Preeclampsia and future maternal health

Long-Term Cardiovascular Risk and Maternal History of Pre-Eclampsia

Pre-eclampsia is a severe pregnancy complication affecting 5-8% of pregnancies worldwide, marked by high blood pressure and organ damage typically occurring after 20 weeks of gestation. It is a leading cause of maternal and fetal morbidity and mortality. Though its exact cause is unknown, it involves placental abnormalities and improper blood vessel development. Risk factors include a history of pre-eclampsia, chronic hypertension, diabetes, obesity, and autoimmune disorders. Symptoms include high blood pressure, proteinuria, headaches, vision changes, and abdominal pain. Untreated, it can lead to seizures, stroke, preterm birth, or death. Delivery is the definitive treatment, with management strategies such as monitoring and blood pressure control. Pre-eclampsia significantly increases long-term cardiovascular disease (CVD) risks, including hypertension, ischemic heart disease, and stroke, linked to shared mechanisms like endothelial dysfunction and inflammation. Women with severe or recurrent pre-eclampsia have heightened risks, often developing chronic hypertension within a decade postpartum. It also impacts offspring, with daughters at elevated risk for pre-eclampsia and CVD. Hypertensive disorders of pregnancy, including pre-eclampsia, induce changes like left ventricular hypertrophy and diastolic dysfunction, raising risks for heart failure with preserved ejection fraction and coronary atherosclerosis. Overlapping with peripartum cardiomyopathy, pre-eclampsia underscores a spectrum of pregnancy-related cardiovascular disorders. Long-term monitoring and lifestyle interventions are crucial for managing risks, with research into genetic and biological mechanisms offering the potential for targeted prevention.

Biomarkers and point of care screening approaches for the management of preeclampsia

Preeclampsia is a multi-organ pregnancy complication, that is primarily detected when pregnant people have high blood pressure, and is confirmed by testing for the presence of protein in the urine. While more specific and accurate diagnostic and imaging tests are becoming available, they are still in the process of undergoing widespread regulatory adoption, and so are not yet the standard of care. Since biochemical processes are a precursor to the systemic progression of disease, we review some established, emerging, and promising biomarkers that are proposed to be associated with preeclampsia, and newly developed approaches for screening them at the point of care, to reduce the burden of the disease.

Syncytin-1, syncytin-2 and suppressyn in human health and disease

In this review, we summarized the results of experimental and clinical studies about three human endogenous retroviruses and their products-syncytin-1, syncytin-2, and suppressyn in human physiology and pathophysiology. We summed up the described connection with various pathological processes and diseases, mainly with pregnancy-induced hypertensive diseases such as preeclampsia, oncogenesis, gestational trophoblastic disease, and multiple sclerosis. Supposed mechanisms of action and the potential of clinical applications are also described.

Maternal and Perinatal Outcome in Patients With Eclampsia: A Study Done at a Tertiary Care Centre

Background One of the leading causes contributing to morbidity and mortality globally is attributed to eclampsia. Hence, it is vital to comprehensively review each female having eclampsia and to evaluate the factors that govern the outcomes in females with eclampsia. Aim To decode the fetal and maternal outcomes in subjects having eclampsia and to evaluate various factors that govern the outcomes. Methods This retrospective cohort and epidemiological study commenced at the Department of Obstetrics and Gynaecology, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, in January 2016 till April 2017, and included females that either developed eclampsia in hospital stay duration or presented with pre-existing eclampsia. In included females, various fetal and maternal parameters were assessed along with the outcome of pregnancy. The institutional data records and the database were also used to determine the prevalence and incidence of eclampsia. Baseline maternal parameters were recorded from the already-existing institute data. These included the gestational age (in years), socioeconomic status, educational attainment, parity, gravidity, and the number of weeks of gestation present at the time of delivery. Antenatal care data assessed were blood pressure recordings, any proteinuria documented in the data, and the number of antenatal visits by the subjects. Statistical analysis was performed to assess both parameters. Results  In the current investigation, there were 0.34% eclampsia cases among females visiting the institution for deliveries. Incidences of stillbirth were seen in 19.04% and 8% of study participants, respectively. We found 9.52% (n=4) of female infants to have perished from eclampsia. Preterm births, a delayed start to the treatment, and insufficient care were all linked to poor foetal and mother outcomes. The longer the period between the beginning of a fit and delivery, the greater the likelihood of unfavourable results. Seizure onset before or after birth, parity, or subject age had no impact on mother or foetal health. The p-value for statistical significance was kept at 0.05. Conclusion Most of the research participant women, had intrapartum eclampsia, postpartum eclampsia, and antepartum eclampsia, based on the time of the convulsions in relation to the labor. It was highlighted that there was no conclusive evidence linking the date of the fit's beginning to unfavourable results or an elevated risk of complications. Neonatal mortality and stillbirth were observed with vaginal delivery in eclampsia cases. Outcomes in eclampsia can be improved by early treatment initiation, timely and appropriate referral, early disease recognition, and appropriate antenatal care.

Harm! foul! How acute kidney injury SHReDDs patient futures

PURPOSE OF REVIEW

Transition from acute kidney injury (AKI) to chronic kidney disease (CKD) is increasingly accepted. Less well recognized, but supported by very similar data, is development of disease of other organ systems after AKI. Awareness of other-organ sequelae of AKI may inform efforts to improve the care of patients after AKI.

RECENT FINDINGS

Stroke, hypertension, reproductive risk, dementia, and death (SHReDD) are sequelae, which occur with increased risk relative to that of non-AKI within 6 months-3 years after AKI diagnosis, and which are supported by preclinical/mechanistic study. Adjusted hazard ratios for these sequelae are strikingly similar to that of AKI-CKD, ranging from 1.2 to 3.0. Mechanistic studies suggest kidney-centric mechanisms including sodium regulation, volume status regulation, and the renin-angiotensin system are drivers of long-term, extra-renal, change.

SUMMARY

Further clinical characterization and mechanistic insight is necessary, and may have considerable translational impact. Programs which screen or follow post-AKI patients may increase clinical utility if focus is expanded to include the SHReDD complications.

Meta-Analysis of Cardiovascular Risk Factors in Offspring of Preeclampsia Pregnancies

This study aimed to assess cardiovascular risk factors in the offspring of preeclampsia (PE) pregnancies. PubMed, Web of Science, Ovid, and other foreign language databases, as well as SinoMed, China National Knowledge Infrastructure, Wanfang, and China Science and Technology Journal Databases, were searched. The case-control studies on cardiovascular risk factors in the offspring of PE pregnancies from 1 January 2010 to 31 December 2019 were collected. A random-effects model or a fixed-effects model was used, and RevMan 5.3 software was used for meta-analysis to determine the OR value and 95%CI of each cardiovascular risk factor. A total of 16 documents were included in this research, all of which were case-control studies, with a total of 4046 cases in the experimental group and 31,505 in the control group. The meta-analysis that was conducted demonstrated that SBP [MD = 1.51, 95%CI (1.15, 1.88)] and DBP [MD = 1.90, 95%CI (1.69, 2.10)] values in the PE pregnancy offspring group presented an elevation relative to the non-PE pregnancy offspring group. The total cholesterol value in the PE pregnancy offspring group presented an elevation relative to the non-PE pregnancy offspring group [MD = 0.11, 95%CI (0.08, 0.13)]. The low-density lipoprotein cholesterol value in the PE pregnancy offspring group was comparable to that in the non-PE pregnancy offspring group [MD = 0.01, 95%CI (-0.02, 0.05)]. The high-density lipoprotein cholesterol value in the PE pregnancy offspring group presented an elevation relative to the non-PE pregnancy offspring group [MD = 0.02, 95%CI (0.01, 0.03)]. The non-HDL cholesterol value in the PE pregnancy offspring group presented an elevation relative to the non-PE pregnancy offspring group [MD = 0.16, 95%CI (0.13, 0.19)]. The triglycerides [MD = -0.02, 95%CI (-0.03, -0.01)] and glucose [MD = -0.08, 95%CI (-0.09, -0.07)] values in the PE pregnancy offspring group presented a depletion relative to the non-PE pregnancy group. The insulin value in the PE pregnancy offspring group presented a depletion relative to the non-PE pregnancy offspring group [MD = -0.21, 95%CI (-0.32, -0.09)]. The BMI value in the PE pregnancy offspring group presented an elevation relative to the non-PE pregnancy offspring group [MD = 0.42, 95%CI (0.27, 0.57)]. In conclusion, dyslipidemia, elevated blood pressure, and increased BMI occur postpartum with PE, all of which are risk factors for cardiovascular diseases.

