The detection, investigation and management of hypertension in pregnancy: full consensus statement

Current Approaches and Innovations in Managing Preeclampsia: Highlighting Maternal Health Disparities

Preeclampsia (PE) is a major cause of maternal mortality and morbidity, affecting 3-6% of pregnancies worldwide and ranking among the top six causes of maternal deaths in the U.S. PE typically develops after 20 weeks of gestation and is characterized by new-onset hypertension and/or end-organ dysfunction, with or without proteinuria. Current management strategies for PE emphasize early diagnosis, blood pressure control, and timely delivery. For prevention, low-dose aspirin (81 mg/day) is recommended for high-risk women between 12 and 28 weeks of gestation. Magnesium sulfate is also advised to prevent seizures in preeclamptic women at risk of eclampsia. Emerging management approaches include antiangiogenic therapies, hypoxia-inducible factor suppression, statins, and supplementation with CoQ10, nitric oxide, and hydrogen sulfide donors. Black women are at particularly high risk for PE, potentially due to higher rates of hypertension and cholesterol, compounded by healthcare disparities and possible genetic factors, such as the APOL1 gene. This review explores current and emerging strategies for managing PE and addresses the underlying causes of health disparities, offering potential solutions to improve outcomes.

Maternal exposure to bioclimatic stress and hypertensive disorders of pregnancy in Western Australia: identifying potential critical windows of susceptibility

The anthropogenic climate change may impact pregnancy outcomes. Rather than ambient temperature, we aimed to use a composite bioclimatic metric (Universal Thermal Climate Index, UTCI) to identify critical susceptible windows for the associations between bioclimatic exposure and hypertensive disorders of pregnancy (HDPs) risk. Daily UTCI exposure from 12 weeks of preconception through pregnancy was linked to 415,091 singleton pregnancies between 1st January 2000 and 31st December 2015 in Western Australia. Adjusted weekly-specific and cumulative odds ratios (ORs) and 95% confidence intervals (CIs) of gestational hypertension and preeclampsia were estimated with distributed lag non-linear and standard non-linear logistic regressions. Exposures from early pregnancy to week 30 were associated with greater odds of HDPs with critical susceptible windows, particularly elevated at the 1st (10.2 °C) and 99th (26.0 °C) exposure centiles as compared to the median (14.2 °C). The most elevated ORs were 1.07 (95% CI 1.06, 1.08) in weeks 8-18 for gestational hypertension and 1.10 (95% CI 1.08, 1.11) in weeks 11-16 for preeclampsia for the 99th exposure centile. Cumulative exposures associated with HDPs with relatively higher but less precise ORs. The effects of high exposure to HDPs indicated sociodemographic inequalities. The identified critical periods and subpopulations could benefit from climate-related interventions.

Dual Tragedy of Fetal and Maternal Loss: A Case of Acute Liver Failure in the Third Trimester

The traditional criteria for diagnosing preeclampsia include a new onset of hypertension and new-onset proteinuria at 20 weeks gestation. However recent studies suggest preeclampsia and even eclampsia may develop in the absence of either proteinuria or hypertension. This paper reports a dual tragedy of maternal and fetal loss after 36 weeks in the third trimester. Autopsy findings revealed an enlarged liver with multiple patchy hemorrhages, and histopathology confirmed submassive hepatic necrosis. Early diagnosis with timely referrals to higher centers is always helpful for the patients in such cases.

Immunologic aspects of preeclampsia

Preeclampsia is a syndrome with multiple etiologies. The diagnosis can be made without proteinuria in the presence of dysfunction of at least 1 organ associated with hypertension. The common pathophysiological pathway includes endothelial cell activation, intravascular inflammation, and syncytiotrophoblast stress. There is evidence to support, among others, immunologic causes of preeclampsia. Unlike defense immunology, reproductive immunology is not based on immunologic recognition systems of self/non-self and missing-self but on immunotolerance and maternal-fetal cellular interactions. The main mechanisms of immune escape from fetal to maternal immunity at the maternal-fetal interface are a reduction in the expression of major histocompatibility complex molecules by trophoblast cells, the presence of complement regulators, increased production of indoleamine 2,3-dioxygenase, activation of regulatory T cells, and an increase in immune checkpoints. These immune protections are more similar to the immune responses observed in tumor biology than in allograft biology. The role of immune and nonimmune decidual cells is critical for the regulation of trophoblast invasion and vascular remodeling of the uterine spiral arteries. Regulatory T cells have been found to play an important role in suppressing the effectiveness of other T cells and contributing to local immunotolerance. Decidual natural killer cells have a cytokine profile that is favored by the presence of HLA-G and HLA-E and contributes to vascular remodeling. Studies on the evolution of mammals show that HLA-E, HLA-G, and HLA-C1/C2, which are expressed by trophoblasts and their cognate receptors on decidual natural killer cells, are necessary for the development of a hemochorial placenta with vascular remodeling. The activation or inhibition of decidual natural killer cells depends on the different possible combinations between killer cell immunoglobulin-like receptors, expressed by uterine natural killer cells, and the HLA-C1/C2 antigens, expressed by trophoblasts. Polarization of decidual macrophages in phenotype 2 and decidualization of stromal cells are also essential for high-quality vascular remodeling. Knowledge of the various immunologic mechanisms required for adequate vascular remodeling and their dysfunction in case of preeclampsia opens new avenues of research to identify novel biological markers or therapeutic targets to predict or prevent the onset of preeclampsia.

Effect of Compound Danshen Injection Combined with Magnesium Sulfate on Oxidative Stress, TNF-α, NO, and Therapeutic Efficacy in Severe Preeclampsia

Aims

This study is designed to explore the effect of compound Danshen injection combined with magnesium sulfate on TNF-α, NO, oxidative stress, and therapeutic efficacy in severe preeclampsia (S-PE).

Methods

Sixty S-PE patients were placed into the control group and the therapy group, randomly. The control group was under the treatment of magnesium sulfate, and the therapy group was under the treatment of compound Danshen injection with magnesium sulfate. After treatment, the therapeutic efficacy of the two groups was comparatively analyzed.

Results

7 days after treatment, DBP, SBP, and 24 h urinary protein were sharply lower than those before treatment. The 24 h urinary protein was notably lower in the therapy group. After treatment, the expression level of TNF-α in both groups was notably higher than before treatment, while NO level was higher than that before treatment. Furthermore, D-D level in two groups was dramatically decreased compared to that before treatment. Moreover, Fib, PT, and APTT in two groups showed statistically significant differences after 7 days. The contents of ALT, AST, BUN, and Scr in therapy group were notably lower than those in control group.

Conclusion

Our results indicated that compound Danshen injection could improve renal function, blood hypercoagulability, and oxidative stress level and had a better therapeutic effect on S-PE.

Dysregulation of Oxygen Sensing/Response Pathways in Pregnancies Complicated by Idiopathic Intrauterine Growth Restriction and Early-Onset Preeclampsia

Preeclampsia (PE) and intrauterine growth restriction (IUGR) are the leading causes of maternal and fetal morbidity/mortality. The central deficit in both conditions is impaired placentation due to poor trophoblast invasion, resulting in a hypoxic milieu in which oxidative stress contributes to the pathology. We examine the factors driving the hypoxic response in severely preterm PE (n = 19) and IUGR (n = 16) placentae compared to the spontaneous preterm (SPT) controls (n = 13) using immunoblotting, RT-PCR, immunohistochemistry, proximity ligation assays, and Co-IP. Both hypoxia-inducible factor (HIF)-1α and HIF-2α are increased at the protein level and functional in pathological placentae, as target genes prolyl hydroxylase domain (PHD)2, PHD3, and soluble fms-like tyrosine kinase-1 (sFlt-1) are increased. Accumulation of HIF-α-subunits occurs in the presence of accessory molecules required for their degradation (PHD1, PHD2, and PHD3 and the E3 ligase von Hippel–Lindau (VHL)), which were equally expressed or elevated in the placental lysates of PE and IUGR. However, complex formation between VHL and HIF-α-subunits is defective. This is associated with enhanced VHL/DJ1 complex formation in both PE and IUGR. In conclusion, we establish a significant mechanism driving the maladaptive responses to hypoxia in the placentae from severe PE and IUGR, which is central to the pathogenesis of both diseases.

The evolution of the diagnostic criteria of preeclampsia-eclampsia

As the understanding of the pathophysiology of preeclampsia has improved, its diagnostic criteria have evolved. The classical triad of hypertension, edema, and proteinuria has become hypertension and organ dysfunction-renal, hepatic, neurologic, hematological, or uteroplacental. However, the most recent definitions have largely been based off consensus and expert opinion, not primary research. In this review, we explore how the criteria have evolved, particularly through the second half of the 20^th and the beginning of the 21st century and offer a critical appraisal of the evidence that has led the criteria to where they stand today. Some key themes are the following: the debate between having a simple and convenient blood pressure cutoff vs a blood pressure cutoff that accounts for influencing factors such as age and weight; whether a uniform blood pressure threshold, a rise in blood pressure, or a combination is most discriminatory; whether existing evidence supports blood pressure and proteinuria thresholds in diagnosing preeclampsia; and whether using flow-charts and decision trees might be more appropriate than a single set of criteria. We also discuss the future of a preeclampsia diagnosis. We challenge the move toward a broad (vs restrictive) diagnosis, arguing instead for criteria that directly relate to the prognosis of preeclampsia and the response to treatments.

