Materno-fetal outcome with PlGF above or below cutoff during second half of pregnancy in high-risk women

OBJECTIVE

To evaluate the materno-fetal outcome of high-risk women using placental growth factor (PlGF).

METHODS

This prospective cohort study was performed at a tertiary care hospital from September 2019 to April 2022. Women having clinically major or minor high risk factors of pre-eclampsia were included after consent. The placental growth factor (PlGF) was evaluated among high-risk women at 20-22, 28-30, and 34-36 weeks of gestation. They were followed throughout pregnancy until delivery. Materno-fetal outcome was evaluated based on PlGF levels at three different time points. The gestational age specific cutoff was derived. Those with levels below cutoff were taken as cases and those with values above cutoff were considered as controls. The odds of having complications if the PlGF was below cutoff were determined.

RESULTS

Out of 287 high-risk women, 46 (16%) had pre-eclampsia (PE). The derived cutoff of PlGF was 224, 211, and 176 pg/mL at 20-22, 28-30, and 34-36 weeks, respectively. With PlGF below the cutoff at 20-22 weeks the odds of having HELLP syndrome was 15.8, with low PlGF at 28-30 weeks the odds for developing early onset PE was 11.3. Low PlGF was also significantly associated with preterm delivery (P < 0.001) and early onset FGR (P < 0.001). The sensitivity (91.7%) and specificity (78.5%) of PlGF for PE prediction was highest at 28-30 weeks.

CONCLUSION

Low PlGF at 28-30 weeks was associated with high likelihood of developing early onset PE, and the PlGF cutoff should be gestational age specific.

Comparison of the efficacy of intravenous labetalol versus oral nifedipine in patients with severe pregnancy-induced hypertension beyond 30 weeks of gestation

Hypertensive disorders of pregnancy affect 5% to 10% of all pregnancies globally. The aim of treatment is to bring down blood pressure (BP) quickly and smoothly, which is safe for the mother and baby. The aim of our study was to study the efficacy and safety of intravenous labetalol and oral nifedipine in severe pregnancy-induced hypertension.

Materials and Methods

It is a retrospective observational study, intravenous labetalol 20 mg was given initially in escalating doses of 40 mg, 80 mg, 80 mg, and 80 mg every 15 mins up to a maximum dose of 5 or until the goal BP ≤150/100 mmHg was reached. Some women with severe pregnancy-induced hypertension were given oral nifedipine to control their BP according to the choice of the attending consultant. Nifedipine 10 mg tablet was given initially in repeated doses of 10 mg every 15 mins up to a maximum of five doses or until the goal of BP ≤150/100 mmHg was reached.

Results

In our study, we found that there was a strong statistical significance in stabilizing the BP with oral nifedipine than with intravenous labetalol drug used. The majority of the patients in the oral nifedipine group got to normal BP quicker when compared to intravenous labetalol group patients.

Conclusion

From this study, both drugs were found to be safe and effective in the reduction in BP. The use of nifedipine may be recommended in low-resource settings since it has an oral regimen and dosage is simple when compared to incremental intravenous dosing of labetalol.

Comparison of outcomes following intravenous magnesium compared with intravenous labetalol and oral nifedipine in 355 pregnant Han Chinese women with preeclampsia

As per the American College of Obstetricians and Gynecologists in 2013, magnesium sulfate is the gold standard for the management of preeclampsia, but it has a short action time that does not provide stable maintenance of blood pressure. Labetalol is currently recommended as first-line treatment by the national UK guidance. This study included 355 pregnant Han Chinese women with preeclampsia and aimed to compare outcomes following intravenous magnesium compared with intravenous labetalol and oral nifedipine. Women received 4 g intravenous magnesium sulfate followed by the maintenance dose of 1 g/h intravenous magnesium sulfate (MS cohort, n = 104) or intravenous labetalol (LB cohort, n = 115), or oral nifedipine (NF cohort, n = 136). Therapy success: systolic blood pressure ~140 mm Hg and diastolic blood pressure ~90 mm Hg, therapy failure: persistent systolic blood pressure ≥ 160 or diastolic blood pressure ≥ 110 mm Hg after maximum dosage of therapy (EL). Women of all cohorts successfully decreased systolic and diastolic blood pressures at EL as compared to them before therapy conditions (P < .001, for all). At EL, systolic and diastolic blood pressures of women of the LB cohort decreased more than those of women of the MS and NF cohorts (P < .05, for all). Therapy was more successful in women of the LB cohort than those of the NF cohort (107 [93%] vs 112 [82%], P = .0132). More numbers of women were reduced blood pressure after 1 day of therapy from the LB cohort than those of the NF (75 [65%] vs 21 [15%]) and MS (75 [65%] vs 35 [34%]) cohorts (P < .0001 for both). Labetalol-induced tachycardia, bradycardia, and intracranial hemorrhage in pregnant women and respiratory distress syndrome and hypoglycemia in neonates. Intravenous labetalol provides proper reduction of blood pressure in Han Chinese women with preeclampsia but has the risk of undesirable maternal and neonatal adverse effects (Level of Evidence: IV; Technical Efficacy: Stage 4).

Apelin and Visfatin Expression in Placental Tissue in Women With Preeclampsia and Overweight/Obesity

BACKGROUND

Preeclampsia (PE) is a multifunctional and multisystem disorder. Several factors favor the development of PE, including obesity. Cytokines are also expressed in the placenta, predisposing to local alterations that favor the development of distinct pathological processes, including PE. This study aimed to evaluate the apelin and visfatin mRNA expression in the placental tissue of women with preeclampsia and overweight/obesity and correlates with maternal and fetal variables.

METHODS

A cross-sectional analytical study was performed with 60 pregnant women and their newborns. Clinical, anthropometric, and laboratory variables were collected. Placental tissue samples were obtained, and the apelin and visfatin mRNA expression levels were assessed by qRT-PCR.

RESULTS

The main findings evidenced lower levels of apelin expression in overweight/obese women, accompanied by a negative correlation with BMI and pre-pregnancy weight; a higher expression of apelin was also observed in women with late PE and no personal history of PE. For visfatin levels, higher expression levels were observed in women with late PE and term delivery. Furthermore, a positive correlation was observed between visfatin levels and fetal anthropometric parameters, such as weight, length, and head circumference.

CONCLUSION

Apelin levels were less expressed in overweight/obese women. Apelin and visfatin levels were correlated/associated with maternal-fetal variables.

Who Needs a Second Dose of Exogenous Surfactant?

OBJECTIVE

To identify prenatal and postnatal risk factors associated with surfactant redosing.

STUDY DESIGN

Retrospective, single-regional center study including all infants born from 24 + 0 to 31 + 6 weeks of gestation in the Marche Region, Italy, and admitted to a single level III regional NICU from January 1, 2004, to February 28, 2021. Clinical factors associated with surfactant redosing were identified through logistic regression analysis.

RESULTS

Of 1615 consecutive admissions, 662 infants were treated with exogenous surfactant: 462 (70%) received a single dose and 200 (30%) received more than 1 dose (25.5% two doses and 4.5% three doses). Risk of redosing was higher for infants born to mothers with hypertension in pregnancy (OR 3.95, P < .001), for small for gestational age (SGA) infants (OR 3.93, P < .001) and when the first surfactant dose was 100 mg/kg instead of 200 mg/kg (OR 4.56/4.61, P < .001). Infants with greater GA, delayed first surfactant administration, and milder respiratory distress syndrome had reduced risk of redosing. Infants who required multiple surfactant doses had a higher rate of bronchopulmonary dysplasia and mortality, as well as longer duration of respiratory support than patients that received 1 dose.

CONCLUSIONS

Hypertension in pregnancy and SGA status were found to be statistically and clinically significant predictors of surfactant redosing. Understanding the pathophysiology of these conditions requires further investigation.

Mode of delivery and perinatal outcomes by modified World Health Organization classification of maternal cardiovascular risk in pregnancy

BACKGROUND

Cardiac disease is a leading cause of maternal morbidity and mortality in the United States, and an increasing number of patients with known cardiac disease are reaching childbearing age. Although guidelines indicate that cesarean deliveries should be reserved for obstetrical indications, rates of cesarean delivery among obstetrical patients with cardiovascular disease are higher than those of the general population.

OBJECTIVE

This study aimed to evaluate mode of delivery and perinatal outcomes among patients with low-risk and moderate to high-risk cardiac disease as defined by the modified World Health Organization classification of maternal cardiovascular risk.

STUDY DESIGN

We performed a retrospective cohort study of obstetrical patients with known cardiac disease, as defined by the modified World Health Organization cardiovascular classification categories in pregnancy, who underwent a perinatal transthoracic echocardiogram at a single academic medical center between October 1, 2017 and May 1, 2022. Demographics, clinical characteristics, and perinatal outcomes were collected. Comparisons were made between patients with low- (modified World Health Organization Class I) and moderate to high-risk (modified World Health Organization Class II-IV) cardiac disease using chi-square, Fisher exact, or Student t-tests. Cohen d tests were used to estimate the effect size between group means. Logistic regression models were used to evaluate the odds of vaginal and cesarean delivery in low- and moderate to high-risk groups.

RESULTS

A total of 108 participants were eligible for inclusion, with 41 participants in the low-risk cardiac group and 67 in the moderate to high-risk group. Participants had a mean age of 32.1 (±5.5) years at the time of delivery and a mean pregravid body mass index of 29.9 (±7.8) kg/m2. Chronic hypertension (13.9%) and a history of hypertensive disorder of pregnancy (14.9%) were the most common comorbid medical conditions. In total, 17.1% of the sample had a history of a cardiac event (eg, arrhythmia, heart failure, myocardial infarction). Rates of vaginal and cesarean deliveries were similar between the low- and moderate to high-risk cardiac groups. Patients in the moderate to high-risk cardiac group were more likely to be admitted to the intensive care unit during pregnancy (odds ratio, 7.8; P<.05) and experience severe maternal morbidity compared with patients in the low-risk cardiac group (P<.01). Mode of delivery was not associated with severe maternal morbidity in the higher-risk cardiac group (odds ratio, 3.2; P=.12). In addition, infants of mothers with higher-risk disease were more likely to be admitted to the neonatal intensive care unit (odds ratio, 3.6; P=.06) and have longer neonatal intensive care unit stays (P=.005).