The Assessment of Maternal and Fetal Intima-Media Thickness in Perinatology

Intima-media thickness (IMT) measurement is a non-invasive method of arterial wall assessment. An increased IMT is a common manifestation of atherosclerosis associated with endothelial dysfunction. In the course of pregnancy, various maternal organs, including the endothelium, are prepared for their new role. However, several pre-gestational conditions involving endothelial dysfunction, such as diabetes, chronic hypertension, and obesity, may impair the adaptation to pregnancy, whereas vascular changes may also affect fetal development, thus, influencing the fetal IMT. In the conducted studies, a correlation was found between an increased fetal abdominal aorta IMT (aIMT) and placental dysfunctions, which may subsequently impact both the mother and the fetus, and contribute to gestational hypertension, preeclampsia (PE), and fetal growth restriction (FGR). In fact, data indicate that following the delivery, the endothelial dysfunction persists and influences the future health of the mother and the newborn. Hypertensive disorders in pregnancy increase the maternal risk of chronic hypertension, obesity, and vascular events. Moreover, individuals born from pregnancies complicated by preeclampsia or fetal growth restriction are at high risk of obesity, diabetes, hypertension, and cardiovascular disease. Therefore, understanding the pathomechanism underlying an increased aIMT in preeclampsia and FGR, as well as subsequent placental dysfunctions, is essential for developing targeted therapies. This review summarizes recent publications regarding IMT and demonstrates how IMT measurements affect predicting perinatal complications.

Preeclampsia and Fetal Congenital Heart Defects

Endothelial dysfunction, impaired implantation and placental insufficiency have been identified as mechanisms behind the development of pre-eclampsia, resulting in angiogenic factors' alteration. Angiogenic imbalance is also associated with congenital heart defects, and this common physiologic pathway may explain the association between them and pre-eclampsia. This review aims to understand the physiology shared by these two entities and whether women with pre-eclampsia have an increased risk of fetal congenital heart defects (or the opposite). The present research has highlighted multiple vasculogenic pathways associated with heart defects and preeclampsia, but also epigenetic and environmental factors, contributing both. It is also known that fetuses with a prenatal diagnosis of congenital heart disease have an increased risk of several comorbidities, including intrauterine growth restriction. Moreover, the impact of pre-eclampsia goes beyond pregnancy as it increases the risk for following pregnancies and for diseases later in life in both offspring and mothers. Given the morbidity and mortality associated with these conditions, it is of foremost importance to understand how they are related and its causative mechanisms. This knowledge may allow earlier diagnosis, an adequate surveillance or even the implementation of preventive strategies.

Fetal growth restriction as the initial finding of preeclampsia is a clinical predictor of maternal and neonatal prognoses: a single-center retrospective study

BACKGROUND

Preeclampsia (PE) is a hypertensive disorder specific to pregnancy that can cause severe maternal-neonatal complications. The International Society for the Study of Hypertension in Pregnancy revised the PE criteria in 2018; a PE diagnosis can be established in the absence of proteinuria when organ or uteroplacental dysfunction occurs. The initial findings of PE (IFsPE) at the first diagnosis can vary considerably across patients. However, the impacts of different IFsPE on patient prognoses have not been reported. Thus, we investigate the predictors of pregnancy complications and adverse pregnancy outcomes based on IFsPE according to the new criteria.

METHODS

This retrospective study included 3729 women who delivered at our hospital between 2015 and 2019. All women were reclassified based on the new PE criteria and divided into three groups based on the IFsPE: Classification 1 (C-1), proteinuria (classical criteria); Classification 2 (C-2), damage to other maternal organs; and Classification 3 (C-3), uteroplacental dysfunction. Pregnancy complications and adverse pregnancy outcomes were assessed and compared among the three groups.

RESULTS

In total, 104 women with PE were included. Of those, 42 (40.4%), 28 (26.9%), and 34 (32.7%) were assigned to C-1, C-2, and C-3 groups, respectively. No significant differences in maternal characteristics were detected among the three groups, except for gestational age at PE diagnosis (C-1, 35.5 ± 3.0 weeks; C-2, 35.2 ± 3.6 weeks; C-3, 31.6 ± 4.6 weeks, p <  0.01). The rates of premature birth at < 37 weeks of gestation, fetal growth restriction (FGR), and neonatal acidosis were significantly higher in the C-3 group compared to the C-1 and C-2 groups. Additionally, the composite adverse pregnancy outcomes of the C-3 group compared with C-1 and C-2 represented a significantly higher number of patients.

CONCLUSIONS

PE patients with uteroplacental dysfunction as IFsPE had the most unfavorable prognoses for premature birth, FGR, acidosis, and composite adverse pregnancy outcomes.

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.

Association of Endothelial Nitric Oxide Synthase 894G > T Polymorphism with Preeclampsia Risk: A Systematic Review and Meta-Analysis based on 35 Studies

Several case-control studies have been performed to investigate the association between 894 G > T polymorphism in endothelial nitric oxide synthase (eNOS) gene and susceptibility to preeclampsia. However, the results were inconsistent and inconclusive. Therefore, we conducted this meta-analysis to investigate the association. Methods: All studies published up to September 30, 2019 were identified by searching electronic databases such as PubMed, EMBASE, CNKI, and WANFANG. Results: A total of 35 case- control studies with 4,254 cases and 5,801 controls were selected. There was a significant association between the eNOS 894 G > T and preeclampsia risk. When stratified by ethnicity, an increased risk of preeclampsia was found in Caucasian and Mixed populations, but not in Asians or Africans. Conclusion: Based on our meta-analysis, the eNOS 894 G > T polymorphism was associated with an increased risk of preeclampsia, especially among Caucasian and Mixed populations.

Unraveling the role of oxidative stress and lipid status parameters in the onset of preeclampsia

OBJECTIVE: The aim of the study was to assess the potential role of oxidative stress and lipid status in the onset of preeclampsia.METHODS: 138 high-risk pregnant women were prospectively followed. Assessment of oxidative stress (TAS, TOS, AOPP and SH groups) and lipid status (t-C, LDL-C, HDL-C, TGC, APO-A1, APO-B) was carried out during the pregnancy.RESULTS: 30 women developed preeclampsia. TGC, atherogenic index of plasma, TAS and SH levels were higher in women who subsequently developed preeclampsia (p<0.05).CONCLUSION: Oxidative stress and lipid status disturbance have a potential role in the onset of preeclampsia in high risk pregnancies.

Chorionic villus sampling and preeclampsia & eclampsia: coincidence or not?

OBJECTIVES

The purpose of the study is to investigate potential association of chorionic villus sampling (CVS) with subsequent development of preeclampsia (PE) and eclampsia (E).

STUDY DESIGN

The development of PE and E was compared between two groups as follows: 1- CVS group: women who underwent CVS (n = 228) and 2- Control group: maternal and gestational age matched women without invasive prenatal diagnostic procedure (n = 456). Main outcome measures were incidence of PE (mild, severe) and E.

RESULTS

The incidence of PE and E was not significantly different between CVS and control groups. There was no significant difference regarding mild and severe PE development between the two groups. The incidence of early- and late-onset PE was similar in CVS and control groups.

