Pre-eclampsia

Preeclampsia pathogenesis and prediction - where are we now: the focus on the role of galectins and miRNAs

Preeclampsia is a complex, progressive multisystem hypertensive disorder during pregnancy that significantly contributes to increased maternal and perinatal morbidity and mortality. Two screening algorithms are in clinical use for detecting preeclampsia: first-trimester screening, which has been developed and validated for predicting early-onset preeclampsia but is less effective for late-onset disease; and the sFlt-1:PlGF biomarker ratio (soluble tyrosine kinase and placental growth factor) used in suspected cases of preeclampsia. This ratio has a high negative predictive value, allowing for the reliable exclusion of the disease. Both of these screening tests have not met expectations. This review attempts to summarize the current knowledge on the pathogenesis and prediction of preeclampsia and to draw attention to novel biomarkers with a focus on microRNAs and galectins. Although these molecules belong to two distinct biological classes, they functionally converge in regulating placental and immune pathways. Ample evidence supports their involvement in the molecular mechanisms underlying preeclampsia. Based on current knowledge, galectin-13, C19MC members, and miRNA-210 are associated with the trophoblast/placenta and conditions of placental ischemia or hypoxia. Their levels differ significantly in pregnant women at risk of preeclampsia as early as the late first and early second trimester, making them potential markers for predicting preeclampsia.

Role of oxysterol 4β-hydroxycholesterol and liver X receptor alleles in pre-eclampsia

BACKGROUND

Liver X receptors (LXRs) are expressed in placenta and may be associated with pre-eclampsia (PE). Oxysterols act as agonists for LXRs. We recently proposed a new blood pressure-regulating circuit with oxysterol 4β-hydroxycholesterol (4βHC) acting as a hypotensive factor via LXRs.

MATERIALS AND METHODS

This study investigated the association between maternal plasma 4βHC, blood pressure (BP) indices, placental expression of LXR target genes, and patient characteristics using data from the Finnish Genetics of Pre-Eclampsia Consortium (FINNPEC) cohort. Plasma samples of 144 women with PE and 38 healthy pregnant controls as well as 44 PE and 40 control placental samples were available. In addition, genetic data from the FinnGen project was utilized to explore the associations of LXR alleles with PE and pregnancy hypertension.

RESULTS

There were no significant associations between 4βHC and BP or maternal and perinatal characteristics in FINNPEC cohort. However, plasma 4βHC was inversely correlated with the maternal body mass index. There were no associations with the genetic variants of LXRs with PE in FinnGen. LXR target genes APOD, SCARB1, TGM2, and LPCAT3 were expressed differently between PE and normal pregnancies in placental samples of FINNPEC.

CONCLUSIONS

Our results demonstrate that plasma 4βHC and genetic LXR variants do not play a major role in PE and BP regulation during pregnancy. However, key LXR target genes involved in lipid metabolism were expressed differently in normal and PE pregnancies. Further research is needed to understand the complexities of oxysterols, LXRs, and their potential contributions to placental function and pregnancy outcomes.

Pregnancy urine biomarkers for effectively preeclampsia prediction: a systematic review and meta-analysis

Preeclampsia (PE) is a common multi-organ disorder in pregnancy. Urine as a source for test samples is noninvasive and easy to obtain. This study followed the Priority Reporting Project for Systematic Evaluation and Meta-Analysis protocol. We searched PubMed and Web of Science databases for studies relating to urine biomarker analysis for PE from inception to the 28th of February 2023. The Chi-squared test was utilized to evaluate the statistical heterogeneity of the results. The combined sensitivity, combined specificity, combined positive likelihood ratio, combined negative likelihood ratio, combined diagnostic odds ratio for urine analysis in the context of PE were calculated. Sixty-five studies were eventually included in the final analysis. In only hypertensive disorders of pregnancy (HDP) pregnant women, the the area under the summary receiver operating characteristic curve (AUC) of urine analysis to predict PE was 0.93 (0.91-0.95). The results show that spot random urine analysis or shortened-hour urinary analysis for the diagnosis of PE is a credible alternative method when 24-h urine collection is difficult to complete. The protein/creatinine ratio from spot random urine analysis may be an effective biomarker of the further progression of HDP into PE.

Association of Postpartum Cardiovascular Biomarkers with HIV Among Women with Recent Preeclampsia in Zambia

OBJECTIVES

Women recovering from preeclampsia with elevated vascular biomarkers have a higher risk of future cardiovascular diseases. We investigated whether HIV on treatment was associated with biomarkers of cardiovascular risk in the weeks following delivery.

METHODS

We analyzed data from a six-month prospective cohort study conducted from January 2022 to June 2023. Following delivery and at six weeks postpartum, we measured cystatin C, high sensitivity C-reactive protein (hs-CRP), Interleukine-2 (IL-2), Interleukine-6 (IL-6) and Tumor necrosis factor-alpha (TNFa). A generalized linear regression model with Poisson distribution estimated the association between vascular biomarkers and HIV on treatment.

RESULTS

This study included 75 participants with a median age of 29 years (interquartile range [IQR] = 27-34 years), with 35 (46.7%) living with HIV on ART and 40 (53.3%) HIV-negative. Women living with HIV on ART had higher levels of hs-CRP than HIV-negative women (4.68 mg/l vs 3.60 mg/l, p = 0.025) at six weeks. On the other hand, women living with or without HIV on ART had similar levels of cystatin C (0.78 mg/l vs 0.81 mg/l, p = 0.303), IL-2 (0.64 pg/ml vs 0.67 pg/ml, p = 0.131), IL-6 (0.64 pg/ml vs 0.64 pg/ml, p = 0.422), and TNFa (24.2 pg/ml vs 24.1 pg/ml, p = 0.346). Living with HIV while on ART was associated with an increased risk of presenting as hypertensive with elevated hs-CRP (aRR = 2.88, 95% CI: 1.09-7.60).

CONCLUSIONS

Women living with HIV on ART had elevated hs-CRP but similar levels of other biomarkers after preeclampsia. Further studies are needed to explore the differential impact of HIV disease vs. antiretroviral treatment on inflammatory responses.

Outcomes of Postpartum Preeclampsia: A Retrospective Cohort Study of 1.3 Million Pregnancies

OBJECTIVE

We assessed the association between postpartum preeclampsia and the risk of adverse maternal and neonatal outcomes. Evidence suggests that postpartum preeclampsia is initiated antenatally, but the impact on birth outcomes is unclear.

DESIGN

Retrospective cohort study.

SETTING

All deliveries in hospitals of Quebec, Canada.

POPULATION

1 317 181 pregnancies between 2006 and 2022.

METHODS

We identified patients who developed preeclampsia in the postpartum period. Using log-binomial regression models, we estimated adjusted risk ratios (RR) and 95% confidence intervals (CI) for the association of postpartum or antepartum preeclampsia with adverse pregnancy outcomes relative to no preeclampsia.

MAIN OUTCOME MEASURES

Preterm birth, placental abruption, severe maternal morbidity and recurrent preeclampsia.

RESULTS

Postpartum preeclampsia was less frequent than antepartum preeclampsia (n = 4123 [0.3%] vs. 51 269 [3.9%]). Postpartum preeclampsia was associated with preterm birth (RR 1.45, 95% CI 1.34-1.57), placental abruption (RR 1.36, 95% CI 1.16-1.59) and severe maternal morbidity (RR 6.48, 95% CI 5.87-7.16) compared with no preeclampsia. Antepartum preeclampsia was also associated with these outcomes. Moreover, patients with postpartum preeclampsia in a first pregnancy were at risk of adverse outcomes in a subsequent pregnancy, particularly recurrent preeclampsia (RR 7.77, 95% CI 6.54-9.23).

CONCLUSIONS

Postpartum preeclampsia is associated with adverse outcomes at delivery, despite being detected only postnatally. Our findings suggest that patients with adverse birth outcomes may benefit from blood pressure measurements up to 6 weeks following delivery.

Prediction of hypertension and diabetes in twin pregnancy using machine learning model based on characteristics at first prenatal visit: national registry study

OBJECTIVE

To develop a prediction model for hypertensive disorders of pregnancy (HDP) and gestational diabetes mellitus (GDM) in twin pregnancy using characteristics obtained at the first prenatal visit.

METHODS

This was a cross-sectional study using national live-birth data in the USA between 2016 and 2021. The association of all prenatal candidate variables with HDP and GDM was tested on univariable and multivariable logistic regression analyses. Prediction models were built with generalized linear models using the logit link function and classification and regression tree (XGboost) machine learning algorithm. Performance was assessed with repeated 2-fold cross-validation and the area under the receiver-operating-characteristics curve (AUC) was calculated. A P value < 0.001 was considered statistically significant.

RESULTS

A total of 707 198 twin pregnancies were included in the HDP analysis and 723 882 twin pregnancies were included in the GDM analysis. The incidence of HDP and GDM increased significantly from 12.6% and 8.1%, respectively, in 2016 to 16.0% and 10.7%, respectively, in 2021. Factors associated with increased odds of HDP in twin pregnancy were maternal age < 20 years or ≥ 35 years, infertility treatment, prepregnancy diabetes mellitus, non-Hispanic Black race, overweight prepregnancy BMI, prepregnancy obesity and Medicaid as the payment source for delivery (P < 0.001 for all). Obesity Class II and III more than doubled the odds of HDP. Factors associated with increased odds of GDM in twin pregnancy were maternal age ≤ 24 years or ≥ 30 years, infertility treatment, prepregnancy hypertension, non-Hispanic Asian race, maternal birthplace outside the USA and prepregnancy obesity (P < 0.001 for all). Maternal age ≥ 30 years, non-Hispanic Asian race and obesity Class I, II and III more than doubled the odds of GDM. For both HDP and GDM, the performances of the machine learning model and logistic regression model were mostly similar, with negligible differences in the performance domains tested. The mean ± SD AUCs of the final machine learning models for HDP and GDM were 0.620 ± 0.001 and 0.671 ± 0.001, respectively.

CONCLUSIONS

The incidence of HDP and GDM in twin pregnancies in the USA is increasing. The predictive accuracy of the machine learning models for HDP and GDM in twin pregnancies was similar to that of the logistic regression models. The models for HDP and GDM had modest predictive performance, were well calibrated and did not have poor fit. © 2024 The Author(s). Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Anxiety and depression during pregnancy: Differential impact in cases complicated by preeclampsia and preterm premature rupture of membranes

BACKGROUND

Maternal mental health is crucial for the well-being of both the mother and the fetus. Obstetric complications have been linked to anxiety and depression during pregnancy. Among them, preeclampsia (PE) and preterm premature rupture of membranes (PPROM), are the more common causes of maternal admission. The aim of this study is to explore whether there is an increasing prevalence in the gradient of anxiety and depression among women with uncomplicated pregnancies, those admitted for PPROM, and those admitted for PE.