Maternal folate, one-carbon metabolism and pregnancy outcomes

Single nucleotide polymorphisms and pre- and peri-conception folic acid (FA) supplementation and dietary data were used to identify one-carbon metabolic factors associated with pregnancy outcomes in 3196 nulliparous women. In 325 participants, we also measured circulating folate, vitamin B12 and homocysteine. Pregnancy outcomes included preeclampsia (PE), gestational hypertension (GHT), small for gestational age (SGA), spontaneous preterm birth (sPTB) and gestational diabetes mellitus (GDM). Study findings show that maternal genotype MTHFR A1298C(CC) was associated with increased risk for PE, whereas TCN2 C766G(GG) had a reduced risk for sPTB. Paternal MTHFR A1298C(CC) and MTHFD1 G1958A(AA) genotypes were associated with reduced risk for sPTB, whereas MTHFR C677T(CT) genotype had an increased risk for GHT. FA supplementation was associated with higher serum folate and vitamin B12 concentrations, reduced uterine artery resistance index and increased birth weight. Women who supplemented with <800 μg daily FA at 15-week gestation had a higher incidence of PE (10.3%) compared with women who did not supplement (6.1%) or who supplemented with ≥800 μg (5.4%) (P < .0001). Higher serum folate levels were found in women who later developed GDM compared with women with uncomplicated pregnancies (Mean ± SD: 37.6 ± 8 nmol L-1 vs. 31.9 ± 11.2, P = .007). Fast food consumption was associated with increased risk for developing GDM, whereas low consumption of green leafy vegetables and fruit were independent risk factors for SGA and GDM and sPTB and SGA, respectively. In conclusion, maternal and paternal genotypes, together with maternal circulating folate and homocysteine concentrations, and pre- and early-pregnancy dietary factors, are independent risk factors for pregnancy complications.

A Randomised Trial to Optimise Gestational Weight Gain and Improve Maternal and Infant Health Outcomes through Antenatal Dietary, Lifestyle and Exercise Advice: The OPTIMISE Randomised Trial

There are well-recognised associations between excessive gestational weight gain (GWG) and adverse pregnancy outcomes, including an increased risk of pre-eclampsia, gestational diabetes and caesarean birth. The aim of the OPTIMISE randomised trial was to evaluate the effect of dietary and exercise advice among pregnant women of normal body mass index (BMI), on pregnancy and birth outcomes. The trial was conducted in Adelaide, South Australia. Pregnant women with a body mass index in the healthy weight range (18.5–24.9 kg/m²) were enrolled in a randomised controlled trial of a dietary and lifestyle intervention versus standard antenatal care. The dietitian-led dietary and lifestyle intervention over the course of pregnancy was based on the Australian Guide to Healthy Eating. Baseline characteristics of women in the two treatment groups were similar. There was no statistically significant difference in the proportion of infants with birth weight above 4.0 kg between the Lifestyle Advice and Standard Care groups (24/316 (7.59%) Lifestyle Advice versus 26/313 (8.31%) Standard Care; adjusted risk ratio (aRR) 0.91; 95% confidence interval (CI) 0.54 to 1.55; p = 0.732). Despite improvements in maternal diet quality, no significant differences between the treatment groups were observed for total GWG, or other pregnancy and birth outcomes.

Cardiovascular health and vascular age after severe preeclampsia: A cohort study

BACKGROUND AND AIMS

Severe preeclampsia increases lifetime-risk for cardiovascular disease (CVD). It remains unclear when this risk translates to subclinical atherosclerosis and whether this is related to cardiovascular health (CVH) after pregnancy. Our aims were (1) to determine CVH after severe preeclampsia, (2) to relate CVH to carotid intima-media thickness (CIMT), as a marker of subclinical atherosclerosis and (3) to relate CVH to chronological and vascular age.

METHODS

A prospective cohort study was performed in women with previous severe pre-eclampsia. CVH, proposed by the American Heart Association, was assessed one year after pregnancy. The CVH score (range 0-14) includes seven metrics (blood pressure, total-cholesterol, glucose, smoking, physical activity, diet and body mass index [BMI]), each weighted as poor (0), intermediate (1) or ideal (2). Vascular age was determined by CIMT. We related CVH to delta age (chronological age - vascular age).

RESULTS

In 244 women, the median CVH score was 10 (90% range 7.0, 13.0). Low CVH (<10) was associated with a larger CIMT than high CVH (≥12) (median 626.3 μm vs. 567.0 μm, respectively). Higher CVH was also associated with a lower vascular age (-2.0 years, 95%CI -3.3, -0.60). Women with low CVH had a larger delta age (22.5 years [90% range -3.9, 49.6) than women with high CVH (16.5 years [90% range -11.9, 43.3).

CONCLUSIONS

CVH is inversely related to subclinical atherosclerosis and to vascular age one year after severe preeclampsia. Especially low CVH is associated with a large difference between chronological age and vascular age. CVH counseling might provide the opportunity for timely cardiovascular prevention.

Phytosterol enhances oral nifedipine treatment in pregnancy-induced preeclampsia: A placebo-controlled, double-blinded, randomized clinical trial

Preeclampsia is a severe complication which influences pregnant women all around the world, the symptom of which is serious maternal hypertension. Phytosterol is a type of natural compound commonly found in plant products, and has been incorporated into various food vectors and natural drugs. In the paper, the curative effect on preeclampsia by combination of oral nifedipine and phytosterol was assessed. Random grouping was carried out, with 253 preeclampsia patients being registered and taking orally nifedipine+phytosterol or nifedipine+placebo. The time for controlling the blood pressure and the time needed for the occurrence of another hypertensive crisis were defined as primary endpoints. The dosage required for controlling blood pressure, and the adverse effects from infants and mothers were defined as secondary endpoints. The nifedipine+phytosterol group required a remarkably shorter time for controlling blood pressure than the nifedipine+placebo group, an obviously delayed time for the occurrence of new hypertensive crisis, and an obvious lower dosage for controlling blood pressure. There was no difference between the two groups regarding the adverse effects from infants and mothers. Findings in the study suggest that phytosterol is an effective and safe adjuvant of the oral nifedipine and can alleviate the hypertension symptoms in preeclampsia patients.

Lifestyle and pregnancy complications in polycystic ovary syndrome: The SCOPE cohort study

OBJECTIVES

To investigate the risk of pregnancy complications in women with and without polycystic ovary syndrome after consideration of lifestyle factors.

DESIGN

Prospective cohort.

PATIENTS AND MEASUREMENTS

Participants (n = 5628) were apparently healthy nulliparous women with singleton pregnancies from the Screening for Pregnancy Endpoints study in New Zealand, Australia, United Kingdom and Ireland. Multivariable regression models were performed assessing the association of self-reported polycystic ovary syndrome status with pregnancy complications with consideration of lifestyle factors at the 15th week of gestation.

RESULTS

Women with polycystic ovary syndrome (n = 354) were older, had a higher socio-economic index and body mass index and were less likely to consume alcohol and smoke but more likely to do vigorous exercise and take multivitamins. In univariable analysis, polycystic ovary syndrome was associated with increased risk of gestational diabetes (OR: 2.2, 95% CI: 1.2, 4.0). In multivariable models, polycystic ovary syndrome was only significantly associated with decreased risk of large for gestational age (OR: 0.62, 95% CI: 0.40, 0.98) with a population attributable risk of 0.22%. None of the other outcomes were attributable to polycystic ovary syndrome status.

CONCLUSIONS

Polycystic ovary syndrome is associated with a lower risk of large for gestational age infants. In this low-risk population, the risk of pregnancy complications was not increased in women with polycystic ovary syndrome who were following a healthy lifestyle. Further studies are warranted assessing the contribution of lifestyle factors to the risk of pregnancy complications in higher risk groups of women with and without polycystic ovary syndrome.

Guided imagery for treating hypertension in pregnancy

BACKGROUND

Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non-pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind-body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure.

OBJECTIVES

To determine the effect of guided imagery as a non-pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes.

SEARCH METHODS

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). We would have included RCTs using a cluster-randomised design, but none were identified. We excluded quasi-RCTs and cross-over trials.We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non-pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device-guided slow breathing, hypnosis, physical exercise, and yoga).

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains.We could not perform a meta-analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self-monitoring of blood pressure, and thermal biofeedback-assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar - one was quiet rest, and the other was quiet rest as bed rest.None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre-eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured.Low-certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22).

AUTHORS' CONCLUSIONS

There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy.The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low-certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision.The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non-pharmacological method for hypertension.Large and well-designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short-term and long-term maternal and neonatal health. Trials could also consider utilisation and costs of health service.

Effect of metformin in addition to dietary and lifestyle advice for pregnant women who are overweight or obese: the GRoW randomised, double-blind, placebo-controlled trial

BACKGROUND

Maternal overweight and obesity are associated with well recognised pregnancy complications. Antenatal dietary and lifestyle interventions have a modest effect on gestational weight gain without affecting pregnancy outcomes. We aimed to assess the effects on maternal and infant outcomes of antenatal metformin given in addition to dietary and lifestyle advice among overweight and obese pregnant women.

