The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy

Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries

Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.

Pregnancy outcomes of women presenting with stage 1 hypertension during the first prenatal clinic visit before 20 gestational weeks

OBJECTIVE

To determine the pregnancy outcomes of women who had 2017 American College of Cardiologists stage 1 hypertension during the first prenatal clinic visit before 20 gestational weeks in a tertiary hospital in South Africa.

STUDY DESIGN

A retrospective cohort study involving the review of medical records of 127 participants with stage 1 hypertension and 128 control with blood pressure (BP) less than stage 1 hypertension before 20 weeks' gestation.

MAIN OUTCOME MEASURES

The primary outcome measure was progression to stage 2 hypertension (BP ≥ 140/90 mmHg). Secondary outcome measures were a combination of maternal variables (postpartum BP ≥ 140/90 mmHg, use of antihypertensives within 24 h postpartum, pulmonary oedema, and maternal death within 24 h postpartum) and perinatal variables (fetal growth restriction, gestational age at delivery, fetal compromise, abruptio placenta, birth weight, Apgar score in 1 and 5 min).

RESULTS

The study and control arms were similar in age, parity, and comorbidities (p > 0.05). The following maternal outcomes were worse (p < 0.001) in the study compared to control arm: progression to stage 2 hypertension (46 % vs 1.6 %), postpartum systolic BP ≥ 140 mmHg (33.9 % vs 1.6 %), postpartum diastolic BP ≥ 90 mmHg (22.1 % vs 1.6 %) and use of antihypertensives within 24 h postpartum (27.6 % vs 0.8 %). Other outcome measures did not differ between the two groups (p > 0.05).

CONCLUSIONS

Stage 1 hypertension occurring before 20 weeks' gestation increases the risk of progression to stage 2 hypertension in pregnancy and the use of antihypertensive drug therapy within 24 h postpartum.

Determinants of Preeclampsia Among Pregnant Women in Public Hospitals of Wolaita and Dawuro Zones, Southern Ethiopia: A Case-Control Study

INTRODUCTION

Preeclampsia is a leading cause of maternal and fetal morbidity and mortality in Ethiopia. It is defined by the onset of new hypertension (HTN) and proteinuria in the second trimester of pregnancy. There is a research gap in the study area and there is an inconsistency of findings in previous studies. Therefore, this study aimed to determine the factors of preeclampsia among pregnant women in public hospitals.

METHODS AND MATERIALS

An institution-based unmatched case-control study was conducted in public hospitals in Wolaita and Dawuro Zones from February 1 to June 26, 2021. Women who were diagnosed with preeclampsia were cases, while those who did not have it were controls. They were selected using a consecutive sampling method. Descriptive statistics and logistic regression were done by STATA.

RESULTS

A total of 349 cases and 698 controls participated in this study. The average age of the cases and controls was 26.1 ± 4.6 standard deviation (SD) and 24.6 ± 4.8 SD years, respectively. The determinants of preeclampsia in this study were a family history of HTN (adjusted odds ratio [AOR = 11.5; 95% confidence interval, CI: 6.46-20.41], family history of diabetes mellitus [AOR = 2.1; 95% CI: 1.10-3.90], having two or multiple pregnancies [AOR = 6.33; 95% CI: 2.28-17.51], primigravida [AOR = 1.49; 95% CI: 1.01-2.21], and being gravida 5-9 [AOR = 2.47; 95% CI: 1.34-4.58]).

CONCLUSION

In this study, family history of HTN, family history of diabetes mellitus, history of preeclampsia, primigravida, and multiple gestation pregnancies were the determinants of preeclampsia. As a result, health care providers should pay special attention to pregnant women with a family history of HTN, primigravida, and two or multiple gestation pregnancies during antenatal care follow-up.

Surgical excision of benign spindle cell neoplasm of the cervix predating miscarriage due to cervical insufficiency: A case report

This case report is on cervical spindle cell neoplasm and complications of its excision. A 34-year-old multiparous woman presented with a one-year history of mild to moderate non-radiating lower abdominal pain and a sensation of a mass in the vagina when urinating. These symptoms were associated with a recurrent foul-smelling yellow vaginal discharge which was unresponsive to antibiotic therapy prescribed at a primary healthcare clinic. Vaginal examination at a gynaecological clinic revealed a firm circular cervical mass. Excision biopsy of the mass (attached between the 1 and 3 o'clock positions on the cervix) showed a benign spindle cell neoplasm. The patient became pregnant six months after the surgical excision and had a miscarriage at 18 weeks of gestation due to cervical insufficiency. The report highlights the importance of antenatal surveillance for women following surgical excision of a cervical lesion such as spindle cell neoplasm as they may be predisposed to cervical insufficiency.

