Risks of hypertensive disorders in the second pregnancy

Postpartum and interpregnancy care of women with a history of hypertensive disorders of pregnancy

Hypertensive disorders of pregnancy (HDP) are common complications associated with maternal and neonatal morbidity and mortality worldwide. Insights gained from long-term cohort studies have revealed that women with a history of HDP are predisposed to recurrent HDP in subsequent pregnancies and face heightened risks for cardiovascular and metabolic diseases later in life. Pregnancy is a unique condition that overloads maternal cardiac and metabolic functions, and is recognized as a "maternal stress test" for future cardiovascular and metabolic diseases. Pregnancy and postpartum period provide a valuable opportunity for identifying women with underlying and unrecognized cardiovascular and metabolic risk factors. Establishing an effective postpartum healthcare program for women who have experienced HDP is crucial in reducing the future risk of health complications. Postpartum care consists of supportive care for both mothers and children, including not only the assessment of physical and psychological well-being but also long-term postpartum preventive health management. Interpregnancy care is a continuum from postpartum care and includes supportive care to prepare for future pregnancies. Various initiatives across nations have been initiated to establish follow-up programs for women with a history of HDP; however, sufficient evidence of the impact of such programs is not available. Substantial challenges persist in establishing an efficient postpartum follow-up program, including educational strategies, selection of effective lifestyle interventions, and collaboration among various healthcare providers. This review outlines the postpartum and interpregnancy care of women who have experienced HDP as well as the current status and challenges of related healthcare initiatives in Japan.

Challenges in Conducting Clinical Trials for Preeclampsia

PURPOSE OF REVIEW

To review recent data describing the challenges and innovations in therapeutic research focused on the prevention and treatment of preeclampsia.

RECENT FINDINGS

Pregnant individuals have traditionally been excluded from therapeutic research, resulting in a paucity of innovation in therapeutics for pregnancy-specific medical conditions, especially preeclampsia. With the increased awareness of maternal morbidity and mortality, there is significant interest among researchers to expand therapeutic research in pregnancy. Several medications, including aspirin, pravastatin, metformin, and esomeprazole, which are commonly used in non-pregnant populations, are now being investigated for preeclampsia prevention. However, given the historic precedent of exclusion, along with the regulatory, ethical, and feasibility concerns that accompany this population, the study of these and novel medications has been complicated by numerous challenges. While complex, and laden with challenges, there is great ongoing need for therapeutic research to address preeclampsia. Aspirin, pravastatin, metformin, and esomeprazole have all shown promise as potential therapeutic agents; however, their use remains to be optimized, and innovative therapeutics need to be developed.

Leveraging quality improvement to promote health equity: standardization of prenatal aspirin recommendations

OBJECTIVE

Aspirin (ASA) is recommended for patients at elevated risk of preeclampsia. Limited data exists on adherence to guidelines for ASA prescription. This project evaluates the implementation of a standardized approach to ASA prescription in an academic OB/Gyn practice.

METHODS

We implemented a quality improvement project to evaluate compliance with the United States Preventative Services Task Force (USPSTF) recommendations for ASA to prevent preeclampsia. Pre-intervention, we analyzed prescription adherence at 201 New Obstetric (NOB) visits. A multi-step intervention was then implemented at 199 NOB visits. Nurses utilized a checklist created from USPSTF guidelines to identify high-risk patients, defined as having ≥1 high-risk factor or ≥2 moderate-risk factors. ASA orders were placed by physicians. A Plan-Do-Study-Act (PDSA) cycle was performed, and changes implemented. Primary outcome was percent of patients screened at RN intake visit (goal = 90%). Secondary outcomes were percent of patients who screened positive that received the ASA recommendation (goal = 80%) and percent screened and recommended by race.

RESULTS

Pre-intervention, 47% of patients met criteria for ASA and 28% received a documented recommendation. Post-intervention, 99% were screened. Half (48%) met criteria for an ASA recommendation and 79% received a recommendation (p = < 0.001). Rates of appropriate recommendation did not differ by Black (80%) vs. non-Black (79%) status (p = 0.25). Subsequent PDSA cycles for 12 months neared 100% RN screening rates. Physicians correctly recommended ASA 80-100% of the time.

CONCLUSION

It is feasible, sustainable and equitable to standardize screening and implementation of ASA to patients at high risk for preeclampsia. Providers can easily reproduce our processes to improve delivery of equitable and reliable preventative obstetric care.

Association of the Severity of Hypertensive Disorders in Pregnancy with Birthweight, Childhood Obesity, and Blood Pressure at Age 7

We aimed to examine the effects of various severities of hypertensive disorders in pregnancy on birthweight, blood pressure (BP), and body mass index in offspring at age 7. In the China Labor and Delivery Survey and the United States Collaborative Perinatal Project (CPP), the relationship of the severity of hypertensive disorders and nutritional and cardiovascular outcomes in offspring was assessed using a multivariable logistic and general linear regression model. In both datasets, those with gestational hypertension were more likely to deliver large for gestational age (LGA) and macrosomia (adjusted odds ratios (aOR) ranged from 1.29 to 1.91), as well as low birth weight (LBW) neonates (aOR ranged from 1.23 to 3.56), compared with normotensive mothers. In the CPP, when gestational hypertension was further stratified into mild and severe, only those with mild gestational hypertension (the mild group) were more likely to deliver macrosomia and LGA (aOR ranged from 1.25 to 1.32). Others (severe gestational hypertension and preeclampsia/eclampsia) were closely related to LBW and small for gestational age (aOR ranged from 1.27 to 2.77). Moreover, children of mothers in the mild group tended to be overweight/obese and had elevated diastolic BP. We concluded that the severity of hypertensive disorders had different effects on birthweight, childhood overweight, and BP.

Hypertensive disorders of pregnancy and long-term cardiovascular health: FIGO Best Practice Advice

Hypertensive disorders of pregnancy (HDP) are the most common causes of maternal and perinatal morbidity and mortality. They are responsible for 16% of maternal deaths in high-income countries and approximately 25% in low- and middle-income countries. The impact of HDP can be lifelong as they are a recognized risk factor for future cardiovascular disease. During pregnancy, the cardiovascular system undergoes significant adaptive changes that ensure adequate uteroplacental blood flow and exchange of oxygen and nutrients to nurture and accommodate the developing fetus. Failure to achieve normal cardiovascular adaptation is associated with the development of HDP. Hemodynamic alterations in women with a history of HDP can persist for years and predispose to long-term cardiovascular morbidity and mortality. Therefore, pregnancy and the postpartum period are an opportunity to identify women with underlying, often unrecognized, cardiovascular risk factors. It is important to develop strategies with lifestyle and therapeutic interventions to reduce the risk of future cardiovascular disease in those who have a history of HDP.

Effects of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries: an individual participant data meta-analysis of 2 198 655 pregnancies

BACKGROUND

Existing evidence on the effects of race and ethnicity on pregnancy outcomes is restricted to individual studies done within specific countries and health systems. We aimed to assess the impact of race and ethnicity on perinatal outcomes in high-income and upper-middle-income countries, and to ascertain whether the magnitude of disparities, if any, varied across geographical regions.

