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Thompson B, Vereen RJ, Plowden TC, Lutgendorf MA. Personal reflections on race-based medicine: narrative analysis of a case study using a situated lens. J Natl Med Assoc 2025:S0027-9684(25)00032-X. [PMID: 40413161 DOI: 10.1016/j.jnma.2025.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2024] [Revised: 04/07/2025] [Accepted: 04/17/2025] [Indexed: 05/27/2025]
Abstract
BACKGROUND Race-based medicine was initially established to risk-stratify patients using algorithms based on biological similarities. This generalized form of medicine resulted in harmful practices and health inequities. Although race-based medicine has received increasing attention as a harmful practice contributing to structural and systemic racism in medicine, the individual patient perspective remains relatively under-studied, particularly in obstetrics. This qualitative case study uses a situated lens to explore the individual experience and perspective of race-based medicine in perinatal care. METHODS This was an institutional review board approved qualitative study utilizing semi-structured interviews as part of a larger study investigating the birth experiences of military beneficiaries. The interview was recorded and transcribed with data inductively analyzed using narrative analysis with positioning theory to identify positions and lived experiences during the individual's care experiences. RESULTS Narrative analysis yielded the following themes: (1) self-identity; (2) reinforcing racial sensitivity; (3) health individualization; (4) internal conflict with external perception and honesty; (5) trust and respect; (6) resisting negative influence and press/stories; (7) intellectualization; and (8) fear vs. empowerment for personalized birth wishes. Each theme represented valid concerns patients may experience with race-based medicine in a healthcare setting. CONCLUSIONS The application of race-based medicine during prenatal care may harm the relationship between pregnant individuals and clinicians, leading to an overall negative experience and erosion of trust in the healthcare system. Implementing personalized race-conscious healthcare rather than race-based medicine is essential to improving patient-doctor relationships by building trust and eliminating unnecessary medical practices.
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Affiliation(s)
- Breanna Thompson
- New York Institute of Technology College of Osteopathic Medicine, United States
| | - Rasheda J Vereen
- Department of Pediatrics, Uniformed Services University of the Health Sciences, United States
| | - Torie C Plowden
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Monica A Lutgendorf
- Department of Gynecologic Surgery and Obstetrics, Uniformed Services University of the Health Sciences, Bethesda, MD, United States.
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2
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Levene J, Chang A, Reddy A, Hauspurg A, Davis EM, Countouris M. The Role of Race in Pregnancy, Hypertension, and Long-Term Outcomes. Curr Cardiol Rep 2025; 27:71. [PMID: 40111654 DOI: 10.1007/s11886-025-02224-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2025] [Indexed: 03/22/2025]
Abstract
PURPOSE OF REVIEW This review aims to discuss racial and ethnic differences in the prevalence of hypertensive disorders of pregnancy (HDP), disparities in peripartum and postpartum outcomes, and strategies to improve health equity. RECENT FINDINGS Racial disparities in HDP are significant contributors to maternal morbidity and mortality. The prevalence of preeclampsia has increased over the last 20 years, with the highest prevalence among non-Hispanic Black, non-Hispanic American Indian and Alaska Native individuals. Black birthing individuals are at increased risk for cardiovascular-related morbidity and mortality, particularly from complications of HDP. Factors such as social determinants of health and systemic racism have a significant impact on disparities in maternal and fetal outcomes related to HDP. System changes and provider implicit bias training can help address systemic racism. Interventions aimed at improving access to care, such as telehealth and home blood pressure monitoring, as well as incorporating health system navigators that provide peripartum and postpartum support can improve outcomes and promote health equity.
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Affiliation(s)
- Jacqueline Levene
- Heart and Vascular Institute, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Alyssa Chang
- Heart and Vascular Institute, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA
| | - Anisha Reddy
- Department of Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alisse Hauspurg
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Alpert Medical School of Brown University, Providence, RI, USA
| | - Esa M Davis
- Department of Family and Community Medicine, University of Maryland, Baltimore, MD, USA
| | - Malamo Countouris
- Heart and Vascular Institute, University of Pittsburgh, 200 Lothrop St., Pittsburgh, PA, 15213, USA.
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3
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Jochum M, Garcia M, Hammerquist A, Howell J, Stanford M, Liu R, Olewine M, Hayek EE, Phan E, Showalter L, Shope C, Suter M, Campen M, Aagaard K, Barrozo E. Elevated Micro- and Nanoplastics Detected in Preterm Human Placentae. RESEARCH SQUARE 2025:rs.3.rs-5903715. [PMID: 39975889 PMCID: PMC11838745 DOI: 10.21203/rs.3.rs-5903715/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/21/2025]
Abstract
Recent analytical advancements have uncovered increasing micro- and nanoplastics (MNPs) in environmental, dietary, and biological domains, raising concerns about their health impacts. Preterm birth (PTB), a leading cause of maternal and neonatal morbidity and mortality, may be influenced by MNP exposure, yet this relationship remains unexplored. This study quantified 12 MNP polymers in placentae from term (n=87) and preterm (n=71) deliveries using pyrolysis-gas chromatography/mass spectrometry (Py-GC/MS). Cumulative MNP concentrations were 28% higher in PTB placentae (mean ±SD: 224.7 ± 180.7 μg/g vs. 175.5 ± 137.9 μg/g; p=0.038). Polyvinyl chloride (PVC), polyethylene terephthalate (PET), polyurethane (PU), and polycarbonate (PC) were significantly elevated in PTB, and PET, PU, and PC inversely correlated with gestational age and birth weight. Logistic regression identified PVC and PC as independent predictors of PTB. These findings suggest total and specific MNPs are associated with PTB, providing actionable insights and emphasizing the importance of minimizing exposure during pregnancy.
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Affiliation(s)
- Michael Jochum
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | | | - Alexandra Hammerquist
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | - Jacquelyne Howell
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | - Myla Stanford
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | | | | | | | - Emily Phan
- Department of Pharmaceutical Sciences, University of New Mexico
| | - Lori Showalter
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | - Cynthia Shope
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital
| | - Melissa Suter
- Baylor College of Medicine, Department of Obstetrics & Gynecology
| | | | - Kjersti Aagaard
- Oregon National Primate Research Center & HCA Healthcare and HCA Healthcare Research Institute & Boston Children's Hospital, Harvard Medical School
| | - Enrico Barrozo
- Baylor College of Medicine and Texas Children's Hospital
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4
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Conklin MB, Wells BM, Doe EM, Strother AM, Tarasiewicz MEB, Via ER, Conrad LB, Farias-Eisner R. Understanding Health Disparities in Preeclampsia: A Literature Review. Am J Perinatol 2024; 41:e1291-e1300. [PMID: 36603833 DOI: 10.1055/a-2008-7167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Preeclampsia is a multifactorial pathology with negative outcomes in affected patients in both the peripartum and postpartum period. Black patients in the United States, when compared to their White and Hispanic counterparts, have higher rates of preeclampsia. This article aims to review the current literature to investigate how race, social determinants of health, and genetic profiles influence the prevalence and outcomes of patients with preeclampsia. Published studies utilized in this review were identified through PubMed using authors' topic knowledge and a focused search through a Medline search strategy. These articles were thoroughly reviewed to explore the contributing biosocial factors, genes/biomarkers, as well as negative outcomes associated with disparate rates of preeclampsia. Increased rates of contributing comorbidities, including hypertension and obesity, which are largely associated with low access to care in Black patient populations lead to disparate rates of preeclampsia in this population. Limited research shows an association between increased rate of preeclampsia in Black patients and specific APOL1, HLA-G, and PP13 gene polymorphisms as well as factor V Leiden mutations. Further research is required to understand the use of certain biomarkers in predicting preeclampsia within racial populations. Understanding contributing biosocial factors and identifying genes that may predispose high-risk populations may help to address the disparate rates of preeclampsia in Black patients as described in this review. Further research is required to understand if serum, placental, or urine biomarkers may be used to predict individuals at risk of developing preeclampsia in pregnancy. KEY POINTS: · Prevalence of preeclampsia in the U.S. is higher in Black patients compared to other racial groups.. · Patients with preeclampsia are at risk for poorer health outcomes both during and after delivery.. · Limited research suggests specific biomarkers or gene polymorphisms contribute to this difference; however, explanations for this disparity are multifactorial and further investigation is necessary..
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Affiliation(s)
- Mary B Conklin
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey
| | | | - Emily M Doe
- School of Medicine, Creighton University, Omaha, Nebraska
| | | | | | - Emily R Via
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, Renaissance School of Medicine at Stony Brook University, Stony Brook, New York
| | - Lesley B Conrad
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
| | - Robin Farias-Eisner
- School of Medicine, Creighton University, Omaha, Nebraska
- Department of Obstetrics and Gynecology, School of Medicine, Creighton University, Omaha, Nebraska
- Lynch Comprehensive Cancer Research Center, School of Medicine, Creighton University, Omaha, Nebraska
- College of Osteopathic Medicine of the Pacific Northwest, Western University of Health Sciences, Pomona, California
- Department of Obstetrics and Gynecology, David Geffen School of Medicine, the University of California at Los Angeles, Los Angeles, California
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5
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Aerden M, De Borre M, Thienpont B. Cell-free DNA methylation-based preeclampsia prediction: A journey to improve maternal health. Prenat Diagn 2024; 44:418-421. [PMID: 38047711 DOI: 10.1002/pd.6478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 11/20/2023] [Accepted: 11/20/2023] [Indexed: 12/05/2023]
Abstract
Presymptomatic prediction of preeclampsia (PE) is crucial to enable early prophylactic treatment. Current screening tools are either complex or lack predictive value. We recently demonstrated that cell-free DNA methylation can be leveraged to predict early-onset PE in 57% at a 10% false positive rate. Importantly, this minimally invasive screening test can be implemented as an add-on to current widespread noninvasive prenatal aneuploidy screening. Here, we highlight the pitfalls and promising prospects of this research.
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Affiliation(s)
- Mio Aerden
- Laboratory for Functional Epigenetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
- Center for Human Genetics, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Marie De Borre
- Laboratory for Functional Epigenetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
- Center for Human Genetics, University Hospitals Leuven, University of Leuven, Leuven, Belgium
| | - Bernard Thienpont
- Laboratory for Functional Epigenetics, Department of Human Genetics, KU Leuven, Leuven, Belgium
- KU Leuven Center for Single Cell Omics, Leuven, Belgium
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6
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Johnson JD. Black Pregnancy-Related Mortality in the United States. Obstet Gynecol Clin North Am 2024; 51:1-16. [PMID: 38267121 DOI: 10.1016/j.ogc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2024]
Abstract
The maternal mortality rate for non-Hispanic Black birthing people is 69.9 deaths per 100,000 live births compared with 26.6 deaths per 100,000 live births for non-Hispanic White birthing people. Black pregnancy-related mortality has been underrepresented in research and the media; however, there is growing literature on the role of racism in health disparities. Those who provide care to Black patients should increase their understanding of racism's impact and take steps to center the experiences and needs of Black birthing people.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Indiana University School of Medicine, 550 North University Bloulevard, Suite 2440, Indianapolis, IN 46202, USA.
