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Loftness BC, Bernstein I, McBride CA, Cheney N, McGinnis EW, McGinnis RS. Preterm Preeclampsia Risk Modelling: Examining Hemodynamic, Biochemical, and Biophysical Markers Prior to Pregnancy. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.02.28.23286590. [PMID: 36945548 PMCID: PMC10029036 DOI: 10.1101/2023.02.28.23286590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
Preeclampsia (PE) is a leading cause of maternal and perinatal death globally and can lead to unplanned preterm birth. Predicting risk for preterm or early-onset PE, has been investigated primarily after conception, and particularly in the early and mid-gestational periods. However, there is a distinct clinical advantage in identifying individuals at risk for PE prior to conception, when a wider array of preventive interventions are available. In this work, we leverage machine learning techniques to identify potential pre-pregnancy biomarkers of PE in a sample of 80 women, 10 of whom were diagnosed with preterm preeclampsia during their subsequent pregnancy. We explore biomarkers derived from hemodynamic, biophysical, and biochemical measurements and several modeling approaches. A support vector machine (SVM) optimized with stochastic gradient descent yields the highest overall performance with ROC AUC and detection rates up to .88 and .70, respectively on subject-wise cross validation. The best performing models leverage biophysical and hemodynamic biomarkers. While preliminary, these results indicate the promise of a machine learning based approach for detecting individuals who are at risk for developing preterm PE before they become pregnant. These efforts may inform gestational planning and care, reducing risk for adverse PE-related outcomes.
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Affiliation(s)
| | - Ira Bernstein
- University of Vermont (UVM), Burlington, VT 05405 USA
- UVM Medical Center, Burlington, VT 05405 USA
| | | | - Nick Cheney
- University of Vermont (UVM), Burlington, VT 05405 USA
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Gokina NI, Fairchild RI, Prakash K, DeLance NM, Bonney EA. Deficiency in CD4 T Cells Leads to Enhanced Postpartum Internal Carotid Artery Vasoconstriction in Mice: The Role of Nitric Oxide. Front Physiol 2021; 12:686429. [PMID: 34220551 PMCID: PMC8242360 DOI: 10.3389/fphys.2021.686429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Accepted: 05/10/2021] [Indexed: 11/13/2022] Open
Abstract
The risk of postpartum (PP) stroke is increased in complicated pregnancies. Deficiency in CD4 T cell subsets is associated with preeclampsia and may contribute to PP vascular disease, including internal carotid artery (ICA) stenosis and stroke. We hypothesized that CD4 T cell deficiency in pregnancy would result in ICA dysregulation, including enhanced ICA vasoconstriction. We characterized the function, mechanical behavior, and structure of ICAs from C57BL/6 (WT) and CD4 deficient (CD4KO) mice, and assessed the role of NO in the control of ICA function at pre-conception and PP. WT and CD4KO mice were housed under pathogen-free conditions, mated to same-strain males, and allowed to litter or left virgin. At 3 days or 4 weeks PP, mice were euthanized. The responses to phenylephrine (PE), high K+ and acetylcholine (ACh) were assessed in pressurized ICAs before and after NOS inhibition. Passive lumen diameters were measured at 3–140 mmHg. eNOS and iNOS expression as well as the presence of T cells were evaluated by immunohistochemistry. Constriction of WT ICAs to PE was not modified PP. In contrast, responses to PE were significantly increased in ICAs from PP as compared to virgin CD4KO mice. Constriction to high K+ was not enhanced PP. ICAs from WT and CD4KO mice were equally sensitive to ACh with a significant rightward shift of dose-response curves after L-NNA treatment. NOS inhibition enhanced PE constriction of ICAs from WT virgin and PP mice. Although a similar effect was detected in ICAs of virgin CD4KO mice, no such changes were observed in vessels from PP CD4KO mice. Passive arterial distensibility at physiological levels of pressure was not modified at PP. ICA diameters were significantly increased in PP with no change in vascular wall thickness. Comparison of eNOS expression in virgin, 3 days and 4 weeks PP revealed a reduced expression in ICA from CD4 KO vs. WT PP vessels which reached significance at 4 weeks PP. iNos expression was similar and decreased over the PP period in vessels from WT and CD4KO mice. Dysregulation of the CD4 T cell population in pregnancy may make ICA vulnerable to vasospasm due to decreased NO-dependent control of ICA constriction. This may lead to cerebral hypoperfusion and increase the risk of maternal PP stroke.
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Affiliation(s)
- Natalia I Gokina
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Rebecca I Fairchild
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Kirtika Prakash
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Nicole M DeLance
- Microscopy Imaging Center, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
| | - Elizabeth A Bonney
- Department of Obstetrics, Gynecology and Reproductive Sciences, Larner College of Medicine, The University of Vermont, Burlington, VT, United States
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Gokina NI, Fairchild RI, Bishop NM, Dawson TE, Prakash K, Bonney EA. Kinetics of Postpartum Mesenteric Artery Structure and Function Relative to Pregnancy and Lactation in Mice. Reprod Sci 2021; 28:1200-1215. [PMID: 33415648 PMCID: PMC7935827 DOI: 10.1007/s43032-020-00402-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022]
Abstract
Epidemiological evidence suggests that normal pregnancy in women is associated with decreased cardiovascular risk in later life. Clinical studies have provided evidence that alterations in vascular function and structure are detectable long after delivery. To understand these findings, we examined mesenteric artery reactivity at both early (3 days and 2–4 weeks) and late (12 weeks) postpartum (PP) time points in relation to late pregnancy (LP) and lactation. Vessels from virgin controls, LP, PP, and nursing and non-nursing mothers were tested for responses to phenylephrine (PE), high potassium solutions (high K+), and acetylcholine (ACh). Passive arterial distensibility, vessel dimensions, and collagen and elastin content were evaluated for the studied groups. We observed that (1) there was a significant inhibition of vascular reactivity to PE in LP, 3 days and 2 weeks PP vessels that returned to pre-pregnancy levels at 4 and 12 weeks PP; (2) inhibition of NO production in PP vessels restored PE-induced constriction to pre-pregnancy levels; (3) vasodilator responses to ACh were similar at all PP periods; (4) LP and early PP was associated with a persistent increase in arterial distensibility that correlates with a PP-induced reduction in wall collagen, and regressed to pre-conception levels at 12 weeks PP; (5) vessels from non-nursing PP mice demonstrated an increased PE reactivity, diminished responses to ACh, and reduced distensibility compared to breastfeeding mice. These studies provide a timeframe for mesenteric artery adaptations that occur during pregnancy and extend to the PP period, but which may be modified by PP events.