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Cervical insufficiency results from a defect in the mechanical properties of the cervix.

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Cervical surgery predisposes to cervical insufficiency.

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Spindle cell tumour of the cervix is rare and its excision weakens the cervix.

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Surveillance of the cervix is required in pregnancy after cervical surgery.

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Cerclage is recommended after cervical surgery for women with a history of preterm delivery.

Pre-delivery angiogenic factors and their association with peripartum perceived stress and pain in pre-eclampsia with severe features and normotensive pregnancies

OBJECTIVE

To determine if any of maternal pre-delivery soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PIGF), or sFlt-1/PIGF ratio correlate with either perceived stress scale (PSS) or verbal numeric rating scale (VNRS) pain scores.

METHODS

Among 50 pregnant women with severe pre-eclampsia and 90 normotensive pregnant women observed from 48 h or less before delivery until day 3 postpartum, correlations between the following were performed: (1) serum concentrations of each angiogenic factor (sFlt-1, PIGF, and sFlt-1/PIGF ratio) sampled within 48 h before childbirth and a four-item PSS (pre-delivery and one-off 48-72 h postpartum score); (2) the same angiogenic factors above and VNRS ranging from 0 to 10; and (3) PSS and VNRS (both pre-delivery and postpartum).

RESULTS

In the normotensive group, there was a positive correlation between sFlt-1 and postpartum PSS (ρ +0.214 and P = 0.043), and between sFlt-1/PIGF ratio and postpartum PSS (ρ +0.213 and P = 0.044). In the normotensive and severe pre-eclampsia groups there were non-significant negative correlations between PIGF and postpartum PSS (P > 0.096) and non-significant positive correlations between pre-delivery PSS and pre-delivery VNRS (P > 0.053). Other correlations were uninformative.

CONCLUSION

Maternal pre-delivery sFlt-1/PIGF ratio in normotensive pregnancy is a promising biomarker for identifying risk of increased postpartum PSS to enable early counselling.

HIV Associated Preeclampsia: A Multifactorial Appraisal

Introduction: This review explores angiogenesis, vascular dysfunction, the complement system, RAAS, apoptosis and NETosis as potential pathways that are dysregulated during preeclampsia, HIV infection and ART usage. Results: HIV-1 accessory and matrix proteins are protagonists for the elevation of oxidative stress, apoptosis, angiogenesis, and elevation of adhesion markers. Despite the immunodeficiency during HIV-1 infection, HIV-1 exploits our cellular defence arsenal by escaping cell-mediated lysis, yet HIV-1 infectivity is enhanced via C5a release of TNF-α and IL-6. This review demonstrates that PE is an oxidatively stressed microenvironment associated with increased apoptosis and NETosis, but with a decline in angiogenesis. Immune reconstitution in the duality of HIV-1 and PE by protease inhibitors, HAART and nucleoside reverse transcriptase, affect similar cellular pathways that eventuate in loss of endothelial cell integrity and, hence, its dysfunction. Conclusions: HIV-1 infection, preeclampsia and ARTs differentially affect endothelial cell function. In the synergy of both conditions, endothelial dysfunction predominates. This knowledge will help us to understand the effect of HIV infection and ART on immune reconstitution in preeclampsia.

The role of Tenascin-C in HIV associated pre-eclampsia

INTRODUCTION

Pre-eclampsia (PE) accounts for 14.8% of maternal deaths in South Africa. Tenascin C (TN-C) is an anti-inflammatory cytokine expressed in the extracellular matrix and may be dysregulated in the hyperinflammatory PE microenvironment.

MATERIAL AND METHODS

This study examined serum TN-C in normotensive pregnant (n = 36) and pre-eclamptic (n = 36) HIV positive and negative women using an immunoassay.

RESULTS

TN-C was significantly upregulated in PE vs normotensive pregnant women (p = 0.0075) and HIV-positive vs negative pregnant women (p = 0.0009). TN-C levels across all groups was statistically different (p < 0.0001).

CONCLUSION

This study demonstrates an elevation of TN-C in HIV-associated PE. The potential benefit of TN-C as a biomarker to detect PE development requires investigation.