CONCLUSIONS

CVS does not appear to increase the risk of PE and E. The spontaneous elevation of trophoblastic load in the maternal circulation rather than the iatrogenic elevation through CVS may contribute to the development of PE and E.

Bisphenol A, Bisphenol F, and Bisphenol S: The Bad and the Ugly. Where Is the Good?

Background: Bisphenol A (BPA), a reprotoxic and endocrine-disrupting chemical, has been substituted by alternative bisphenols such as bisphenol F (BPF) and bisphenol S (BPS) in the plastic industry. Despite their detection in placenta and amniotic fluids, the effects of bisphenols on human placental cells have not been characterized. Our objective was to explore in vitro and to compare the toxicity of BPA to its substitutes BPF and BPS to highlight their potential risks for placenta and then pregnancy. Methods: Human placenta cells (JEG-Tox cells) were incubated with BPA, BPF, and BPS for 72 h. Cell viability, cell death, and degenerative P2X7 receptor and caspases activation, and chromatin condensation were assessed using microplate cytometry and fluorescence microscopy. Results: Incubation with BPA, BPF, or BPS was associated with P2X7 receptor activation and chromatin condensation. BPA and BPF induced more caspase-1, caspase-9, and caspase-3 activation than BPS. Only BPF enhanced caspase-8 activity. Conclusions: BPA, BPF, and BPS are all toxic to human placental cells, with the P2X7 receptor being a common key element. BPA substitution by BPF and BPS does not appear to be a safe alternative for human health, particularly for pregnant women and their fetuses.

Increased of the carotid intima media thickness in preeclampsia

Objectives The aim of the study was to determine carotid intima-media thickness (CIMT) values in patients who developed and did not develop preeclampsia (PE), and to determine whether CIMT values could be predictors of PE development. Methods The study included pregnant women who were examined by regular ultrasound examination at the Materno-Infantil Presidente Vargas Hospital (HMIPV) in Porto Alegre, Brazil, from April 2016 to September 2017. The examinations were performed every three months. Patients were divided into two groups. The first group included patients diagnosed with PE (n=21) and second group included patients who did not have PE (n=199). A high frequency ultrasound device (12 MHz) with a semi-automatic method was used to estimate CIMT. Results CIMT was significantly higher in pregnant women with PE than in women without PE (55±0.11 vs. 0.44±0.06, respectively; p<0.001). Using a cut-off value of 0.51 mm, CIMT had a specificity of 77.9% and sensitivity of 81% in the diagnosis of PE. With CIMT ≥0.6 mm, the probability of a patient developing PE was 44.4%; with CIMT >0.42 mm, the probability was only 4.2%. Conclusions An increase in CIMT was associated with the onset of PE. CIMT values were significantly higher in patients who develop PE.

Early Onset Preeclampsia Diagnosis Prior to the 20th Week of Gestation in a Twin Pregnancy Managed via Selective Reduction of an Intrauterine Growth Restriction Fetus: A Case Report and Literature Review

A single, healthy, 44-year-old perimenopausal woman pursuing a pregnancy, employed donor embryos, resulting to a dichorionic diamniotic twin pregnancy. In the 18th week of gestation severe symptoms indicated early onset preeclampsia reporting severe hypertension (BP 180/90 mmHg), intense headaches and nausea as well as elevated 24-h urine protein levels (1.5 g/day). Concurrently diagnosis of an IUGR fetus was concluded. Standard pharmaceutical administration for treating preeclampsia was ordered. Persistence of symptoms indicated recommendation for pregnancy termination, however the patient opted against this. Selective embryo reduction was performed as the last resort prior to pregnancy termination. Following selective reduction the headaches and nausea were successfully subdued and the patient’s blood pressure was adjusted (mean BP 130/80 mmHg). This enabled further progression of pregnancy for an impressive 11 week-period, and a live birth on the 30th week. To conclude, only a few rare cases have been reported with diagnosis of early onset preeclampsia prior to the 20th week mark and none report live births. Albeit termination of pregnancy was recommended, the management of selective reduction of the IUGR fetus enabled successful treatment of preeclampsia coupled by a live birth of a healthy infant without any perinatal or postnatal complications reported.

Association between circulating visfatin and pre-eclampsia: a systematic review and meta-analysis

OBJECTIVE

Pre-eclampsia (PE) is a serious pregnancy status characterized by high blood pressure. Although visfatin is usually associated with PE. Observational studies evaluating the relationship between circulating visfatin and pre-eclampsia have reported inconsistent results. We conducted this systematic review and meta-analysis to summarize published data on the association between visfatin and pre-eclampsia.

METHODS

Electronic databases PubMed, ISI web of science, EMBASE, Scopus and the Cochrane library were comprehensively searched for selection of eligible studies until January 5, 2020. A random-effects model and the generic inverse variance method were used for quantitative data synthesis. The assessment of study quality was performed using the e Newcastle-Ottawa scale and the Agency for Healthcare Research and Quality. Sensitivity analyses and prespecified subgroup were conducted to evaluate potential heterogeneity. Random-effects meta-regression was conducted to assess the impact of potential confounders on the estimated effect sizes. The protocol for this study was registered in PROSPERO (No. CRD42018105861) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Thirteen studies comprising a total of 536 subjects were included in this meta-analysis. We observed that the pre-eclampsia risk is associated with a statistically significant elevation of visfatin level [SMD (1.33 µg/l) (95% CI 0.37, 2.2) p = .007]. No significant publication bias was observed in the meta-analysis. Subgroup and sensitivity analyses indicated that the pooled effects size were affected by systolic blood pressure [SMD (1.82 µg/l) 95% CI (0.94, 2.7), p < .05], gestational age [SMD (2.01 µg/l) 95% CI (0.57, 3.4), p = .006], body mass index [SMD (1.6 µg/l) 95% CI (0.37, 3), p < .05] and pregnancy trimesters[SMD (2.3 µg/l) 95% CI (0.95, 3.7), p = .001]. Random-effects meta-regression showed a significant association of visfatin level with potential confounders including systolic blood pressure, gestational age and birth weight at delivery of pre-eclampsia patients.

CONCLUSIONS

Collectively, our data revealed that the increase of visfatin level can be associated with the risk of pre-eclampsia. However, further studies on pre-eclampsia populations are warranted for corroboration of our findings.

Hypertension Drug Therapy

Hypertension is still the number one global killer. No matter what causes are, lowering blood pressure can significantly reduce cardiovascular complications, cardiovascular death, and total death. Unfortunately, some hypertensive individuals simply do not know having hypertension. Some knew it but either not being treated or treated but blood pressure does not achieve goal. The reasons for inadequate control of blood pressure are many. One important reason is that we are not very familiar with antihypertensive agents and less attention has been paid to comorbidities, complications as well as the hypertension-modified target organ damage in patients with hypertension. The right antihypertensive drug was not given to the right hypertensive patients at right time. This reviewer studied comprehensively the literature, hopefully that the review will help improve antihypertensive drug selection and antihypertensive therapy.

Super-enhancer-guided mapping of regulatory networks controlling mouse trophoblast stem cells

Trophectoderm (TE) lineage development is pivotal for proper implantation, placentation, and healthy pregnancy. However, only a few TE-specific transcription factors (TFs) have been systematically characterized, hindering our understanding of the process. To elucidate regulatory mechanisms underlying TE development, here we map super-enhancers (SEs) in trophoblast stem cells (TSCs) as a model. We find both prominent TE-specific master TFs (Cdx2, Gata3, and Tead4), and >150 TFs that had not been previously implicated in TE lineage, that are SE-associated. Mapping targets of 27 SE-predicted TFs reveals a highly intertwined transcriptional regulatory circuitry. Intriguingly, SE-predicted TFs show 4 distinct expression patterns with dynamic alterations of their targets during TSC differentiation. Furthermore, depletion of a subset of TFs results in dysregulation of the markers for specialized cell types in placenta, suggesting a role during TE differentiation. Collectively, we characterize an expanded TE-specific regulatory network, providing a framework for understanding TE lineage development and placentation.