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Affiliation(s)
- Natalia I Gokina
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Larner College of Medicine, Given Building, 89 Beaumont Avenue, Burlington, VT, 05405, USA.
| | - Rebecca I Fairchild
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Larner College of Medicine, Given Building, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Nicole M Bishop
- Microscopy Imaging Center, University of Vermont, Larner College of Medicine, 149 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Taylor E Dawson
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Larner College of Medicine, Given Building, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Kirtika Prakash
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Larner College of Medicine, Given Building, 89 Beaumont Avenue, Burlington, VT, 05405, USA
| | - Elizabeth A Bonney
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Larner College of Medicine, Given Building, 89 Beaumont Avenue, Burlington, VT, 05405, USA
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Affiliation(s)
- Kent L. Thornburg
- Department of MedicineSchool of MedicineOregon Health and Science UniversityPortlandOR
- Knight Cardiovascular InstituteSchool of MedicineOregon Health and Science UniversityPortlandOR
- Bob and Charlee Moore Institute for Nutrition and WellnessSchool of MedicineOregon Health and Science UniversityPortlandOR
- Department of Chemical Physiology and BiochemistrySchool of MedicineOregon Health and Science UniversityPortlandOR
- Department of Obstetrics and GynecologySchool of MedicineOregon Health and Science UniversityPortlandOR
| | - Rachel Drake
- Knight Cardiovascular InstituteSchool of MedicineOregon Health and Science UniversityPortlandOR
- Department of Chemical Physiology and BiochemistrySchool of MedicineOregon Health and Science UniversityPortlandOR
| | - Amy M. Valent
- Department of Obstetrics and GynecologySchool of MedicineOregon Health and Science UniversityPortlandOR
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Osol G, Ko NL, Mandalà M. Altered Endothelial Nitric Oxide Signaling as a Paradigm for Maternal Vascular Maladaptation in Preeclampsia. Curr Hypertens Rep 2017; 19:82. [PMID: 28942512 DOI: 10.1007/s11906-017-0774-6] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to present the newest insights into what we view as a central failure of cardiovascular adaptation in preeclampsia (PE) by focusing on one clinically significant manifestation of maternal endothelial dysfunction: nitric oxide signaling. The etiology, symptoms, and current theories of the PE syndrome are described first, followed by a review of the available evidence, and underlying causes of reduced endothelial nitric oxide (NO) signaling in PE. RECENT FINDINGS PE maladaptations include, but are not limited to, altered physiological stimulatory inputs (e.g., estrogen; VEGF/PlGF; shear stress) and substrates (L-Arg; ADMA), augmented placental secretion of anti-angiogenic and inflammatory factors such as sFlt-1 and Eng, changes in eNOS (polymorphisms, expression), and reduced bioavailability of NO secondary to oxidative stress. PE is a complex obstetrical syndrome that is associated with maternal vascular dysfunction. Diminished peripheral endothelial vasodilator influence in general, and of NO signaling specifically, are key in driving disease progression and severity.
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Affiliation(s)
- George Osol
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont College of Medicine, Given H.S.C. C-217A 89 Beaumont Ave, Burlington, VT, 5405, USA.
| | - Nga Ling Ko
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont College of Medicine, Given H.S.C. C-217A 89 Beaumont Ave, Burlington, VT, 5405, USA
| | - Maurizio Mandalà
- Department of Biology, Ecology and Earth Science, University of Calabria, Cosenza, Italy
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Howe L, Hammer E, Badger G, Bernstein IM. Effect of Pregnancy Interval on Second Pregnancy Blood Pressure Following Prior Preeclampsia. Reprod Sci 2017; 25:727-732. [PMID: 28826367 DOI: 10.1177/1933719117725815] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Preeclampsia generally occurs in first pregnancies and tends not to recur when the interpregnancy interval (IPI) is short. We hypothesized that, in women experiencing preeclampsia in their first pregnancy, the difference in mean arterial pressure (MAP) across pregnancy between their index and subsequent pregnancy would be inversely associated with the length of time between pregnancies and that the interval between pregnancies will be directly associated with the likelihood of preeclampsia recurrence. METHODS This was a retrospective chart review evaluating 171 women diagnosed with preeclampsia during their first pregnancy who had a subsequent pregnancy at our institution. Blood pressures were collected from each pregnancy, marking the recurrence of hypertensive disorders, including preeclampsia. Antepartum MAP was compared between pregnancies, examining differences as a function of IPI. RESULTS There was a significant association of IPI with the reduction in MAP between pregnancies across trimesters ( P = .04), but this reduction became smaller over time. The MAP during the third trimester decreased significantly between pregnancies across all patient groups (IPI <24 months: -5.7 mm Hg, P < .0001; IPI 24-48 months: -4.5 mm Hg, P < .0001; IPI >48 months -3.4 mm Hg, P = .03). The recurrence rate of preeclampsia did not vary significantly with IPI ( P = .21). CONCLUSION The IPI influences the MAP of the second pregnancy in women with prior preeclampsia. Shorter IPI is associated with a greater reduction in MAP when compared to the longer IPI. Although there was a trend toward higher preeclampsia recurrence with longer IPI, this trend did not reach statistical significance.
