of pregnancy: development and validation of prediction model for personalized interpregnancy weight management

The growing recognition of the importance of interpregnancy weight management in reducing hypertensive disorders of pregnancy (HDP) underscores the importance of effective preventive strategies. However, developing effective systems remains a challenge. We aimed to bridge this gap by constructing a prediction model. This study retrospectively analyzed the data of 1746 women who underwent two childbirths across 14 medical facilities, including both tertiary and primary facilities. Data from 2009 to 2019 were used to create a derivation cohort (n = 1746). A separate temporal-validation cohort was constructed by adding data between 2020 and 2024 (n = 365). Furthermore, the external-validation cohort was constructed using the data from another tertiary center between 2017 and 2023 (n = 340). We constructed a prediction model for HDP development in the second pregnancy by applying logistic regression analysis using 5 primary clinical information: maternal age, pre-pregnancy body mass index, and HDP history; and pregnancy interval and weight change velocity between pregnancies. Model performance was assessed across all three cohorts. HDP in the second pregnancy occurred 7.3% in the derivation, 10.1% in the temporal-validation, and 7.9% in the external-validation cohorts. This model demonstrated strong discrimination, with c-statistics of 0.86, 0.88, and 0.86 for the respective cohorts. Precision-recall area under the curve values were 0.90, 0.85, and 0.91, respectively. Calibration showed favorable intercepts (-0.02 to -0.00) and slopes (0.96-1.02) for all cohorts. In conclusion, this externally validated model offers a robust basis for personalized interpregnancy weight management goals for women planning future pregnancies.

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

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

Low-dose aspirin improves blood perfusion of obstetric anticardiolipin syndrome in China

OBJECTIVE

This study evaluates the endometrial receptivity of obstetric anticardiolipin syndrome (OAPS) patients using various ultrasound indicators and the efficacy of low-dose aspirin (LDA) treatment.

METHODS

This retrospective study recruited patients from Shanghai Ren Ji Hospital, China from January 2022 to December 2023. Doppler parameters of the endometrium and uterine artery blood flow were recorded to assess the endometrial receptivity of OAPS patients compared with normal pregnant women and an other immune diseases group. The receiver operating characteristic curve was used to predict the risk of OAPS patients. Doppler parameters of OAPS patients were conducted repeatedly after a 2-month period of treatment with LDA.

RESULTS

Compared with normal pregnant women, the OAPS group showed remarkably increased endometrial perfusion resistance (PI, RI, S/D) and uterine artery perfusion resistance (RI and S/D) (P < 0.001) and had good predictive values (area under the curve = 0.806, 0.976, 0.942, 0.902, and 0.901, respectively). The endometrial thickness of the OAPS group was much thinner than that of the normal group (P < 0.001). Uterine blood flow impedance PI showed no difference in both groups (P = 0.68). In comparison to other autoimmune diseases, the OAPS group also showed an increasing trend in the resistance of endometrium and uterine artery blood flow. After LDA treatment, there was an obvious improvement in the endometrial blood flow perfusion in the OAPS group (P < 0.01).

CONCLUSION

Compared with the normal group and other autoimmune diseases, the resistance of endometrial and uterine artery blood flow in the OAPS group was increased significantly. The Doppler index showed the predictive value of OAPS, and it was confirmed that LDA could enhance blood perfusion among OAPS women.

Hypertension in Pregnancy and Postpartum: Current Standards and Opportunities to Improve Care

Hypertension in pregnancy contributes substantially to maternal morbidity and mortality, persistent hypertension, and rehospitalization. Hypertensive disorders of pregnancy are also associated with a heightened risk of cardiovascular disease, and timely recognition and modification of associated risk factors is crucial in optimizing long-term maternal health. During pregnancy, there are expected physiologic alterations in blood pressure (BP); however, pathophysiologic alterations may also occur, leading to preeclampsia and gestational hypertension. The diagnosis and effective management of hypertension during pregnancy is essential to mitigate maternal risks, such as acute kidney injury, stroke, and heart failure, while balancing potential fetal risks, such as growth restriction and preterm birth due to altered uteroplacental perfusion. In the postpartum period, innovative and multidisciplinary care solutions that include postpartum maternal health clinics can help optimize short- and long-term care through enhanced BP management, screening of cardiovascular risk factors, and discussion of lifestyle modifications for cardiovascular disease prevention. As an adjunct to or distinct from postpartum clinics, home BP monitoring programs have been shown to improve BP ascertainment across diverse populations and to lower BP in the months after delivery. Because of concerns about pregnant patients being a vulnerable population for research, there is little evidence from trials examining the diagnosis and treatment of hypertension in pregnant and postpartum individuals. As a result, national and international guidelines differ in their recommendations, and more studies are needed to bolster future guidelines and establish best practices to achieve optimal cardiovascular health during and after pregnancy. Future research should focus on refining treatment thresholds and optimal BP range peripartum and postpartum and evaluating interventions to improve postpartum and long-term maternal cardiovascular outcomes that would advance evidence-based care and improve outcomes worldwide for people with hypertensive disorders of pregnancy.

First-Trimester PlGF and PAPP-A and the Risk of Placenta-Mediated Complications: PREDICTION Prospective Study

OBJECTIVES

This study aimed to estimate the association between low first-trimester maternal serum PlGF (placental growth factor) and PAPP-A (pregnancy-associated plasma protein A) and the risk of placenta-mediated complications.

METHODS

We performed a secondary analysis of the PREDICTION study, including nulliparous participants recruited at 11 to 14 weeks of pregnancy. First-trimester PlGF and PAPP-A levels were reported in multiples of the median (MoM) adjusted for maternal characteristics and gestational age. Participants were stratified into 4 groups based on absence/presence of low (<0.4 MoM) PlGF and PAPP-A values. A composite of adverse pregnancy outcomes (including preeclampsia, fetal growth restriction, fetal death, and placental abruption) was calculated for deliveries occurring before 34 weeks, before 37 weeks, and at or after 37 weeks.

RESULTS

Out of the 7262 participants, 86 (1.2%) experienced the composite outcome before 37 weeks of gestation, including 35 (0.4%) before 34 weeks. The combination of low PAPP-A and low PlGF levels was associated with the greatest risk of adverse outcomes before 37 weeks (21%) and before 34 weeks (12%) compared with low PlGF alone (7% and 3%), low PAPP-A alone (2% and 1%), or neither marker (1% and 0.4%, respectively; P < 0.001). For preterm preeclampsia specifically, the combination of low PAPP-A and low PlGF was also associated with a greater risk (12%) compared with low PlGF alone (6%), low PAPP-A alone (0.5%), or neither marker (0.7%; P < 0.001).

CONCLUSIONS

The combination of low PAPP-A and low PlGF levels is associated with a very high risk for adverse outcomes before 34 and 37 weeks. An isolated low PAPP-A should not be considered a risk factor for adverse pregnancy outcomes.

Adverse Obstetric Outcomes in Pregnancies With Major Fetal Congenital Heart Defects

Importance

Understanding the risk profile of obstetric complications in pregnancies with fetal major congenital heart defects (MCHDs) is crucial for obstetric counseling and care.

Objective

To investigate the risk of placenta-related adverse obstetric outcomes in pregnancies complicated by fetal MCHDs.

Design, Setting, and Participants

This cohort study retrieved data from June 1, 2008, to June 1, 2018, from the Danish Fetal Medicine Database, which includes comprehensive data on more than 95% of all pregnancies in Denmark since the database was instituted in 2008. All singleton pregnancies that resulted in a live-born child after 24 weeks' gestation without chromosomal aberrations were included. A systematic search of the literature was performed in PubMed, Embase, and the Cochrane Library from inception to June 1, 2024, to compile existing knowledge and data on adverse obstetric outcomes among MCHD subtypes.

