Ovarian reserve in women with a previous history of severe pre-eclampsia

PURPOSE

Severe pre-eclampsia affects maternal health with long-term consequences. It is postulated that during the process of implantation and cell differentiation, embryos resulting from the fertilization of ageing oocytes produce malfunctioning trophoectoderm leading to placental dysfunction. Therefore, severe pre-eclampsia may be associated with a decreased ovarian reserve. The objective of this study was to compare serum markers of ovarian reserve and function between women who had severe pre-eclampsia and those who had normal pregnancies.

METHODS

Twenty women who had severe pre-eclampsia (PE) and 20 who had uncomplicated pregnancies (controls) matched for age and body mass index were included in the study. Fasting blood samples were taken during the follicular phase (day 5) of the menstrual cycle 6 months to 5 years after the delivery. Serum was separated and frozen at -70 °C until analyzed for anti-Mϋllerian hormone (AMH), total and free testosterone (TT), free-androgen index (FAI), luteinizing hormone (LH), and follicle-stimulating hormone (FSH) hormone to evaluate ovarian reserve and function, and the results were compared between two groups.

RESULTS

The median AMH was 0.91 ng/mL in PE group compared to 0.72 ng/mL in controls (p = 0.995). No significant differences were found between the two groups in the levels of LH (5.65 vs. 5.4 IU/L, respectively, p = 0.897) and FSH (4.95 vs. 5.1 IU/L, respectively, p = 0.523). However, total and free-TT levels as well as FAI were significantly lower in the PE group compared to controls (p = 0.017, p = 0.006, and p = 0.011, respectively).

CONCLUSIONS

Ovarian reserve and function are not altered significantly in women with a previous history of pre-eclampsia compared with women who had an uncomplicated pregnancy.

PP079. Ovarian reserve and function is preserved following severe preeclampsia

INTRODUCTION

Preeclampsia is a multi-organ disorder that predominantly affects renal, cardiovascular, and endocrine systems with long-term consequences for the women's health. As advanced age and history of subfertility increase the risk of developing preeclampsia, reduced ovarian reserve may be associated with preeclampsia. However, long-term effect of preeclampsia on the ovarian function and reserve is not known. We hypothesized that the ovarian reserve and function are reduced in women with a previous history of severe preeclampsia.

OBJECTIVE

To compare the plasma levels of markers of ovarian function (FSH, LH, SHBG, testosterone) and reserve (anti-Müllerian hormone, AMH) in women who previously had preeclampsia with their matched controls.

METHOD

Twenty women who had severe preeclampsia (PE group) requiring delivery before 36 weeks of gestation and 20 controls were matched for age, parity, height and weight were included in the study. Women were not breast-feeding, they were having regular menstrual periods and were not using any hormonal contraception. Fasting blood samples were taken during the follicular phase. Plasma was separated and frozen at -70 degrees until analyzed. Comparison between groups was performed using paired sample t-test for parametric and Wilcoxon T-test for nonparametric data. A two-tailed p-value <0.05 was considered significant.

RESULTS

The mean age was 36.4 years, height 164cm and weight 72kg in PE group, compared to 37.0 years, 165cm and 69kg, respectively in control group. The mean AMH was 1.34ng/mL in PE group compared to 1.55ng/mL in controls (p=NS). No significant differences were found in the levels of LH (6.72 versus 6.53 IU/L), FSH (5.27 versus 7.16 IU/L), LH/FSH ratio (1.39 versus 1.11), SHBG (63.65 versus 52.90 versus 52.90nmol/L), and testosterone (0.72 versus 1.01nmol/L) between groups.

CONCLUSION

Ovarian reserve and function is not altered significantly in women with a previous history of preeclampsia.