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Affiliation(s)
- Lindsay Howe
- 1 Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA
| | - Erica Hammer
- 1 Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA
| | - Gary Badger
- 2 Department of Medical Biostatistics, University of Vermont, Burlington, VT, USA
| | - Ira M Bernstein
- 1 Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT, USA
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Emerging role for dysregulated decidualization in the genesis of preeclampsia. Placenta 2017; 60:119-129. [PMID: 28693893 DOI: 10.1016/j.placenta.2017.06.005] [Citation(s) in RCA: 85] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/10/2017] [Accepted: 06/07/2017] [Indexed: 12/31/2022]
Abstract
In normal human placentation, uterine invasion by trophoblast cells and subsequent spiral artery remodeling depend on cooperation among fetal trophoblasts and maternal decidual, myometrial, immune and vascular cells in the uterine wall. Therefore, aberrant function of anyone or several of these cell-types could theoretically impair placentation leading to the development of preeclampsia. Because trophoblast invasion and spiral artery remodeling occur during the first half of pregnancy, the molecular pathology of fetal placental and maternal decidual tissues following delivery may not be informative about the genesis of impaired placentation, which transpired months earlier. Therefore, in this review, we focus on the emerging prospective evidence supporting the concept that deficient or defective endometrial maturation in the late secretory phase and during early pregnancy, i.e., pre-decidualization and decidualization, respectively, may contribute to the genesis of preeclampsia. The first prospectively-acquired data directly supporting this concept were unexpectedly revealed in transcriptomic analyses of chorionic villous samples (CVS) obtained during the first trimester of women who developed preeclampsia 5 months later. Additional supportive evidence arose from investigations of Natural Killer cells in first trimester decidua from elective terminations of women with high resistance uterine artery indices, a surrogate for deficient trophoblast invasion. Last, circulating insulin growth factor binding protein-1, which is secreted by decidual stromal cells was decreased during early pregnancy in women who developed preeclampsia. We conclude this review by making recommendations for further prospectively-designed studies to corroborate the concept of endometrial antecedents of preeclampsia. These studies could also enable identification of women at increased risk for developing preeclampsia, unveil the molecular mechanisms of deficient or defective (pre)decidualization, and lead to preventative strategies designed to improve (pre)decidualization, thereby reducing risk for preeclampsia development.
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Bernstein IM, Hale SA, Badger GJ, McBride CA. Differences in cardiovascular function comparing prior preeclamptics with nulliparous controls. Pregnancy Hypertens 2016; 6:320-326. [PMID: 27939476 DOI: 10.1016/j.preghy.2016.07.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 06/30/2016] [Accepted: 07/04/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The objective of the current study was to evaluate cardiovascular function; including blood pressure, cardiac output, pulse wave velocity and vascular compliance in nonpregnant nulliparous women compared to women with a history of preterm preeclampsia. STUDY DESIGN This was a case control study. Blood pressure was measured using the Finapres Pro. Baseline cardiac output was determined by echocardiography. Pulse wave velocity was estimated using simultaneous electrocardiographic tracings and ultrasound determined arterial flow waveforms and calculated as estimated distance divided by the time interval between EKG r-wave peak and ultrasound derived peak popliteal artery flow. During volume challenge, 500mL of lactated Ringers solution was infused through an indwelling antecubital catheter over 10min. Cardiac output and blood pressure during and 15min after the infusion were estimated using the Finapres Pro. MAIN OUTCOME MEASURES Indices of arterial stiffness and vascular compliance. RESULTS Previous preeclamptics exhibited a significant increase in pulse pressure and cardiac output in response to volume challenge when compared with nulliparous controls. Prior preeclamptics had a strong positive correlation between blood pressure indices (r=0.50-0.68, p⩽0.01) and pulse pressure (r=0.58, P=0.008) with pulse wave velocity that was not evident in control women. CONCLUSIONS In women with prior preterm preeclampsia a relationship between blood pressure, intravascular volume and arterial stiffness, is evident in the nonpregnant state and in the absence of hypertension or overt cardiovascular disease. This supports an overarching hypothesis that nonpregnant physiology is an important contributor to pregnancy adaptations.
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Affiliation(s)
- Ira M Bernstein
- Obstetrics, Gynecology and Reproductive Sciences, 89 Beaumont Ave, University of Vermont, Burlington, VT 05405, United States.
| | - Sarah A Hale
- Obstetrics, Gynecology and Reproductive Sciences, 89 Beaumont Ave, University of Vermont, Burlington, VT 05405, United States
| | - Gary J Badger
- Department of Medical Biostatistics, University of Vermont, Burlington, VT 05405, United States
| | - Carole A McBride
- Obstetrics, Gynecology and Reproductive Sciences, 89 Beaumont Ave, University of Vermont, Burlington, VT 05405, United States
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Ali SMJ, Khalil RA. Genetic, immune and vasoactive factors in the vascular dysfunction associated with hypertension in pregnancy. Expert Opin Ther Targets 2015; 19:1495-515. [PMID: 26294111 DOI: 10.1517/14728222.2015.1067684] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Preeclampsia (PE) is a major complication of pregnancy that could lead to maternal and fetal morbidity and mortality. The pathophysiological mechanisms of PE are not completely understood, but recent research has begun to unravel some of the potential mechanisms. AREAS COVERED Genetic polymorphisms and altered maternal immune response may cause impaired remodeling of the spiral arteries; a potential early defect in PE. Inadequate invasion of cytotrophoblasts into the decidua leads to reduced uteroplacental perfusion pressure (RUPP) and placental ischemia/hypoxia. Placental ischemia causes the release of biologically active factors such as anti-angiogenic factors, inflammatory cytokines, reactive oxygen species, hypoxia-inducible factors, and angiotensin II receptor autoantibodies. These vasoactive factors could cause systemic vascular endotheliosis and consequent increase in vascular resistance and blood pressure, glomerular endotheliosis causing proteinuria, cerebrovascular endotheliosis causing cerebral edema, seizures and visual disturbances, and hepatic endotheliosis, which may contribute to the manifestations of HELLP syndrome. PE-associated vascular endotheliosis causes a decrease in vasodilator mediators such as nitric oxide, prostacyclin and endothelium-derived hyperpolarizing factor, an increase in vasoconstrictors such as endothelin-1, angiotensin II and thromboxane A2, and enhanced mechanisms of vascular smooth muscle contraction such as intracellular Ca(2+), protein kinase C and Rho-kinase. Changes in matrix metalloproteinase activity and extracellular matrix cause vascular remodeling and further vasoconstriction. EXPERT OPINION Some of the genetic, immune and vasoactive factors involved in vascular endotheliosis could be used as biomarkers for early detection, and as potential targets for prevention and treatment of PE.
