Angiogenic imbalance in pre-eclampsia and fetal growth restriction: enhanced soluble fms-like tyrosine kinase-1 binding or diminished production of placental growth factor?

OBJECTIVES

To assess levels of total placental growth factor (PlGF), soluble fms-like tyrosine kinase-1 (sFlt-1) and free PlGF in women with pre-eclampsia (PE) with or without a small-for-gestational-age (SGA) neonate in order to establish whether low free PlGF levels associated with PE and SGA are due to enhanced sFlt-1 binding or decreased PlGF production.

METHODS

This was a secondary analysis of a prospective multicenter cohort study involving 407 pregnancies with suspected or confirmed PE, in which total PlGF levels were calculated from measured sFlt-1 and free PlGF levels. The control group included women who were suspected to have PE at a certain point in pregnancy but did not develop PE. The analysis was stratified according to whether PE was early- or late-onset (gestational age < 34 weeks vs ≥ 34 weeks) and according to the presence of SGA at birth, which was used as a proxy of fetal growth restriction in the absence of Doppler ultrasound and biometric data.

RESULTS

In early-onset PE, both women with and those without SGA had lower free (19 and 45 pg/mL) and total (44 and 100 pg/mL) PlGF levels compared with women without PE (free and total PlGF, 300 and 381 pg/mL, respectively). SGA alone did not affect free and total PlGF in this condition (free and total PlGF, 264 and 352 pg/mL, respectively). Observations in women with late-onset PE were similar, although the changes were more modest. Both SGA (gestational age < 34 weeks) and PE were individually associated with increased sFlt-1 and, in women with both PE and SGA, the upregulation of sFlt-1 occurred in a synergistic manner, thus resulting in the highest sFlt-1/free PlGF ratio in this group. This occurred in both early- and late-onset PE.

CONCLUSIONS

Particularly in pregnancies with early-onset PE and SGA, diminished PlGF production is an important cause of low free PlGF levels. Under such conditions, sFlt-1 lowering is unlikely to restore the angiogenic balance. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

The impact of COVID 19 pandemic on urology literature: a bibliometric analysis

Introduction

The COVID-19 pandemic has caused wide-reaching change to many aspects of life on a worldwide scale. The impact of these changes on peer-reviewed research journals, including those dedicated to urology, is still unknown.

Material and methods

The Web of Science database was queried to retrieve all COVID-19 urological articles written in English language and published between January 1^st, 2020 and December 10^th, 2021. Only original and review articles were considered. A bibliometric analysis of the total number of papers, citations, institutions and publishing journals was performed. Non-COVID-19 publications were also retrieved to compare the duration of publication stages.

Results

A total of 428 COVID-19 articles and 14,874 non-COVID-19 articles were collected. Significant differences in the duration of all the publication stages were found between COVID-19 and non-COVID-19 articles (all p <0.001). The most productive countries were the USA (100 articles), Italy (59 articles) and the United Kingdom (55 articles). The published literature has focused on four topics: COVID-19 genitourinary manifestations, management of urological diseases during the pandemic, repercussions on quality of life and impact on healthcare providers.

Conclusions

A significant reduction in peer review time for COVID-19 articles might raise concerns regarding the quality of peer review itself. USA, Italy and UK published the highest number of COVID-19 related articles. Restrictive measures taken by governments to reduce the spread of infection had a strong impact on mental stress and anxiety of patients and healthcare professionals. A coerced deferral of diagnosis and treatment of emergencies and uro-oncological cases represented the most challenging task from a clinical standpoint.

Prediction of pre-eclampsia-related complications in women with suspected or confirmed pre-eclampsia: development and internal validation of clinical prediction model

OBJECTIVE

A model that can predict reliably the risk of pre-eclampsia (PE)-related pregnancy complications does not exist. The aim of this study was to develop and validate internally a clinical prediction model to predict the risk of a composite outcome of PE-related maternal and fetal complications within 7, 14 and 30 days of testing in women with suspected or confirmed PE.

METHODS

The data for this study were derived from a prospective, multicenter, observational cohort study on women with a singleton pregnancy and suspected or confirmed PE at 20 to < 37 weeks' gestation. For the development of the prediction model, the possible contribution of clinical and standard laboratory variables, as well as the biomarkers soluble fms-like tyrosine kinase-1 (sFlt-1), placental growth factor (PlGF) and their ratio, in the prediction of a composite outcome of PE-related complications, consisting of maternal and fetal adverse events within 7, 14 and 30 days, was explored using multivariable competing-risks regression analysis. The discriminative ability of the model was assessed using the concordance (c-) statistic. A bootstrap validation procedure with 500 replications was used to correct the estimate of the prediction model performance for optimism and to compute a shrinkage factor for the regression coefficients to correct for overfitting.

RESULTS

Among 384 women with suspected or confirmed PE, 96 (25%) had an adverse PE-related outcome at any time after hospital admission. Important predictors of adverse PE-related outcome included sFlt-1/PlGF ratio, gestational age at the time of biomarker measurement and protein-to-creatinine ratio as continuous variables. The c-statistics (corrected for optimism) for developing a PE-related complication within 7, 14 and 30 days were 0.89, 0.88 and 0.87, respectively. There was limited overfitting, as indicated by a shrinkage factor of 0.91.

