Risk factors for pre-eclampsia in nulliparous and parous women: the Jerusalem perinatal study

Postpartum care in a cardio-obstetric clinic after preterm preeclampsia: patient and healthcare provider perspectives

BACKGROUND

Despite the significant disruption and health implications of preterm preeclampsia with severe features for birthing people, little is known about how the system of postpartum care might be strengthened for affected families. Multidisciplinary cardio-obstetric clinics are emerging; however, there is limited research on patient and healthcare provider perspectives.

OBJECTIVE

To describe patient and healthcare provider perspectives of services in a cardio-obstetric clinic following preterm preeclampsia with severe features.

STUDY DESIGN

Individuals who experienced preterm preeclampsia with severe features and presented to a cardio-obstetric clinic were approached for study participation. Providers were approached if they provided postpartum care to patients with preterm preeclampsia with severe features and considered a referral to the cardio-obstetric clinic. Participants completed a remotely conducted, semistructured interview between March 2022 and April 2023. The interviews were audio-recorded, professionally transcribed, and checked for accuracy. Responses were inductively coded for content analysis around the study questions of clinical referrals, patient education, visit expectations, and care coordination in relation to ambulatory clinical services.

RESULTS

Twenty participants (n=10 patients and n=10 providers) completed interviews. Healthcare system navigation was difficult, particularly in the context of postpartum needs. When patients are informed about their diagnosis, the information could both increase anxiety and be useful for long-term healthcare planning. Language concordant care did not always occur, and both patients and providers described gaps in quality services. Within the theme of responsibility, patients described needing to be vigilant, and providers recognized the gaps in referral and care coordination systems. Comprehensible patient education provided with birthing parents' companions and enhanced systems for care coordination were areas for further improvement in providing postpartum cardio-obstetric care following preterm preeclampsia.

CONCLUSION

This qualitative study identified patients' struggles with a confusing postpartum healthcare system and captured providers' concerns about maintaining consistent care and improving access to long-term healthcare services to improve outcomes for patients at risk of cardiovascular disease.

Cardiovascular multimodality imaging in women: a scientific statement of the European Association of Cardiovascular Imaging of the European Society of Cardiology

Cardiovascular diseases (CVD) represent an important cause of mortality and morbidity in women. It is now recognized that there are sex differences regarding the prevalence and the clinical significance of the traditional cardiovascular (CV) risk factors as well as the pathology underlying a range of CVDs. Unfortunately, women have been under-represented in most CVD imaging studies and trials regarding diagnosis, prognosis, and therapeutics. There is therefore a clear need for further investigation of how CVD affects women along their life span. Multimodality CV imaging plays a key role in the diagnosis of CVD in women as well as in prognosis, decision-making, and monitoring of therapeutics and interventions. However, multimodality imaging in women requires specific consideration given the differences in CVD between the sexes. These differences relate to physiological changes that only women experience (e.g. pregnancy and menopause) as well as variation in the underlying pathophysiology of CVD and also differences in the prevalence of certain conditions such as connective tissue disorders, Takotsubo, and spontaneous coronary artery dissection, which are all more common in women. This scientific statement on CV multimodality in women, an initiative of the European Association of Cardiovascular Imaging of the European Society of Cardiology, reviews the role of multimodality CV imaging in the diagnosis, management, and risk stratification of CVD, as well as highlights important gaps in our knowledge that require further investigation.

Determinants of pre-eclampsia among pregnant women attending antenatal care and delivery services at Bahir Dar public hospitals, northwest Ethiopia: A case-control study

Background and Aims

Pre-eclampsia (PE) is a pregnancy-related syndrome that occurs after 20 weeks of pregnancy. The current study was designed to evaluate the determinants of PE in pregnant women following antenatal and delivery services.

Methods

An institution-based case-control study was performed in governmental hospitals of Bahir Dar city. The data were collected using an interview-administered questionnaire and analyzed by SPSS version 20 software. Bivariate and multivariable logistic regression models were utilized for the analysis of variables. A p < 0.05 was used to declare the level of significance.

Results

In this study, the mean ages (in years) of cases and controls were 28.20 ± 5.66 and 27.52 ± 4.70, respectively. Factors such as: being primiparous (adjusted odds ratio [AOR]: 3.19 at 95% confidence interval [CI]: 1.71, 5.97), family history of hypertension (HTN) (AOR: 4.14 at 95% CI: 1.71, 10.05), previous history of PE (AOR: 7.97 at 95% CI: 2.42, 26.63), number of antenatal care (ANC) visits (AOR: 5.43 at 95% CI: 2.86, 10.33), not taking iron and folic acid supplement (AOR: 4.46 at 95% CI: 1.59, 12.48), body mass index ≥25 kg/m² (AOR: 3.47 at 95% CI: 1.78, 6.77), not consuming vegetables (AOR: 1.99 at 95% CI: 1.07, 3.69) and not consuming egg, milk and milk products (AOR: 3.00 at 95% CI: 1.47, 6.11) were the determinants of PE.