METHODS

A cross-sectional t study was conducted involving three groups of pregnant women consecutively attended: 1) women admitted with severe PE; 2) women admitted with PPROM; and 3) uncomplicated pregnancies. Participants completed validated questionnaires to measure anxiety (State-Trait Anxiety Inventory, STAI), depression (Edinburgh Postnatal Depression Scale, EPDS). Differences in median scores across the study groups were analysed by quantile regression, adjusted for gestational age at evaluation and the STAI-Trait score.

RESULTS

The analysis included 214 women: 106 with uncomplicated pregnancies, 55 with PPROM, and 53 with severe PE. A higher proportion of nulliparity and chronic hypertension was observed in women with preeclampsia. Significant trends across the study groups were observed for both depression and anxiety scores. Women with severe preeclampsia had higher scores on the State-Trait Anxiety Inventory-State (STAI-S) compared to those with PPROM (27 vs. 24; p=0.049). The PPROM and PE groups showed significantly higher proportions of abnormal scores in STAI-S>30, EPDS>10, and EPDS>13 compared to uncomplicated pregnancies.

CONCLUSIONS

Higher levels of anxiety and depression are present in women admitted in hospital for PPROM and severe PE. Compared to PPROM, severe PE is associated with higher scores of anxiety. The importance of screening and offering specific interventions for patients with PE is highlighted.

Rule-in and rule-out of pre-eclampsia using a novel point-of-care placental growth factor test

OBJECTIVE

To evaluate test performance of the point-of-care Lepzi® Quanti placental growth factor (PlGF) test to rule-in and rule-out pre-eclampsia at various time points, in women presenting with suspected preeclampsia.

STUDY DESIGN

242 frozen plasma samples from women with suspected pre-eclampsia were analysed from a prospective cohort study. Participants were recruited from two obstetric tertiary referral centres in London.

MAIN OUTCOME MEASURES

PlGF concentration was quantified using the Lepzi® Quanti PlGF test, which is a point-of-care PlGF test. Test performance for diagnosis of pre-eclampsia was evaluated at various thresholds, and at different gestations. The area under the receiver operator curve (AUROC) was determined for the Lepzi® Quanti PlGF test and compared to that of the nationally recommended Delfia® Xpress PlGF1-2-3 test, in the same cohort of participants.

RESULTS

The LEPZI® Quanti PlGF test showed high test performance for rule-out of pre-eclampsia within seven and 28 days. A threshold of ≥ 129 pg/ml (in plasma) had high negative predictive value (NPV) for rule out of preeclampsia within seven days of sampling: NPV 96.9 % at < 34 weeks' gestation (95 % confidence interval (CI) 91.2-99.4), NPV 97.0 %; at 34 - 37 weeks' gestation (95 % CI 84.2-99.9), NPV 80.0 % at ≥ 37 weeks gestation (95 % CI 44.4-97.5).

CONCLUSION

The LEPZI® Quanti PlGF test demonstrates high test performance for diagnosis of pre-eclampsia, comparable to test performance for validated, nationally recommended PlGF tests. The LEPZI® Quanti PlGF test is a whole blood, point-of-care option to optimise risk stratification, enhanced surveillance, and appropriate management strategies; this would be suitable for low- and middle-income settings, as well as high-income settings.

Cadmium exposure causes trophoblast abnormal syncytization and endocrine dysfunction in preeclampsia

INTRODUCTION

Cadmium exposure increases the risk of preeclampsia. Present study aimed to explore the mechanism of abnormal syncytization of trophoblasts caused by cadmium exposure and its relationship with preeclampsia.

METHODS

RT-PCR, Western blot and Hematoxylin-Eosin were used to detect syncytization in placenta. BeWo cells were treated with forskolin (50 μM) and CdCl2 (20 μM) to verify the mechanism through which cadmium exposure led to abnormal syncytization and cadmium exposure subsequently caused endocrine dysfunction of syncytiotrophoblast.

RESULTS

Compared with normotension control, abnormal accumulation of syncytial knots was found in placenta of preeclampsia. Cell fusion rate was increased and gene expressions of GCM1, SYN-1, SYN-2, PLGF and β-hCG were elevated in FSK-treated cells. In BeWo cells co-treated with FSK and CdCl2 and in BeWo cells co-treated with FSK and GCM1 siRNA, cell fusion rate was decreased and gene expression of SYN-2 was reduced as compared with FSK-treated cells. Nuclear translocation level of GCM1 was lower in placenta of preeclampsia and BeWo cells co-treated with FSK and CdCl2. The mRNA level of GCM1 and β-hCG were decreased in CdCl2 treated JEG3 cells. The expression of sFlt1 was increased and the expression of PLGF was decreased in placenta of preeclampsia, CdCl2 treated and GCM1 siRNA transfected JEG3 cells. Compared with cells treated with CdCl2 and GCM1 siRNA, co-treatment with CdCl2 and GCM1 siRNA resulted in decreased expressions of β-hCG, PLGF and GCM1 and increased expression of sFlt1 in JEG3 cells.

CONCLUSION

The results indicated that cadmium exposure during pregnancy led to abnormal syncytization and endocrine dysfunction of trophoblasts and were related to the occurrence of preeclampsia.

A systematic review on the determinants of long-term kidney sequelae after hypertensive diseases of pregnancy

INTRODUCTION

Preeclampsia is a pregnancy syndrome defined by high blood pressure (≥140/90 mmHg) and at least one other associated complication, including proteinuria, maternal organ dysfunction, or uteroplacental dysfunction, after 20 weeks of gestation. The long-term effects of this disease on the kidneys are still not fully understood. This systematic review aimed to evaluate the risk of chronic kidney disease after preeclampsia and the determinants of these sequelae.

MATERIAL AND METHODS

We included observational studies on kidney outcomes from cohorts of women with a history of preeclampsia from the PubMed, Web of Science, and Cochrane databases.

RESULTS

Two hundred and seventy-seven articles were evaluated. Thirty-one (published between 2000 and 2022) were included in this systematic review. Twenty-two authors focused on the risk of chronic kidney disease and/or persistent proteinuria. Five authors found a more significant risk of kidney disease after preeclampsia, with a risk ranging from two to three times higher. Regarding end-stage kidney disease, most studies found a risk of between 4 and 14 times higher of developing end-stage kidney disease after preeclampsia. For several authors, early preeclampsia, preterm delivery, and recurrent pregnancies complicated by preeclampsia seemed to be the three major factors for determining the risk of kidney sequelae or proteinuria.

CONCLUSIONS

Women with a history of preeclampsia have a greater risk of chronic kidney disease or end-stage kidney disease. Some determinants seem to increase the risk. Further research is required to identify these determinants of kidney sequelae.

m6A deficiency impairs uterine spiral artery remodeling to induce preeclampsia-like symptoms via FGF2

Failures in uterine spiral artery remodeling can lead to placental defects and subsequent preeclampsia, a leading cause of fetal and maternal mortality during pregnancy. N6-methyladenosine (m6A), the most abundant mRNA modification, is dysregulated in samples with preeclampsia. However, whether and how m6A regulates uterine spiral artery remodeling and leads to subsequent preeclampsia in vivo remains unexplored. In this study, we generated two m6A deficiency mouse models: one with a trophoblast-specific knockout of the m6A methyltransferase gene Mettl3, and another with a methyltransferase enzyme mutation. Using these models, we demonstrated that m6A deficiency impaired extravillous trophoblasts (EVTs) infiltration into the uterine spiral arteries, and the remodeling of the spiral arteries in vivo. We further showed that m6A inhibition induced preeclampsia-like symptoms. Mechanistically, we revealed that the m6A modification of FGF2 mRNA, which encodes a secreted peptide implicated in preeclampsia, facilitated its expression. Notably, administration of the FGF2 peptide largely restored EVTs invasion and uterine spiral artery remodeling in m6A-deficient mice. Our findings underscore the importance of m6A in facilitating uterine spiral artery remodeling and prove the pathological mechanisms in vivo, suggesting a new therapeutic approach for preeclampsia caused by m6A deficiency.

Chemerin facilitates placental trophoblast invasion and spiral artery remodeling through the pentose phosphate pathway

AIMS

The invasion of trophoblasts and remodeling of spiral arteries are the requisite processes for successful placentation. A defect of trophoblast invasion is closely associated with pregnancy complications, including miscarriage and preeclampsia. In this study, we investigated the function of chemerin in trophoblast invasion and artery remodeling and explored the underlying mechanism in this process.

MAIN METHODS

Immunostaining was performed to examine chemerin expression in different days of mouse placenta and early stage of human placenta. Chemerin KO and LPS-treated mice, with exogenous chemerin peptide, were used to evaluate trophoblast giant cells (TGC) invasion, artery remodeling, and NK cell infiltration. Chemerin KO and LPS-treated decidua on E8.5 were conducted in metabolites file and measured related enzymes' expression. Chemerin's function was further examined by human trophoblast HTR-8 cell migration and the enzymes expression in the pentose phosphate pathway.

KEY FINDINGS

Chemerin has high expression in mouse-invasive TGC and human extra-villous trophoblast cells. Deficiency of chemerin and LPS treatment in pregnant mice impaired placental TGC invasion, spiral artery remodeling, and NK cell infiltration in decidua, which mainly attributed to the downregulation of metabolites and G6PD and RPIA expression in pentose phosphate pathway (PPP). Chemerin activated the PPP to accelerate HTR-8 cell migration. Exogenous chemerin administration remarkably attenuated the defect of TGC invading and artery remodeling in LPS-treated mice, and promoted NK infiltration and maternal blood perfusion.

SIGNIFICANCE

This study described the indispensable role of chemerin in trophoblast invasion and arterial remodeling, and suggested its potential application in pregnancy complications miscarriage and preeclampsia.

Hydroxychloroquine for preventing hypertensive pregnancy disorders in recurrent spontaneous abortion: a retrospective cohort study in a single referral center

OBJECTIVE

We aimed to assess the effectiveness of hydroxychloroquine (HCQ) in preventing hypertensive pregnancy disorders (HPD) among women with recurrent spontaneous abortion (RSA).