CONCLUSIONS

We propose a simple clinical prediction model with good discriminative performance to predict PE-related complications. Determination of its usefulness in clinical practice awaits further investigation and external validation. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

POS0542 DISEASE ACTIVITY IN PREGNANT WOMEN WITH RHEUMATOID ARTHRITIS: IMPACT ON THE SOLUBLE FMS-LIKE TYROSINE KINASE-1 TO PLACENTAL GROWTH FACTOR RATIO

Background:

An elevated sFlt-1 indicates soluble Fms-like tyrosine kinase-1 (sFlt-1)/ placental growth factor (PlGF) ratio has recently been validated as significant predictor of preeclampsia (PE)(1). However, raised sFlt-1 levels due to inflammation are observed in patients with rheumatoid arthritis (RA)(2). The use of the sFlt-1/PlGF ratio for the prediction of PE has not been evaluated in pregnant women with diseases that are characterized by high levels of inflammation, such as RA

Objectives:

We investigated whether sFlt-1 and/or PlGF are altered in pregnant women with RA according to disease activity, and evaluated whether a sFlt-1/PlGF ratio of ≤38 could be used to predict the absence of PE in pregnant RA-patients.

Methods:

This study was embedded in a nationwide, observational, prospective cohort study on pregnant women with RA (PARA-study). sFlt-1 and PlGF levels were measured, using automated analyzer (Cobas-6000, e-module; Roche-Diagnostics), in the third trimester of pregnancy.

Results:

A total of 221 women, aged 21–42 years, were included. Values of sFlt-1, PlGF and sFlt-1/PlGF ratio were not significantly correlated with the DAS28-CRP (Figure 1). CRP correlated weakly with PlGF (r=-0.14, p=0.03), while no correlation was found with sFlt-1 or the sFlt-1/PlGF ratio.

Preeclampsia occurred in four out of 214 women with a ratio ≤38 (2%) in contrast to three out of seven women with a ratio >38 (43%), p<0.001 (Table 1). When stratified to a sFlt-1/PlGF ratio of ≤38 only 2% of women developed preeclampsia, compared to 43% of the women with a ratio >38. The observed sensitivity and specificity for a sFlt-1/PlGF ratio cut-off of ≤38 were 42.1% and 98.1%, respectively, with a negative predictive value (NPV) of 98%. All women that developed PE, developed PE >4 weeks after collecting of blood samples in the 3rd trimester, therefore the observed NPV could be even higher.

Table 1.

Pregnancy Outcome according to sFlt-1/PlGF ratio with a cut-off value of 38.

ParameterRatio ≤38Ratio >38P-valueN2147GA at birth, weeks39 (38 - 40)37 (36 - 40)0.05<342 (1)0(0)1.0034 - 3718 (8)2 (29)0.12Male, n (%)113 (53)5 (71)0.45Birth weight, grams3420 (2998 - 3800)2620 (2360 - 2850)<0.01Maternal OutcomeGestational Hypertension15 (7)2 (29)0.09Preeclampsia4 (2)3 (43)<0.001Time to delivery, days66 (52 - 75)52 (44 - 66)0.08Fetal OutcomeBirth weight percentile <1033 (15)5 (71)<0.01Fetal/Neonatal Death1 (1)0 (0)1.00

Data are reported as median (interquartile range) or number (percentage). sFlt-1 indicates soluble Fms-like tyrosine kinase-1; PlGF, placental growth factor; GA, gestational age. Time to delivery is defined as the amount of days between blood sampling and delivery.

Conclusion:

Our study shows that in pregnant women with RA, the sFlt-1/PlGF ratio is not altered due to disease activity, and a cut-off of ≤38 of this ratio can be used to exclude preeclampsia.

References:

[1]H. Zeisler et al. Predictive Value of the sFlt-1:PlGF Ratio in Women with Suspected Preeclampsia. N Engl J Med 2016; 374: 13-22. DOI 10.1056/NEJMoa1414838.

[2]S. Ballara et al. Paleolog. Raised serum vascular endothelial growth factor levels are associated with destructive change in inflammatory arthritis. Arthritis Rheum 2001; 44: 2055-2064. DOI 10.1002/1529-0131(200109)44:9<2055::AID-ART355>3.0.CO;2-2.

Figure 1.

Correlations between sFlt-1, PlGF and sFlt-1/PlGF ratio with DAS28-CRP and CRP. Correlation coefficients for sFlt-1 (A-B), PlGF (C-D) and sFlt-1/PlGF ratio (E-F) with DAS28-CRP and CRP.

Acknowledgements:

The kits for measurement of sFlt-1/PlGF ratio were a kind gift from Roche Diagnostics, Germany. We thank all participants of the PARA study. Additionally, we extend our gratitude to the laboratory workers, in particular Nadine Davelaar and Priyanka Bangoer, and research assistants for their contribution to the data collection. We thank ReumaNederland (LLP project number: LLP-26) for their financial support.