Exposure

Fetal MCHDs including 1 of 11 subtypes.

Main Outcomes and Measures

The primary outcome was a composite adverse obstetric outcome defined as preeclampsia, preterm birth, fetal growth restriction, or placental abruption. Secondary outcomes consisted of each adverse obstetric event. Adjusted odds ratios (AORs) were computed using generalized estimating equations adjusted for maternal body mass index, age, smoking, and year of delivery. Meta-analyses were conducted using random-effects models to pool effect sizes for each MCHD subtype and adverse obstetric outcome.

Results

A total of 534 170 pregnancies were included in the Danish cohort, including 745 with isolated fetal MCHDs (median [IQR] maternal age, 29.0 [26.0-33.0] years) and 533 425 without MCHDs (median [IQR] maternal age, 30.0 [26.0-33.0] years). Pregnancies with fetal MCHDs exhibited a higher rate of adverse obstetric outcomes at 22.8% compared with 9.0% in pregnancies without fetal MCHDs (AOR, 2.96; 95% CI, 2.49-3.53). Preeclampsia (AOR, 1.83; 95% CI, 1.33-2.51), preterm birth at less than 37 weeks (AOR, 3.84; 95% CI, 3.15-4.71), and fetal growth restriction (AOR, 3.25; 95% CI, 2.42-4.38) occurred significantly more frequently in pregnancies with MCHDs. Except for fetal transposition of the great arteries (AOR, 1.19; 95% CI, 0.66-2.15), all MCHD subtypes carried a greater risk of adverse obstetric outcomes. The meta-analysis included 10 additional studies that supported these results.

Conclusions and Relevance

These findings suggest that nearly 1 in 4 women expecting a child with an MCHD, except transposition of the great arteries, may be at high risk of adverse obstetric outcomes.

Gut microbiota and potential serum metabolites biomarkers of pregnant woman for preeclampsia

BACKGROUND

The pathogenesis of preeclampsia (PE) remains unclear, but the interaction between intestinal flora and PE has been attention in recent studies. Several studies have shown that imbalanced intestinal flora plays an important role in the inducement of PE.

PURPOSE

The potential correlation among intestinal flora, metabolites, and fetal growth restriction was explored by integrating data and analyzing neonatal growth. The study is hoped to provide references for subsequent studies.

METHODS

A comparison between the intestinal flora of healthy pregnant women and pregnant with PE was conducted using 16S rRNA gene sequencing. Subsequently, the feces, serum and umbilical cord blood collected from healthy pregnant women and those with PE were analyzed using global untargeted metabolomics to identify differences in metabolites.

RESULTS

The results showed that Bifidobacterium, Chryseobacterium, Eubacterium, Pravotella and Bacteroides are the core species associated with many metabolites. Normal-birth weight had a negative correlation with the abundance of raclopride, Phe-Gly-O and Lys-Phe-OH showed a positive correlation with Phosphonate and Lys-Gly. Simultaneously, these core metabolites showed a strong correlation with other growth indices (BPD, AC, FL). In summary, the imbalance of intestinal flora in pregnant women may alter the abundance of the core metabolites, thereby affecting the neonatal growth.

CONCLUSIONS

A global untargeted metabolomics was performed on the samples including feces, serum, and umbilical cord blood. The integrated multi-omics analysis revealed the interaction among intestinal flora, metabolites and the clinical indices, demonstrating the potential effects of the imbalance of intestinal flora on neonatal growth in the pregnant women with PE.

Fetal Fraction of Cell-Free DNA in the Prediction of Adverse Pregnancy Outcomes: A Nationwide Retrospective Cohort Study

OBJECTIVE

To assess the added value of fetal fraction of cell-free DNA in the maternal circulation in the prediction of adverse pregnancy outcomes.

DESIGN

Retrospective cohort study.

SETTING

Nationwide implementation study on non-invasive prenatal testing (NIPT; TRIDENT-2 study).

POPULATION

Pregnant women in the Netherlands opting for NIPT between June 2018 and June 2019.

METHODS

Two logistic regression prediction models were constructed for each adverse pregnancy outcome. The first model (base model) included prognostic clinical parameters that were selected from existing first-trimester prediction models for adverse pregnancy outcomes. The second model (fetal fraction model) included fetal fraction as a predictor on top of the prognostic clinical parameters included in the base model. The added prognostic value of fetal fraction was assessed by comparing the base and fetal fraction models in terms of goodness of fit and predictive performance.

MAIN OUTCOME MEASURES

Likelihood ratio test (LRT), area under the curve (AUC) and Integrated Discrimination Improvement (IDI) index.

RESULTS

The study cohort consisted of 56 110 pregnancies. The incidence of adverse pregnancy outcomes was 5.7% for hypertensive disorders of pregnancy (HDP; n = 3207), 10.2% for birthweight < p10 (n = 5726), 3.2% for birthweight < p2.3 (n = 1796), 3.4% for spontaneous preterm birth (sPTB; n = 1891), 3.4% for diabetes (n = 1902) and 1.3% for congenital anomalies (n = 741). Adding fetal fraction to the base model improved model fit for HDP, birthweight < p10, birthweight < p2.3, all sPTB, and diabetes, but not for congenital anomalies (LRT p < 0.05). For HDP, the AUC improved from 0.67 to 0.68 by adding fetal fraction to the base model (p = 0.14) with an IDI of 0.0018 (p < 0.0001). For birthweight < p10, the AUC improved from 0.65 to 0.66 (p < 0.0001) with an IDI of 0.0023 (p < 0.0001). For birthweight < p2.3, the AUC improved from 0.67 to 0.69 (p < 0.0001) with an IDI of 0.0011 (p < 0.0001). For all sPTB, the AUC was similar for both models (AUC 0.63, p = 0.021) with an IDI of 0.00028 (p = 0.0023). For diabetes, the AUC was similar (AUC 0.72, p = 0.35) with an IDI of 0.00055 (p = 0.00015).

CONCLUSIONS

Fetal fraction has statistically significant but limited prognostic value in the prediction of adverse pregnancy outcomes in addition to known prognostic clinical parameters.

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

BACKGROUND

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

OBJECTIVE

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Care of late intrauterine fetal death and stillbirth: Green-top Guideline No. 55

A combination of mifepristone and a prostaglandin preparation should usually be recommended as the first-line intervention for induction of labour (Grade B). A single 200 milligram dose of mifepristone is appropriate for this indication, followed by: 24+0-24+6 weeks of gestation - 400 micrograms buccal/sublingual/vaginal/oral of misoprostol every 3 hours; 25+0-27+6 weeks of gestation - 200 micrograms buccal/sublingual/vaginal/oral of misoprostol every 4 hours; from 28+0 weeks of gestation - 25-50 micrograms vaginal every 4 hours, or 50-100 micrograms oral every 2 hours [Grade C]. There is insufficient evidence available to recommend a specific regimen of misoprostol for use at more than 28+0 weeks of gestation in women who have had a previous caesarean birth or transmural uterine scar [Grade D]. Women with more than two lower segment caesarean births or atypical scars should be advised that the safety of induction of labour is unknown [Grade D]. Staff should be educated in discussing mode of birth with bereaved parents. Vaginal birth is recommended for most women, but caesarean birth will need to be considered for some [Grade D]. A detailed informed discussion should be undertaken with parents of both physical and psychological aspects of a vaginal birth versus a caesarean birth [Grade C]. Parents should be cared for in an environment that provides adequate safety according to individual clinical circumstance, while meeting their needs to grieve and feel supported in doing so (GPP). Clinical and laboratory tests should be recommended to assess maternal wellbeing (including coagulopathy) and to determine the cause of fetal death, the chance of recurrence and possible means of avoiding future pregnancy complications [Grade D]. Parents should be advised that with full investigation (including postmortem and placental histology) a possible or probable cause can be found in up to three-quarters of late intrauterine fetal deaths [Grade B]. All parents should be offered cytogenetic testing of their baby, which should be performed after written consent is given (GPP). Parents should be advised that postmortem examination can provide information that can sometimes be crucial to the management of future pregnancy [Grade B].