METHODS

GRoW was a multicentre, randomised, double-blind, placebo-controlled trial in which pregnant women at 10-20 weeks' gestation with a BMI of 25 kg/m² or higher were recruited from three public maternity units in Adelaide, SA, Australia. Women were randomly assigned (1:1) via a computer-generated schedule to receive either metformin (to a maximum dose of 2000 mg per day) or matching placebo. Participants, their antenatal care providers, and research staff (including outcome assessors) were masked to treatment allocation. All women received an antenatal dietary and lifestyle intervention. The primary outcome was the proportion of infants with birthweight greater than 4000 g. Secondary outcomes included measures of maternal weight gain, maternal diet and physical activity, maternal pregnancy and birth outcomes, maternal quality of life and emotional wellbeing, and infant birth outcomes. Outcomes were analysed on an intention-to-treat basis (including all randomly assigned women who did not withdraw consent to use their data, and who did not have a miscarriage or termination of pregnancy before 20 weeks' gestation, or a stillbirth). The trial is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12612001277831.

FINDINGS

Of 524 women who were randomly assigned between May, 28 2013 and April 26, 2016, 514 were included in outcome analyses (256 in the metformin group and 258 in the placebo group). Median gestational age at trial entry was 16·29 weeks (IQR 14·43-18·00) and median BMI was 32·32 kg/m² (28·90-37·10); 167 (32%) participants were overweight and 347 (68%) were obese. There was no significant difference in the proportion of infants with birthweight greater than 4000 g (40 [16%] with metformin vs 37 [14%] with placebo; adjusted risk ratio [aRR] 0·97, 95% CI 0·65 to 1·47; p=0·899). Women receiving metformin had lower average weekly gestational weight gain (adjusted mean difference -0·08 kg, 95% CI -0·14 to -0·02; p=0·007) and were more likely to have gestational weight gain below recommendations (aRR 1·46, 95% CI 1·10 to 1·94; p=0·008). Total gestational weight gain, pregnancy and birth outcomes, maternal diet and physical activity, and maternal quality of life and emotional wellbeing did not differ significantly between groups. Similar numbers of women in both treatment groups (76% [159/208] in the metformin group and 73% [144/196] in the placebo group) reported side-effects including nausea, diarrhoea, and vomiting. Two stillbirths (placebo group) and one neonatal death (metformin group) occurred; none of the perinatal deaths were determined to be attributable to participation in the trial.

INTERPRETATION

For pregnant women who are overweight or obese, metformin given in addition to dietary and lifestyle advice initiated at 10-20 weeks' gestation does not improve pregnancy and birth outcomes.

FUNDING

Australian National Health and Medical Research Council.

Blood Pressure Profile 1 Year After Severe Preeclampsia

Preeclampsia increases the long-term risk of cardiovascular disease, possibly through occurrence of hypertension after delivery, such as masked hypertension, night-time hypertension, and an adverse systolic night-to-day blood pressure (BP) ratio. These types of hypertension are often unnoticed and can only be detected with ambulatory BP monitoring (ABPM). We aimed to determine hypertension prevalence and 24-hour BP pattern with ABPM and office BP measurements in women 1 year after severe preeclampsia. This is a retrospective cohort study. As part of a follow-up program after severe preeclampsia, 200 women underwent ABPM and an office BP measurement 1 year after delivery. We calculated hypertension prevalence (sustained hypertension, masked hypertension, and white-coat hypertension) and systolic night-to-day BP ratio (dipping pattern). Medical files and questionnaires provided information on preexisting hypertension and antihypertensive treatment. One year after delivery, 41.5% of women had hypertension (sustained hypertension, masked hypertension, or white-coat hypertension) with ABPM. Masked hypertension was most common (17.5%), followed by sustained hypertension (14.5%) and white-coat hypertension (9.5%). With sheer office BP measurement, only 24.0% of women would have been diagnosed hypertensive. Forty-six percent of women had a disadvantageous dipping pattern. Hypertension is common 1 year after experiencing severe preeclampsia. Masked hypertension and white-coat hypertension are risk factors for future cardiovascular disease and can only be diagnosed with ABPM. Therefore, ABPM should be offered to all these women at high risk of developing hypertension and possibly future cardiovascular disease.

Metabolic syndrome in pregnancy and risk for adverse pregnancy outcomes: A prospective cohort of nulliparous women

BACKGROUND

Obesity increases the risk for developing gestational diabetes mellitus (GDM) and preeclampsia (PE), which both associate with increased risk for type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD) in women in later life. In the general population, metabolic syndrome (MetS) associates with T2DM and CVD. The impact of maternal MetS on pregnancy outcomes, in nulliparous pregnant women, has not been investigated.

METHODS AND FINDINGS

Low-risk, nulliparous women were recruited to the multi-centre, international prospective Screening for Pregnancy Endpoints (SCOPE) cohort between 11 November 2004 and 28 February 2011. Women were assessed for a range of demographic, lifestyle, and metabolic health variables at 15 ± 1 weeks' gestation. MetS was defined according to International Diabetes Federation (IDF) criteria for adults: waist circumference ≥80 cm, along with any 2 of the following: raised trigycerides (≥1.70 mmol/l [≥150 mg/dl]), reduced high-density lipoprotein cholesterol (<1.29 mmol/l [<50 mg/dl]), raised blood pressure (BP) (i.e., systolic BP ≥130 mm Hg or diastolic BP ≥85 mm Hg), or raised plasma glucose (≥5.6 mmol/l). Log-binomial regression analyses were used to examine the risk for each pregnancy outcome (GDM, PE, large for gestational age [LGA], small for gestational age [SGA], and spontaneous preterm birth [sPTB]) with each of the 5 individual components for MetS and as a composite measure (i.e., MetS, as defined by the IDF). The relative risks, adjusted for maternal BMI, age, study centre, ethnicity, socioeconomic index, physical activity, smoking status, depression status, and fetal sex, are reported. A total of 5,530 women were included, and 12.3% (n = 684) had MetS. Women with MetS were at an increased risk for PE by a factor of 1.63 (95% CI 1.23 to 2.15) and for GDM by 3.71 (95% CI 2.42 to 5.67). In absolute terms, for PE, women with MetS had an adjusted excess risk of 2.52% (95% CI 1.51% to 4.11%) and, for GDM, had an adjusted excess risk of 8.66% (95% CI 5.38% to 13.94%). Diagnosis of MetS was not associated with increased risk for LGA, SGA, or sPTB. Increasing BMI in combination with MetS increased the estimated probability for GDM and decreased the probability of an uncomplicated pregnancy. Limitations of this study are that there are several different definitions for MetS in the adult population, and as there are none for pregnancy, we cannot be sure that the IDF criteria are the most appropriate definition for pregnancy. Furthermore, MetS was assessed in the first trimester and may not reflect pre-pregnancy metabolic health status.

CONCLUSIONS

We did not compare the impact of individual metabolic components with that of MetS as a composite, and therefore cannot conclude that MetS is better at identifying women at risk. However, more than half of the women who had MetS in early pregnancy developed a pregnancy complication compared with just over a third of women who did not have MetS. Furthermore, while increasing BMI increases the probability of GDM, the addition of MetS exacerbates this probability. Further studies are required to determine if individual MetS components act synergistically or independently.

External Validation and Clinical Usefulness of First Trimester Prediction Models for the Risk of Preeclampsia: A Prospective Cohort Study

INTRODUCTION

This study assessed the external validity of all published first trimester prediction models for the risk of preeclampsia (PE) based on routinely collected maternal predictors. Moreover, the potential utility of the best-performing models in clinical practice was evaluated.

MATERIAL AND METHODS

Ten prediction models were systematically selected from the literature. We performed a multicenter prospective cohort study in the Netherlands between July 1, 2013, and December 31, 2015. Eligible pregnant women completed a web-based questionnaire before 16 weeks' gestation. The outcome PE was established using postpartum questionnaires and medical records. Predictive performance of each model was assessed by means of discrimination (c-statistic) and a calibration plot. Clinical usefulness was evaluated by means of decision curve analysis and by calculating the potential impact at different risk thresholds.

RESULTS

The validation cohort contained 2,614 women of whom 76 developed PE (2.9%). Five models showed moderate discriminative performance with c-statistics ranging from 0.73 to 0.77. Adequate calibration was obtained after refitting. The best models were clinically useful over a small range of predicted probabilities.

DISCUSSION

Five of the ten included first trimester prediction models for PE showed moderate predictive performance. The best models may provide more benefit compared to risk selection as used in current guidelines.

Optimising gestational weight gain and improving maternal and infant health outcomes through antenatal dietary, lifestyle and physical activity advice: the OPTIMISE randomised controlled trial protocol

INTRODUCTION

Obesity represents a significant health burden, and WHO recognises the importance of preventing weight gain and subsequent development of obesity among adults who are within the healthy weight range. Women of reproductive age have demonstrated high rates of weight gain during pregnancy placing them at risk of becoming overweight or obese. We will evaluate the effects of dietary and physical activity advice on maternal, fetal and infant health outcomes, among pregnant women of normal body mass index (BMI).