STUDY DESIGN

This retrospective cohort study included 462 pregnant women with RSA. Inverse probability of treatment weighting (IPTW) and propensity score matching (PSM) were used to balance baseline characteristics between HCQ and non-HCQ groups. The primary outcome comprised a composite of HPD, including preeclampsia, eclampsia, and gestational hypertension. Secondary outcomes included maternal complications and neonatal outcomes.

RESULTS

HCQ was associated with a 62% decreased risk of HPD compared to no HCQ (weighted hazard ratio 0.38, 95% CI 0.16-0.94, P < 0.001). The cumulative incidence of HPD at 34 weeks was lower among HCQ users (5% vs 14%, P = 0.03). HCQ demonstrated greater efficacy in preventing HPD among women aged < 35 years, a body mass index (BMI) of ≥ 28, non-in vitro fertilization (IVF) pregnancies, and fewer than three prior miscarriages (P-interaction < 0.05). Notably, the risk of HPD was significantly lowered by 56 and 53% in combined HCQ and aspirin with/without low-molecular-weight heparin (LMWH) group compared with no HCQ counterpart, respectively.

CONCLUSIONS

HCQ demonstrated promising efficacy in reducing HPD, particularly when used in conjunction with aspirin and/or LMWH therapy.

Alpha-fetoprotein (AFP) is reduced at 36 weeks' gestation in pregnancies destined to deliver small for gestational age infants

Alpha-fetoprotein (AFP) is a protein commonly used to screen for aneuploidy in pregnancy. This study measured circulating AFP in maternal plasma at 36 weeks' gestation preceding diagnosis of term preeclampsia or delivery of a small for gestational age infant (SGA; <10 % birthweight centile) in a case-cohort design (122 SGA; 23 preeclampsia; 182 controls). AFP was significantly reduced in SGA < 5th birthweight centile (n = 51; P = 0.002) but not changed preceding preeclampsia diagnosis. This suggests that AFP is reduced near term preceding SGA diagnosis and may have potential as a biomarker if combined with other candidate molecules.

A nomogram based on peripheral blood count between 12 and 18 weeks of gestation for predicting early-onset pre-eclampsia in pregnant women: a retrospective case-control study

BACKGROUND

Early-onset pre-eclampsia (PE), which delivered before 34 weeks of gestation, is associated with high maternal and pediatric morbidity and mortality. Several studies have examined predictive factors and models to identify individuals at risk for early-onset pre-eclampsia. However, implementing these methods often requires additional tests and increases the financial burden on pregnant women. Our study aimed to determine if early-onset PE development could be predicted using a simple, convenient, and easily accessible test: the peripheral blood count.

METHODS

In this study, we conducted a review of pregnant women who received routine prenatal visit and delivered in our hospital from April 2019 to April 2022. For each patient with PE, we matched them 1:1 with healthy pregnant women who were similar in terms of age, parity, and pre-gestational BMI. We gathered routine peripheral blood cell results between 12 and 18 weeks of gestation and utilized multivariate logistic regression to determine independent risk factors. Subsequently, a nomogram was created to forecast the likelihood of early-onset pre-eclampsia. Lastly, we assessed the model's predictive performance.

RESULTS

In our study, a total of 254 patients with PE were included, comprising of 41 patients with early-onset PE and 213 patients with late-onset PE, as well as 254 cases of normotensive pregnancy. The nomogram included four risk factors: mean corpuscular hemoglobin concentration (MCHC) ≥ 340.50 g/l, neutrophil-to-lymphocyte ratio (NLR) ≤ 4.40, platelet-to-lymphocyte ratio (PLR) ≤ 118.01, and platelet-to-mean platelet volume (PC/MPV) ≤ 17.81. Notably, the nomogram exhibited good diagnostic performance with an area under the curve (AUC) of 0.874, sensitivity of 95.1%, and specificity of 62.2%. Furthermore, the nomogram was validated through a decision curve analysis (DCA), which demonstrated a favorable positive net benefit, and the calibration curve showed a good fit and alignment with the ideal curve.

CONCLUSIONS

Our nomogram, based on four predictors derived from peripheral blood cells and related ratios, offers a practical screening tool for early-onset PE in pregnant women.

Review: The potential role of placental extracellular vesicles in blood-brain barrier disruption and neuroinflammation in preeclampsia

Preeclampsia is a complex pregnancy disorder characterized by hypertension and multisystem organ damage, notably affecting the liver, kidneys, and brain. Eclampsia, a severe form of preeclampsia, is marked by the sudden onset of generalized tonic-clonic seizures. Brain complications, including eclampsia, are responsible for 60-70 % of preeclampsia-related maternal deaths, particularly in low-income regions. Despite the significant impact of brain complications in preeclampsia, their underlying pathophysiology remains unclear. Evidence suggests that brain edema in preeclampsia and eclampsia results from disruption of the blood-brain barrier (BBB). Although direct analysis of the BBB is challenging, in vitro studies indicate that plasma from women with preeclampsia can compromise the BBB, with the specific circulating factors involved still unidentified. Among the potential culprits, recent findings highlight placental-derived small extracellular vesicles (PDsEVs) as key players in BBB disruption observed in preeclampsia. This review examines the role of PDsEVs in the pathophysiology of brain edema associated with preeclampsia, emphasizing areas for future research, including neuroinflammation and neuron dysfunction. Additionally, we discuss the protective role of magnesium sulfate in these processes.

Development a nomogram for predicting HELLP syndrome in women complicated with gestational hypertension

OBJECTIVES

The unpredictability of HELLP syndrome and the severe adverse outcomes for both mother and children make it especially important for us to seek predictive model. This study aimed to develop a clinically accessible prediction model for assessing the risk of HELLP syndrome progression in patients with hypertensive disorders of pregnancy (HDP) and find effective factors that may predict the progression of HELLP within 3 days.

METHODS

We used electronic data from Women's Hospital, Zhejiang University School of Medicine, between January 1,2014 and December 31,2023. A total of 808 patients were included in this study, including 607 patients in the non-HELLP syndrome group and 201 patients in the HELLP syndrome group. We collected clinical and laboratory information, and conducted single- and multiple-factor logistic regression analyses to identify independent factors influencing the occurrence of HELLP syndrome and the onset of HELLP syndrome within 3 days. A nomogram was constructed based on these predictors to provide a visual representation of risk estimation. The model's performance was evaluated through internal and external validation, with metrics such as the area under the curve(AUC), receiver operating characteristic curve (ROC), precision, recall, and F1 score. Calibration and decision curve analyses were also performed to assess model robustness and clinical utility.

RESULTS

Multiple logistic regression analysis indicated prenatal BMI, neurologic symptoms, other system symptoms, 24-h urine protein, lowest SBP at admission, lowest DBP at admission, prenatal albumin, prenatal platelet and prenatal blood urea nitrogen as independent factors of HELLP syndrome. The prediction model achieved an AUC of 0.975 (95% CI: 0.966-0.985) in the internal validation dataset with a sensitivity of 0.962(95% CI: 0.962-1.000) and specificity of 0.885(95% CI: 0.962-1.000). The AUC of the external validation dataset was 0.838 (95% CI: 0.785-0.892). The optimal cutoff value calculated using Youden's index was 0.613, with a sensitivity of 0.891(95% CI: 0.473-0.836) and specificity of 0.722(95% CI: 0.667-0.818). In multivariate regression analysis, blood urea nitrogen and the creatinine-to-blood urea nitrogen ratio were significant predictors in predicting HELLP syndrome within 3 days. The sensitivity was found to be 0.68 and 0.65, specificity to be 0.74 and 0.686 respectively.

CONCLUSIONS

This study successfully developed and validated a prediction model that can reliably predict the risk of HELLP syndrome in HDP patients. And blood urine nitrogen and the ratio of creatinine over blood urea nitrogen could be efficient predictors of HELLP syndrome occurring within 3 days.

Recurrence of preeclampsia is common, even during rigorously controlled multidisciplinary follow-up: a pilot experience

Background

The risk of kidney failure increases after preeclampsia (PE), further increasing after two or more episodes. Recurrence is variably estimated. The aim of this study was to assess the recurrence rate and its predictors in the setting of obstetric-nephrology follow-up of pregnancies after PE.

Methods

In a prospective study (2018-24), from 108 pregnancies with prior hypertensive disorders of pregnancy we selected 77 singleton deliveries after excluding twins, miscarriages, terminations, ongoing pregnancies, and drop-outs. PE recurrence and potential associated factors were tested in univariable and multivariable logistic regression models. Gestational age at time of delivery was analyzed using Kaplan-Meier curves and Cox regression. The diagnostic potential of angiogenic placental biomarkers (soluble FMS-like tyrosine kinase-1 and placental growth factor) was likewise tested.

Results

In the context of a high prevalence of previous preterm delivery (53.6%), PE recurrence was 42.9%. Furthermore, 19.5% of the women experienced other complications and only 37.7% had an uneventful pregnancy; 60.6% of recurrences occurred after the 37th gestational week (GW), making later delivery possible (median: 38 GW in the index pregnancy versus 35 GW in the previous pregnancy). The covariates associated with PE recurrence were chronic hypertension (OR 7.662, 95% CI 2.122-33.379) and having had a baby with a centile <10th (OR 7.049, 95% CI 1.56-41.027), while those associated with time to delivery were hypertension and maternal age. Being diagnosed with chronic kidney disease after a previous PE episode was not associated with a significantly increased risk of recurrent PE.

Conclusions

Risk of PE recurrence was high but delayed in this cohort on multidisciplinary follow-up. The question of whether a proactive approach to delivery can help to preserve long-term maternal kidney health is open.

Risk of preeclampsia and other pregnancy complications in frozen single euploid embryo transfers after natural versus artificial endometrial preparation: A truncated randomized controlled trial

INTRODUCTION

To determine for the first time the incidence of preeclampsia and other pregnancy complications according to the mode of endometrial preparation for frozen embryo transfer (FET) in a randomized fashion.

METHODS

Women about to undergo FET of a single euploid blastocyst were randomly assigned to a modified natural cycle (MNC) or an artificial cycle (AC). Inclusion criteria were as follows: Caucasian; non-obese; 18-43 years of age; nulliparity; regular menstrual cycles; and autologous oocytes. Exclusion criteria were as follows: uterine alterations; moderate-heavy smokers; gamete donation; and chronic diseases. A pilot sub-study of first-trimester markers of preeclampsia was performed in 60 of the patients.