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7
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Zhang L, Wang W, Gong J, Wang X, Liang J, Gu S, Su M, Bi S, Sun M, Chen J, Zheng W, Wu J, Wang Z, Liu J, Li H, Chen D, Du L. Development, validation, and clinical utility of a risk prediction model for recurrent preeclampsia. J Hypertens 2024; 42:236-243. [PMID: 37796172 DOI: 10.1097/hjh.0000000000003580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
OBJECTIVES We aim to establish a predictive model for recurrent preeclampsia. METHODS A retrospective review of medical records from three hospitals between 2010 and 2021 was conducted. The study included women who had two consecutive singleton deliveries at the same hospital, with the first delivery complicated by preeclampsia. A multivariable logistic regression model was constructed using a training cohort, and subsequently cross-validated and tested using an independent cohort. The model's performance was assessed in terms of discrimination and calibration, and its clinical utility was evaluated using decision curve analysis (DCA). RESULTS Among 296 405 deliveries, 694 women met the inclusion criteria, with 151 (21.8%) experiencing recurrent preeclampsia. The predictive model incorporated 10 risk factors from previous preeclampsia, including gestational weeks with elevated blood pressure, gestational diabetes mellitus (GDM), pericardial effusion, heart failure, limb edema, serum creatinine, white blood cell count, low platelet counts within one week before delivery, SBP on the first postpartum day, and postpartum antihypertensive use. Additionally, one risk factor from the index pregnancy was included, which was antihypertensive use before 20 weeks. The model demonstrated better discrimination, calibration, and a net benefit across a wide range of recurrent preeclampsia risk thresholds. Furthermore, the model has been translated into a clinical risk calculator, enabling clinicians to calculate individualized risks of recurrent preeclampsia. CONCLUSION Our study demonstrates that a predictive tool utilizing routine clinical and laboratory factors can accurately estimate the risk of recurrent preeclampsia. This predictive model has the potential to facilitate shared decision-making by providing personalized and risk-stratified care.
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Affiliation(s)
- Lizi Zhang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weiwei Wang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Jingjin Gong
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Xinghe Wang
- Dongguan Maternal and Children Health Hospital
| | - Jingying Liang
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shifeng Gu
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Minglian Su
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Shilei Bi
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Manna Sun
- Dongguan Maternal and Children Health Hospital
| | - Jingsi Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Weitan Zheng
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Junwei Wu
- Guangzhou Panyu District Maternal and Child Health Hospital
| | - Zhijian Wang
- Department of Obstetrics and Gynecology, Nanfang Hospital, Southern Medical University, Guangzhou
| | - Jianmeng Liu
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Hongtian Li
- Institute of Reproductive and Child Health, National Health Commission Key Laboratory of Reproductive Health, Peking University Health Science Center, Beijing, China
| | - Dunjin Chen
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
| | - Lili Du
- Department of Obstetrics and Gynecology, Guangdong Provincial Key Laboratory of Major Obstetric Diseases
- Guangdong Provincial Clinical Research Center for Obstetrics and Gynecology
- Guangdong-Hong Kong-Macao Greater Bay Area Higher Education Joint Laboratory of Maternal-Fetal Medicine
- The Third Affiliated Hospital of Guangzhou Medical University
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8
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Ayyash M, Goyert G, Pitts D, Khangura R, Garcia R, Jacobsen G, Shaman M. Provider adherence to aspirin prophylaxis prescription guidelines for preeclampsia. Pregnancy Hypertens 2023; 34:1-4. [PMID: 37696232 DOI: 10.1016/j.preghy.2023.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Revised: 09/02/2023] [Accepted: 09/05/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE To evaluate provider adherence to aspirin prophylaxis prescription guidelines for patients at risk. STUDY DESIGN A retrospective chart review was performed at Henry Ford Health (HFH) between October 2015 and December 2020. In October 2015, low-dose aspirin was recommended for women who met high risk criteria for preeclampsia at HFH; in February 2019, aspirin recommendation expanded to include women who met either moderate or high-risk criteria. A total of 46,016 pregnancies occurred between Oct 2015 and Dec 2020 of which 15,167 (33.0%) met high and moderate risk criteria. RESULTS From the population at risk, 1,255 (8.3%) had a history of preeclampsia, 2,534 (16.7%) had a history of chronic hypertension, 1,418 (9.3%) had a history of diabetes, 7,470 (49.3%) were nulliparous, 4,038 (26.6%) were 35 years of age or older, 6,395 (42.2%) had a body mass index greater than 30 kg/m2, and 8,174 (54.5%) were African Americans. Only 630 out of 3,584 (17.6%) of women meeting the high-risk criteria for preeclampsia between Oct 2015 and Jan 2019 received low-dose aspirin and only 891 out of 5,874 (15.2%) of women meeting the high or moderate risk criteria for preeclampsia between Feb 2019 and Dec 2020 received low-dose aspirin prophylaxis. CONCLUSION Adherence to aspirin prophylaxis guidelines was low. Most urban healthcare systems serve diverse, high-risk populations with multiple comorbidities rendering many women at risk for preeclampsia. Educational efforts to improve provider knowledge regarding this important preventative measure are indicated. Recommendation for implementing universal aspirin in such high-risk populations should also be considered.
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Affiliation(s)
- Mariam Ayyash
- Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States.
| | - Gregory Goyert
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - D'Angela Pitts
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Raminder Khangura
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Robyn Garcia
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
| | - Gordon Jacobsen
- Department of Public Health Sciences, Henry Ford Health, Detroit, MI, United States
| | - Majid Shaman
- Division of Maternal and Fetal Medicine, Department of Obstetrics and Gynecology, Henry Ford Health, Detroit, MI, United States
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Gross ME, Godecker A, Hughes A, Sampene K. Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations. BMC Pregnancy Childbirth 2023; 23:651. [PMID: 37684606 PMCID: PMC10492279 DOI: 10.1186/s12884-023-05922-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 08/14/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice. METHODS We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race. RESULTS Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time. CONCLUSION It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.
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Affiliation(s)
- Maya E Gross
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
| | - Amy Godecker
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Ainsley Hughes
- Department of Obstetrics and Gynecology, George Washington School of Medicine, Washington, DC, USA
| | - Katherine Sampene
- Department of Obstetrics and Gynecology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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10
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Jin PP, Ding N, Dai J, Liu XY, Mao PM. Investigation of the relationship between changes in maternal coagulation profile in the first trimester and the risk of developing preeclampsia. Heliyon 2023; 9:e17983. [PMID: 37496928 PMCID: PMC10366388 DOI: 10.1016/j.heliyon.2023.e17983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 06/20/2023] [Accepted: 07/04/2023] [Indexed: 07/28/2023] Open
Abstract
Normal pregnancy is a hypercoagulable state with an increase in coagulation factor levels and a decrease in natural anticoagulation. However, a higher hypercoagulable state with prolonged activated partial thromboplastin time (APTT), prothrombin time (PT), increased D-dimer, and mean platelet volume is seen in women with preeclampsia at the time of onset. In addition, endothelial dysfunction occurs before the clinical symptoms of preeclampsia. Therefore, we undertook this study to investigate the coagulation profile in the first trimester in women who developed preeclampsia later. A total of 853 pregnant women with singleton births at the Obstetrics and Gynecology Hospital of Fudan University between January 2021 and December 2021 were included in this case-control study. In the comparison with the controls (n = 531), the mean value of D-dimer, APTT, thrombin time (TT), antithrombin (AT)), and fibrin degradation products (FDP) was significantly lower in preeclamptic women at the time of diagnosis (n = 322). The changes in the coagulation profile were not associated with the severity or the time of onset. The reduced values of D-dimer, AT, and FDP, and increased values of TT were also observed in the first trimester in women who developed preeclampsia later and were not associated with the severity, or the time of onset of preeclampsia. After adjusting for maternal age and BMI, the values of D-dimer and AT in the first trimester were correlated to the risk of developing preeclampsia. Our findings suggest that there is an abnormal maternal response to the hemostatic system in early gestational age in women who developed preeclampsia later and measuring the coagulation profile could be an additional predictive marker of preeclampsia.
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Affiliation(s)
- Pei-Pei Jin
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Ning Ding
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jing Dai
- Department of Laboratory Medicine, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiao-Yan Liu
- Department of Blood Transfusion, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Pei-Min Mao
- Department of Blood Transfusion, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
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11
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Campo B, Fogel J, Na S, Bryson L. Impact of Aspirin Supplementation for Pre-Eclampsia Prevention on Neonatal Outcomes. Kans J Med 2023; 16:41-47. [PMID: 36845263 PMCID: PMC9957593 DOI: 10.17161/kjm.vol16.18138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 01/09/2023] [Indexed: 02/24/2023] Open
Abstract
Introduction Pre-eclampsia negatively affects pregnancy. In 2018, the American College of Obstetricians and Gynecologists (ACOG) updated their low dose aspirin (LDA) supplementation recommendation to include pregnant women at moderate risk for pre-eclampsia. In addition to the potential benefit of LDA supplementation for delaying or preventing pre-eclampsia, LDA supplementation can affect neonatal outcomes. The association of LDA supplementation was studied with six neonatal outcomes in a sample of mostly minority pregnant women from Hispanic and Black race/ethnicities that included those of low, moderate, and high-risk designation for pre-eclampsia. Methods This was a retrospective study of 634 patients. The main predictor variable was maternal LDA supplementation for six neonatal outcomes: NICU admission, neonatal readmission, one- and five-minute Apgar scores, neonatal birth weight (BW), and hospital length of stay (LOS). Demographics, comorbidities, and maternal high-or moderate-risk designation were adjusted for per ACOG guidelines. Results High-risk designation was associated with neonatal increased rate of NICU admission (OR: 3.80, 95% CI: 2.02, 7.13, p < 0.001), LOS (B = 0.15, SE = 0.04, p < 0.001), and decreased BW (B = -442.10, SE = 75.07, p < 0.001). No significant associations were found with LDA supplementation or moderate-risk designation for NICU admission, readmission, low one- and five-minute Apgar scores, BW, and LOS. Conclusions Clinicians recommending maternal LDA supplementation should be aware that LDA supplementation did not appear to provide any benefits for the above neonatal outcomes.
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Affiliation(s)
- Bertha Campo
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
| | - Joshua Fogel
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
- Department of Business Management, Brooklyn College, Brooklyn, NY
| | - Sean Na
- Stony Brook University, Renaissance School of Medicine, Stony Brook, NY
| | - Lennox Bryson
- Department of Obstetrics and Gynecology, Nassau University Medical Center, East Meadow, NY
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12
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de Moreuil C, Pan-Petesch B, Trémouilhac C, Dupré PF, Merviel P, Anouilh F, Bellot C, Müller M, Drugmanne G, Nowak E, Coadic J, Bihan L, Gourhant L, Lemarié C, Robin S, Couturaud F, Moigne EL. Clinical risk factors for vasculo-placental disorders: results from a prospective case-control study nested in HEMOTHEPP French cohort study. J Gynecol Obstet Hum Reprod 2023; 52:102511. [PMID: 36417979 DOI: 10.1016/j.jogoh.2022.102511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/18/2022] [Accepted: 11/18/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE Determine clinical risk factors for vasculo-placental disorders in singleton pregnancies. DESIGN Prospective case-control study nested in HEMOTHEPP French cohort. SETTING Women delivered between June, 2015 and January, 2019 in any maternity ward of Finistère. POPULATION Cases were women with vasculo-placental disorders (pre-eclampsia, intrauterine growth restriction (IUGR), placental abruption or stillbirth). Controls were women matched for age at delivery and parity. METHODS Clinical data were collected by obstetricians or midwives during antenatal care visits and delivery, and recorded by trained research assistants. MAIN OUTCOME MEASURES Occurrence of a vasculo-placental disorder. RESULTS 505 women with vasculo-placental disorder (299 pre-eclampsia, 253 IUGR, 44 placental abruptions, 11 stillbirths) and 1515 matched controls were selected out of 20,075 participants. In multivariable analysis, four clinical parameters were associated with pre-eclampsia: obesity (Odd ratio (OR) = 3.11, 95%CI 2.11-4.58), French overseas origin (OR = 4.41, 95%CI 1.87-10.42), previous vasculo-placental disorder (OR = 5.14, 95%CI 2.72-9.70), aspirin during pregnancy (OR = 10.10, 95%CI 1.99-51.08). Three clinical parameters were associated with IUGR: auto-immune/inflammatory disorder (OR = 3.75, 95%CI 1.83-7.68), previous vasculo-placental disorder (OR = 3.63, 95%CI 2.06-6.41), smoking during pregnancy (OR = 2.66, 95%CI 1.91- 3.71). A previous venous thromboembolism (VTE) was associated with IUGR in univariable but not in multivariable analysis (OR = 3.72, 95%CI 0.82-17.00, p = 0.09). CONCLUSIONS Clinical risk factors differ between IUGR and pre-eclampsia, the later, but not the former, being associated with cardiovascular risk factors.