Disclosure of Interests:

Hieronymus TW Smeele: None declared, R.I. Neuman: None declared, A.H.J. Danser: None declared, Radboud Dolhain Speakers bureau: Yes UCB, Roche, Abbvie, Genzyme, Novartis, Consultant of: Yes, Galapagos, Grant/research support from: Yes, UCB, W. Visser: None declared

Copeptin and mid-regional pro-atrial natriuretic peptide in women with suspected or confirmed pre-eclampsia: comparison with sFlt-1/PlGF ratio

OBJECTIVES

Arginine vasopressin (AVP) and atrial natriuretic peptide (ANP) may contribute to the pathogenesis of pre-eclampsia (PE), but their role remains to be elucidated. Our aims were to evaluate the surrogates of AVP and ANP, C-terminal pro-AVP (copeptin) and mid-regional pro-ANP (MR-proANP), as biomarkers for the prediction of PE-related pregnancy complications and whether they are associated with angiogenic markers and/or clinical manifestations of PE.

METHODS

This was a retrospective analysis of a prospective cohort study that enrolled pregnant women with suspected or confirmed PE, between December 2013 and April 2016. From each patient, a blood sample was obtained at study entry and serum levels of copeptin, MR-proANP, soluble fms-like tyrosine kinase-1 (sFlt-1) and placental growth factor (PlGF) were measured. We evaluated the ability of sFlt-1, PlGF, sFlt-1/PlGF ratio, copeptin and MR-proANP, assessed either alone or combined with traditional predictors (gestational age, parity, diastolic blood pressure and proteinuria), to predict maternal complications and fetal/neonatal complications. Models were compared using concordance statistic (C-index).

RESULTS

A total of 526 women were evaluated in the study. Women with confirmed PE displayed elevated serum copeptin and MR-proANP levels in comparison to those with suspected PE but no hypertensive disease of pregnancy. When combined with traditional predictors, the sFlt-1/PlGF ratio displayed a higher C-index than copeptin and MR-proANP (0.76, 0.63 and 0.67, respectively, vs 0.60 for the traditional predictors alone) for the prediction of maternal complications. Similarly, for the prediction of fetal/neonatal complications, the sFlt-1/PlGF ratio displayed a higher C-index than copeptin and MR-proANP when added to the traditional model (0.83, 0.79 and 0.80, respectively, vs 0.79 for the traditional predictors alone). When subdividing women according to sFlt-1/PlGF ratio (≥ 85 vs < 85), no differences in copeptin levels were observed, while MR-proANP level was elevated in women with sFlt-1/PlGF ratio ≥ 85. Multiple regression analysis revealed that copeptin and MR-proANP were independent determinants of proteinuria.

CONCLUSIONS

Copeptin and MR-proANP have limited value in predicting PE-related complications when compared with the sFlt-1/PlGF ratio. However, both copeptin and MR-proANP were associated with proteinuria, with copeptin exerting this effect independently of the sFlt-1/PlGF ratio. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Determinants of serum 25-hydroxyvitamin D levels in healthy young adults living in the Western Cape, South Africa

Background: Vitamin D deficiency is fast emerging as a global pandemic. In South Africa few studies have been conducted to determine the vitamin D status of the healthy population.Methods: This prospective study with an analytical component investigated vitamin D status of healthy undergraduate students at two time points (winter and summer) at Stellenbosch University. Serum 25(OH)D was determined, anthropometric measurements taken and dietary vitamin D intake estimated (food-frequency questionnaire). Skin tone was determined (Fitzpatrick skin type classification), and a skin reflectometry device used to measure dermal melanin content.Results: Results of 242 students indicated a mean serum 25(OH)D of 63.80 ± 41.35 ng/ml and a high prevalence of vitamin D sufficiency (88%). Significantly more females experienced suboptimal vitamin D levels than males (18 vs. 5%; p 0.01). Participants with lighter skin tones had higher levels of 25(OH)D than those with darker skin tones (chi-square = 24.02; p = 0.02). The majority (60.74%) had a normal BMI, although there was no significant relationship between BMI and serum 25 (OH)D (Spearman’s r=–0.11; p = 0.09). Total mean dietary vitamin D intake was 7.99 ± 13.81 mcg, with 87.2% having inadequate intake ( 15 mcg). The relationship between total vitamin D intake and serum 25(OH)D was found to be significant in winter (p 0.001) and summer (p = 0.01). Serum vitamin D levels were significantly higher in the winter phase (p 0.001).Conclusions: A low prevalence of vitamin D deficiency was found amongst healthy young adults, despite low dietary vitamin D intakes. Significant relationships were found between serum 25(OH)D and gender, skin tone and vitamin D intake. Further studies need to be conducted, especially in high-risk groups, before results are applied to the greater South African public.

Soluble fms-like tyrosine kinase-1 and placental growth factor kinetics during and after pregnancy in women with suspected or confirmed pre-eclampsia

OBJECTIVES

To assess the evolution of the soluble fms-like tyrosine kinase-1 (sFlt-1) to placental growth factor (PlGF) ratio in women with suspected or confirmed pre-eclampsia (PE), and to investigate the changes in sFlt-1 and PlGF levels in pre-eclamptic women after delivery.

METHODS

This was an exploratory study in which secondary analysis was performed on a prospective cohort study that enrolled women with a singleton pregnancy and suspected or confirmed PE from 18 weeks' gestation, carried out between December 2013 and April 2016 at the Department of Obstetrics of the Erasmus Medical Center in Rotterdam. sFlt-1 and PlGF were determined using Roche Diagnostics Elecsys assays in two groups of patients. In the first group, patients with suspected or confirmed PE had sFlt-1 and PlGF levels measured at least twice during their pregnancy. Changes in these biomarkers over the course of pregnancy were compared for patients in this group with a baseline sFlt-1/PlGF ratio of ≤ 38 and for those with a ratio > 38. In the second group, sFlt-1 and PlGF levels of women with PE or HELLP syndrome were measured before and after delivery. For this group, pre- and postpartum sFlt-1 and PlGF levels were compared and half-lives were calculated.