Patient awareness of long-term cardiovascular and metabolic disease risks after hypertensive disorders of pregnancy in Japan

AIM

Given the increasing recognition of the importance of postpartum follow-up care for women with a history of hypertensive disorders of pregnancy (HDP) to mitigate their future risk of cardiovascular and metabolic diseases, here we aimed to evaluate the current status of postpartum follow-up care in Japan and explore the challenges to its implementation.

METHODS

A web-based survey was conducted using a smartphone application among postpartum women between March and May 2024 to assess their knowledge of HDP-related future risk and postpartum follow-up care.

RESULTS

A total of 880 valid responses were obtained, 73 (8.3%) of which were from women with a history of HDP. Of them, 56.2% were aware of the heightened risk of cardiovascular disease and even fewer knew about the risks of metabolic syndrome (37.0%) and the preventive use of low-dose aspirin (12.3%); in fact, 31.5% reported receiving no information about their risk or preventive measures from healthcare providers. Furthermore, 43.8% did not consult specialists or attend regular checkups after their 1-month checkup. Among women with a history of HDP, those who received information and guidance were more likely to implement behavioral changes than those who did not.

CONCLUSIONS

Patient awareness level of HDP-related risk was low and the information provided by their healthcare professionals was insufficient, indicating that postpartum follow-up care in Japan is not satisfactory. This study highlights the need for improved educational strategies and systematic follow-up protocols to ensure that women are adequately informed and supported in managing their long-term health risks.

Efficacy of combining aspirin with hydroxychloroquine in pregnancies at high risk for pre-eclampsia: a prospective, multicentre, open-label, single-arm clinical trial, investigator-initiated study (HUGS study)

INTRODUCTION

The use of hydroxychloroquine (HCQ) during pregnancies complicated by systemic lupus erythematosus or refractory antiphospholipid antibody syndrome has demonstrated a significant ability to prevent pre-eclampsia (PE). As such, the potential for the administration of HCQ to prevent PE in other high-risk pregnancies is an important clinical research agenda among maternal and fetal medicine specialists. Mechanistically, the anti-inflammatory and immunomodulatory effects of HCQ can offer vascular protection and inhibit the placental dysfunction-associated thrombotic changes underlying the pathophysiology of PE, fetal growth restriction (FGR) and fetal death in utero (FDIU). Placenta-mediated complications exhibit a distinctive overlapping syndrome between pregnancies, and low-dose aspirin is the only prevention method currently in use. This study investigated the effects of improvements in outcomes with HCQ administration in high-risk pregnancies complicated by a previous experience of PE, FGR or FDIU.

METHODS AND ANALYSIS

This multicentre, open-label, single-arm trial commenced on 31 May 2022, in three tertiary hospitals in Korea. Pregnant women with a prior history of PE, FGR or FDIU are eligible to participate. This single-arm study set the previous study with the most similar inclusion criteria, aspirin dose and drug administration period as the comparison group. The required sample size was determined to be 58, with an expected dropout rate of 10%.

ETHICS AND DISSEMINATION

This study protocol was approved by the following institutions and committees: Institutional Review Boards of Chung-Ang University Gwangmyeong Hospital (2304-082-056), Samsung Medical Center (2021-11-087-003) and Kyungpook National University Chilgok Hospital (2021-06-005-006) and the Ministry of Food and Drug Safety. The results will be disseminated to the general public, grant funder, maternal-fetal medicine specialists and other researchers.

TRIAL REGISTRATION NUMBER

NCT05287321.

Sensitive objective markers for measuring aspirin responsiveness in pregnancy: An explorative scoping review

BACKGROUND

Aspirin is frequently used in pregnancy to decrease the risk of developing pre-eclampsia. Studies have highlighted this potential benefit which in theory happens by inhibition of platelet function. However, questions remain on the appropriate dosing and the reliability of serum markers in determining aspirin responsiveness in pregnancy (ARP).

OBJECTIVE

review the literature on ARP and identify the gaps, followed by investigating the objective biomarkers used to assess ARP. This includes the factors associated such as aspirin formulations, doses, and patient comorbidities.

METHODS

A comprehensive search was conducted using keywords such as 'aspirin', 'pregnancy', and 'responsiveness' in relevant databases such as PubMed, SCOPUS, Cochrane from inception to March 2024. Our inclusion criteria enrolled pregnant women aged 18 years old and above, irrespective of their trimester status, who were prescribed aspirin for any medical indication.

RESULTS

The research findings encompass three key areas. Firstly, examination of the impact of different aspirin formulations on responsiveness revealed no significant differences between different formulations. Secondly, nine papers were identified with varied dosages of administered aspirin, highlighting a need for standardized approach to dosing, and investigating higher dosing and its impact. Thirdly, there is a lack of consensus on biomarkers used to assess ARP. Finally, this synthesis sheds light on prognostic factors of developing aspirin non-responsiveness, such as medical comorbidities.

CONCLUSION

This scoping review identifies several residual uncertainties on ARP. The main gaps are validation of serum markers, understanding the influence of underlying morbidity on ARP, and determining appropriate aspirin dosing in pregnancy.

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

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

Introduction to the Proteomic Analysis of Placentas with Fetal Growth Restriction and Impaired Lipid Metabolism

Fetal growth restriction (FGR) is a disorder defined as the failure of a fetus to achieve its full biological development potential due to decreased placental function, which can be attributed to a range of reasons. FGR is linked to negative health outcomes during the perinatal period, including increased morbidity and mortality. Long-term health problems, such as impaired neurological and cognitive development, as well as cardiovascular and endocrine diseases, have also been found in adulthood. Aspirin administered prophylactically to high-risk women can effectively prevent FGR. FGR pregnancy care comprises several steps, including the weekly assessment of several blood vessels using Doppler measurements, amniotic fluid index (AFI), estimated fetal weight (EFW), cardiotocography (CTG), as well as delivery by 37 weeks. Pregnancy is a complex condition characterized by metabolic adjustments that guarantee a consistent provision of vital metabolites allowing the fetus to grow and develop. The lipoprotein lipid physiology during pregnancy has significant consequences for both the fetus and baby, and for the mother. In the course of a typical pregnancy, cholesterol levels increase by roughly 50%, LDL-C (low-density lipoprotein cholesterol) levels by 30-40%, HDL-C by 25% (high-density lipoprotein cholesterol). Typically, there is also a 2- to 3-fold increase in triglycerides. Low maternal blood cholesterol levels during pregnancy are linked to a decrease in birth weight and an increased occurrence of microcephaly. FGR impacts the placenta during pregnancy, resulting in alterations in lipid metabolism. Research has been undertaken to distinguish variations in protein expression between normal placentas and those impacted by FGR. This can aid in comprehending the fundamental pathogenic mechanisms of FGR and perhaps pave the way for the creation of novel diagnostic and treatment methods. Commonly employed approaches for detecting and analyzing variations in placental proteomes include mass spectrometry, bioinformatic analysis, and various proteomic techniques.