METHODS

For this individual participant data (IPD) meta-analysis we used data from the International Prediction of Pregnancy Complications (IPPIC) Network of studies on pregnancy complications; the full dataset comprised 94 studies, 53 countries, and 4 539 640 pregnancies. We included studies that reported perinatal outcomes (neonatal death, stillbirth, preterm birth, and small-for-gestational-age babies) in at least two racial or ethnic groups (White, Black, south Asian, Hispanic, or other). For our two-step random-effects IPD meta-analysis, we did multiple imputations for confounder variables (maternal age, BMI, parity, and level of maternal education) selected with a directed acyclic graph. The primary outcomes were neonatal mortality and stillbirth. Secondary outcomes were preterm birth and a small-for-gestational-age baby. We estimated the association of race and ethnicity with perinatal outcomes using a multivariate logistic regression model and reported this association with odds ratios (ORs) and 95% CIs. We also did a subgroup analysis of studies by geographical region.

FINDINGS

51 studies from 20 high-income and upper-middle-income countries, comprising 2 198 655 pregnancies, were eligible for inclusion in this IPD meta-analysis. Neonatal death was twice as likely in babies born to Black women than in babies born to White women (OR 2·00, 95% CI 1·44-2·78), as was stillbirth (2·16, 1·46-3·19), and babies born to Black women were at increased risk of preterm birth (1·65, 1·46-1·88) and being small for gestational age (1·39, 1·13-1·72). Babies of women categorised as Hispanic had a three-times increased risk of neonatal death (OR 3·34, 95% CI 2·77-4·02) than did those born to White women, and those born to south Asian women were at increased risk of preterm birth (OR 1·26, 95% CI 1·07-1·48) and being small for gestational age (1·61, 1·32-1·95). The effects of race and ethnicity on preterm birth and small-for-gestational-age babies did not vary across regions.

INTERPRETATION

Globally, among underserved groups, babies born to Black women had consistently poorer perinatal outcomes than White women after adjusting for maternal characteristics, although the risks varied for other groups. The effects of race and ethnicity on adverse perinatal outcomes did not vary by region.

FUNDING

National Institute for Health and Care Research, Wellbeing of Women.

Racial and ethnic differences in the relationship between infant loss after prior live birth and hypertensive disorders in pregnancy

BACKGROUND

Race and ethnicity influence the distribution and severity of hypertensive disorders of pregnancy (HDP) in the U.S. population, although the impact of prior infant loss on this relationship requires further investigation.

OBJECTIVES

The aim of this study was to assess the relationship between history of infant loss and the risk of HDP by maternal race and ethnicity.

METHODS

For this large cross-sectional study, data were analyzed from the National Center for Health Statistics Vital Statistics Natality Birth Data, 2014-2017. The primary outcome was HDP, and the primary predictor was infant loss after prior live birth. Maternal race/ethnicity was the secondary predictor categorized as Non-Hispanic White (NHW), Non-Hispanic Black (NHB), Hispanic, Asian, or Other. Multiple logistic regression was used to assess the association between history of infant loss and HDP by race and ethnicity.

RESULTS

The 9,439,520 women included in this sample were 51% NHW, 15% NHB, 25% Hispanic, 6% Asian, and 3% Other with a mean age of 29.8 ± 5.3 years. In adjusted analyses, infant loss after prior live birth was significantly associated with an 11% odds of HDP (OR 1.11, 95% CI 1.08, 1.13). Stratified by race, NHB (OR 1.28; 95% CI 1.21, 1.36) women had significantly higher odds of HDP, and Hispanic (OR 0.84, 95% CI 0.79, 0.90) and Asian (OR 0.85, 95% CI 0.75, 0.97) women had significantly lower odds compared to NHW women. Within races, all women with infant loss after prior live birth had significantly higher odds of HDP (p < .001), except Other women (p = .632).

CONCLUSIONS

Infant loss after prior live birth was significantly associated with higher odds of HDP among NHB women after adjusting for covariates. Further research is warranted to assess underlying mechanisms associated with higher odds of HDP in NHB women.

A global view of hypertensive disorders and diabetes mellitus during pregnancy

Two important maternal cardiometabolic disorders (CMDs), hypertensive disorders in pregnancy (HDP) (including pre-eclampsia) and gestational diabetes mellitus (GDM), result in a large disease burden for pregnant individuals worldwide. A global consensus has not been reached about the diagnostic criteria for HDP and GDM, making it challenging to assess differences in their disease burden between countries and areas. However, both diseases show an unevenly distributed disease burden for regions with a low income or middle income, or low-income and middle-income countries (LMICs), or regions with lower sociodemographic and human development indexes. In addition to many common clinical, demographic and behavioural risk factors, the development and clinical consequences of maternal CMDs are substantially influenced by the social determinants of health, such as systemic marginalization. Although progress has been occurring in the early screening and management of HDP and GDM, the accuracy and long-term effects of such screening and management programmes are still under investigation. In addition to pharmacological therapies and lifestyle modifications at the individual level, a multilevel approach in conjunction with multisector partnership should be adopted to tackle the public health issues and health inequity resulting from maternal CMDs. The current COVID-19 pandemic has disrupted health service delivery, with women with maternal CMDs being particularly vulnerable to this public health crisis.

Prenatal antidepressant use and the implication of hypertensive disorders during pregnancy

BACKGROUND

Evidence for the association between prenatal antidepressant use and the development of hypertensive disorders of pregnancy is inconsistent. Previous studies have reported that antidepressant use during pregnancy increases the risk for gestational hypertension and preeclampsia, but the results of these studies are potentially confounded by important methodologic limitations. Furthermore, it remains unknown whether a higher cumulative dose of antidepressant increases the risk for hypertensive disorders of pregnancy.

OBJECTIVE

This study aimed to investigate the association between prenatal antidepressant use and the risk for hypertensive disorders of pregnancy and the potential effect of a higher cumulative antidepressant dose.

STUDY DESIGN

This retrospective cohort study used data from the Health and Welfare Database in Taiwan. Pregnant women with depression aged 18 to 49 years were enrolled as part of the study population. Prenatal antidepressant use was defined as at least 1 dispensing record of an antidepressant between the conception date and 20 weeks of gestation. Antidepressant users were further divided into groups according to the cumulative defined daily dose based on whether they took the defined daily dose for ≤10 weeks (low cumulative dose group ≤70 cumulative defined daily dose) or for >10 weeks (high cumulative dose group >70 cumulative defined daily dose). The primary outcome was hypertensive disorders of pregnancy defined as the diagnosis of either gestational hypertension or preeclampsia during the period from 20 weeks of gestation to delivery. Propensity score matching and stabilized inverse probability of treatment weighting were used to balance the confounders between the comparison groups. A robust Cox regression model was used to evaluate the association between exposure and outcome.

RESULTS

A total of 5664 pregnant women with depression were included in the study (2832 antidepressant users matched to 2832 antidepressant nonusers). Prenatal antidepressant use was not associated with an increased risk for hypertensive disorders of pregnancy (adjusted hazard ratio, 0.89; 95% confidence interval, 0.67-1.18). However, among antidepressant users, the risk for hypertensive disorders of pregnancy was higher among women with a higher cumulative defined daily dose than among women with a lower cumulative defined daily dose (adjusted hazard ratio, 2.46; 95% confidence interval, 1.05-5.74).

CONCLUSION

No association was found between antidepressant use and the development of hypertensive disorders of pregnancy. However, women taking higher cumulative doses of antidepressants were at greater risk. More frequent or regular monitoring of blood pressure may be warranted in women on high cumulative doses of antidepressants.

Validation and development of models using clinical, biochemical and ultrasound markers for predicting pre-eclampsia: an individual participant data meta-analysis

BACKGROUND

Pre-eclampsia is a leading cause of maternal and perinatal mortality and morbidity. Early identification of women at risk is needed to plan management.

OBJECTIVES

To assess the performance of existing pre-eclampsia prediction models and to develop and validate models for pre-eclampsia using individual participant data meta-analysis. We also estimated the prognostic value of individual markers.