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Affiliation(s)
- Sajjadh M J Ali
- a Brigham and Women's Hospital, Vascular Surgery Research Laboratory, Harvard Medical School, Division of Vascular and Endovascular Surgery , Boston, MA, USA +1 617 525 8530 ; +1 617 264 5124 ;
| | - Raouf A Khalil
- a Brigham and Women's Hospital, Vascular Surgery Research Laboratory, Harvard Medical School, Division of Vascular and Endovascular Surgery , Boston, MA, USA +1 617 525 8530 ; +1 617 264 5124 ;
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Morris EA, Hale SA, Badger GJ, Magness RR, Bernstein IM. Pregnancy induces persistent changes in vascular compliance in primiparous women. Am J Obstet Gynecol 2015; 212:633.e1-6. [PMID: 25576820 DOI: 10.1016/j.ajog.2015.01.005] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 12/01/2014] [Accepted: 01/05/2015] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Pregnancy induces rapid, progressive, and substantial changes to the cardiovascular system. The low recurrence risk of preeclampsia, despite familial predisposition, suggests an adaptation associated with pregnancy that attenuates the risk for subsequent preeclampsia. We aimed to evaluate the persistent effect of pregnancy on maternal cardiovascular physiology. STUDY DESIGN Forty-five healthy nulliparous women underwent baseline cardiovascular assessment before conception and repeated an average of 30 months later. After baseline evaluation, 17 women conceived singleton pregnancies and all delivered at term. The remaining 28 women comprised the nonpregnant control group. We measured mean arterial blood pressure, cardiac output, plasma volume, pulse wave velocity, uterine blood flow, and flow-mediated vasodilation at each visit. RESULTS There was a significant decrease in mean arterial pressure from the prepregnancy visit to postpartum in women with an interval pregnancy (prepregnancy, 85.3±1.8; postpartum, 80.5±1.8 mm Hg), with no change in nonpregnant control subjects (visit 1, 80.3±1.4; visit 2, 82.8±1.4 mm Hg) (P=.002). Pulse wave velocity was significantly decreased in women with an interval pregnancy (prepregnancy, 2.73±0.05; postpartum, 2.49±0.05 m/s), as compared with those without an interval pregnancy (visit 1, 2.56±0.04; visit 2, 2.50±0.04 m/s) (P=.005). We did not observe a residual effect of pregnancy on cardiac output, plasma volume, uterine blood flow, or flow-mediated vasodilation. CONCLUSION Our observations of decreased mean arterial pressure and reduced arterial stiffness following pregnancy suggest a significant favorable effect of pregnancy on maternal cardiovascular remodeling. These findings may represent a mechanism by which preeclampsia risk is reduced in subsequent pregnancies.
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Zenclussen ML, Linzke N, Schumacher A, Fest S, Meyer N, Casalis PA, Zenclussen AC. Heme oxygenase-1 is critically involved in placentation, spiral artery remodeling, and blood pressure regulation during murine pregnancy. Front Pharmacol 2015; 5:291. [PMID: 25628565 PMCID: PMC4292788 DOI: 10.3389/fphar.2014.00291] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 12/15/2014] [Indexed: 12/26/2022] Open
Abstract
The onset of pregnancy implies the appearance of a new organ, the placenta. One main function of the placenta is to supply oxygen to the fetus via hemoproteins. In this review, we highlight the importance of the enzyme heme oxygenase-1 (HO-1) for pregnancy to be established and maintained. HO-1 expression is pivotal to promote placental function and fetal development, thus determining the success of pregnancy. The deletion of the gene Hmox1 in mice leads to inadequate remodeling of spiral arteries and suboptimal placentation followed by intrauterine growth restriction (IUGR) and fetal lethality. A partial Hmox1 deletion leads to IUGR as well, with heterozygote and wild-type fetuses being born, but Hmox1 (-/-) significantly below the expected Mendelian rate. This strong phenotype is associated with diminished number of pregnancy-protective uterine natural killer (uNK) cells. Pregnant heterozygote females develop gestational hypertension. The protective HO-1 effects on placentation and fetal growth can be mimicked by the exogenous administration of carbon monoxide (CO), a product of heme catalyzed by HO-1. CO application promotes the in situ proliferation of uNK cells, restores placentation and fetal growth, while normalizing blood pressure. Similarly, HO-1 inhibition provokes hypertension in pregnant rats. The HO-1/CO axis plays a pivotal role in sustaining pregnancy and aids in the understanding of the biology of pregnancy and reveals a promising therapeutic application in the treatment of pregnancy complications.