Conclusion

In this study, different determinants of PE were identified. Hence, special attention should be given for primiparous women, women having previous history of PE and family history of HTN. Moreover, nutritional counseling should be given for pregnant women during ANC visits. Besides, higher officials should design an appropriate strategy to increase the number of mothers to complete their ANC visits and to take iron and folic acid supplements. Furthermore, to verify the determinants of PE, community-based cohort studies are warranted.

Preeclampsia: Recent Advances in Predicting, Preventing, and Managing the Maternal and Fetal Life-Threatening Condition

Preeclampsia accounts for one of the most common documented gestational complications, with a prevalence of approximately 2 to 15% of all pregnancies. Defined as gestational hypertension after 20 weeks of pregnancy and coexisting proteinuria or generalized edema, and certain forms of organ damage, it is life-threatening for both the mother and the fetus, in terms of increasing the rate of mortality and morbidity. Preeclamptic pregnancies are strongly associated with significantly higher medical costs. The maternal costs are related to the extra utility of the healthcare system, more resources used during hospitalization, and likely more surgical spending due to an elevated rate of cesarean deliveries. The infant costs also contribute to a large percentage of the expenses as the babies are prone to preterm deliveries and relevant or causative adverse events. Preeclampsia imposes a considerable financial burden on our societies. It is important for healthcare providers and policy-makers to recognize this phenomenon and allocate enough economic budgets and medical and social resources accordingly. The true cellular and molecular mechanisms underlying preeclampsia remain largely unexplained, which is assumed to be a two-stage process of impaired uteroplacental perfusion with or without prior defective trophoblast invasion (stage 1), followed by general endothelial dysfunction and vascular inflammation that lead to systemic organ damages (stage 2). Risk factors for preeclampsia including race, advanced maternal age, obesity, nulliparity, multi-fetal pregnancy, and co-existing medical disorders, can serve as warnings or markers that call for enhanced surveillance of maternal and fetal well-being. Doppler ultrasonography and biomarkers including the mean arterial pressure (MAP), uterine artery pulsatility index (UtA-PI), and serum pregnancy-associated plasma protein A (PAPP-A) can be used for the prediction of preeclampsia. For women perceived as high-risk individuals for developing preeclampsia, the administration of low-dose aspirin on a daily basis since early pregnancy has proven to be the most effective way to prevent preeclampsia. For preeclamptic females, relevant information, counseling, and suggestions should be provided to facilitate timely intervention or specialty referral. In pregnancies complicated with preeclampsia, closer monitoring and antepartum surveillance including the Doppler ultrasound blood flow study, biophysical profile, non-stress test, and oxytocin challenge test can be arranged. If the results are unfavorable, early intervention and aggressive therapy should be considered. Affected females should have access to higher levels of obstetric units and neonatal institutes. Before, during, and after delivery, monitoring and preparation should be intensified for affected gravidas to avoid serious complications of preeclampsia. In severe cases, delivery of the fetus and the placenta is the ultimate solution to treat preeclampsia. The current review is a summary of recent advances regarding the knowledge of preeclampsia. However, the detailed etiology, pathophysiology, and effect of preeclampsia seem complicated, and further research to address the primary etiology and pathophysiology underlying the clinical manifestations and outcomes is warranted.

Placental morphology and the prediction of underlying cardiovascular risk factors

OBJECTIVE

Pre-eclampsia is associated with an increased risk of future cardiovascular disease. Maladaptive placentation or malperfusion, as well as predisposing cardiovascular or metabolic risk for endothelial dysfunction, contribute to the systemic inflammatory response that establishes the origins of the disease. The purpose of this study was to investigate the relationship between placental size and cardiovascular risk when assessed at six months postpartum in women who experienced pre-eclampsia.

STUDY DESIGN

Maternal clinical and biochemical cardiovascular risk factors were used to categorize preeclamptic women into high vs. low lifetime cardiovascular disease risk profiles at six months postpartum. A multivariable logistic regression model was then used to identify the association between placental weight to birth weight ratio and high lifetime cardiovascular disease risk, adjusting for maternal age, pre-pregnancy BMI, and severity of pre-eclampsia. A p-value of < 0.05 was deemed statistically significant.

RESULTS

186/216 women with pre-eclampsia who attended the Maternal Health Clinic met inclusion criteria. No significant differences were observed for placental morphometric measurements between women who screened as having a high vs. low lifetime risk profile for cardiovascular disease at six months postpartum. However, using multivariable modelling that controlled for maternal age, pre-pregnancy body mass index, gestational age at delivery, and severity of pre-eclampsia, a low placenta to birth weight ratio (<15%) was associated with an increased odds of high lifetime cardiovascular disease risk (p < 0.009).

CONCLUSION

The findings of the current study identify clinical measurements that can be collected at the time of delivery which may help identify specific women who may benefit most from postpartum cardiovascular risk screening and intervention.

Epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and national levels: a population-based study

BACKGROUND

Relevant studies focusing on epidemiological of profiles hypertensive disorders of pregnancy from global data that report the cause-specific prevalence and trends of hypertensive disorders of pregnancy at global, regional and national levels from 1990 to 2019 by age and sociodemographic index are still limited.

METHODS

For hypertensive disorders of pregnancy, point prevalence, annual incidence, and years lived with disability numbers and age standardized rates per 100,000 population were compared at regional and national levels by age and sociodemographic index using data from the global Burden of Disease 2019 Study, covering populations from 204 countries and territories. Estimates are reported with uncertainty intervals to exhibit the changing trends during a specific period.

RESULTS

The incidence of hypertensive disorders of pregnancy increased from 16.30 million to 18.08 million globally, with a total increase of 10.92 % from 1990 to 2019. The age-standardized incidence rate decreased, with an estimated annual percent change of -0.68 (95 % confidence interval [CI] -0.49 to -0.86). The number of deaths due to hypertensive disorders of pregnancy was approximately 27.83 thousand in 2019, representing a 30.05 % decrease from 1990. Based on the incidence and prevalence, the number of deaths and years lived with disability were highest in the group aged 25-29 years, followed by the groups aged 30-34 and 20-24 years, while the lowest estimated incidence rate was observed in the group aged 25-29 years and higher incidence rates were observed in the youngest and oldest groups. Positive associations between incidence rates and the sociodemographic index and human development index were found for all countries and regions in 2019. Age-standardized incidence rates were higher in countries/regions with lower sociodemographic indices and human development indices.

CONCLUSIONS

Our study provides a comprehensive overview of the global burden of hypertensive disorders of pregnancy. The death and incidence rates are decreasing in most countries and all regions except for those with low sociodemographic and human development indexes. This difference is mainly due to the increasing attention to prenatal examinations and health education. Further investigations should focus on forecasting the global disease burden of specific hypertensive disorders of pregnancy and modifiable risk factors.

Pregnancy and the Postpartum Period as an Opportunity for Cardiovascular Risk Identification and Management

Cardiovascular disease (CVD) is the leading cause of death in women. Because women generally present with more atypical symptoms of CVD than do men and because underlying CVD risk factors are often present for years before the onset of CVD, it is important to use innovative ways to identify women who should undergo CVD risk screening at a younger age. Pregnancy and the postpartum period afford us that opportunity, given that the development of certain pregnancy complications (hypertensive disorders of pregnancy, gestational diabetes, preterm birth, delivery of a neonate with fetal growth restriction, and significant placental abruption) can reliably identify women with underlying, often unrecognized, CVD risk factors. Women with one or more of these pregnancy complications should be identified at the time of delivery and referred for regular follow-up. This would ideally take the form of a multidisciplinary clinic including clinicians and allied health specialists to carry out physical and biochemical screening and counseling regarding lifestyle modification and possible therapeutic interventions. Longer-term follow-up and recommendations should be individualized based on findings and risks. There is also an opportunity for future pregnancy counseling and discussion about the importance of weight loss between pregnancies, initiation of a routine involving physical activity, use of preconception folic acid, and the potential initiation of low-dose aspirin for those women at risk for future preeclampsia and fetal growth restriction or the use of progesterone for women at risk for preterm labor. The link between pregnancy complications and future CVD affords us with the earliest opportunity for CVD risk assessment for health preservation and disease prevention.

ACOG Practice Bulletin No. 202: Gestational Hypertension and Preeclampsia

Hypertensive disorders of pregnancy constitute one of the leading causes of maternal and perinatal mortality worldwide. It has been estimated that preeclampsia complicates 2-8% of pregnancies globally (). In Latin America and the Caribbean, hypertensive disorders are responsible for almost 26% of maternal deaths, whereas in Africa and Asia they contribute to 9% of deaths. Although maternal mortality is much lower in high-income countries than in developing countries, 16% of maternal deaths can be attributed to hypertensive disorders (). In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004 (). Moreover, in comparison with women giving birth in 1980, those giving birth in 2003 were at 6.7-fold increased risk of severe preeclampsia (). This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion ($1.03 billion for women and $1.15 billion for infants), which was disproportionately borne by premature births (). This Practice Bulletin will provide guidelines for the diagnosis and management of gestational hypertension and preeclampsia.

Risk of adverse maternal and fetal outcomes during pregnancy in living kidney donors: A matched cohort study

BACKGROUND

We examined the risk of adverse pregnancy outcomes in primiparous kidney donors compared to matched controls.

METHODS

Fifty-nine women with a history of kidney donation prior to their first pregnancy with normal renal function and no history of kidney disease, diabetes or chronic hypertension were matched 1:4 by age (within 2 years) and race to women with two kidneys using data from an integrated healthcare delivery system. Adverse pregnancy outcomes were defined as preterm delivery (delivery <37 weeks), delivery via cesarean section, gestational hypertension, preeclampsia/eclampsia, gestational diabetes, length of stay in the hospital >3 days, infant death/transfer to acute facility and low birthweight (<2500 g).