RESULTS

Women with suspected or confirmed PE for whom sFlt-1 and PlGF levels were measured at least twice during pregnancy (n = 46) had a median gestational age at inclusion of 26 weeks (range, 18-40 weeks). In 27 of the 30 patients with sFlt-1/PlGF ratio ≤ 38 at baseline, thereby ruling out PE, the sFlt-1/PlGF ratio remained stable for up to 100 days. In the remaining three patients with a ratio ≤ 38 and in most of the 16 patients with a ratio > 38, the ratio increased further. For women diagnosed with PE or HELLP syndrome for whom sFlt-1 and PlGF levels were measured before and after delivery (n = 26), median gestational age at inclusion was 29 weeks (range, 16-37 weeks) and median time between antepartum measurement and delivery was 2 days (range, 1-17 days). In this group, after delivery, sFlt-1 dropped to < 1% of its pre-delivery value, with a half-life of 1.4 ± 0.3 days, while PlGF dropped to ∼30% of its pre-delivery value, with a half-life of 3.7 ± 4.3 days.

CONCLUSIONS

Based on this small cohort, up to 10% of pregnant women admitted with suspected or confirmed PE presenting with a sFlt-1/PlGF ratio of ≤ 38 display a rise in sFlt-1/PlGF ratio in subsequent weeks, implying that repeat determination of the sFlt-1/PlGF ratio is required to exclude definitively a diagnosis of PE. Furthermore, the rapid and pronounced decline in sFlt-1 levels after delivery in patients with PE/HELLP syndrome suggests that sFlt-1, in contrast to PlGF, is almost entirely derived from the placenta. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Relative to open surgery, minimally-invasive renal and ureteral pediatric surgery offers no improvement in 30-day complications, yet requires longer operative time: Data from the National Surgical Quality Improvement Program Pediatrics

Purpose

Performance of minimally-invasive surgery (MIS) is increasing relative to open surgery. We sought to compare the contemporary rates of short-term complications of open versus laparoscopic renal and ureteral surgery in pediatric patients.

Materials and Methods

A retrospective cross-sectional analysis of the National Surgical Quality Improvement Program Pediatrics database was performed of all cases in 2014 identified using CPT procedure codes for nephrectomy, partial nephrectomy (PN), ureteroneocystostomy (UNC), and pyeloplasty, and reviewed for postoperative complications. Univariate analysis was performed to determine 30-day complications, with comparison between open and MIS approaches. Receiver operator curve (ROC) analysis was performed to determine differences in body surface area (BSA) and age for open versus MIS.

Results

Review identified 207 nephrectomies, 72 PN, 920 UNC, and 625 pyeloplasties. MIS was associated with older age and larger BSA except for cases of UNC. Apart from PN, operative durations were longer with MIS. However, only PN was associated with significantly longer length of hospital stay (LOS). There was no difference in incidence of all other 30-day complications. When evaluating BSA via ROC, the area under the curve (AUC) was found to be 0.730 and was significant. Children with a BSA greater than 0.408 m² were more likely to have MIS (sensitivity, 66.9%; specificity, 69.3%). Regarding age, the AUC was 0.732. Children older than 637.5 days were more likely to have MIS (sensitivity, 72.8%; specificity, 63.3%).

Conclusions

Pediatric MIS is associated with longer operative time for nephrectomy, but shorter LOS following PN. Surgical approach was not associated with difference in short-term complications.

ENDOCRINOLOGY IN PREGNANCY: Pheochromocytoma in pregnancy: case series and review of literature

Pheochromocytoma in pregnancy is extremely rare. Early recognition is crucial as antepartum diagnosis can largely decrease maternal and fetal mortality rates. As symptoms of pheochromocytoma are rather similar to those of other far more common causes of hypertension during pregnancy, timely diagnosis is a challenge. In pregnant patients, similar to non-pregnant patients, increased plasma and/or 24-h urine (nor)metanephrine concentrations most reliably confirm the diagnosis of pheochromocytoma. MRI and ultrasound are the only imaging modalities that can be used safely during pregnancy to localize the tumor. During pregnancy, pretreatment consists of alpha blockade as usual. However, dosing of α-adrenergic receptor blockers during pregnancy is a challenge as hypertension must be treated while preserving adequate uteroplacental circulation. When the diagnosis is made within the first 24 weeks of pregnancy, it is generally recommended to remove the tumor in the second trimester, while resection is generally postponed till after delivery when the diagnosis is made in the third trimester and medical pretreatment is sufficient. Both during and after pregnancy, laparoscopic surgery is the preferred approach for resection of the tumor. There is no consensus in literature about the preferred route and timing of delivery. Therefore, in our opinion, decisions should be made on an individual basis by an experienced and dedicated multidisciplinary team. Over the last decades, maternal and fetal prognosis has improved considerably. Further increasing awareness of this rare diagnosis and treatment of these patients by a dedicated team in a tertiary referral hospital are critical factors for optimal maternal and fetal outcome.