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Affiliation(s)
- Maria L Zenclussen
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Nadja Linzke
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Anne Schumacher
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Stefan Fest
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Nicole Meyer
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Pablo A Casalis
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
| | - Ana C Zenclussen
- Experimental Obstetrics and Gynecology, Medical Faculty, Otto-von-Guericke University Magdeburg, Magdeburg , Germany
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Osol G, Bernstein I. Preeclampsia and maternal cardiovascular disease: consequence or predisposition? J Vasc Res 2014; 51:290-304. [PMID: 25300258 DOI: 10.1159/000367627] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2014] [Accepted: 08/13/2014] [Indexed: 11/19/2022] Open
Abstract
Formerly preeclamptic women stand a higher chance of developing cardiovascular disease (CVD) later in life and may experience a shortened life span. This review updates the pathophysiology and definition of this complex disease and highlights the protective role of pregnancy by considering the relationship between pregnancy interval and likelihood of disease recurrence. The evidence for persistent maternal cardiovascular impairment following preeclampsia (PE) is considered, e.g. postpartum changes in CVD occurrence, blood pressure elevation and changes in the renin-angiotensin-aldosterone system). Since maternal endothelial dysfunction is a hallmark of PE, we summarize the evidence for reduced flow-mediated dilation in women with previous PE, and consider the utility and shortcomings of this clinical measure. In addition to viewing postpartum changes as a consequence of this disease, we consider the alternative view that PE might be the manifestation of a maternal phenotype that already has some predisposition to or is in the earlier stages of CVD; in this case, some of the postpartum residual deficits (or their antecedents) may have already been present prior to pregnancy. Finally, we consider the use of novel biomarkers for predicting or detecting PE prior to the appearance of clinical symptoms.
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Affiliation(s)
- George Osol
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vt., USA
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McBride CA, Hale SA, Subramanian M, Badger GJ, Bernstein IM. The relationship of a family history for hypertension, myocardial infarction, or stroke with cardiovascular physiology in young women. Reprod Sci 2013; 21:509-16. [PMID: 24023034 DOI: 10.1177/1933719113503402] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiovascular disease (CVD) and preeclampsia share several pathophysiologic risk factors. We examined family history (FH) and physiologic status in 60 healthy, nulliparous women to determine the relationship between FH and known risk factors for CVD. Data are presented as mean ± standard error (SE). Decreased uterine blood flow was observed in women with FH of hypertension (+FH: 21.5 ± 1.7, no FH: 33.3 ± 9.0 mL/min; P = .04). Women reporting an FH of stroke showed increased alpha- and beta-adrenergic response, as measured by Valsalva maneuver (α: FH: 24.7 ± 1.9, -FH: 18.9 ± 1.1 mm Hg, P = .02; β: FH: 22.0 ± 2.1, -FH: 16.9 ± 1.4 mm Hg; P = .04), and increased cardiac output (4.83 ± 0.22 vs 4.31 ± 0.12 L/min; P = .01). We identified no significant physiologic associations linked to an FH of myocardial infarction. Our observations show significant differences in physiologic characteristics in women with specific CVD family histories. These data, coupled with known heritable contributions to CVD and preeclampsia, suggest a distinct physiologic phenotype that may link preeclampsia risk with FH of CVD, independent of pregnancy.
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Affiliation(s)
- Carole A McBride
- 1University of Vermont, Departments of Obstetrics, Gynecology and Reproductive Sciences, Burlington, VT, USA
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Hale SA, Badger GJ, McBride C, Magness R, Bernstein IM. Prepregnancy Vascular Dysfunction in Women who Subsequently Develop Hypertension During Pregnancy. Pregnancy Hypertens 2013; 3:140-145. [PMID: 23772359 DOI: 10.1016/j.preghy.2013.01.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate vascular dysfunction using both physiologic measures and biochemical markers, longitudinally, prior to and during pregnancy, in nulliparous women who had uncomplicated pregnancies compared to those who developed complicated hypertension during pregnancy. METHODS Twenty healthy nulliparous women were studied during the follicular phase and in early (EP) and late (LP) pregnancy. All had singleton conceptions and delivered at term, seventeen with uncomplicated pregnancies (NP) and three who developed complicated hypertension (HP) after the LP evaluation. We compared prepregnancy, EP and LP pulse wave velocity (PWV) and soluble vascular cell adhesion molecule (sVCAM-1) between the NP and HP groups. PWV was measured using ultrasound and simultaneous echocardiogram tracing then calculated as the estimated distance divided by interval between EKG r-wave peak and peak brachial artery flow. SVCAM-1 was measured using a commercially available kit. Data are means ± SE, significance accepted as p < 0.05. RESULTS The NP group had significantly lower prepregnant PWV (NP: 2.66 ± 0.06 m/s, HP: 3.00 ± 0.04, p=.02), but PWV was not different at the EP or LP time points. SVCAM-1 was significantly lower prior to pregnancy and during EP and LP in the NP group (Prepregnancy: NP: 712 ± 32 ng/mL, HP: 1058 ± 107, p < .001; EP: NP: 695 ± 31 ng/mL, HP: 924 ± 52, p = .004; LP: NP: 663 ± 25 ng/mL, HP: 946 ± 36, p < .001). CONCLUSIONS PWV and sVCAM-1 may be important prepregnancy discriminators useful in assessing risk for preeclampsia prior to pregnancy.
