Baseline check of blood pressure readings of an automated device in severe pre-eclampsia and healthy normotensive pregnancy

Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries

Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.

The role of genetics in maternal susceptibility to preeclampsia in women of African ancestry

Racial disparities exist in the prevalence of preeclampsia (PE), with women of African ancestry suffering the highest rates of morbidity and mortality. Genetic changes may play a role in the preponderance of PE among women of African ancestry. This review discusses 30 genes with variants that have been studied in PE in women of African ancestry. These studies found that a single gene is not responsible for PE susceptibility as 13 genes have been implicated. These genes subserve endothelial, immune, hemodynamic, homeostatic, thrombophilic, oxidative stress, and lipid metabolic pathways. Notably, maternal-fetal gene interactions also contribute to the susceptibility of the disease. For instance, the maternal KIR AA genotype and paternally inherited fetal HLA-C2 genotype confer risk for developing PE. Additionally, genetic changes such as epigenetic modulation of expression of the MTHFR gene through DNA methylation is also associated with the occurrence of PE. In contrast, some genes such as the KIR B centromeric region protect against development of PE in some women. The soluble fms-like tyrosine kinase 1 (sFlt-1) contributes to the development of PE and is a potential novel therapeutic option for targeted gene silencing of anti-angiogenic sFLT-1 gene. Additionally, NOS3 gene is an important target for pharmacogenomics because it is responsible for the production of endothelial nitric oxide. In conclusion, maternal genetic and epigenetic variants confer susceptibility to PE, indicating the need for further studies to develop a screening tool incorporating maternal genetic variants to identify women at high risk for PE and offer them a preventive therapy.

Postpartum blood pressure patterns in severe preeclampsia and normotensive pregnant women following abdominal deliveries: a cohort study

Objective: To determine blood pressure (BP) patterns in the immediate postpartum period in preeclampsia with severe features (sPE) and normotensive pregnant women who had cesarean deliveries (CD).Study design: The BP levels of two groups comprising 50 sPE and 90 normotensive pregnant women who had CD were measured before delivery and on days 0-3 postpartum at four time points (05:00, 08:00, 14:00, and 22:00). Soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PIGF) were measured in the maternal serum ≤48 h before delivery.Results: Antihypertensive therapy was administered to 98, 96, 82, 78, and 56% of sPE antepartum and on postpartum days 0-3, respectively. De novo postpartum hypertension (BP ≥ 140/90 mmHg) occurred in 24.4% (22/90) of the normotensive group but only one required antihypertensive therapy. The occurrence of de novo postpartum hypertension was associated with maternal weight before delivery ≥ 84.5 kg (relative risks (RR) 2.6, CI 95% 1.2-5.8, p = .017), and body mass index before delivery ≥ 33.3 kg/m2 (RR 2.9, CI 95% 1.3-6.4, p = .008). In sPE, the BP decreased between predelivery period and postpartum day 0. From days 1 to 3 postpartum, there was a continuous increase in the daily mean BPs in both groups, with average daily increments (systolic/diastolic) being 5.6/4.6 mmHg and 0.6/1.3 mmHg in the sPE and normotensive women, respectively. Patient's group and time had a significant effect on BP, p < .001. Overall, daily mean BPs were higher in the sPE than the normotensive group (p < .001). Perceived stress (p = .022), low birth weight (p = .002), 5 min Apgar score ≤ 6 (p < .001) were significantly higher in the sPE group. sFlt-1/PIGF ratio was high in the hypertensive groups: sPE versus normotensive group, p < .001; de novo postpartum hypertension versus normotensives group that remained normotensive, p = .102.Conclusion: Postpartum BP and antihypertensive requirements are important considerations in managing sPE and normotensive pregnancies. sPE is associated with increased maternal stress and poor perinatal outcomes.

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction

there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa.

Methods

fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours.

Results

nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3.

Conclusion

a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.

The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy

BACKGROUND

The imbalance between circulating concentrations of anti- and pro-angiogenic factors is usually intense in preeclampsia with severe features (sPE). It is possible that pre-delivery circulating levels of angiogenic factors in sPE may be associated with postpartum antihypertensive drug requirements.

OBJECTIVE

To determine the predictive association between maternal pre-delivery serum concentrations of angiogenic factors and the use of ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to three following caesarean delivery.

STUDY DESIGN

Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited prior to childbirth. Serum samples were obtained from each participant < 48 hours before delivery to assess the concentrations of placental growth factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the Roche Elecsys platform. Each participant was followed up on postpartum days zero, one, two and three to monitor BP and confirm antihypertensive treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver operating characteristic curve predictive of the antihypertensive therapy were subjected to diagnostic accuracy assessment.

RESULTS

The majority 58% (29/50) of sPE had multiple severe features of preeclampsia in the antenatal period with the commonest presentation being severe hypertension in 88% (44/50) of this group, followed by features of impending eclampsia which occurred in 42% (21/50). The median gestational age at delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6) weeks, p < 0.001 in normotensive and sPE groups respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively, p < 0.001. Of the 50 sPE participants, 34% (17/50) had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early- and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37) respectively, p = 0.006. From postpartum days zero to three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50), postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow- and/or a rapid-acting antihypertensive drug on postpartum days zero, one and two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8 respectively (sensitivity 72.7-75.0%, specificity 64.7-78.6%, positive predictive value 40.0-50.0% and negative predictive value 84.6% - 94.3%). The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the sPE was not statistically significant (area under receiver operating characteristic curve, 0.6; 95% CI, 0.3-0.8).

CONCLUSION

A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug therapy in the immediate postpartum period in sPE.