Acidosis: A potential explanation for adverse fetal outcome in intrahepatic cholestasis of pregnancy. A case report

BACKGROUND

Intrahepatic cholestasis of pregnancy is a cholestatic disorder with an increased risk for adverse perinatal outcome. The mechanism underlying intrauterine demise is poorly understood.

CASE

A nulliparous woman with gestational age of 36 plus 6 weeks presented with suspected intrahepatic cholestasis. Continuous CTG monitoring evolved from a normal pattern towards a non-reassuring pattern. A male neonate was delivered by caesarean section. Apgar scores 0, 1 and 4 at 1, 5 and 10 min. Fetal cord gas analysis showed pH 6.98, base deficit -15 mmol/L. Blood results showed maternal serum bile acid concentration of 220 µmol/L.

CONCLUSION

Our case suggests gradual evolution towards hypoxia and acidosis. It is unknown whether certain components in the bile acid concentrations might contribute to a fetal metabolic component of the acidosis.

Variation of urinary protein to creatinine ratio during the day in women with suspected pre-eclampsia

OBJECTIVE

To investigate the stability throughout the day of the protein to creatinine ratio (PCR) in spot urine, to demonstrate whether the PCR is a valid alternative for 24-hour protein investigation in pregnant women.

DESIGN

Prospective study.

SETTING

Tertiary referral university centre.

POPULATION

Women suspected of having pre-eclampsia, admitted to the Erasmus Medical Centre.

METHODS

Twenty-four-hour urine collections and simultaneously three single voided 5-ml aliquots were obtained at 8 a.m., 12 a.m. (noon) and 5 p.m. A PCR was measured in each specimen and compared with the 24-hour protein excretion.

MAIN OUTCOME MEASURES

The 24-hour proteinuria and PCR measured in spontaneous voids.

RESULTS

The PCRs correlated strongly with each other and with the 24-hour protein excretion but did show variation throughout the day (mean coefficient of variation 36%; 95% confidence interval 31-40%). The coefficient of variation was unrelated to the degree of 24-hour proteinuria. Receiver operating characteristics curves to discriminate between values below and greater than or equal to the threshold of 0.3 g protein per 24-hour had an area under the curve of respectively 0.94 (8 a.m.), 0.96 (noon) and 0.97 (5 p.m.). Sensitivities at 8 a.m., noon and 5 p.m. were respectively 89%, 96% and 94%; specificities were 75%, 78% and 78% with the proposed PCR cut-off of 30 mg/mmol (0.26 g/g) (National Institute for Health and Care Excellence guidelines).There is no evidence of a difference between the three measurement times regarding the sensitivities and specificities.

CONCLUSION

The PCR determined in spot urine varies throughout the day but is a valid alternative for 24-hour urine collections in pregnant women. It is especially useful to rapidly identify clinically relevant proteinuria.

Nicardipine in pre-eclamptic patients: placental transfer and disposition in breast milk

To assess the safety risks to the fetus and neonate caused by maternal use of nicardipine in pre-eclamptic patients, we evaluated the placental transfer and the transfer to breast milk after maternal intravenous administration of nicardipine. In ten pre-eclamptic subjects, nicardipine concentrations of maternal blood (P) and both arterial and venous umbilical cord blood samples (Uarterial and Uvenous) were assessed, and the U/P ratio was calculated as an indication of placental transfer. We found a median transfer of 0.15 (Uarterial/P, range 0.05-0.22) and 0.17 (Uvenous/P, range 0.023-0.22). The highest umbilical cord concentration found after maternal dosage of 4.5 mg/hour was 18 ng/ml, which can be considered as subtherapeutic. Therefore, adverse fetal reactions caused by a direct pharmacological effect of nicardipine are unlikely to occur. Nicardipine levels were determined in 34 breast milk samples of seven women, and were found to be undetectable in 82% of the samples. In six breast milk samples of four different women, nicardipine levels (ranging from 5.1 to 18.5 ng/ml) were detectable during maternal nicardipine dosages ranging from 1 to 6.5 mg/hour. The maximum possible exposure of a neonate to nicardipine was calculated to be less than 300 ng/day, which is an insignificant fraction of therapeutic dosages used in neonates. In conclusion, the exposure of a fetus and neonate to nicardipine through placental transfer and disposition in breast milk expression is low.

The effect of maternal ketanserin treatment on foetal 5-HT receptor function in umbilical cord artery of pre-eclamptic patients

BACKGROUND

Maternal treatment with the 5-HT(2A) receptor antagonist ketanserin (KT) in pre-eclamptic patients is associated with a high placental transmission of KT, resulting in pharmacologically active levels of KT in the umbilical cord artery (UCA) and the neonate. Prolonged exposure to a 5-HT receptor antagonist may influence the functionality of foetal 5-HT receptors and compromise foetal development.

OBJECTIVE

To study whether exposure to KT influences the characteristics of foetal 5-HT receptors, functional studies were performed on 5-HT(2A) and 5-HT(1B/1D) receptors in UCA from pre-eclamptic patients treated with KT.

METHODS

UCAs were obtained, immediately after delivery, from pre-eclamptic patients (n = 7), treated antenatally with intravenous KT. Pre-eclamptic patients (n = 13), not treated with KT (non-KT), were included as a control group. Segments of UCA were prepared and mounted in tissue baths and isometric force changes were determined. Cumulative concentration response curves to 5-HT and to the 5-HT(1B/1D )receptor agonist sumatriptan were constructed in the absence or presence of the 5-HT(2A) receptor antagonist KT or the 5-HT(1B/1D) receptor antagonist GR125743, respectively.