Effect of aspirin on biomarker profile in women at high risk for preeclampsia

BACKGROUND

There is limited evidence in the literature regarding the temporal changes of preeclampsia-related biomarkers during pregnancy in high-risk women who develop preeclampsia despite the administration of aspirin prophylaxis.

OBJECTIVE

This study aimed to compare the temporal changes in mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 across gestation in women identified as having high risk for preterm preeclampsia receiving aspirin prophylaxis and low-risk women without aspirin treatment.

STUDY DESIGN

This was a prospective longitudinal nested case-control study of 2007 women with singleton pregnancies who participated in the first-trimester screen-and-prevent program for preeclampsia at the Prince of Wales Hospital, Hong Kong Special Administrative Region, China, between January 2020 and May 2023. The risk of developing preterm preeclampsia was determined using the Fetal Medicine Foundation triple test (maternal factors, mean arterial pressure, uterine artery pulsatility index, and placental growth factor). High-risk women (adjusted risk ≥1:100) were administered a daily dose of aspirin at either 100 or 160 mg according to maternal weight, starting before 16 weeks until 36 weeks or until delivery or the onset of preeclampsia before 36 weeks. Low-risk women were matched according to maternal age, weight, and the date of the scan. The participants were followed up at 12 to 15+6, 20 to 24+6, and 30 to 37+6 weeks to measure mean arterial pressure, uterine artery pulsatility index, placental growth factor, and soluble fms-like tyrosine kinase-1 at each visit. The level of biomarker was expressed as multiple of the median. Log10 transformation was applied to fit the data to a Gaussian distribution before statistical analysis. A linear mixed-effects analysis was performed to compare the longitudinal changes of these biomarkers across gestation between the study groups.

RESULTS

Our study involved 403 low-risk women without preeclampsia, 1471 high-risk women without preeclampsia, and 133 high-risk women who developed preeclampsia. The low-risk group had significantly lower estimated marginal mean log10 mean arterial pressure multiple of the median, log10 uterine artery pulsatility index multiple of the median, and log10 soluble fms-like tyrosine kinase-1 multiple of the median, and higher estimated marginal mean log10 placental growth factor multiple of the median across gestation compared with the high-risk groups (P<.001). Among high-risk women, those who developed preeclampsia exhibited a significantly higher estimated marginal mean log10 mean arterial pressure multiple of the median (0.06378 vs 0.02985; P<.001), log10 uterine artery pulsatility index multiple of the median (0.08651 vs 0.02226; P<.001), and log10 soluble fms-like tyrosine kinase-1 multiple of the median (0.13204 vs 0.01234; P<.001), and lower estimated marginal mean log10 placental growth factor multiple of the median (-0.33504 vs -0.16388; P<.001) across gestation compared with those without preeclampsia. In the individual gestational time point analysis, compared with high-risk women without preeclampsia, those who developed preeclampsia exhibited higher log10 mean arterial pressure multiple of the median in all 3 trimesters, higher log10 uterine artery pulsatility index multiple of the median and lower log10 placental growth factor multiple of the median in the second and third trimesters, and higher log10 soluble fms-like tyrosine kinase-1 multiple of the median in the third trimester.

CONCLUSION

This study demonstrated that high-risk women who developed preeclampsia consistently exhibited high mean arterial pressure levels from the first trimester that remained unchanged during pregnancy, high uterine artery pulsatility index levels and low placental growth factor levels starting from the second trimester, and high soluble fms-like tyrosine kinase-1 levels in the third trimester compared with those who did not develop preeclampsia despite the administration of low-dose aspirin. These findings underscore the role of these biomarkers in further risk stratification for the development of preeclampsia among high-risk women following aspirin administration.

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

Background

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

Methods

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

Results

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

Conclusion

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

Factors Associated with Maternal Morbidity in Patients with Eclampsia in Three Obstetric Intensive Care Units: A Retrospective Study

(1) Introduction. Eclampsia is a rare complication that can occur during pregnancy and has a significant impact on maternal and neonatal outcomes. The aim of this study was to investigate the risk factors associated with significant maternal morbidity after an eclamptic seizure. (2) Methods. An observational retrospective study was performed in three maternity hospitals in Romania between 2015 and 2023 and included pregnant patients diagnosed with eclampsia. Clinical and paraclinical data were investigated, and the impact of several risk factors was assessed using multiple logistic regression analysis. The results were reported as risk ratios (RRs) and 95% confidence intervals (Cis). (3) Results. A total of 104 patients with preeclampsia, of whom 23 experienced eclamptic seizures, were included in this study. A total of 82.6% of the patients diagnosed with eclampsia experienced a form of significant morbidity (stroke, PRES syndrome, or any organ failure/dysfunction). Our regression analysis revealed that advanced maternal age (RR: 12.24 95% CI: 4.29-36.61, p = 0.002), the presence of thrombotic disorders (RR: 9.17, 95% CI: 3.41-23.70, p = 0.03), obesity (RR: 4.89, 95% CI: 0.78-18.15, p = 0.036), and smoking status (RR: 2.18, 95% CI: 0.13- 6.51, p = 0.042) significantly increase the risk of maternal comorbidities. (4) Conclusions. Careful monitoring of pregnant patients, adequate weight control during pregnancy, and correct anticoagulation of individual patients could reduce the extent of postpartum comorbidities that can result from an eclamptic seizure.

Implementation of First-Trimester Screening and Prevention of Preeclampsia: A Stepped Wedge Cluster-Randomized Trial in Asia

BACKGROUND

This trial aimed to assess the efficacy, acceptability, and safety of a first-trimester screen-and-prevent strategy for preterm preeclampsia in Asia.

METHODS

Between August 1, 2019, and February 28, 2022, this multicenter stepped wedge cluster randomized trial included maternity/diagnostic units from 10 regions in Asia. The trial started with a period where all recruiting centers provided routine antenatal care without study-related intervention. At regular 6-week intervals, one cluster was randomized to transit from nonintervention phase to intervention phase. In the intervention phase, women underwent first-trimester screening for preterm preeclampsia using a Bayes theorem-based triple-test. High-risk women, with adjusted risk for preterm preeclampsia ≥1 in 100, received low-dose aspirin from <16 weeks until 36 weeks.

RESULTS

Overall, 88.04% (42 897 of 48 725) of women agreed to undergo first-trimester screening for preterm preeclampsia. Among those identified as high-risk in the intervention phase, 82.39% (2919 of 3543) received aspirin prophylaxis. There was no significant difference in the incidence of preterm preeclampsia between the intervention and non-intervention phases (adjusted odds ratio [aOR], 1.59 [95% CI, 0.91-2.77]). However, among high-risk women in the intervention phase, aspirin prophylaxis was significantly associated with a 41% reduction in the incidence of preterm preeclampsia (aOR, 0.59 [95% CI, 0.37-0.92]). In addition, it correlated with 54%, 55%, and 64% reduction in the incidence of preeclampsia with delivery at <34 weeks (aOR, 0.46 [95% CI, 0.23-0.93]), spontaneous preterm birth <34 weeks (aOR, 0.45 [95% CI, 0.22-0.92]), and perinatal death (aOR, 0.34 [95% CI, 0.12-0.91]), respectively. There was no significant between-group difference in the incidence of aspirin-related severe adverse events.

CONCLUSIONS

The implementation of the screen-and-prevent strategy for preterm preeclampsia is not associated with a significant reduction in the incidence of preterm preeclampsia. However, low-dose aspirin effectively reduces the incidence of preterm preeclampsia by 41% among high-risk women. The screen-and-prevent strategy for preterm preeclampsia is highly accepted by a diverse group of women from various ethnic backgrounds beyond the original population where the strategy was developed. These findings underpin the importance of the widespread implementation of the screen-and-prevent strategy for preterm preeclampsia on a global scale.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT03941886.