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Affiliation(s)
- Claire de Moreuil
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France.
| | - Brigitte Pan-Petesch
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Centre de traitement de l'hémophilie, Hématologie, CHU Brest - Brest (France), France
| | - Christophe Trémouilhac
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France
| | - Pierre-François Dupré
- Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France; INSERM 1078, équipe GTCA, France
| | - Philippe Merviel
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Service de Gynécologie Obstétrique, CHU Brest - Brest (France), France
| | - François Anouilh
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Ecole de Sage-femmes, UFR Santé - Brest (France), France
| | - Charles Bellot
- Service de Gynécologie Obstétrique, CHIC de Quimper - Quimper (France), France
| | - Matthieu Müller
- Service de Gynécologie Obstétrique, CH des Pays de Morlaix - Morlaix (France), France
| | | | | | | | - Line Bihan
- CIC1412, INSERM - Brest (France), France
| | - Lénaick Gourhant
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France
| | - Catherine Lemarié
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France
| | - Sara Robin
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
| | - Francis Couturaud
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
| | - Emmanuelle Le Moigne
- UMR 1304, GETBO, Université de Bretagne Occidentale - Brest (France), France; Département de médecine interne, médecine vasculaire et pneumologie, CHU Brest - Brest (France), Boulevard Tanguy Prigent, F-29609 Brest Cedex, France
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13
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Bond RM, Phillips K, Ivy KN, Ogueri V, Parapid B, Miller SC, Ansong A. Cardiovascular Health of Black Women Before, During, and After Pregnancy: A Call to Action and Implications for Prevention. CURRENT CARDIOVASCULAR RISK REPORTS 2022. [DOI: 10.1007/s12170-022-00703-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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14
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Li S, Wang Z, Vieira LA, Zheutlin AB, Ru B, Schadt E, Wang P, Copperman AB, Stone JL, Gross SJ, Kao YH, Lau YK, Dolan SM, Schadt EE, Li L. Improving preeclampsia risk prediction by modeling pregnancy trajectories from routinely collected electronic medical record data. NPJ Digit Med 2022; 5:68. [PMID: 35668134 PMCID: PMC9170686 DOI: 10.1038/s41746-022-00612-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 05/19/2022] [Indexed: 11/15/2022] Open
Abstract
Preeclampsia is a heterogeneous and complex disease associated with rising morbidity and mortality in pregnant women and newborns in the US. Early recognition of patients at risk is a pressing clinical need to reduce the risk of adverse outcomes. We assessed whether information routinely collected in electronic medical records (EMR) could enhance the prediction of preeclampsia risk beyond what is achieved in standard of care assessments. We developed a digital phenotyping algorithm to curate 108,557 pregnancies from EMRs across the Mount Sinai Health System, accurately reconstructing pregnancy journeys and normalizing these journeys across different hospital EMR systems. We then applied machine learning approaches to a training dataset (N = 60,879) to construct predictive models of preeclampsia across three major pregnancy time periods (ante-, intra-, and postpartum). The resulting models predicted preeclampsia with high accuracy across the different pregnancy periods, with areas under the receiver operating characteristic curves (AUC) of 0.92, 0.82, and 0.89 at 37 gestational weeks, intrapartum and postpartum, respectively. We observed comparable performance in two independent patient cohorts. While our machine learning approach identified known risk factors of preeclampsia (such as blood pressure, weight, and maternal age), it also identified other potential risk factors, such as complete blood count related characteristics for the antepartum period. Our model not only has utility for earlier identification of patients at risk for preeclampsia, but given the prediction accuracy exceeds what is currently achieved in clinical practice, our model provides a path for promoting personalized precision therapeutic strategies for patients at risk.
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Affiliation(s)
| | | | - Luciana A Vieira
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Pei Wang
- Department of Genetics and Genomic Sciences, The Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Alan B Copperman
- Sema4, Stamford, CT, USA.,Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Reproductive Endocrinology and Infertility, Reproductive Medicine associates of New York, New York, NY, USA
| | - Joanne L Stone
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Susan J Gross
- Sema4, Stamford, CT, USA.,Department of Genetics and Genomic Sciences, The Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | - Siobhan M Dolan
- Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY, USA.,Department of Genetics and Genomic Sciences, The Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Eric E Schadt
- Sema4, Stamford, CT, USA. .,Department of Genetics and Genomic Sciences, The Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
| | - Li Li
- Sema4, Stamford, CT, USA. .,Department of Genetics and Genomic Sciences, The Icahn Institute for Genomics and Multiscale Biology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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15
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Johnson JD, Louis JM. Does race or ethnicity play a role in the origin, pathophysiology, and outcomes of preeclampsia? An expert review of the literature. Am J Obstet Gynecol 2022; 226:S876-S885. [PMID: 32717255 DOI: 10.1016/j.ajog.2020.07.038] [Citation(s) in RCA: 119] [Impact Index Per Article: 39.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/17/2020] [Accepted: 07/22/2020] [Indexed: 12/15/2022]
Abstract
The burden of preeclampsia, a substantial contributor to perinatal morbidity and mortality, is not born equally across the population. Although the prevalence of preeclampsia has been reported to be 3% to 5%, racial and ethnic minority groups such as non-Hispanic Black women and American Indian or Alaskan Native women are widely reported to be disproportionately affected by preeclampsia. However, studies that add clarity to the causes of the racial and ethnic differences in preeclampsia are limited. Race is a social construct, is often self-assigned, is variable across settings, and fails to account for subgroups. Studies of the genetic structure of human populations continue to find more variations within racial groups than among them. Efforts to examine the role of race and ethnicity in biomedical research should consider these limitations and not use it as a biological construct. Furthermore, the use of race in decision making in clinical settings may worsen the disparity in health outcomes. Most of the existing data on disparities examine the differences between White and non-Hispanic Black women. Fewer studies have enough sample size to evaluate the outcomes in the Asian, American Indian or Alaskan Native, or mixed-race women. Racial differences are noted in the occurrence, presentation, and short-term and long-term outcomes of preeclampsia. Well-established clinical risk factors for preeclampsia such as obesity, diabetes, and chronic hypertension disproportionately affect non-Hispanic Black, American Indian or Alaskan Native, and Hispanic populations. However, with comparable clinical risk factors for preeclampsia among women of different race or ethnic groups, addressing modifiable risk factors has not been found to have the same protective effect for all women. Abnormalities of placental formation and development, immunologic factors, vascular changes, and inflammation have all been identified as contributing to the pathophysiology of preeclampsia. Few studies have examined race and the pathophysiology of preeclampsia. Despite attempts, a genetic basis for the disease has not been identified. A number of genetic variants, including apolipoprotein L1, have been identified as possible risk modifiers. Few studies have examined race and prevention of preeclampsia. Although low-dose aspirin for the prevention of preeclampsia is recommended by the US Preventive Service Task Force, a population-based study found racial and ethnic differences in preeclampsia recurrence after the implementation of low-dose aspirin supplementation. After implementation, recurrent preeclampsia reduced among Hispanic women (76.4% vs 49.6%; P<.001), but there was no difference in the recurrent preeclampsia in non-Hispanic Black women (13.7 vs 18.1; P=.252). Future research incorporating the National Institute on Minority Health and Health Disparities multilevel framework, specifically examining the role of racism on the burden of the disease, may help in the quest for effective strategies to reduce the disproportionate burden of preeclampsia on a minority population. In this model, a multilevel framework provides a more comprehensive approach and takes into account the influence of behavioral factors, environmental factors, and healthcare systems, not just on the individual.
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Affiliation(s)
- Jasmine D Johnson
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, NC
| | - Judette M Louis
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of South Florida, Tampa, FL.
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16
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More evidence for low-dose aspirin in preventing pre-eclampsia. Drug Ther Bull 2021; 60:19. [PMID: 34949585 DOI: 10.1136/dtb.2021.000071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Overview of: Henderson JT, Vesco KK, Senger CA, et al Aspirin use to prevent preeclampsia and related morbidity and mortality: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2021;326:1192-1206.
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17
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Henderson JT, Vesco KK, Senger CA, Thomas RG, Redmond N. Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2021; 326:1192-1206. [PMID: 34581730 DOI: 10.1001/jama.2021.8551] [Citation(s) in RCA: 107] [Impact Index Per Article: 26.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Preeclampsia is a hypertensive disorder of pregnancy that poses serious maternal and infant health risks. Previous systematic reviews have established benefits of low-dose aspirin taken during pregnancy to prevent preeclampsia and its sequelae. OBJECTIVE To update evidence for the US Preventive Services Task Force (USPSTF) on effectiveness of aspirin use in preventing preeclampsia in individuals at increased risk based on clinical risk factors or measurements associated with higher disease incidence than in the general population. DATA SOURCES Studies from previous USPSTF review (2014), literature published January 2013 through May 15, 2020, in MEDLINE, PubMed (for publisher-supplied records only), EMBASE, and Cochrane Central Register of Controlled Trials. Ongoing surveillance through January 22, 2021. STUDY SELECTION Good- and fair-quality randomized clinical trials (RCTs) of low-dose aspirin use during pregnancy to prevent preeclampsia among individuals at increased risk; studies conducted in general populations to evaluate potential harms. DATA EXTRACTION AND SYNTHESIS Dual article screening and risk-of-bias assessment. Study data abstracted into prespecified forms, checked for accuracy. Random-effects meta-analysis. MAIN OUTCOMES AND MEASURES Diagnosis of preeclampsia; adverse pregnancy health outcomes and complications including eclampsia, perinatal mortality, preterm birth, small for gestational age, and potential bleeding harms or infant/child harms from aspirin exposure. RESULTS A total of 23 randomized clinical trials (RCTs) (N = 26 952) were included; 18 were conducted among participants at increased preeclampsia risk. Aspirin dosages ranged from 50 mg/d to 150 mg/d. Most trials enrolled majority White populations selected based on a range of risk factors. The incidence of preeclampsia among the trials of participants at increased risk ranged from 4% to 30%. Aspirin use was significantly associated with lower risk of preeclampsia (pooled relative risk [RR], 0.85 [95% CI, 0.75-0.95]; 16 RCTs [n = 14 093]; I2 = 0%), perinatal mortality (pooled RR, 0.79 [95% CI, 0.66-0.96]; 11 RCTs [n = 13 860]; I2 = 0%), preterm birth (pooled RR, 0.80 [95% CI, 0.67-0.95]; 13 RCTs [n = 13 619]; I2 = 49%), and intrauterine growth restriction (pooled RR, 0.82 [95% CI, 0.68-0.99]; 16 RCTs [n = 14 385]; I2 = 41%). There were no significant associations of aspirin use with risk of postpartum hemorrhage (pooled RR, 1.03 [95% CI, 0.94-1.12]; 9 RCTs [n = 23 133]; I2 = 0%) and other bleeding-related harms, or with rare perinatal or longer-term harms. Absolute risk reductions for preeclampsia associated with aspirin use ranged from -1% to -6% across larger trials (n >300) and were greater in smaller trials. For perinatal mortality, absolute risk reductions ranged from 0.5% to 1.1% in the 3 largest trials. CONCLUSIONS AND RELEVANCE Daily low-dose aspirin during pregnancy was associated with lower risks of serious perinatal outcomes for individuals at increased risk for preeclampsia, without evident harms.