CONCLUSION

There was no difference in mode of delivery by modified World Health Organization cardiac classification, and mode of delivery was not associated with risk of severe maternal morbidity. Despite the overall increased risk of morbidity in the higher-risk group, vaginal delivery should be considered as an option for certain patients with well-compensated cardiac disease. However, larger studies are needed to confirm these findings.

Childhood obesity and hypertension in pregnancy: a two-sample Mendelian randomization analysis

BACKGROUND

The causal relationship between childhood obesity and hypertension in pregnancy remains unclear. To examine the causal association between childhood obesity and hypertension in pregnancy, two-sample Mendelian randomization analysis was applied.

METHODS

Single-nucleotide polymorphisms (SNPs) associated with childhood obesity were obtained from a published genome-wide association study (GWAS) of 13 848 European individuals. Summary-level data for hypertension in pregnancy were obtained from the FinnGen consortium (11534 cases and 162212 controls). Inverse-variance weighted analysis, weighted-median analysis, and Mendelian randomization-Egger regression were conducted in this Mendelian randomization analysis. Sensitivity analyses were conducted to confirm the accuracy and robustness of our results.

RESULTS

Genetically determined childhood obesity significantly affects hypertension in pregnancy by IVW [odds ratio (OR) = 1.161, 95% confidence interval (CI) 1.086-1.039; P = 9.92 × 10 -6 ] and weighted median (OR = 1.123, 95% CI 1.038-1.214; P  = 0.004). These results were validated by multiple sensitivity analyses.

CONCLUSION

A causal effect between genetically predicted childhood obesity and the risk of hypertension in pregnancy was identified. The prevention of hypertension in pregnancy should be promoted in populations with childhood obesity.

Alterations in Antioxidant Micronutrient Concentrations in Placental Tissue, Maternal Blood and Urine and the Fetal Circulation in Pre-eclampsia

Trace elements such as selenium and zinc are vital components of many enzymes, including endogenous antioxidants, and can interact with each other. Women with pre-eclampsia, the hypertensive disease of pregnancy, have been reported as having changes in some individual antioxidant trace elements during pregnancy, which are related to maternal and fetal mortality and morbidity. We hypothesised that examination of the three compartments of (a) maternal plasma and urine, (b) placental tissue and (c) fetal plasma in normotensive and hypertensive pregnant women would allow identification of biologically significant changes and interactions in selenium, zinc, manganese and copper. Furthermore, these would be related to changes in the angiogenic markers, placental growth factor (PlGF) and Soluble Fms-Like Tyrosine Kinase-1 (sFlt-1) concentrations. Venous plasma and urine were collected from healthy non-pregnant women (n = 30), normotensive pregnant controls (n = 60) and women with pre-eclampsia (n = 50) in the third trimester. Where possible, matched placental tissue samples and umbilical venous (fetal) plasma were also collected. Antioxidant micronutrient concentrations were measured by inductively coupled plasma mass-spectrometry. Urinary levels were normalised to creatinine concentration. Plasma active PlGF and sFlt-1 concentrations were measured by ELISA. Maternal plasma selenium, zinc and manganese were all lower in women with pre-eclampsia (p < 0.05), as were fetal plasma selenium and manganese (p < 0.05 for all); maternal urinary concentrations were lower for selenium and zinc (p < 0.05). Conversely, maternal and fetal plasma and urinary copper concentrations were higher in women with pre-eclampsia (p < 0.05). Differences in placental concentrations varied, with lower overall levels of selenium and zinc (p < 0.05) in women with pre-eclampsia. Maternal and fetal PlGF were lower and sFlt-1 higher in women with pre-eclampsia; maternal plasma zinc was positively correlated with maternal plasma sFlt-1 (p < 0.05). Because of perceptions that early- and late-onset pre-eclampsia have differing aetiologies, we subdivided maternal and fetal data accordingly. No major differences were observed, but fetal sample sizes were small following early-onset. Disruption in these antioxidant micronutrients may be responsible for some of the manifestations of pre-eclampsia, including contributing to an antiangiogenic state. The potential benefits of mineral supplementation, in women with deficient intakes, during pregnancy to reduce pre-eclampsia remain an important area for experimental and clinical research.

Metabolic profiling of pregnancies complicated by preeclampsia: A longitudinal study

INTRODUCTION

Preeclampsia is associated with maternal metabolic disturbances, but longitudinal studies with comprehensive metabolic profiling are lacking. We aimed to determine metabolic profiles across gestation in women who developed preeclampsia compared with women with healthy pregnancies. We also explored the respective effects of body mass index (BMI) and preeclampsia on various metabolic measures.

MATERIAL AND METHODS

We measured 91 metabolites by high-throughput nuclear magnetic resonance spectroscopy at four time points (visits) during pregnancy (weeks 14-16, 22-24, 30-32 and 36-38). Samples were taken from a Norwegian pregnancy cohort. We fitted a linear regression model for each metabolic measure to compare women who developed preeclampsia (n = 38) and healthy controls (n = 70).

RESULTS

Among women who developed preeclampsia, 92% gave birth after 34 weeks of gestation. Compared to women with healthy pregnancies, women who developed preeclampsia had higher levels of several lipid-related metabolites at visit 1, whereas fewer differences were observed at visit 2. At visit 3, the pattern from visit 1 reappeared. At visit 4 the differences were larger in most subgroups of very-low-density lipoprotein particles, the smallest high-density lipoprotein, total lipids and triglycerides. Total fatty acids were also increased, of which monounsaturated fatty acids and saturated fatty acids showed more pronounced differences. Concentration of glycine tended to be lower in pregnancies with preeclampsia until visit 3, although this was not significant after correction for multiple testing. After adjustment for age, BMI, parity and gestational weight gain, all significant differences were attenuated at visits 1 and 2. The estimates were less affected by adjustment at visits 3 and 4.

CONCLUSIONS

In early pregnancy, the metabolic differences between preeclamptic and healthy pregnancies were primarily driven by maternal BMI, probably representing the women's pre-pregnancy metabolic status. In early third trimester, several weeks before clinical manifestation, the differences were less influenced by BMI, indicating preeclampsia-specific changes. Near term, women with preeclampsia developed an atherogenic metabolic profile, including elevated total lipids, very-low-density lipoprotein, triglycerides, and total fatty acids.

Hyperglycemia in Pregnancy and Women's Health in the 21st Century

Hyperglycemia is the commonest medical condition affecting pregnancy and its incidence is increasing globally in parallel with the twin epidemics of diabetes and obesity. Both pre-pregnancy diabetes and gestational diabetes are associated with short term pregnancy complications, with the risk of immediate complications generally broadly rising with more severe hyperglycemia. In this article we firstly consider these risks and their optimal management during pregnancy and then broaden our scope to consider the long-term implications of hyperglycemia in pregnancy as it relates to overall maternal and offspring health in a life course perspective.

Primary Functioning Hepatic Paraganglioma Treated by Laparoscopy: A Case Report

Paragangliomas are highly vascularised and often heritable tumors derived from the paraganglia. They are typically discovered in the retroperitoneal space as well as the head and neck region but are rarely encountered in the liver parenchyma. We report a case of a primary functioning hepatic paraganglioma and provide an up-to-date literature review of patients with such tumors. We present a case of functioning paraganglioma in a 34-year-old female patient who suffered a solitary lesion in her left lateral lobe with symptoms of hypertension since pregnancy. She did not have any family history and her pre-pregnancy examination was negative. An abdominal CT imaging revealed a 6.5 × 5.7 cm liver lesion in segments II and III. Laboratory investigations identified elevation in plasma-free catecholamines. With sufficient preoperative preparation, the patient underwent laparoscopic left hemihepatectomy. Immunohistochemical staining revealed Syn (+) tumor cell nests surrounded by S-100 sustentacular cells (+), providing a definitive diagnosis of paraganglioma. The patient recovered uneventfully without signs of recurrence during a 1-year follow-up period. Our case demonstrates that primary refractory hypertension in pregnancy should be screened for paraganglioma through abdominal ultrasound and plasma free catecholamines. On the other hand, laparoscopic surgery is technically safe and feasible for the treatment of patients with hepatic paragangliomas in favorable locations.

Health professionals' perspectives on clinical challenges in managing hypertensive disorders of pregnancy and recommendations for improving care: A multi-center qualitative study

Background

Hypertensive disorders of pregnancy (HDP) are a leading cause of maternal mortality and morbidity globally despite the intensive international effort to improving maternal care. Substandard clinical care has emerged as a major contributing factor to the high maternal deaths associated with maternal hypertension globally and the impact is severer in low- and middle-income countries (LMICs). Context specific challenges impact negatively on the quality of maternity care and health providers play a crucial role in achieving positive pregnancy experiences for women. This study explored the perspectives of health professionals on the clinical challenges associated with the management of HDP in Ghana and recommendations for improving care.

Methods

A multi-center qualitative study using in-depth interviews (IDIs) was conducted in five major hospitals in the Greater Accra Region of Ghana between June 2018 and March 2019. Health professionals (midwives/nurses and medical doctors) who have worked at the study sites for at least three months were included. Data were analysed based on thematic content using Nvivo software.