AGA Clinical Practice Update on Pregnancy-Related Gastrointestinal and Liver Disease: Expert Review

DESCRIPTION

The purpose of this American Gastroenterological Association (AGA) Institute Clinical Practice Update is to review the available published evidence and expert advice regarding the clinical management of patients with pregnancy-related gastrointestinal and liver disease.

METHODS

This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Gastroenterology. This article provides practical advice for the management of pregnant patients with gastrointestinal and liver disease based on the best available published evidence. The Best Practice Advice statements were drawn from a review of the published literature and from expert opinion. Because formal systematic reviews were not performed, these Best Practice Advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations. Best Practice Advice Statements BEST PRACTICE ADVICE 1: To optimize gastrointestinal and liver disease before pregnancy, preconception and contraceptive care counseling by a multidisciplinary team should be encouraged for reproductive-aged persons who desire to become pregnant. BEST PRACTICE ADVICE 2: Procedures, medications, and other interventions to optimize maternal health should not be withheld solely because a patient is pregnant and should be individualized after an assessment of the risks and benefits. BEST PRACTICE ADVICE 3: Coordination of birth for a pregnant patient with complex inflammatory bowel disease, advanced cirrhosis, or a liver transplant should be managed by a multidisciplinary team, preferably in a tertiary care center. BEST PRACTICE ADVICE 4: Early treatment of nausea and vomiting of pregnancy may reduce progression to hyperemesis gravidarum. In addition to standard diet and lifestyle measures, stepwise treatment consists of symptom control with vitamin B6 and doxylamine, hydration, and adequate nutrition; ondansetron, metoclopramide, promethazine, and intravenous glucocorticoids may be required in moderate to severe cases. BEST PRACTICE ADVICE 5: Constipation in pregnant persons may result from hormonal, medication-related, and physiological changes. Treatment options include dietary fiber, lactulose, and polyethylene glycol-based laxatives. BEST PRACTICE ADVICE 6: Elective endoscopic procedures should be deferred until the postpartum period, whereas nonemergent but necessary procedures should ideally be performed in the second trimester. Pregnant patients with cirrhosis should undergo evaluation for, and treatment of, esophageal varices; upper endoscopy is suggested in the second trimester (if not performed within 1 year before conception) to guide consideration of nonselective β-blocker therapy or endoscopic variceal ligation. BEST PRACTICE ADVICE 7: In patients with inflammatory bowel disease, clinical remission before conception, during pregnancy, and in the postpartum period is essential for improving outcomes of pregnancy. Biologic agents should be continued throughout pregnancy and the postpartum period; use of methotrexate, thalidomide, and ozanimod must be stopped at least 6 months before conception. BEST PRACTICE ADVICE 8: Endoscopic retrograde cholangiopancreatography during pregnancy may be performed for urgent indications, such as choledocholithiasis, cholangitis, and some cases of gallstone pancreatitis. Ideally, endoscopic retrograde cholangiopancreatography should be performed during the second trimester, but if deferring the procedure may be detrimental to the health of the patient and fetus, a multidisciplinary team should be convened to decide on the advisability of endoscopic retrograde cholangiopancreatography. BEST PRACTICE ADVICE 9: Cholecystectomy is safe during pregnancy; a laparoscopic approach is the standard of care regardless of trimester, but ideally in the second trimester. BEST PRACTICE ADVICE 10: The diagnosis of intrahepatic cholestasis of pregnancy is based on a serum bile acid level >10 μmol/L in the setting of pruritus, typically during the second or third trimester. Treatment should be offered with oral ursodeoxycholic acid in a total daily dose of 10-15 mg/kg. BEST PRACTICE ADVICE 11: Management of liver diseases unique to pregnancy, such as pre-eclampsia; hemolysis, elevated liver enzymes, and low platelets syndrome; and acute fatty liver of pregnancy requires planning for delivery and timely evaluation for possible liver transplantation. Daily aspirin prophylaxis for patients at risk for pre-eclampsia or hemolysis, elevated liver enzymes, and low platelets syndrome is advised beginning at week 12 of gestation. BEST PRACTICE ADVICE 12: In patients with chronic hepatitis B virus infection, serum hepatitis B virus DNA and liver biochemical test levels should be ordered. Patients not on treatment but with a serum hepatitis B virus DNA level >200,000 IU/mL during the third trimester of pregnancy should be considered for treatment with tenofovir disoproxil fumarate. BEST PRACTICE ADVICE 13: In patients on immunosuppressive therapy for chronic liver diseases or after liver transplantation, therapy should be continued at the lowest effective dose during pregnancy. Mycophenolate mofetil should not be administered during pregnancy.

Obstetric care provider's knowledge about the use of low dose aspirin for preeclampsia prevention in low and middle income countries: a systematic review and meta-analysis

INTRODUCTION

Preeclampsia can elevate the likelihood of unfavorable consequences for a mother, such as severe morbidity and mortality. World Health Organization recommends low dose acetylsalicylic acid (aspirin, 75 mg per day) for the prevention of preeclampsia in women at moderate or high risk of developing the condition. The use of low dose aspirin is dependent on the knowledge of health care providers working in the antenatal care units. We found inconsistent figures regarding the knowledge level of health care providers on low dose aspirin for preeclampsia prevention around different low and middle income countries in the world. Thus, determining the pooled knowledge level of health care providers is very important.

METHODS

This systematic review and meta-analysis (SRMA) was conducted on the knowledge level of among obstetric care providers towards preeclampsia prevention in low and middle income countries. We identified relevant literature in the English language only. A comprehensive search was conducted on databases such as PubMed, Google Scholar, HINARI, and Scopus. Subsequently, all datasets were exported to Mendeley reference manager and transferred to a Microsoft Excel spreadsheet to eliminate duplicate data during the review process. The extracted Microsoft Excel spreadsheet format data was imported to STATA software version 17 (STATA corporation, Texas, USA) for analysis. Then random effect model was used to estimate the pooled level of knowledge of health care providers on low dose aspirin for preeclampsia prevention in low income countries. Cochrane Q-test and I2 statistics were computed to assess heterogeneity among all the studies included in this SRMA.

RESULT

A total of 1231 articles were identified through our search strategies, including Google Scholar, PubMed, Hinari and Scopus. Ultimately, six articles met the eligibility criteria for inclusion in the final SRMA. The pooled knowledge level of healthcare providers regarding the use of low-dose aspirin for preeclampsia prevention in low-income countries was found to be 16.38% (95% CI: 4.36-28.40). The Cochrane heterogeneity index, with a substantial I2 value of 98.89% and a significant P-value of 0.01, indicated significant heterogeneity among the primary studies included.

CONCLUSION

the knowledge level of obstetric care providers in low and middle income countries is found very low and all the governmental and non-governmental organizations should strive to enhance the knowledge of obstetric care providers on the use of low dose aspirin for preeclampsia prevention in low and middle income countries.