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Affiliation(s)
- Jillian T Henderson
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Kimberly K Vesco
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Caitlyn A Senger
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Rachel G Thomas
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
| | - Nadia Redmond
- Kaiser Permanente Evidence-based Practice Center, Center for Health Research, Kaiser Permanente, Portland, Oregon
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18
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Affiliation(s)
- Jimmy Espinoza
- Texas Children's Hospital Pavilion for Women and Baylor College of Medicine, Houston
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19
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Gonzalez-Brown VM, Ma'ayeh M, Kniss DA, Cackovic M, Landon MB, Rood KM. Low-dose aspirin increases 15-epi-lipoxins A 4 in pregnancies at high-risk for developing preeclampsia. Pregnancy Hypertens 2021; 26:75-78. [PMID: 34563982 DOI: 10.1016/j.preghy.2021.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Revised: 06/21/2021] [Accepted: 09/09/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND LDA triggers biosynthesis of endogenous anti-inflammatory molecules, aspirin-triggered 15-epi-lipoxin A4 (15-epi-LXA4), which may counteract inflammatory process of preeclampsia (PE), and play role in LDA's mechanism of action in PE prevention in high-risk patients. OBJECTIVE Investigate the effects of daily LDA on levels of 15-epi-LXA4 in pregnancies at high-risk for developing PE. MATERIALS AND METHODS Secondary analysis of multi-centered randomized controlled trial investigating effects of daily LDA (60 mg) in high-risk pregnancies. Maternal samples were drawn at three points: before LDA initiation (13-26 weeks' gestation), 24-28 weeks' gestation (at least two weeks after LDA) and 34-36 weeks' gestation. 15-epi-LXA4 levels were measured by ELISA. RESULTS Analysis included 82 patients: 63 receiving daily LDA and 29 receiving daily placebo starting between 13 and 25 weeks gestation. Prior to randomization, baseline 15-epi-LXA4 levels were similar between both groups (75.9 pg/mL [IQR; 63.8-114.0] vs 136.2 pg/mL [52.4-476.2]; p = 0.10). Patients receiving daily LDA were noted to have significantly increased levels of 15-epi-LXA4 after LDA administration (136.2 pg/mL [IQR; 52.4-476.2] vs 1758.2 pg/mL [905.4-6638.5]; p < 0.001). They also had higher 15-epi-LXA4 levels compared to those receiving placebo at 24-28 weeks' (50.3 [38.1-94.2] vs 1758.2 [905.4-6638.5]; p < 0.001 and 34-38 weeks' gestation (57.9 [41.9-76.7] vs 2310.3 pg/mL [656.9-10609.4]; p < 0.001). After LDA administration in the second trimester, patients who developed PE had decrease in 15-epi-LXA4 levels compared to those without PE (942 pg/mL [348.3-1810.3] vs 1758.2 pg/mL [905.4-6638.5]; p = 0.129). CONCLUSION Daily LDA administration increases 15-epi-LXA4 levels in high-risk pregnancies for PE. In LDA group, pregnancies complicated by PE have lower levels of 15-epi-LXA4 compared to pregnancies without PE.
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Affiliation(s)
- Veronica M Gonzalez-Brown
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, San Antonio Uniformed Services Health Science Consortium, Brooke Army Medical Center, Ft Sam Houston, TX, United States.
| | - Marwan Ma'ayeh
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Douglas A Kniss
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Michael Cackovic
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Mark B Landon
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Kara M Rood
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The Ohio State University College of Medicine, Columbus, OH, United States
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20
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Cabunac P, Karadžov Orlić N, Ardalić D, Damnjanović Pažin B, Stanimirović S, Banjac G, Stefanović A, Spasojević-Kalimanovska V, Egić A, Rajović N, Milić N, Miković Ž. Use of FMF algorithm for prediction of preeclampsia in high risk pregnancies: a single center longitudinal study. Hypertens Pregnancy 2021; 40:171-179. [PMID: 33979553 DOI: 10.1080/10641955.2021.1921791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE: This study aimed to assess the accuracy of The Fetal Medicine Foundation (FMF) screening algorithm for the prediction of preeclampsia.METHODS: Out of 138 women with high-risk pregnancies prospectively followed, 30 developed preeclampsia. The clinical examination and biochemical measurements were performed at first, second, early and late third trimester.RESULTS: A lower PAPP-A levels were found in the first trimester, while sFlt/PlGF was increased in the second and early third trimester in preeclampsia (p>0.05). FMF algorithm presented higher specificity (>70%), but had a drawback of lower sensitivity (35-77%).CONCLUSION: FMF algorithm had modest performance in the prediction of preeclampsia for high-risk pregnancies.
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Affiliation(s)
- Petar Cabunac
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Nataša Karadžov Orlić
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Daniela Ardalić
- Department of Medical Biochemistry, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Barbara Damnjanović Pažin
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Srđan Stanimirović
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Gorica Banjac
- Department of Medical Biochemistry, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Aleksandra Stefanović
- Department of Medical Biochemistry, Faculty of Pharmacy, University of Belgrade, Belgrade, Serbia
| | | | - Amira Egić
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Nina Rajović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Medical Biochemistry, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia
| | - Nataša Milić
- Institute for Medical Statistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Division of Nephrology and Hypertension, Mayo Clinic, Rochester, USA
| | - Željko Miković
- Department of High-Risk Pregnancy, Clinic of Gynecology and Obstetrics "Narodni Front", Belgrade, Serbia.,Faculty of Medicine, University of Belgrade, Belgrade, Serbia
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21
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Parikh NI, Gonzalez JM, Anderson CAM, Judd SE, Rexrode KM, Hlatky MA, Gunderson EP, Stuart JJ, Vaidya D. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation 2021; 143:e902-e916. [PMID: 33779213 DOI: 10.1161/cir.0000000000000961] [Citation(s) in RCA: 366] [Impact Index Per Article: 91.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
This statement summarizes evidence that adverse pregnancy outcomes (APOs) such as hypertensive disorders of pregnancy, preterm delivery, gestational diabetes, small-for-gestational-age delivery, placental abruption, and pregnancy loss increase a woman's risk of developing cardiovascular disease (CVD) risk factors and of developing subsequent CVD (including fatal and nonfatal coronary heart disease, stroke, peripheral vascular disease, and heart failure). This statement highlights the importance of recognizing APOs when CVD risk is evaluated in women, although their value in reclassifying risk may not be established. A history of APOs is a prompt for more vigorous primordial prevention of CVD risk factors and primary prevention of CVD. Adopting a heart-healthy diet and increasing physical activity among women with APOs, starting in the postpartum setting and continuing across the life span, are important lifestyle interventions to decrease CVD risk. Lactation and breastfeeding may lower a woman's later cardiometabolic risk. Black and Asian women experience a higher proportion APOs, with more severe clinical presentation and worse outcomes, than White women. More studies on APOs and CVD in non-White women are needed to better understand and address these health disparities. Future studies of aspirin, statins, and metformin may better inform our recommendations for pharmacotherapy in primary CVD prevention among women who have had an APO. Several opportunities exist for health care systems to improve transitions of care for women with APOs and to implement strategies to reduce their long-term CVD risk. One proposed strategy includes incorporation of the concept of a fourth trimester into clinical recommendations and health care policy.
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Boelig RC, Wanees M, Zhan T, Berghella V, Roman A. Improving Utilization of Aspirin for Prevention of Preeclampsia in a High-Risk Urban Cohort: A Prospective Cohort Study. Am J Perinatol 2021; 38:544-552. [PMID: 33099285 PMCID: PMC8491097 DOI: 10.1055/s-0040-1718580] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to evaluate the utilization of aspirin for preeclampsia prevention before and after implementation of a screening tool during nuchal translucency (NT) ultrasound. STUDY DESIGN One-year prospective cohort study of patients at high risk for preeclampsia after the implementation of a screening tool (postscreen) administered to all patients at check in for NT (11-13 weeks) ultrasound. Prospective cohort was compared with one-year retrospective cohort (prescreen) the year prior (2017). All patients who presented for NT ultrasound in both cohorts were evaluated for the presence of one or more risk factor for preeclampsia with screening tool collected prospectively and chart review retrospectively. Provider recommendation for aspirin determined by documentation in prenatal record. Primary outcome was rate of provider recommendation for aspirin pre versus post screening tool, compared by Chi-square test and adjusted for potential confounders with multiple regression analysis. RESULTS Pre- (n = 156) and postscreen (n = 136) cohorts were similar except for race and multifetal gestation. Prescreen, rate of provider recommendation for aspirin was 74%. Of those with prior preeclampsia, 96% were recommended aspirin, compared with 64% of patients with other risk factors (p < 0.001). Postscreen, provider recommendation of aspirin improved to 95% (p < 0.001). Rate of preeclampsia/gestational hypertension were similar between cohorts; however, there was a reduced adjusted risk in overall preterm birth <37 weeks (adjusted odds ratio [aOR] = 0.50 [0.25-0.99]) and preterm birth <34 weeks (aOR = 0.33 [0.13-0.88]) postscreening tool implementation. CONCLUSION Prior to implementation of a simple screening questionnaire, approximately 25% of high risk patients did not receive the recommendation of aspirin for preeclampsia prevention. High-risk patients who lack a history of preeclampsia were less likely to be advised of aspirin prophylaxis. Use of a simple universal screening tool at time of NT ultrasound significantly improved utilization of aspirin for preeclampsia prevention and may improve patient outcomes. KEY POINTS · Despite recommendations, aspirin use for preeclampsia prevention is suboptimal.. · High-risk patients who lack a history preeclampsia were less likely to be advised of aspirin use.. · A simple universal screening tool can significantly improve aspirin utilization..
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Affiliation(s)
- Rupsa C Boelig
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mariam Wanees
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Tingting Zhan
- Division of Biostatistics, Department of Pharmacology and Experimental Therapeutics, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Vincenzo Berghella
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amanda Roman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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Dong X, Han M, Zeb S, Tong M, Li X, Chen Q. Active Management Reduces the Incidence of Recurrent Pre-eclampsia and Improves Maternal and Fetal Outcomes in Women With Recurrent Pre-eclampsia. Front Med (Lausanne) 2021; 8:658022. [PMID: 33996861 PMCID: PMC8116559 DOI: 10.3389/fmed.2021.658022] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 04/07/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Women with previous pre-eclampsia are at an increased risk of developing recurrent pre-eclampsia. Intervention with low dose aspirin had been recommended to reduce the incidence of recurrent pre-eclampsia. However, the association between interventions and maternal and neonatal outcomes in subsequent pregnancies in women with previous pre-eclampsia has not been fully studied. Methods: In this prospective study, a total of 41 patients with previous pre-eclampsia received low dose aspirin and active management (including psychological and physiological intervention), between 10 to 28 weeks until 32 to 34 weeks in our regional referral hospital. The recurrence of pre-eclampsia, and maternal and neonatal outcomes in this pregnancy were analyzed and compared to our previous study which reported a 60% recurrence of pre-eclampsia in our regional referral hospital. Results: Thirteen women with previous pre-eclampsia developed recurrent pre-eclampsia. The time of onset or severity of pre-eclampsia in the previous pregnancy was not associated with the incidence of recurrent pre-eclampsia. The time of onset of previous pre-eclampsia was also not associated with the time of onset in subsequent pre-eclampsia. However, the number of severe recurrent pre-eclampsia was significantly reduced, compared to their first pregnancies. The number of SGA and stillbirth/neonatal death was also significantly reduced in recurrent pre-eclampsia that was actively managed, compared to their first pregnancies. Conclusion: Despite the small sample size included in this study, our study demonstrates that active obstetric management reduces the incidence of recurrent pre-eclampsia, compared to our previous study, and reduces the severity of recurrent pre-eclampsia. It also improves neonatal outcomes in recurrent pre-eclampsia. However, because of no controls in this study, our findings need to confirmed by a case-control or randomized clinical trial study.
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Affiliation(s)
- Xin Dong
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Min Han
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Shahn Zeb
- School of Medicine, Xi'an Jiaotong University, Xi'an, China
| | - Mancy Tong
- Department of Obstetrics, Gynecology and Reproductive Sciences, Yale University, New Haven, CT, United States
| | - Xuelan Li
- Department of Obstetrics & Gynecology, First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Qi Chen
- Department of Obstetrics & Gynecology, The University of Auckland, Auckland, New Zealand
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Zhang N, Tan J, Yang H, Khalil RA. Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world. Biochem Pharmacol 2020; 182:114247. [PMID: 32986983 PMCID: PMC7686229 DOI: 10.1016/j.bcp.2020.114247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/21/2020] [Accepted: 09/23/2020] [Indexed: 11/15/2022]
Abstract
Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.