Results

We included 62 health professionals comprising 40 midwives/nurses (64.5%) with a median age of 32.5 years (range 26 to 59) and 22 medical doctors (34.5%) with a median age of 34 years (range 25 to 55). Health providers highlighted major challenges associated with clinical management of hypertension in pregnancy: (1) patient-related factors (inadequate understanding and misconceptions about hypertension in pregnancy, women's non-compliance with clinical advice, financial constraints); (2) health system-related challenges (frequent unavailability of logistics, medications and laboratory support, delays in provision of care and limitations in the health insurance coverage); (3) health provider associated factors (inadequate number of health professionals and poor attitudes). Context-specific recommendations suggested for improving the quality of care in managing maternal hypertension include restructuring of the health system to reduce delays in providing care, improving financial coverage of medical insurance, encouraging social/family support, enhancing education on HDP and strengthening the health workers' numbers and working conditions.

Conclusion

Major challenges in the clinical management of HDP relate to the health system, health professionals and pregnant women themselves. Context-specific interventions are required to improve the quality of care for hypertensive mothers including regular health education, re-structuring of the health systems, refresher courses for health providers, improvement in health insurance coverage and government subsidy for hypertensive women.

Value of soluble fms-like tyrosine kinase-1/placental growth factor test in third trimester of pregnancy for predicting preeclampsia in asymptomatic women

OBJECTIVES

To estimate the value of screening maternal serum soluble fms-like tyrosine kinase/placental growth factor (sFlt-1/PlGF) ratio in asymptomatic women during 3rd trimester to predict preeclampsia (PE) development.

METHODS

The investigated group comprised of 178 pregnant women. During this gestation, 24 cases had developed PE and 12 isolated gestational hypertension (GH); whereas 142 remained normotensive. Blood samples were collected between 180 and 259 gestational days (g.d.) when the participants were asymptomatic. Serums were analyzed using the BRAHMS sFlt-1 Kryptor/BRAHMS PlGF plus Kryptor PE ratio test (Thermo Fisher Scientific, Henningdorf, Germany). High-risk pregnancies for the PE development were defined as sFlt-1/PlGF>38.

RESULTS

The detection rate (DR) for manifestation of PE≤30 days after sampling was 83.3% and overall DR during pregnancy 58.3%. Ten of 15 women having false positive prediction of PE suffered from GH, preterm birth and/or delivery of a small-for-gestational-age-newborn. False positive rate was significantly higher at 239-253 g.d. compared to sampling at 210-224 g.d. and 225-238 g.d. (21.9% vs. 7.8% and 5.3%; p < 0.05).

CONCLUSIONS

The sFlt-1/PlGF test during 180-259 g.d. detected approximately half of subsequent PE cases. An optimal time to use the test for screening purposes was estimated 225-238 g.d. (DR 66.7%). False positive test results were more common to cases with other adverse pregnancy outcomes and samples drawn at higher gestational age.

Pregnancy-Associated Acute Kidney Injury in Low-Resource Settings: Progress Over the Last Decade

Despite immense global effort, the maternal mortality rate in low-resource settings remains unacceptably high. Globally, this reflects the grave inequalities in access to health and reproductive services. Pregnancy-associated acute kidney injury (PRAKI) is an independent risk factor for mortality. The reported incidence of PRAKI in low- and middle-income countries is higher than that of high-income countries (4%-26% versus 1%-2.8%, respectively). Hypertensive disorders are now the leading cause of PRAKI in many regions, followed by hemorrhage and sepsis. PRAKI in low-resource settings carries a high mortality for both mother and child. Outcome studies suggest that PRAKI is associated with residual kidney dysfunction and may lead to dialysis dependence. This can be a death sentence in many regions with limited kidney replacement therapy. This review will summarize data on PRAKI on the African, Latin American, and Asian continents over the past decade. It will include the progress in published data, mortality, and treatment interventions and provide recommendations for the next decade.

Placental findings in singleton stillbirths: a case-control study from a tertiary-care center in India

OBJECTIVES

Placental examination in a case of stillbirth can provide insight into causative/associated factors with fetal demise. The aim of this study was to compare placental and umbilical cord pathologies in singleton stillbirth and livebirth placentas, and to find prevalence of various associated maternal and fetal clinical factors.

METHODS

This case-control study was conducted at a tertiary-care center in India over a period of 20 months. About 250 women who delivered stillborn fetus ≥28 weeks' gestation and 250 maternal-age-matched controls were recruited. Sociodemographic and clinical details were noted and placental gross and microscopic examination was done. Placental findings were compared between stillbirth and livebirth (overall), preterm stillbirth and preterm livebirth as well as term stillbirth and term livebirth in six categories - placenta gross, cord gross, membranes gross, maternal vascular malperfusion, fetal vascular malperfusion and inflammatory response. Prevalence of 11 maternal and fetal factors were studied in all categories of placental findings in both livebirth and stillbirth.

RESULTS

Placental findings in all six categories were significantly associated with stillbirths (p<0.05). The placental findings associated with stillbirth with highest odds included placental hypoplasia (OR 9.77, 95% CI 5.46-17.46), necrotizing chorioamnionitis (OR 9.30, 95% CI 1.17-73.96) and avascular villi (OR 8.45, 95% CI 3.53-20.25). More than half of the women with stillbirths had medical disorders (n=130, 52.0%) and the most prevalent was hypertensive disorder (n=45, 18.0%).

CONCLUSIONS

Changes in placenta are associated with development of stillbirth. Therefore, antenatal investigations to identify placental dysfunction should be investigated to determine whether these reduce stillbirth. Also, placental examination in a case of stillbirth can detect/diagnose many maternal/fetal conditions and thereby can help in preventing future stillbirths.

Hypertensive disorders of pregnancy and breastfeeding practices: A secondary analysis of data from the All Our Families Cohort

INTRODUCTION

Hypertensive disorders of pregnancy occur in approximately 7%-10% of pregnancies and are associated with adverse maternal cardiovascular health outcomes across the lifespan. In contrast, breastfeeding has been associated with a reduction in cardiovascular risk factors in a dose-dependent manner. Despite the potential protective effects of lactation on cardiovascular risk, how hypertensive disorders of pregnancy relate to breastfeeding practices and experiences is not well understood. The aim of this study was to investigate the association between hypertensive disorders of pregnancy and breastfeeding outcomes in the first year postpartum.

MATERIAL AND METHODS

We conducted a secondary analysis of prospective data from the All Our Families Cohort, a population-based study conducted in Calgary, Alberta, Canada. Women with a singleton pregnancy (n = 1418) who completed self-report questionnaires at <25 weeks and 34-36 weeks of gestation, and 4 months and 12 months postpartum, and provided consent to link to electronic medical records that identified diagnoses of hypertensive disorders of pregnancy (n = 122). Logistic and multiple linear regression analyses were used to model associations between hypertensive disorders of pregnancy and breastfeeding outcomes. Outcomes included breastfeeding intention, intended duration, exclusive breastfeeding at 4 months, breastfeeding duration at 12 months and breastfeeding difficulties.

RESULTS

Hypertensive disorders of pregnancy were not associated with breastfeeding intention (odds ration [OR] 1.30, 95% confidence interval [CI] 0.47-3.03, P = 0.57), intended breastfeeding duration (b = -3.28, 95% CI -7.04 to 0.48, P = 0.09), or initiation (OR = 0.64, 95% CI 0.29- 1.65, P = 0.32), but were associated with an increase in the odds of non-exclusive breastfeeding at 4 months postpartum (OR = 2.11, 95% CI 1.39-3.22, P < 0.001). Women with hypertensive disorders breastfed for 6.26 (95% CI -10.00 to -2.51, P < 0.001) weeks less over 12 months postpartum, had significantly higher odds of reporting insufficient milk supply (OR = 1.75, 95% CI 1.19-2.46, P < 0.05) and had lower odds of breast and/or nipple pain (OR = 0.66, 95% CI 0.44-0.92, P < 0.05) compared with those without hypertensive disorders of pregnancy.

CONCLUSIONS

Hypertensive disorders of pregnancy are associated with altered breastfeeding practices and experiences during the first year postpartum. Further research is needed to examine biopsychosocial mechanisms through which hypertensive disorders associate with shorter breastfeeding duration, and to examine whether greater breastfeeding duration, intensity or exclusivity reduces short- or long-term maternal cardiovascular risk.

Changes in ophthalmic artery Doppler during acute blood-pressure control in hypertensive pregnant women

OBJECTIVE

To examine the changes in ophthalmic artery Doppler indices and their association with changes in mean arterial blood pressure (MAP) and systolic (SBP) and diastolic (DBP) blood pressure, following acute antihypertensive treatment in women with hypertensive disorders of pregnancy presenting with high blood pressure.

METHODS

This was a prospective cohort study of 31 pregnant women presenting at 30 + 0 to 39 + 6 weeks' gestation for management of their hypertension. Paired maternal blood-pressure and ophthalmic-artery-Doppler measurements were performed prior to and at 30 min and 60 min after starting antihypertensive medication. In patients who did not achieve blood-pressure control (i.e. when blood pressure was < 140/90 mmHg) by 60 min, paired readings were continued up to 120 min. If blood-pressure control was still not achieved at that point, patients were admitted to hospital. Univariate linear regression was performed to determine the association of ophthalmic artery peak systolic velocity (PSV) ratio with SBP, DBP and MAP before treatment and after blood-pressure control. The longitudinal changes in MAP, SBP, DBP and PSV ratio from pretreatment to 30 min and 60 min after commencement of antihypertensives were examined by repeated measure, multilevel, linear mixed-effects analysis.