RESULTS

Living kidney donors did not have a higher risk of adverse outcomes compared to matched controls. There was a trend toward an increased risk of preeclampsia/eclampsia in kidney donors but it did not reach statistical significance (Odds ratio [OR]: 2.96, 95% CI: 0.98-8.94, P = 0.06). However, in kidney donors ≤30 years of age, there was a fourfold increased risk of preeclampsia/eclampsia (OR: 4.09, 95% CI: 1.07-15.59, P = 0.04).

CONCLUSION

Overall, the risk of pregnancy-associated complications following kidney donation is small but potential female kidney donors should be counseled on the possible increased risk of preeclampsia.

Determinants of preeclampsia in women with type 1 diabetes

AIMS

Despite improvement in diabetic care over the years, the incidence of hypertensive disorders of pregnancy is still very high. Therefore, the aim of our study was to determine risk factors for PE in women with T1DM.

METHODS

This study was a prospective, nested case-control study on a population of 165 women with T1DM. Women were divided into 3 subgroups: normotensive (N = 141), gestational hypertension (GH) (N = 8), and PE (N = 16). Clinical data were collected in the first trimester (< 12th week), in mid-pregnancy (20-24th weeks), and just prior to delivery (34-39th weeks). IR in the first trimester was quantified using the estimated glucose disposal rate formula (eGDR, milligrams/kilogram/minute). Simple logistic regression was used to search for factors associated with PE and GH. For multivariate comparisons, we used multiple logistic regression with stepwise selection.

RESULTS

All preeclampsia cases were diagnosed in primiparae. The presence of vasculopathy was the strongest determinant of PE (OR 10.8, 95% CI 3.27-35.97, P = 0.0001), followed by a history of chronic hypertension (6.05, 1.75-20.8, P = 0.004) and the duration of diabetes (1.11, 1.03-1.12, P = 0.009). However, chronic hypertension and duration of diabetes were no longer associated with PE after adjustment for the presence of vasculopathy. Higher gestational weight gain (GWG) was associated with PE, and this association remained significant after adjustment for first trimester body mass index (1.14, 1.02-1.28, P = 0.02). Both systolic and diastolic blood pressure assessed in the first trimester were significant determinants of PE; however, this association was no longer observed after adjustment for the presence of chronic hypertension. Glycated hemoglobin (HbA_1c) levels from all 3 trimesters were significantly associated with PE (first trimester: 1.38, 1.01-1.87, P = 0.04; second trimester: 2.76, 1.43-5.31, P = 0.002; third trimester: 2.42, 1.30-4.51, P = 0.005). There was a negative association between eGDR and PE (0.66, 0.50-0.87, P = 0.003). Among lipids, triglycerides (TG) in all 3 trimesters were positively associated with PE, and this association was independent of HbA_1c levels (first trimester: 5.32, 1.65-17.18, P = 0.005; second trimester: 2.52, 1.02-6.26, P = 0.05; third trimester: 2.28, 1.39-3.74, P = 0.001. We did not find any predictors of GH in the regression analysis among all analyzed factors.

CONCLUSIONS

Primiparity and diabetic vasculopathy seem to be the strongest risk factors for PE in women with type 1 diabetes. However, preexisting hypertension and higher GWG were also associated with PE in women with T1DM. Among laboratory results, higher HbA_1c and TG levels in all 3 trimesters were associated with PE. The association between higher IR and PE in women with T1DM needs further study.

Preeclampsia, of mice and women

Preeclampsia (PE) is a devastating disorder of pregnancy that affects up to 8% of pregnant women in the United States. The diagnosis of PE is made by the presentation of new-onset hypertension, ≥140 mmHg systolic blood pressure (BP) or ≥90 mmHg diastolic BP, and either proteinuria or another accompanying sign/symptom, such as renal insufficiency, thrombocytopenia, hepatic dysfunction, pulmonary edema, or cerebral/visual. These signs can occur suddenly and without warning. PE that presents before 34 wk of gestation is considered early onset and carries a greater risk for perinatal morbidity/mortality than late-onset PE that occurs at or after 34 wk of gestation. At this time there is no cure for PE, and the only effective treatment is delivery of the baby and placenta. If allowed to progress to eclampsia (PE with neurologic involvement), seizures will occur and possibly death through stroke. PE also carries the risk of significant fetal and neonatal morbidity/mortality in addition to long-term health risks for mother and child. Despite significant research efforts to accurately predict, diagnose, and treat PE, a cure eludes us. Elucidating the pathophysiological mechanisms that can cause PE will aid in our ability to accurately prevent, manage, and treat PE to avoid maternal and fetal losses. Intense research efforts are focused on PE, and the mouse has proven to be a useful animal model for investigating molecular mechanisms that may hold the key to unraveling the mysteries of PE in women.