METHODS AND ANALYSIS

We will conduct a randomised controlled trial, consenting and randomising women with a live singleton pregnancy between 10+0 and 20+0 weeks and BMI 18.5-24.9 kg/m2 at first antenatal visit, from a tertiary maternity hospital. Women randomised to the Lifestyle Advice Group will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant) and three telephone calls over pregnancy, in which they will be provided with dietary and lifestyle advice and encouraged to make change using a SMART goals approach. Women randomised to the Standard Care Group will receive routine antenatal care. The primary outcome is infant birth weight >4 kg. Secondary outcomes will include adverse infant and maternal outcomes, maternal weight change, maternal diet and physical activity changes, maternal quality of life and emotional well-being, fetal growth and costs of healthcare. We will recruit 624 women to detect a reduction from 8.72% to 3.87% (alpha 0.05 (two-tailed); power 70%) in infants with birth weight >4 kg. Analyses will be intention to treat with estimates reported as relative risks and 95% CIs.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Women's and Children's Hospital ethics committee. Findings will be disseminated widely via journal publication and conference presentation(s), and participants informed of results.

TRIAL REGISTRATION NUMBER

ACTRN12614000583640.

Epidural therapy for the treatment of severe pre-eclampsia in non labouring women

BACKGROUND

Pre-eclampsia is a pregnancy-specific multi-organ disorder, which is characterised by hypertension and multisystem organ involvement and which has significant maternal and fetal morbidity and mortality. Failure of the placental vascular remodelling and reduced uteroplacental flow form the etiopathological basis of pre-eclampsia. There are several established therapies for pre-eclampsia including antihypertensives and anticonvulsants. Most of these therapies aim at controlling the blood pressure or preventing complications of elevated blood pressure, or both. Epidural therapy aims at blocking the vasomotor tone of the arteries, thereby increasing uteroplacental blood flow. This review was aimed at evaluating the available evidence about the possible benefits and risks of epidural therapy in the management of severe pre-eclampsia, to define the current evidence level of this therapy, and to determine what (if any) further evidence is required.

OBJECTIVES

To assess the effectiveness, safety and cost of the extended use of epidural therapy for treating severe pre-eclampsia in non-labouring women. This review aims to compare the use of extended epidural therapy with other methods, which include intravenous magnesium sulphate, anticonvulsants other than magnesium sulphate, with or without use of the antihypertensive drugs and adjuncts in the treatment of severe pre-eclampsia.This review only considered the use of epidural anaesthesia in the management of severe pre-eclampsia in the antepartum period and not as pain relief in labour.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (13 July 2017) and reference lists of retrieved studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) or quasi-RCTs comparing epidural therapy versus traditional therapy for pre-eclampsia in the form of antihypertensives, anticonvulsants, magnesium sulphate, low-dose dopamine, corticosteroids or a combination of these, were eligible for inclusion. Trials using a cluster design, and studies published in abstract form only are also eligible for inclusion in this review. Cross-over trials were not eligible for inclusion in this review.

DATA COLLECTION AND ANALYSIS

The two review authors independently assessed trials for inclusion and trial quality. There were no relevant data available for extraction.

MAIN RESULTS

We included one small study (involving 24 women). The study was a single-centre randomised trial conducted in Mexico. This study compared a control group who received antihypertensive therapy, anticonvulsant therapy, plasma expanders, corticosteroids and dypyridamole with an intervention group that received epidural block instead of the antihypertensives, as well as all the other four drugs. Lumbar epidural block was given using 0.25% bupivacaine, 10 mg bolus and 5 mg each hour on continuous epidural infusion for six hours. This study was at low risk of bias in three domains but was assessed to be high risk of bias in two domains due to lack of allocation concealment and blinding of women and staff, and unclear for random sequence generation and outcome assessor blinding.The included study did not report on any of this review's important outcomes. Meta-analysis was not possible.For the mother, these were: maternal death (death during pregnancy or up to 42 days after the end of the pregnancy, or death more than 42 days after the end of the pregnancy); development of eclampsia or recurrence of seizures; stroke; any serious morbidity: defined as at least one of stroke, kidney failure, liver failure, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulation, pulmonary oedema.For the baby, these were: death: stillbirths (death in utero at or after 20 weeks' gestation), perinatal deaths (stillbirths plus deaths in the first week of life), death before discharge from the hospital, neonatal deaths (death within the first 28 days after birth), deaths after the first 28 days; preterm birth (defined as the birth before 37 completed weeks' gestation); and side effects of the intervention. Reported outcomesThe included study only reported on a single secondary outcome of interest to this review: the Apgar score of the baby at birth and after five minutes and there was no clear difference between the intervention and control groups.The included study also reported a reduction in maternal diastolic arterial pressure. However, the change in maternal mean arterial pressure and systolic arterial pressure, which were the other reported outcomes of this trial, were not significantly different between the two groups.

AUTHORS' CONCLUSIONS

Currently, there is insufficient evidence from randomised controlled trials to evaluate the effectiveness, safety or cost of using epidural therapy for treating severe pre-eclampsia in non-labouring women.High-quality randomised controlled trials are needed to evaluate the use of epidural agents as therapy for treatment of severe pre-eclampsia. The rationale for the use of epidural is well-founded. However there is insufficient evidence from randomised controlled trials to show that the effect of epidural translates into improved maternal and fetal outcomes. Thus, there is a need for larger, well-designed studies to come to an evidence-based conclusion as to whether the lowering of vasomotor tone by epidural therapy results in better maternal and fetal outcomes and for how long that could be maintained. Another important question that needs to be answered is how long should extended epidural be used to ensure any potential clinical benefits and what could be the associated side effects and costs. Interactions with other modalities of treatment and women's satisfaction could represent other avenues of research.

Vitamin D Enhances Efficacy of Oral Nifedipine in Treating Preeclampsia with Severe Features: A Double Blinded, Placebo-Controlled and Randomized Clinical Trial

Vitamin D (VD) has exhibited immunomodulatory role in the pathogenesis of preeclampsia. We hypothesize VD potentiate nifedipine treatment for preeclampsia by shortened the time to control blood pressure and prolong time before subsequent hypertensive crisis. We conduct a randomized trial of 683 primigravid women with preeclampsia, who were assigned to different treatment groups, either nifedipine+placebo or nifedipine+VD orally, by random after screening. Primary endpoints include time to control hypertension and time before another hypertensive crisis. Maternal adverse effects including nausea, vomiting, chest pain, mild headache, dizziness, maternal tachycardia, hypotension or shortness of breath, and neonatal parameters including birth weight and Apgar scores, as well as the minimum number of dosages needed to control hypertension were defined as secondary endpoints. Serum levels of cytokines tumor necrosis factor-α (TNF-α) and interleukin-10 (IL-10) were also examined. There was a marked reduction of the time required to control hypertension and a significant lengthening (p = 0.013) of the time before a new hypertensive crisis in participants received nifedipine+VD treatments (41.8 ± 18.3 min), in comparison with the nifedipine+placebo controls (61.1 ± 15.9 min). In women treated with nifedipine+VD, the minimum number of dosages needed to control hypertension was also lower. With regard to adverse effects, no statistical difference was observed between the two treatment groups. Moreover, treatment with VD increased IL-10 and reduced TNF-α serum levels. VD possesses the potential of serving as a safe and effective adjuvant to oral nifedipine in treating women with preeclampsia against hypertension, possibly through the upregulation of IL-10 and the downregulation of TNF-α.

Nifedipine Prevents Apoptosis of Alcohol-Exposed First-Trimester Trophoblast Cells

BACKGROUND

Maternal alcohol abuse leading to fetal alcohol spectrum disorder (FASD) includes fetal growth restriction (FGR). Ethanol (EtOH) induces apoptosis of human placental trophoblast cells, possibly disrupting placentation and contributing to FGR in FASD. EtOH facilitates apoptosis in several embryonic tissues, including human trophoblasts, by raising intracellular Ca²⁺ . We previously found that acute EtOH exposure increases trophoblast apoptosis due to signaling from both intracellular and extracellular Ca²⁺ . Therefore, nifedipine, a Ca²⁺ channel blocker that is commonly administered to treat preeclampsia and preterm labor, was evaluated for cytoprotective properties in trophoblast cells exposed to alcohol.

METHODS

Human first-trimester chorionic villous explants and the human trophoblast cell line HTR-8/SVneo (HTR) were pretreated with 12.5 to 50 nM of the Ca²⁺ channel blocker nifedipine for 1 hour before exposure to 50 mM EtOH for an additional hour. Intracellular Ca²⁺ concentrations were monitored in real time by epifluorescence microscopy, using fluo-4-AM. Apoptosis was assessed by terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL), accumulation of cytoplasmic cytochrome c, and cleavage rates of caspase 3 and caspase 9.

RESULTS

The increase in intracellular Ca²⁺ upon exposure to EtOH in both villous explants and HTR cells was completely blocked (p < 0.05) when pretreated with nifedipine, accompanied by inhibition of EtOH-induced release of cytochrome c, caspase activities, and TUNEL.

CONCLUSIONS

This study indicates that nifedipine can interrupt the apoptotic pathway downstream of EtOH exposure and could provide a novel strategy for future interventions in women with fetuses at risk for FASD.

Efficacy of resveratrol to supplement oral nifedipine treatment in pregnancy-induced preeclampsia

OBJECTIVE

Preeclampsia (PE) is a complication affecting pregnant women worldwide, which usually manifests as severe maternal hypertension. Resveratrol (RESV), a naturally existing polyphenol, is known to exhibit beneficial effects in cardiovascular disease including hypertension. We evaluated the outcome of treatment combining oral nifedipine (NIFE) and RESV against PE.