Trophectoderm lineage development is essential for implantation, placentation, and healthy pregnancy. Here the authors map super-enhancers (SEs) in trophoblast stem cells and find both TE-specific master regulators and 150 previous uncharacterised transcription factors that are SE-associated, providing insight into trophectoderm-specific regulatory networks.

Long-term cardiovascular disorders in the STOX1 mouse model of preeclampsia

Adverse long-term cardiovascular (CV) consequences of PE are well established in women. However, the mechanism responsible for that risk remains unknown. Here, we mated wild-type female mice of the FVB/N strain to STOX1A-overexpressing mice to mimic severe PE and investigated the long-term consequences on the maternal cardiovascular system. Ultrasonography parameters were analyzed in mice before pregnancy and at 3 and 6 months post-pregnancy. At 6 months post-pregnancy, cardiac stress test induced by dobutamine injection revealed an abnormal ultrasonography Doppler profile in mice with previous PE. Eight months post-pregnancy, the heart, endothelial cells (ECs) and plasma of females were analyzed and compared to controls. The heart of mice with PE showed left-ventricular hypertrophy associated with altered histology (fibrosis). Transcriptomic analysis revealed the deregulation of 1149 genes in purified ECs and of 165 genes in the hearts, many being involved in heart hypertrophy. In ECs, the upregulated genes were associated with inflammation and cellular stress. Systems biology analysis identified interleukin 6 (IL-6) as a hub gene connecting these pathways. Plasma profiling of 33 cytokines showed that, 8 of them (Cxcl13, Cxcl16, Cxcl11, IL-16, IL-10, IL-2, IL-4 and Ccl1) allowed to discriminate mice with previous PE from controls. Thus, PE triggers female long-term CV consequences on the STOX1 mouse model.

Development of a biophysical screening model for gestational hypertensive diseases

Background

To investigate the possibility of using maternal biophysical parameters only in screening for the different types of gestational hypertensive diseases.

Methods

A total of 969 pregnant women were randomly screened in first and second trimester, of which 8 developed Early-onset Preeclampsia, 29 Late-onset Preeclampsia, 35 Gestational Hypertension and 897 women had a normal outcome. An observational maternal hemodynamics assessment was done via standardized electrocardiogram-Doppler ultrasonography, Impedance Cardiography and bio-impedance, acquiring functional information on heart, arteries, veins and body fluid. Preliminary prediction models were developed to test the screening potential for early preeclampsia, late preeclampsia and gestational hypertension using a Partial Least Square Discriminant Analysis.

Results

A combined model using maternal characteristics with cardiovascular parameters in first and second trimester offers high screening performance with Area Under the Curve of 99,9% for Early-onset Preeclampsia, 95,3% for Late-onset Preeclampsia and 94% for Gestational Hypertension.

Conclusions

Using biophysical parameters as fundament for a new prediction model, without the need of biochemical parameters, seems feasible. However, validation in a large prospective study will reveal its true potential.

The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention

Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.

A successful pregnancy in a patient with secondary hypertension caused by adrenal adenoma: a case report

Background

Secondary hypertension is a rare complication in pregnancy that causes poor outcomes, such as preeclampsia, premature delivery, intrauterine growth retardation, stillbirths, spontaneous abortion or intrauterine death. Cushing’s disease caused by an adrenal adenoma is rare during pregnancy and may be overlooked by obstetricians and physicians, but can lead to hypertension, diabetes mellitus and an increased risk of fetal and maternal morbidity. Approximately 200 cases have been reported in the literature. Here, we report the successful management of a pregnant patient with Cushing’s syndrome due to an adrenal adenoma.

Case presentation

The 35-year-old Chinese female had no individual or family medical history of hypertension, and did not exhibit chronic kidney disease, diabetes mellitus, autoimmune and common endocrine diseases. Her blood pressure was elevated from the 16th week of gestation and was not controlled by 30 mg nifedipine twice a day. Examination in our department revealed her 24 h urinary free cortisol (24 h UFC) level was 1684.3 μg/24 h (normal range: 20.26–127.55 μg/24 h) and plasma adrenocorticotropic hormone was < 1.00 ng/L in three independent measurements (normal range: 5–78 ng/L). Ultrasonography demonstrated a mass (2.9 cm × 2.8 cm) in the right side of the adrenal gland. Magnetic resonance imaging without contrast showed a 3.2 cm diameter mass in the right-side of the adrenal gland. Other medical tests were normal. Laparoscopic adrenalectomy was performed at the 26th week of gestation by a urological surgeon in the West China Hospital. Histopathology revealed an adrenocortical adenoma. After surgery, the patient accepted glucocorticoid replacement therapy. The remaining trimester continued without complication and her blood pressure was normal at the 32nd week of gestation without antihypertensive therapy. The patient gave birth to a healthy boy at the 40th week of gestation.

Conclusions

Cushing’s syndrome caused by adrenal adenoma is rare during pregnancy. This unique case suggested that analysis of the UFC level and circadian rhythm of plasma cortisol provides a suitable strategy to diagnose Cushing’s syndrome during pregnancy. Laparoscopic surgical resection in the second trimester provides a reasonable approach to treat pregnant patients exhibiting Cushing’s syndrome caused by an adrenal adenoma.

Trimester-specific plasma exosome microRNA expression profiles in preeclampsia

Objective: To identify microRNAs (miRNAs) differentially expressed in plasma exosomes collected in women diagnosed with preeclampsia compared with women with uncomplicated pregnancies.Materials and methods: Exosomes were purified from plasma samples obtained at each trimester from four women subsequently diagnosed with preeclampsia and from five matched healthy controls. RNA was purified from the exosomes, and expression of 368 miRNAs was profiled using A-Set TaqMan low density array (TLDA).Results: One-third of the 368 miRNAs profiled are not expressed in exosomes. Further, those that are not expressed tend to be evolutionarily younger and have a significantly different mature sequence signature than do miRNAs that are expressed in exosomes. Among miRNAs that are expressed in exosomes, a total of eight (miR-134, miR-196b, miR-302c, miR-346, miR-376c, miR-486-3p, miR-590-5p, and miR-618) were found to display statistically significant differential expression between women who developed preeclampsia as compared with those who did not. Moreover, half of these miRNAs (miR-134, miR-376c, miR-486-3p, and miR-590-5p) displayed statistically significant differential expression in the first trimester.Conclusions: Not all miRNAs are expressed in exosomes. Those that tend to be evolutionarily older and have a significantly different mature sequence signature than those that are not. A few exosome-expressed miRNAs do display expression patterns in women subsequently diagnosed with preeclampsia that are significantly different than in women having an uncomplicated and, among these, several appear in the first trimester. These miRNAs are potential early markers of preeclampsia risk.

Maternal Serum Uric Acid as a Predictor of Severity of Hypertensive Disorders of Pregnancy: A Prospective Cohort Study

Objective: To assess the relationship between maternal serum uric acid and severity of Hypertensive disorders of pregnancy in a rural tertiary care centre.

Materials and Methods: Present study was conducted in Obstetrics and Gynaecology department of rural tertiary care cen-tre of Northern India over seven months (October 2016-May 2017) on 110 women admitted with a Hypertensive disorder of pregnancy (Gestational hypertension, Pre-eclampsia, Eclampsia) at ≥34 weeks gestation. Maternal serum uric acid levels were compared in three groups in relation to disease severity, mode of delivery, maternal outcome.