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Affiliation(s)
- Ning Zhang
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Jing Tan
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - HaiFeng Yang
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
| | - Raouf A Khalil
- Vascular Surgery Research Laboratories, Division of Vascular and Endovascular Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA.
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Tran PL, Randria JM, Ratsiatosika AT, Winer A, Schweizer C, Omarjee A, Peretti V, Dumont C, Dennis T, Lazaro G, Robillard PY, Boukerrou M. Admission into intensive care unit in preeclampsia: a four-year population-based study in Reunion Island. J Matern Fetal Neonatal Med 2020; 35:4285-4290. [PMID: 33207978 DOI: 10.1080/14767058.2020.1849106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Preeclampsia is one of the leading causes of maternal and fetal morbidity and mortality. The objective of our study was to study risk factors and complications associated with severe preeclampsia requiring intensive care unit (ICU) admission. METHODS Retrospective comparative study over a period from 1st of January 2015 to 1st of January 2019 in the University's maternity unit of South Reunion (Indian Ocean). Our sampling included all preeclamptic patients who delivered in the Southern part of the island. Patients admitted to intensive care unit (ICU) and those who remained in the maternity unit (controls) were reviewed. RESULTS Out of 482 preeclampsia cases, 94 women (19.5%) needed a transfer in ICU, of which only 21 (4.3%) needed invasive intensive care. Mean length of stay was 2.4 ± 2.1 days. ICU admission was associated with HELLP syndrome (OR 8.5 [4.9-14.9], p<.001), severe post-partum hemorrhage (OR 5.86 [1.29-26.70], p=.01) and early onset of preeclampsia (<34 weeks gestation), 2.97 [1.9-4.7], p<.001), leading to higher rate of C-section (OR 2.83 [1.67-4.78], p<.001). There were three patients with a history of eclampsia and no case of maternal death was reported. Fetal prognosis was much poorer in maternal ICU admissions than in controls, with outcomes including lower birth weight (1776 vs. 2304 g, p<.001) and higher perinatal morbidity (infant respiratory distress syndrome 3.70 [1.94-7.05], p<.001) and mortality (<.001). CONCLUSIONS Women needing invasive ICU represented 4.3% of preeclampsia cases. This experience is of interest for lower resource settings such as in countries like Madagascar where very intensive ICU means are very poor, but simpler ICU surveillance is possible. Fetal prognosis was poor though no maternal death was reported. Thus, a multidisciplinary approach of patients with preeclampsia should be encouraged; admission into ICU should be facilitated, as soon as any sign of severity and complications appears.
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Affiliation(s)
- Phuong Lien Tran
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island.,Centre d'Etudes Périnatales Océan Indien Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - José Mahenina Randria
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island.,Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Joseph Raseta Befelatanana, Antananarivo, Madagascar
| | | | - Arnaud Winer
- Service de Réanimation Polyvalente, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Chloé Schweizer
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Asma Omarjee
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Véronique Peretti
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Coralie Dumont
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Thomas Dennis
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | | | - Pierre-Yves Robillard
- Centre d'Etudes Périnatales Océan Indien Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island.,Service de Réanimation néonatale, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island
| | - Malik Boukerrou
- Service de Gynécologie-Obstétrique, Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island.,Centre d'Etudes Périnatales Océan Indien Centre Hospitalier Universitaire Sud-Réunion, Saint-Pierre cedex, Réunion Island.,Faculté de médecine, Unité de formation et de recherche santé de la Réunion, Saint Denis, France
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26
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Koire A, Chu DM, Aagaard K. Family history is a predictor of current preterm birth. Am J Obstet Gynecol MFM 2020; 3:100277. [PMID: 33451608 DOI: 10.1016/j.ajogmf.2020.100277] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 10/28/2020] [Accepted: 11/06/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Reliable prediction of spontaneous preterm birth remains limited, particularly for nulliparous and multiparous women without a personal history of preterm birth. Although previous preterm birth is a risk factor for recurrent preterm birth, most spontaneous preterm births occur in women with no previous history of preterm birth. OBJECTIVE This study aimed to determine whether patients' self-reported maternal family history of preterm births among siblings and across 3 generations was an independent risk factor for spontaneous preterm births after controlling for potential confounders. STUDY DESIGN This was a retrospective analysis of a prospectively acquired cohort using a comprehensive single, academic center database of deliveries from August 2011 to July 2017. The objective of the current analysis was to evaluate the risk of preterm birth among women with and without a family history of preterm birth. All subjects in the database were directly queried regarding familial history across 3 generations, inclusive of obstetrical morbidities. Index subjects with probable indicated preterm birth (eg, concurrent diagnosis of preeclampsia; hemolysis, elevated liver enzymes, and low platelet count; or placenta previa or placenta accreta) were excluded, as were nonsingleton pregnancies. Univariate and multivariate analyses with logistic regression were used to determine significance and adjusted relative risk. RESULTS In this study, 23,816 deliveries were included, with 2345 (9.9%) born prematurely (<37 weeks' gestation). Across all subjects, preterm birth was significantly associated with a maternal family history of preterm birth by any definition (adjusted relative risk, 1.44; P<.001), and the fraction of preterm birth occurring in women with a positive family history increased with decreasing gestational age at which the index subjects of preterm birth occurred. For nulliparous women, a history in the subject's sister posed the greatest risk (adjusted relative risk, 2.25; P=.003), whereas for multiparous women with no previous preterm birth, overall family history was most informative (P=.003). Interestingly, a personal history of the index subject herself being born preterm presented the greatest individual risk factor (adjusted relative risk, 1.94; P=.004). CONCLUSION Spontaneous preterm birth in the current pregnancy was significantly associated with a maternal family history of preterm birth among female relatives within 3 generations and notably sisters. The risk persisted among gravidae without a previous preterm birth, demonstrating the capacity for familial history to independently predict risk of spontaneous preterm birth even in the context of a negative personal history. This study provides evidence that self-reported maternal family history is relevant in a US population cohort and across more distant generations than has previously been reported.
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Affiliation(s)
- Amanda Koire
- Department of Quantitative and Computational Biology, Baylor College of Medicine, Houston, TX; Medical Scientist Training Program, Baylor College of Medicine, Houston, TX
| | - Derrick M Chu
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX; Interdepartmental Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX
| | - Kjersti Aagaard
- Medical Scientist Training Program, Baylor College of Medicine, Houston, TX; Interdepartmental Program in Translational Biology and Molecular Medicine, Baylor College of Medicine, Houston, TX; Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital, Houston, TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX.
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Platelet activation and placenta-mediated adverse pregnancy outcomes: an ancillary study to the Effects of Aspirin in Gestation and Reproduction trial. Am J Obstet Gynecol 2020; 223:741.e1-741.e12. [PMID: 32434001 DOI: 10.1016/j.ajog.2020.05.026] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 04/20/2020] [Accepted: 05/12/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Platelet activation may play a role in the pathophysiology of placenta-mediated obstetrical complications, as evidenced by the efficacy of aspirin in preventing preeclampsia, but published data regarding the relationship between biomarkers for platelet activation and adverse obstetrical outcomes are sparse. In particular, it is unknown whether prepregnancy biomarkers of platelet activation are associated with adverse pregnancy outcomes. OBJECTIVE This study aimed to determine the following: (1) whether maternal plasma concentrations of platelet factor 4 are associated with risk of placenta-mediated adverse obstetrical outcomes, and (2) whether these associations are modified by low-dose aspirin. STUDY DESIGN This ancillary study included measurement of platelet factor 4 among 1185 of 1228 women of reproductive age enrolled in the Effects of Aspirin in Gestation and Reproduction trial with available plasma samples, with relevant outcomes assessed among 584 women with pregnancies lasting at least 20 weeks' gestation. We measured platelet factor 4 in plasma samples obtained at the prepregnancy study visit (before randomization to low-dose aspirin or placebo), 12 weeks' gestation, and 28 weeks' gestation. The primary outcome was a composite of hypertensive disorders of pregnancy, placental abruption, and small-for-gestational-age infant. We estimated the relative risks (RRs) and 95% confidence intervals (CIs) for the association between platelet factor 4 and the composite and individual outcomes at each time point using log-binomial regression that was weighted to account for potential selection bias and adjusted for age, body mass index, education, income, and smoking. To evaluate the potential effect modification of aspirin, we stratified the analyses by aspirin treatment assignment. RESULTS During follow-up, 95 women experienced the composite adverse obstetrical outcome, with 57 cases of hypertensive disorders of pregnancy, 35 of small for gestational age, and 6 of placental abruption. Overall, prepregnancy platelet factor 4 was positively associated with the composite outcome (third tertile vs first tertile; relative risk, 2.36; 95% confidence interval, 1.38-4.03) and with hypertensive disorders of pregnancy (third tertile vs first tertile; relative risk, 2.14; 95% confidence interval, 1.08-4.23). In analyses stratified by treatment group, associations were stronger in the placebo group (third tertile vs first tertile; relative risk, 3.36; 95% confidence interval, 1.42-7.93) than in the aspirin group (third tertile vs first tertile; relative risk, 1.78; 95% confidence interval, 0.90-3.50). CONCLUSION High concentrations of platelet factor 4 before pregnancy are associated with increased risk of placenta-mediated adverse pregnancy outcomes, particularly for hypertensive disorders of pregnancy. Aspirin may mitigate the increased risk of these outcomes among women with higher plasma concentrations of preconception platelet factor 4, but low-dose aspirin nonresponders may require higher doses of aspirin or alternate therapies to achieve obstetrical risk reduction.
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Jayaram A, Collier CH, Martin JN. Preterm parturition and pre-eclampsia: The confluence of two great gestational syndromes. Int J Gynaecol Obstet 2020; 150:10-16. [PMID: 32524594 DOI: 10.1002/ijgo.13173] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/15/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Preterm birth (PTB) and pre-eclampsia independently, and frequently concurrently, adversely affect the pregnancy outcomes of millions of mothers and infants worldwide each year. OBJECTIVES To fill the gap between PTB and pre-eclampsia, which continue to constitute the two most important current global challenges to maternal and perinatal health. METHODS Pubmed, Embase, and Cochrane databases were searched from inception until December 2019 using the terms spontaneous PTB (SPTB), indicated preterm delivery (IPTD), early-onset pre-eclampsia, and pre-eclampsia. RESULTS History of PTB and pre-eclampsia were the strongest risk factors contributing to the occurrence of SPTB or IPTB. The risk of PTB and pre-eclampsia among non-Hispanic African American women was higher than the rate among all other racial/ethnic groups in the United States. Low-dose aspirin (LDA) has been reported to reduce the risk of pre-eclampsia by at least 10% and PTB by at least 14%. Lastly, women and their fetuses who develop early-onset pre-eclampsia are at higher risk for developing hypertension and cardiovascular disease later in life. CONCLUSIONS While better clarity is needed, efforts to coordinate prevention of both PTB and pre-eclampsia, even though imperfect, are critically important as part of any program to make motherhood as safe as possible.