DESIGN AND METHODS

Using a randomized group assignment, 400 PE patients were enrolled and received oral treatments of either NIFE + RESV or NIFE + placebo. Primary endpoints were defined as time to control blood pressure and time before a new hypertensive crisis. Secondary endpoints were defined as the number of doses needed to control blood pressure, maternal and neonatal adverse effects.

RESULTS

Compared with the NIFE + placebo group, the time needed to control blood pressure was significantly reduced in NIFE + RESV group, while time before a new hypertensive crisis was greatly delayed in NIFE + RESV group. The number of treatment doses needed to control blood pressure was also categorically lower in NIFE + RESV group. No differences in maternal or neonatal adverse effects were observed between the two treatment groups.

CONCLUSION

Our data support the potential of RESV as a safe and effective adjuvant of oral NIFE to attenuate hypertensive symptoms among PE patients.

External Validation Study of First Trimester Obstetric Prediction Models (Expect Study I): Research Protocol and Population Characteristics

BACKGROUND

A number of first-trimester prediction models addressing important obstetric outcomes have been published. However, most models have not been externally validated. External validation is essential before implementing a prediction model in clinical practice.

OBJECTIVE

The objective of this paper is to describe the design of a study to externally validate existing first trimester obstetric prediction models, based upon maternal characteristics and standard measurements (eg, blood pressure), for the risk of pre-eclampsia (PE), gestational diabetes mellitus (GDM), spontaneous preterm birth (PTB), small-for-gestational-age (SGA) infants, and large-for-gestational-age (LGA) infants among Dutch pregnant women (Expect Study I). The results of a pilot study on the feasibility and acceptability of the recruitment process and the comprehensibility of the Pregnancy Questionnaire 1 are also reported.

METHODS

A multicenter prospective cohort study was performed in The Netherlands between July 1, 2013 and December 31, 2015. First trimester obstetric prediction models were systematically selected from the literature. Predictor variables were measured by the Web-based Pregnancy Questionnaire 1 and pregnancy outcomes were established using the Postpartum Questionnaire 1 and medical records. Information about maternal health-related quality of life, costs, and satisfaction with Dutch obstetric care was collected from a subsample of women. A pilot study was carried out before the official start of inclusion. External validity of the models will be evaluated by assessing discrimination and calibration.

RESULTS

Based on the pilot study, minor improvements were made to the recruitment process and online Pregnancy Questionnaire 1. The validation cohort consists of 2614 women. Data analysis of the external validation study is in progress.

CONCLUSIONS

This study will offer insight into the generalizability of existing, non-invasive first trimester prediction models for various obstetric outcomes in a Dutch obstetric population. An impact study for the evaluation of the best obstetric prediction models in the Dutch setting with respect to their effect on clinical outcomes, costs, and quality of life-Expect Study II-is being planned.

TRIAL REGISTRATION

Netherlands Trial Registry (NTR): NTR4143; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4143 (Archived by WebCite at http://www.webcitation.org/6t8ijtpd9).

Development and validation of Prediction models for Risks of complications in Early-onset Pre-eclampsia (PREP): a prospective cohort study

BACKGROUND

The prognosis of early-onset pre-eclampsia (before 34 weeks' gestation) is variable. Accurate prediction of complications is required to plan appropriate management in high-risk women.

OBJECTIVE

To develop and validate prediction models for outcomes in early-onset pre-eclampsia.

DESIGN

Prospective cohort for model development, with validation in two external data sets.

SETTING

Model development: 53 obstetric units in the UK. Model transportability: PIERS (Pre-eclampsia Integrated Estimate of RiSk for mothers) and PETRA (Pre-Eclampsia TRial Amsterdam) studies.

PARTICIPANTS

Pregnant women with early-onset pre-eclampsia.

SAMPLE SIZE

Nine hundred and forty-six women in the model development data set and 850 women (634 in PIERS, 216 in PETRA) in the transportability (external validation) data sets.

PREDICTORS

The predictors were identified from systematic reviews of tests to predict complications in pre-eclampsia and were prioritised by Delphi survey.

MAIN OUTCOME MEASURES

The primary outcome was the composite of adverse maternal outcomes established using Delphi surveys. The secondary outcome was the composite of fetal and neonatal complications.

ANALYSIS

We developed two prediction models: a logistic regression model (PREP-L) to assess the overall risk of any maternal outcome until postnatal discharge and a survival analysis model (PREP-S) to obtain individual risk estimates at daily intervals from diagnosis until 34 weeks. Shrinkage was used to adjust for overoptimism of predictor effects. For internal validation (of the full models in the development data) and external validation (of the reduced models in the transportability data), we computed the ability of the models to discriminate between those with and without poor outcomes (c-statistic), and the agreement between predicted and observed risk (calibration slope).

RESULTS

The PREP-L model included maternal age, gestational age at diagnosis, medical history, systolic blood pressure, urine protein-to-creatinine ratio, platelet count, serum urea concentration, oxygen saturation, baseline treatment with antihypertensive drugs and administration of magnesium sulphate. The PREP-S model additionally included exaggerated tendon reflexes and serum alanine aminotransaminase and creatinine concentration. Both models showed good discrimination for maternal complications, with anoptimism-adjusted c-statistic of 0.82 [95% confidence interval (CI) 0.80 to 0.84] for PREP-L and 0.75 (95% CI 0.73 to 0.78) for the PREP-S model in the internal validation. External validation of the reduced PREP-L model showed good performance with a c-statistic of 0.81 (95% CI 0.77 to 0.85) in PIERS and 0.75 (95% CI 0.64 to 0.86) in PETRA cohorts for maternal complications, and calibrated well with slopes of 0.93 (95% CI 0.72 to 1.10) and 0.90 (95% CI 0.48 to 1.32), respectively. In the PIERS data set, the reduced PREP-S model had a c-statistic of 0.71 (95% CI 0.67 to 0.75) and a calibration slope of 0.67 (95% CI 0.56 to 0.79). Low gestational age at diagnosis, high urine protein-to-creatinine ratio, increased serum urea concentration, treatment with antihypertensive drugs, magnesium sulphate, abnormal uterine artery Doppler scan findings and estimated fetal weight below the 10th centile were associated with fetal complications.

CONCLUSIONS

The PREP-L model provided individualised risk estimates in early-onset pre-eclampsia to plan management of high- or low-risk individuals. The PREP-S model has the potential to be used as a triage tool for risk assessment. The impacts of the model use on outcomes need further evaluation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN40384046.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

A retrospective cohort review of intrahepatic cholestasis of pregnancy in a South Australian population

OBJECTIVE

To review the management and outcomes of Intrahepatic Cholestasis of Pregnancy (ICP) in South Australia (SA) over the past decade.

DESIGN

Retrospective cohort review.

SETTING

Public clinics at two teaching hospitals in SA.

POPULATION

All pregnancies associated with ICP (defined as pruritus with serum bile acids≥10μmol/L) managed 2001-2010.

METHODS

Identification of subjects (laboratory database), detailed chart-review to ascertain demographics, maternal/perinatal outcomes and associated pregnancy comorbidities, analysis of mild/severe disease cohorts, comparison with normal population data, using Student's t-test or Mann-Whitney U test as appropriate for continuous variables, and Pearson's chi-square test or Fisher's exact test for categorical variables. Unadjusted odds ratios (OR) with 95% confidence intervals (95% CI) were calculated in comparison with the general pregnant population for clinically significant outcomes.

RESULTS

320 women (359 pregnancies) were diagnosed with ICP over the 10-years: incidence 0.6%/year. Within the cohort, the incidences of gestational diabetes (12.5%; OR 3.06, 95% CI 2.23-4.18), pre-eclampsia (10.3%; OR 75.84, 95% CI 52.91-178.70), and spontaneous preterm labour (23.1%; OR 2.05, 95% CI 1.41-2.98) were much higher than in the general SA pregnant population. Pregnancies with severe ICP (serum bile acids≥40μmol/L) had ICP diagnosed earlier (231 vs 248 days, P<0.001), and ended earlier (256 vs 260 days, P<0.001) with lower birthweights (2827g vs 3093g, P <0.001) than those with mild ICP. Neonates of severe ICP mothers were more likely to require special-care-nursery admission, but perinatal complication rates did not differ. There were no stillbirths.

CONCLUSION

This large Australian retrospective cohort study confirms generally favourable outcomes associated with ICP, mild or severe, with no stillbirths, likely secondary to proactive medical management. A high proportion of pregnancies were also affected by gestational diabetes, pre-eclampsia, and/or spontaneous pre-term labour compared with the general population.

Epigallocatechin gallate enhances treatment efficacy of oral nifedipine against pregnancy-induced severe pre-eclampsia: A double-blind, randomized and placebo-controlled clinical study

WHAT IS KNOWN AND OBJECTIVE

Oral nifedipine is commonly used to treat pre-eclampsia, one of the most severe complications during pregnancy, but its clinical efficacy is less than ideal. Epigallocatechin gallate (EGCG), a natural compound from green tea, could benefit cardiovascular health especially hypertension. We investigated the clinical efficacy of EGCG, when complemented with oral nifedipine, in treating pre-eclampsia.

METHODS

A total of 350 pregnant women with severe pre-eclampsia were recruited and randomized to receive oral nifedipine, together with placebo (NIF+placebo) or EGCG (NIF+EGCG). The primary treatment outcome was the time needed to control blood pressure and interval time before a new hypertensive crisis, whereas the secondary treatment outcome was the number of treatment doses to effectively control blood pressure, maternal adverse effects and neonatal complications.