Metabolic syndrome in preeclampsia women in gorgan

The aim of study was to assess the metabolic syndrome in preeclampsia women. The study was performed on 50 women. The metabolic syndrome prevalence was 66%. Serum glucose, triglyceride and LDL-cholesterol levels significantly were increased and HDL- cholesterol level significantly was decreased in metabolic syndrome patients. These patients showed high prevalence of components of the syndrome. Our results show the importance of dyslipidemia in preeclampsia in overweight and obese women. Preeclampsia and cardiovascular disease are important problems for the health of women. It may be useful to give a treat to people with a high-normal blood pressure in early pregnancy.

The impact of change in pregnancy body mass index on the development of gestational hypertensive disorders

OBJECTIVE

To examine the impact of change in body mass index (BMI) during pregnancy on the incidence of gestational hypertension/preeclampsia.

STUDY DESIGN

This is a retrospective cohort study using linked California birth certificate and discharge diagnosis data from the year 2007. Adjusted odds ratios (aOR) and 95% confidence intervals (CI) were calculated for the outcome of gestational hypertension/preeclampsia, as a function of a categorical change in pregnancy BMI: BMI loss (<-0.5), no change (-0.5 to 0.5), minimal (0.6 to 5), moderate (5.1 to 10) and excessive (>10). The impact of change in pregnancy BMI was evaluated for the entire cohort and then as a function of prepregnancy BMI category. Women with no change in pregnancy BMI served as the reference group.

RESULT

The study population consisted of 436 414 women with singleton gestations. Overall, women with excessive BMI change had a nearly twofold increased odds of gestational hypertension/preeclampsia (aOR=1.94; 95% CI=1.72 to 2.20). By prepregnancy BMI class, overweight and obese women who had a moderate change in pregnancy BMI also had increased odds of developing gestational hypertension/preeclampsia with aOR ranging from 1.73 to 1.97.

CONCLUSION

Regardless of prepregnancy BMI category, women with excessive BMI change have a higher chance of developing gestational hypertension/preeclampsia. Overweight and obese women with moderate BMI change may also be at increased risk.

Epidemiology of preeclampsia: impact of obesity

Preeclampsia is a pregnancy-specific disorder that affects 2-8% of all pregnancies and remains a leading cause of maternal and perinatal morbidity and mortality worldwide. Diagnosis is based on new onset of hypertension and proteinuria. Multiple organ systems can be affected, with severe disease resulting. The wide range of risk factors reflects the heterogeneity of preeclampsia. Obesity, which is increasing at an alarming rate, is also a risk factor for preeclampsia as well as for later-life cardiovascular disease. Exploring common features may provide insight into the pathophysiologic mechanisms underlying preeclampsia among obese and overweight women.

The prevalence and risk factors of infantile haemangiomas: a case-control study in the Dutch population

Haemangiomas are considered to be the most common tumours of infancy. However, despite their frequent occurrence the aetiological determinants of their development remain unknown. Identifying these factors may provide insight on their pathogenesis. We performed cross-sectional screening for haemangiomas in newborns (0-16 months of age) in the general Dutch population. Haemangioma-specific and pregnancy-related data were collected in children with a haemangioma. These data were compared in a case-control design using multivariable logistic regression analysis. Among 2204 newborns, 219 (9.9%) had a haemangioma. The male-to-female ratio was 1:2. The majority of haemangiomas were located on the trunk (37%). The general practitioners or medical specialists were consulted in only a minority of cases (<7%). Amniocentesis [odds ratio (OR) 3.6, 95% confidence interval (CI) 1.11, 11.42], breech presentation [OR 2.3, 95% CI 1.14, 4.44], being first-born [OR 1.55, 95% CI 1.03, 2.33] and a birthweight ≤2500 g [OR 4.95, 95% CI 1.63, 15.05] were independent factors associated with the development of a haemangioma. Duration of pregnancy did not differ between study groups. Our study showed that the prevalence of a haemangioma is 9.9% in the general (Dutch) population. Four factors appear relevant in the development of haemangiomas. These factors may provide clues to its pathogenesis.

Selenium and preeclampsia: A global perspective

Preeclampsia is a complex multisystem disorder of pregnancy where oxidative stress plays an important aetiological role. The role of selenium in the synthesis of endogenous antioxidants is well documented, and a significant reduction in selenium has been reported in preeclamptic women. The objective of this study was to map global selenium status and preeclampsia incidence. This study identified peer reviewed journal articles reporting national preeclampsia incidence (%) and matched these with reported values of selenium intake and plasma/serum selenium concentrations (μg/L). Matched data were obtained for 45 regions, reporting 6456,570 births, spanning Europe, Asia, Australasia, Africa, North and South America. Increasing plasma selenium concentration was found to be correlated with a reduction in preeclampsia incidence (Pearson's r=-0.604, P<0.0001). Countries with a reported serum/plasma selenium level of ⩾95μg/L were considered selenium sufficient and a significant reduction in preeclampsia incidence for countries above this value (P=0.0007) was noted. Significant reductions in preeclampsia incidence were found to coincide with increases in plasma/serum selenium concentration in the New Zealand (P=0.0003) and Finland (0.0028) populations following Government intervention. This study supports the hypothesis that selenium supplementation may be beneficial in reducing oxidative stress in women at risk of preeclampsia.