Hypertensive Disorders of Pregnancy in Saudi Arabia: Evaluating Maternal and Neonatal Risks, Outcomes, and Aspirin Prophylaxis: A Review Article

Hypertensive disorders during pregnancy, including pre-eclampsia and eclampsia, pose significant risks to both maternal and neonatal health. This review article evaluates the prevalence, maternal and neonatal outcomes, and the efficacy of aspirin prophylaxis in managing these conditions in Saudi Arabia. Utilizing data from multiple retrospective studies and recent guidelines, we highlight the regional variations in the outcomes of hypertensive disorders of pregnancy. Severe complications such as Hemolysis, Elevated Liver enzymes and Low Platelets (HELLP) syndrome occurred in 6.6% of cases, while eclampsia was reported in 6.7% of cases. Cesarean sections were notably high, with rates reaching up to 79% among affected pregnancies. Maternal risk factors identified include chronic hypertension (prevalence 17%), diabetes (ranging from 10.4% to 26.3%), and advanced maternal age. Neonatal complications often involve preterm birth, reported in 26.5% to 26.7% of cases, intrauterine growth restriction (ranging from 15.7% to 25%), and increased NICU admissions, reported in 2.4% of cases. No data were found in the included studies to evaluate the prophylactic use of low-dose aspirin in reducing the incidence of pre-eclampsia or improving fetomaternal outcomes. Despite the effectiveness of aspirin, awareness and implementation of prophylaxis guidelines remain suboptimal among healthcare providers in Saudi Arabia. A national survey revealed that only a fraction of obstetrical care providers were fully knowledgeable about aspirin prophylaxis guidelines. This review underscores the necessity for enhanced educational programs and standardized guidelines to improve maternal and neonatal outcomes in hypertensive pregnancies within the region.

Aspirin pharmacokinetics and pharmacodynamics through gestation

BACKGROUND

Low dose aspirin is recommended for prevention of preeclampsia, however there is not consensus on the appropriate dose. Pregnancy specific changes have the potential to impact the pharmacology of aspirin in pregnancy, however there are very limited studies on aspirin pharmacokinetics in pregnancy and none linking pharmacokinetics (PK, drug dose and drug level) to pharmacodynamics (PD, drug dose and physiologic response) in pregnancy. As a result, we do not have a good understanding of the pharmacologic response to aspirin in pregnancy, which has important implications for clinical efficacy. We sought to describe the PK and PD of aspirin through pregnancy and to identify individual covariates that impacted aspirin PK/PD.

OBJECTIVE

We sought to describe the PK and PD of aspirin through pregnancy (first and third trimester), to identify covariates that significantly impact aspirin PK and to identify the relationship between aspirin PK and PD.

STUDY DESIGN

This is a prospective study of patients at high risk for preeclampsia recommended to take 81 mg aspirin daily. This study involved 3 visits as follows: (1) baseline, first trimester (10-16 weeks of gestation) 6-hour PK visit, done before initiation of aspirin; (2) follow-up 1: 2 to 4 weeks after aspirin initiation; and (3) follow-up 2: third trimester 6-hour PK visit (28-32 weeks of gestation). The following were assessed at each visit: weight or body mass index, platelet function analysis-100 (Siemens), urinary thromboxane B2, serum thromboxane B2, and plasma salicylic acid. The PK visits consisted of blood work done at baseline (predose), administration of 81 mg nonenteric coated aspirin, and then plasma blood level of salicylic acid assessed at 30 minutes and then hourly 1 to 6 hours after dose. Pearson correlation and multivariable regression were used to identify associations between parameters and identify relevant covariates. Log-adjusted values were used for regression analysis. P<.05 was considered statistically significant.

RESULTS

Nineteen participants were included with first trimester data, and 16 with third trimester data. There was no statistically significant change in mean PK parameters between the first and third trimester, although there was a trend to lower peak concentration in the third than in the first trimester (P=.08). In multivariable regression, baseline obesity and current body mass index as a continuous measures were negatively associated with log-adjusted peak salicylic acid concentration (-0.28 [-0.46 to -0.11], P=.003 and -0.02 [-0.03 to -0.009], P=.001, respectively) and log-adjusted plasma salicylic acid area under the curve 0 to 6 hours postdose (-0.25 [-0.45 to 0.05], P=.02, -0.04 [-0.07 to -0.01], P=.008 respectively). There was a significant decrease in urinary thromboxane 2 to 4 weeks after aspirin initiation compared with baseline, which correlated with a concomitant increase in platelet function analysis-100 closure time. In multivariable regression model, there was a strong association between plasma salicylic acid concentration (area under the curve 0-6 hours postdose) and urinary thromboxane (B=-3.12 [-5.38 to -1.04], P=.006), and with urinary thromboxane suppression and platelet inhibition, platelet function analysis-100 (-0.23 [-0.31 to -0.14], P<.001). With progressive thromboxane suppression, platelet inhibition (platelet function analysis-100 closure time) increased. Individual comorbidities, including weight, hypertension, and pregestational diabetes (Type I or II), also impacted aspirin response.

CONCLUSION

We have demonstrated the relationship between individual factors, plasma concentrations of salicylic acid, thromboxane suppression, and platelet inhibition at a single dose (81 mg) of aspirin taken through pregnancy. Our findings suggest that dose modification of aspirin in pregnancy may help to achieve the optimal response. Our results may be used to facilitate computational modeling to identify optimal dosing, taking into consideration individual factors.

Pre-eclampsia challenges and care in low and middle-income countries: Understanding diagnosis, management, and health impacts in remote and developing regions

As an example of a low- and middle-income country (LMIC), India ranks pre-eclampsia among the top three causes of maternal mortality, following haemorrhage and infections. It is one of the primary concerns for maternal and perinatal health in LMICs. Many LMICs lack clear consensus and guidelines for the prevention, diagnosis, and management of hypertensive disorders in pregnancy, including pre-eclampsia. The International Society for the Study of Hypertension in Pregnancy 2021 guidelines address LMIC applications, offering customisable solutions. Atypical presentations of pre-eclampsia contribute to diagnostic delays, resulting in additional adverse maternal and perinatal outcomes. Implementing management strategies faces challenges in both urban and rural settings. Adapting global research involving local populations is imperative, with the potential for cost-effective adoption of international guidelines. Prevention, early diagnosis, and education dissemination are essential, involving healthcare providers and advocacy initiatives. Encouraging government investment in pre-eclampsia management as a public health initiative is important. This article explores socio-economic, cultural, and legislative factors influencing the management of pre-eclampsia in LMICs, addressing emerging challenges and potential partnerships for healthcare provision.

Early pregnancy maternal blood pressure and risk of preeclampsia: Does the association differ by parity? Evidence from 14,086 women across 7 countries

OBJECTIVE

To determine if the relationship between blood pressure (BP) before 16 weeks' gestation and subsequent onset of preeclampsia differs by parity, and by history of hypertensive disorders of pregnancy (HDP) in parous women.

STUDY DESIGN

Data from two studies were pooled. First, routinely collected clinical data from three metropolitan hospitals in Sydney, Australia (2017-2020), where BP was measured as part of routine clinical care using validated mercury-free sphygmomanometers. Second, prospectively collected research data from the INTERBIO-21st Study, conducted in six countries, investigating the epidemiology of fetal growth restriction and preterm birth, where BP was measured by dedicated research staff using an automated machine validated for use in pregnancy.

MAIN OUTCOME

Adjusted odds ratios (aOR) (95% confidence interval (CI)) for the association of systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) with preeclampsia were obtained from logistic regression models. Models were adjusted for age, smoking, body mass index, previous hypertension, previous diabetes, and previous preeclampsia. Interactions for parity, and history of HDP in parous women were included.

RESULTS

There were 14,086 pregnancies (Sydney = 11008, INTERBIO-21st = 3078) in the pooled analyses, 6914 (49 %) were parous, of which 414 (6.0 %) had a history of HDP. Nulliparous women had a higher risk of preeclampsia (2.6 %) compared with parous women (1.5 %): [aOR (95 %CI) 3.61 (2.67, 4.94)], as did parous women with a history of HDP (15.0 %) compared with no history (0.7 %) [12.70 (8.02, 20.16)]. MAP before 16 weeks' gestation (mean [SD] 78.8[8.6] mmHg) was more strongly associated than SBP or DBP with development of preeclampsia in parous women [2.22 (1.81, 2.74)] per SD higher MAP] compared with nulliparous women [1.58 (1.34, 1.87)] (p for interaction 0.013). There were no significant differences on the effect of blood pressure on preeclampsia in parous women by history of HDP (p for interaction 0.5465).