Results: Of total 110 women with a Hypertensive disorder of pregnancy; 35 (31.81%) had Gestational Hypertension, 49 (44.54%) preeclampsia and 26 (23.63%) had eclampsia. Mean±SD values for serum uric acid were 5.47±1.93 mg/dl in women with Gestational Hypertension; 6.72±2.15 mg/dl in Pre-eclampsia and 8.71±2.97 mg/dl in the eclamptic group. Of 110 women 34(97.14%) with gestational hypertension, 27(55.10%) with pre-eclampsia and one (3.85%) with eclampsia re-mained stable in post-partum period, 17 (34.69%) women with severe pre-eclampsia and 15 (57.69%) with eclampsia re-quired intensive care in postpartum period and one (2.86%) women with gestational hypertension, five (10.20%) with pre-eclmapsia and ten (38.46%) with eclampsia required ventilator support and high dependency unit care. Of these 16 women with the severe disease, ten succumbed to death. Also, in women with serum uric acid,>6mg/dl, most common mode of de-livery was a lower segment cesarean section (50.90%).

Conclusion: Significant correlation was observed between maternal serum uric acid, disease severity and maternal outcome.

Preeclampsia: Disease biology and burden, its management strategies with reference to India

Preeclampsia is the cause of significant maternal and fetal mortality and morbidity. It is characterized by new-onset hypertension and proteinuria after 20 weeks of gestation. Preeclamptic women and children born from preeclamptic pregnancies are at greater risk to develop severe cardiovascular complications and metabolic syndromes later in life. The incidence of preeclampsia is estimated to be seven times higher in developing countries as compared to the developed countries. This review summarizes the pathophysiology of preeclampsia, emerging new hypothesis of its origin, risk factors that make women susceptible to developing preeclampsia and the potential of various biomarkers being studied to predict preeclampsia. The health care of developing countries is continuously challenged by substantial burden of maternal and fetal mortality. India despite being a fast developing country, is still far behind in achieving the required maternal mortality rates as per Millennium Development Goals set by the World Health Organization. Further, this review discusses the prevalence of preeclampsia in India, health facilities to manage preeclampsia, current guidelines and protocols followed and government policies to combat this complication in Indian condition.

EG-VEGF Maintenance Over Early Gestation to Develop a Pregnancy-Induced Hypertensive Animal Model

During the last decade, multiple animal models have been developed to mimic hallmarks of pregnancy-induced hypertension (PIH) diseases, which include gestational hypertension, preeclampsia (PE), or eclampsia. Converging in vitro, ex vivo, and clinical studies from our group strongly suggested the potential involvement of the new angiogenic factor EG-VEGF (endocrine gland-derived-VEGF) in the development of PIH. Here, we described the protocol that served to demonstrate that maintenance of EG-VEGF production over 11.5 days post coitus (dpc) in the gravid mice caused the development of PIH. The developed model exhibited most hallmarks of preeclampsia.

Maternal left ventricular hypertrophy and diastolic dysfunction and brain natriuretic peptide concentration in early- and late-onset pre-eclampsia

OBJECTIVE

Pre-eclampsia (PE) is associated with maternal cardiac remodeling and diastolic dysfunction. The aim of this study was to assess and compare maternal left ventricular structure and diastolic function and levels of brain natriuretic peptide (BNP) in women with early-onset (< 34 weeks' gestation) vs those with late-onset (≥ 34 weeks' gestation) PE.

METHODS

This was a prospective, cross-sectional, observational study of 30 women with early-onset PE, 32 with late-onset PE and 23 normotensive controls. Maternal cardiac structure and diastolic function were assessed by echocardiography and plasma levels of BNP were measured by enzyme immunoassay.

RESULTS

Early- and late-onset PE were associated with increased left ventricular mass index and relative wall thickness compared with normotensive controls. In women with early-onset PE, the prevalence of concentric hypertrophy (40%) and diastolic dysfunction (23%) was also significantly higher (both P < 0.05) compared with women with late-onset PE (16% for both). Maternal serum BNP levels were significantly higher (P < 0.05) in women with early-onset PE and correlated with relative wall thickness and left ventricular mass index.

CONCLUSIONS

Early-onset PE is associated with more severe cardiac impairment than is late-onset PE, as evidenced by an increased prevalence of concentric hypertrophy, diastolic dysfunction and higher levels of BNP. These findings suggest that early-onset PE causes greater myocardial damage, increasing the risk of both peripartum and postpartum cardiovascular morbidity. Although these cardiovascular effects are easily identified by echocardiographic parameters and measuring BNP, further studies are needed to assess their clinical utility. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Arterial stiffness in women previously with preeclampsia from a semi-rural region of South Africa

Women with pre-eclampsia have an increased risk of cardiovascular disease later in life. The aim of the study was to establish the presence and pattern of arterial stiffness in women previously with pre-eclampsia from a semi-rural region of South Africa. This was a prospective longitudinal study which involved 36 previously pre-eclamptic women and 86 non-pregnant controls (NPC) who had a past history of non-complicated pregnancy. Maternal wave reflection (augmentation index) and carotid-femoral pulse wave velocity were assessed noninvasively, using applanation tonometry with the SphygmoCor device. Endothelial function was assessed by EndoPAT 2000 device; pneumatic probes were fitted to the index fingers; induced flow-mediated reactive hyperemia; the ratio of the readings before and after occlusion was then used to calculate the score, the reactive hyperemia index (RHI) as a measure of endothelial function. Pulse wave velocity remained significantly higher in previously pre-eclamptic women than non-pregnant controls up to three months after delivery (p < 0.05), then it reduced to nonsignificant values. All blood pressure indices (central and brachial pressures), were higher in previously pre-eclamptic women as compared to nonpregnant controls up to one year postpartum. Regional (aortic) arterial stiffness, though it persists for some time after delivery, is transitory in previously pre-eclamptic women from the rural Africa setting. However, their increase blood pressure is an indication of compromised arterial compliance in women previously with pre-eclampsia.

Icariin improves acute kidney injury and proteinuria in a rat model of pregnancy‑induced hypertension

Icariin has previously been demonstrated to attenuate hyperglycemia-induced renal injury, however the renoprotective effects of icariin in a rat model of pregnancy-induced hypertension (PIH) remain to be elucidated. The present study aimed to investigate the effect of icariin on PIH-induced acute kidney injury (AKI) and proteinuria. Following 18 days of icariin treatment between day 1 and day 18 of gestation, which was combined with NG-nitro-L-arginine methyl ester (L-NAME) treatment between day 12 and day 18 of gestation to induce PIH, the 24 h urine protein level, blood urea nitrogen and serum creatinine were measured by using the Coomassie Brilliant Blue method, a commercial enzymatic kit and the picric acid method, respectively. Renal tissues were collected at day 18 of gestation for hematoxylin and eosin staining and immunohistochemistry. The mRNA expression of AGT and protein expression of angiotensin II (Ang II) in the kidneys of control and PIH rats was investigated by reverse transcription-quantitative polymerase chain reaction and western blot analysis, respectively, to determine the effect of icariin on components of the renin-angiotensin system. The results demonstrated that L-NAME treatment in pregnant rats resulted in significant increases in systolic blood pressure (SBP) and diastolic blood pressure, in addition to the induction of severe proteinuria. The significant increase in SBP and proteinuria in PIH rats was prevented by icariin. L-NAME-induced AKI resulted in profound renal histological alterations, including mesangial expansion and glomerular lesions. L-NAME administration exerted a marked decrease in the mRNA and protein expression levels of nephrin in the kidneys from PIH rats compared with control group. Furthermore, upregulation of circulating and renal Ang II levels in PIH rats was observed. However, icariin treatment significantly reversed the L-NAME-induced downregulation of nephrin and upregulation of circulating and renal Ang II levels in PIH rats. These results demonstrated that icariin administration improved urinary protein excretion levels and renal tissue damage in PIH rats, and the underlying mechanism was mediated in part, via upregulation of nephrin expression and downregulation of Ang II.