RESULTS

Of the 1260 patients estimated, 591 met the inclusion criteria and were willing to participate; of these, 306 and 285 were randomly assigned to a MNC or AC, respectively. After exclusion, 242 and 227 patients finally underwent a MNC or AC, resulting in 131 and 103 clinical pregnancies, 121 and 92 live births, and 91 and 70 questionnaires obtained concerning pregnancy complications, respectively. The incidence of preeclampsia was double in the AC group (10.00 % versus 4.39 %), though not significantly different. In the AC group, the prevalence of first trimester bleeding was significantly higher (42.85 % versus 15.38 %), and there was a significant reduction in live birth rates (40.53 % versus 50.00 %) in the per protocol analysis. No differences in early markers of preeclampsia were detected between the two groups.

DISCUSSION

Although this randomized study was truncated, our findings are in accordance with previous reports of a higher risk of preeclampsia and other complications when the endometrium is artificially prepared for FET.

The effect of pregnancy vitamin D supplementation on maternal blood pressure: real-world data analysis within the MAVIDOS randomised placebo-controlled trial

PURPOSE

Observational studies have suggested negative associations between maternal 25-hydroxyvitamin D (25(OH)D) status and risk of hypertensive disorders of pregnancy [pregnancy-induced hypertension (PIH) and preeclampsia (PET)]. Data from intervention studies are limited. We hypothesised that vitamin D supplementation would lower maternal blood pressure (BP) during pregnancy and reduce the incidence of hypertensive disorders of pregnancy.

METHODS

The Maternal Vitamin D Osteoporosis Study (MAVIDOS) was a randomised placebo-controlled trial. Pregnant women with a baseline 25(OH)D of 25-100 nmol/l were randomized to either 1000 IU/day cholecalciferol or placebo from 14 to 17 weeks' gestation until delivery. BP recordings documented during routine clinical pregnancy care were obtained from clinical records and grouped into gestational windows based on the schedule for routine antenatal care in the United Kingdom (23+0-24+6, 27+0-28+6, 33+0-35+6, 37+0-38+6, 39+0-40+6 and ≥ 41+0 weeks+days). Systolic and diastolic BP measurements in these gestational windows were compared between randomisation groups. Diagnoses of PIH or PET (in accordance with national guidelines) and the use of antihypertensive agents were also noted and compared between groups.

RESULTS

Data for 734 women (366 cholecalciferol, 368 placebo) were included. Maternal mean systolic and diastolic BP did not differ between the randomization groups at any of the gestations studied. The incidences of PIH (placebo 1.6%, cholecalciferol 3.6%, p = 0.10) and PET (placebo 3.3%, cholecalciferol 3.8%, p = 0.68) were similar between the two groups.

CONCLUSIONS

Gestational vitamin D supplementation with 1000 IU/day from 14 to 17 weeks gestation did not lower maternal BP or reduce the incidences of PIH or PET in this trial.

Inhibitory effect of exercise on elevated blood pressure and fetal growth restriction during pregnancy in Dahl salt-sensitive rats

Exercise is effective in preventing gestational hypertension, but its mechanism remains unclear. This study investigates the effects of exercise on Dahl salt-sensitive (DSS) rats, which develop elevated blood pressure and fetal growth restriction during pregnancy. DSS rats were divided into exercise and non-exercise groups, with Sprague-Dawley rats as controls. Exercise consisted of voluntary running, starting 4 weeks prior to pregnancy until the last trimester. Cardiovascular parameters, molecular characteristics of the brain and placenta, and fetal conditions were evaluated. Exercise significantly improved elevated blood pressure at early pregnancy and was associated with improved baroreceptor reflex gain. Gene expression analysis in the rostral ventrolateral medulla (RVLM) showed exercise-induced downregulation of nitric oxide synthase and upregulation of superoxide dismutase. These genetic changes suggest that exercise impacts circulatory regulation mechanisms, contributing to blood pressure improvement. In addition, placental analysis revealed a marked increase in placental growth factor expression due to exercise. In conclusion, exercise alleviates elevated blood pressure at early gestation and fetal growth restriction in DSS rats. Genetic modifications in the RVLM may play a critical role in exercise-induced cardiovascular improvements. This study highlights the potential of exercise as a therapeutic approach for managing gestational elevated blood pressure and fetal growth restriction and provides insights into its underlying mechanisms.

Real-world evidence for the utility of serum soluble fms-like tyrosine kinase 1/placental growth factor test for routine clinical evaluation of hospitalized women with hypertensive disorders of pregnancy

BACKGROUND

An imbalance of the antiangiogenic factor, soluble fms-like tyrosine kinase-1, and proangiogenic factor, placental growth factor, in the circulation is a reliable predictor for the development of preeclampsia with severe features and related adverse outcomes. In 2023, the US Food and Drug Administration approved a serum soluble fms-like tyrosine kinase-1/placental growth factor test at a cutoff of 40 to aid in the risk assessment of women hospitalized for hypertensive disorders of pregnancy for the progression to preeclampsia with severe features between 23 and 35 weeks.

OBJECTIVE

This study aimed to generate real-world evidence for clinical utility for serum soluble fms-like tyrosine kinase-1/placental growth factor test when made available to clinicians in a timely fashion as an aid in risk stratification of development of preeclampsia with severe features within 2 weeks of testing among hospitalized patients with hypertensive disorders of pregnancy.

STUDY DESIGN

Hospitalized patients with hypertensive disorders of pregnancy between 23 weeks to 34 weeks and 6 days of gestation were prospectively studied from June 2023 to January 2024 after the implementation of serum soluble fms-like tyrosine kinase-1/placental growth factor testing into routine clinical practice. Serum samples were obtained from patients via venipuncture and analyzed on an automated immunoassay platform (placental growth factor and soluble fms-like tyrosine kinase-1 assays; Thermo Fisher Scientific). Before implementation, physicians were educated on appropriate use and management guidelines on the basis of biomarkers but made pragmatic management decisions independently. Results of soluble fms-like tyrosine kinase-1/placental growth factor tests were available to clinicians within 24 hours of venipuncture. The association between soluble fms-like tyrosine kinase-1/placental growth factor ≥40 and progression to preeclampsia with severe features and adverse maternal/perinatal outcomes were assessed.

RESULTS

Of the 65 patient encounters, 36 had a soluble fms-like tyrosine kinase-1/placental growth factor <40 (55.4%). The rate of delivery for indications related to hypertensive disorders of pregnancy within 2 weeks was significantly lower among encounters with a low ratio vs high ratio (2/36 [5.6%] vs 21/29 [72.4%]) even after controlling for relevant confounders (adjusted hazard ratio, 7.52; 95% confidence interval, 3.05-18.54; P<.001). A diagnosis of preeclampsia with severe features within 2 weeks of testing was also less likely among the encounters with soluble fms-like tyrosine kinase-1/placental growth factor ratio <40 when compared with soluble fms-like tyrosine kinase-1/placental growth factor ratio ≥40 (2/36 [5.6%] vs 23/29 [79.3%], P<.001; positive predictive value of 79% [95% confidence interval, 0.65-0.94] and negative predictive value of 0.94 [95% confidence interval, 0.87-1.00]). The positive and negative likelihood ratios for the development of preeclampsia with severe features within 2 weeks of testing were 6.13 and 0.09, respectively. Encounters with a soluble fms-like tyrosine kinase-1/placental growth factor ratio <40 were less likely to experience a maternal or fetal adverse event as compared with encounters with soluble fms-like tyrosine kinase-1/placental growth factor ratio ≥40 (3/36 [8.3%] vs 10/29 [34.5%], P=.01). Among 36 encounters involving low soluble fms-like tyrosine kinase-1/placental growth factor values, 22 had had equivocal clinical or laboratory criteria resembling preeclampsia at presentation but were expectantly managed on the basis of biomarkers, and none developed preeclampsia with severe features or adverse outcomes at 2 weeks. The median latency defined as days between biomarker measurement and delivery in patients with a low biomarker ratio was 33 (interquartile ratio, 23-47) vs 7 (interquartile ratio, 4-14) days among patients with a high ratio (P<.001). Corticosteroid use within 2 weeks was also significantly reduced in the low biomarker group when compared with the high biomarker group (8/35 [22.9%] vs 24/29 [82.8%], P<.001).

CONCLUSION

In this study, the incorporation of soluble fms-like tyrosine kinase-1/placental growth factor ratio into clinical practice serves as a dependable supplement in assessing risk for progression to preeclampsia with severe features and adverse outcomes in patients with hypertensive disorders of pregnancy in the United States. Among patients with a low ratio, pregnancy may be prolonged, which results in better neonatal outcomes without harm to the mother.

Deciphering the preeclampsia-specific immune microenvironment and the role of pro-inflammatory macrophages at the maternal-fetal interface

Preeclampsia (PE), a major cause of maternal and perinatal mortality with highly heterogeneous causes and symptoms, is usually complicated by gestational diabetes mellitus (GDM). However, a comprehensive understanding of the immune microenvironment in the placenta of PE and the differences between PE and GDM is still lacking. In this study, cytometry by time of flight indicated that the frequencies of memory-like Th17 cells (CD45RA-CCR7+IL-17A+CD4+), memory-like CD8+ T cells (CD38+CXCR3-CCR7+Helios-CD127-CD8+) and pro-inflam Macs (CD206-CD163-CD38midCD107alowCD86midHLA-DRmidCD14+) were increased, while the frequencies of anti-inflam Macs (CD206+CD163-CD86midCD33+HLA-DR+CD14+) and granulocyte myeloid-derived suppressor cells (gMDSCs, CD11b+CD15hiHLA-DRlow) were decreased in the placenta of PE compared with that of normal pregnancy (NP), but not in that of GDM or GDM&PE. The pro-inflam Macs were positively correlated with memory-like Th17 cells and memory-like CD8+ T cells but negatively correlated with gMDSCs. Single-cell RNA sequencing revealed that transferring the F4/80+CD206- pro-inflam Macs with a Folr2+Ccl7+Ccl8+C1qa+C1qb+C1qc+ phenotype from the uterus of PE mice to normal pregnant mice induced the production of memory-like IL-17a+Rora+Il1r1+TNF+Cxcr6+S100a4+CD44+ Th17 cells via IGF1-IGF1R, which contributed to the development and recurrence of PE. Pro-inflam Macs also induced the production of memory-like CD8+ T cells but inhibited the production of Ly6g+S100a8+S100a9+Retnlg+Wfdc21+ gMDSCs at the maternal-fetal interface, leading to PE-like symptoms in mice. In conclusion, this study revealed the PE-specific immune cell network, which was regulated by pro-inflam Macs, providing new ideas about the pathogenesis of PE.