CONCLUSION

The risk of preeclampsia differs according to parity and history of HDP in a previous pregnancy. Blood pressure in early pregnancy predicts preeclampsia in all groups, although more strongly associated in parous than nulliparous women, but no different in parous women by history of HDP.

Maternal Vascular Malperfusion and Anatomic Cord Abnormalities Are Prevalent in Pregnancies With Fetal Congenital Heart Disease

OBJECTIVE

Impairments in the maternal-fetal environment are associated with adverse postnatal outcomes among infants with congenital heart disease. Therefore, we sought to investigate placental anomalies as they related to various forms of fetal congenital heart disease (FCHD).

METHODS

We reviewed the placental pathology in singleton pregnancies with and without FCHD. FCHD was divided into separate categories (transposition physiology, obstructive left, obstructive right, biventricular without obstruction, and others). Exclusion criteria included other prenatally known structural malformations and/or aneuploidy. The significance threshold was set at p < 0.05 or False Discovery rate q < 0.05 when multiple tests were performed.

RESULTS

The cohort included 215 FCHD and 122 non-FCHD placentas. FCHD placentas showed increased rates of maternal vascular malperfusion (24% vs. 5%, q < 0.001) and cord anomalies (27% vs. 1%, q < 0.001). Placentas with fetal TGA demonstrated a lower rate of hypoplasia when compared with other FCHD types (1/39 vs. 51/176, Fisher's exact p = 0.015).

CONCLUSION

Placental maternal vascular malperfusion is increased in FCHD. The prevalence of vascular malperfusion did not differ by FCHD type, indicating that CHD type does not predict the likelihood of placental vascular dysfunction. Further investigation of the placental-fetal heart axis in FCHD is warranted given the importance of placental health.

Safety and efficacy of phosphodiesterase-5 (PDE-5) inhibitors in fetal growth restriction: a systematic literature review and meta-analysis

Introduction: Fetal growth restriction (FGR) is associated with a higher risk of perinatal morbidity and mortality, as well as long-term health issues in newborns. Currently, there is no effective medicine for FGR. Phosphodiesterase-5 (PDE-5) inhibitors have been shown in pre-clinical studies to improve FGR. This study aimed to evaluate the latest evidence about the clinical outcomes and safety of PDE-5 inhibitors for the management of FGR. Methods: Eight databases (PubMed, Embase, Medline, Web of Science, Cochrane Library, Chinese National Knowledge Infrastructure, Chinese Biomedical Database and WangFang Database) were searched for English and Chinese articles published from the database inception to December 2023. Randomized controlled trials (RCTs) reporting the use of PDE-5 inhibitors in FGR were included. The quality of the RCTs was assessed using the Cochrane Risk of Bias Tool. Odds ratio and mean difference (MD) (95% confidence intervals) were pooled for meta-analysis. Results: From 253 retrieved publications, 16 studies involving 1,492 pregnant women met the inclusion criteria. Only sildenafil (15 RCTs) and tadalafil (1 RCT) were studied for FGR. Compared with the control group (placebo, no treatment, or other medication therapies), sildenafil increased birth weight, pregnancy prolongation and umbilical artery pulsatility indices. However, it also increased the risk of pulmonary hypertension in newborns, as well as headache and flushing/rash in mothers. There were no significant differences in gestation age, perinatal mortality or major neonatal morbidity, stillbirth, neonate death, infants admitted to neonatal intensive care unit, intraventricular hemorrhage and necrotizing enterocolitis in infants, as well as pregnancy hypertension and gastrointestinal side effects in mothers between the treatment and the control groups. Discussion: Sildenafil was the most investigated PDE-5 inhibitors for FGR. Current evidence suggests that sildenafil can improve birth weight and duration of pregnancy but at the same time increase the risk of neonatal pulmonary hypertension. It remains uncertain whether the benefits of sildenafil in FGR outweigh the risks and further high-quality RCTs are warranted. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=325909.

Placenta-Mediated Conditions: Past, Present, and Future Perspectives

Pregnancy is a highly regulated biological condition in which a successful outcome is heavily dependent on maintaining a delicate balance through maternal-fetal dialog at various levels [...].

Obstetric antiphospholipid syndrome

Antiphospholipid syndrome (APS) is the most frequent acquired thrombophilia of autoimmune basis. Pregnancy complications of APS may include recurrent miscarriage, and placental dysfunction presenting as fetal death, prematurity, intrauterine growth restriction and preeclampsia. For the management of obstetric APS, a coordinated medical-obstetric management is essential, and this should start for a preconceptional visit in order to estimate the individual risk for complications, adjust therapies and establish the indications for preconceptional and first-trimester therapy. The basis of APS therapy during pregnancy is low-dose aspirin, combined in certain clinical scenarios with low-molecular weight heparin. Induction of delivery should not be routinely indicated in the absence of maternal and/or fetal complications. Postpartum management should be warranted.

Implementation of aspirin use during pregnancy in community midwifery-led care in the Netherlands: A pilot survey

INTRODUCTION

Aspirin nowadays is widely used in pregnancy, but implementation among gynecologists took nearly four decades. For a complete insight in the implementation of aspirin, community midwives are to be involved. Community midwives do not have authority to prescribe aspirin and have to refer to a general practitioner or consultant obstetrician for a prescription.

METHODS

The study was an online, national pilot survey about the implementation of aspirin use during pregnancy among independently practicing community midwives consisting of 29 items with five categories: background, advising, prescribing, possible indications, and clinical practice.

RESULTS

Forty-seven community midwives completed the survey between April and May 2021. All respondents had experience on advising aspirin use in pregnancy. History of preterm pre-eclampsia or HELLP syndrome was identified as a risk factor for developing utero-placental complications by 97.9% of the community midwives. Moderate risk factors in women with otherwise low-risk pregnancy were identified by >75% of the participants. Practical issues in prescribing aspirin were experienced by one-third of the respondents. Suggestions were made to obtain authority for community midwives to prescribe aspirin and improve collaboration with consultant obstetricians and general practitioners.

CONCLUSIONS

Community midwives seem to be adequate in identifying risk factors for developing utero-placental complications in women with otherwise low-risk pregnancy. Practical issues for prescribing aspirin occur often. Obtaining authority for community midwives to prescribe aspirin after education should be considered and consulting a consultant obstetrician should become more accessible to overcome the practical issues. Further educating community midwives and general practitioners might improve implementation rates and perinatal outcomes.

Fetal fraction of cell-free DNA in noninvasive prenatal testing and adverse pregnancy outcomes: a nationwide retrospective cohort study of 56,110 pregnant women

BACKGROUND

Noninvasive prenatal testing by cell-free DNA analysis is offered to pregnant women worldwide to screen for fetal aneuploidies. In noninvasive prenatal testing, the fetal fraction of cell-free DNA in the maternal circulation is measured as a quality control parameter. Given that fetal cell-free DNA originates from the placenta, the fetal fraction might also reflect placental health and maternal pregnancy adaptation.

OBJECTIVE

This study aimed to assess the association between the fetal fraction and adverse pregnancy outcomes.