DESIGN

This was an individual participant data meta-analysis of cohort studies.

SETTING

Source data from secondary and tertiary care.

PREDICTORS

We identified predictors from systematic reviews, and prioritised for importance in an international survey.

PRIMARY OUTCOMES

Early-onset (delivery at < 34 weeks' gestation), late-onset (delivery at ≥ 34 weeks' gestation) and any-onset pre-eclampsia.

ANALYSIS

We externally validated existing prediction models in UK cohorts and reported their performance in terms of discrimination and calibration. We developed and validated 12 new models based on clinical characteristics, clinical characteristics and biochemical markers, and clinical characteristics and ultrasound markers in the first and second trimesters. We summarised the data set-specific performance of each model using a random-effects meta-analysis. Discrimination was considered promising for C-statistics of ≥ 0.7, and calibration was considered good if the slope was near 1 and calibration-in-the-large was near 0. Heterogeneity was quantified using I ² and τ². A decision curve analysis was undertaken to determine the clinical utility (net benefit) of the models. We reported the unadjusted prognostic value of individual predictors for pre-eclampsia as odds ratios with 95% confidence and prediction intervals.

RESULTS

The International Prediction of Pregnancy Complications network comprised 78 studies (3,570,993 singleton pregnancies) identified from systematic reviews of tests to predict pre-eclampsia. Twenty-four of the 131 published prediction models could be validated in 11 UK cohorts. Summary C-statistics were between 0.6 and 0.7 for most models, and calibration was generally poor owing to large between-study heterogeneity, suggesting model overfitting. The clinical utility of the models varied between showing net harm to showing minimal or no net benefit. The average discrimination for IPPIC models ranged between 0.68 and 0.83. This was highest for the second-trimester clinical characteristics and biochemical markers model to predict early-onset pre-eclampsia, and lowest for the first-trimester clinical characteristics models to predict any pre-eclampsia. Calibration performance was heterogeneous across studies. Net benefit was observed for International Prediction of Pregnancy Complications first and second-trimester clinical characteristics and clinical characteristics and biochemical markers models predicting any pre-eclampsia, when validated in singleton nulliparous women managed in the UK NHS. History of hypertension, parity, smoking, mode of conception, placental growth factor and uterine artery pulsatility index had the strongest unadjusted associations with pre-eclampsia.

LIMITATIONS

Variations in study population characteristics, type of predictors reported, too few events in some validation cohorts and the type of measurements contributed to heterogeneity in performance of the International Prediction of Pregnancy Complications models. Some published models were not validated because model predictors were unavailable in the individual participant data.

CONCLUSION

For models that could be validated, predictive performance was generally poor across data sets. Although the International Prediction of Pregnancy Complications models show good predictive performance on average, and in the singleton nulliparous population, heterogeneity in calibration performance is likely across settings.

FUTURE WORK

Recalibration of model parameters within populations may improve calibration performance. Additional strong predictors need to be identified to improve model performance and consistency. Validation, including examination of calibration heterogeneity, is required for the models we could not validate.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015029349.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 72. See the NIHR Journals Library website for further project information.

A case of hypertensive disorders of pregnancy that developed at 9 weeks of gestation

Preeclampsia and superimposed preeclampsia usually develop after 20 weeks of gestation. We report a case of a 35-year-old Japanese woman who developed hypertensive disorders of pregnancy (HDP) before 20 weeks of gestation. She presented with hypertension and proteinuria at 9 and 11 weeks of gestation, respectively, and developed nephrotic syndrome at 17 weeks of gestation. She did not have definite hypertension or urinary abnormalities before pregnancy. The patient was serologically positive for the antinuclear antibody. However, the complement levels were normal and anti-phospholipid antibody was not detected. A renal biopsy performed at 18 weeks of gestation showed diffuse endotheliosis and tip lesions of secondary focal segmental glomerulosclerosis but no hypertensive changes of the arterioles. Although electron microscopic examination showed electron-dense deposits in the subendothelial lesions, they were considered nonspecific plasma exudation by mass spectrometry. An abortion was performed at 20 weeks gestation because the patient's congestive symptoms due to nephrotic syndrome had worsened and marked fetal growth restriction was observed. After delivery, the patient's symptoms resolved immediately without any additional treatment; however, continuous antihypertensive medication was required. Finally, the patient was diagnosed with HDP based on the renal biopsy findings and her clinical course after delivery. Compared to previous reports, this case describes the earliest onset of HDP. Thus, HDP should be considered as a differential diagnosis in pregnant women with hypertension or proteinuria presenting with symptoms before 20 weeks of gestation.

Prevalence and determinants of hypertensive disorders of pregnancy in Ethiopia: A systematic review and meta-analysis

Introduction

Hypertensive disorder of pregnancy is the second commonest causes of maternal death globally. Different public health studies were conducted on hypertensive disorder of pregnancy which presented inconsistent result. Therefore, this systematic review and meta-analysis was commenced to summarize the findings conducted in several parts of the country and to generate the nationwide representative data on the prevalence and risk factors of hypertensive disorder of pregnancy in Ethiopia.

Methods and materials

Electronic databases such as PubMed, Scopus, Google Scholar, Hinari, and African Journals Online were searched for studies published in English up to March, 2020. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument and Newcastle-Ottawa Scale were used for data extraction and quality assessment of the included studies. The meta- regression analysis was computed at 95% CI to present the pooled prevalence and risk factors of hypertensive disorder of pregnancy.

Results

Thirty four studies were included in this systematic review and meta-analysis. The pooled prevalence of hypertensive disorder of pregnancy and preeclampsia in Ethiopia were 6.82% (95% CI (5.90, 7.74)) and 4.74% (95% CI (3.99, 5.49)) respectively. Maternal age ≥35 years (Adjusted Odds Ratio (AOR): 2.91 (95% CI: 1.60, 5.26)), twin pregnancy (AOR: 3.04 (95% CI: 1.89, 4.87)), previous history of preeclampsia (AOR: 5.36 (95% CI: 3.37, 8.53)), family history of hypertension (AOR: 4.01 (95% CI: 2.65, 6.07)), family history of diabetes mellitus (AOR: 3.07 (95% CI: 1.66, 7.70)), body mass index ≥25 (AOR: 3.92 (95% CI: 1.82, 8.42)), alcohol consumption (AOR: 1.77 (95% CI: 1.11, 2.83)), urinary tract infection (AOR: 4.57 (95% CI: 3.47, 6.02)), lack of nutritional counseling during antenatal period (AOR: 4.87 (95% CI: 3.36, 7.06)), lack of fruits (AOR: 3.49 (95% CI: 2.29, 5.30)), and vegetables consumption (AOR: 2.94 (95% CI: 2.01, 4.31)) were the risk factors of hypertensive disorder of pregnancy in Ethiopia.

Conclusions

The pooled prevalence of hypertensive disorder of pregnancy is relatively higher compared with the previous reports. Maternal age ≥35 years, twin pregnancy, previous history of preeclampsia, family history of hypertension, family history of diabetes mellitus, body mass index ≥25, alcohol consumption, urinary tract infection, lack of fruits and vegetables during pregnancy were risk factors of hypertensive disorder of pregnancy. The governments and stakeholders should work to strengthen the antenatal care practice to include the possible risk factors of hypertensive disorders of pregnancy.

Association Between Funisitis and Childhood Intellectual Development: A Prospective Cohort Study

Background: Previous studies have suggested that prenatal inflammation could damage the immature brain of preterm infants. In this study, we aimed to investigate whether funisitis could affect childhood neurodevelopment. We hypothesized that childhood neurodevelopment would vary across groups with or without funisitis.