Amniotic fluid-derived exosomal miR-146a-5p ameliorates preeclampsia phenotypes by inhibiting HIF-1α/FLT-1 expression

INTRODUCTION

Preeclampsia (PE) is a pregnancy-specific complication that begins with hypertension and proteinuria and seriously threatens the health of pregnant women and fetuses. Abnormal expression of amniotic fluid-derived exosomal miR-146a-5p was observed in PE. However, the role of human amniotic fluid-derived exosomes (AF-Exos) and miR-146a-5p in PE remains unclear.

METHODS

We determined the miR-146a-5p expression pattern in the AF-Exos. AF-Exos, Cobalt chloride (CoCl2) and miR-146a-5p mimic were added to trophoblast cell lines HTR-8/SVneo and JEG-3, respectively. Then the proliferation and migration function of HTR-8/SVneo and JEG-3 cells were examined. The expression of miR-146a-5p, HIF-1α and FLT-1 in HTR-8/SVneo and JEG-3 cells were detected by RT-qPCR and western blotting. Finally, we determined the effect of AF-Exos in PE rat models.

RESULTS

MiR-146a-5p was down-regulated in AF-Exos of PE compared to normal. Co-cultured with normal AF-Exos significantly promoted proliferation and migration of HTR-8/SVneo and JEG-3 cells. CoCl2 inhibited proliferation and migration of HTR-8/SVneo and JEG-3 cells, while miR-146a-5p mimic reversed them by suppressing HIF-1α/FLT-1 expression. After treatment of AF-Exos, the blood pressure and 24-h urinary protein of PE rats were substantially decreased, the quality of fetuses and placenta exhibited improved, and HIF-1α/FLT-1 expression of placenta, sFlt-1 and sEng levels of blood, were substantial suppressed.

CONCLUSION

The study provided experimental evidence for the protective effects of normal AF-Exos on ameliorating preeclampsia phenotypes, and miR-146a-5p may act an important role in enhancing the proliferation and migration of trophoblast cells by targeting HIF-1α.

Indole-3-lactic acid derived from tryptophan metabolism promotes trophoblast migration and invasion by activating the AhR/VCAN pathway

BACKGROUND

Preeclampsia (PE) is a life-threatening condition that is unique to human pregnancy, and it is a leading cause of maternal and neonatal morbidity and mortality. Currently, the only definitive treatment for PE is delivery of the placenta. Several studies have suggested that the gut microbiota and its derived metabolites may be associated with PE. Our previous work indicated that the level of indole-3-lactic acid (ILA), which is a metabolite derived from tryptophan (Trp) metabolism in the gut, is increased in PE patients. However, the effects of ILA on trophoblast function and its underlying mechanisms remain largely unknown.

METHODS

Transwell assays were conducted to assess the effects of ILA on trophoblast migration and invasion. Moreover, the aryl hydrocarbon receptor (AhR) signaling pathway was examined by qRT-PCR, western blotting and siRNA transfection. Additionally, RNA-seq analysis was performed to explore the mechanism underlying the ILA-mediated effects on trophoblast function. Finally, in vivo trophoblast invasion was evaluated through immunohistochemical analysis.

RESULTS

Our data demonstrated that ILA promoted HTR-8/SVneo cell migration and invasion through AhR signaling pathway activation. Mechanistically, VCAN upregulation played a key role in mediating the effects of ILA on trophoblasts after AhR activation. Notably, ILA supplementation improved spiral artery remodeling and increased trophoblast invasion in PE-like mice, primarily by increasing VCAN levels.

CONCLUSIONS

These data strongly suggest that elevated ILA in PE serve as a protective mechanism against trophoblast dysfunction. Therefore, we propose that ILA may be a novel and promising therapeutic approach for treating PE by enhancing trophoblast functions.

Investigating the association of albuminuria with the incidence of preeclampsia and its predictive capabilities: a systematic review and meta-analysis

BACKGROUND

Preeclampsia (PE) is a severe hypertensive disorder affecting approximately 6.7% of pregnancies worldwide. Identifying reliable biomarkers for early prediction could significantly reduce the incidence of PE and facilitate closer monitoring and timely management. This study aims to investigate the association between albuminuria in early pregnancy and the subsequent development of PE, and to explore its predictive abilities.

METHODS

A systematic search was conducted across PubMed, Embase, and Web of Science on July 15, 2024, for studies published between January 1, 1990, and June 30, 2024. Quality assessments were performed using the Joanna Briggs Institute Critical Appraisal and Risk of Bias in Non-randomized Studies - of Exposures Checklists. Random-effects models in STATA were used to conduct meta-analyses comparing urine albumin and albumin-to-creatinine ratio levels in patients who later developed PE versus those who did not. The incidence of PE was also compared between patients with and without albuminuria in early pregnancy. The predictive ability of albuminuria for PE was assessed using META-DISC software.

RESULTS

A total of 26 studies comprising 7,640 pregnant women were systematically reviewed. Of these, 17 studies met the quality criteria for inclusion in the meta-analyses. Our findings indicate that urine albumin (Hedges's g = 0.48 [95% confidence interval (CI): 0.16-0.80]; p-value < 0.001) and albumin-to-creatinine ratio (Hedges's g = 0.48 [95% CI: 0.16-0.80]; p-value = 0.003) were significantly higher in the early stages of pregnancy in patients who later developed PE compared to those who did not. The incidence of PE was higher in patients with early-diagnosed albuminuria (log odds ratio = 2.56 [95% CI: 1.75-3.38]; p-value < 0.001). The pooled sensitivity and specificity for albuminuria in predicting PE were 56% [95% CI: 48-64%] and 87% [95% CI: 85-89%], respectively.

CONCLUSIONS

Elevated maternal urine albumin and albumin-to-creatinine ratio in early pregnancy are associated with a higher risk of developing PE. While these biomarkers show promise for early identification of at-risk patients, the relatively low sensitivity suggests that albuminuria alone may not be a robust predictor of PE, which underscores the need for future research in this regard.

TRIAL REGISTRATION

Review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the code CRD42024575772.

Increased circulating miR-155 identifies a subtype of preeclamptic patients

INTRODUCTION

Preeclampsia is a common and severe pregnancy complication. The syndrome is highly heterogeneous, making accurate classification difficult, which is not conductive to find ways to predict and prevent this syndrome. Recently, we reported that high placental miR-155 defined a new subtype of preeclampsia. Here, we aimed to examine whether high maternal sero-miR-155 could be a marker to identify this subtype.

METHODS

To explore whether the patients with high sero-miR-155 no matter in first and third trimester, we conducted a case-control and a longitudinal cohort study. We measured the sero-miR-155 levels at first, second and third trimesters in all pregnant women. Then, using the 95th percentile (P95) of sero-miR-155 in controls as the cut-off value, we divided the preeclamptic patients into high sero-miR-155 group (≥ P95) and normal sero-miR-155 group (< P95). We compared the difference of clinical manifestations between two groups and used t-distributed stochastic neighbor embedding (t-SNE) to evaluate whether the patients with high sero-miR-155 could be clustered as a subtype. Finally, we evaluated the predictive value of sero-miR-155 in the subtype.

RESULTS

The case-control study included 525 subjects (350 controls and 175 preeclampsia) and the longitudinal cohort study included 411 subjects (274 controls and 137 preeclampsia). Sero-miR-155 was significantly elevated in preeclampsia. Compared with preeclamptic patients with normal sero-miR-155 levels, the cases with high sero-miR-155 had significantly higher blood pressure and other severe preeclampsia-related complications. The incidences of HELLP syndrome [5.2% (5/96) vs. 0.9% (2/216), p < 0.01], visual disturbance [15.6% (15/96) vs. 4.6% (10/216), p < 0.01], hypertensive retinopathy [13.5% (13/96) vs. 3.2% (7/216), p < 0.01], and placenta abruption [7.3% (7/96) vs. 0.9% (2/216), p < 0.01] in patients with high miR-155 level were significantly increased. T-SNE analysis showed the patients with high sero-miR-155 were predominantly clustered on the left of the plot.

CONCLUSIONS

The patients with high sero-miR-155 exhibited more severe clinical manifestations and sero-miR-155 could be a biomarker to identify a subtype of preeclampsia with high sero-miR-155.

Exposure to Bisphenol A jeopardizes decidualization and consequently triggers preeclampsia by up-regulating CYP1B1

Preeclampsia (PE) is a pregnancy-related disease that poses a significant threat to the health of both the mother and the fetus. Previous studies have primarily focused on the role of the placenta in PE pathogenesis; however, normal decidualization is crucial for the subsequent development of the placenta and pregnancy. Bisphenol A (BPA) is an environmental endocrine disruptor commonly used in the synthesis of polycarbonate and epoxy resins. Overexposure to BPA can result in severe reproductive issues. To further investigate the effects of BPA exposure on pregnancy, C57BL/6 mice were continuously exposed to either 0 or 100 mg/kg of BPA in this study. As a result, these mice developed symptoms of hypertension and proteinuria, indicative of PE. Additionally, their decidualization process was impaired. Transcriptome sequencing of artificially induced decidua revealed a significant upregulation in the expression of CYP1B1 within the BPA-treated group. This upregulation accelerated the metabolism of estrogen and progesterone, leading to significant decreases in their levels. Furthermore, the expression levels of estrogen and progesterone receptors and their responding genes were significantly reduced. These findings suggest that BPA exposure can negatively impact decidualization and placental development, potentially contributing to the development of PE.

The interdependence of mid-trimester blood pressure and glucose levels in shaping fetal growth and neonatal outcomes: implications for risk-benefit assessment and co-management

BACKGROUND

Maternal hypertension and hyperglycemia are closely related but have distinct impacts on fetal growth and are managed independently. How the interdependence of blood pressure (BP) and glucose levels quantitatively influences risk patterns for abnormal fetal growth and neonatal complications remains unexplored.

METHODS

Maternal BP and fasting plasma glucose (FPG) levels were measured between 20 and 28 weeks of gestation in a cohort including 56,881 singleton pregnancies. Linear and quantile regression analyses were used to evaluate the relationship between BP and FPG. We examined the dose-response relationships between BP and FPG with small-for-gestational age (SGA) and large-for-gestational age (LGA) by using restricted cubic spline (RCS) curves. Additionally, multivariable fractional polynomial interaction (MFPI) analysis was conducted to assess the effects of higher versus lower BP levels across the full range of FPG levels. Heatmaps were created to visualize the contributions of BP and FPG by categorizing them into ordered groups.