RESULTS

All UCA segments showed contractile responses to both 5-HT and sumatriptan, and the concentration response curves showed a rightward shift with increasing concentrations of KT and GR125743, respectively, indicating the presence of functional 5-HT(2A) and 5-HT(1B/1D) receptors in the foetal tissue. No significant differences were found in maximum response (E(max))(expressed in percent of response on 100 mM KCl) or potency (pEC(50)) of 5-HT in both groups (E(max) = 141 +/- 7.7%, pEC(50) = 7.67 +/- 0.26 in KT-treated group and E(max) = 162 +/- 12.6%, pEC(50) = 7.69 +/- 0.14 in non-KT treated group, respectively). No significant differences were found in the potency of the antagonist KT in both study groups (pK(b) = 7.65 +/- 0.31 in KT group and 7.46 +/- 0.17 in non-KT group, respectively). Similarly, with sumatriptan, no significant differences were found between KT-treated patients and non-KT treated patients (E(max) = 142 +/- 16.2 and 140 +/- 14.7%, respectively, pEC(50) = 6.17 +/- 0.37 and 6.41 +/- 0.28 respectively, pK(b) of GR125743 = 7.83 +/- 0.48 and 8.43 +/- 0.29, respectively).

CONCLUSION

Foetal exposure to KT in pre-eclamptic patients does not seem to influence the functional characteristics of 5-HT(2A) and 5-HT(1B/1D) receptors in the UCA.

[Two pregnant women with shortness of breath due to peripartum cardiomyopathy]

Two primigravidae, 33 and 30 years of age, were admitted for pre-eclampsia after 41 and 32 weeks ofamenorrhoea, respectively. Both complained of dyspnoea that turned out to be due to heart failure. The foetuses both died before birth, but the women recovered following intensive care. Peripartum cardiomyopathy is a relatively rare but serious disease that usually develops during the last month of pregnancy or the first five months after delivery. Adequate diagnosis and treatment of pregnant women with signs of heart failure can prevent much suffering on the part of both mother and child. Because peripartum cardiomyopathy is diagnosed by exclusion, other causes of heart failure should first be ruled out. The subsequent preconceptional advice will depend on the recovery of cardiac function. Women with residual myocardial dysfunction run a severe risk of aggravated heart failure and should be strongly advised against becoming pregnant again.

Morbidity and development in childhood of infants born after temporising treatment of early onset pre-eclampsia

OBJECTIVE

To assess morbidity and development in childhood of infants born after temporising management of severe early onset pre-eclampsia.

DESIGN

Cohort study with matched controls.

SETTING

University centre for high risk obstetrics.

SAMPLES

Three groups of neonates matched for gender and year of birth: one born after temporising treatment of severe early onset (<32 weeks) pre-eclampsia with an average delay of delivery of two weeks (n= 193); one born at the duration of pregnancy [1 week] of the pre-eclamptic mother on admission (control group I, n = 192); and one born at the same gestational age [1 week] as the infant of the pre-eclamptic mother (control group II, n= 189).

METHOD

Follow up at four years of age or more using medical records and questionnaires.

MAIN OUTCOME MEASURES

The presence of various morbidities including mental retardation, cerebral palsy, motor skill problems, visual handicap, hearing loss, speech and language problems, education level and acute or chronic respiratory problems.

RESULTS

Median follow up of seven years (range 4-12) was achieved in 159 infants in the study group (83%), 122 in control group I (64%) and 110 in control group II (58%). Missing data analysis showed no differences in neonatal characteristics and morbidity between infants with and without follow up in the study group. All major and minor handicaps were less frequent in the study group than in control group I but statistical significance was reached only for acute and chronic respiratory disorders in the study group (13.8%) compared with control group I (27%).

CONCLUSION

Average delay of delivery of two weeks with temporising management in severe early onset pre-eclampsia is associated with a reduced risk of respiratory disorders in childhood.

Ketanserin in pre-eclamptic patients: transplacental transmission and disposition in neonates

The aim of this prospective, observational study was to assess transplacental transmission of ketanserin, an antihypertensive drug used in pre-eclampsia, and to determine disposition and effects in the neonate after maternal ketanserin use. In 22 pregnant women with severe pre-eclampsia, admitted to the antenatal ward in the period 1999-2001, the ratio of drug levels in the umbilical cord to drug levels in maternal blood just before delivery was used as an indicator of placental transmission. Disposition of ketanserin was assessed using neonatal plasma concentrations of ketanserin in eight neonates after birth. A median placental transmission was found in the pre-eclamptic women of 0.95 (0.612-1.24) for ketanserin and for its metabolite, ketanserinol, of 0.60 (0.5-0.77). Pharmacologically relevant concentrations of ketanserin were found in the neonate after delivery. The elimination half-life of ketanserin in the neonate varied between 12.7 and 43.7 hours (median 19.3 hours) and of ketanserinol between 13.8 and 34.4 hours (median 18.7 hours). Despite the high placental transmission and disposition in the neonate, no apparent adverse effects in the neonates could be detected. In conclusion, a high placental transmission of ketanserin and its metabolite ketanserinol occurred after maternal treatment of pre-eclampsia with ketanserin and pharmacologically active concentrations of ketanserin are found in the neonate for a prolonged period after delivery.