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Affiliation(s)
- Sarah A Hale
- Obstetrics, Gynecology and Reproductive Sciences, 89 Beaumont Ave, University of Vermont, Burlington, VT, United States, 05405
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Shroff MR, Holzman C, Tian Y, Evans RW, Sikorskii A. Mid-pregnancy maternal leptin levels, birthweight for gestational age and preterm delivery. Clin Endocrinol (Oxf) 2013; 78:607-13. [PMID: 22934578 PMCID: PMC4004085 DOI: 10.1111/cen.12029] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2012] [Revised: 08/19/2012] [Accepted: 08/23/2012] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Maternal blood leptin levels are positively associated with adiposity. Recent studies suggest that leptin is also abundantly produced by the placenta and may function as a regulator of foetal growth. Our goal was to examine mid-pregnancy levels of leptin in maternal blood in relation to birthweight for gestational age (BW/GA) and timing of delivery after accounting for maternal prepregnancy body mass index (prepreg-BMI) and pregnancy complications. PATIENTS Data were from 1304 subcohort mother/infant pairs who participated in the Pregnancy Outcomes and Community Health (POUCH) Study (1998-2004). MEASUREMENTS Leptin levels, measured at 16-27 weeks' gestation, were log-transformed. Geometric mean (GMean) leptin levels were estimated by weighted linear regression with gestational age at blood draw as a covariate. GMean was re-transformed to the original scale for reporting. RESULTS Using the GMeans leptin in mothers of term appropriate-for-gestational age (AGA) neonates as the referent (25·2 μg/l), we observed lower levels in mothers of preterm-AGA (21·9 μg/l), term small-for-gestational age (SGA) (20·3 μg/l) and preterm-SGA neonates (21·7 μg/l). Results were largely unchanged after adjustment for prepreg-BMI. Leptin levels were higher in mothers who delivered large-for-gestational age (LGA) neonates, both preterm (33·6 μg/l) and term (29·1 μg/l), but the GMeans were markedly attenuated after adjustment for prepreg-BMI. CONCLUSION The association between BW/GA and maternal leptin levels after adjustment for prepreg-BMI may represent: (i) a residual effect of maternal adiposity that is not fully captured by BMI; and/or (ii) variation in placental leptin levels entering the maternal circulation. In conclusion, mid-pregnancy maternal blood leptin levels may be an early indicator of foetal growth status.
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Bonney EA. Demystifying animal models of adverse pregnancy outcomes: touching bench and bedside. Am J Reprod Immunol 2013; 69:567-84. [PMID: 23448345 DOI: 10.1111/aji.12102] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 01/28/2013] [Indexed: 01/21/2023] Open
Abstract
This represents an overview of the use of animal models to study the adverse pregnancy outcomes seen in humans. The purpose is to entice clinicians to utilize some of this information to seek out the literature and have more meaningful and profitable discussions with their academic colleagues and enhance transdisciplinary research in reproductive health.
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Affiliation(s)
- Elizabeth A Bonney
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont College of Medicine, Burlington, VT, USA.
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Gyselaers W, Peeters L. Physiological implications of arteriovenous anastomoses and venous hemodynamic dysfunction in early gestational uterine circulation: a review. J Matern Fetal Neonatal Med 2013; 26:841-6. [DOI: 10.3109/14767058.2013.766705] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Mandala M, Osol G. Physiological Remodelling of the Maternal Uterine Circulation during Pregnancy. Basic Clin Pharmacol Toxicol 2011; 110:12-8. [DOI: 10.1111/j.1742-7843.2011.00793.x] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Phillips JK, Janowiak M, Badger GJ, Bernstein IM. Evidence for distinct preterm and term phenotypes of preeclampsia. J Matern Fetal Neonatal Med 2010; 23:622-6. [PMID: 20482241 DOI: 10.3109/14767050903258746] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine differences in maternal and fetal characteristics in pregnancies complicated by preterm versus term preeclampsia. METHODS Using our electronic database we identified 143 women who met the American College of Obstetricians and Gynecologists criteria for preeclampsia between January 1995 and August 2003. We collected data on age, smoking status, maternal serum markers, and newborns. We compared the group delivering preterm (<37 weeks) with those delivering at term (> or =37 weeks). Analyses were based on ANOVA, Wilcoxon Rank Sum test, and chi-square test. Statistical significance was determined based on alpha = 0.05. Data are expressed as mean +/- SD unless otherwise indicated. RESULTS Eighty women delivered preterm and 63 delivered at term. Women who delivered preterm with preeclampsia were younger, lighter, and were more likely to smoke cigarettes than those delivering at term with preeclampsia. Maternal liver enzyme concentrations were significantly greater in the preterm group. Newborn birthweight percentile (gestational age specific) was significantly lower for preterm preeclampsia. We found no significant differences in maternal platelet count, uric acid concentration, or newborn gender between groups. CONCLUSIONS Differences exist in maternal and fetal characteristics between women who develop preterm preeclampsia and those who develop preeclampsia at term. These data support the hypothesis that multiple preeclamptic phenotypes exist.
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Affiliation(s)
- Julie K Phillips
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Vermont, Fletcher Allen Health Care, 111 Colchester Avenue, Burlington, Vermont, USA.
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Hale S, Choate M, Schonberg A, Shapiro R, Badger G, Bernstein IM. Pulse pressure and arterial compliance prior to pregnancy and the development of complicated hypertension during pregnancy. Reprod Sci 2010; 17:871-7. [PMID: 20639475 DOI: 10.1177/1933719110376545] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
We examined the relationship between prepregnant pulse pressure (PP), mean arterial pressure (MAP), cardiac output (CO)/PP, a measure of arterial compliance, and development of complicated hypertension (CH) during pregnancy with the goal of identifying a potential predictor of CH. Twenty nulliparous participants were studied before pregnancy; 17 had normal pregnancies (control; CTL) and 3 CH. Blood pressure monitoring was performed using tonometry. Cardiac output was determined by Doppler echocardiograph. Data are expressed as mean +/- SD. Prepregnant PP was significantly higher in CH participants (CH: 58.3 +/- 6.3, CTL: 46.2 +/- 1.7 mm Hg; P = .02). Cardiac output /pulse pressure was significantly lower in CH participants (CH: 6.9 +/- 1.8, CTL: 10.6 +/- 2.8; P = .04). Mean arterial pressure was not significantly different. Increased PP before pregnancy may suggest increased risk for CH. With accurate prediction of CH before pregnancy, initiation of preventative measures could begin earlier, either prior to or in early pregnancy, potentially increasing preventative efficacy and decreasing CH.
