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Torres-Torres J, Espino-y-Sosa S, Martinez-Portilla R, Borboa-Olivares H, Estrada-Gutierrez G, Acevedo-Gallegos S, Ruiz-Ramirez E, Velasco-Espin M, Cerda-Flores P, Ramirez-Gonzalez A, Rojas-Zepeda L. A Narrative Review on the Pathophysiology of Preeclampsia. Int J Mol Sci 2024; 25:7569. [PMID: 39062815 PMCID: PMC11277207 DOI: 10.3390/ijms25147569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Revised: 07/06/2024] [Accepted: 07/08/2024] [Indexed: 07/28/2024] Open
Abstract
Preeclampsia (PE) is a multifactorial pregnancy disorder characterized by hypertension and proteinuria, posing significant risks to both maternal and fetal health. Despite extensive research, its complex pathophysiology remains incompletely understood. This narrative review aims to elucidate the intricate mechanisms contributing to PE, focusing on abnormal placentation, maternal systemic response, oxidative stress, inflammation, and genetic and epigenetic factors. This review synthesizes findings from recent studies, clinical trials, and meta-analyses, highlighting key molecular and cellular pathways involved in PE. The review integrates data on oxidative stress biomarkers, angiogenic factors, immune interactions, and mitochondrial dysfunction. PE is initiated by poor placentation due to inadequate trophoblast invasion and improper spiral artery remodeling, leading to placental hypoxia. This triggers the release of anti-angiogenic factors such as soluble fms-like tyrosine kinase-1 (sFlt-1) and soluble endoglin (sEng), causing widespread endothelial dysfunction and systemic inflammation. Oxidative stress, mitochondrial abnormalities, and immune dysregulation further exacerbate the condition. Genetic and epigenetic modifications, including polymorphisms in the Fms-like tyrosine kinase 1 (FLT1) gene and altered microRNA (miRNA) expression, play critical roles. Emerging therapeutic strategies targeting oxidative stress, inflammation, angiogenesis, and specific molecular pathways like the heme oxygenase-1/carbon monoxide (HO-1/CO) and cystathionine gamma-lyase/hydrogen sulfide (CSE/H2S) pathways show promise in mitigating preeclampsia's effects. PE is a complex disorder with multifactorial origins involving abnormal placentation, endothelial dysfunction, systemic inflammation, and oxidative stress. Despite advances in understanding its pathophysiology, effective prevention and treatment strategies remain limited. Continued research is essential to develop targeted therapies that can improve outcomes for both mothers and their babies.
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Affiliation(s)
- Johnatan Torres-Torres
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
- Obstetric and Gynecology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico (P.C.-F.)
| | - Salvador Espino-y-Sosa
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
| | - Raigam Martinez-Portilla
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
| | - Hector Borboa-Olivares
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
| | - Guadalupe Estrada-Gutierrez
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
| | - Sandra Acevedo-Gallegos
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City 11000, Mexico; (R.M.-P.)
| | - Erika Ruiz-Ramirez
- Obstetric and Gynecology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico (P.C.-F.)
| | - Martha Velasco-Espin
- Obstetric and Gynecology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico (P.C.-F.)
| | - Pablo Cerda-Flores
- Obstetric and Gynecology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico (P.C.-F.)
| | - Andrea Ramirez-Gonzalez
- Obstetric and Gynecology Department, Hospital General de México Dr. Eduardo Liceaga, Mexico City 06720, Mexico (P.C.-F.)
| | - Lourdes Rojas-Zepeda
- Maternal-Fetal Medicine Department, Instituto Materno Infantil del Estado de Mexico, Toluca 50170, Mexico
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de Kok B, Chirwa Kajombo M, Matinga P, Kaunda B. (In)visibilising pregnancy loss in Southern Malawi. CULTURE, HEALTH & SEXUALITY 2024:1-16. [PMID: 38469825 DOI: 10.1080/13691058.2024.2324001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 02/23/2024] [Indexed: 03/13/2024]
Abstract
Miscarriages, stillbirths and neonatal deaths have received limited attention in global health programmes and research, even though pregnancy loss is common, traumatic and stigmatised. This paper seeks to illuminate lived experiences of pregnancy loss in southern Malawi, drawing on findings from semi-structured interviews and focus groups with women who have experienced loss, health professionals and community members, and observations of maternity care. Combining thematic and discourse analysis, we show how societal and medical discourses frame women as responsible for (failed) reproduction, and restrict possibilities to speak about, and respond to, loss. Some accounts and (care) practices invisibilise loss and associated suffering. However, invisibilisation may also be intended as support, and underscores rather than denies the social significance of parenthood. Other accounts (e.g. women emphasising faith and acceptance) constitute moral survival strategies to avoid the acquisition of a 'spoiled identity'. We conclude that societal and medical discourses of loss enact stigmatised, subaltern subject positions for women experiencing pregnancy loss, create social suffering, and amount to a form of structural violence. Programmes and interventions should change these discourses.