A screening and intervention program aimed to reduce mortality and serious morbidity associated with severe neonatal alloimmune thrombocytopenia

The study's objective was to identify HPA 1a-negative women and to offer them an intervention program aimed to reduce morbidity and mortality of neonatal alloimmune thrombocytopenia (NAIT). HPA 1 typing was performed in 100 448 pregnant women. The HPA 1a-negative women were screened for anti-HPA 1a. In immunized women, delivery was performed by Cesarean section 2 to 4 weeks prior to term, with platelets from HPA 1a-negative donors reserved for immediate transfusion if petechiae were present and/or if platelet count was less than 35 x 10(9)/L. Of the women screened, 2.1% were HPA 1a negative, and anti-HPA 1a was detected in 10.6% of these. One hundred seventy pregnancies were managed according to the intervention program, resulting in 161 HPA 1a-positive children. Of these, 55 had severe thrombocytopenia (< 50 x 10(9)/L), including 2 with intracranial hemorrhage (ICH). One woman with a twin pregnancy missed the follow-up and had one stillborn and one severely thrombocytopenic live child. In 15 previous prospective studies (136 814 women) there were 51 cases of severe NAIT (3 intrauterine deaths and 7 with ICH). Acknowledging the limitation of comparing with historic controls, implementation of our screening and intervention program seemed to reduce the number of cases of severe NAIT-related complications from 10 of 51 to 3 of 57.

Neonatal alloimmune thrombocytopenia due to anti-HPA 1a antibodies; the level of maternal antibodies predicts the severity of thrombocytopenia in the newborn

Eleven thousand one hundred pregnant women were genotyped for human platelet antigen HPA 1, and 198 HPA 1bb women were followed in the pregnancy with quantitative assay for anti-HPA la antibodies. Antibodies were detected in 24 women, and nine children were born with severe thrombocytopenia (< 50x10(9)/L). All mothers with high levels of antibodies were delivered of children with severe thrombocytopenia. None of the newborn infants had clinical signs of intra-cranial haemorrhage. The level of maternal anti-HPA 1a antibodies is predictive for fetal thrombocytopenia and may be used in decisions related to time and mode of delivery.

Evidence of dysfunctional beta2-adrenoceptor signal system in pre-eclampsia

OBJECTIVES

To determine how beta2-adrenoceptor binding and function differ between healthy women and those with pre-eclampsia.

DESIGN

Case-control study.

SETTING

Faculty of Medicine, University of Tromsø, Norway.

PARTICIPANTS

Two groups of pregnant women: eight cases with pre-eclampsia, matched with eight healthy controls.

METHODS

Venous blood was drawn from women in both groups after an overnight rest. The two groups were matched for gestational age which was (mean (SD)) 36 x 4 (3 x 8) and 36 x 5 (4 x 4) weeks for the pre-eclamptic and control groups, respectively. Six weeks after delivery a second blood sample was obtained. The binding and function of beta2-adrenoceptors were determined in isolated human mononuclear leukocytes. The levels of adrenaline and noradrenaline were determined in plasma from venous blood.

RESULTS

An elevated density of functional beta2-adrenoceptors was observed in normal pregnancy [mean (SD) 390 (90) vs 270 (60) sites/cell postpartum], due to an increased fraction of receptors in high affinity state, with unaltered total receptor density. The number of functional beta2-adrenoceptors was reduced in pre-eclampsia [mean (SD) 80 (40) vs 240 (30) sites/cell postpartum], due to a reduction in the total receptor number with an unaltered fraction of high affinity receptors. In pregnancy, both unstimulated and isoprenaline-stimulated cAMP levels were reduced in the women with pre-eclampsia (0 x 5 (0 x 2) and 1 x 7 (0 x 9) pmol/10(6) cells, respectively) compared with the normal pregnant controls (mean (SD) 1 x 2 (0 x 3) and 4 x 7 (1 x 8) pmol/10(6) cells, respectively). Plasma catecholamine levels were not elevated in the women with pre-eclampsia.

CONCLUSIONS

The increased number of functional beta2-adrenoceptors may contribute to the vasodilatation seen in normal pregnancy, while the reduced overall number of receptors may be one of several factors that account for increased peripheral vascular resistance in pre-eclampsia.

Late onset postpartum thrombocytosis in preeclampsia

BACKGROUND

During pregnancy, changes in blood coagulation and fibrinolysis create a hypercoagulable state. In the puerperium this thrombogenicity is even higher, and the chance of developing thromboembolism is 3-5 times higher in this period than during pregnancy. In preeclampsia, platelets are activated and play a substantial role in the pathogenesis of the disease. Systematic information on longitudinal changes in platelet number and size postpartum after normotensive and preeclamptic pregnancies is not available.