Material sand Methods: Using data from the U.S. Collaborative Perinatal Project (1959–1976), 29,725 subjects with available intelligence quotient (IQ) were studied. Detailed placental examinations were conducted according to a standard protocol with quality control procedures. Multivariate logistic regression models were applied to evaluate the relationship between funisitis and IQ at age 4 or 7 years after adjusting for confounders.

Results: Early preterm birth children with funisitis had a 3.0-fold (95% confidence interval 1.2, 7.3) risk of low full-scale IQ (<70) at age 4 years, which disappeared until age 7 years. Term birth children with funisitis had 1.9-fold (95% confidence interval 1.2, 3.0) risk of low performance IQ at age 7 years, but they did not have increased risk of low full-scale IQ. No difference in IQ score was found in late preterm birth children.

Conclusion: Funisitis may injure the developmental brain of infants, leading to the relative low IQ in childhood at age 4, but the negative effect is only existed in performance IQ at age of 7.

Aspirin use during pregnancy and hypoxia-related placental pathology

OBJECTIVE

Aspirin has been shown to prevent preeclampsia. But the mechanisms remain unclear despite that improved placental circulation is considered as an underlying contributor. Our aim was to examine the hypoxia-related morphological and histopathological placental measures in relation to aspirin use during pregnancy.

STUDY DESIGN

We used the Collaborative Perinatal Project (CPP) data, which is a cohort study conducted in the U.S. from 1959 to 1976. A total of 23, 604 women who had information on placental pathology and aspirin intake during pregnancy were included in the analysis. Among them, 1474 women had a history of hypertension or preeclampsia/eclampsia and were classified as a high-risk population; the rest were considered as a low-risk population. 47 placenta measures considered to be relevant to hypoxia were selected to build a composite hypoxia- related placenta index. The generalized linear mixed model was used to fit the relationship between aspirin and placental pathology.

MAIN OUTCOME MEASURES

Hypoxia-related placental pathology.

RESULTS

Aspirin use during pregnancy was associated with a reduced risk of hypoxia-related placental pathology in the high-risk population [the adjusted odds ratio and 95% confidence interval in the 1st, 2nd, and 3rd trimesters: 0.55 (0.31, 1.00), 0.76 (0.49, 1.17), and 0.53 (0.29, 0.94), respectively]. Longer duration of aspirin use in pregnancy tended to have a lower risk of hypoxia-related placental pathologies in the high-risk population.

CONCLUSIONS

Aspirin use during pregnancy reduced risks of hypoxia-related placental pathologies in the high-risk women for preeclampsia. The duration of aspirin use determined its effects.

Placental pathology and hypospadias

BACKGROUND

Studies have shown that hypospadias is associated with placenta-mediated pregnancy complication (PMPC). The role of placental lesions is still unclear. We aimed to examine the association between hyposadias and placental pathology, and the effect of PMPC.

METHODS

Using data from the US Collaborative Perinatal Project in 1959-1966, we identified 15,780 male subjects (167 hypospadias) for analysis. Detailed placental examinations were conducted following a standard protocol. Subjects were divided into two groups according to whether they had PMPC, including small-for-gestational-age, pre-eclampsia/eclampsia or placental abruption. Logistic regression models were used to explore the association.

RESULTS

The prevalence of hypospadias was two times higher in subjects with PMPC than those without. Compared to pregnancies with PMPC but no hypospadias, those with both PMPC and hypospadias had significant higher prevalence of placental lesions, such as low placental weight, vascular lesions, villous lesions, and membranous insertion of cord (adjusted odds ratio (OR) ranging from 2.6 to 5.2) after adjusting for potential confounders. In subjects without PMPC, no significant difference of placental pathology was found between those with or without hypospadias.

CONCLUSION

About one third of hypospadias cases were complicated with PMPC and had a higher risk of placental lesions, suggesting heterogeneity of hypospadias etiology and mechanisms.

Epidemiology of hypertensive disorders in pregnancy: prevalence, risk factors, predictors and prognosis

Hypertensive disorders in pregnancy (HDP) represent some of the most important problems faced by public health because HDP is a major cause of maternal and prenatal morbidity and mortality. Several epidemiological studies have been performed to determine the prevalence and risk factors of HDP as well as its subtypes. The prevalences of HDP, gestational hypertension and preeclampsia are 5.2-8.2%, 1.8-4.4% and 0.2-9.2%, respectively. Body mass index, anemia and lower education appear to be modifiable risk factors for HDP. Maternal age, primiparous, multiple pregnancy, HDP in previous pregnancy, gestational diabetes mellitus, preexisting hypertension, preexisting type 2 diabetes mellitus, preexisting urinary tract infection and a family history of hypertension, type 2 diabetes mellitus and preeclampsia appear to be nonmodifiable risk factors. Genetic variants including a single-nucleotide polymorphism in the angiotensinogen gene have also been reported to be nonmodifiable risk factors. Epidemiological studies have recently examined the associations between a history of HDP and its subtypes and future risks of other diseases. These studies have reported associations between a history of HDP and a risk of coronary heart disease, heart failure, dysrhythmia, stroke, hypertension, diabetes mellitus, end-stage renal dysfunction and cardiomyopathy. HDP is not associated with the future incidence of total cancer. In conclusion, HDP is not a rare complication of pregnancy and the influence of HDP remains for an extended duration. Physicians should consider the effects of HDP when treating chronic diseases in women.

Programming of maternal and offspring disease: impact of growth restriction, fetal sex and transmission across generations

Babies born small are at an increased risk of developing myriad adult diseases. While growth restriction increases disease risk in all individuals, often a second hit is required to unmask 'programmed' impairments in physiology. Programmed disease outcomes are demonstrated more commonly in male offspring compared with females, with these sex-specific outcomes partly attributed to different placenta-regulated growth strategies of the male and female fetus. Pregnancy is known to be a major risk factor for unmasking a number of conditions and can be considered a 'second hit' for women who were born small. As such, female offspring often develop impairments of physiology for the first time during pregnancy that present as pregnancy complications. Numerous maternal stressors can further increase the risk of developing a maternal complication during pregnancy. Importantly, these maternal complications can have long-term consequences for both the mother after pregnancy and the developing fetus. Conditions such as preeclampsia, gestational diabetes and hypertension as well as thyroid, liver and kidney diseases are all conditions that can complicate pregnancy and have long-term consequences for maternal and offspring health. Babies born to mothers who develop these conditions are often at a greater risk of developing disease in adulthood. This has implications as a mechanism for transmission of disease across generations. In this review, we discuss the evidence surrounding long-term intergenerational implications of being born small and/or experiencing stress during pregnancy on programming outcomes.

Pre-pregnant Prediction of Recurrent Preeclampsia in Normotensive Thrombophilic Formerly Preeclamptic Women Receiving Prophylactic Antithrombotic Medication

BACKGROUND

Both hemodynamic abnormalities and thrombophilia predispose to pregnancy-associated vascular complications such as fetal growth restriction, stillbirth, preeclampsia, and placental abruption. Antithrombotic treatment may reduce the risk for these events. In this study we tested the hypothesis that in normotensive thrombophilic formerly preeclamptic women certain alterations in hemodynamic function as measured under nonpregnant conditions predict the development of hypertensive disorders and/or fetal growth restriction in the subsequent pregnancy.