Vitamins supplementation affects the onset of preeclampsia

Preeclampsia may affect between 2-8% of all pregnancies. It seriously affects maternal health after pregnancy. This meta-analysis was performed to define the efficacy of vitamins supplementation on the risk of preeclampsia. Potential articles were systematically searched on the databases of Pubmed, Embase and Web of Science up to May 2016. Relative risk (RR) and 95% confidence intervals (95%CIs) were used to analyze the relationship of vitamins supplementation with risk of preeclampsia. Cochran Q test was used to test inter-study heterogeneity. Begg's funnel plot was adopted to assess the potential publication bias. 28 eligible studies were selected. Pooled results indicated that vitamins supplementation could reduce the risk of preeclampsia (RR = 0.74, 95%CI = 0.64-0.86). The studies with non-randomized controlled trial (RCT) analysis also suggested the significant relationship of vitamins supplementation with risk of preeclampsia (RR = 0.60, 95%CI = 0.42-0.85). However, negative results were observed in studies with RCT analysis. Subgroup analysis by vitamin type was performed among the studies with RCT analysis. The results indicated that vitamin D supplementation could significantly reduce the risk of preeclampsia (RR = 0.41, 95%CI = 0.22-0.78). Similar results were observed in the studies with multivitamins supplementation (RR = 0.69, 95%CI = 0.51-0.93). Vitamins supplementation could reduce the onset of preeclampsia.

The Gene Variants of Maternal/Fetal Renin-Angiotensin System in Preeclampsia: A Hybrid Case-Parent/Mother-Control Study

Preeclampsia (PE) is a common pregnancy-related complication, and polymorphisms in angiotensinogen (AGT), angiotensin-converting enzyme (ACE), and angiotensin II type 1 receptor (AT1R) are believed to contribute to PE development. We implemented a hybrid study to investigate the influence of maternal and fetal ACE I/D, ACE G2350A, AGT M235T, AGT T174M, and AT1R A1166C polymorphisms on PE in Han Chinese women. Polymorphisms were genotyped in 1,488 subjects (256 patients experiencing PE, along with their fetuses and partners, and 360 normotensive controls with their fetuses). Transmission disequilibrium tests revealed that ACE I/D (P = 0.041), ACE G2350A (P = 0.035), and AT1R A1166C (P = 0.018) were associated with maternal PE. The log-linear analyses revealed that mothers whose offspring carried the MM genotype of AGT M235T had a higher risk of PE (OR = 1.54, P = 0.010), whereas mothers whose offspring carried the II genotype of ACE I/D or the GG genotype of ACE G2350A had a reduced risk (OR = 0.58, P = 0.039; OR = 0.47, P = 0.045, respectively). Our findings demonstrate that fetal ACE I/D, ACE G2350A, AGT M235T, and AT1R A1166C polymorphisms may play significant roles in PE development among pregnant Han Chinese women.

The MDM2 promoter T309G polymorphism was associated with preeclampsia susceptibility

PURPOSE

Preeclampsia (PE) is a hypertensive disorder of pregnancy in which abnormal proliferation and apoptosis of placenta trophoblast has a pivotal role in its pathophysiology. The aim of the current study was to examine the association between Mouse Double Minute 2 (MDM2) T309G and 40 bp insertion/deletion (I/D) polymorphisms and PE risk.

METHODS

A case-control study was conducted on 208 PE women and 164 healthy pregnant women matching age, sex, and ethnicity. Polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and PCR methods were used for genotyping.

RESULTS

The MDM2 309GG genotype was associated with PE, and this genotype was found to be a risk factor for PE. There was no association between the MDM2 I/D polymorphism and PE. The haplotype-based association analysis revealed no association between MDM2 T309G and 40 bp I/D polymorphisms and PE. The frequency of TT-DD and GG-DD combined genotypes were significantly higher in PE women with marginal P values (P = 0.046).

CONCLUSIONS

The MDM2 309GG genotype was associated with higher risk of PE. The TT-DD and GG-DD combined genotypes were higher in PE women.

Pharmacogenetics in the treatment of pre-eclampsia: current findings, challenges and perspectives

Pre-eclampsia (PE) is defined as pregnancy-induced hypertension and proteinuria, and is a major cause of maternal and perinatal morbidity and mortality. A large subgroup of pregnant women with PE is nonresponsive to antihypertensive drugs, including methyldopa, nifedipine and hydralazine. Pharmacogenomics may help to guide the individualized therapy for this nonresponsive subgroup. However, just a few pharmacogenetic studies examined the effects of genetic polymorphisms on response to antihypertensive drugs in PE, and the criteria of responsiveness used to define responsive or nonresponsive subgroups to antihypertensive therapy should be replicated by others. We review these gene–drugs interactions, novel approaches to pharmacogenomics research and potential novel drugs for PE therapy. Finally, we discuss the challenges and perspectives of pharmacogenetics in the treatment of PE.

Comparison of Hydralazine and Labetalol to lower severe hypertension in pregnancy

OBJECTIVE

To compare the intravenous Labetalol versus intravenous hydralazine in patients having severe Pregnancy induced hypertension (PIH) and pre eclampsia (PE) in pregnancy.

METHODS

Seventy eight women admitted in the Department of Gynecology and Obstetrics, Civil Hospital Karachi, having severe PIH/PE and fulfilling the inclusion criteria were included in the study. Random selection of patients was performed using sealed opaqe envelop for administration of either intravenous noted (IV) Labetalol or Hydrallazine. The mean fall in the MAP in each group was noted. This data was analyzed by applying SPSS version 13. The study was conducted from November 2012 to April 2013.

RESULTS

The mean (±SD) age of the labetalol group was 27.46 (±5.28) years while that in the hydralazine group was 26.28 (±5.17) years. The mean fall in MAP observed in the labetalol group was 29.10 ± 7.21 mmHg and that in the hydralazine group was 25.05 ± 10.15 mmHg which was statistically significant with the p value being 0.046.

CONCLUSION

Intra Venous labetalol lowered MAP more than hydralazine, when administered to pregnant females with severe Pregnancy induced hypertension and pre eclampsia in pregnancy.

Intensive Care Unit issues in eclampsia and HELLP syndrome

Preeclampsia, eclampsia and HELLP syndrome are life-threatening hypertensive conditions and common causes of ICU admission among obstetric patients The diagnostic criteria of preeclampsia include: 1) systolic blood pressure (SBP) ≥140 mmHg or diastolic blood pressure (DBP) ≥90 mmHg on two occasions at least 4 hours apart and 2) proteinuria ≥300 mg/day in a woman with a gestational age of >20 weeks with previously normal blood pressures. Eclampsia is defined as a convulsive episode or altered level of consciousness occurring in the setting of preeclampsia, provided that there is no other cause of seizures. HELLP syndrome is a life-threatening condition frequently associated with severe preeclampsia-eclampsia and is characterized by three hallmark features of hemolysis, elevated liver enzymes and low platelets. Early diagnosis and management of preeclampsia, eclampsia and HELLP syndrome are critical with involvement of a multidisciplinary team that includes Obstetrics, Maternal Fetal Medicine and Critical Care. Expectant management may be acceptable before 34 weeks with close fetal and maternal surveillance and administration of corticosteroid therapy, parenteral magnesium sulfate and antihypertensive management. Worsening condition requires delivery. Complications that can be related to this spectrum of disease include disseminated Intravascular coagulation (DIC), acute respiratory distress syndrome, stroke, acute renal failure, hepatic dysfunction with hepatic rupture or liver hematoma and infection/sepsis.

Features of the urine peptidome under the condition of hypertensive pathologies of pregnancy

In order to find a peptide panel to differentiate close hypertensive conditions a case-control study was designed for 64 women from 4 groups: preeclampsia (PE), chronic hypertension superimposed with PE, chronic hypertension, and healthy individuals. Chromatography coupled with mass-spectrometry and subsequent bioinformatic analysis showed several patterns in the changes of the urine peptidome. There were 36 peptides common for four groups. Twenty two of them 22 belonged to alpha-1-chain of collagen I, nine peptides were from alpha-1-chain of collagen III, two from alpha-2-chain of collagen I, one from alpha-1/2-chain of collagen I, one from alpha-1-chain of collagen I/XVIII and one from uromodulin. Patients with hypertensive disorders had 34 common peptides: 12 from alpha-1-chain of collagen I, 10 from fibrinogen alpha-chain, eight from alpha-1-chain of collagen III, and 4 per other types of collagen. Comparative analysis revealed 12 peptides, which could be used as a diagnostic panel for confident discrimination of pregnant women with various hypertensive disorders.