METHODS

We measured platelet number, mean platelet volume and the median volume of the 20% largest platelets in eleven preeclamptic and eleven normotensive pregnant women matched for mode of delivery. The blood samples were taken antepartum and every 2-3 days in the postpartum period until the platelet count decreased/normalized.

RESULTS

In the preeclamptic group, the platelet count increased significantly from 240x10(9)/l antepartum to 621x10(9)/l on day 6-14 postpartum (p<0.01). In the control group, the platelet count increased from 214x10(9)/l antepartum to 251x10(9)/l on day 2-5 (p<0.01) and 351x10(9)/l on day 6-14 postpartum (p<0.01). The platelet count was significantly higher in the preeclamptic than in the control group 6-14 days postpartum (p<0.01). Antepartum, mean platelet volume and the median of the 20% largest platelets were significantly higher in the preeclamptic than in the control group.

CONCLUSION

The platelet count is significantly increased postpartum both after normotensive, and 2-3 fold more after preeclamptic pregnancies. The time to peak values is between 6-14 days, usually at a time when patients are discharged from hospital.

Hormone replacement therapy reduces the reactivity of monocytes and platelets in whole blood--a beneficial effect on atherogenesis and thrombus formation?

OBJECTIVE

Our purpose was to investigate the effects of hormone replacement therapy on the reactivity of monocytes and platelets in whole blood, measured by tissue factor activity, tumor necrosis factor-alpha, and thromboxane B2.

STUDY DESIGN

Thirty-two women were randomized into either transdermal or oral combined hormone replacement therapy and underwent blood sampling before and after 3 and 12 months of treatment. The tissue factor activity in monocytes was measured both in unstimulated whole blood and after a weak lipopolysaccharide stimulation. Tumor necrosis factor-alpha and thromboxane B2 formation in plasma were measured after a weak lipopolysaccharide stimulation of whole blood.

RESULTS

After 12 months of hormone replacement therapy there were significant reductions of tissue factor activity in both unstimulated and lipopolysaccharide-stimulated monocytes (p < 0.001) and significant reductions in the formation of tumor necrosis factor-alpha (p < 0.03) and thromboxane B2 (p < 0.02). There were no differences in these parameters between the transdermal and the oral groups. No changes were observed after 3 months of therapy.

CONCLUSION

Twelve months of hormone replacement therapy reduces cellular activation of blood monocytes and platelets; these changes may account for some of the beneficial effects in reducing the risk of cardiovascular disease.

Enhanced sensitivity of the extrinsic coagulation system during ovarian stimulation for in-vitro fertilization

The tissue factor activity in blood monocytes was investigated during ovarian stimulation for in-vitro fertilization (IVF) in 13 women. Blood samples were taken prior to hormonal stimulation (days 2-3 of the menstrual cycle, median serum oestradiol concentration 70 pmol/l) and the day after ovulation induction with human chorionic gonadotrophin (days 11-13, median serum oestradiol concentration 6270 pmol/l). The tissue factor activity in unstimulated monocytes and factor VII concentration were unchanged during the treatment. However, the tissue factor activity in lipopolysaccharide-stimulated monocytes was on average more than twice as high after stimulation (P < 0.02). A positive correlation was found between the tissue factor activity and the serum concentration of oestradiol (r = 0.514, P < 0.02). The tumour necrosis factor (TNF)-alpha increased during ovarian stimulation (P = 0.05), and there was a positive correlation between the change in TNF-alpha and the change in tissue factor activity (r = 0.663, P < 0.05). Our results indicate an enhanced sensitivity of the extrinsic coagulation system during IVF treatment since more tissue factor is available upon stimulation. It is suggested that this may be important in thrombotic situations. Further studies are necessary to elucidate the mechanism behind this response.

[Postmenopausal hormone replacement and cardiovascular disease]

We review the evidence that hormone replacement therapy protects against the development of cardiovascular disease in women. Most studies show that this treatment reduces risk of cardiovascular disease by about 50%. The results are reasonably consistent, and biologically plausible. The protective effects are mediated through effects on lipid metabolism, but also through direct effects on vessel wall physiology and blood flow. The beneficial effect of hormone replacement therapy seems to be most marked in high-risk patients and in women with severe coronary artery disease.