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Affiliation(s)
- Bregje de Kok
- Department of Anthropology, Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Marion Chirwa Kajombo
- Language and Communication Studies, Malawi University of Science and Technology, Limbe, Malawi
| | | | - Blessings Kaunda
- School of Global and Public Health, Kamuzu University of Health Sciences, Chichiri, Malawi
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Mukosha M, Hatcher A, Mutale W, Lubeya MK, Conklin JL, Chi BH. Prevalence of persistent hypertension following pregnancy complicated by hypertensive disorders in low- and middle-income countries: a systematic review. Front Glob Womens Health 2024; 5:1315763. [PMID: 38495126 PMCID: PMC10940323 DOI: 10.3389/fgwh.2024.1315763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Background Hypertensive disorders of pregnancy can lead to persistent hypertension (pHTN) in the months and even years following delivery. However, its prevalence in low- and middle-income countries (LMICs) is not well characterized. Objective To synthesize available evidence on the pHTN prevalence following a pregnancy complicated by hypertensive disorders of pregnancy in LMICs. Search strategy PubMed, CINAHL Plus, Global Health (EBSCOhost), and Scopus from inception through a search date of July 12, 2022, and updated on January 2, 2024. Selection criteria Cross-sectional studies and cohort studies reporting pHTN prevalence were eligible. Data collection and analysis We conducted a narrative synthesis of data and categorized reported prevalence time points into several broader categories. We used the Newcastle-Ottawa checklist to assess the risk of bias. The protocol is registered in PROSPERO (CRD42022345739). Results We reviewed 1,584 abstracts and identified 22 studies that reported pHTN between 2000 and 2023 from 14 LMICs. The overall prevalence of pHTN ranged between 6.9% and 62.2%, with the highest prevalence noted within African studies and the lowest in South American studies. Estimates at different follow-up periods postpartum were 6.9%-42.9% at six weeks, 34.0%-62.2% at three months, 14.8%-62.2% at six months, 12.7%-61.2% at 12 months, and 7.5%-31.8% at more than 12 months. The quality score of the selected studies ranged from 50% to 100%. Conclusions The extant literature reports a high prevalence of pHTN in LMICs following a pregnancy complicated by hypertensive disorders. To reduce long-term complications of pHTN, programs should emphasize early screening and linkages to long-term care for at-risk women. Systematic Review Registration https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=345739, PROSPERO (CRD42022345739).
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Affiliation(s)
- Moses Mukosha
- Department of Pharmacy, School of Health Sciences, University of Zambia, Lusaka, Zambia
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Abigail Hatcher
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Health Behavior, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Wilbroad Mutale
- School of Public Health, University of Zambia, Lusaka, Zambia
| | - Mwansa Ketty Lubeya
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Department of Obstetrics and Gynaecology, School of Medicine, The University of Zambia, Lusaka, Zambia
| | - Jamie L Conklin
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Benjamin H Chi
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
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Torres-Torres J, Villafan-Bernal JR, Martinez-Portilla RJ, Hidalgo-Carrera JA, Estrada-Gutierrez G, Adalid-Martinez-Cisneros R, Rojas-Zepeda L, Acevedo-Gallegos S, Camarena-Cabrera DM, Cruz-Martínez MY, Espino-Y-Sosa S. Performance of machine-learning approach for prediction of pre-eclampsia in a middle-income country. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:350-357. [PMID: 37774112 DOI: 10.1002/uog.27510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/28/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
OBJECTIVE Pre-eclampsia (PE) is a serious complication of pregnancy associated with maternal and fetal morbidity and mortality. As current prediction models have limitations and may not be applicable in resource-limited settings, we aimed to develop a machine-learning (ML) algorithm that offers a potential solution for developing accurate and efficient first-trimester prediction of PE. METHODS We conducted a prospective cohort study in Mexico City, Mexico to develop a first-trimester prediction model for preterm PE (pPE) using ML. Maternal characteristics and locally derived multiples of the median (MoM) values for mean arterial pressure, uterine artery pulsatility index and serum placental growth factor were used for variable selection. The dataset was split into training, validation and test sets. An elastic-net method was employed for predictor selection, and model performance was evaluated using area under the receiver-operating-characteristics curve (AUC) and detection rates (DR) at 10% false-positive rates (FPR). RESULTS The final analysis included 3050 pregnant women, of whom 124 (4.07%) developed PE. The ML model showed good performance, with AUCs of 0.897, 0.963 and 0.778 for pPE, early-onset PE (ePE) and any type of PE (all-PE), respectively. The DRs at 10% FPR were 76.5%, 88.2% and 50.1% for pPE, ePE and all-PE, respectively. CONCLUSIONS Our ML model demonstrated high accuracy in predicting pPE and ePE using first-trimester maternal characteristics and locally derived MoM. The model may provide an efficient and accessible tool for early prediction of PE, facilitating timely intervention and improved maternal and fetal outcome. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- J Torres-Torres