Stem cell insights into human trophoblast lineage differentiation

BACKGROUND

The human placenta is vital for fetal development, yet little is understood about how it forms successfully to ensure a healthy pregnancy or why this process is inadequate in 1 in 10 pregnancies, leading to miscarriage, intrauterine growth restriction or preeclampsia. Trophoblasts are placenta-specific epithelial cells that maximize nutrient exchange. All trophoblast lineages are thought to arise from a population of trophoblast stem cells (TSCs). However, whilst the isolation of murine TSC has led to an explosion in understanding murine placentation, the isolation of an analogous human TSC has proved more difficult. Consequently, alternative methods of studying human trophoblast lineage development have been employed, including human embryonic stem cells (hESCs), induced pluripotent stem cells (iPS) and transformed cell lines; but what do these proxy models tell us about what is happening during early placental development?

OBJECTIVE AND RATIONALE

In this systematic review, we evaluate current approaches to understanding human trophoblast lineage development in order to collate and refine these models and inform future approaches aimed at establishing human TSC lines.

SEARCH METHODS

To ensure all relevant articles were analysed, an unfiltered search of Pubmed, Embase, Scopus and Web of Science was conducted for 25 key terms on the 13th May 2016. In total, 47 313 articles were retrieved and manually filtered based on non-human, non-English, non-full text, non-original article and off-topic subject matter. This resulted in a total of 71 articles deemed relevant for review in this article.

OUTCOMES

Candidate human TSC populations have been identified in, and isolated from, both the chorionic membrane and villous tissue of the placenta, but further investigation is required to validate these as 'true' human TSCs. Isolating human TSCs from blastocyst trophectoderm has not been successful in humans as it was in mice, although recently the first reported TSC line (USFB6) was isolated from an eight-cell morula. In lieu of human TSC lines, trophoblast-like cells have been induced to differentiate from hESCs and iPS. However, differentiation in these model systems is difficult to control, culture conditions employed are highly variable, and the extent to which they accurately convey the biology of 'true' human TSCs remains unclear, particularly as a consensus has not been met among the scientific community regarding which characteristics a human TSC must possess.

WIDER IMPLICATIONS

Human TSC models have the potential to revolutionize our understanding of trophoblast differentiation, allowing us to make significant gains in understanding the underlying pathology of pregnancy disorders and to test potential therapeutic interventions on cell function in vitro. In order to do this, a collaborative effort is required to establish the criteria that define a human TSC to confirm the presence of human TSCs in both primary isolates and to determine how accurately trophoblast-like cells derived from current model systems reflect trophoblast from primary tissue. The in vitro systems currently used to model early trophoblast lineage formation have provided insights into early human placental formation but it is unclear whether these trophoblast-like cells are truly representative of primary human trophoblast. Consequently, continued refinement of current models, and standardization of culture protocols is essential to aid our ability to identify, isolate and propagate 'true' human TSCs from primary tissue.

Hypertensive disorders of pregnancy

PURPOSE

In this continuing professional development module, we review recent Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines for the classification and diagnosis of hypertensive disorders of pregnancy (HDP) as well as review the clinical features, laboratory investigations, and outcomes of HDP. We explore the evidence for anesthetic management and prevention of end-organ damage in women with HDP and describe the role and contribution of anesthesiologists as part of a multidisciplinary care team.

PRINCIPAL FINDINGS

Hypertensive disorders of pregnancy can have variable presentations with clinical signs and symptoms that often do not correlate with the underlying severity and progression of the disease. Failure of timely diagnosis and treatment contributes significantly to adverse maternal (neurologic complications, pulmonary edema, and postpartum hemorrhage) and neonatal (respiratory and neurologic complications and stillbirth) outcomes. In the Canadian context, improvements in medical care have led to better maternal and neonatal outcomes. Timing of delivery is crucial in balancing maternal risks and fetal benefits of ongoing pregnancy. Evidence-based SOGC guidelines regarding diagnosis and management of HDP address many aspects of clinical care relevant to anesthesiologists, who have an important role in the multidisciplinary care team.

CONCLUSIONS

Hypertensive disorders of pregnancy are on the rise worldwide, and this trend is expected to continue. The major contributors to maternal mortality are failure to recognize HDP promptly or to treat the condition adequately. It is essential that anesthesiologists understand the disease process and acquire knowledge of the guidelines governing current obstetrical care in order to provide evidence-based multidisciplinary quality care to these patients. Anesthetic management helps prevent potentially deleterious maternal and fetal outcomes.

[Hypertension in pregnancy and future maternal health]

Preeclampsia is a specific risk factor chronic of hypertension, of coronary events (Ray et al., 2005), of stroke (Brown et al., 2006), of chronic renal failure (Kattah and Garovic, 2005; McDonald et al., 2003; Williams, 2003) and a specific risk factor of cardio-cerebrovascular mortality (Magnussen et al., 2009). According to Magnusson et al. (2009), the relative long-term risk of developing hypertension is multiplied by 4; the risk of diabetes and metabolic syndrome multiplied by 3; the risk of coronary heart disease and stroke multiplied by 2. Cardiovascular risk is particularly important when pregnancy was complicated by maternal and fetal events or occurring precociously (Williams, 2003; Newstead et al., 2007). Early PE is associated with a relative risk of death by 7 of CV disease. Several pathophysiological factors are common between CV disease and preeclampsia: endothelial dysfunction, hypertension, obesity, insulin resistance, dyslipidemia and CV heredity. Metabolic syndrome could be the link between preeclampsia and CV disease. Hypertension in pregnancy and preeclampsia could unmask metabolic syndrome "latent" existing (Silva et al., 2008). Recently, scientific societies have published guidelines dedicated to cardiovascular risk in women and for the prevention of stroke in women. They recognize hypertension in pregnancy and preeclampsia as specific emerging risk (Mosca et al., 2011; European Society of Gynecology et al., 2011; Bushnell et al., 2014). Paradoxically, information and prevention of these women at risk is insufficient to ignorance and lack of awareness among health professionals (Brown et al., 2013). The education of women has become a major issue of prevention, developing specific consultation after delivery, encouraging them to optimize their lifestyle with a coordinated follow-up (Newstead et al., 2007; Mosca et al., 2011; European Society of Gynecology et al., 2011; Bushnell et al., 2014, Harskamp and Zeeman, 2007). In the end, the implementation of structured care pathway, further monitoring of these women, aims to improve the practices of health professionals (Manten et al., 2007; Adams et al., 2014; Mounier-Vehier et al., 2014).

Sustained Endocrine Gland-Derived Vascular Endothelial Growth Factor Levels Beyond the First Trimester of Pregnancy Display Phenotypic and Functional Changes Associated With the Pathogenesis of Pregnancy-Induced Hypertension

Pregnancy-induced hypertension diseases are classified as gestational hypertension, preeclampsia, or eclampsia. The mechanisms of their development and prediction are still to be discovered. Endocrine gland-derived vascular endothelial growth factor (EG-VEGF) is an angiogenic factor secreted by the placenta during the first trimester of human pregnancy that was shown to control trophoblast invasion, to be upregulated by hypoxia, and to be abnormally elevated in pathological pregnancies complicated with preeclampsia and intrauterine growth restriction. These findings suggested that sustaining EG-VEGF levels beyond the first trimester of pregnancy may contribute to pregnancy-induced hypertension. To test this hypothesis, osmotic minipumps delivering EG-VEGF were implanted subcutaneously into gravid OF1 (Oncins France 1) mice on day 11.5 post coitus, which is equivalent to the end of the first trimester of human pregnancy. Mice were euthanized at 15.5 and 18.5 days post coitus to assess (1) litter size, placental, and fetal weights; (2) placental histology and function; (3) maternal blood pressure; (4) renal histology and function; and (5) circulating soluble fms-like tyrosine kinase 1 and soluble endoglin. Increased EG-VEGF levels caused significant defects in placental organization and function. Both increased hypoxia and decreased trophoblast invasion were observed. Treated mice had elevated circulating soluble fms-like tyrosine kinase 1 and soluble endoglin and developed gestational hypertension with dysregulated maternal kidney function. EG-VEGF effect on the kidney function was secondary to its effects on the placenta as similarly treated male mice had normal kidney functions. Altogether, these data provide a strong evidence to confirm that sustained EG-VEGF beyond the first trimester of pregnancy contributes to the development of pregnancy-induced hypertension.