RESULTS AND DISCUSSION

Comparing NIF+EGCG group to NIF+placebo group, the time needed to control blood pressure was significantly shorter (NIF+EGCG 31.2±16.7 minutes, NIF+placebo 45.3±21.9 minutes; 95% CI 9.7-18.5 minutes), whereas interval time before a new hypertensive crisis was significantly prolonged (NIF+EGCG 7.2±2.9 hours, NIF+placebo 4.1±3.7 hours; 95% CI 2.3-3.9 hours), and the number of treatment dosages needed to effectively control blood pressure was also lower. Between the two treatment groups, no differences in incidence rates of maternal adverse effects or neonatal complications were observed.

WHAT IS NEW AND CONCLUSIONS

EGCG is both safe and effective in enhancing treatment efficacy of oral nifedipine against pregnancy-induced severe pre-eclampsia, but formal validation is required prior to its recommendation for use outside of clinical trials.

Celastrol synergizes with oral nifedipine to attenuate hypertension in preeclampsia: a randomized, placebo-controlled, and double blinded trial

Preeclampsia, a disease mainly manifesting as serious hypertension during pregnancy, affects expectant mothers around the globe. Celastrol, a naturally existing triterpenoid, is known to exhibit beneficial effects attenuating cardiovascular symptoms including hypertension. We here assessed the treatment outcome against preeclampsia with a combined use of celastrol and nifedipine. A total of 626 patients with preeclampsia were enrolled, screened, and assigned by random to groups receiving either nifedipine + placebo or nifedipine + celastrol orally. Time required to control hypertension as well as time before another hypertensive crisis were defined as primary end points. Secondary end points include the number of dosages required to control hypertension, as well as maternal and neonatal adverse effects. The time to control hypertension showed a marked reduction in nifedipine + celastrol group, while time before a new hypertensive crisis was significantly lengthened with the treatment, compared with the nifedipine + placebo group. The number of dosages required to control hypertension was also lower in the nifedipine + celastrol group. The two treatment groups were not statistically different regarding adverse effects, either maternal or neonatal. Results from the current study provide evidence for the potential role of celastrol serving as an effective and safe adjuvant to oral nifedipine against hypertension in patients with preeclampsia.

Associations between maternal size and health outcomes for women undergoing caesarean section: a multicentre prospective observational study (The MUM SIZE Study)

OBJECTIVES

To investigate associations between maternal body mass index (BMI) at delivery (using pregnancy-specific BMI cut-off values 5 kg/m² higher in each of the WHO groups) and clinical, theatre utilisation and health economic outcomes for women undergoing caesarean section (CS).

DESIGN

A prospective multicentre observational study.

SETTING

Seven secondary or tertiary referral obstetric hospitals.

PARTICIPANTS

One thousand and four hundred and fifty-seven women undergoing all categories of CS.

DATA COLLECTION

Height and weight were recorded at the initial antenatal visit and at delivery. We analysed the associations between delivery BMI (continuous and pregnancy-specific cut-off values) and total theatre time, surgical time, anaesthesia time, maternal and neonatal adverse outcomes, total hospital admission and theatre costs.

RESULTS

Mean participant characteristics were: age 32 years, gestation at delivery 38.4 weeks and delivery BMI 32.2 kg/m². Fifty-five per cent of participants were overweight, obese or super-obese using delivery pregnancy-specific BMI cut-off values. As BMI increased, total theatre time, surgical time and anaesthesia time increased. Super-obese participants had approximately 27% (17 min, p<0.001) longer total theatre time, 20% (9 min, p<0.001), longer surgical time and 40% (11 min, p<0.001) longer anaesthesia time when compared with normal BMI participants. Increased BMI at delivery was associated with increased risk of maternal intensive care unit admission (relative risk 1.07, p=0.045), but no increased risk of neonatal admission to higher acuity care. Total hospital admission costs were 15% higher in super-obese women compared with normal BMI women and theatre costs were 27% higher in super-obese women.

CONCLUSIONS

Increased maternal BMI was associated with increased total theatre time, surgical and anaesthesia time, increased total hospital admission costs and theatre costs. Clinicians and health administrators should consider these clinical risks, time implications and financial costs when managing pregnant women.

Clinical and biochemical factors associated with preeclampsia in women with obesity

OBJECTIVE

To compare early pregnancy clinical and biomarker risk factors for later development of preeclampsia between women with obesity (body mass index, BMI ≥30 kg/m² ) and those with a normal BMI (20-25 kg/m² ).

METHODS

In 3,940 eligible nulliparous women from the Screening for Pregnancy Endpoints (SCOPE) study, a total of 53 biomarkers of glucose and lipid metabolism, placental function, and known markers of preeclampsia were measured at 14 to 16 weeks' gestation. Logistic regression was performed to identify clinical and biomarker risk factors for preeclampsia in women with and without obesity.

RESULTS

Among 834 women with obesity and 3,106 with a normal BMI, 77 (9.2%) and 105 (3.4%) developed preeclampsia, respectively. In women with obesity, risk factors included a family history of thrombotic disease, low plasma placental growth factor, and higher uterine artery resistance index at 20 weeks. In women with a normal BMI, a family history of preeclampsia or gestational hypertension, mean arterial blood pressure, plasma endoglin and cystatin C, and uterine artery resistance index were associated with preeclampsia, while high fruit intake was protective.

CONCLUSIONS

Women with obesity and a normal BMI have different early pregnancy clinical and biomarker risk factors for preeclampsia.

Early-onset preeclampsia appears to discourage subsequent pregnancy but the risks may be overestimated

BACKGROUND

Early-onset preeclampsia is associated with adverse maternal and perinatal outcomes. For women who consider another pregnancy after one complicated by early-onset preeclampsia, the likelihood of recurrence and the subsequent pregnancy outcome for themselves and their babies are pertinent considerations.

OBJECTIVES

The purpose of this study was to determine the subsequent pregnancy rate after a nulliparous pregnancy that was complicated by early-onset preeclampsia and among those who have a subsequent pregnancy, the risk of recurrence by gestational week, and adverse pregnancy outcomes.

STUDY DESIGN

This was a population-based record linkage cohort study. The study population included nulliparous women with a singleton pregnancy and early-onset preeclampsia (<34 weeks gestation) who gave birth in New South Wales Australia from 2001-2010 (the index birth), with follow-up data for a subsequent birth through 2012. Early-onset in the index birth was further categorized as <28 vs 28-33 weeks gestation. Subsequent pregnancy outcomes that were assessed included the pregnancy rate, preeclampsia recurrence, and maternal and perinatal morbidity and mortality rates. The risk of preeclampsia necessitating delivery at each gestational week for women who were at risk was plotted, and the net gain or loss of gestational age when comparing the index with the subsequent pregnancy was calculated.

RESULTS

Among 361,031 nulliparous women with singleton pregnancies, 1473 (0.4%) had early-onset preeclampsia. Women with early-onset preeclampsia in their first pregnancy had a lower subsequent pregnancy rate (59.7%) than women without preeclampsia (67.7%). Of the 758 women with a subsequent singleton birth, 256 (33.8%) experienced preeclampsia in the next pregnancy; 57 women (7.5%) with recurrent early-onset preeclampsia were included. Cumulative rates of preeclampsia in the subsequent pregnancy were higher at every gestation from 23 weeks gestation when the index birth was <28 weeks compared with 28-33 weeks gestation. The cumulative rate and gestation-specific risk of recurrent preeclampsia rose most steeply at 32-38 weeks gestation. Most women (94.6%) progressed to a later gestational age in their subsequent pregnancy. The median overall increase in gestational age at delivery was 6 weeks (interquartile range, 4-8); among women with recurrent preeclampsia, the median increase was 5 weeks (interquartile range, 2-7). Women with index birth <28 weeks gestation compared with 28-33 weeks gestation were more likely to deliver preterm (38.8% vs 28.7%; relative risk, 1.35; 95% confidence interval, 1.04-1.75) and have a perinatal death (4.3% vs 1.2%; relative risk, 3.46; 95% confidence interval, 1.15-10.39) at the subsequent birth, but live born infants had similar rates of severe morbidity (17.1% vs 15.0%; relative risk, 1.14; 95% confidence interval, 0.73-1.79).

CONCLUSION

Women with early-onset preeclampsia in a first pregnancy appear less likely than women without preeclampsia to have a subsequent pregnancy. Maternal and perinatal outcomes in the subsequent pregnancy are generally better than in the first; most women will not have recurrent preeclampsia, and those who do usually will give birth at a greater gestational age compared with their index birth.

Renal Interlobar Vein Impedance Index as a First-Trimester Marker Does Not Predict Hypertensive Disorders of Pregnancy

OBJECTIVES

The purpose of this study was to examine whether the maternal renal interlobar vein impedance index as assessed by first-trimester sonography is able to predict the later development of hypertensive disorders of pregnancy.

METHODS

Venous Doppler parameters of both maternal kidneys were studied in 214 pregnant women at gestational ages of 11 weeks to 13 weeks 6 days. Patients were classified according to outcomes related to hypertensive disorders. Detection rates and areas under receiver operating characteristic curves were determined for the maternal renal interlobar vein impedance index as a first-trimester predictor of preeclampsia and gestational hypertension.