RESULTS

Antihypertensive treatment was associated with a decrease in SBP, DBP, MAP and PSV ratio. At 60 min following antihypertensive treatment, the decrease in SBP, DBP, MAP and PSV ratio was 12.1 mmHg (95% CI, 9.0-15.1 mmHg; P < 0.0001), 9.1 mmHg (95% CI, 6.5-11.5 mmHg; P < 0.0001), 10.0 mmHg (95% CI, 7.6-12.4 mmHg; P < 0.0001) and 0.07 (95% CI, 0.03-0.11 mmHg; P < 0.001), respectively. From the total cohort, 20 (64.5%) women had achieved blood-pressure control at 60 min and another seven (22.6%) by 120 min from commencement of antihypertensive treatment. Four (12.9%) women did not achieve blood-pressure control during this period and were admitted to hospital. The relationship between PSV ratio and SBP, DBP and MAP was assessed before treatment (n = 31) and at the point of blood-pressure control in women in whom this was achieved by 120 min (n = 27). Prior to treatment, there was a significant association between PSV ratio and MAP (P < 0.0001, R²  = 0.39). This was primarily due to the association of PSV ratio with DBP (P < 0.0001, R²  = 0.39) and less so due to its association with SBP (P = 0.02, R²  = 0.16). At the point of achieving blood-pressure control, there was no significant association between PSV ratio and MAP (P = 0.7), DBP (P = 0.5) or SBP (P = 0.7).

CONCLUSIONS

Acute blood-pressure control in pregnancy is associated with a concomitant reduction in blood pressure and ophthalmic artery PSV ratio. In hypertensive pregnant women, there is a significant association of PSV ratio with MAP, SBP and DBP, which disappears after blood pressure is reduced to < 140/90 mmHg following antihypertensive treatment. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Ophthalmic artery peak systolic velocity ratio distinguishes preeclampsia from chronic and gestational hypertension: A prospective cohort study

OBJECTIVE

To examine whether the ophthalmic artery peak systolic velocity ratio (OA PSV-ratio) is higher in women with preeclampsia (PE), compared to gestational hypertension (GH) and chronic hypertension (CH), after controlling for confounding variables.

DESIGN

Prospective cohort.

SETTING

Specialist hypertension clinic in a tertiary referral centre.

POPULATION

Singleton pregnancies presenting between 32+0 to 36+6 weeks' gestation with PE (n=50), GH (n=54) and CH (n=56).

METHODS

Paired measurements of maternal mean arterial pressure (MAP) and OA PSV-ratio were performed by trained sonographers. Multiple linear regression was fitted to the OA PSV-ratio, including maternal characteristics and medical history, GH, PE and MAP and use of antihypertensive medication.

MAIN OUTCOME MEASURE

Whether PE is independently associated with higher OA PSV-ratio.

RESULTS

MAP was significantly higher in both GH (p=0.0015) and PE (p=0.008) than in CH pregnancies. There was no significant difference between PE and GH (0.670). The OA PSV-ratio was significantly higher in PE than CH (p=0.0008) and GH (p=0.015). There was no significant difference between the OA PSV-ratio in CH and GH (p=0.352). Multiple linear regression modelling showed that the OA PSV-ratio was influenced by maternal weight (p=0.005), maternal age (p=0.014), antihypertensive medications (p=0.007) and MAP (p<0.0001). After controlling for these variables, the OA PSV-ratio was still significantly higher in those with PE (p=0.0002).

CONCLUSIONS

The OA PSV-ratio is influenced by maternal weight, age, antihypertensive medications and MAP. PE is an independent predictor of OA PSV-ratio, which therefore may be a useful point-of-care test when assessing women presenting with hypertension.

A Potential Three-Gene-Based Diagnostic Signature for Hypertension in Pregnancy

Background

Hypertensive disorders of pregnancy affect approximately 5–10% of all pregnancies, and this study aims to identify potential diagnostic signatures.

Methods

We downloaded the mRNA profiles of GSE75010 (placenta samples) and GSE48424 (blood samples) datasets with or without hypertension in pregnancy from the Gene Expression Omnibus database. Differential expression analysis was performed on the placenta samples using limma package of R language. GO terms and KEGG pathways enrichment analyses were performed on the placenta samples by the clusterProfiler package of R language. Infiltrating immune cell proportion of the placenta samples was evaluated using CIBERSORT software. The key genes involved in hypertension in pregnancy were screened from protein–protein interaction (PPI) network constructed based on the differentially expressed genes (DEGs). The logistic regression model was constructed by the glm package of R language, and receiver operating characteristic (ROC) curve was plotted to determine the accuracy of the model.

Results

For the placenta samples, a total of 104 DEGs were identified, and 39 GO terms and 7 KEGG pathways were significantly enriched based on these 104 genes. Furthermore, the analysis of infiltrating immune cells indicated that the difference in the amount of immune cells might be the potential cause of hypertension in pregnancy. The logistic regression model was constructed based on three optimal genes (LEP, PRL and IGFBP1) screened from PPI network and could efficiently separate patients with hypertension in pregnancy from healthy subjects.

Conclusion

A predictive model based on three potential genes LEP, PRL and IGFBP1 was obtained, suggesting that these genes might be potential diagnostic signatures for hypertension in pregnancy.

An exploratory study of white blood cell proportions across preeclamptic and normotensive pregnancy by self-identified race in individuals with overweight or obesity

Objective: Examine white blood cell (WBC) proportions across preeclamptic (n = 28 cases) and normotensive (n = 28 controls) pregnancy in individuals with overweight/obesity.Methods: WBC proportions were inferred from genome-wide DNA methylation data and compared by case/control status and self-identified race.Results: In Trimester 1, ean B cell proportions were suggestively lower in cases in the overall sample and significantly lower in White participants but not in Black participants. More significant WBC proportion changes were observed across normotensive than preeclamptic pregnancy.Conclusions: These findings in a small sample demonstrate need for additional studies investigating the relationship between self-identified race and WBCs in pregnancy.

Effects of blood pressure level management on maternal and perinatal outcomes in pregnant women with mild to moderate gestational hypertension

OBJECTIVES

This study aims to investigate the effects of blood pressure control level on maternal and perinatal outcomes in pregnant women with mild to moderate gestational hypertension (GHp).

MATERIAL AND METHODS

A total of 344 pregnant women who initially diagnosed as mild to moderate gestational hypertension were recruited in this study. They were divided into 4 groups according to the stabilized blood pressure level (BPL) during pregnancy. The clinical parameters and the incidence of adverse pregnancy outcomes were compared among the four groups. The association between blood pressure levels and relative factors were analyzed using the χ2 test. Multivariate logistic regression analysis was adopted for risk factors associated with adverse pregnancy outcomes.

RESULTS

The results showed the prevalence of obesity was significantly associated with blood pressure levels of mild-moderate GHp pregnant women (p = 0.029). The incidence of severe GHp, SPE in group A, group B, and group C were statistically significant (p < 0.001, p = 0.041, respectively). In the patients who used drugs to control BPL, the incidence of severe GHp has a significant association with the initial blood pressure levels (p = 0.004). However, no significant difference was found in the incidence of sPE, PE + Upro, and SGA (all p > 0.05). Multivariate logistic regression analyses results showed that the gestational factor BPL was an independent risk factor for the incidence of sGHp. The AMA, primigravida, gestational BPL, and edema were risk factors for the incidence of preeclampsia with proteinuria. To the incidence of sPE, gestational BPL is the independent risk factor. Finally, preeclampsia anamnesis and FGR trend are the high-risk parameters to the incidence of SGA.

CONCLUSIONS

Timely management and control of blood pressure in pregnant women with mild to moderate GHp were beneficial to reduce the occurrence of severe GHp and sPE, but the incidence of SGA does not affected.

Increased Placental Cell Senescence and Oxidative Stress in Women with Pre-Eclampsia and Normotensive Post-Term Pregnancies

Up to 11% of pregnancies extend to post-term with adverse obstetric events linked to pregnancies over 42 weeks. Oxidative stress and senescence (cells stop growing and dividing by irreversibly arresting their cell cycle and gradually ageing) can result in diminished cell function. There are no detailed studies of placental cell senescence markers across a range of gestational ages, although increased levels have been linked to pre-eclampsia before full term. This study aimed to determine placental senescence and oxidative markers across a range of gestational ages in women with uncomplicated pregnancies and those with a diagnosis of pre-eclampsia. Placentae were obtained from 37 women with uncomplicated pregnancies of 37-42 weeks and from 13 cases of pre-eclampsia of 31+2-41+2 weeks. The expression of markers of senescence, oxidative stress, and antioxidant defence (tumour suppressor protein p16INK4a, kinase inhibitor p21, interleukin-6 (IL-6), NADPH oxidase 4 (NOX4), glutathione peroxidases 1, 3, and 4 (GPx1, GPx3, and GPx4), placental growth factor (PlGF), and soluble fms-like tyrosine kinase-1 (sFlt-1)) genes was measured (quantitative real-time PCR). Protein abundance of p16INK4a, IL-6, NOX4, 8-hydroxy-2'-deoxy-guanosine (8-OHdG), and PlGF was assessed by immunocytochemistry. Placental NOX4 protein was higher in post-term than term deliveries and further increased by pre-eclampsia (p < 0.05 for all). P21 expression was higher in post-term placentae (p = 0.012) and in pre-eclampsia (p = 0.04), compared to term. Placental P16INK4a protein expression was increased post-term, compared to term (p = 0.01). In normotensive women, gestational age at delivery was negatively associated with GPx4 and PlGF (mRNA and protein) (p < 0.05 for all), whereas a positive correlation was seen with placental P21, NOX4, and P16INK4a (p < 0.05 for all) expression. Markers of placental oxidative stress and senescence appear to increase as gestational age increases, with antioxidant defences diminishing concomitantly. These observations increase our understanding of placental health and may contribute to assessment of the optimal gestational age for delivery.

Prognostic role of increased serum homocysteine concentration in preeclampsia

Objective: To assess homocysteine (Hcy) concentration in women with preeclampsia (PE).Methods: Hcy concentrations were detected by ELISA in 305 pregnancies.Results: Hcy concentration in patients with PE was 16.07 umol/L at 10-14 weeks as compared to 7.19 umol/L in normotensive pregnancies (p < 0.0001). Optimal cutoff level for Hcy in the first trimester of pregnancy was >9.55 umol/L with area under curve of 0.859, sensitivity of 91.67%, specificity of 72.24%.Conclusion: Assessment of serum Hcy concentration may be used as a predictor of PE, with the highest diagnostic utility in the first trimester of pregnancy.