RESULTS

Quantile regression revealed consistent positive correlations between mean arterial pressure (MAP) and FPG, with a steeper increase in MAP coefficients above the 0.5 quantile of FPG. MAP had a non-linear positive association with SGA risk, while FPG showed a non-linear negative association. Heatmaps revealed the highest SGA risk with high BP (MAP ≥ 85 mmHg)/low glucose (< 85 mg/dL) combinations and the lowest risk with low BP (MAP < 85 mmHg)/high glucose (≥ 85 mg/dL), with equivalent risk at both high BP/high glucose and low BP/low glucose. In hypertensive patients, SGA risk worsened continuously as glucose levels decreased. LGA risk was not influenced by BP levels. Neonatal complications decreased by approximately 47% as MAP declined from the highest to lowest category, and by about 17% with decreasing glucose levels.

CONCLUSIONS

Based on a large pregnancy cohort in China, this study revealed an interdependent association between maternal BP and glucose levels and their combined impact on the risk of SGA. It provided quantitative evidence of how this interdependence shapes the transition of risk patterns for SGA, neonatal complications, and LGA. These findings underscore the need for an integrated approach to co-managing BP and glucose levels during pregnancy.

The relationship between folic acid deficiency and preeclampsia-like phenotypes in rats

BACKGROUND

Pre-eclampsia is a significant contributor to maternal and neonatal morbidity and mortality. However, its etiology remains elusive. More and more studies have highlighted the potential involvement of folic acid metabolism in the development of pre-eclampsia. Folic acid is known to be important for DNA synthesis and methylation processes, which are crucial during pregnancy. Disruptions in these pathways may contribute to the pathogenesis of pre-eclampsia. Clinical studies investigating associations between folic acid supplementation and pre-eclampsia produced inconsistent results. The research aims to explore the potential link between folic acid deficiency and the development of pre-eclampsia-like symptoms in rat models, shedding light on the possible role of one-carbon metabolic pathways in the etiology of pre-eclampsia.

METHODS

Establishing a rat model with severe and moderate folate deficiency by providing female rats with a folate-deficient diet from birth or weaning, respectively. The effects on folate and homocysteine levels during pregnancy were then studied.

RESULTS

Both groups exposed to folate deficiency exhibited decreased levels of 5-methyltetrahydrofolic acid in both plasma and red blood cells, along with increased levels of homocysteine in plasma, compared to the control group. Consistent high blood pressure and urinary protein excretion were not significantly different among the three groups. However, fetuses from the folate-deficient group exhibited noticeably lower body weight compared to those from the folate-replete group.

CONCLUSIONS

Folate deficiency alone may not be sufficient to cause pre-eclampsia in rats, but it does increase the risk of offspring being small for their gestational age at birth.

sFlt-1, Coagulation Function, and Platelets as Predictors of Preeclampsia

OBJECTIVE

To investigate the predictive value of soluble FMS-like tyrosine kinase-1 (sFlt-1), coagulation function, and platelet (PLT) parameters for preeclampsia (PE).

METHODS

A prospective study was conducted on women registered and delivered at Shanghai Fifth People's Hospital from October 2020 to December 2021. All eligible pregnant women were recruited at the time of initial registration in the first trimester. We then obtained serum samples uniformly at 240-280 weeks and stored these samples in a freezer at -80°C and labelled them to create a biobank. Later, when PE was diagnosed, we followed the markers to find their blood samples and complete the tests. Participants were divided into healthy pregnant (HP) and PE groups. Participants were divided into HP and PE groups. Approximately 5 mL of venous blood was collected from each participant at 240-280 weeks gestation. Serum sFlt-1 was measured by enzyme-linked immunosorbent assay. Additionally, D-dimer, activated partial thromboplastin time (APTT), thrombin time (TT), prothrombin time (PT), antithrombin III (ATIII), fibrinogen, PLT, PLT distribution width (PDW), and mean PLT volume (MPV) were recorded. SPSS 27.0 software was used to analyze the correlation of these parameters with PE. Receiver operating characteristic curve analysis determined the optimal cutoff value for each parameter.

RESULTS

Serum sFlt-1, APTT, TT, ATIII, PLT, MPV, and PDW levels were significantly different between the PE and HP groups (P < 0.05). Among single-factor indicators for predicting PE, sFlt-1 exhibited the highest value. With an optimal cutoff value of 4.409 ng/mL, sFlt-1 demonstrated a sensitivity and specificity of 85.4% and 87.5%, respectively. The combination of sFlt-1, APTT, TT, PDW, and MPV yielded the highest predictive value, with an area under the receiver operating characteristic curve of 0.946, sensitivity of 86.8%, and specificity of 87.5%.

CONCLUSIONS

This study demonstrates that a combination of sFlt-1, APTT, TT, PDW, and MPV is a valuable tool for predicting PE.

Association between deep learning radiomics based on placental MRI and preeclampsia with fetal growth restriction: A multicenter study

PURPOSE

Preeclampsia (PE) is associated with placental insufficiency and could lead to adverse pregnancy outcomes. The study aimed to develop a placental T2-weighted image-based automatic quantitative model for the identification of PE pregnancies and disease severity.

METHODS

Between July 2013 and September 2022, the retrospective multicenter study featured 420 pregnant women, including 140 cases of PE and 280 cases of normotensive pregnancies. The semi-supervised approach was used to gain an automatic segmentation for placental MRI. The radiomics, deep learning, and deep learning radiomics (DLR) models were built.

RESULTS

In PE pregnancies, 65 (46.4 %) fetuses developed PE with fetal growth restriction (FGR), and 75 (53.6 %) cases were PE without FGR. The Dice of semi-supervised placental segmentation was 0.917. The AUCs of the DLR signature for discriminating PE pregnancies from normotensive pregnancies were 0.839 (95 % CI: 0.793-0.886), 0.858 (95 % CI: 0.742-0.974), 0.888 (95 % CI: 0.783-0.992), and 0.843 (95 % CI: 0.731-1.000) in the training, test, internal validation, and external validation sets, respectively. This DLR analysis model performed well in discriminating between PE with FGR and normotensive pregnancies (AUC = 0.918, 95 % CI: 0.879-0.957) and PE without FGR (AUC = 0.742, 95 % CI: 0659-0.824).

CONCLUSION

The automatic radiomics analysis has been developed to identify PE pregnancies by determining DLR features on placental T2-weighted images, and to predict FGR exposed to PE.

Research Hotspots and Thematic Trends in the Management of Preeclampsia: A Bibliometric Analysis from 2000 to 2022

Preeclampsia (PE) is one of the serious complications of pregnancy, and the management of PE remains an important problem for obstetricians. This study aims to identify the characteristics and trends of published articles on PE management through bibliometric analysis. We searched the Web of Science database for articles related to PE management from 2000 to 2022. Metadata was obtained, including the titles, publication dates, authors, institutions, countries, and keywords of all articles, and then network visualization and burst keyword analysis were performed using Citespace and VOSviewer software. A total of 5190 articles were included in the analysis. The number of publications in the field of PE management has steadily increased over the years, and a visual analysis of collaborative networks of authors, institutions, and countries revealed that the United States, United Kingdom, Australia, and Canada have contributed the most to the field and formed extensive collaborations. The Journal of maternal-fetal & neonatal medicine has the most publications in this field, and the Journal of Obstetrics and gynecology has not only more publications but also 64.75 citations per article. The keywords mainly focused on prevention, diagnosis, risk factors, and outcome of PE. In addition, hypertensive disorders of pregnancy and fetal growth restriction have received a lot of attention in this field in recent years. We analyzed the partnerships in the field of PE management through bibliometrics and showed trends and developments in the field. The available results suggest that PE management will continue to be a focus of attention for obstetricians and researchers.

Barriers and facilitators for adequate calcium intake during pregnancy: A mixed methods study

OBJECTIVE

This study evaluates the effectiveness of calcium supplementation as a preventive measure for pregnant women with insufficient calcium intake, examining adherence to the recommended 1000 mg daily intake and identifying influencing factors.

METHODS

A survey (Expect cohort II, n = 823) evaluated calcium adherence among pregnant women, followed by interviews with sixteen purposefully selected participants. Verbatim transcripts were independently analyzed to identify key themes.

RESULTS

Among survey participants, 82 % discussed the importance of calcium intake, with 83 % expressing intent to improve intake. Of those counselled on calcium, 48 % had insufficient intake, compared to 64 % without counseling. Facilitators included perceived safety, maternal motivation to keep child safe, trust in professionals, supportive environments, and increased awareness. Obstacles included lack of knowledge on calcium sources, pill dosage, low intrinsic motivation, information comprehension and novelty of the advice.

CONCLUSION

Despite of awareness raising efforts through counseling, only half of the women reached adequate calcium levels, with interviews revealing limited understanding. Clear messages on calcium benefits, dispelling concerns about potential harm, and offering concrete guidance can improve intake. Repetition of advice and increase publicity can normalize and enhance acceptability of calcium consumption during pregnancy.

Neonatal cost savings in hypertensive disorders of pregnancy: Economic evaluation of the sFlt-1/PlGF test with real world implementation of biomarkers

BACKGROUND

Preeclampsia is a key cause of prematurity in the U.S. and incurs significant healthcare costs. An imbalance between soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) predicts severe preeclampsia and aids in its management.

OBJECTIVE

This study aimed to assess the cost-effectiveness of the sFlt-1/PlGF test as an addition to standard care for patients at risk of developing preeclampsia.

STUDY DESIGN

A decision tree analysis was conducted to assess the cost effectiveness of the ratio test in the United States, using data from Preeclampsia Risk Assessment: Evaluation of Cut-offs to Improve Stratification [PRAECIS] and from a real-world evidence study conducted after the implementation of sFlt-1/PlGF testing into routine clinical practice (Biomarker Examination and Analysis for Clinical Obstetrical Navigation Study [BEACON]). The model compared standard of care alone versus a biomarker-based approach utilizing the sFlt-1/PlGF test for managing patients at risk of preeclampsia with severe features. Published data was used to estimate theoretical cost values of infants for their first six months of life.

RESULTS

The analysis indicated potential total neonatal cost savings of nearly $10,595,332 (95% CI: $6,555,439 to $14,730,536) per 1,000 patients using the sFlt-1/PlGF ratio test, translating to about $10,595 saved per patient. The incremental cost-effectiveness ratio (ICER) analysis showed a mean cost savings of $62,572 for each pregnancy prolonged by two weeks.