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Affiliation(s)
- Sarah Hale
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Vermont, Burlington, VT 05405, USA
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Bernstein IM, Damron D, Schonberg AL, Sallam RM, Shapiro R. The relationship of plasma volume, sympathetic tone, and proinflammatory cytokines in young healthy nonpregnant women. Reprod Sci 2009; 16:980-5. [PMID: 19531800 PMCID: PMC2874877 DOI: 10.1177/1933719109338876] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Preeclampsia has been associated with elevated proinflammatory markers, increased sympathetic activity, and decreased plasma volume (PV). We hypothesized that these associations would be identified in women prior to a first pregnancy. METHODS We studied 76 healthy nulligravid participants measuring the proinflammatory markers C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor alpha (TNF-alpha). Plasma volume was measured in supine position and corrected for body mass index (BMI). We examined supine plasma levels of epinephrine and norepinephrine and blood pressure response to Valsalva maneuver to quantify sympathetic activation. We then examined the association of PV and sympathetic activity with proinflammatory cytokines with P < .05 accepted for significance. RESULTS CRP was significantly increased in participants with lowest PV/BMI quartile when compared to middle 2 quartiles and highest quartile (analysis of variance [ANOVA], P = .037). We found no significant association of PV/BMI with either IL-6 or TNF-alpha. Both plasma epinephrine concentration (r = .29, P = .02) and the late phase II (phase II_L) blood pressure response to Valsalva maneuver (r = .44, P < .0001) were associated with serum IL-6 concentrations. CONCLUSIONS Low PV is associated with increased CRP levels and increased sympathetic tone is linked to elevated IL-6 concentration in young nonpregnant women. These findings represent elements of a nonpregnancy phenotype that parallels the findings observed in preeclampsia and in women at risk for ischemic cardiovascular disease. This suggests that the relationships observed during preeclampsia, which have been associated with placental pathology, may predate pregnancy and be independent of placental activity.
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Affiliation(s)
- Ira M Bernstein
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont 05405, USA.
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Mikolajczyk RT, Zhang J, Ford J, Grewal J. Effects of interpregnancy interval on blood pressure in consecutive pregnancies. Am J Epidemiol 2008; 168:422-6. [PMID: 18495629 DOI: 10.1093/aje/kwn115] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The lower risk of preeclampsia observed in parous women has prompted a hypothesis that cardiovascular adaptation from a first pregnancy has ongoing benefits which contribute to a reduced risk of preeclampsia in the second pregnancy. However, how the interpregnancy interval affects mean arterial pressure (MAP) as an indicator of cardiovascular adaptation in subsequent pregnancies has not been well studied. The authors examined the effect of interpregnancy interval on MAP in consecutive pregnancies using data from the Collaborative Perinatal Project (1959-1965) and a semiparametric random-effects regression model. Prenatal MAP measurements were available for 533 women with both first and second births. MAP was lower in the second pregnancy (by approximately 2 mmHg) for very short interpregnancy intervals. However, this difference diminished when the interval increased, and it totally disappeared for intervals longer than 2 years. The authors conclude that although MAP is lower in the second pregnancy than in the first pregnancy, the effect persists for only a short time. It is therefore unlikely that mechanisms involving MAP as an indicator of cardiovascular adaptation contribute appreciably to the reduced risk of preeclampsia in subsequent pregnancies. However, it does not rule out the possibility that other mechanisms of cardiovascular adaptation persist longer.
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Affiliation(s)
- Rafael T Mikolajczyk
- Epidemiology Branch, National Institute of Child Health and Human Development, Bethesda, MD 20892, USA
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Bonney EA. Preeclampsia: a view through the danger model. J Reprod Immunol 2007; 76:68-74. [PMID: 17482268 PMCID: PMC2246056 DOI: 10.1016/j.jri.2007.03.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 03/11/2007] [Accepted: 03/14/2007] [Indexed: 11/22/2022]
Abstract
Classical thinking suggests that the immune system undergoes activation on the basis of discrimination between 'self' and 'non-self'. Accordingly, the fetus activates the mother's immune system because the fetus is in part 'non-self'. Thus, successful pregnancy depends on constraint of maternal immunity. Preeclampsia is an outcome of lost constraint. Instead, the danger model suggests that normal pregnancy, regardless of the expression of 'non-self' antigens, does not activate the maternal immune system unless that pregnancy expresses danger signals. Thus, preeclampsia stems from stress or abnormal cell death in pregnancy-related tissues. This compels expression of specific danger signals and potential activation of anti-fetal immunity, which secondarily feeds the syndrome. Study of preeclampsia from this perspective may bring forth novel mechanisms and indicators of vascular and metabolic dysfunction during pregnancy.
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Affiliation(s)
- Elizabeth A Bonney
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Given Building, Room C-244, 89 Beaumont Avenue, Burlington, VT 05405, USA.
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Phillips JK, Bernstein IM, Mongeon JA, Badger GJ. Seasonal Variation in Preeclampsia Based on Timing of Conception. Obstet Gynecol 2004; 104:1015-20. [PMID: 15516394 DOI: 10.1097/01.aog.0000143306.88438.cf] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Studies have suggested that the incidence of preeclampsia may be partially dependent on the month or season of delivery. We sought to evaluate whether preeclampsia occurs seasonally in our population and whether the timing of conception or delivery is more strongly associated with risk. METHODS Between January 1995 and August 2003, we identified 142 primiparous women with singleton pregnancies who met the American College of Obstetricians and Gynecologists' definition for preeclampsia and compared them with 7,762 primiparous control deliveries. We analyzed rates of preeclampsia by individual month and 3-month seasonal blocks based on conception and delivery. Data were analyzed with the chi2 test, and logistic regression and odds ratios were calculated where appropriate. RESULTS Preeclampsia occurred in 1.8% of singleton primiparous gestations (142/7,904). Cases were younger than controls (26.5 +/- 5.6 versus 28.0 +/- 0 6.0 years, P < .003), of similar race (97% white versus 96% white, P = .69), and equally likely to have a female child (45% versus 48%, P = .41). We found no significant association of month (logistic regression P = .20) of delivery with the risk of preeclampsia. There was a significant association of month (P = .003) of conception with risk of preeclampsia. Conception during the summer months had the highest risk (incidence 2.3%; odds ratio 1.7; 95% confidence limits 1.06, 2.75) compared with spring (incidence 1.4%). Fall (1.7%) and winter (1.6%) conceptions were associated with intermediate rates of preeclampsia. CONCLUSION We identified a seasonal variation in preeclampsia that appears to be more strongly related to timing of conception than to the timing of delivery. The highest incidence of preeclampsia was associated with conception in the summer months. LEVEL OF EVIDENCE II-2.