Evaluation of Implementation and Unit Impact of a Hypertensive Disorder of Pregnancy Guideline: A Model-Based Approach

BACKGROUND

Hypertensive disorders of pregnancy are a leading cause of maternal mortality and morbidity. To address this, a large Midwestern hospital initiated a practice guideline. Practice guidelines should improve outcomes, but implementation of these remains challenging. At the time of initiation of the guideline, no implementation or evaluation plan was conceived.

OBJECTIVE

Evaluate the implementation and unit impact of a guideline for the management of hypertensive disorders of pregnancy in a large academic health system in the Midwest.

METHODS

Six objectives, guided by the constructs of the Ottawa Model of Research Utilization, were operationalized to evaluate the implementation and unit impact of the guideline.

RESULTS

The guideline implemented was consistent with national recommendations. Intervention education was inconsistent across provider types. A survey of staff revealed insight into a unit in the midst of practice change. A chart review revealed below-target management of patients with severe range blood pressures. Not following the guideline was associated with hospital readmission.

CONCLUSIONS

Guideline implementation can be efficiently and holistically evaluated with a model-based framework, even in projects that were not initiated with such an approach.

IMPLICATIONS FOR NURSING PRACTICE

Nurses provide expertise in model-based approaches that result in comprehensive evaluations of quality improvement processes.

Added prognostic value of longitudinal changes of angiogenic factors in early-onset severe pre-eclampsia: a prospective cohort study

OBJECTIVE

To assess in women with early-onset severe pre-eclampsia whether longitudinal changes in angiogenic factors improve the prediction of adverse outcome.

DESIGN

Prospective cohort study.

SETTING

Maternity units in two Spanish hospitals.

POPULATION

Women with diagnosis of early-onset severe pre-eclampsia.

METHODS

Levels of placental growth factor (PlGF), soluble fms-like tyrosine kinase (sFlt-) and sFlt-1/PlGF ratio were measured at admission and before delivery, and average daily change calculated. The association of longitudinal changes of angiogenic factors with the time interval to delivery and with complications was evaluated by logistic and Cox regression.

MAIN OUTCOME MEASURES

Interval to delivery and composite of adverse outcomes.

RESULTS

We included 63 women, of which 26 (41.3%) had a complication. Longitudinal changes of sFlt-1 were more pronounced in complicated pregnancies (median: 1047 versus 342 pg/ml/day; P = 0.04). On the multivariate analysis, the clinical risk score and sFlt-1 at admission explained 6.2% of the uncertainty for complication; the addition of sFlt-1 longitudinal changes improved this to 25.3% (P = 0.002). The median time from admission to delivery was 4 days (95% CI 1.6-6.04) in those in the highest quartile of sFlt-1 longitudinal changes versus 16 days (95% CI 12.4-19.6) in the remaining women (Log-rank test P < 0.001).

CONCLUSIONS

Longitudinal changes in sFlt-1 maternal levels from admission for confirmed early-onset severe pre-eclampsia add to baseline characteristics in the prediction of adverse outcome and interval to delivery.

TWEETABLE ABSTRACT

In early-onset severe pre-eclampsia, longitudinal changes in sFlt-1 levels improve the prediction of complications and interval to delivery.

Labetalol-Induced Hepatotoxicity during Pregnancy: A Case Report

Background  Drug-induced liver injury is a common cause of transaminitis, occurring in up to 5% of patients who are hospitalized for liver failure. In pregnancy, transaminitis is seen in conditions which may require expedited delivery. Case  A 39-year-old G2P0010 at 27 ^2/7 weeks' gestation with chronic hypertension on labetalol was found to have elevated transaminases. Evaluation for preeclampsia, acute fatty liver, nonalcoholic steatohepatitis, cholelithiasis, infections, and autoimmune conditions were all negative. Labetalol was then discontinued, and liver biopsy was performed. After discontinuation of labetalol, her hepatitis improved, and she was discharged on hospital day 12 and went on to deliver at term. Conclusion  Labetalol-induced hepatitis should be considered in the differential for transaminitis during pregnancy to prevent iatrogenic preterm delivery.

A Proposed Plan for Prenatal Care to Minimize Risks of COVID-19 to Patients and Providers: Focus on Hypertensive Disorders of Pregnancy

Hypertensive disorders are the most common medical complications of pregnancy and a major cause of maternal and perinatal morbidity and death. The detection of elevated blood pressure during pregnancy is one of the cardinal aspects of optimal antenatal care. With the outbreak of novel coronavirus disease 2019 (COVID-19) and the risk for person-to-person spread of the virus, there is a desire to minimize unnecessary visits to health care facilities. Women should be classified as low risk or high risk for hypertensive disorders of pregnancy and adjustments can be accordingly made in the frequency of maternal and fetal surveillance. During this pandemic, all pregnant women should be encouraged to obtain a sphygmomanometer. Patients monitored for hypertension as an outpatient should receive written instructions on the important signs and symptoms of disease progression and provided contact information to report the development of any concern for change in status. As the clinical management of gestational hypertension and preeclampsia is the same, assessment of urinary protein is unnecessary in the management once a diagnosis of a hypertensive disorder of pregnancy is made. Pregnant women with suspected hypertensive disorders of pregnancy and signs and symptoms associated with the severe end of the disease spectrum (e.g., headaches, visual symptoms, epigastric pain, and pulmonary edema) should have an evaluation including complete blood count, serum creatinine level, and liver transaminases (aspartate aminotransferase and alanine aminotransferase). Further, if there is any evidence of disease progression or if acute severe hypertension develops, prompt hospitalization is suggested. Current guidelines from the American College of Obstetricians and Gynecologists (ACOG) and The Society for Maternal-Fetal Medicine (SMFM) for management of preeclampsia with severe features suggest delivery after 34 ^0/7 weeks of gestation. With the outbreak of COVID-19, however, adjustments to this algorithm should be considered including delivery by 30 ^0/7 weeks of gestation in the setting of preeclampsia with severe features. KEY POINTS: · Outbreak of novel coronavirus disease 2019 (COVID-19) warrants fewer office visits.. · Women should be classified for hypertension risk in pregnancy.. · Earlier delivery suggested with COVID-19 and hypertensive disorder..

The Differential Expression of ERAP1/ERAP2 and Immune Cell Activation in Pre-eclampsia

Pre-eclampsia (PE) is a disorder of pregnancy, often leading to serious and fatal complications. Endoplasmic reticulum aminopeptidase 1 and 2 (ERAP1/ERAP2) are present in the placenta. They are involved in processes regulating blood pressure, angiogenesis, cytokine receptor shedding, and immune recognition. Previous studies have associated both ERAP1/ERAP2 genetic variants with PE, although the underlying mechanisms remain unknown. Less is known about the roles for these enzymes in early placentation, which could be a contributory factor to PE. To ascertain whether ERAP1/ERAP2 change in PE and whether such a change is present before PE is clinically diagnosed, we analyzed mRNA and ERAP1/2 protein expression in the placenta in the early first trimester (8–14 weeks) and at delivery in normotensive or PE women (n = 12/group). Gene expression was analyzed using qPCR, and protein expression and localization were assessed by immunohistochemistry. Additionally, we profiled peripheral immune cells from normotensive and PE (n = 5/group) women for activation and expression of cytotoxic markers using flow cytometry to investigate a possible correlation with placental expression of ERAP1/2. Finally, we characterized the cytokines released from immune cells isolated from normotensive women and those with PE, stimulated ex vivo by JEG-3 trophoblast cells. The ERAP1 protein was significantly upregulated in first trimester placentae compared to placentae at delivery from both normotensive and PE women (p < 0.05): expression of placental ERAP1 protein was also relatively higher in normotensive than PE women. Although the protein expression of both ERAP1/ERAP2 was significantly lower in women with PE compared to normotensive controls (p < 0.05), ERAP2 protein expression remained unchanged in normotensive women at delivery compared to expression in the first trimester. Flow cytometry analysis revealed an increase in activation and cytotoxic natural killer (NK) cells in peripheral blood of PE compared to normotensive women. Intriguingly, there was a notable difference in cytokine release from the activated immune cells when further stimulated by trophoblast cells. The immune cells from PE released elevated expressions of interleukin (IL)-2, IL-4, and most notably, pro-inflammatory IL-13 and IL-17α, inflammatory cytokines tumor necrosis factor (TNF)-α and interferon (IFN)-γ, and granulocyte-macrophage colony-stimulating factor (GM-CSF) compared to normal peripheral blood mononuclear cells (PBMCs). Taken together, these findings suggest that differential lymphocyte activation could be associated with altered ERAP1/ERAP2 expression.

Fetal growth and well-being in a study of maternal hypertension in rabbits

Obtaining growth and physiologic data in the postnatal laboratory animal is common. However, monitoring growth in utero is far more difficult, with little data available except upon termination of pregnancy. High-resolution ultrasound was used to monitor growth, morphology, and fetal well-being in normotensive and hypertensive rabbits (21 fetuses) at day 16, 20, and 26 of the 32 day gestational period. Set protocols, comparable to those routinely assessed in humans, were devised and followed for each examination. Birth weight was greater in offspring of hypertensive as compared to normotensive mothers (p < 0.001); however, litter size was reduced. The greater birth weight was reflected in growth parameters measured throughout gestation indicating the predictive value of ultrasound. High-resolution ultrasound was a reliable and sensitive method for biometric and morphologic assessment of the fetal rabbit, demonstrating that growth trajectory of offspring of hypertensive mothers may be altered early in gestation.