CONCLUSION

The sFlt-1/PlGF test, when used alongside standard care, enhances risk stratification for severe preeclampsia and may lead to significant neonatal cost savings by reducing preterm deliveries and neonatal intensive care admissions.

Single-Cell RNA Sequencing to Guide Autologous Preterm Cord Mesenchymal Stromal Cell Therapy

Rationale: The chronic lung disease bronchopulmonary dysplasia (BPD) remains the most common complication of extreme prematurity (<28 wk of gestation). Umbilical cord-derived mesenchymal stromal cells (UC-MSCs) represent an opportunity for autologous cell therapy, as UC-MSCs have been shown to improve lung function and structure in experimental BPD. However, characterization and repair capacity of UC-MSCs derived from donors with pregnancy-related complications associated with prematurity remain unexplored. Objectives: To characterize UC-MSCs' transcriptome and determine if pregnancy-related complications (preeclampsia and chorioamnionitis) alter their therapeutic potential. Methods: Single-cell RNA sequencing was used to compare the transcriptome of UC-MSCs derived from 5 term donors, 16 preterm donors, and human neonatal dermal fibroblasts (control cells of mesenchymal origin) and correlated with their therapeutic potential in experimental BPD. Using publicly available neonatal lung single-nucleus RNA sequencing data, we also determined putative communication networks between UC-MSCs and resident lung cell populations. Measurements and Main Results: Most UC-MSCs displayed a similar transcriptome despite their pregnancy-related conditions and mitigated hyperoxia-induced lung injury in newborn rats. Conversely, human neonatal dermal fibroblasts and one term and two preterm with preeclampsia UC-MSC donors exhibited a distinct transcriptome enriched in genes related to fibroblast function and senescence and were devoid of therapeutic benefit in hyperoxia-induced BPD. Conversely, therapeutic UC-MSCs displayed a unique transcriptome active in cell proliferation and distinct cell-cell interactions with neonatal lung cell populations, including NEGR (neuronal growth regulator 1) and NRNX (neurexin) pathways. Conclusions: Term and preterm UC-MSCs are lung protective in experimental BPD. Single-cell RNA sequencing allows us to identify donors with a distinct UC-MSC transcriptome characteristic of reduced therapeutic potential.

Association of MTHFR C677T and A1298C variants with preeclampsia risk and angiogenic imbalance in Tunisian women

Preeclampsia (PE) is a pregnancy-specific vascular disorder associated with endothelial dysfunction, hypertension, and proteinuria. The methylenetetrahydrofolate reductase (MTHFR) enzyme regulates essential cellular functions in pregnancy owing to its effects on folate metabolism and DNA methylation. Previous studies implicated the association of rs1801133 (C677T; Ala222Val) and rs1801131 (A1298C; Glu429Ala) in the MTHFR gene with PE in different ethnic groups, but with mixed outcomes.

METHODS

Study cases comprised 675 Tunisian pregnant women, of whom 350 PE presented with PE, and the remaining 325 normotensive women served as controls. Genotyping of C677T and A1298C variants was performed by real-time PCR.

RESULTS

There was no statistically significant difference in the minor allele frequencies of C677T and A1298C between preeclampsia cases and controls after adjusting for key covariates. In addition, the prevalence of MTHFR C677T and A1298C minor allele homozygote genotypes was significantly higher in PE cases. The association of 1298C/C, but not 677T/T, with PE persisted after adjusting for the main covariates. Carrying the (minor) 677T allele was associated with marginally higher BMI, significantly higher sFlt-1 serum levels, and median sFlt-1/PlGF ratio and sFlt-1/PlGF ratio ≥ 85. Setting the major allele homozygotes (C677/A1298) as a reference, haplotype analysis demonstrated a higher prevalence of C677/C1298 and T677/C1298 haplotypes (P = 0.03) in PE cases compared to controls, which persisted for C677/C1298, but not T677/C1298 after controlling for key covariates.

DISCUSSION

Our results support an association between MTHFR polymorphisms and increased risk of PE, and an imbalance of PE-associated sFLT-1/PlGF.

Glycosylated fibronectin in preeclampsia: a systematic review and meta-analysis

BACKGROUND

Preeclampsia (PE) is a complex multisystem disease, and its timely diagnosis and treatment impact the health of patients and perinatal infants. Studies have reported elevated levels of maternal serum glycosylated fibronectin (GlyFn) in patients with PE compared with pregnant women without PE (controls), suggesting its potential as a novel biomarker for screening and diagnosing PE. Therefore, this study aims to evaluate maternal serum GlyFn levels and their diagnostic accuracy in PE.

METHODS

A systematic literature search was conducted using PubMed, EMBASE, Web of Science, and the Cochrane Library up to January 15, 2024. The Newcastle-Ottawa Quality Assessment Scale and the Quality Assessment of Diagnostic Accuracy Studies-2 tool were used to evaluate study quality. Heterogeneity was assessed using I2 statistics. In the meta-analysis comparing maternal serum GlyFn levels between PE and controls, standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated. Publication bias was detected, and sensitivity and subgroup analyses were conducted to verify the robustness of the results and identify potential sources of heterogeneity. For the meta-analysis of diagnostic, the accuracy of maternal serum GlyFn levels between PE and controls, sensitivity and specificity were pooled and the summary receiver operating characteristic curve and area under the curve were used as measures of overall accuracy. This review was registered in the International Prospective Register of Systematic Reviews (registration number: CRD42024512172).

RESULTS

A total of 11 studies were included, and the meta-analysis revealed that maternal serum GlyFn levels were significantly higher in the PE group than in the control group (SMD = 1.08, 95% CI = 0.72-1.43, P < 0.001). Heterogeneity may arise from differences in the detection method and research type. Overall, the combined sensitivity and specificity of maternal serum GlyFn levels in diagnosing PE were 0.81 (95% CI = 0.77-0.85, P < 0.001) and 0.80 (95% CI = 0.77-0.82, P < 0.001), respectively, with an area under the curve of 0.90.

CONCLUSIONS

This meta-analysis confirmed that maternal serum GlyFn levels are significantly higher in patients with PE and exhibit high diagnostic accuracy for PE diagnosis, suggesting its potential as a biomarker for screening and diagnosing PE.

Dissecting the association of genetically predicted neuroticism with pre-eclampsia: A 2-sample Mendelian randomization study

Previous observational clinical studies have found a causal relationship between neurotic personality traits and various disorders. However, the relationship between neurotic personality characteristics and pre-eclampsia (PE) is not unclear. Two-sample Mendelian randomization (MR) was employed to examine the influence of neurotic personality traits on the risk of PE. From the Finnish genome-wide database, we identified 32 single-nucleotide polymorphisms linked to neuroticism personality traits, excluding 7 confounding variables related to blood pressure and BMI. The number of tool variables associated with PE was 25. Causality was assessed using inverse variance weighting, weighted median, MR-Egger, and weighted model methods. Sensitivity analyses, such as Cochran's Q statistic, MR-Egger intercept, MR pleiotropy residual sum and outlier, and leave-one-out analysis, were conducted to identify potential heterogeneity and horizontal pleiotropy. The present 2-sample MR study did not reveal any genetic associations between neuroticism and PE. A 2-sample Mendelian randomization analysis of 12 dichotomous neuroticism items indicated that genetic predisposition to worrying elevates the risk of PE. The inverse variance weighted method produced an odds ratio (OR) of 2.23 (95% CI: 1.36-3.65, P < .05), while the weighted median analysis indicated an OR of 2.41 (95% CI: 1.20-4.85, P < .05). However, there were no significant correlations between the MR Egger and weighted modes. This study found no genetic causal link between neuroticism and PE; however, carriers may have a genetically increased risk of PE, offering a more reliable foundation for future prevention efforts.

Adverse pregnancy outcomes, familial predisposition, and cardiovascular risk: a Swedish nationwide study

BACKGROUND AND AIMS

Adverse pregnancy outcomes (APOs) are recognized as significant female-specific risk factors for cardiovascular disease (CVD). A potential shared familial susceptibility between APOs and CVD has been proposed, but not thoroughly explored. This study employs a quasi-experimental family comparison design to investigate shared familial predisposition between APOs and CVD, by assessing risk of CVD in APO-exposed women and their APO-free sisters.

METHODS

Nationwide population-based cohort study encompassing primiparous women, without prior CVD, with registered singleton births in the Swedish Medical Birth Register between 1992 and 2019, grouped into: women with ≥1 APO (165 628), APO-free sisters (60 769), and unrelated APO-free comparator women (992 108). All study participants were followed longitudinally, through linkage with national health registers, from delivery until 2021, for primary endpoint major adverse cardiac events, and its individual components: ischaemic heart disease, heart failure, and cerebrovascular events.

RESULTS

Over a median follow-up of 14 years, APO-exposed women exhibited increased rates of CVDs compared with APO-free comparators. Adverse pregnancy outcome-free sisters exhibited elevated adjusted hazard ratios (aHRs) of major adverse cardiac event {aHR 1.39 [95% confidence interval (CI) 1.13-1.71]}, heart failure [aHR 1.65 (95% CI 1.14-2.39)], and cerebrovascular events [aHR 1.37 (1.04-1.72)] compared with the APO-free comparators, while no significant increase in ischaemic heart disease was observed. Within-family analysis revealed lower CVD rates in APO-free sisters compared with their APO-exposed counterparts, except for no significant difference in cerebrovascular events.

CONCLUSIONS

Sisters of women with APOs face a moderately increased risk of CVD, suggesting a genetic and/or environmental influence on the association between APOs and CVDs. These findings underscore the need for evaluating the effectiveness of targeted preventive measures in women with APOs and their sisters.

Factors associated with preeclampsia and the hypertensive disorders of pregnancy amongst Indigenous women of Canada, Australia, New Zealand, and the United States: A systematic review and meta-analysis

PURPOSE OF THE REVIEW

Preeclampsia and the Hypertensive Disorders of Pregnancy (HDP) occur more frequently amongst Indigenous women and can have short- and long-term impacts on maternal and infant health and wellbeing. To understand factors associated with increased risk for Indigenous women a systematic review and meta-analysis was conducted. The PRISMA guidelines were adhered to, and the review protocol was registered on PROSPERO (Registration CRD42023381847). EndNote, Covidence and Excel were used to screen and extract data, with studies assessed using JBI critical appraisal tools.