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
- Obstetrics and Gynecology Department, The American British Cowdray Medical Center, Mexico City, Mexico
| | - J R Villafan-Bernal
- Laboratory of Immunogenomics and Metabolic Diseases, INMEGEN, Mexico City, Mexico
| | - R J Martinez-Portilla
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
| | - J A Hidalgo-Carrera
- Obstetrics and Gynecology Department, The American British Cowdray Medical Center, Mexico City, Mexico
| | - G Estrada-Gutierrez
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
| | | | - L Rojas-Zepeda
- Maternal-Fetal Medicine Department, Instituto Materno Infantil del Estado de México, Toluca, Mexico
| | - S Acevedo-Gallegos
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
| | - D M Camarena-Cabrera
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
| | - M Y Cruz-Martínez
- Centro de Investigación en Ciencias de la Salud, Universidad Anáhuac México Campus Norte, Huixquilucan, Mexico
| | - S Espino-Y-Sosa
- Clinical Research Branch, Instituto Nacional de Perinatología Isidro Espinosa de los Reyes, Mexico City, Mexico
- Obstetrics and Gynecology Department, The American British Cowdray Medical Center, Mexico City, Mexico
- Centro de Investigación en Ciencias de la Salud, Universidad Anáhuac México Campus Norte, Huixquilucan, Mexico
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Sukmanee J, Liabsuetrakul T. Risk of future cardiovascular diseases in different years postpartum after hypertensive disorders of pregnancy: A systematic review and meta-analysis. Medicine (Baltimore) 2022; 101:e29646. [PMID: 35905265 PMCID: PMC9333537 DOI: 10.1097/md.0000000000029646] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE There are limited data on the optimal timing and frequency of postpartum follow-up visits after hypertensive disorders of pregnancy (HDP) for primary prevention and early detection of cardiovascular diseases (CVDs) in high-risk women. We aimed to evaluate the risk of cardiovascular outcomes later in life in women with prior HDP in different years postpartum and in preeclamptic women with severe features, or early onset of preeclampsia. METHODS We searched MEDLINE, Cochrane Library, Web of Science, and Scopus without language restriction for relevant articles published from inception to March 16, 2022. We included prospective and retrospective cohort studies assessing hypertension, ischemic heart disease, heart failure, venous thromboembolism, peripheral vascular disease, stroke, dementia, composite cardiovascular and/or cerebrovascular diseases, and mortality after 6 weeks postpartum, in women with prior HDP compared with controls. Two authors independently selected and appraised the studies. Article quality was independently assessed using the Newcastle-Ottawa Scale (NOS). Random-effect models were used for meta-analysis. Stratified analyses based on years postpartum, severity, and onset of preeclampsia were performed. RESULTS We included 59 studies for qualitative review, of which 56 were included in quantitative meta-analysis, involving 1,262,726 women with prior HDP and 14,711,054 controls. Women with prior HDP had increased risks of hypertension (relative risk [RR] 3.46, 95% confidence interval [CI]: 2.67-4.49), ischemic heart disease (RR 2.06, 95% CI: 1.38-3.08), and heart failure (RR 2.53, 95% CI: 1.28-5.00) later in life, compared with those with normotensive pregnancies. The risk of hypertension was highest during 5 years postpartum (RR 5.34, 95% CI: 2.74-10.39). Compared with normotensive pregnancies, the risk of future CVDs significantly increased in preeclamptic women. DISCUSSION A history of HDP is associated with approximately 2- to 4-fold increase in the risk of CVDs. Screening for CVDs and their risk factors in women with prior HDP since delivery, especially the first 5 years after delivery is suggested for early detection and appropriate management. Evidence on the risks of CVDs in preeclampsia with severe features and early onset of preeclampsia is limited due to having few studies and high heterogeneity. FUNDING The Royal Golden Jubilee PhD Program-RGJ (PHD/0183/2561); Thailand Science Research and Innovation (TSRI) Research Career Development Grant-RSA (RSA6180009); Targeted Research Grants Program of the Faculty of Medicine, Prince of Songkla University, Thailand. REGISTRATION CRD42020191550.
