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Trajectory of blood pressure levels and weight gain in pregnant women: A group-based approach

BACKGROUND AND OBJECTIVES

Morbidities associated with increased blood pressure levels during pregnancy represent one of the main causes of maternal mortality. The objective was to identify patterns of systolic blood pressure (SPB) trajectory in pregnant women undergoing prenatal care at the Unified Health System, and associations with weight gain trajectory, demographic, obstetric, anthropometric data, and health related behaviors.

METHODS AND RESULTS

Cohort study with pregnant women using the public health services in Brazil. Data were collected through questionnaires and medical records. Trajectory patterns of SBP and weight gain were identified by a group-based trajectory model. For trajectory analysis, 460 women had SBP information available, totaling 2839 measurements, with an average of 6.2 measurements during pregnancy. Three SBP trajectory patterns were identified and classified as "Group 1" (48.0%), with a mean of 103 mmHg (95% CI 102.5-103.7 mmHg), "Group 2" (42.7%) with a mean of 114 mmHg (95% CI 113.7-114.9 mmHg), and "Group 3" (9.1%) with the highest mean SBP value of 130 mmHg (95% CI 128.8-131.5 mmHg). It was observed that regardless of the weight gain trajectory group, women classified in the group with the highest SBP had the highest SBP levels. The probability of being classified in Group 3 was higher among women with higher education, who started pregnancy presenting obesity, and who were using antihypertensive drugs.

CONCLUSION

The probability of belonging to groups with a greater trajectory of SBP during pregnancy was associated with obesity, education, and hypertension under treatment.

PREPARE: protocol for a stepped wedge trial to evaluate whether a risk stratification model can reduce preterm deliveries among women with suspected or confirmed preterm pre-eclampsia

BACKGROUND

Preeclampsia (PE) is a major cause of short and long-term morbidity for affected infants, including consequences of fetal growth restriction and iatrogenic prematurity. In Brazil, this is a special problem as PE accounts for 18% of preterm births (PTB). In the PREPARE (Prematurity REduction by Pre-eclampsia cARE) study, we will test a novel system of integrated care based on risk stratification and knowledge transfer, to safely reduce PTB.

METHODS

This is a stepped wedge cluster randomised trial that will include women with suspected or confirmed PE between 20 + 0 and 36 + 6 gestational weeks. All pregnant women presenting with these findings at seven tertiary centres in geographically dispersed sites, throughout Brazil, will be considered eligible and evaluated in terms of risk stratification at admission. At randomly allocated time points, sites will transition to risk stratification performed according to sFlt-1/PlGF (Roche Diagnostics) measurement and fullPIERS score with both results will be revealed to care providers. The healthcare providers of women stratified as low risk for adverse outcomes (sFlt-1/PlGF ≤38 AND fullPIERS< 10% risk) will receive the recommendation to defer delivery. sFlt-1/PlGF will be repeated once and fullPIERS score twice a week. Rates of prematurity due to preeclampsia before and after the intervention will be compared. Additionally, providers will receive an active program of knowledge transfer about WHO recommendations for preeclampsia, including recommendations regarding antenatal corticosteroids for foetal benefits, antihypertensive therapy and magnesium sulphate for seizure prophylaxis. This study will have 90% power to detect a reduction in PTB associated with PE from a population estimate of 1.5 to 1.0%, representing a 33% risk reduction, and 80% power to detect a reduction from 2.0 to 1.5% (25% risk reduction). The necessary number of patients recruited to achieve these results is 750. Adverse events, serious adverse events, both anticipated and unanticipated will be recorded.

DISCUSSION

The PREPARE intervention expects to reduce PTB and improve care of women with PE without significant adverse side effects. If successful, this novel pathway of care is designed for rapid translation to healthcare throughout Brazil and may be transferrable to other low and middle income countries.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT03073317.

Creating biobanks in low and middle-income countries to improve knowledge - The PREPARE initiative

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Low and middle-income (LMIC) countries still suffer with pre-eclampsia.

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Risk assessment of pre-eclampsia has evolved in high-income countries.

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Biobanks can provide a unique opportunity to understand preeclampsia in LMIC.