[HELLP syndrome--a life-threatening pregnancy complication]

A serious complication to pregnancy-induced hypertension and preeclampsia is the HELLP syndrome (H - haemolysis, EL - elevated liver enzymes, LP - low platelet count). Perinatal and maternal mortality are reported to be high, 7-60% and 2-24%, respectively. A non-obstetric diagnosis is often made, such as gastrointestinal or haematologic disease. Typical symptoms are epigastric and right upper-quadrant pain and tenderness, nausea and vomiting. Recognition of the clinical and laboratory findings is important, so that early, aggressive therapy can be initiated in order to prevent maternal and perinatal death. We present data from 14 patients with the HELLP syndrome treated in our hospital. There was one intrauterine death. The other infants were discharged in good condition. Two of the patients had eclampsia.

[Preventive low dosage treatment and pre-eclampsia]

Pregnancy-induced hypertension and pre-eclampsia occur in 10% of pregnancies and are recognised as important and prevalent sources of risk to both mother and foetus. Although the exact cause of the disease is unknown, several mechanisms have been suggested, including enhanced sensitivity to vasopressors and imbalance in the production of prostaglandins. This may lead to vasoconstriction of small arteries, activation of platelets and uteroplacental insufficiency. Since thromboxane A2 and prostacyclin are derived from arachidonic acid through the action of cyclooxygenase, low dose aspirin selectively inhibits the synthesis of platelet thromboxane A2 without affecting production of endothelium-derived prostacyclin. Data available from clinical trials suggest that, when given to high risk patients, low dose aspirin reduces risk of preeclampsia and intrauterine growth retardation by 50%, with no observed risk of adverse effects to either mother or foetus.

Increased plasma levels of vasoactive intestinal polypeptide in pre-eclampsia

OBJECTIVE

To investigate the plasma vasoactive peptide (VIP) levels in pregnancies complicated by pre-eclampsia.

DESIGN

A prospective clinical study.

SETTING

University Department of Obstetrics, Tromsø, Norway.

SUBJECTS

18 women with untreated gestational proteinuric hypertension between 32 and 40 weeks gestation (13 primigravid) and 8 women with normal pregnancies of similar gestational age.

INTERVENTIONS

Fasting blood samples on two occasions, 10 min apart.

MAIN OUTCOME MEASURES

Plasma VIP measured by radioimmunoassay.

RESULTS

Mean maternal plasma VIP was 13.9 (SEM 1.7) pmol/l in those with pre-eclampsia and 4.4 (SEM 0.5) pmol/l in normal pregnancies (P less than 0.0001).

CONCLUSION

The increased levels of VIP in pre-eclampsia may represent a powerful compensatory mechanism to restore vascular perfusion of various organs, including the uterus and placenta.

Does ovarian stimulation for in-vitro fertilization induce a hypercoagulable state?

Effects on blood coagulation and fibrinolytic activity during ovarian stimulation for in-vitro fertilization (IVF) were examined in 12 women. Blood samples were taken prior to hormonal stimulation (days 2-3 of the menstrual cycle, mean serum oestradiol concentration 0.16 nmol/l) and the day after ovulation induction with human chorionic gonadotrophin (HCG) (days 10-12, mean serum oestradiol concentration 5.35 nmol/l). We measured whole blood clotting time, whole blood clot lysis time, plasma fibrinogen, factor VII and antithrombin III. The whole blood clotting time was slightly, but not significantly shortened after ovarian stimulation. A significant rise in plasma fibrinogen (P less than 0.001) and reduction in antithrombin III (P less than 0.001) were observed, whereas no change in factor VII was found. The blood fibrinolytic activity was significantly reduced as evaluated by an increase in the clot lysis time (P less than 0.02). These results indicate that ovarian stimulation for IVF may create a state of hypercoagulability.

Effect of pregnancy and hormonal changes on the activity of rheumatoid arthritis

The effect of pregnancy on the activity of rheumatoid arthritis (RA) was evaluated in 31 patients who had given birth to 49 infants after the onset of their disease. Pregnancy-associated remission of RA was experienced by 75% of the patients. On the other hand, disease exacerbation after delivery occurred in 62% of them. RA had no harmful effect on pregnancy or on the fetus. Hormonal changes during the menstrual cycle or during the use of hormonal contraceptives did not seem to influence the symptoms of RA. Factors possibly involved in remission of RA during pregnancy are discussed.