RESULTS

Among the 214 patients, 22 (10.3%) developed preeclampsia; 10 (4.7%) developed gestational hypertension; and 182 were unaffected by hypertensive disorders (controls; 85.0%). In the overall study population, there was no difference in the impedance index between the right (0.44; 95% confidence interval, 0.35-0.50) and left (0.43; 95% confidence interval, 0.35-0.53) sides (P = .86). The average impedance index did not differ among women destined to develop preeclampsia (0.46; 95% confidence interval, 0.38-0.57), gestational hypertension (0.39; 95% confidence interval, 0.33-0.46), or pregnancies uncomplicated by hypertensive disease (0.42; 95% confidence interval, 0.37-0.50; P = .15). Low detection rates and the area under the curve analysis demonstrated that the impedance index was not predictive of hypertensive disorders of pregnancy.

CONCLUSIONS

The maternal renal interlobar vein impedance index should not be considered a first-trimester marker of hypertensive disorders of pregnancy.

Metformin and dietary advice to improve insulin sensitivity and promote gestational restriction of weight among pregnant women who are overweight or obese: the GRoW Randomised Trial

Background

Obesity is a significant global health problem, with approximately 50% of women entering pregnancy having a body mass index greater than or equal to 25 kg/m². Obesity during pregnancy is associated with a well-recognised increased risk of adverse health outcomes both for the woman and her infant. Currently available data from large scale randomised trials and systematic reviews highlight only modest effects of antenatal dietary and lifestyle interventions in limiting gestational weight gain, with little impact on clinically relevant pregnancy outcomes. Further information evaluating alternative strategies is required.

The aims of this randomised controlled trial are to assess whether the use of metformin as an adjunct therapy to dietary and lifestyle advice for overweight and obese women during pregnancy is effective in improving maternal, fetal and infant health outcomes.

Methods

Design: Multicentre randomised, controlled trial.

Inclusion Criteria: Women with a singleton, live gestation between 10⁺⁰-20⁺⁰ weeks who are obese or overweight (defined as body mass index greater than or equal to 25 kg/m²), at the first antenatal visit.

Trial Entry & Randomisation: Eligible, consenting women will be randomised between 10⁺⁰ and 20⁺⁰ weeks gestation using an online computer randomisation system, and randomisation schedule prepared by non-clinical research staff with balanced variable blocks. Stratification will be according to maternal BMI at trial entry, parity, and centre where planned to give birth.

Treatment Schedules: Women randomised to the Metformin Group will receive a supply of 500 mg oral metformin tablets. Women randomised to the Placebo Group will receive a supply of identical appearing and tasting placebo tablets. Women will be instructed to commence taking one tablet daily for a period of one week, increasing to a maximum of two tablets twice daily over four weeks and then continuing until birth. Women, clinicians, researchers and outcome assessors will be blinded to the allocated treatment group.

All women will receive three face-to-face sessions (two with a research dietitian and one with a trained research assistant), and three telephone calls over the course of their pregnancy, in which they will be provided with dietary and lifestyle advice, and encouraged to make change utilising a SMART goals approach.

Primary Study Outcome: infant birth weight >4000 grams.

Sample Size: 524 women to detect a difference from 15.5% to 7.35% reduction in infants with birth weight >4000 grams (p = 0.05, 80% power, two-tailed).

Discussion

This is a protocol for a randomised trial. The findings will contribute to the development of evidence based clinical practice guidelines.

Trial registration

Australian and New Zealand Clinical Trials Registry ACTRN12612001277831, prospectively registered 10^th of December, 2012.

Triggers for Preeclampsia Onset: a Case-Crossover Study

BACKGROUND

Risk factors for preeclampsia are well established, whereas, the triggers associated with timing of preeclampsia onset are not. The aim of this study was to establish whether recent infection or other triggers were associated with timing of preeclampsia onset.

METHODS

We used a case-crossover design with preeclampsia cases serving as their own controls. Women with singleton pregnancies of ≥20 weeks gestation presenting at three hospitals were eligible for inclusion. Exposures to potential triggers were identified via guided questionnaire. Infective episodes included symptoms lasting >24 h. Preeclampsia was defined as hypertension (BP ≥140 mmHg and/or ≥90 mmHg) and proteinuria (protein/creatinine ratio ≥30 mg/mmol). Conditional logistic regression was used to compare the odds of exposure to potential triggers in the case windows (1-7 days preceding diagnosis of preeclampsia) and control windows (8-14 days prior to diagnosis); unadjusted odds ratios (ORs) are reported.

RESULTS

Among 286 recruited women, 25 (8.7%) reported a new infection in the 7 days prior to preeclampsia onset and 21 (7.3%) in the 8-14 days prior. There was no significant association between onset of infection in the 7 days prior and preeclampsia diagnosis (OR 1.24, 95% CI 0.65, 2.34). Consumption of caffeine (OR 0.51, 95% CI 0.33, 0.77), spicy food (OR 0.49, 95% CI 0.30, 0.81), and alcohol (OR 0.26, 95% CI 0.10, 0.71) were strongly inversely associated with preeclampsia onset.

CONCLUSION

Recent infection does not appear to trigger preeclampsia. Decreased consumption of caffeine, spicy food, and alcohol may be prodromal markers. Such behaviours may be early markers of imminent preeclampsia.

Infant and mother related outcomes from exposure to metals with endocrine disrupting properties during pregnancy

BACKGROUND

Endocrine-related adverse health effects from exposure to heavy metals such as lead, arsenic, cadmium, and mercury are yet to be adequately described. The purpose of this review was to gain insight into maternal exposure to heavy metals, and to identify potential endocrine-related adverse health effects in the mother and the infant.

METHODS

Relevant databases were searched for original research reports and a total of 46 articles were retained for scrutiny. Required data was extracted from these studies and their methodology was assessed.

RESULTS

Impaired fetal growth was observed from exposure to all endocrine disrupting metals, while exposure to lead and arsenic were associated with spontaneous abortion, stillbirth and neonatal deaths. Maternal exposure to arsenic was associated with impaired glucose tolerance in these mothers.

CONCLUSION

Impaired fetal growth, fetal loss, and neonatal deaths were significantly associated with heavy metals exposure during pregnancy; however, hypertension and gestational diabetes require further investigation.

Alterations in the Maternal Peripheral Microvascular Response in Pregnancies Complicated by Preeclampsia and the Impact of Fetal Sex

OBJECTIVE

Peripheral microvascular function is altered in preeclampsia (PE). Recent studies suggest that maternal physiology varies with fetal sex. We wanted to examine if there were sex-specific differences in maternal peripheral microvascular function in normal pregnancy and pregnancy complicated by PE.

METHODS

Peripheral microvascular responses were examined using the noninvasive technique of laser Doppler flowmetry in normotensive healthy pregnant women and in women diagnosed with PE. We measured baseline perfusion, response to thermal hyperemia, post-occlusive reperfusion, and vasodilatation in response to corticotropin-releasing hormone (CRH), a potent vasodilator in human skin.

RESULTS

At 31 to 40 weeks' gestation those women with a male fetus exhibited increased vasodilatation in response to CRH (P <.05) and greater baseline perfusion (P <.05) than those pregnant with a female fetus. PE women pregnant with a male fetus demonstrated a significantly reduced vasodilatation in response to CRH (P <.05), reduced baseline perfusion (P <.05), and reduced response to thermal hyperemia (P <.05) compared to normotensive women pregnant with a male fetus. Microvascular function was not significantly different between preeclamptic and normotensive women with a female fetus.

CONCLUSION

These data show that there are differences in maternal peripheral microvascular function in relation to fetal sex.

Prediction and prevention of hypertensive disorders of pregnancy

The most common classifications of hypertensive disorders of pregnancy consist of chronic hypertension, gestational hypertension, preeclampsia (PE) and superimposed PE. A common final pathophysiology of PE is endothelial dysfunction. The most successful translational research model for explaining the cause-effect relationship in the genesis of PE is the angiogenic/angiostatic balance theory, involving soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF) and soluble endoglin (sEng). In a systematic review of articles on the prediction of early-onset PE using angiogenesis-related factors, we revealed that the prediction of early-onset PE in the first trimester is clinically possible, but the prediction of early-onset PE in the early third trimester might be ideal. In addition, an onset threshold or a serial approach appeared to be clinically useful for predicting the imminent onset of PE, with onset at <4 weeks after blood sampling in the second and early third trimesters, because the positive likelihood ratio was >10 and the positive predictive value was >20%. The National Institute for Health and Care Excellence guidelines state that the Triage PlGF testing and Elecsys immunoassay for the sFlt-1/PlGF ratio could help to exclude PE in women with suspected PE at 20-34 weeks of gestation. Until now, we have not found any effective therapies to prevent PE. However, low-dose aspirin treatment starting at ⩽16 weeks of gestation might be associated with a marked reduction in PE. In addition, early statin treatment might prevent the occurrence of PE. Currently, a clinical trial using pravastatin for the prevention of PE is ongoing.