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Databanks can provide a unique opportunity to understand preeclampsia in LMIC.

The Millennium Development Goal 5, a project signed in 2000, intended to improve maternal health and reduce maternal mortality by 75% by 2015. Despite all efforts, little progress has been achieved in low and middle-income countries (LMIC) and 99% of all maternal deaths related to pre-eclampsia (PE) still occur in these settings. It is important to determine whether women in LMIC, where PE carries a greater risk than in high-income countries (HIC), have unique risk factors. Some variances may alter the risk, severity and pertinent pathophysiology of PE. We posit based upon this, that women from LMIC may have biomarkers specific to this population. Discovering such specific biomarkers and testing the relevance of biomarkers developed in high-income populations could increase the clinical usefulness of these analyses without increasing cost-effective approaches for prediction of PE.

Here we briefly describe our platform to develop the PREPARE – Biobank in tertiary hospitals or basic units for antenatal care from 6 different cities in Brazil.

The PREPARE – Biobank has been developed with two arms. The first arm is a cross-sectional study that will collect clinical information and biosamples from more than 1000 women who developed preterm PE. The second arm is a cohort study of 7000 women. It will collect clinical information and longitudinal biosamples from women at three times during pregnancy, <16 weeks, between 28 and 32 weeks and at delivery or diagnosis of adverse outcomes.

The biobank will be supported and complemented by a Brazilian database using the CoLab COLLECT Database.

Prospective study of the hemodynamic behavior of ophthalmic arteries in postpartum preeclamptic women: A doppler evaluation

The aim of this study was to evaluate the hemodynamic behavior of the ophthalmic artery by means of the Doppler ultrasound, in postpartum preeclamptic women. It was an observational prospective study with 44 postpartum preeclamptic women (group 1) and 49 postpartum normal women with normal blood pressure and with no previous illnesses known (group 2). All the pregnant women had a Doppler ultrasound exam of the ophthalmic artery in the immediate puerperium, that is, 10 days for the delivery (time 1). Group 1 was then followed prospectively, 26 patients of which returned to the last test in the remote puerperium in 45 days (time 2) and 29 patients returned to the last test in the remote puerperium in 90 days (time 3). All these women had preeclampsia before the delivery. The resistance index (RI), pulsatility index (PI), peak systolic velocity (PSV), end diastolic flow velocity (EDV), second peak of systolic velocity (P2), and the peak ratio (PR) were calculated. The data obtained are expressed in average and standard deviation, by using the Lilliefors test for normality. The average of the Doppler indexes in groups 1 and 2 was compared by means of test t of the student. Group 1 was analyzed separately, comparing the three times, using the test of ANOVA for repetitive measures and Tukey post-hoc range test. In the "Results" section, the statically meaningful differences in RI, PI, P2, RPV, and EDV (p < 0.0001, p < 0.0001, p < 0.0009, p < 0.0001, p < 0.0028) were found in the immediate puerperium of group 1 in relation to group 2, indicating the persistence of hyperperfusion and orbital vasodilatation in the immediate postpartum period in patients who had complicated pregnancies previously due to preeclampsia. In the evolutionary analysis of group 1, comparing the Doppler indexes between the immediate and late puerperium, statistically relevant differences between the rates of RI, P2, and PR (p < 0,01) were observed, showing a raise of RI and reduction of P2 and PR, and also a tendency of normalization of these rates in the late puerperium. When the same indexes were compared (PI, P2, and PR) now in times 2 and 3, the remote, and late puerperium, respectively, there were no significant differences, indicating the stabilization of these indexes since the 45th day of the puerperium. Within 90 days, RI, PI, and PR are not stabilized yet in relation to the control, even though there is a tendency of these indexes to reach the control. In conclusion, there was persistence of signs of vasodilatation and hyperperfusion of the orbital territory, represented by Doppler of the ophthalmic artery in the immediate puerperium of preeclamptic women. A tendency of normalization of the orbital hemodynamic standard in the pregnant women from the period of the late puerperium was observed, but there was no complete normalization of the vascular pattern on the remote postpartum.