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Affiliation(s)
- Aswathi Jayaram
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charlene H Collier
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - James N Martin
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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Pollock W, Peek MJ, Wang A, Li Z, Ellwood D, Homer CSE, Jackson Pulver L, McLintock C, Vaughan G, Knight M, Sullivan EA. Eclampsia in Australia and New Zealand: A prospective population-based study. Aust N Z J Obstet Gynaecol 2020; 60:533-540. [PMID: 31840809 DOI: 10.1111/ajo.13100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eclampsia is a serious consequence of pre-eclampsia. There are limited data from Australia and New Zealand (ANZ) on eclampsia. AIM To determine the incidence, management and perinatal outcomes of women with eclampsia in ANZ. MATERIALS AND METHODS A two-year population-based descriptive study, using the Australasian Maternity Outcomes Surveillance System (AMOSS), carried out in 263 sites in Australia, and all 24 New Zealand maternity units, during a staggered implementation over 2010-2011. Eclampsia was defined as one or more seizures during pregnancy or postpartum (up to 14 days) in any woman with clinical evidence of pre-eclampsia. RESULTS Of 136 women with eclampsia, 111 (83%) were in Australia and 25 (17%) in New Zealand. The estimated incidence of eclampsia was 2.2 (95% confidence interval (CI) 1.9-2.7) per 10 000 women giving birth. Aboriginal and Torres Strait Islander women were over-represented in Australia (n = 9; 8.1%). Women with antepartum eclampsia (n = 58, 42.6%) were more likely to have a preterm birth (P = 0.04). Sixty-three (47.4%) women had pre-eclampsia diagnosed prior to their first eclamptic seizure of whom 19 (30.2%) received magnesium sulphate prior to the first seizure. Nearly all women (n = 128; 95.5%) received magnesium sulphate post-seizure. No woman received prophylactic aspirin during pregnancy. Five women had a cerebrovascular haemorrhage, and there were five known perinatal deaths. CONCLUSIONS Eclampsia is an uncommon consequence of pre-eclampsia in ANZ. There is scope to reduce the incidence of this condition, associated with often catastrophic morbidity, through the use of low-dose aspirin and magnesium sulphate in women at higher risk.
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Affiliation(s)
- Wendy Pollock
- Maternal Critical Care, Melbourne, Victoria, Australia
- Department of Nursing, The University of Melbourne, Melbourne, Victoria, Australia
- School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
| | - Michael J Peek
- Obstetrics and Gynaecology, ANU Medical School, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Alex Wang
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zhuoyang Li
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - David Ellwood
- Department of Obstetrics and Gynaecology, Griffiths University, Southport, Queensland, Australia
| | - Caroline S E Homer
- Maternal and Child Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Lisa Jackson Pulver
- Indigenous Strategy and Services, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire McLintock
- National Women's Health, Auckland City Hospital, University of Auckland, Auckland, New Zealand
| | - Geraldine Vaughan
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Marian Knight
- Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Sullivan
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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Tskhay V, Schindler A, Shestakova M, Klimova O, Narkevich А. The role of progestogen supplementation (dydrogesterone) in the prevention of preeclampsia. Gynecol Endocrinol 2020; 36:698-701. [PMID: 31876197 DOI: 10.1080/09513590.2019.1706085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Our goal was determine the effects of dydrogesterone supplementation to reduce the incidence of preeclampsia (PE) in early pregnancy (from 6 to 20 weeks of gestation). A total of 406 pregnant women were involved into the study. The Study group enrolled 169 women, supplemented with dydrogesterone at a dose of 30 mg/d 6-20 weeks of gestation compared with the control group (237 subjects) - without dydrogesterone supplementation. The women were randomized by age, race, obstetrics complications, and their somatic history. The use of dydrogesterone in early pregnancy - before 20 weeks of gestation (at a dose of 30 mg/d) with high-risk factors of PE contributed to a statistically significant reduction in the frequency of this complication (13.1% and 71.4%, p < .001). It was seen, that women who took dydrogesterone developed significantly less such disorders like hypertension (3.2% and 71.2%, p < .001), proteinuria (0.0% and 66.18%, p < .001), fetal growth retardation syndrome (2.2% and 21.58%, p < .001), destroy of uteri-placenta velocity (3.2% and 21.58%, p < .001), preterm labor (8.6% and 53.95%, p < .001). Dydrogesterone supplementation in the first and second period of pregnancy (from 6 to 20 weeks of gestation) significantly reduced the incidence of PE in women with higher risk pregnancy.
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Affiliation(s)
- V Tskhay
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - A Schindler
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
- Institute for Medical Research and Education, Essen, Germany
| | - M Shestakova
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - O Klimova
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
| | - А Narkevich
- Perinatology, Obstetrics and Gynecology Department, Krasnoyarsk State Medical University named after Voino-Yasenetsky, Krasnoyarsk, Russia
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Tolcher MC, Sangi-Haghpeykar H, Mendez-Figueroa H, Aagaard KM. Low-dose aspirin for preeclampsia prevention: efficacy by ethnicity and race. Am J Obstet Gynecol MFM 2020; 2:100184. [PMID: 33345910 DOI: 10.1016/j.ajogmf.2020.100184] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/01/2020] [Accepted: 07/14/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Low-dose aspirin is recommended for the prevention of preeclampsia among women at a high risk of developing the disease. Aspirin undergoes polymorphic metabolism, and it is well known that common genetic polymorphisms are related to aspirin intolerance. We hypothesized that the efficacy of aspirin prophylaxis may differ by ethnicity and race. OBJECTIVE This study aimed to compare the rates of preeclampsia among low- and high-risk women who received aspirin compared with placebo, stratifying results by ethnicity and race as a first-pass approximation of genomic polymorphisms. STUDY DESIGN This is a secondary analysis of 2 randomized controlled trials previously performed by the Maternal-Fetal Medicine Units Network: the Low-Risk Aspirin trial and the High-Risk Aspirin trial. For the Low-Risk Aspirin trial, normotensive, nulliparous women were enrolled between 13 and 26 weeks' gestation and randomized to 60 mg aspirin daily or placebo. For the High-Risk Aspirin trial, women with pregestational insulin-treated diabetes mellitus, chronic hypertension, multiple gestations, or a history of preeclampsia in a previous pregnancy were enrolled between 13 and 26 weeks' gestation and randomized to 60 mg aspirin daily or placebo. The primary outcome of our secondary analysis was preeclampsia. Secondary outcomes included gestational age at delivery, preterm delivery, placental abruption, small for gestational age, stillbirth, and neonatal death. Outcomes were stratified by ethnicity and race (Hispanic, non-Hispanic white, non-Hispanic black, or other). RESULTS In the Low-Risk Aspirin trial of 3135 women, the risk of preeclampsia was significantly reduced among non-Hispanic white women who received aspirin compared with non-Hispanic white women who received placebo (relative risk, 0.19; 95% confidence interval, 0.06-0.63; P=.007). The risk of preeclampsia was not different when comparing the aspirin and placebo groups among the Hispanic, non-Hispanic black, or other ethnicity and race groups. The efficacy among non-Hispanic white women persisted after consideration of compliance and gestational age at randomization (relative risk, 0.07; 95% confidence interval, 0.009-0.51; P=.009). As noted in the original trial, there was an increased risk of placental abruption in the aspirin group overall compared with placebo (P=.025). The risk of stillbirth was significantly increased among non-Hispanic black women who received aspirin compared with non-Hispanic black women who received placebo (P=.048). In the High-Risk Aspirin trial of 2539 women, 269 were Hispanic (10.6%), 832 were non-Hispanic white (32.8%), 1426 were non-Hispanic black (56.2%), and 12 were categorized as other (0.5%). Stratification by ethnicity and race did not reveal a decreased incidence of preeclampsia for any of the subgroups (P>.05). Moreover, there was no significant difference in other measured outcomes including preterm delivery at <37 weeks' gestation, placental abruption, small for gestational age, stillbirth, or neonatal death. CONCLUSION The incidence of preeclampsia was significantly reduced among low-risk non-Hispanic white women who received aspirin compared with placebo (P=.007), but not overall or among Hispanic or non-Hispanic black women. The analysis of high-risk women did not indicate a difference in the efficacy of aspirin by ethnicity and race.
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Affiliation(s)
- Mary Catherine Tolcher
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Haleh Sangi-Haghpeykar
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX
| | - Hector Mendez-Figueroa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, TX
| | - Kjersti M Aagaard
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX; Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, TX; Department of Molecular and Cell Biology, Baylor College of Medicine, Houston, TX.
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Chaemsaithong P, Cuenca-Gomez D, Plana MN, Gil MM, Poon LC. Does low-dose aspirin initiated before 11 weeks' gestation reduce the rate of preeclampsia? Am J Obstet Gynecol 2020; 222:437-450. [PMID: 31494125 DOI: 10.1016/j.ajog.2019.08.047] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 08/23/2019] [Accepted: 08/23/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE DATA Preconception or early administration of low-dose aspirin might improve endometrial growth, placental vascularization, and organogenesis. Most studies have evaluated the potential benefit of preconception or early administration of low-dose aspirin in women with a history of recurrent pregnancy loss, women who have undergone in vitro fertilization, or women with thrombophilia or antiphospholipid syndrome. These women are at an increased risk of placenta-associated complications of pregnancy, including preeclampsia, preterm delivery, and fetal growth restriction. STUDY OUTCOMES We performed a systematic review and meta-analysis to evaluate the effect of low-dose aspirin initiated at <11 weeks' gestation on the risk of preeclampsia, gestational hypertension, or any hypertensive disorder of pregnancy. Secondary outcomes included preterm delivery at <37 weeks' gestation and fetal growth restriction. STUDY APPRAISAL AND SYNTHESIS METHODS We searched in MEDLINE via PubMed, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform from 1985 to November 2018. Entry criteria were randomized controlled trials evaluating the effect of aspirin administered at <11 weeks' gestation in preventing preeclampsia and/or hypertensive disorders in pregnancy or improving pregnancy outcomes in women with recurrent miscarriage as compared with placebo or no treatment and outcome data available or provided by authors for >85% of the study population. Relative risks with 95% confidence intervals were calculated for each study and pooled for global analysis as the effect measure. We assessed statistical heterogeneity in each meta-analysis using the χ2 statistics, I2, and Tau2. Heterogeneity was considered substantial if an I2 was greater than 50% and either the Tau2 was greater than zero or there was a low P value (<0.10) in the χ2 test for heterogeneity. Random-effects meta-analysis, weighted by the size of the studies, was performed to produce an overall summary on aspirin effect for each outcome. Sensitivity analysis by sequential omission of each individual study and by fixed-effects model was performed. Publication bias was not assessed because of the small number of included studies. Statistical analysis was performed using Stata release 14.0 (StataCorp). RESULTS The entry criteria were fulfilled by 8 randomized controlled trials on a combined total of 1426 participants. Low-dose aspirin initiated at <11 weeks' gestation was associated with a nonsignificant reduction in the risk of preeclampsia (relative risk, 0.52; 95% confidence interval, 0.23-1.17, P = .115), gestational hypertension (relative risk, 0.49; 95% confidence interval, 0.20-1.21; P = .121), and any hypertensive disorder of pregnancy (relative risk, 0.59; 95% confidence interval, 0.33-1.04, P = .067). Early administration of low-dose aspirin reduced the risk of preterm delivery (relative risk, 0.52; 95% confidence interval, 0.27-0.97, P = .040) but had no impact on the risk of fetal growth restriction (relative risk, 1.10; 95% confidence interval, 0.58-2.07, P = .775). Except for preterm delivery and any hypertensive disorder of pregnancy, sensitivity analysis demonstrated similar observations, therefore confirming the robustness of the analysis. CONCLUSION The administration of low-dose aspirin at <11 weeks' gestation in women at high risk does not decrease the risk of preeclampsia, gestational hypertension, any hypertensive disorder of pregnancy, and fetal growth restriction. However, it might reduce the risk of preterm delivery. Larger randomized controlled trials will be required to substantiate the findings.
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de Moreuil C, Alavi Z, Pasquier E. Hydroxychloroquine may be beneficial in preeclampsia and recurrent miscarriage. Br J Clin Pharmacol 2020; 86:39-49. [PMID: 31633823 PMCID: PMC6983516 DOI: 10.1111/bcp.14131] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 08/30/2019] [Accepted: 09/05/2019] [Indexed: 02/06/2023] Open
Abstract
Recurrent miscarriage (RM) and vasculoplacental disorders, such as preeclampsia (PE), affect women of childbearing age worldwide. Vascular endothelial dysfunction and immunological impairment are associated with both RM and PE. To date, there is no effective or optimal therapeutic approach for these conditions. Notably, aspirin use is only partially effective in the prevention of PE. Hydroxychloroquine (HCQ) has demonstrated beneficial effects on disease flares, pregnancy outcomes and cardiovascular impairment in systemic erythaematosus lupus (SLE) through its immunomodulatory, vasculoprotective and antithrombotic properties. Here, in the context of the underlying physiological dysregulation associated with PE and RM, the beneficial properties and potential therapeutic efficacy of HCQ are reviewed in anticipation of the results of current and future trials. Two related trials addressing RM in the absence of maternal autoimmune disease are ongoing. Other trials addressing pregnancy outcomes in the presence of maternal autoimmune disease are forthcoming. In this review, we hypothesise that the immunological and endothelial effects of HCQ may be beneficial in the context of PE and RM, regardless of the maternal autoimmune status.