Evidence of a Role for One-Carbon Metabolism in Blood Pressure: Can B Vitamin Intervention Address the Genetic Risk of Hypertension Owing to a Common Folate Polymorphism?

Hypertension in adulthood is recognized as the leading risk factor contributing to mortality worldwide, primarily from cardiovascular disease, whereas hypertension in pregnancy leads to serious adverse fetal and maternal outcomes. This article explores the under-recognized role of one-carbon metabolism in blood pressure (BP) and the potential for folate-related B vitamins to protect against hypertension. Genome-wide association studies and clinical studies provide evidence linking the 677C→T polymorphism in the gene encoding methylenetetrahydrofolate reductase (MTHFR) with BP and increased risk of hypertension and hypertension in pregnancy. A novel role for riboflavin (the MTHFR cofactor) has recently emerged, however, with evidence from randomized trials that supplemental riboflavin can lower BP specifically in adults with the variant MTHFR 677TT genotype. Further studies are required to elucidate the biological mechanisms linking one-carbon metabolism with BP and explore the effect of riboflavin in modulating the genetic risk of hypertension in early and later life.

Long-Term Cardiovascular Risk in Women With Hypertension During Pregnancy

BACKGROUND

History of a hypertensive disorder of pregnancy (HDP) among women may be useful to refine atherosclerotic cardiovascular disease risk assessments. However, future risk of diverse cardiovascular conditions in asymptomatic middle-aged women with prior HDP remains unknown.

OBJECTIVES

The purpose of this study was to examine the long-term incidence of diverse cardiovascular conditions among middle-aged women with and without prior HDP.

METHODS

Women in the prospective, observational UK Biobank age 40 to 69 years who reported ≥1 live birth were included. Noninvasive arterial stiffness measurement was performed in a subset of women. Cox models were fitted to associate HDP with incident cardiovascular diseases. Causal mediation analyses estimated the contribution of conventional risk factors to observed associations.

RESULTS

Of 220,024 women included, 2,808 (1.3%) had prior HDP. The mean age at baseline was 57.4 ± 7.8 years, and women were followed for median 7 years (interquartile range: 6.3 to 7.7 years). Women with HDP had elevated arterial stiffness indexes and greater prevalence of chronic hypertension compared with women without HDP. Overall, 7.0 versus 5.3 age-adjusted incident cardiovascular conditions occurred per 1,000 women-years for women with versus without prior HDP, respectively (p = 0.001). In analysis of time-to-first incident cardiovascular diagnosis, prior HDP was associated with a hazard ratio (HR) of 1.3 (95% CI: 1.04 to 1.60; p = 0.02). HDP was associated with greater incidence of CAD (HR: 1.8; 95% CI: 1.3 to 2.6; p < 0.001), heart failure (HR: 1.7; 95% CI: 1.04 to 2.60; p = 0.03), aortic stenosis (HR: 2.9; 95% CI: 1.5 to 5.4; p < 0.001), and mitral regurgitation (HR: 5.0; 95% CI: 1.5 to 17.1; p = 0.01). In causal mediation analyses, chronic hypertension explained 64% of HDP's association with CAD and 49% of HDP's association with heart failure.

CONCLUSIONS

Hypertensive disorders of pregnancy are associated with accelerated cardiovascular aging and more diverse cardiovascular conditions than previously appreciated, including valvular heart disease. Cardiovascular risk after HDP is largely but incompletely mediated by development of chronic hypertension.

Awareness of Pregnancy-Associated Health Risks Among Pregnant Women and Male Partners Surveyed in a Prenatal Clinic

Background: Underestimation of pregnancy-associated health risks could compromise informed decision-making and reduce demand for preconception care. We assessed the knowledge of pregnant women and male partners about several health risks posed by pregnancy to identify potential gaps in reproductive health literacy. Materials and Methods: Pregnant women and male partners were surveyed about their knowledge of seven common health risks associated with pregnancy (venous thromboembolism [VTE], diabetes, gallstones, hemorrhoids, hypertension [HTN], kidney infection, and anemia) in either English or Spanish in a prenatal clinic at Harbor-UCLA Medical Center in Torrance, California. Results: The response rate for women was estimated to be 66% and was 85% for men. Of the 285 respondents, 5.0% of women and 5.6% of men were able to correctly report that all seven health risks increased during pregnancy. Overall, 30.6% of women and 24% of men recognized that pregnancy increased the risks of the three most serious conditions (VTE, diabetes, and HTN). While higher education was associated with a higher awareness of these three serious risks, the majority of individuals with the highest education nonetheless incorrectly reported that these risks were reduced or unchanged in pregnancy. Age, parity, language, gender, and gestational age did not impact study findings. Overall, 77.9% of respondents rated oral birth control pills more hazardous to a woman's health than pregnancy. Conclusions: Surveyed pregnant women and male partners have significant knowledge deficiencies concerning common and serious health hazards associated with pregnancy that may hamper women's ability to make informed choices about their reproductive health options.

Prediction of pre-eclampsia: review of reviews

OBJECTIVE

Primary studies and systematic reviews provide estimates of varying accuracy for different factors in the prediction of pre-eclampsia. The aim of this study was to review published systematic reviews to collate evidence on the ability of available tests to predict pre-eclampsia, to identify high-value avenues for future research and to minimize future research waste in this field.

METHODS

MEDLINE, EMBASE and The Cochrane Library including DARE (Database of Abstracts of Reviews of Effects) databases, from database inception to March 2017, and bibliographies of relevant articles were searched, without language restrictions, for systematic reviews and meta-analyses on the prediction of pre-eclampsia. The quality of the included reviews was assessed using the AMSTAR tool and a modified version of the QUIPS tool. We evaluated the comprehensiveness of search, sample size, tests and outcomes evaluated, data synthesis methods, predictive ability estimates, risk of bias related to the population studied, measurement of predictors and outcomes, study attrition and adjustment for confounding.

RESULTS

From 2444 citations identified, 126 reviews were included, reporting on over 90 predictors and 52 prediction models for pre-eclampsia. Around a third (n = 37 (29.4%)) of all reviews investigated solely biochemical markers for predicting pre-eclampsia, 31 (24.6%) investigated genetic associations with pre-eclampsia, 46 (36.5%) reported on clinical characteristics, four (3.2%) evaluated only ultrasound markers and six (4.8%) studied a combination of tests; two (1.6%) additional reviews evaluated primary studies investigating any screening test for pre-eclampsia. Reviews included between two and 265 primary studies, including up to 25 356 688 women in the largest review. Only approximately half (n = 67 (53.2%)) of the reviews assessed the quality of the included studies. There was a high risk of bias in many of the included reviews, particularly in relation to population representativeness and study attrition. Over 80% (n = 106 (84.1%)) summarized the findings using meta-analysis. Thirty-two (25.4%) studies lacked a formal statement on funding. The predictors with the best test performance were body mass index (BMI) > 35 kg/m² , with a specificity of 92% (95% CI, 89-95%) and a sensitivity of 21% (95% CI, 12-31%); BMI > 25 kg/m² , with a specificity of 73% (95% CI, 64-83%) and a sensitivity of 47% (95% CI, 33-61%); first-trimester uterine artery pulsatility index or resistance index > 90^th centile (specificity 93% (95% CI, 90-96%) and sensitivity 26% (95% CI, 23-31%)); placental growth factor (specificity 89% (95% CI, 89-89%) and sensitivity 65% (95% CI, 63-67%)); and placental protein 13 (specificity 88% (95% CI, 87-89%) and sensitivity 37% (95% CI, 33-41%)). No single marker had a test performance suitable for routine clinical use. Models combining markers showed promise, but none had undergone external validation.

CONCLUSIONS

This review of reviews calls into question the need for further aggregate meta-analysis in this area given the large number of published reviews subject to the common limitations of primary predictive studies. Prospective, well-designed studies of predictive markers, preferably randomized intervention studies, and combined through individual-patient data meta-analysis are needed to develop and validate new prediction models to facilitate the prediction of pre-eclampsia and minimize further research waste in this field. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Management of pregnancy blood pressure increase in the emergency room: role of PlGF-based biochemical markers and relative economic impact

INTRODUCTION

To evaluate the clinical and economic impact of healthcare management of pregnant women with blood pressure increase (BPI) accessing emergency room (ER) and the utility of the introduction of a PlGF-based test in clinical practice.

MATERIALS AND METHODS

This retrospective cohort study included women with single pregnancies who performed at least 1 ER access for BPI after the 20th gestational week in 2016. BPI was subsequently classified as significant if associated with preeclampsia (PE) or Fetal Growth Restriction (FGR) and not significant otherwise. Two experts evaluated potential changes in patients' management with the introduction of a PlGF-based test. The direct healthcare cost was estimated.

RESULTS

We enrolled 107 patients, of which 30% showed significant BPI (17 PE cases, 13 FGR, and 2 both pathologies). Anamnestic, clinical, and laboratory evaluations were not effective in differentiating between significant and not significant BPI (p-values: .8320, .2856, and .2297, respectively). The introduction of a PlGF-based test would have reduced overtreatment and undertreatment. The test would have avoided 18% of all hospitalizations, 35% of hospitalizations for BPI, 43% of outpatient referrals, and 13% of ER accesses. The number of avoidable accesses was higher in women with not significant BPI. Overall, the mean total cost (from first ER access until delivery) was €2634 per woman and €401 would have been avoidable.

CONCLUSION

The clinical integration of PlGF-based tests is advantageous in diagnostic, prognostic and economic terms, as an objective marker of placental dysfunction.

Responses of the renin-angiotensin-aldosterone system in pregnant chronic kidney disease patients with and without superimposed pre-eclampsia

Background

Women with chronic kidney disease (CKD) are at increased risk of superimposed pre-eclampsia (SPE). Accurate identification of SPE is challenging. We hypothesized that specific components of the renin-angiotensin-aldosterone system (RAAS) would discriminate between CKD and SPE. The aim of the study was to establish differences in circulating and intrarenal RAAS in women with CKD with and without SPE and compare these to normotensive controls (NCs) and women with pre-eclampsia (PE).