RECENT FINDINGS

Seven studies from Canada, Australia, and the United States (none from New Zealand) were included in this review. Meta-analysis showed women classified as overweight (OR 1.32, 95% CI: 1.09-1.60), obese (OR 1.88, 95% CI: 1.57-2.25), or having high mean BMI (MD 3.02 95% CI: 1.72-4.31), high mean systolic blood pressure (MD 15.19 95% CI: 12.83-17.541), or high mean diastolic blood pressure (MD 15.26 95% CI: 13.05-17.47), pre-pregnancy diabetes (OR 3.63, 95% CI: 1.66-17.94), or high microalbuminuria (OR 2.76, 95% CI: 1.40-5.43) were more likely to be diagnosed with preeclampsia. Smoking (OR 0.77, 95% CI: 0.58-1.03), alcohol consumption (OR 1.70, 95% CI: 0.76-3.81), and gestational diabetes (OR 1.74, 95% CI: 0.90-3.37) were not associated with preeclampsia. Understanding factors associated with increased preeclampsia/HDP risk amongst Indigenous women is important to minimising adverse perinatal events and future health complications. This review demonstrates current gaps in the evidence, specifically in relation to social, economic, and environmental factors.

Intracranial Hemorrhage During Pregnancy: An Interdisciplinary Literature Review and a Rare Case Report of Early-Onset Eclampsia with Intracranial Hemorrhage and HELLP Syndrome

Intracranial hemorrhage is a rare yet potentially devastating event during pregnancy with a significant risk of maternal and fetal mortality and morbidity. The risk of intracranial hemorrhage increases during the third trimester of pregnancy and is greatest during labor and the postpartum period. Interdisciplinary diagnosis and treatment of the pregnant population often begins in the emergency department setting and is key to increasing patient survival rates through immediate and adequate treatment, including emergency medicine, neurosurgical and obstetrical procedures. A unique case report with a diagnostic pathway for intracranial hemorrhage due to eclampsia in a primipara at 24 weeks of gestation is presented, illustrating potential diagnostic dilemmas as the patient rapidly progresses into hemolysis, elevated liver enzymes and low platelets syndrome. A literature review was conducted to uncover the etiology of intracranial hemorrhage during pregnancy, as well as its diagnostic challenges and treatment. Pregnancy should not be viewed as a barrier to performing angiography or endovascular treatment for vascular causes of intracranial hemorrhage. Patient transport to a tertiary reference center and the interdisciplinary cooperation of specialists are key to achieving correct and rapid treatment. Continuous prevention of preeclampsia and patient education are necessary to decrease the incidence of eclampsia and its complications. Key message: Intracranial hemorrhage and eclampsia in pregnant patients are rare yet may result in high rates of maternal and fetal morbidity and mortality. The diagnostic process is difficult and requires interdisciplinary cooperation to start the correct treatment immediately.

Prevalence, risk factors, and adverse perinatal outcomes in Chinese women with preeclampsia: a large retrospective cohort study

BACKGROUND

Preeclampsia (PE) is the primary cause of maternal and neonatal morbidity and mortality. However, comprehensive studies on the related risk factors with PE and its effects on adverse perinatal outcomes are limited. This study aimed to evaluate the prevalence, risk factors, and adverse perinatal outcomes in Chinese women with preeclampsia.

METHODS

We conducted a retrospective cohort study from January 1, 2018, to December 31, 2019, which enrolled 38,496 women without preeclampsia (non-PE) and 1130 women with PE. Univariate and multivariate logistic regression models were used to determine the risk factors and adverse perinatal outcomes of PE.

RESULTS

Multivariate logistic regression models showed that maternal age > 35 years, pp-BMI overweight/obesity, excessive gestational weight gain, multiparity, twin pregnancy, IVF, cesarean section history, times of abortion history ≥ 2, GDM, and ICP were significantly associated with the risk of PE (all P < 0.05). Women with PE in singleton pregnancies were associated with an increased risk of maternal outcomes of cesarean section, and preterm birth, and a higher risk of neonatal outcomes of stillbirth, low birth weight, fetal distress, neonatal asphyxia, and neonatal unit admission, which were also observed in women with PE in twin pregnancies, except for stillbirth and neonatal asphyxia.

CONCLUSION

This study identified the risk factors and associated adverse perinatal outcomes of PE, which providing comprehensive evidence for clinicians to manage women at risk of PE.

Prophylactic Aspirin Dose and Preeclampsia

Importance

It is unclear whether a higher dose (150-160 mg) or a lower dose (75 mg) of aspirin should be used to prevent preeclampsia.

Objectives

To compare the risk of preeclampsia and bleeding complications between women using 150 to 160 mg of aspirin and those using 75 mg of aspirin for preeclampsia prevention.

Design, Setting, and Participants

This nationwide cohort study included 13 828 women giving birth at 22 weeks' gestation or later in Sweden between January 2017 and December 2020 who used low dose aspirin (75-160 mg) during pregnancy. Data were analyzed from October to November 2023.

Exposure

The use of 150 to 160 mg or 75 mg of aspirin in pregnancy.

Main Outcome and Measures

The main outcome was a preeclampsia diagnosis recorded in the maternal birth record at the time of hospital discharge. The main safety outcome was postpartum hemorrhage, defined as bleeding more than 1000 mL after delivery. Relative risks (RRs) and 95% CIs were estimated using a doubly robust inverse probability-weighted regression adjustment model controlling for background characteristics.

Results

In the total cohort of 13 828 women, the mean (SD) age was 33.0 (5.5) years and 3003 women (21.7%) were nulliparous. Of the women, 4687 (33.9%) were prescribed 150 to 160 mg of aspirin, and 9141 (66.1%) were prescribed 75 mg of aspirin. A total of 10 635 women (76.9%) had at least 2 dispensed prescriptions of low-dose aspirin. Among women using 150 to 160 mg of aspirin, 443 (9.5%) developed preeclampsia compared with 812 (8.9%) of those using 75 mg of aspirin (adjusted RR [aRR], 1.07; 95% CI, 0.93-1.24). Additionally, the risk of postpartum hemorrhage between the groups was similar, with 326 women (6.9%) using 150 to 160 mg of aspirin experiencing a postpartum hemorrhage compared with 581 (6.4%) in the 75-mg group (aRR, 1.08; 95% CI, 0.90-1.30).

Conclusions and Relevance

In this cohort study of 13 828 women, no difference was found in preeclampsia incidence or bleeding complications between those using 150 to 160 mg of aspirin vs 75 mg of aspirin during pregnancy for preeclampsia prevention. These findings suggest that either dose may be a reasonable choice when using aspirin to prevent preeclampsia. However, large randomized trials investigating aspirin dose in pregnancy are still needed.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Variations in emergency care for severe pre-eclampsia in Uganda: a national evaluation study

Background

Worldwide, 70% of maternal deaths occur in Sub-Saharan Africa. Approximately 10% are attributable to hypertensive disorders of pregnancy, primarily complications of pre-eclampsia. Timely and effective care improves outcomes, but this is not consistently available, particularly in low-resource settings such as Uganda.

Objectives

We conducted a national evaluation of the provision of prompt and safe care for women with severe pre-eclampsia across all regions of Uganda. We explored the wider health system-related factors, eg supply availability, facilities, and emergency training drills, that may affect the ability of healthcare facilities to deliver optimal pre-eclampsia care.

Study design

A multidisciplinary research team carried out in-person, unannounced visits to maternity facilities across Uganda to assess the quality of care provided. Evaluations of facilities, staff interviews, and case notes reviews were performed.

Results

75 maternity facilities were included from all regions of Uganda. Of these, 25% were unable to provide correct emergency care for severe pre-eclampsia, and 21% were unable to consistently provide delivery or referral for eclamptic seizure within 12 hours. Factors strongly associated with not providing optimal pre-eclampsia care were lack of staff training, lack of readily available clinical protocols, lack of antenatal education, lack of close postnatal monitoring and care that was not always woman-centered.

Conclusions

The key barriers associated with delayed or poor quality pre-eclampsia care across Uganda are potentially modifiable with strengthened clinical governance initiatives. Developing context-specific, standardized, national training and educational programmes could be effective in reducing rates of maternal and neonatal morbidity and mortality from pre-eclampsia.

Preterm preeclampsia as an independent risk factor for thromboembolism in a large national cohort

BACKGROUND

Preterm preeclampsia, a product of vascular dysfunction, is associated with prolonged hospital admission and proteinuria, significant risk factors for thromboembolism in pregnancy. The risk of thromboembolism in preterm preeclampsia warrants further investigation.

OBJECTIVE

To determine the relationship between preterm preeclampsia and thromboembolic risk. We hypothesize that preterm preeclampsia is an independent risk factor for thromboembolism in pregnancy.

STUDY DESIGN

This is a retrospective cohort study using the National Inpatient Sample database via Healthcare Cost and Utilization Project-Agency for Healthcare Cost and Utilization Project from 2017-2019. All subjects with an International Classification of Diseases, Tenth Revision code for pregnancy or peripartum encounter were included. Subjects were excluded if the gestational age at delivery was <20 weeks or if they had a history of thromboembolism, inherited thrombophilia, or antiphospholipid syndrome. Patients with preterm (delivered <37 weeks) preeclampsia and term (delivered ≥37 weeks) preeclampsia were compared with those without preeclampsia. The primary outcome was a composite of any thromboembolic event, including pulmonary embolism, deep vein thrombosis, cerebral thrombosis or transient ischemic attack, or other thromboses. The secondary outcomes were rates of each type of thromboembolic event. The groups were compared via variance analysis, chi-square, and logistic regression analyses. The logistic regression included those variables that differed between groups with P<.05.

RESULTS

Of individuals in the database, >2.2 million met the inclusion criteria. A total of 56,446 (2.7%) had preterm preeclampsia, and 86,152 (6.7%) had term preeclampsia. Those with preterm preeclampsia were more likely to be older, identify as non-Hispanic black, have obesity, have chronic hypertension among other chronic diseases, and be in the lowest quartile of income (P<.001). Among patients with preterm preeclampsia, 0.32% experienced thromboembolism, whereas those with term preeclampsia and without preeclampsia experienced thromboembolism at 0.10% and 0.09%, respectively. After controlling for confounders that differed between groups with P<.05, preterm preeclampsia remained independently associated with any thromboembolic event (adjusted odds ratio, 2.21 [95% confidence interval, 1.84-2.65]), and each type of thromboembolism. Term preeclampsia was not associated with an increased risk of thromboembolism (adjusted odds ratio, 1.18 [95% confidence interval, 0.94-1.48]).

CONCLUSION

Preterm preeclampsia is independently associated with an increased risk of thromboembolic events.