Transient gestational hypertension and pre-eclampsia: Two case reports and literature review on the need for stringent monitoring

Transient gestation hypertension is a contributor to adverse pregnancy outcomes particularly when it progresses to pre-eclampsia (PE). This requires frequent monitoring. We illustrate the need for stringent monitoring of gestational hypertension, transient gestational hypertension (TGH) and PE without severe features and conducted a brief rapid review of the literature. Two cases are presented: Firstly, a 25-year-old primigravida at 30 gestational weeks who had an isolated TGH with high blood pressure (BP) of 141/87 mmHg, which was not investigated. Four weeks later, she presented with a BP of 202/128 mmHg, imminent eclampsia and intrauterine foetal death and had an uncomplicated induction of labour and delivered a 1400 g macerated male stillborn. Secondly, a 30-year-old primigravida at 30 gestational weeks who developed PE but her monitoring was compromised initially by inadequate healthcare capacity including unavailability of hospital bed-space for inpatient care and later by poor clinic attendance as a result of poor finances. At 32 gestational weeks, she presented with decreased foetal movement and was diagnosed as haemolysis, elevated liver enzymes, low platelet count (HELLP) syndrome and intrauterine foetal death. She was stabilised, had induction of labour and delivered a 1400 g male macerated stillborn. Thereafter, the need for her to go home to complete the cultural burial rites of her baby and the pressure from her workplace resulted in an inadequate postpartum follow-up care. In conclusion, transient gestational hypertension is associated with adverse maternal and foetal outcomes, including foetal demise. Unavailability of hospital bed-space and poor personal finances interfere with stringent monitoring of hypertensive disorders and can be associated with adverse pregnancy outcomes. Stringent laboratory monitoring in these cases is defined by the authors as testing at least blood levels of serum Creatinine, Haemoglobin concentration, Alanine transaminase and Platelet count (abbreviated as ‘CHAP’) weekly.

Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period

Introduction

there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa.

Methods

fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours.

Results

nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3.

Conclusion

a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.

Morphometric image analysis of vascular endothelial growth factor receptor-3 in preeclamptic, HIV infected women

OBJECTIVE

To ascertain the expression of vascular endothelial growth factor receptor-3 (VEGFR-3) in placental conducting and exchange villi from normotensive, preeclamptic (PE) and antiretroviral treated pregnant women, using morphometric image analysis.

STUDY DESIGN

This study utilizes retrospectively collected, paraffin wax-embedded, placental samples (n = 90) that were immuno-stained for VEGFR-3. During selection of the retrospective study, women with chronic illnesses were filtered out, to exclusively allow for the examination of VEGFR-3 immuno-expression in HIV and preeclamptic women. The study population consisted of normotensive (n = 30) and preeclamptic (n = 60) groups which were further divided on the basis of HIV status (negative - and positive +), and early and late onset preeclampsia (EOPE and LOPE respectively). The resulting groups were as follows; N- (n = 15), N+ (n = 15), EOPE- (n = 15), EOPE+ (n = 15), LOPE- (n = 15) and LOPE+ (n = 15). Microscopic examination and morphometric image analysis were performed on the immuno-stained placental tissue samples.

RESULTS

Analysis on HIV status did not yield a significant difference in conducting (p =  0.3015) or exchange (p =  0.4535) villi, regardless of pregnancy type. The N vs. PE analysis showed a reduced immuno-expression of VEGFR-3 in both conducting (p =  0.0107) and exchange (p <  0.0001) villi. Results from a multiple group comparative analysis of N vs. EOPE vs. LOPE VEGFR-3 immuno-expression, showed a significant difference between the N vs. EOPE groups.

CONCLUSION

The results presented provide compelling evidence that HIV infection does not significantly alter angiogenesis in placental villi. PE however, has caused angiogenic dysregulation and trophoblast pathology was observed. We report a severe downregulation of VEGFR-3 in placental villi from EOPE woman, regardless of HIV status. Hence we suggest a future investigation into EOPE's aetiology and its downstream effects on pregnancy.

Angiogenesis, Lymphangiogenesis, and the Immune Response in South African Preeclamptic Women Receiving HAART

Purpose of the review: This review highlights the role of angiogenesis, lymphangiogenesis, and immune markers in human immunodeficiency virus (HIV)-associated preeclamptic (PE) pregnancies in an attempt to unravel the mysteries underlying the duality of both conditions in South Africa. Recent findings: Studies demonstrate that HIV-infected pregnant women develop PE at a lower frequency than uninfected women. In contrast, women receiving highly active anti-retroviral therapy (HAART) are more inclined to develop PE, stemming from an imbalance of angiogenesis, lymphangiogenesis, and immune response. Summary: In view of the paradoxical effect of HIV infection on PE development, this study examines angiogenesis, lymphangiogenesis, and immune markers in the highly HIV endemic area of KwaZulu-Natal. We believe that HAART re-constitutes the immune response in PE, thereby predisposing women to PE development. This susceptibility is due to an imbalance in the angiogenic/lymphangiogenic/immune response as compared to normotensive pregnant women. Further large-scale studies are urgently required to investigate the effect of the duration of HAART on PE development.