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Affiliation(s)
- Claire de Moreuil
- EA 3878, Groupe d'Etude de la Thrombose de Bretagne OccidentaleBrestFrance
- Département de médecine interne et pneumologieCHRU de Brest, Hôpital de la Cavale BlancheBrestFrance
| | - Zarrin Alavi
- INSERM, Centre d'Investigation Clinique – 1412, CHRU de BrestBrestFrance
| | - Elisabeth Pasquier
- EA 3878, Groupe d'Etude de la Thrombose de Bretagne OccidentaleBrestFrance
- Département de médecine interne et pneumologieCHRU de Brest, Hôpital de la Cavale BlancheBrestFrance
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Smith-Whitley K. Complications in pregnant women with sickle cell disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:359-366. [PMID: 31808864 PMCID: PMC6913482 DOI: 10.1182/hematology.2019000039] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/19/2023]
Abstract
Pregnancy in women with sickle cell disease (SCD) is associated with increased maternal and fetal morbidity and mortality. Outcomes vary widely owing to methodological limitations of clinical studies, but overall, hypertensive disorders of pregnancy, venothromboembolism, poor fetal growth, and maternal and perinatal mortality are increased globally. Few therapeutic interventions have been explored other than prophylactic and selective transfusion therapy. Unfortunately, existing data are limited, and it remains unclear whether prophylactic use of chronic transfusions will improve pregnancy outcomes. Management of pregnant women with SCD is best accomplished with a multidisciplinary team that includes a sickle cell expert and an obstetrician familiar with high-risk pregnancies. Women with SCD should have individualized care plans that outline management of acute pain and guidelines for transfusion therapy. Neonates require close monitoring for neonatal abstinence syndrome and hemolytic disease of the newborn. Ideally all young women with SCD will have a "reproductive life plan" developed as a component of preconception counseling and health promotion. Research leading to improved pregnancy management focused on diminishing adverse maternal and neonatal outcomes is overdue. International collaborations should be considered to improve subject recruitment and foster timely completion of clinical trials. Additional therapeutic interventions outside of transfusion therapy should be explored.
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Affiliation(s)
- Kim Smith-Whitley
- Division of Hematology, The Children's Hospital of Philadelphia, Philadelphia, PA
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35
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Chaemsaithong P, Pooh RK, Zheng M, Ma R, Chaiyasit N, Tokunaka M, Shaw SW, Seshadri S, Choolani M, Wataganara T, Yeo GSH, Wright A, Leung WC, Sekizawa A, Hu Y, Naruse K, Saito S, Sahota D, Leung TY, Poon LC. Prospective evaluation of screening performance of first-trimester prediction models for preterm preeclampsia in an Asian population. Am J Obstet Gynecol 2019; 221:650.e1-650.e16. [PMID: 31589866 DOI: 10.1016/j.ajog.2019.09.041] [Citation(s) in RCA: 93] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/22/2019] [Accepted: 09/25/2019] [Indexed: 12/17/2022]
Abstract
BACKGROUND The administration of aspirin <16 weeks gestation to women who are at high risk for preeclampsia has been shown to reduce the rate of preterm preeclampsia by 65%. The traditional approach to identify such women who are at risk is based on risk factors from maternal characteristics, obstetrics, and medical history as recommended by the American College of Obstetricians and Gynecologists and the National Institute for Health and Care Excellence. An alternative approach to screening for preeclampsia has been developed by the Fetal Medicine Foundation. This approach allows the estimation of patient-specific risks of preeclampsia that requires delivery before a specified gestational age with the use of Bayes theorem-based model. OBJECTIVE The purpose of this study was to examine the diagnostic accuracy of the Fetal Medicine Foundation Bayes theorem-based model, the American College of Obstetricians and Gynecologists, and the National Institute for Health and Care Excellence recommendations for the prediction of preterm preeclampsia at 11-13+6 weeks gestation in a large Asian population STUDY DESIGN: This was a prospective, nonintervention, multicenter study in 10,935 singleton pregnancies at 11-13+6 weeks gestation in 11 recruiting centers across 7 regions in Asia between December 2016 and June 2018. Maternal characteristics and medical, obstetric, and drug history were recorded. Mean arterial pressure and uterine artery pulsatility indices were measured according to standardized protocols. Maternal serum placental growth factor concentrations were measured by automated analyzers. The measured values of mean arterial pressure, uterine artery pulsatility index, and placental growth factor were converted into multiples of the median. The Fetal Medicine Foundation Bayes theorem-based model was used for the calculation of patient-specific risk of preeclampsia at <37 weeks gestation (preterm preeclampsia) and at any gestation (all preeclampsia) in each participant. The performance of screening for preterm preeclampsia and all preeclampsia by a combination of maternal factors, mean arterial pressure, uterine artery pulsatility index, and placental growth factor (triple test) was evaluated with the adjustment of aspirin use. We examined the predictive performance of the model by the use of receiver operating characteristic curve and calibration by measurements of calibration slope and calibration in the large. The detection rate of screening by the Fetal Medicine Foundation Bayes theorem-based model was compared with the model that was derived from the application of American College of Obstetricians and Gynecologists and National Institute for Health and Care Excellence recommendations. RESULTS There were 224 women (2.05%) who experienced preeclampsia, which included 73 cases (0.67%) of preterm preeclampsia. In pregnancies with preterm preeclampsia, the mean multiples of the median values of mean arterial pressure and uterine artery pulsatility index were significantly higher (mean arterial pressure, 1.099 vs 1.008 [P<.001]; uterine artery pulsatility index, 1.188 vs 1.063[P=.006]), and the mean placental growth factor multiples of the median was significantly lower (0.760 vs 1.100 [P<.001]) than in women without preeclampsia. The Fetal Medicine Foundation triple test achieved detection rates of 48.2%, 64.0%, 71.8%, and 75.8% at 5%, 10%, 15%, and 20% fixed false-positive rates, respectively, for the prediction of preterm preeclampsia. These were comparable with those of previously published data from the Fetal Medicine Foundation study. Screening that used the American College of Obstetricians and Gynecologists recommendations achieved detection rate of 54.6% at 20.4% false-positive rate. The detection rate with the use of National Institute for Health and Care Excellence guideline was 26.3% at 5.5% false-positive rate. CONCLUSION Based on a large number of women, this study has demonstrated that the Fetal Medicine Foundation Bayes theorem-based model is effective in the prediction of preterm preeclampsia in an Asian population and that this method of screening is superior to the approach recommended by American College of Obstetricians and Gynecologists and the National Institute for Health and Care Excellence. We have also shown that the Fetal Medicine Foundation prediction model can be implemented as part of routine prenatal care through the use of the existing infrastructure of routine prenatal care.
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Affiliation(s)
| | - Ritsuko K Pooh
- CRIFM Clinical Research Institute of Fetal Medicine, Osaka, Japan
| | | | - Runmei Ma
- First Affiliated Hospital of Kunming Medical University, Kunming, China
| | | | | | | | | | | | | | | | | | | | | | - Yali Hu
- Nanjing Drum Tower Hospital, Nanjing, China
| | | | - Shigeru Saito
- University of Toyama University Hospital, Toyama, Japan
| | - Daljit Sahota
- Chinese University of Hong Kong, Hong Kong SAR, China
| | | | - Liona C Poon
- Chinese University of Hong Kong, Hong Kong SAR, China.
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Taylor YJ, Liu TL, Howell EA. Insurance Differences in Preventive Care Use and Adverse Birth Outcomes Among Pregnant Women in a Medicaid Nonexpansion State: A Retrospective Cohort Study. J Womens Health (Larchmt) 2019; 29:29-37. [PMID: 31397625 DOI: 10.1089/jwh.2019.7658] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Lack of quality preventive care has been associated with poorer outcomes for pregnant women with low incomes. Health policy changes implemented with the Affordable Care Act (ACA) were designed to improve access to care. However, insurance coverage remains lower among women in Medicaid nonexpansion states. We compared health care use and adverse birth outcomes by insurance status among women giving birth in a large health system in a Medicaid nonexpansion state. Materials and Methods: We conducted a population-based retrospective cohort study using data for 9,613 women with deliveries during 2014-2015 at six hospitals associated with a large vertically integrated health care system in North Carolina. Adjusted logistic regression and zero-inflated negative binomial models examined associations between insurance status at delivery (commercial, Medicaid, or uninsured) and health care utilization (well-woman visits, late prenatal care, adequacy of prenatal care, postpartum follow-up, and emergency department [ED] visits) and outcomes (preterm birth, low birth weight, preeclampsia, and gestational diabetes). Results: Having Medicaid at delivery was associated with lower rates of well-woman visits (rate ratio [RR] 0.25, 95% CI 0.23-0.28), higher rates of ED visits (RR 2.93, 95% CI 2.64-3.25), and higher odds of late prenatal care (odds ratio [OR] 1.18, 95% CI 1.03-1.34) compared to having commercial insurance, with similar results for uninsured women. Differences in adverse pregnancy outcomes were not statistically significant after adjusting for patient characteristics. Conclusions: Findings suggest that large gaps exist in use of preventive care between Medicaid/uninsured and commercially insured women. Policymakers should consider ways to improve potential and realized access to care.
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Affiliation(s)
- Yhenneko J Taylor
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Tsai-Ling Liu
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina
| | - Elizabeth A Howell
- Department of Population Health Science and Policy, Department of Obstetrics, Gynecology, and Reproductive Science, and the Blavatnik Family Women's Health Research Institute at the Icahn School of Medicine at Mount Sinai, New York, New York
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Bernardes TP, Mol BW, Ravelli AC, van den Berg PP, Boezen HM, Groen H. Recurrence risk of preeclampsia in a linked population-based cohort: Effects of first pregnancy maximum diastolic blood pressure and gestational age. Pregnancy Hypertens 2019; 15:32-36. [DOI: 10.1016/j.preghy.2018.10.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 10/18/2018] [Accepted: 10/31/2018] [Indexed: 10/27/2022]
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Andrikopoulou M, Purisch SE, Handal-Orefice R, Gyamfi-Bannerman C. Low-dose aspirin is associated with reduced spontaneous preterm birth in nulliparous women. Am J Obstet Gynecol 2018; 219:399.e1-399.e6. [PMID: 29913174 DOI: 10.1016/j.ajog.2018.06.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/03/2018] [Accepted: 06/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Preterm birth is one of the leading causes of perinatal morbidity and mortality. Clinical data suggest that low-dose aspirin may decrease the rate of overall preterm birth, but investigators have speculated that this is likely due to a decrease in medically indicated preterm birth through its effect on the incidence of preeclampsia and other placental disease. We hypothesized that low-dose aspirin may also have an impact on the mechanism of spontaneous preterm labor. OBJECTIVE Our objective was to determine whether low-dose aspirin reduces the rate of spontaneous preterm birth in nulliparous women without medical comorbidities. STUDY DESIGN This is a secondary analysis of a randomized, placebo-controlled trial of low-dose aspirin for the prevention of preeclampsia in healthy, low-risk, nulliparous women. Low-risk women were defined by the absence of hypertension, renal disease, diabetes, other endocrine disorders, seizures, heart disease, or collagen vascular disease. Our study was limited to singleton, nonanomalous gestations. Women were eligible if they had prior pregnancy terminations but not prior spontaneous pregnancy loss <20 weeks. Current pregnancies that resulted in a loss or termination <20 weeks or antepartum stillbirth or had missing follow-up data were excluded. The treatment intervention was 60 mg of aspirin, initiated at 13-25 weeks' gestation or matching placebo. The primary outcome was spontaneous preterm birth <34 weeks' gestation. Secondary outcomes included spontaneous preterm birth <37 weeks and overall preterm birth <37 and <34 weeks. Baseline demographics and primary and secondary outcomes were compared between treatment groups. A logistic regression model was used to adjust for confounders related to spontaneous preterm birth. RESULTS Of 2543 included women, 1262 (49.6%) received low-dose aspirin and 1281 (50.4%) placebo. Baseline characteristics were similar between groups, except for marital status. The rate of spontaneous preterm birth <34 weeks was 1.03% (n = 13) and 2.34% (n = 30) in the low-dose aspirin and placebo group, respectively (odds ratio, 0.43, 95% confidence interval, 0.26-0.84). Additionally, the rate of spontaneous preterm birth <37 weeks was 6.58% (n = 83) in the low-dose aspirin group and 7.03% (n = 90) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.71-1.33), and the rate of overall preterm birth <37 weeks was 7.84% (n = 99) in the low-dose aspirin group and 8.2% (n = 105) in the placebo group (odds ratio, 0.97, 95% confidence interval, 0.72-1.31). After adjustment for variables that were clinically relevant or statistically significant, including body mass index, race, tobacco use, marital status, and education level, there was a significant reduction in spontaneous preterm birth <34 weeks in the low-dose aspirin group (adjusted odds ratio, 0.46, 95% confidence interval, 0.23-0.89). The rates of overall preterm birth <34 and <37 weeks and spontaneous preterm birth <37 weeks were similar in women who received low-dose aspirin compared with placebo. CONCLUSION Low-dose aspirin is associated with a substantial decrease in spontaneous preterm birth <34 weeks in healthy nulliparous women without comorbidities. These findings suggest a new therapeutic option for preterm birth prevention that requires further study.