Hypertension in pregnancy: a comprehensive update

Hypertensive disorders of pregnancies remain a central public health concern throughout the world, and are a major cause of maternal mortality in the developing world. Although treatment options have not significantly changed in recent years, insight on the pathogenesis of preeclampsia/eclampsia has been remarkable. With improved animal models of preeclampsia and large-scale human trials, we have embarked upon a new era where angiogenic biomarkers based on mechanism of disease can be designed to assist in early diagnosis and treatment. There is also a growing recognition of how elusive the diagnosis of eclampsia can be, especially in the postpartum period. Proper treatment of these patients depends heavily on the correct diagnosis, especially by the emergency physician. Finally, large epidemiologic studies have revealed that preeclampsia, once thought to be a self-limited entity, now appears to portend real damage to the cardiovascular and other organ systems in the long term. This review will present the latest update on our understanding of the various hypertensive disorders of pregnancies and their treatment options.

The ERAP2 gene is associated with preeclampsia in Australian and Norwegian populations

Preeclampsia is a heritable pregnancy disorder that presents new onset hypertension and proteinuria. We have previously reported genetic linkage to preeclampsia on chromosomes 2q, 5q and 13q in an Australian/New Zealand (Aust/NZ) familial cohort. This current study centered on identifying the susceptibility gene(s) at the 5q locus. We first prioritized candidate genes using a bioinformatic tool designed for this purpose. We then selected a panel of known SNPs within ten prioritized genes and genotyped them in an extended set of the Aust/NZ families and in a very large, independent Norwegian case/control cohort (1,139 cases, 2,269 controls). In the Aust/NZ cohort we identified evidence of a genetic association for the endoplasmic reticulum aminopeptidase 1 (ERAP1) gene (rs3734016, P (uncorr) = 0.009) and for the endoplasmic reticulum aminopeptidase 2 (ERAP2) gene (rs2549782, P (uncorr) = 0.004). In the Norwegian cohort we identified evidence of a genetic association for ERAP1 (rs34750, P (uncorr) = 0.011) and for ERAP2 (rs17408150, P (uncorr) = 0.009). The ERAP2 SNPs in both cohorts remained statistically significant (rs2549782, P (corr) = 0.018; rs17408150, P (corr) = 0.039) after corrections at an experiment-wide level. The ERAP1 and ERAP2 genes encode enzymes that are reported to play a role in blood pressure regulation and essential hypertension in addition to innate immune and inflammatory responses. Perturbations within vascular, immunological and inflammatory pathways constitute important physiological mechanisms in preeclampsia pathogenesis. We herein report a novel preeclampsia risk locus, ERAP2, in a region of known genetic linkage to this pregnancy-specific disorder.

A history of preeclampsia identifies women who have underlying cardiovascular risk factors

OBJECTIVE

The objective of this study was to prospectively assess physical and biochemical cardiovascular risk markers in women who had developed preeclampsia (PE) at 1 year postpartum.

STUDY DESIGN

Following an overnight fast, previously PE (n = 70) and normotensive women (n = 70) had weight and blood pressure recorded and levels of morning blood for insulin, glucose, C-reactive protein, lipids, cholesterol, and urine for microalbumin and creatinine measured. Body mass index, homeostatic model assessment index, and incidence of metabolic syndrome were determined.

RESULTS

At 1 year postpartum, markers of cardiovascular disease were different between the groups. There were also differences in the number of women with abnormal values. Mathematical modeling of cardiovascular event risk suggests that PE increases the risk by 2- to 3-fold; the risk was greatest for women with severe PE.

CONCLUSION

The development of PE is 1 of the earliest clinically identifiable markers of a woman's heightened risk of cardiovascular disease.

Analytical approaches to detect maternal/fetal genotype incompatibilities that increase risk of pre-eclampsia

BACKGROUND

In utero interactions between incompatible maternal and fetal genotypes are a potential mechanism for the onset or progression of pregnancy related diseases such as pre-eclampsia (PE). However, the optimal analytical approach and study design for evaluating incompatible maternal/offspring genotype combinations is unclear.

METHODS

Using simulation, we estimated the type I error and power of incompatible maternal/offspring genotype models for two analytical approaches: logistic regression used with case-control mother/offspring pairs and the log-linear regression used with case-parent triads. We evaluated a real dataset consisting of maternal/offspring pairs with and without PE for incompatibility effects using the optimal analysis based on the results of the simulation study.