STUDY DESIGN

We performed a retrospective cohort study of women with singleton pregnancies opting for noninvasive prenatal testing between June 2018 and June 2019 within the Dutch nationwide implementation study (Trial by Dutch Laboratories for Evaluation of Non-Invasive Prenatal Testing [TRIDENT]-2). Multivariable logistic regression analysis was used to assess associations between fetal fraction and adverse pregnancy outcomes. Fetal fraction was assessed as a continuous variable and as <10th percentile, corresponding to a fetal fraction <2.5%.

RESULTS

The cohort comprised 56,110 pregnancies. In the analysis of fetal fraction as a continuous variable, a decrease in fetal fraction was associated with increased risk of hypertensive disorders of pregnancy (adjusted odds ratio, 2.27 [95% confidence interval, 1.89-2.78]), small for gestational age neonates <10th percentile (adjusted odds ratio, 1.37 [1.28-1.45]) and <2.3rd percentile (adjusted odds ratio, 2.63 [1.96-3.57]), and spontaneous preterm birth from 24 to 37 weeks of gestation (adjusted odds ratio, 1.02 [1.01-1.03]). No association was found for fetal congenital anomalies (adjusted odds ratio, 1.02 [1.00-1.04]), stillbirth (adjusted odds ratio, 1.02 [0.96-1.08]), or neonatal death (adjusted odds ratio, 1.02 [0.96-1.08]). Similar associations were found for adverse pregnancy outcomes when fetal fraction was <10th percentile.

CONCLUSION

In early pregnancy, a low fetal fraction is associated with increased risk of adverse pregnancy outcomes. These findings can be used to expand the potential of noninvasive prenatal testing in the future, enabling the prediction of pregnancy complications and facilitating tailored pregnancy management through intensified monitoring or preventive measures.

Therapeutic Value of Low-Dose Acetylsalicylic Acid for the Prevention of Preeclampsia in High-Risk Bulgarian Women

Introduction Preeclampsia (PE) is a syndrome that affects pregnant women after 20 weeks of gestation and involves numerous organ systems. Screening for PE is essential to prevent complications and guide management. Some existing guidelines for screening have limitations in terms of detection rates and false positives. The aim of this study is to assess the therapeutic value of low-dose acetylsalicylic acid (ASA) for the prevention of PE in high-risk Bulgarian women. Methodology A prospective cohort research was carried out, encompassing women who were recruited from several routine consultations, such as booking, scanning, and regular prenatal visits. We utilized the purposive sampling technique to carefully choose potential participants. The study was conducted by a maternal-fetal medicine center located in Plovdiv, Bulgaria. The data-gathering period spanned from January 2018 to November 2020. At the appointment, the following procedures were conducted: 1) recording history; 2) assessing height, weight, and blood pressure; 3) collecting blood specimens for biochemical markers; and 4) ultrasound examination. Results A total sample size of 1,383 individuals was categorized into two distinct groups: high-risk patients (n = 506) and low-risk patients (n = 877). The mean uterine artery pulsatility index (UtA-PI) and mean arterial pressure (MAP) ratios were all greater in high-risk group women (p < 0.05). The data revealed that a significant number of high-risk women failed to adhere to the prescribed dosage or regular use of ASA as recommended by their doctor. There were only 384 (75.9%) high-risk women who took low-dose ASA regularly. Conclusion The findings emphasize the importance of personalized prenatal care and early risk assessment to improve maternal and fetal outcomes. Therefore, it is crucial to educate pregnant women, considering the benefits and risks of low-dose ASA when appropriately indicated.

Controversies and Clarifications Regarding the Role of Aspirin in Preeclampsia Prevention: A Focused Review

Preeclampsia is one of the leading causes of maternal and perinatal morbidity and mortality worldwide. In recent decades, many studies have evaluated different interventions in order to prevent the occurrence of preeclampsia. Among these, administration of low-dose aspirin from early pregnancy showed consistent evidence of its prophylactic role. In this article, we review the scientific literature on this topic, highlighting the rationale for aspirin use, who should be treated, the timing of initiation and cessation of therapy, the importance of proper dosing, and its role in the prevention of other adverse outcomes.

Hypertensive Disorders of Pregnancy and the Cardiovascular System: Causes, Consequences, Therapy, and Prevention

Hypertensive disorders of pregnancy continue to be significant contributors to adverse perinatal outcome and maternal mortality, as well as inducing life-long cardiovascular health impacts that are proportional to the severity and frequency of pregnancy complications. The placenta is the interface between the mother and fetus and its failure to undergo vascular maturation in tandem with maternal cardiovascular adaptation by the end of the first trimester predisposes to hypertensive disorders and fetal growth restriction. While primary failure of trophoblastic invasion with incomplete maternal spiral artery remodeling has been considered central to the pathogenesis of preeclampsia, cardiovascular risk factors associated with abnormal first trimester maternal blood pressure and cardiovascular adaptation produce identical placental pathology leading to hypertensive pregnancy disorders. Outside pregnancy blood pressure treatment thresholds are identified with the goal to prevent immediate risks from severe hypertension >160/100 mm Hg and long-term health impacts that arise from elevated blood pressures as low as 120/80 mm Hg. Until recently, the trend for less aggressive blood pressure management during pregnancy was driven by fear of inducing placental malperfusion without a clear clinical benefit. However, placental perfusion is not dependent on maternal perfusion pressure during the first trimester and risk-appropriate blood pressure normalization may provide the opportunity to protect from the placental maldevelopment that predisposes to hypertensive disorders of pregnancy. Recent randomized trials set the stage for more aggressive risk-appropriate blood pressure management that may offer a greater potential for prevention for hypertensive disorders of pregnancy. KEY POINTS: · Optimal management of maternal blood pressure to prevent preeclampsia and its risks is undefined.. · Early gestational rheological damage to the intervillous space predisposes to preeclampsia and FGR.. · First trimester blood pressure management may need to aim for normotension to prevent preeclampsia..

Prospective Validation of First-Trimester Screening for Preterm Preeclampsia in Nulliparous Women (PREDICTION Study)

BACKGROUND

Fetal Medicine Foundation (FMF) studies suggest that preterm preeclampsia can be predicted in the first trimester by combining biophysical, biochemical, and ultrasound markers and prevented using aspirin. We aimed to evaluate the FMF preterm preeclampsia screening test in nulliparous women.

METHODS

We conducted a prospective multicenter cohort study of nulliparous women recruited at 11 to 14 weeks. Maternal characteristics, mean arterial blood pressure, PAPP-A (pregnancy-associated plasma protein A), PlGF (placental growth factor) in maternal blood, and uterine artery pulsatility index were collected at recruitment. The risk of preterm preeclampsia was calculated by a third party blinded to pregnancy outcomes. Receiver operating characteristic curves were used to estimate the detection rate (sensitivity) and the false-positive rate (1-specificity) for preterm (<37 weeks) and for early-onset (<34 weeks) preeclampsia according to the FMF screening test and according to the American College of Obstetricians and Gynecologists criteria.

RESULTS

We recruited 7554 participants including 7325 (97%) who remained eligible after 20 weeks of which 65 (0.9%) developed preterm preeclampsia, and 22 (0.3%) developed early-onset preeclampsia. Using the FMF algorithm (cutoff of ≥1 in 110 for preterm preeclampsia), the detection rate was 63.1% for preterm preeclampsia and 77.3% for early-onset preeclampsia at a false-positive rate of 15.8%. Using the American College of Obstetricians and Gynecologists criteria, the equivalent detection rates would have been 61.5% and 59.1%, respectively, for a false-positive rate of 34.3%.

CONCLUSIONS

The first-trimester FMF preeclampsia screening test predicts two-thirds of preterm preeclampsia and three-quarters of early-onset preeclampsia in nulliparous women, with a false-positive rate of ≈16%.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT02189148.