METHODS

In 350 nondiabetic formerly preeclamptic women, we measured in the follicular phase of the menstrual cycle at least 5 months postpartum central hemodynamic, metabolic, and hemostatic variables. In the subsequent ongoing pregnancy we determined fetal outcome variables and the incidence of maternal vascular complications. In addition to a normotensive thrombophilic profile, inclusion for final analysis required a subsequent singleton pregnancy, established within 1 year following the pre-pregnant evaluation and ongoing beyond 16 weeks' gestation. As a consequence, 47 normotensive thrombophilic formerly preeclamptic women could be included for final analysis. All formerly preeclamptic participants received aspirin throughout pregnancy. Additionally, those with thrombophilia or hyperhomocysteinemia were treated with low molecular weight heparin and with pyridoxine and folic acid supplementation, respectively.

RESULTS

Among 350 formerly preeclamptic women, 266 (76%) were normotensive and 84 (24%) hypertensive. About half (140/266) of normotensive formerly preeclamptic participants were thrombophilic. One hundred eighteen formerly preeclamptic participants succeeded in establishing an ongoing pregnancy within 1 year. From this subset of formerly preeclamptic women, 47 were normotensive thrombophilic; 23 remained normotensive (THROMB), whereas 24 developed at least gestational hypertension (COMPLITHROMB). Participants in the latter subgroup were more obese than those remaining normotensive. In addition, this former subset of women had a higher vascular resistance index, and a lower plasma volume and cardiac index. With respect to fetal outcome, COMPLITHROMB gave birth to an infant with a lower birth weight relative to THROMB. Preeclampsia with or without the hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome recurred in 26% of the participants in the whole thrombophilic group, in which a low pre-pregnant plasma volume and a raised vascular resistance predisposed for recurrent hypertensive disorders.

CONCLUSION

Pre-pregnant hemodynamic, metabolic, and clotting variables in formerly preeclamptic women can predict hypertension in the subsequent pregnancy.

Delivery Blood Pressure and Other First Pregnancy Risk Factors in Relation to Hypertensive Disorders in Second Pregnancies

BACKGROUND

First pregnancy characteristics and blood pressure (BP) measures may be associated with second pregnancy hypertensive disorder risk. We examined the association between first pregnancy risk factors and second pregnancy hypertensive disorders.

METHODS

Electronic medical records of nulliparas (n = 26,787) delivering at least twice in Utah (2002-2010) were used. Polychotomous logistic regression models estimated the association of first pregnancy risk factors with second pregnancy hypertensive disorders (gestational hypertension, preeclampsia, or chronic hypertension) stratified by first pregnancy hypertensive status and adjusted for second characteristics.

RESULTS

Among normotensive women in their first pregnancy, preterm birth (<34 weeks) and elevated BP at delivery admission in the first pregnancy increased odds of all incident hypertensive disorders in the second. Even borderline admission BP (either systolic or diastolic BP: 130-139 or 85-89 mm Hg, respectively) was associated with a doubling of hypertensive disorder risk in a subsequent pregnancy. First pregnancy BP was also associated with recurrence risks for hypertensive disorders, but the relation was stronger for women with gestational hypertension in their first pregnancy with more than 2-fold elevated risk across all BP categories (odds ratios range: 2.32-12.6). However, the majority of women (75%) with a hypertensive disorder in the first pregnancy do not repeat this outcome in the second pregnancy.

CONCLUSION

Delivery admission BP of a first pregnancy was strongly related to hypertensive disorder incidence and recurrence in the subsequent pregnancy. Although crude, these measures may prove useful as a predictor of long-term maternal health and future pregnancy risk.

Recurrence of hypertensive disorders of pregnancy: an individual patient data metaanalysis

OBJECTIVE

We performed an individual participant data (IPD) metaanalysis to calculate the recurrence risk of hypertensive disorders of pregnancy (HDP) and recurrence of individual hypertensive syndromes.

STUDY DESIGN

We performed an electronic literature search for cohort studies that reported on women experiencing HDP and who had a subsequent pregnancy. The principal investigators were contacted and informed of our study; we requested their original study data. The data were merged to form one combined database. The results will be presented as percentages with 95% confidence interval (CI) and odds ratios with 95% CI.

RESULTS

Of 94 eligible cohort studies, we obtained IPD of 22 studies, including a total of 99,415 women. Pooled data of 64 studies that used published data (IPD where available) showed a recurrence rate of 18.1% (n=152,213; 95% CI, 17.9-18.3%). In the 22 studies that are included in our IPD, the recurrence rate of a HDP was 20.7% (95% CI, 20.4-20.9%). Recurrence manifested as preeclampsia in 13.8% of the studies (95% CI,13.6-14.1%), gestational hypertension in 8.6% of the studies (95% CI, 8.4-8.8%) and hemolysis, elevated liver enzymes and low platelets (HELLP) syndrome in 0.2% of the studies (95% CI, 0.16-0.25%). The delivery of a small-for-gestational-age child accompanied the recurrent HDP in 3.4% of the studies (95% CI, 3.2-3.6%). Concomitant HELLP syndrome or delivery of a small-for-gestational-age child increased the risk of recurrence of HDP. Recurrence increased with decreasing gestational age at delivery in the index pregnancy. If the HDP recurred, in general it was milder, regarding maximum diastolic blood pressure, proteinuria, the use of oral antihypertensive and anticonvulsive medication, the delivery of a small-for-gestational-age child, premature delivery, and perinatal death. Normotensive women experienced chronic hypertension after pregnancy more often after experiencing recurrence (odds ratio, 3.7; 95% CI, 2.3-6.1).

CONCLUSION

Among women that experience hypertension in pregnancy, the recurrence rate in a next pregnancy is relatively low, and the course of disease is milder for most women with recurrent disease. These reassuring data should be used for shared decision-making in women who consider a new pregnancy after a pregnancy that was complicated by hypertension.

Risk factors differ between recurrent and incident preeclampsia: a hospital-based cohort study

PURPOSE

To examine whether risk factors, including prepregnancy body mass index (BMI), differ between recurrent and incident preeclampsia.

METHODS

Data included electronic medical records of nulliparas (n = 26,613) delivering 2 times or more in Utah (2002-2010). Modified Poisson regression models were used to examine (1) adjusted relative risks (RR) of preeclampsia and 95% confidence intervals (CI) associated with prepregnancy BMI; (2) maternal risk factor differences between incident and recurrent preeclampsia among primiparous women.

RESULTS

In the first pregnancy, compared with normal weight women (BMI: 18.5-24.9), preeclampsia risks for overweight (BMI: 25-29.9), obese class I (BMI: 30-34.9), and obese class II/III (BMI: ≥ 35) women were 1.82 (95% CI = 1.60-2.06), 2.10 (95% CI = 1.76-2.50), and 2.84 (95% CI = 2.32-3.47), respectively, whereas second pregnancy-incident preeclampsia risks were 1.66 (95% CI = 1.27-2.16), 2.31 (95% CI = 1.67-3.20), and 4.29 (95% CI = 3.16-5.82), respectively. Recurrent preeclampsia risks associated with BMI were highest among obese class I women (RR = 1.60; 95% CI = 1.06-2.42) without increasing in a dose-response manner. Nonwhite women had higher recurrence risk than white women (RR = 1.70; 95% CI = 1.16-2.50), whereas second pregnancy-incident preeclampsia risk did not differ by race.

CONCLUSION

Prepregnancy BMI appeared to have stronger associations with risk of incident preeclampsia either in the first or second pregnancy, than with recurrence risk. Nonwhite women had higher recurrence risk.

Prediction of recurrence of hypertensive disorders of pregnancy in the term period, a retrospective cohort study

OBJECTIVES

To assess the recurrence risk of term hypertensive disease of pregnancy and to determine which potential risk factors are predictive of recurrence.