RESULTS

We identified a single coding scheme for the incompatibility effect that was equally or more powerful than all of the alternative analysis models evaluated, regardless of the true underlying model for the incompatibility effect. In addition, the log-linear regression was more powerful than the logistic regression when the heritability was low, and more robust to adjustment for maternal or fetal effects. For the PE data, this analysis revealed three genes, lymphotoxin alpha (LTA), von Willebrand factor (VWF), and alpha 2 chain of type IV collagen (COL4A2) with possible incompatibility effects.

CONCLUSION

The incompatibility model should be evaluated for complications of pregnancy, such as PE, where the genotypes of two individuals may contribute to the presence of disease.

Hypertensive disorders of pregnancy and long-term risk of hypertension: what do Ontario prenatal care providers know, and what do they communicate?

OBJECTIVES

The objective of this study was to ascertain the knowledge base of Ontario maternity care providers (family physicians, obstetrician-gynaecologists, and midwives) regarding the future health risks of gestational hypertension and preeclampsia and the practices with respect to communication of these risks.

METHODS

In 2004, all obstetricians (639) and midwives (249) in Ontario and a random sample of 600 Ontario family physicians were mailed a survey and a reminder. Non-responders were also sent a second, and in some cases, a third copy of the survey. The survey addressed areas of knowledge, reported practices, and both patient and interprofessional communication. Descriptive analysis was used for the responses.

RESULTS

The overall response rate was 42%. The majority of respondents were familiar with the long-term risks of gestational hypertension and preeclampsia. Although maternity care providers stated that they inform women with these conditions about their subsequent risks and recommend follow-up, only 36% usually inform the women's primary care providers about that subsequent risk. Only 58% of family physicians reported that they are usually informed by the maternity care providers about their patients who developed hypertension in pregnancy, compared with the 83% of maternity care providers who reported that they usually communicate this information to family physicians.

CONCLUSION

We have identified weaknesses in knowledge base and communication amongst Ontario maternity care providers that suggest that the identification and follow-up of women with hypertensive disorders of pregnancy is not occurring. These deficiencies would be amenable to directed educational activities, including reviews, presentations, and the development and implementation of guidelines.

Preeclampsia--a pressing problem: an executive summary of a National Institute of Child Health and Human Development workshop

On September 21 and 22, 2006, the National Institute of Child Health and Human Development of the National Institutes of Health sponsored a 2-day workshop titled "Preeclampsia--A Pressing Problem." The purpose of the workshop was to bring together leaders in the field to present and discuss their diverse research areas, which ranged from basic science to clinical trials and management, and to identify scientific gaps. This article is a summary of the proceedings of that workshop. Although much progress is being made in understanding the underpinnings of preeclampsia, a number of research gaps are identified that, if filled, would hasten progress in the field. It is the overall consensus that preeclampsia is a multifactorial disease whose pathogenesis is not solely vascular, genetic, immunologic, or environmental but a complex combination of factors. In addition, a number of specific scientific gaps are identified including insufficient multidisciplinary and collaborative research, clinical trials and studies of patient management, and a lack of in-depth mechanistic research. The research community needs to focus on these gaps to better understand the disease, with the ultimate goal of preventing the disorder.

Prepregnancy body mass index, hypertensive disorders of pregnancy, and long-term maternal mortality

OBJECTIVE

Recent studies have shown increased maternal mortality rates after hypertensive disorders of pregnancy (HDP), but the reasons for this increase remain unclear. This study examines the relationship between elevated prepregnancy body mass index (BMI), HDP, and postpregnancy mortality.

STUDY DESIGN

Data came from a 1975-1976 subset (n = 13,722 women) of a population-based cohort. Multiple logistic regression was used to examine the risk of HDP by BMI; age-adjusted Cox proportional hazards models were used to examine survival rates.

RESULTS

Overweight (BMI, 25-29.9 kg/m2) and obesity (BMI, > or = 30 kg/m2) were associated with increased HDP (odds ratio [OR], 2.82; 95% confidence interval [CI], 2.40-3.31 and OR, 5.51; 95% CI, 4.15-7.31]) and decreased survival (hazard ratio [HR], 1.42; 95% CI, 1.10-1.83 and HR, 2.43; 95% CI, 1.61-3.68), compared with normal weight (BMI, 18.5-24.9 kg/m2). HDP was significantly associated with increased mortality rates for women who survived > 15 years (HR, 1.94; 95% CI, 1.42-2.67]; HR adjusted for BMI, 1.65; 95% CI, 1.19-2.79]). A greater increase in risk of death after HDP was seen in the overweight women (HR, 1.86; 95% CI, 1.07-3.20) and obese women (HR, 2.90; 95% CI, 1.28-6.58), compared with normal weight women (HR, 1.26; 95% CI, 0.74-2.14).

CONCLUSION

Elevated prepregnancy BMI is associated with increased risk of HDP, which are in turn is associated with increased long-term maternal mortality rates. This association between HDP and mortality rates increases with elevated prepregnancy BMI.