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Affiliation(s)
- Jarawee Sukmanee
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Tippawan Liabsuetrakul
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
- Department of Obstetrics and Gynecology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
- * Correspondence: Tippawan Liabsuetrakul, MD, PhD, Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand (e-mail: )
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Burger RJ, Delagrange H, van Valkengoed IGM, de Groot CJM, van den Born BJH, Gordijn SJ, Ganzevoort W. Hypertensive Disorders of Pregnancy and Cardiovascular Disease Risk Across Races and Ethnicities: A Review. Front Cardiovasc Med 2022; 9:933822. [PMID: 35837605 PMCID: PMC9273843 DOI: 10.3389/fcvm.2022.933822] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/06/2022] [Indexed: 12/30/2022] Open
Abstract
Pregnancy is often considered to be a "cardiometabolic stress-test" and pregnancy complications including hypertensive disorders of pregnancy can be the first indicator of increased risk of future cardiovascular disease. Over the last two decades, more evidence on the association between hypertensive disorders of pregnancy and cardiovascular disease has become available. However, despite the importance of addressing existing racial and ethnic differences in the incidence of cardiovascular disease, most research on the role of hypertensive disorders of pregnancy is conducted in white majority populations. The fragmented knowledge prohibits evidence-based targeted prevention and intervention strategies in multi-ethnic populations and maintains the gap in health outcomes. In this review, we present an overview of the evidence on racial and ethnic differences in the occurrence of hypertensive disorders of pregnancy, as well as evidence on the association of hypertensive disorders of pregnancy with cardiovascular risk factors and cardiovascular disease across different non-White populations, aiming to advance equity in medicine.
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Affiliation(s)
- Renée J Burger
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands
| | - Hannelore Delagrange
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Irene G M van Valkengoed
- Department of Public and Occupational Health, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Public Health, Health Behaviors & Chronic Diseases, Amsterdam, Netherlands
| | - Christianne J M de Groot
- Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands.,Department of Obstetrics and Gynaecology, Amsterdam UMC Location Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Bert-Jan H van den Born
- Department of Vascular Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Cardiovascular Sciences, Atherosclerosis and Ischemic Syndromes, Amsterdam, Netherlands
| | - Sanne J Gordijn
- Department of Obstetrics, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Wessel Ganzevoort
- Department of Obstetrics and Gynaecology, Amsterdam UMC Location University of Amsterdam, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Pregnancy and Birth, Amsterdam, Netherlands
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Mooij R, Kapanga RR, Mwampagatwa IH, Mgalega GC, van Dillen J, Stekelenburg J, de Kok BC. Role of male partners in the long-term well-being of women who have experienced severe pre-eclampsia and eclampsia in rural Tanzania: a qualitative study. J OBSTET GYNAECOL 2021; 42:906-913. [PMID: 34558378 DOI: 10.1080/01443615.2021.1958766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Men can be essential sources of support in maternal health, even more so in case of severe acute maternal morbidity (SAMM), affecting 1-2% of childbearing women in low-resource settings. In a qualitative study using semi-structured interviews, we explored the perspectives of nine male partners of women who suffered from (pre-)eclampsia six to seven years earlier in rural Tanzania. Male partners considered their role to be pivotal regarding finances, decision-making in healthcare-seeking and family planning and provided physical and emotional support. After SAMM, households may be affected in the long run. Some men took over their female partner's household duties until up to two years after birth. Providing men with more information on complication readiness and birth preparedness would enable them to extend their role in maternal morbidity prevention.IMPACT STATEMENTWhat is already known on this subject? The essential role of male partners in maternal health in low- and middle-income countries is well-studied in relation to its impact on care-seeking behaviour. After childbirth, the long-term role of male partners has not yet been studied.What do the results of this study add? We demonstrated the important role of men during, but also after SAMM. Households may be affected years after women suffered from SAMM. For women with the most urgent support needs, this study suggest that at least some men feel responsible for their partner and have different pivotal roles.What are the implications of these findings for clinical practice and/or further research? Because of their motivation to support their female partner, strategies to reduce recurring complications in subsequent pregnancies should include targeting male partners, for example, by increasing birth preparedness and complication readiness. Further studies should confirm the results from our innovative but small-scale study, as well as investigate the long-term role of male partners after uncomplicated births. Other studies could investigate the separation of couples after SAMM, family planning decisions after SAMM and strategies for involving men and increasing complication readiness and birth preparedness.
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Affiliation(s)
- Rob Mooij
- Ndala Hospital, Ndala, Tanzania.,University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands
| | - Ruth R Kapanga
- Athena Institute, Faculty of Science, VU University, Amsterdam, The Netherlands
| | | | | | - Jeroen van Dillen
- Department of Gynaecology and Obstetrics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Jelle Stekelenburg
- University Medical Centre Groningen/University of Groningen, Groningen, The Netherlands.,Department of Gynaecology and Obstetrics, Leeuwarden Medical Centre, Leeuwarden, The Netherlands
| | - Bregje C de Kok
- Anthropology Department, University of Amsterdam, Amsterdam, The Netherlands
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