STUDY DESIGN

We performed a retrospective cohort study in two secondary and one tertiary care hospitals in the Netherlands. We identified women with a hypertensive disorder in the index pregnancy and delivery after 37weeks of gestation between January 2000 and December 2002. Data were extracted from medical files and women were approached for additional information on subsequent pregnancies. Adverse outcome was defined as recurrence of a hypertensive disorder in the next subsequent pregnancy.

MAIN OUTCOME MEASURES

The absolute risk of recurrence and a prediction model containing demographic and clinical factors predictive of recurrence.

RESULTS

We identified 638 women for potential inclusion, of whom 503 could be contacted. Of these women, 312 (62%) had a subsequent pregnancy. Hypertensive disorders recurred in 120 (38%, 95% CI 33-44) women, of whom 15 (5%, 95% CI 3-7) delivered preterm. Women undergoing recurrence were more at risk to develop chronic hypertension after pregnancy (35% versus 16%, OR 2.8, 95% CI 1.5-5.3). Body mass index, non-White European origin, chronic hypertension, maximum diastolic blood pressure, no use of anticonvulsive medication and interpregnancy interval were predictors for recurrence.

CONCLUSIONS

Women with hypertensive disorders and term delivery have a substantial chance of recurrence, but a small risk of preterm delivery. A number of predictors for recurrence could be identified and women with a recurrence more often developed chronic hypertension.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Maternal prepregnancy obesity and child neurodevelopment in the Collaborative Perinatal Project

OBJECTIVES

To examine the association between maternal prepregnancy weight and child neurodevelopment, and the effect of gestational weight gain.

METHODS

Using the U.S. Collaborative Perinatal Project data, 1959-76, a total of 30,212 women with a calculable prepregnancy body mass index (BMI) and gestational weight gain, and term singleton children followed up for more than 7 years were included in this study. Intelligence quotient (IQ) was measured at 7 years of age by Wechsler Intelligence Scales.

RESULTS

Maternal prepregnancy BMI displayed inverted U-shaped associations with child IQ after adjustment for maternal age, maternal education levels, maternal race, marital status, socioeconomic status, smoking during pregnancy, parity and study center. Women with BMI at around 20 kg/m2 appeared to have the highest offspring IQ scores. After controlling for familial factors in the siblings' sample, maternal obesity (BMI≥30.0 kg/m2) was associated with lower Full-scale IQ (adjusted ß=-2.0, 95% confidence interval -3.5 to -0.5), and Verbal scale IQ (adjusted ß=-2.5, 95% confidence interval -4.0 to -1.0), using BMI of 18.5-24.9 kg/m2 as the reference category. Compared with children born to normal-weight women who gained 21-25 lb. during pregnancy, those born to obese women who gained more than 40 lb. had 6.5 points deficit in IQ after adjustment for potential confounders.

CONCLUSIONS

Maternal prepregnancy obesity was associated with lower child IQ, and excessive weight gain accelerated the association. With obesity rising steadily, these results appear to raise serious public health concerns.

Risk for Recurrence of Pre-eclampsia in the Subsequent Pregnancy

BACKGROUND

Pre-eclampsia (PE) is the commonest type of pregnancy induced hypertension and it affects nearly 5% of pregnant women. Besides short term morbidity and mortality that are associated with pregnancy, PE is associated with long term morbidity in women. There is a lack of information on the risk of recurrence of PE in pregnant Asian Indian women.

AIM

To determine the rates and risk factors which were associated with recurrence of PE in the subsequent pregnancies of women with PE in index pregnancies.

SETTINGS AND DESIGN

A retrospective, observational study done at a single tertiary care centre in southern India.

MATERIAL AND METHODS

The study included pregnant women with PE, who delivered at the study institute in 2008 and received care for their subsequent pregnancies at the study institute. Hypertension in pregnancy was categorized, based on the criteria of the International Society for the Study of Hypertension in Pregnancy. Point estimates and the 95% confidence intervals around point estimates of rates of recurrence of PE and associations of potential clinical and laboratory parameters with recurrence were determined by using bivariate analysis, logistic regression models and area under Receiver Operator Characteristic (ROC) curves.

RESULTS

The study included 82 pregnant women with PE in their index pregnancies. Twenty two (26.83%, 95% CI: 17.03, 36.62) of these 82 women developed recurrence of PE in their subsequent pregnancies. Recurrence of PE was significantly higher (OR 3.94, 95% CI: 1.05, 14.80, p=0.04) among women who were nulliparous in their index pregnancies. Recurrence of PE was not significantly associated with clinical factors or laboratory parameters in the index pregnancies.

CONCLUSION

Nearly one in four of pregnant women with PE developed recurrences in their subsequent pregnancies, although a large proportion of pregnant women with PE (63.38% to 82.97%) in their index pregnancies were normotensive in their subsequent pregnancies.

Management of cardiovascular diseases during pregnancy

The prevalence of cardiovascular diseases (CVDs) in women of childbearing age is rising. The successes in medical and surgical treatment of congenital heart disease have led to an increasing number of women at childbearing age presenting with problems of treated congenital heart disease. Furthermore, in developing countries and in immigrants from these countries, rheumatic valvular heart disease still plays a significant role in young women. Increasing age of pregnant women and increasing prevalence of atherosclerotic risk factors have led to an increase in women with coronary artery disease at pregnancy. Successful management of pregnancy in women with CVDs requires early diagnosis, a thorough risk stratification, and appropriate management by a multidisciplinary team of obstetricians, cardiologists, anesthesiologists, and primary care physicians. The following review is based on the recent European guidelines on the management of CVDs during pregnancy, which aim at providing concise and simple recommendations for these challenging problems.

Pre-eclampsia rates in the United States, 1980-2010: age-period-cohort analysis

OBJECTIVE

To estimate the contributions of biological aging, historical trends, and birth cohort effects on trends in pre-eclampsia in the United States.

DESIGN

Population based retrospective study.

SETTING

National hospital discharge survey datasets, 1980-2010, United States.

PARTICIPANTS

120 million women admitted to hospital for delivery.

MAIN OUTCOME MEASURES

Temporal changes in rates of mild and severe pre-eclampsia in relation to maternal age, year of delivery, and birth cohorts. Poisson regression as well as multilevel age-period-cohort models with adjustment for obesity and smoking were incorporated.

RESULTS

The rate of pre-eclampsia was 3.4%. The age-period-cohort analysis showed a strong age effect, with women at the extremes of maternal age having the greatest risk of pre-eclampsia. In comparison with women delivering in 1980, those delivering in 2003 were at 6.7-fold (95% confidence interval 5.6-fold to 8.0-fold) increased risk of severe pre-eclampsia. Period effects declined after 2003. Trends for severe pre-eclampsia also showed a modest birth cohort effect, with women born in the 1970s at increased risk. Compared with women born in 1955, the risk ratio for women born in 1970 was 1.2 (95% confidence interval 1.1 to 1.3). Similar patterns were also evident for mild pre-eclampsia, although attenuated. Changes in the population prevalence of obesity and smoking were associated with period and cohort trends in pre-eclampsia but did not explain the trends.

CONCLUSIONS

Rates of severe pre-eclampsia have been increasing in the United States and age-period-cohort effects all contribute to these trends. Although smoking and obesity have driven these trends, changes in the diagnostic criteria may have also contributed to the age-period-cohort effects. Health consequences of rising obesity rates in the United States underscore that efforts to reduce obesity may be beneficial to maternal and perinatal health.

Recurrence risks of hypertensive diseases in pregnancy after HELLP syndrome

AIM

To determine the recurrence risk for hypertensive diseases in pregnancy after HELLP (Hemolysis Elevated Liver enzymes and Low Platelets) syndrome in a first pregnancy.