Association of aberrant methylation at promoter regions of tumor suppressor genes with placental pathologies

AIM

The resemblance between invasive behavior of cancer cells and placental trophoblasts and the role of aberrant epigenetic regulation in cancer development is well known.

METHODS

We analyzed the role of promoter region CpG-methylation and H3K9/27me3 of tumor suppressor genes in normal and pathological pregnancies and utilized their CpG-methylation data to search for fetal DNA epigenetic marker in maternal blood.

RESULTS

CpG and H3K9/27-methylation associated decreased expression of RASSF1A and APC and increased expression of P16, RB1 and PRKCDBP was observed with advancing normal gestation. Gestational trophoblastic diseases and preeclampsia revealed gene-specific epigenetic deregulation of candidate tumor suppressor genes. Furthermore, APC and PRKCDBP showed the potential to act as fetal DNA epigenetic markers, similar to RASSF1A.

CONCLUSION

Deregulation of methylation of tumor suppressor genes contributes to the development of preeclampsia and gestational trophoblastic diseases. APC and PRKCDBP may act as fetal DNA epigenetic markers for prenatal diagnosis.

Endothelial dysfunction and arterial stiffness in pre-eclampsia demonstrated by the EndoPAT method

OBJECTIVES

The EndoPAT method has been used as a non-invasive method for assessing endothelial function in several non-pregnant populations. We investigated its possible use in assessing endothelial dysfunction in pre-eclampsia.

METHODS

Two hundred and fifteen participants were recruited and grouped as pre-eclamptic cases (105) and normotensive controls (110). Endothelial function and arterial stiffness were measured as reactive hyperaemia index and augmentation index, respectively, using the EndoPAT 2000 machine.

RESULTS

The reactive hyperaemia index was significantly lower in the pre-eclamptic group compared to the normotensive group (p < 0.05). Augmentation index on the other hand was significantly higher in the pre-eclamptic group compared to the normotensive group (p < 0.0001).

CONCLUSION

The EndoPAT method demonstrates endothelial dysfunction and arterial stiffness in pre-eclampsia.

Hypertensive pathologies and egg donation pregnancies: Results of a large comparative cohort study

OBJECTIVE

To determine whether egg donation (ED) pregnancies are at higher risk of pregnancy-induced hypertension (PIH) than those achieved by autologous assisted reproductive technology (ART; controls).

DESIGN

Anonymous comparative observational matched cohort study.

SETTING

Assisted reproductive technology centers.

PATIENT(S)

Two hundred seventeen ED and 363 control singleton pregnancies matched at 7-8 weeks (pregnancy date, parity, cycle type [fresh/frozen] and women's age). According to French practice, all women were under 45.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Percentage of PIH for ED versus controls.

RESULT(S)

The groups were comparable (mean age, 34.5). PIH was more frequent during ED pregnancies (17.8% vs. 5.3%), as was preeclampsia (11.2% vs. 2.8%) and eclampsia (1.8% vs. 0.0%). In multivariate analyses, PIH risk increased with ED (odds ratio [OR], 3.92; 95% confidence interval [CI], 1.93-7.97) and women's age (OR, 1.08; 95% CI, 1.00-1.16). No significant effect of previous pregnancies or cycle rank/type was observed.

CONCLUSION(S)

This study had sufficient power to detect doubling of the PIH rate. It was demonstrated that the risk of PIH was tripled for ED versus controls. Even in young women, ED is a risk factor for PIH. An immunological explanation seems most likely, that is, the fetus is fully allogeneic to its mother. This risk must be acknowledged to inform couples and provide careful pregnancy monitoring.

CLTC as a clinically novel gene associated with multiple malformations and developmental delay

Diagnostic exome sequencing has recently emerged as an invaluable tool in determining the molecular etiology of cases involving dysmorphism and developmental delay that are otherwise unexplained by more traditional methods of genetic testing. Our patient was large for gestational age at 35 weeks, delivered to a 27-year-old primigravid Caucasian whose pregnancy was complicated by preeclampsia. Neonatal period was notable for hypoglycemia, apnea, bradycardia, hyperbilirubinemia, grade I intraventricular hemorrhage, subdural hematoma, laryngomalacia, hypotonia, and feeding difficulties. The patient had numerous minor dysmorphic features. At three and a half years of age, she has global developmental delays and nystagmus, and is being followed for a mediastinal neuroblastoma that is currently in remission. Karyotype and oligo-microarray were normal. Whole-exome, next generation sequencing (NGS) coupled to bioinformatic filtering and expert medical review at Ambry Genetics revealed 14 mutations in 9 genes, and these genes underwent medical review. A heterozygous de novo frameshift mutation, c.2737_2738dupGA p.D913Efs*59, in which two nucleotides are duplicated in exon 17 of the CLTC gene, results in substitution of glutamic acid for aspartic acid at position 913 of the protein, as well as a frame shift that results in a premature termination codon situated 58 amino acids downstream. Clathrin Heavy Chain 1 (CHC1) has been shown to play an important role in the brain for vesicle recycling and neurotransmitter release at pre-synaptic nerve terminals. There is also evidence implicating it in the proper development of the placenta during the early stages of pregnancy. The CLTC alteration identified herein is likely to provide an explanation for the patient's adverse phenotype. Ongoing functional studies will further define the impact of this alteration on CHC1 function and consequently, human disease.

Effect of chorionic villus sampling on the occurrence of preeclampsia and gestational hypertension: An updated systematic review and meta-analysis

OBJECTIVE

To perform a meta-analysis for an assessment of the risk of preeclampsia or gestational hypertension following chorionic villus sampling (CVS).

DATA SOURCE

PubMed was systematically searched from its inception through January 2016.

MATERIAL AND METHODS

Nine reports were identified. A pre-specified scale was used to assess their quality.

TABULATION INTEGRATION AND RESULTS

We performed pooling into three subgroups with respect to the control group: A) Patients with no invasive prenatal diagnostic procedure served as a control group for comparison. The odds ratios for gestational hypertension (0.76, 95% CI 0.46-1.26), preeclampsia (0.83, 95% CI 0.42-1.67), and severe preeclampsia (0.49, 95% CI 0.04-5.78) or when hypertension categories were pooled (0.80, 95% CI 0.46-1.41) were not significantly different. B) Patients with midtrimester diagnostic amniocentesis and patients with no invasive prenatal diagnostic procedure were combined as a control group for comparison. The odds ratios for preeclampsia (1, 95% CI 0.46-2.18), severe preeclampsia (0.83, 95% CI 0.14-4.85), and pooled hypertension categories (1.07, 95% CI 0.63-1.84) were not significantly different. C) Patients with midtrimester diagnostic amniocentesis served as a control group. There was a significant difference in the odds ratio for preeclampsia between the CVS and amniocentesis groups (2.47, 95% CI 1.14-5.33). There was a marginal difference in the odds ratio for combined pregnancy-induced hypertension categories between the CVS and amniocentesis groups (1.61, 95% CI 1.02-2.53).

CONCLUSION

The available data do not indicate an increased risk of preeclampsia or gestational hypertension following first trimester CVS. The heterogeneity and retrospective design of existing studies are limiting factors for our analysis and findings.