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Affiliation(s)
- J K Phillips
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont 05401-1435, USA
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Ganzevoort W, Rep A, Bonsel GJ, de Vries JIP, Wolf H. Plasma volume and blood pressure regulation in hypertensive pregnancy. J Hypertens 2004; 22:1235-42. [PMID: 15201535 DOI: 10.1097/01.hjh.0000125436.28861.09] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pre-eclampsia is a multisystem disorder, peculiar to and frequent in human pregnancy. It remains a leading cause of maternal and neonatal morbidity and mortality. Hemodynamic disturbances are the most prominent features of the syndrome. PURPOSE To provide an overview of plasma volume regulation and blood pressure control mechanisms outside pregnancy, and of the changes in normal pregnancies and in pregnancies complicated by hypertensive disorders. Furthermore, to discuss the rationale of several hemodynamic interventions. RESULTS In normal pregnancy, large cardiovascular changes take place. A generalized fall in vascular tone by systemic vasorelaxation causes increased blood volume, heart rate and cardiac output. In the preclinical phase, differences have been observed between normal and hypertensive pregnancies in the function of the autonomic nervous system, cardiac output and plasma volume, the volume remaining at the non-pregnant level. In the clinical phase of pre-eclampsia the typical case picture is one of a vasoconstrictive state with low plasma volume and cardiac output, high blood pressure and systemic vascular resistance in combination with signs of organ damage [proteinuria, hemolysis elevated liver enzymes low platelets (HELLP) syndrome]. Hemodynamic management is necessary in severe disease to prevent maternal complications. Management primarily focuses on pharmacological treatment of blood pressure. Clinicians make educated choices from a limited array of available drugs: beta-receptor antagonists, nifedipine, dihydralazine, methyldopa or ketanserine. Other drugs have restricted use in pregnancy. Management of low circulating volume with plasma expanders remains a subject of controversy.
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Affiliation(s)
- Wessel Ganzevoort
- Department of Obstetrics and Gynecology, Academic Medical Center, Amsterdam, The Netherlands.
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Sanin Aguirre LH, Reza-López S, Levario-Carrillo M. Relation between maternal body composition and birth weight. Neonatology 2004; 86:55-62. [PMID: 15057023 DOI: 10.1159/000077586] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2003] [Accepted: 01/09/2004] [Indexed: 11/19/2022]
Abstract
In order to establish the relationship between maternal body composition indicators (fat-free mass, fat mass, total body water) and birth weight, a cross-sectional study was designed, based on 196 pairs of mothers and live singleton newborns with gestational age of 37 weeks or more. Immediately after delivery, the mothers were interviewed to obtain information about different birth weight predictors. An analysis of maternal body composition through bioelectric impedance was held. Multiple linear regression was used to measure the effect of each variable on birth weight. The birth weight mean was 3,251 +/- 514 g. Maternal height was 160.44 +/- 6.3 cm, total net weight gain was 5.85 +/- 5.15 kg, fat mass consisted of 15.84 +/- 6.72 kg, and fat-free mass was 50.42 +/- 7.65 kg; total body water was 34.82 +/- 5.61 liters. The model which included total body water and all predictors found to be associated with birth weight in the bivariate analysis (maternal age, gestational age, gender, placenta weight, and placenta weight squared) was found to be the best in explaining the variability of birth weight (R(2) = 45.26%). Fat mass was an important predictor only in the subgroup of women within the low tertile of body mass index. In conclusion, fat-free mass and total body water explained a major proportion of the variability of birth weight in comparison with the mother's weight gain during the pregnancy period, which has already been considered an important predictor of birth weight.
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Bernstein IM, Shapiro RE, Whitsel A, Schonberg AL. Relationship of plasma volume to sympathetic tone in nulliparous women. Am J Obstet Gynecol 2003; 188:938-42. [PMID: 12712089 DOI: 10.1067/mob.2003.253] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE We sought to determine whether resting supine plasma volume is related to sympathetic tone in healthy young nulligravid normotensive women. STUDY DESIGN Forty women were examined in the midfollicular phase. Alpha-adrenergic tone was estimated by an examination of the late phase II blood pressure response to the Valsalva maneuver. Resting heart rate was examined to evaluate the balance of sympathetic and parasympathetic input. Plasma catecholamines were measured during supine rest. Plasma volume was estimated by Evans blue dilution. RESULTS Plasma volume corrected for body surface area was correlated inversely to late phase II blood pressure response to the Valsalva maneuver (r = -0.31, P <.05) and was correlated directly to the cardiac R-R interval (r = 0.41, P <.01). There was no relationship of plasma volume corrected for body surface area to mean arterial pressure (r = -0.13, P not significant). We found no significant relationship of plasma epinephrine concentration (r = -0.05, P =.76) or plasma norepinephrine (r = -0.09, P =.60) with plasma volume corrected for body surface area. CONCLUSION We conclude that plasma volume is related inversely to both an estimate of alpha-adrenergic activation and heart rate. These findings are consistent with an adaptive physiologic response that is aimed at the maintenance of blood pressure in the face of reduced plasma volume.
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Affiliation(s)
- Ira M Bernstein
- Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, USA
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