Methods

White European NC women (n = 20), women with PE (n = 9), normotensive CKD without SPE (n = 8) and with SPE (n = 11) were recruited in the third trimester. Plasma renin, plasma and urine total angiotensinogen (AGT) concentrations were quantified by enzyme-linked immunosorbent assay, urinary tetrahydroaldosterone (TH-aldo) concentration by gas chromatography-mass spectrometry and placental growth factor (PlGF) by immunoassay.

Results

Urinary TH-aldo:creatinine ratios were lower in women with PE or SPE compared with NC or women with CKD (P < 0.05 for all). The same group differences were observed for plasma active renin and PlGF concentrations (P < 0.05 for all). Urine total AGT was higher in women with PE compared with NC (P < 0.05) and urine TH-aldo:urine AGT was lower (P < 0.05). However, women with SPE had lower urinary AGT concentrations compared with women with PE (P < 0.05). No differences in plasma total AGT were observed between groups.

Conclusions

Women with SPE have a lower urinary TH-aldo:creatinine ratio, lower plasma active renin and lower PlGF concentrations than women with CKD, comparable to women with PE without pre-existing disease, suggestive of similar pathophysiology. These data suggest disruption of the RAAS pathway in SPE similar to PE. Exploration of the predictive value of RAAS components for adverse pregnancy events in women with CKD is required.

Diagnostic Accuracy of Different Soluble fms-Like Tyrosine Kinase 1 and Placental Growth Factor Cut-Off Values in the Assessment of Preterm and Term Preeclampsia: A Gestational Age Matched Case-Control Study

Introduction: The objective was to investigate the diagnostic accuracy of different thresholds of the soluble vascular endothelial growth factor receptor-1 (sFlt-1) and the placental growth factor (PlGF) in preterm (≤37 weeks) and term (>37 weeks) preeclampsia (PE). Materials and Methods: A nested case-control study was performed from a high-risk Swiss cohort. Only blood samples on the day of PE diagnosis were included. The primary outcome was to verify the diagnosis using the recently proposed cut-off values for PE (sFlt-1:PlGF ratio of ≥85 in ≤ 34 weeks or ≥110 in >34 weeks), and the gestational age dependent centiles. Results: Thirty-four women with preterm PE were matched with 64 controls and 25 women with term PE with 45 controls. The test performance of the sFlt-1:PlGF ratio in preterm PE was very good (AUROCC of 0.95). The sFlt-1:PlGF ratio could adequately predict adverse fetal or neonatal outcome. In term PE, sFlt-1 alone showed a slightly better diagnostic accuracy with an AUROCC of 0.84. Almost all women with a sFlt-1:PlGF ratio above threshold delivered during the following week. Discussion: In pregnant women with high risk of developing PE, the sFlt-1:PlGF ratio and sFlt-1 levels help clinicians to confirm the diagnosis of imminent preterm PE and can additionally be used to rule out PE at term.

New data about preeclampsia: some possibilities of prevention

This concise report deals with the known effects of progestogen lack in early pregnancy with failure of implantation and blood supply to the placenta depending on proper trophoblast invasion, spiral artery remodeling, and vessel dilatation. The pathophysiology of preeclampsia will be outlined and the most recent data on the effect of dydrogesterone presented. Dydrogesterone appears to be able to reduce significantly the development of preeclampsia. The effect is related to begin with such prevention and this should be continued until 37th weeks of gestation which would also mean prevention of premature labor.

Perinatal outcomes associated with abnormal cardiac remodeling in women with treated chronic hypertension

BACKGROUND

Adverse maternal outcomes associated with chronic hypertension include accelerated hypertension and resultant target organ damage. One example is long-standing hypertension leading to maternal cardiac dysfunction. Our group has previously identified that features of such injury manifest as cardiac remodeling with left ventricular hypertrophy. Moreover, these features of cardiac remodeling identified in women with chronic hypertension during pregnancy were associated with adverse perinatal outcomes. Recent definitions of maternal cardiac remodeling using echocardiography have been expanded to include measurements of wall thickness. We hypothesized that these new features characterizing cardiac remodeling in women with chronic hypertension may also be associated with adverse perinatal outcomes.

OBJECTIVE

There were 3 aims in this study of women with treated chronic hypertension during pregnancy: to (1) apply the updated definitions of maternal cardiac remodeling; (2) elucidate whether these features of cardiac remodeling were associated with adverse perinatal outcomes; and (3) determine which, if any, of the newly defined cardiac remodeling strata were most damaging when compared to women with normal cardiac geometry.

STUDY DESIGN

This was a retrospective study of women with treated chronic hypertension during pregnancy delivered from January 2009 through January 2016. Cardiac remodeling was categorized by left ventricular mass index and relative wall thickness into 4 groups determined using the 2015 American Society of Echocardiography guidelines: normal geometry, concentric remodeling, eccentric hypertrophy, and concentric hypertrophy. Perinatal outcomes were analyzed according to each category of cardiac remodeling compared with outcomes in women with normal geometry.

RESULTS

A total of 314 women with treated chronic hypertension underwent echocardiography at a mean gestational age of 17.9 weeks. There were no differences between maternal age (P = .896), habitus (P = .36), or duration of chronic hypertension (P = .212) among the 4 groups. Abnormal cardiac remodeling was found in 51% and was significantly associated with increased rates of superimposed preeclampsia (P = .015), preterm birth (P < .001), and neonatal intensive care admission (P = .003). These outcomes reached the greatest significance when comparisons were made between eccentric hypertrophy and normal geometry.

CONCLUSION

Using current American Society of Echocardiography guidelines, 51% of women with treated chronic hypertension during pregnancy have some degree of abnormal cardiac remodeling. Any suggestion of maternal cardiac remodeling, regardless of subtype, was associated with increased risks for superimposed preeclampsia and preterm birth with its resultant perinatal sequelae. Eccentric ventricular hypertrophy, previously thought to mimic exercise physiology, appears to be the most associated with adverse perinatal outcomes. Despite evidence of cardiac remodeling, ejection fraction was preserved.

Frequency and consequences of ventricular hypertrophy in pregnant women with treated chronic hypertension

BACKGROUND

Ventricular hypertrophy is a known sequela of long-standing chronic hypertension with associated morbidity and mortality.

OBJECTIVE

We sought to assess the frequency and importance of left ventricular hypertrophy in gravidas treated for chronic hypertension during pregnancy.

STUDY DESIGN

This was a retrospective study of pregnant women with chronic hypertension who were delivered at our hospital from January 2009 through February 2015. All women who were given antihypertensive therapy underwent maternal echocardiography and were managed in a dedicated, high-risk prenatal clinic. Left ventricular hypertrophy was defined using the criteria of the American Society of Echocardiography as left ventricular mass indexed to maternal body surface area with a value of >95 g/m². Maternal and infant outcomes were then analyzed according to the presence or absence of left ventricular hypertrophy.

RESULTS

Of 253 women who underwent echocardiography, 48 (19%) met criteria for left ventricular hypertrophy. Women in this latter cohort were significantly more likely to be African American (P = .031), but there were no other demographic differences. More than 85% of the entire cohort had a body mass index >30 kg/m² and a third of all women had class III obesity with a body mass index of >40 kg/m². Importantly, duration of chronic hypertension (P = .248) and gestational age at time of echocardiography (P = .316) did not differ significantly between the groups. Left ventricular function was preserved in both groups as measured by left ventricular ejection fraction (P = .303). Those with ventricular hypertrophy were at greater risk to be delivered preterm (P = .001), to develop superimposed preeclampsia (P = .028), and to have an infant requiring intensive care (P = .023) when compared with women without ventricular hypertrophy. These findings persisted after adjustment for age, race, and parity. The gestational age at delivery according to measured left ventricular size was also examined and with increasing ventricular mass there was a significant association with the severity of preterm birth (P < .001).

CONCLUSION

Left ventricular hypertrophy was identified in 1 in 5 women given antepartum treatment for chronic hypertension. Further analysis showed that these women were at significantly greater risk for superimposed preeclampsia and its attendant perinatal sequelae of preterm birth.

Total and Fetal Circulating Cell-Free DNA, Angiogenic, and Antiangiogenic Factors in Preeclampsia and HELLP Syndrome

BACKGROUND

Preeclampsia (PE) is a hypertensive disorder of pregnancy characterized by hypertension and proteinuria. The HELLP syndrome is the most severe form of PE. The aim of the present study was to determine different potential biomarkers that may help us perform an early diagnosis of the disease, assess on the severity of the disease, and/or predict maternal or fetal adverse outcomes.

METHODS

We measured serum levels of total and fetal circulating cell-free DNA (cfDNA), soluble endoglin, soluble form of vascular endothelial growth factor receptor, and placental growth factor in a healthy control group of pregnant women (n = 26), patients with mild (n = 37) and severe PE (n = 25), and patients with HELLP syndrome (n = 16).

RESULTS

We observed a gradual and strong relationship between all the biomarkers mentioned and the range of severity of PE, with the highest levels in patients with HELLP syndrome. Nevertheless, only the values of total cfDNA were able to significantly differentiate severe PE and HELLP syndrome (20957 ± 2784 vs. 43184 ± 8647 GE/ml, P = 0.01). Receiver operating characteristic (ROC) curves were constructed (i) for the healthy group with respect to the groups with PE and (ii) for patients with PE with respect to the group with HELLP syndrome; sensitivity and specificity values at different cutoff levels were calculated in each case. The maximum ROC area under the curve value for PE and HELLP syndrome (with respect to controls) was 0.91 (P < 0.001).