The impact of maternal plasma volume expansion and antihypertensive treatment with intravenous dihydralazine on fetal and maternal hemodynamics during pre-eclampsia: a clinical, echo-Doppler and viscometric study

OBJECTIVES

To establish the effects of plasma volume expansion (PVE) followed by intravenous dihydralazine (DH) administration on maternal whole blood viscosity (WBV) and hematocrit, uteroplacental and fetoplacental downstream impedance and umbilical venous (UV) volume flow in pre-eclampsia.

METHODS

In 13 pre-eclamptic women maternal and fetal hemodynamics were established by means of combined measurement of maternal arterial blood pressure (BP), WBV, hematocrit and uterine artery (UtA) resistance index (RI) in addition to umbilical artery (UA) pulsatility index (PI) and UV volume flow obtained from UV vessel area and UV time-averaged flow velocity. In each woman all parameters were measured four times at baseline, after PVE, after DH and 24 h after the start of treatment.

RESULTS

Maternal diastolic BP, hematocrit and WBV display a significant reduction after PVE. In the fetus UA PI decreases significantly whereas a significant increase in UV cross-sectional area was detected. After maternal DH administration, arterial systolic and diastolic BP and UA PI show a significant decrease compared with the measurements following PVE. At 24 h, only maternal systolic and diastolic BP display a significant further decrease. No significant changes were established for the UtA RI, UV time-averaged velocity and UV volume flow during the entire study period.

CONCLUSIONS

During pre-eclampsia, maternal PVE followed by DH administration results in a significant reduction in maternal diastolic BP, maternal hematocrit and WBV. Maternal PVE is associated with a significant increase in UV cross-sectional area and a non-significant rise of 11% in UV volume flow. Maternal DH administration does not result in any change in UV cross-sectional area. However, UA PI decreases significantly after both PVE and DH treatment.

[Pregnancy and chronic hypertension: risks and policy]

Chronic hypertension occurs in 5% of pregnancies and can threaten the life of the mother and the fetus. Chronic hypertension should be evaluated before pregnancy; special attention should be paid to the existence of organ damage and the presence of an acceptable incentive for treatment. The risk of complications of chronic hypertension in pregnancy should be discussed with the couple before pregnancy.

[Intrahepatic cholestasis of pregnancy]

Intrahepatic cholestasis of pregnancy occurs mainly in the final months of pregnancy, and is characterised by pruritus. Foetal morbidity and mortality are increased. The disorder is probably caused by a genetic defect in hormonal metabolism which becomes manifest during the altered hormonal balance in pregnancy. The total serum bile acid concentration is the diagnostic hallmark of the disease. Other routine laboratory tests have a low sensitivity and specificity. An active obstetric management with routine foetal assessments, caesarean section if the foetal condition worsens, and termination of the pregnancy at 37-38 weeks, probably prevents a large proportion of complications. Ursodeoxycholic acid treatment should be considered especially in patients with severe pruritus or complications in previous pregnancies.

[Maternal complications of fetal hydrops]

Three women, aged 28, 27 and 25 years, two primigravidae and one woman who had given birth to a hydropic child previously, had four pregnancies with hydrops of the foetus and the placenta: two (in the same patient) due to foetal cardiomyopathy and two with foetal heart block. The patients developed severe oedema and preeclampsia. After the delivery they recovered well. Since the introduction of anti-D rhesus immunoprophylaxis, foetal hydrops has become less frequent. The resulting maternal complications (the maternal hydrops syndrome and enlarged polycystic ovaries) are therefore less well-known. Serious maternal complications occur in around 50% of cases of foetal hydrops. Careful monitoring of the maternal condition in cases of foetal hydrops is therefore warranted.

[The pregnant patient with acute liver disease]

Acute liver disease was diagnosed in three pregnant patients: two 30-year-old women had a 'haemolysis, elevated liver enzymes, low platelets' (HELLP) syndrome and acute fatty liver of pregnancy, respectively, and a 20-year-old woman had acute liver failure due to acute hepatitis B. The first two patients had a caesarean section, the third one delivered her child, which died spontaneously shortly after birth at a gestational age of 23 weeks. She was then treated by liver transplantation. All three patients left the hospital in good condition. Liver diseases in pregnancy may be pregnancy-related, e.g. the HELLP syndrome and acute fatty liver of pregnancy, but they may also be coincidental phenomena, e.g. viral hepatitis. The HELLP syndrome is often associated with pre-eclampsia, and presents with epigastric pain and thrombocytopenia with haemolysis. Acute fatty liver disease and acute liver failure due to hepatitis present with liver insufficiency characterised by anorexia, nausea, coagulopathy, hypoglycaemia and elevated serum ammonia levels. Management depends on the diagnosis and the gestational age; pregnancy complicated by acute fatty liver disease should be terminated while pregnancy complicated by the HELLP syndrome early in pregnancy may be maintained to improve the outcome of the foetus. In acute liver failure due to viral hepatitis, termination of pregnancy alone does not affect the disease.