Ethnicity, Obesity and Emotional Factors Associated With Gestational Hypertension

Identifying factors that can be related to the occurrence of gestational arterial hypertension. The sample was composed by 105 pregnant women in their third trimester of gestation, during the period between September 2013 and August 2014. General assessment questionnaires together with a questionnaire to evaluate anxiety (STAI-A-STATE) were applied; arterial blood pressure values were collected. To classify anxiety, a mean of the final result of all the questionnaires gotten was calculated. Pregnant women who showed scores higher than the mean were considered anxious. All data were analyzed by a logistic regression. The significance level adopted was 0.05. A data analysis allowed us to verify that 92.38% of the pregnant women had an anxious personality STAI-A-STATE and 12.38% of them had a momentary hypertension. The momentary hypertension showed a correlation between the hypertension and the state anxiety score (p = 0.049). The hypertension showed an association with the presence of depression (OR 8.69), obesity (OR 6.45), anxiety (OR 7.77), nausea (OR 12.79) and non-white race (OR 8.18). According to the study realized, the factors non-white race, depression, nausea, obesity and anxiety can be considered risk factors for the occurrence of gestational arterial hypertension. Based on these findings, a high quality prenatal assistance is considered of prime importance.

Diet quality before or during pregnancy and the relationship with pregnancy and birth outcomes: the Australian Longitudinal Study on Women's Health

OBJECTIVE

To assess whether diet quality before or during pregnancy predicts adverse pregnancy and birth outcomes in a sample of Australian women.

DESIGN

The Dietary Questionnaire for Epidemiological Studies was used to calculate diet quality using the Australian Recommended Food Score (ARFS) methodology modified for pregnancy.

SETTING

A population-based cohort participating in the Australian Longitudinal Study on Women's Health (ALSWH).

SUBJECTS

A national sample of Australian women, aged 20-25 and 31-36 years, who were classified as preconception or pregnant when completing Survey 3 or Survey 5 of the ALSWH, respectively. The 1907 women with biologically plausible energy intake estimates were included in regression analyses of associations between preconception and pregnancy ARFS and subsequent pregnancy outcomes.

RESULTS

Preconception and pregnancy groups were combined as no significant differences were detected for total and component ARFS. Women with gestational hypertension, compared with those without, had lower scores for total ARFS, vegetable, fruit, grain and nuts/bean/soya components. Women with gestational diabetes had a higher score for the vegetable component only, and women who had a low-birth-weight infant had lower scores for total ARFS and the grain component, compared with those who did not report these outcomes. Women with the highest ARFS had the lowest odds of developing gestational hypertension (OR=0·4; 95 % CI 0·2, 0·7) or delivering a child of low birth weight (OR=0·4; 95 % CI 0·2, 0·9), which remained significant for gestational hypertension after adjustment for potential confounders.

CONCLUSIONS

A high-quality diet before and during pregnancy may reduce the risk of gestational hypertension for the mother.

Women with an HbA1c of 41-49 mmol/mol (5.9-6.6%): a higher risk subgroup that may benefit from early pregnancy intervention

AIMS

To examine whether women with an HbA1c of 41-49 mmol/mol (5.9-6.6%) at diagnosis of gestational diabetes are higher risk than women with an HbA1c of < 41 mmol/mol (5.9%) and whether pregnancy outcomes are improved if treated at < 24 weeks' gestation.

METHODS

This was an observational study of women with gestational diabetes diagnosed by early HbA1c screening or subsequent oral glucose tolerance test at < 34 weeks' gestation who delivered at National Women's Health, Auckland, from July 2012 to June 2014. Data were extracted from the hospital database. Women with HbA1c 41-49 mmol/mol (5.9-6.6%) were divided into those seen < 24 weeks (Early, n = 134) and those seen ≥ 24 weeks (Later, n = 151). Those with HbA1c < 41 mmol/mol (5.9%) were labelled Other GDM (n = 661).

RESULTS

The Early and Later groups, compared with Other GDM, had more Polynesian and fewer (non-Indian) Asian women, higher BMI and more required medication (P < 0.001). More were smokers (P = 0.007, 0.02) and more had chronic hypertension (P < 0.001, 0.02). There were higher rates of adverse outcomes in the Later group than the Other GDM group (pre-eclampsia 8.0% vs. 2.4%, P = 0.001, preterm birth 16.6% vs. 8.2%, P = 0.002, neonatal admission 15.5% vs. 9.2%, P = 0.02). Outcomes were similar between the Early group and Other GDM group (pre-eclampsia 1.5% vs. 2.4%, P = 0.5, preterm birth 10.5% vs. 8.2% P = 0.4, neonatal admission 13.6% vs. 9.2%, P = 0.12). Comparing the Early and Later groups, the Early group had less pre-eclampsia, 1.5% vs. 8.0%, adjusted P = 0.03. Other outcomes were not statistically different.

CONCLUSIONS

An HbA1c of 41-49 mmol/mol (5.9-6.7%) identifies a higher-risk group of women with gestational diabetes. Overall, our data support early treatment of women with an HbA1c ≥ 41 mmol/mol (5.9%).

Trend in admissions, clinical features and outcome of preeclampsia and eclampsia as seen from the intensive care unit of the Douala General Hospital, Cameroon

INTRODUCTION

Hypertensive disorders in pregnancy (HDP) are a major cause of maternal morbidity and mortality. We aimed at determining the trends in admission, profiles and outcomes of women admitted for preeclampsia and eclampsia to an intensive care unit (ICU) in Cameroon.

METHODS

A retrospective study involving 74 women admitted to the ICU of the Douala General Hospital for severe preeclampsia and eclampsia from January 2007 to December 2014. Clinical profiles and outcome data were obtained from patient records. Statistical analysis was performed using SPSS version 20.

RESULTS

Of the 74 women admitted to ICU (72.5% for eclampsia), mean age was 30.2years and the majority (90.5%) were aged 20-39 years. While overall trend in admission for HDP increased over the years, mortality remained stable. Mean gestational age (GA) on admission was 34.0 weeks (33.5 for preeclampsia vs 35.4 for eclampsia). Most patients presented with complications of which acute kidney injury was most frequent (66.7%). Visual problems were more common in patients with eclampsia compared to preeclampsia (p = 0.01). HELLP syndrome and acute pulmonary oedema (APO) were predominant in patients with preeclampsia, while cerebrovascular accidents (CVA) occurred more in patients with eclampsia. Overall mortality was 24.3%. Presence of APO was associated with mortality in multivariable analysis (O.R.= 0.03, p = 0,01).

CONCLUSION

Trends in admission for HDP were increasing with high but stable mortality rate. Patients presented late most of whom with complications. Interventions improving antenatal care services and multidisciplinary management approach may improve maternal outcome in patients with HDP.

Present status of clinical care for postpartum patients with hypertensive disorders of pregnancy in Japan: findings from a nationwide questionnaire survey

OBJECTIVE

To assess the present status of clinical care for postpartum patients with hypertensive disorders of pregnancy (HDP) in Japan.

METHODS

We conducted a nationwide questionnaire survey of obstetricians, internists and hypertension specialists and analyzed 686 valid responses.

RESULTS

Though HDP is widely known as a risk factor for subsequent hypertension and cardiovascular disease, over one-third of obstetricians terminated their postpartum follow-up of HDP patients without referring them to other departments.

CONCLUSION

It is important to establish an effective referral system, whereby patients with HDP can be smoothly transferred to primary care or a specialist physician after childbirth for long-term monitoring and management of blood pressure.

Gestational diabetes mellitus management with oral hypoglycemic agents

Oral hypoglycemic agents such as glyburide (second-generation sulfonylurea) and metformin (biguanide) are attractive alternatives to insulin due to lower cost, ease of administration, and better patient adherence. The majority of evidence from retrospective and prospective studies suggests comparable efficacy and safety of oral hypoglycemic agents such as glyburide and metformin as compared to insulin when used in the treatment of women with gestational diabetes mellitus (GDM). Glyburide and metformin have altered pharmacokinetics during pregnancy and both agents cross the placenta. In this article, we review the efficacy, safety, and dosage of oral hypoglycemic agents for the treatment of gestational diabetes mellitus. Additional research is needed to evaluate optimal dosage for glyburide and metformin during pregnancy. Comparative studies evaluating the effects of glyburide and metformin on long-term maternal and fetal outcomes are also needed.

Community pharmacist surveillance of hypertension in pregnancy: Are we ready for prime time?

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with serious maternal and perinatal complications. For nonsevere hypertension, there is a lack of consensus regarding treatment during pregnancy and while breastfeeding. Further, there is considerable variability in guidelines for antihypertensive drug choices. As part of a Drug Safety and Effectiveness Network (DSEN)-funded project, we piloted a novel surveillance strategy in which community pharmacists recruited pregnant and breastfeeding women to monitor their blood pressure and medication use and to provide education on HDP.

METHODS

Participating pharmacists were required to complete a certified training program, identify and recruit patients who were pregnant or breastfeeding, obtain informed consent, administer a patient questionnaire and complete an initial case report form for enrolled patients. Study outcomes included the feasibility of community pharmacists to enroll patients and carry out study-related documentation and follow-up. The criteria for success in this pilot study included the ability of pharmacists to recruit 10 participants per pharmacy.

RESULTS

178 community pharmacies across British Columbia agreed to participate in this feasibility study, of which 63 pharmacists completed the study training. Of these, only 21 pharmacists recruited at least 1 patient and 1 pharmacist met the success criteria. Overall, 51 patients were enrolled, 2 withdrew from the study and 7 patients were diagnosed with HDP. Antihypertensive medications used by patients included methyldopa and labetalol.

CONCLUSIONS

While postmarketing surveillance is an important tool for the assessment of drug safety in the pregnant and breastfeeding patient population, the feasibility of community pharmacists taking on this role was not successfully demonstrated.