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de Moreuil C, Fauchais AL, Merviel P, Tremouilhac C, Le Moigne E, Pasquier E, Pan-Petesch B, Lacut K. [Pre-eclampsia prevention in 2018 in general population and in lupic women: At the dawn of a personalized medicine?]. Rev Med Interne 2018; 39:935-941. [PMID: 29933972 DOI: 10.1016/j.revmed.2018.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/27/2018] [Accepted: 06/03/2018] [Indexed: 11/17/2022]
Abstract
Pre-eclampsia prevention represents a major public health issue, as this vasculo-placental disorder generates a great burden of foeto-maternal morbi-mortality. Aspirin has proved its efficacy in primary and secondary pre-eclampsia prevention, especially when it is given at 150mg per day bedtime before 15 weeks of gestation to high-risk women. In the English trial ASPRE, high-risk women were identified by an algorithm taking into account angiogenic biomarkers ascertained at the end of first trimester of pregnancy. This article focuses on physiopathological mechanisms and risk factors of pre-eclampsia and on the interest of early angiogenic biomarkers dosing during pregnancy, for the assessment of pre-eclampsia risk. Unlike Great Britain or Israel, cost-effectiveness of this algorithm in general population has not been assessed in France. Finally, systemic lupus erythematous is at high risk of vasculo-placental disorders. Although few studies of angiogenic biomarkers dosing during lupus pregnancies identified a correlation between high sFlt1 levels at the end of first trimester and subsequent onset of severe vasculo-placental disorders, with a very good negative predictive value of sFtl1. Angiogenic biomarkers ascertainment for screening of vasculo-placental disorders in pregnant women with systemic lupus erythematous could allow targeting at best women needing an aspirin treatment and a closer monitoring.
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Affiliation(s)
- C de Moreuil
- Département de médecine interne et pneumologie, hôpital La Cavale Blanche, CHU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France; EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France.
| | - A-L Fauchais
- Département de médecine interne, CHU de Limoges, 29200 Limoges, France
| | - P Merviel
- EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France; Service de gynécologie et d'obstétrique, hôpital Morvan, CHU de Brest, 29200 Brest, France
| | - C Tremouilhac
- EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France; Service de gynécologie et d'obstétrique, hôpital Morvan, CHU de Brest, 29200 Brest, France
| | - E Le Moigne
- Département de médecine interne et pneumologie, hôpital La Cavale Blanche, CHU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France; EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France
| | - E Pasquier
- Département de médecine interne et pneumologie, hôpital La Cavale Blanche, CHU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France; EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France
| | - B Pan-Petesch
- EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France; Fédération de cancérologie et d'hématologie, hôpital Morvan, CHU de Brest, 29200 Brest, France
| | - K Lacut
- Département de médecine interne et pneumologie, hôpital La Cavale Blanche, CHU de Brest, boulevard Tanguy-Prigent, 29609 Brest cedex, France; EA 3878, GETBO, université Bretagne-Loire, 29200 Brest cedex, France
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Magnesium Supplementation and Blood Pressure in Pregnancy: A Double-Blind Randomized Multicenter Study. J Pregnancy 2018; 2018:4843159. [PMID: 30002931 PMCID: PMC5996415 DOI: 10.1155/2018/4843159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 04/29/2018] [Accepted: 05/07/2018] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the effect of magnesium (Mg) supplementation in healthy pregnant women for prevention of blood pressure increase. Secondary outcomes were comparison of biomarkers for hypertensive disorders and labour and fetal outcomes between the groups. Methods Two hundred nulliparous healthy pregnant women were double-blind randomized to receive Mg daily or placebo. Results There were no differences in blood pressure increase. However, among the Mg-treated women, there was a significant negative correlation between increase in blood levels of magnesium and increase in systolic blood pressure (p = 0.042). Magnesium supplementation seems to be safe for both mother and infant. Conclusion Magnesium supplementation in healthy first-time pregnant women is not to be recommended for prevention of blood pressure increase. Supplementation in risk pregnancies needs to be further investigated. The study is listed on the ISRCTN registry with study ID 13890849.
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Fantasia HC. Low-Dose Aspirin for the Prevention of Preeclampsia. Nurs Womens Health 2018; 22:87-92. [PMID: 29433703 DOI: 10.1016/j.nwh.2017.12.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 10/13/2017] [Indexed: 01/12/2023]
Abstract
Preeclampsia is a hypertensive disorder specific to pregnancy that remains a significant cause of maternal and neonatal morbidity and mortality. Identification of women who are most at risk for preeclampsia is imprecise. Because of the potential negative health consequences of preeclampsia for women and newborns and the lack of effective screening mechanisms preventing preeclampsia is an important component of prenatal care. Researchers have documented that low-dose aspirin, taken daily after the first trimester, can decrease the development of preeclampsia and reduce the incidence of preterm birth and birth of small-for-gestational-age infants. This column includes an overview of low-dose aspirin in pregnancy and a review of current recommendations from leading national organizations.
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Wataganara T, Leetheeragul J, Pongprasobchai S, Sutantawibul A, Phatihattakorn C, Angsuwathana S. Prediction and prevention of pre-eclampsia in Asian subpopulation. J Obstet Gynaecol Res 2018; 44:813-830. [PMID: 29442407 DOI: 10.1111/jog.13599] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Accepted: 12/31/2017] [Indexed: 12/20/2022]
Abstract
The benefit of the early administration of aspirin to reduce preterm pre-eclampsia among screened positive European women from multivariate algorithmic approach (ASPRE trial) has opened an intense debate on the feasibility of universal screening. This review aims to assess the new perspectives in the combined screening of pre-eclampsia in the first trimester of pregnancy and the chances for prevention using low-dose aspirin with special emphasis on the particularities of the Asian population. PubMed, CENTRAL and Embase databases were searched from inception until 15 November 2017 using combinations of the search terms: preeclampsia, Asian, prenatal screening, early prediction, ultrasonography, pregnancy, biomarker, mean arterial pressure, soluble fms-like tyrosine kinase-1, placental growth factor, pregnancy-associated plasma protein-A and pulsatility index. This is not a systematic review or meta-analysis, so the risk of bias of the selected published articles and heterogeneity among the studies need to be considered. The prevalence of pre-eclampsia and serum levels of biochemical markers in Asian are different from Caucasian women; hence, Asian ethnicity needs to be corrected for in the algorithmic assessment of multiple variables to improve the screening performance. Aspirin prophylaxis may still be viable in Asian women, but resource implication needs to be considered. Asian ethnicity should be taken into account before implementing pre-eclampsia screening strategies in the region. The variables included can be mixed and matched to achieve an optimal performance that is appropriate for economical restriction in individual countries.
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Affiliation(s)
- Tuangsit Wataganara
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Jarunee Leetheeragul
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Suchittra Pongprasobchai
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Anuwat Sutantawibul
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Chayawat Phatihattakorn
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
| | - Surasak Angsuwathana
- Department of Obstetrics and Gynecology, Faculty of Medicine Siriraj Hospital, Bangkok, Thailand
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Sonek J, Krantz D, Carmichael J, Downing C, Jessup K, Haidar Z, Ho S, Hallahan T, Kliman HJ, McKenna D. First-trimester screening for early and late preeclampsia using maternal characteristics, biomarkers, and estimated placental volume. Am J Obstet Gynecol 2018; 218:126.e1-126.e13. [PMID: 29097177 DOI: 10.1016/j.ajog.2017.10.024] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Revised: 10/10/2017] [Accepted: 10/20/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Preeclampsia is a major cause of perinatal morbidity and mortality. First-trimester screening has been shown to be effective in selecting patients at an increased risk for preeclampsia in some studies. OBJECTIVE We sought to evaluate the feasibility of screening for preeclampsia in the first trimester based on maternal characteristics, medical history, biomarkers, and placental volume. STUDY DESIGN This is a prospective observational nonintervention cohort study in an unselected US population. Patients who presented for an ultrasound examination between 11-13+6 weeks' gestation were included. The following parameters were assessed and were used to calculate the risk of preeclampsia: maternal characteristics (demographic, anthropometric, and medical history), maternal biomarkers (mean arterial pressure, uterine artery pulsatility index, placental growth factor, pregnancy-associated plasma protein A, and maternal serum alpha-fetoprotein), and estimated placental volume. After delivery, medical records were searched for the diagnosis of preeclampsia. Detection rates for early-onset preeclampsia (<34 weeks' gestation) and later-onset preeclampsia (≥34 weeks' gestation) for 5% and 10% false-positive rates using various combinations of markers were calculated. RESULTS We screened 1288 patients of whom 1068 (82.99%) were available for analysis. In all, 46 (4.3%) developed preeclampsia, with 13 (1.22%) having early-onset preeclampsia and 33 (3.09%) having late-onset preeclampsia. Using maternal characteristics, serum biomarkers, and uterine artery pulsatility index, the detection rate of early-onset preeclampsia for either 5% or 10% false-positive rate was 85%. With the same protocol, the detection rates for preeclampsia with delivery <37 weeks were 52% and 60% for 5% and 10% false-positive rates, respectively. Based on maternal characteristics, the detection rates for late-onset preeclampsia were 15% and 48% for 5% and 10%, while for preeclampsia at ≥37 weeks' gestation the detection rates were 24% and 43%, respectively. The detection rates for late-onset preeclampsia and preeclampsia with delivery at >37 weeks' gestation were not improved by the addition of biomarkers. CONCLUSION Screening for preeclampsia at 11-13+6 weeks' gestation using maternal characteristics and biomarkers is associated with a high detection rate for a low false-positive rate. Screening for late-onset preeclampsia yields a much poorer performance. In this study the utility of estimated placental volume and mean arterial pressure was limited but larger studies are needed to ultimately determine the effectiveness of these markers.
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Affiliation(s)
- Jiri Sonek
- Fetal Medicine Foundation USA, Dayton, OH; Wright State University, Dayton, OH.
| | | | | | - Cathy Downing
- Fetal Medicine Foundation USA, Dayton, OH; Wright State University, Dayton, OH
| | | | | | | | | | | | - David McKenna
- Fetal Medicine Foundation USA, Dayton, OH; Wright State University, Dayton, OH
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