METHODS

The study was designed as a cohort study investigating 148 Caucasian primiparae with a diagnosis of HELLP syndrome in a first pregnancy and at least one subsequent pregnancy conducted beyond the 24th gestational week. Diagnoses were verified by reviewing medical records and classified according to ISSHP (International Society for the Study of Hypertension in Pregnancy) criteria. The recurrence risk of HELLP syndrome or other hypertensive disorders in the subsequent pregnancy was calculated with regard to disease severity in the index pregnancy.

RESULTS

Among 148 pregnancies subsequent to HELLP syndrome, 56.1% of the women were normotensive. The recurrence rate was 12.8% for HELLP syndrome, 16.2% for pre-eclampsia, and 14.2% for gestational hypertension only. Women with HELLP syndrome ≤32 gestational weeks tended to show a greater risk of complicated subsequent pregnancies compared to women presenting with HELLP after 32 gestational weeks.

CONCLUSIONS

Women with a diagnosis of HELLP syndrome are at a strongly increased risk of recurrent HELLP syndrome, pre-eclampsia or gestational hypertension, however, currently no clinical or laboratory parameters allow the prediction of recurrence risk in any individual case.

Complement component C4A and apolipoprotein A-I in plasmas as biomarkers of the severe, early-onset preeclampsia

Preeclampsia is a common pregnancy complication that is associated with maternal perinatal morbidity and mortality. Because of its early onset (before 34 weeks) and the potential for serious outcomes, severe, early-onset preeclampsia (sePE) should be regarded as a different form of preeclampsia. It is an important cause of preterm birth and fetal growth restriction and adverse maternal and neonatal outcomes. As there is no diagnostic test yet available for this disease, we used a proteomic approach to identify novel plasma biomarkers for developing severe, early-onset preeclampsia. We conducted case-control studies comparing nulliparous women with severe preeclampsia requiring delivery prior to 34 weeks of gestation with healthy nulliparous women matched by gestational age at sampling. Plasma was depleted of albumin and IgG and analyzed by two-dimensional gel electrophoresis (2DE). Seven specific plasma proteins for early-onset preeclampsia were detected by mass spectrometry had statistically significant expression differences when compared to controls. The expression of complement component C4A and apolipoprotein A-I were validated by immunoblotting. The complement component C4A in the plasmas of sePE women is lower than the severe, late-onset PE (slPE) women [mean ± SD; 3.05 ± 0.14 times reference level (normal/sePE) in sePE women vs. 2.73 ± 0.10 times reference level (normal/slPE) in slPE women, P < 0.05]. Apolipoprotein A-I is higher in sePE women than slPE women [mean ± SD; 1.58 ± 0.14 times reference level (sePE/normal) in sePE women vs. 1.04 ± 0.16 times reference level (slPE/normal) in slPE women, P < 0.05]. Furthermore, C4A can accurately distinguish severe PE (sePE and slPE) from mild PE (mePE and mlPE) and was proved by the results of ELISA. Further studies have been done to determine the relation between PE and hypoxia. JAR cells were cultured under hypoxia for 72 h. Total cellular proteins were gathered and lysed. Lower C4A and higher apolipoprotein A-I had been observed in JAR of hypoxia conditions than normoxia conditions through western blotting. The result proved that PE is correlated with hypoxia. In summary, C4A and apolipoprotein A-I are able to function as markers to distinguish ePE women from lPE women, and severe PE from mild PE, or perhaps even as disease predictors that might become relevant for diagnostics.

Adverse maternal and perinatal outcomes in women with previous preeclampsia: a prospective study

OBJECTIVE

The purpose of this study was to assess recurrence rates of preeclampsia and neonatal outcomes in women with a history of preeclampsia that required preterm delivery.

STUDY DESIGN

Five hundred women with previous preeclampsia that required delivery at <37 weeks' gestation were followed prospectively.

RESULTS

Preeclampsia reoccurred in 117 women (23%). Predictive factors included black (odds ratio [OR], 2.29; 95% confidence interval [CI], 1.16-4.53) or Asian (OR, 2.98; 95% CI, 1.33-6.59) ethnicity, enrollment systolic blood pressure of >130 mm Hg (OR, 2.89; 95% CI, 1.52-5.50), current antihypertensive use (OR, 6.39; 95% CI, 2.38-17.16), and proteinuria of ≥2+ on enrollment urinalysis (OR, 12.35; 95% CI, 3.45-44.21). Women who previously delivered at <34 weeks' gestation were more likely to deliver preterm again (29% vs 17%; relative risk, 1.69; 95% CI, 1.19-2.40) than were those women with previous delivery between 34 and 37 weeks' gestation.

CONCLUSION

Although this study confirms that women with previous preeclampsia that required early delivery are at high risk of the development of preeclampsia, the study identifies risk factors for recurrence and illustrates that women with previous preeclampsia are at greater risk of adverse neonatal outcome.

Cost-effectiveness of recurrence risk guided care versus care as usual in women who suffered from early-onset preeclampsia including HELLP syndrome in their previous pregnancy (the PreCare study)

Background

Preeclampsia and HELLP syndrome may have serious consequences for both mother and fetus. Women who have suffered from preeclampsia or the HELLP syndrome, have an increased risk of developing preeclampsia in a subsequent pregnancy. However, most women will develop no or only minor complications. In this study, we intend to determine cost-effectiveness of recurrence risk guided care versus care as usual in pregnant women with a history of early-onset preeclampsia.

Methods/design

We developed a prediction model to estimate the individual risk of recurrence of early-onset preeclampsia and the HELLP syndrome. In a before-after study, pregnant women with preeclampsia or HELLP syndrome in their previous pregnancy receiving care as usual (before introduction of the prediction model) will be compared with women receiving recurrence risk guided care (after introduction of the prediction model).

Eligible and pregnant women will be recruited at six university hospitals and seven large non-university tertiary referral hospitals in the Netherlands.

The primary outcome measure is the recurrence of early-onset preeclampsia or HELLP syndrome in women allocated to the regular monitoring group.

For the economic evaluation, a modelling approach will be used. Costs and effects of recurrence risk guided care with those of care as usual will be compared by means of a decision model. Two incremental cost-effectiveness ratios will be calculated: 1) cost per Quality Adjusted Life Year (mother unit of analysis) and 2) cost per live born child (child unit of analysis).

Discussion

This is, to our knowledge, the first study that evaluates prospectively the efficacy of a multivariable prediction rule for recurrent hypertensive disease in pregnancy. Results of this study could either be integrated into the current guideline on Hypertensive Disorders in Pregnancy, or be used to develop a new guideline.

Body Composition of Patients with Hypertensive Complications During Pregnancy

OBJECTIVE

To determine the body composition of women with the diagnoses of gestational hypertension or preeclampsia.

METHODS

Cross-sectional study, including four groups of patients who were in the third trimester: those with an uncomplicated pregnancy (n = 110), those with a diagnosis of gestational hypertension (n = 38), those with mild preeclampsia (n = 8), and those with severe preeclampsia (n = 11). Their fat mass, fat-free mass, and total body water were estimated by bioelectric impedance.

RESULTS

The fat mass was 20 +/- 7 kg in the control group and 26 +/- 13 kg in the group with gestational hypertension (p < 0.05). The total body water was 36 +/- 6 L in the control group, 50 +/- 10 L in the patients with gestational hypertension, 52 +/- 10 L in those with mild preeclampsia, and 48 +/- 9 L in those with severe preeclampsia (p < 0.05).