The effects and mechanisms of primiparity on the risk of pre-eclampsia: a systematic review

Pre-eclampsia has been dubbed as 'a disease of primiparity'. However, the effects and mechanisms of the association of primiparity with pre-eclampsia have not been clearly defined. We conducted a systematic review of studies evaluating the effect of primiparity on the risk of pre-eclampsia, and studies (published between January 1966 and July 2005) on the mechanisms underlying such an association. A total of 26 original studies were identified and a meta-analysis carried out for the risk of pre-eclampsia among primiparous vs. multiparous women. Variably (1.4-5.5 times) higher risks of pre-eclampsia were observed in primiparous women in all studies, with a summary odds ratio (OR) of 2.42 [95% CI 2.16, 2.71]. The adjusted ORs were larger than crude ORs in all but one study after various adjustments. Except for abundant epidemiological evidence in support of the immune maladaptation theory, only four original studies examined the actual mechanisms of such primiparity-associated risk. Two (small) studies suggested differences in immunological responses in the aetiology of pre-eclampsia in primiparous vs. multiparous women. Two recent studies indicated that differences in angiogenic factor profile or reactivity to insulin resistance in early pregnancy may explain the elevated pre-eclampsia risk in first pregnancies. In conclusion, primiparity is associated with approximately 2.4-fold elevated risk of pre-eclampsia. Although immune maladaptation is generally considered as the basis to explain such an elevated risk, few data are available on immune maladaptation parameters in primiparous vs. multiparous pregnancies. Available data are insufficient to interpret the mechanisms of such primiparity-associated excess risk of pre-eclampsia.

The Jerusalem Perinatal Study cohort, 1964-2005: methods and a review of the main results

The Jerusalem Perinatal Study recorded information on population-based cohorts of 92 408 live- and stillbirths in 1964-76, and their parents, with active surveillance of infant deaths and birth defects. Data on maternal conditions, obstetric complications and interventions during labour and delivery were recorded for 92% of the births. Subsets were surveyed with antenatal interviews in 1965-68 (n = 11 467), paediatric admissions to hospital (n = 17 782) and postpartum interviews in 1975-76 (n = 16 912). Data from some offspring were linked to records of a health examination at age 17. The offspring, mothers and fathers have been traced recently, their vital status assessed, and the data linked to Israel's Cancer Registry and Psychiatric Registry. This paper describes the different types of data available, their sources, and some potential biases. Characteristics of this unique population are shown. Findings from the study are reviewed and a list of references is provided. The cohorts provide a unique source of data for a wide variety of studies.

Risk of prematurity, low birthweight and pre-eclampsia in relation to working hours and physical activities: a systematic review

BACKGROUND

Occupational activities are suspected of having an adverse impact on outcomes of pregnancy.

AIM

To assess the evidence relating three major adverse outcomes (preterm delivery, low birthweight (LBW) and pre-eclampsia/gestational hypertension) to five common occupational exposures (prolonged working hours, shift work, lifting, standing and heavy physical workload).

METHODS

A systematic search of Medline and Embase (1966-December 2005) using combinations of keywords and medical subject heading terms was conducted. For each relevant paper, standard details were abstracted that were then used to summarise the design features of studies, to rate their methodological quality (completeness of reporting and potential for important bias or confounding) and to provide estimates of effect. For studies with similar definitions of exposure and outcome, pooled estimates of relative risk (RR) in meta-analysis were calculated.

RESULTS

53 reports were identified-35 on preterm delivery, 34 on birth weight and 9 on pre-eclampsia or gestational hypertension. These included 21 cohort investigations. For pre-term delivery, extensive evidence relating to each of the exposures of interest was found. Findings were generally consistent and tended to rule out a more than moderate effect size (RR >1.4). The larger and most complete studies were less positive, and pooled estimates of risk pointed to only modest or null effects. For small-for-gestational age, the position was similar, but the evidence base was more limited. For pre-eclampsia and gestational hypertension, it was too small to allow firm conclusions.

CONCLUSIONS

The balance of evidence is not sufficiently compelling to justify mandatory restrictions on any of the activities considered in this review. However, given some uncertainties in the evidence base and the apparent absence of important beneficial effects, it may be prudent to advise against long working hours, prolonged standing and heavy physical work, particularly late in pregnancy. Our review identifies several priorities for future investigation.

Preeclampsia

Preeclampsia is a pregnancy complication with serious consequences for mother and infant. The disorder is diagnosed by gestational hypertension and proteinuria but is far more than pregnancy induced hypertension. Preeclampsia is proposed to occur in 2 stages. Stage 1 reduced placental perfusion is postulated as the root cause and to lead to the maternal syndrome, Stage 2. Why perfusion is reduced, how this translates to a maternal disease in some but not all women and what is the linkage of the 2 stages are topics of intense study. In the last decade such studies have provided valuable insights into pathophysiology that now guide ongoing clinical trials.