Significantly higher number of fetal cells in the maternal circulation of women with pre-eclampsia

Although the pathophysiology of pre-eclampsia is unknown, several studies have indicated that abnormal placentation early in pregnancy might play a key role. It has recently been suggested that this abnormal placentation may result in transfusion of fetal cells (feto-maternal transfusion) in women with pre-eclampsia. In the present study, fetal nucleated red blood cells were isolated from 20 women with pre-eclampsia and 20 controls using a very efficient magnetic activated cell sorting (MACS) protocol. The number of male cells was determined using two-color fluorescence in situ hybridization (FISH) for X and Y chromosomes. Significantly more XY cells could be detected in women with pre-eclampsia (0.61+/-1.2 XY cells/ml blood) compared to women with uncomplicated pregnancies (0.02+/-0.04 XY cells/ml blood) (Mann-Whitney U-test, p<0.001). These results suggest that fetal cell trafficking is enhanced in women with pre-eclampsia, and this finding may contribute to the understanding of the pathophysiology of the disease.

Increased translational fidelity caused by the antibiotic kasugamycin and ribosomal ambiguity in mutants harbouring theksgAgene

The aminoglycoside kasugamycin, which has previously been shown to inhibit initiation of protein biosynthesis in vitro, also affects translational accuracy in vitro. This is deduced from the observation that the drug decreases the incorporation of histidine relative to alanine into the coat protein of phage MS2, the gene of which is devoid of histidine codons. The read-through of the MS2 coat cistron, due to frameshifts in vitro, is also suppressed by the antibiotic. In contrast, streptomycin enhances histidine incorporation and read-through in this system. The effects of kasugamycin take place at concentrations that do not inhibit coat protein biosynthesis. Kasugamycin-resistant mutants (ksgA) lacking dimethylation of two adjacent adenosines in 16 S ribosomal RNA, show an increased leakiness of nonsense and frameshift mutants (in the absence of antibiotic). They are therefore phenotypically similar to previously described ribosomal ambiguity mutants (ram).

A polymorphism in the gene for microsomal epoxide hydrolase is associated with pre-eclampsia

OBJECTIVE

Microsomal epoxide hydrolase is an important enzyme involved in the metabolism of endogenous and exogenous toxicants. Polymorphic variants of the human epoxide hydrolase gene vary in enzyme activity. We determined whether genetic variability in the gene encoding for microsomal epoxide hydrolase contributes to individual differences in susceptibility to the development of pre-eclampsia with or without the syndrome of Haemolysis, Elevated Liver enzymes, and Low Platelets (HELLP).

METHODS

A total of 183 non-pregnant women with a history of pre-eclampsia, 96 of whom had concurrently developed the HELLP syndrome, and 151 healthy female controls were genotyped for the 113Tyr-->His polymorphism in exon 3 and the 139His-->Arg polymorphism in exon 4 of the epoxide hydrolase gene by a polymerase chain reaction-restriction fragment length polymorphism assay. Chi-square analysis was used for statistical evaluation of differences in polymorphic rates.

RESULTS

In pre-eclampsia a higher frequency (29%) of the high activity genotype Tyr113 Tyr113 in exon 3 was found as compared to controls (16%, OR 2.0, 95% CI 1.2-3.7). There was no difference between groups for the 139His-->Arg polymorphism. In women with a history of pre-eclampsia, no difference in epoxide hydrolase genotypes was found between women who either did or did not develop the HELLP syndrome. In addition, a significant association was found between predicted EPHX activity and pre-eclampsia.

CONCLUSIONS

Women with the high activity genotype in exon 3, which could reflect differences in metabolic activation of endogenous or exogenous toxic compounds, may have enhanced susceptibility to pre-eclampsia. However, polymorphisms in the epoxide hydrolase gene do not seem to influence the risk for concurrent development of the HELLP syndrome.

Methylenetetrahydrofolate reductase polymorphisms in preeclampsia and the HELLP syndrome

OBJECTIVE

To investigate the prevalence of the 677 (C --> T) and 1298 (A --> C) polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene in our preeclamptic population. For a summary estimation of the risk of the 677 (C --> T) polymorphism for preeclampsia, we also performed a meta-analysis on four previously published case-control studies to which our results were added.

METHODS

Genotypes were analyzed by polymerase chain reaction followed by restriction enzyme analysis. The results of 176 nonpregnant women, previously hospitalized for preeclampsia in a tertiary care center, were compared with 403 Dutch population-based controls. Results were statistically analyzed with a chi-square test.

MEAN OUTCOME MEASURES

The incidence of the 677 (C --> T) and 1298 (A --> C) polymorphisms in the MTHFR gene.

RESULTS

The incidence of both MTHFR missense polymorphisms was not significantly different between cases and controls. We found an odds ratio (OR) of 1.5 [95% confidence interval (CI) 0.8-2.6, p = 0.17] and an OR of 1.0 (95% CI 0.6-1.9, p = 0.23) for the 677 (C --> T) and the 1298 (A --> C) polymorphism, respectively, in cases comparing the prevalence of the homozygous genotype versus the other two genotypes. The meta-analysis resulted in a significant OR of 2.0 (95% CI 1.4-2.9).

CONCLUSIONS

In contrast to four previous studies, we were neither able to confirm an increased risk for preeclampsia to the 677 (C --> T) polymorphism nor did we find an increased risk for preeclampsia to the 1298 (A --> C) polymorphism. From the meta-analysis, however, we conclude that it cannot be ruled out that the homozygous 677TT genotype is a modest but significant risk factor for preeclampsia.