CONCLUSION

The results suggest that maternal body composition shows significant differences in patients with hypertensive complications during pregnancy. These data may be related to a possible inadequate distribution of the volume of water as a result of alterations in capillary permeability.

Recurrence of preeclampsia: effects of gestational age at delivery of the first pregnancy, body mass index, paternity, and interval between births

OBJECTIVES

The purpose of this study was to establish estimates for recurrence risk of preeclampsia based on gestational age at delivery of the first pregnancy complicated by preeclampsia and to determine whether interbirth interval, paternity, and body mass index (BMI) modify that risk in women with prior preeclampsia.

STUDY DESIGN

A population-based, cohort study was conducted using data from Missouri maternally linked birth certificates. The cohort included women who had 2 singleton births between 1989 and 1997: 6157 women with preeclampsia and 97,703 women without preeclampsia at the time of their first deliveries. Data were analyzed using the Poisson regression.

RESULTS

At the time of their second delivery, 14.7% women with prior preeclampsia developed recurrent preeclampsia. The risk of recurrent preeclampsia is inversely related to gestational age at the first delivery: 38.6% for 28 weeks' gestation or earlier, 29.1% for 29-32 weeks, 21.9% for 33-36 weeks, and 12.9% for 37 weeks or more. The recurrent preeclampsia risk was fairly constant if both births occurred within 7 years. Obese and overweight women had higher risks of recurrent preeclampsia (19.3% and 14.2%), compared with women with normal BMI (11.2%). The recurrence risk did not differ according to paternity status.

CONCLUSION

The risk of preeclampsia recurrence increases with earlier gestational age at the first delivery complicated by preeclampsia and with increasing maternal BMI.

Can we predict recurrence of pre-eclampsia or gestational hypertension?

OBJECTIVE

To estimate the rates of recurrence of pre-eclampsia or gestational hypertension in a subsequent pregnancy and to determine factors predictive of recurrence.

DESIGN

Retrospective cohort study.

SETTING

St George Public and Private Hospitals, teaching hospitals without neonatal intensive care units.

PARTICIPANTS

A total of 1515 women with a diagnosis of pre-eclampsia or gestational hypertension between 1988 and 1998 were identified from the St George Hypertension in Pregnancy database, a system designed initially for ensuring quality outcomes of hypertensive pregnancies. Of these, 1354 women were followed up, and a further 333 records from women coded as having a normal pregnancy during that period were selected randomly as controls.

MAIN OUTCOME MEASURES

Likelihood of recurrent pre-eclampsia or gestational hypertension and clinical and routine laboratory factors in the index pregnancy predictive of recurrence of pre-eclampsia or gestational hypertension.

METHODS

The index cases from our unit's database were linked to the matched pregnancy on the State Department of Health database, allowing us to determine whether further pregnancies had occurred at any hospital in the State. The outcome of these pregnancies was determined by review of medical records, using strict criteria for diagnosis of pre-eclampsia or gestational hypertension.

RESULTS

Almost all women with a normal index pregnancy had a further normotensive pregnancy. One in 50 women hypertensive in their index pregnancy had developed essential hypertension by the time of their next pregnancy. Women with pre-eclampsia in their index pregnancy were equally likely to develop either pre-eclampsia or gestational hypertension (approximately 14% each), while women with gestational hypertension were more likely to develop gestational hypertension (26%) rather than pre-eclampsia (6%) in their next pregnancy. Multiparous women with gestational hypertension were more likely than primiparous women to develop pre-eclampsia (11 versus 4%) or gestational hypertension (45 versus 22%) in their next pregnancy. Early gestation at diagnosis in the index pregnancy, multiparity, uric acid levels in the index pregnancy and booking blood pressure parameters in the next pregnancy significantly influenced the likelihood of recurrence, predominantly for gestational hypertension and less so for pre-eclampsia. No value for these parameters was significant enough to be clinically useful as a discriminate value predictive of recurrent pre-eclampsia or gestational hypertension.

CONCLUSIONS

Approximately 70% of women with pre-eclampsia or gestational hypertension will have a normotensive next pregnancy. The highest risk group for recurrent hypertension in pregnancy in this study was multiparous women with gestational hypertension. No readily available clinical or laboratory factor in the index pregnancy reliably predicts recurrence of pre-eclampsia.

Partner change, birth interval and risk of pre-eclampsia: a paradoxical triangle

Immunology has been hypothesised to play a critical role in the development of pre-eclampsia. A number of epidemiological studies have shown that multiparous women who changed partner had an increased risk of pre-eclampsia in the following pregnancy compared with multiparous women with the same partner. However, partner change is often associated with a long birth interval. Two recent papers using data from the same birth registry reported that, after controlling for birth interval, partner change was associated with a reduced risk of pre-eclampsia. Based on a causal diagram, the author argues conceptually that birth interval is not a confounder but more likely to be a collider. Controlling for or stratifying birth interval in the association between partner change and risk of pre-eclampsia could be inappropriate and may have produced a spurious association.

Recurrence of hypertensive disorder in second pregnancy

OBJECTIVE

The purpose of this study was to investigate the recurrence of hypertensive disorders in pregnancy with regard to the type of disorder, the onset of hypertension, and the modulating effect of overweight and weight gain between pregnancies.

STUDY DESIGN

Maternity records from 896 parous women with hypertensive disorders in pregnancy in the first pregnancy were reviewed to reclassify disease status and calculate odds ratios for recurrence.

RESULTS

Recurrence of hypertensive disorders in pregnancy occurred in 58% to 94% of second pregnancies, depending on first pregnancy disorder. Overweight (odds ratio, 1.82) and weight gain (odds ratio, 2.20) were related to recurrence among women with gestational hypertension. Early hypertension (<or =34 weeks of gestation) increased the recurrence risk for women with gestational hypertension (odds ratio, 1.85) and preeclampsia (odds ratio, 3.42).

CONCLUSION

Recurrence of hypertensive disorders in pregnancy is common, but not specified by type of disorder in first pregnancy. Overweight and weight gain between pregnancies are associated with recurrent hypertensive disorders in pregnancy in women with gestational hypertension. Early onset of hypertension is a risk factor, independent of body weight.

Screening and management of inherited thrombophilias in the setting of adverse pregnancy outcome

Inherited thrombophilic conditions are associated with adverse pregnancy outcomes, including severe pre-eclampsia, fetal loss, abruptio placentae, and intauterine growth restriction. Although the prevalence of these complications is approximately 8% in the general population, their presence is associated with a significantly increased recurrence risk. Thrombophilic conditions most strongly associated with adverse pregnancy outcome include factor V Leiden, prothrombin gene mutation, and deficiencies of protein S, protein C, and antithrombin. Other thrombophilic conditions, such as protein Z deficiency, also appear to be associated with an increased risk of pregnancy complications. Antenatal administration of heparin to prevent pregnancy complications has shown promise in small studies, but a randomized, placebo-controlled trial is necessary to determine whether heparin administration is beneficial in preventing adverse pregnancy outcome.

Hypertensive diseases and eclampsia

Worldwide, pre-eclampsia and eclampsia contribute to the death of a pregnant woman every 3 min. In the UK in recent decades, hypertensive disorders of pregnancy have remained one of the leading causes of both maternal and perinatal morbidity and mortality. The management of pregnancies complicated by hypertension has not significantly altered for many years, possibly as a result of little progress being made in our understanding of the condition. New insights, however, have recently been gained into the pathophysiology of pre-eclampsia. These have yet to be translated into new interventions or to make any impact on clinical management of these pregnancies. This review will therefore focus on recent advances relating to research into the aetiology and pathogenesis of pre-eclampsia, but will conclude with a brief update on current therapeutic strategies.