CONCLUSIONS

The measured biomarkers of cell damage, angiogenesis, and antiangiogenesis may reflect the severity of PE, with higher levels in patients who develop HELLP syndrome. In addition, these biomarkers may also help predict adverse fetal and maternal outcomes.

Validation of hospital discharge diagnoses for hypertensive disorders of pregnancy

INTRODUCTION

A correct diagnosis of preeclampsia and gestational hypertension is important for treatment and epidemiological studies. Changes in diagnostic criteria and underreporting in certain subsets of patients may hamper validity of the diagnoses.

MATERIALS AND METHODS

We validated the discharge diagnoses of preeclampsia and gestational hypertension, which are reported to the Danish National Patient Registry, in a cohort of 2163 pregnant women by retrospective evaluation of electronic hospital data.

RESULTS

A preeclampsia discharge diagnosis was found in 113 (5.2%) of the participants. After validation, significantly more patients fulfilled criteria for diagnosis of preeclampsia (n = 163, 7.5%, p = 0.002); more had severe preeclampsia, 14 (0.6%) vs. 70 (3.2%), p < 0.001 and gestational hypertension, 62 (2.9%) vs. 46 (2.1%), p = 0.12. The diagnostic sensitivity for preeclampsia by discharge diagnosis was 55.8%; severe preeclampsia 18.6%; gestational hypertension 39.1%. Corresponding positive predictive values were 80.5, 92.9 and 29.0%. Misclassification occurred in 4.3, 2.7 and 3.3%, respectively. Misclassification was more prevalent in obese compared to lean women (10% vs. 3.6%, p < 0.0001).

CONCLUSIONS

Discharge diagnoses substantially underestimated the prevalence of preeclampsia, especially severe preeclampsia. Misclassification was most common in obese preeclamptic women. These findings depict the limitations associated with the direct use of discharge diagnoses of hypertensive disorders in pregnancy for research purposes.

Effect of a small dose of aspirin on quantitative test of 24-h urinary protein in patients with hypertension in pregnancy

The aim of the present study was to determine the effect of a small dose of aspirin on a quantitative test of 24-h urinary protein in patients with hypertension in pregnancy. In total, 224 patients with hypertension in pregnancy were continuously selected and were randomly divided into the control group (50 cases with conventional therapy), aspirin 50 mg/day group (60 cases), aspirin 75 mg/day group (58 cases), and aspirin 100 mg/day group (56 cases). Clinical effects were compared from 16 gestational weeks to childbirth. According to the comparison in the four groups, there was no statistical difference in the mean arterial pressure, pre-eclampsia rate, gestational weeks, and caesarean section rate (p>0.05). The 24-h urinary protein and endothelin-1 (ET-1) level were significantly decreased following treatment, and were less than the control and 50 mg/day groups. The superoxide dismutase (SOD) level was significantly increased, and higher than the control and 50 mg/day groups. In terms of the 75 and 100 mg/day, control and 50 mg/day groups, there was no statistical difference (p>0.05). A comparison of the complication rate in the four groups of fetuses during the perinatal period, no statistical difference was observed (p>0.05). Thus, the results show that, regarding patients with hypertension in pregnancy, 75 mg/day aspirin can decrease the 24-h urinary protein, SOD, and ET-1 level. However, the results remain to be confirmed to improve maternal and infant outcome in delivery.

Pregnancy outcomes following maternal kidney transplantation: a national cohort study

INTRODUCTION

Internal design flaws in previous reports of pregnancies following kidney transplantation have been outlined, and the need for a validation has been stated. The aim of this study was to collect information about obstetrical and neonatal outcomes in all Norwegian pregnancies following maternal kidney transplantation, and to compare these data with the general Norwegian population.

MATERIAL AND METHODS

A retrospective cohort study based on 1 272 000 deliveries in Norway between 1969 and 2013. All data were collected from medical records. From the source population, we compared 119 first deliveries in kidney transplanted women with 238 first deliveries in nontransplanted women. An explanatory strategy was used in the analysis.

RESULTS

The risk of preeclampsia was significantly increased in kidney-transplanted women compared with nontransplanted women (adjusted incidence rate ratio: 6.06, 95% confidence interval 3.18-11.55). Additionally, preeclampsia in kidney-transplanted women was early onset (diagnosed <34 gestational weeks) in half of the cases. There were also persistent risks of cesarean delivery (adjusted incidence rate ratio 4.14, 95% confidence interval 2.56-6.66), preterm delivery (adjusted incidence rate ratio 4.45, 95% confidence interval 2.13-9.30) and a birthweight below the 10th centile (22.7% vs. 9.7%) in the kidney-transplanted group. A high proportion (63%) of the kidney-transplanted women with chronic hypertension developed preeclampsia.

CONCLUSIONS

Using consistent diagnostic criteria, this study shows high rates of maternal and neonatal complications in pregnancies following kidney transplantation. In particular, we reveal a high rate of early-onset preeclampsia requiring operative preterm delivery, conferring long-term risks on both the mother and child.

Increased risk of systemic lupus erythematosus in pregnancy-induced hypertension: A nationwide population-based retrospective cohort study

Dysregulation of the immune system plays a role in the pathogenesis of both, pregnancy-induced hypertension (PIH) and systemic lupus erythematosus (SLE). It is well known that SLE predisposes to be complicated with PIH. However, few studies have attempted to investigate whether PIH increased subsequent SLE risk.The objectives of this study were to assess the association between PIH and subsequent SLE risk and identify predictive risk factors.Patients with newly diagnosed PIH were selected from the Taiwan National Health Insurance Research Database (NHIRD) and compared with a matched cohort without PIH based on age and the year of delivery. The incidence of new-onset SLE was evaluated in both cohorts. The overall observational period was from January 1, 2000 to December 31, 2013.Among the 23.3 million individuals registered in the NHIRD, 29,091 patients with PIH and 116,364 matched controls were identified. The incidence of SLE was higher among patients with PIH than in the matched controls (incidence rate ratio [IRR] = 4.02, 95% confidence interval [CI] 3.98-4.05, P < 0.0001). The IRR for subsequent SLE development remained significantly higher in all stratifications during the follow-up years. The multivariate Cox regression model was performed and the results showed that PIH may be an independent risk factors for the development of subsequent SLE (hazard ratio [HR] = 2.87, 95% CI 2.07-3.98, P < 0.0001). Moreover, multivariate Cox regression model was used again among the PIH cohort only in order to identify the possible risk factors for subsequent SLE in the population with PIH.Patients with PIH may have higher risk of developing newly diagnosed SLE than those without PIH. In addition, among individuals who have experienced PIH, those younger than 30 years, having experienced preeclampsia/eclampsia, single parity, preterm birth, or chronic kidney disease, may display an increased subsequent risk of SLE.

Posterior reversible encephalopathy syndrome postpartum

Preeclampsia (PE) should be considered in women with headache who are in gestational week 20 or more, are in labor, or have recently given birth. Early diagnosis is essential to arrest disease progression and further prognosis in PE.

Development and validation of a risk factor scoring system for first-trimester prediction of preeclampsia

OBJECTIVE

The aim of this study was to develop a multiparameter risk-based scoring system for first-trimester prediction of preeclampsia and to validate this scoring system in our patient population.

STUDY DESIGN

Secondary analysis of a prospective cohort of 1,200 patients presenting for first-trimester aneuploidy screening. Maternal serum pregnancy-associated plasma protein A (PAPP-A) levels were measured and bilateral uterine artery (UA) Doppler studies performed. Using the first half of the study population, a prediction model for preeclampsia was created. Test performance characteristics were used to determine the optimal score for predicting preeclampsia. This model was then validated in the second half of the population.

RESULTS

Significant risk factors and their weighted scores derived from the prediction model were chronic hypertension (4), history of preeclampsia (3), pregestational diabetes (2), body mass index ≥ 30 kg/m(2) (2), bilateral UA notching (1), and PAPP-A MoM < 10 th percentile (1). The area under the curve (AUC) for the risk scoring system was 0.76 (95% confidence interval [CI], 0.69-0.83), and the optimal threshold for predicting preeclampsia was a total score of ≥ 6. This AUC did not differ significantly from the AUC observed in our validation cohort (AUC, 0.78 [95% CI, 0.69-0.86]; p = 0.75].

CONCLUSION

Our proposed risk factor scoring system demonstrates modest accuracy but excellent reproducibility for first-trimester prediction of preeclampsia.

Role of circulating cell-free DNA levels in patients with severe preeclampsia and HELLP syndrome

BACKGROUND

Increased plasma levels of circulating cell-free DNA (c-f DNA) have been recently described in diseases related to ischemia and/or hypoxia. Preeclampsia (PCL) is a hypertensive disorder of pregnancy, of unknown origin, where a defective placentation resulting in placental ischemia plays an important role. HELLP syndrome (haemolysis, elevated liver enzymes, and low platelet count) is the most serious form of PCL. The origin of the disease is unknown, and there are no markers to help us to make an early diagnosis of disease or to predict patients who are at risk of suffering serious complications.

METHODS

We measured circulating c-f DNA levels in a group of control pregnant women (n = 20), patients with mild PCL (n = 9), patients with severe PCL (n = 24), and patients with HELLP syndrome (n = 8).

RESULTS

Values of circulating c-f DNA were 333.59 ± 64.3 ng/ml in control subjects; 635.11 ± 111.7 ng/ml in patients with mild PCL; 1,264.63 ± 127.1 ng/ml in patients with severe PCL, and 1,595.95 ± 269.8 ng/ml in patients with HELPP syndrome. (P < 0.0001). Values of c-f DNA >950 ng/ml had a sensitivity and specificity for detecting severe PCL and/or HELLLP syndrome of 0.71 and 0.93, respectively.

CONCLUSIONS

As far as we know, this is the first report of increased c-f DNA levels in HELLP syndrome. In this preliminary report, we have observed a gradual and strong relation between c-f DNA levels and range of severity of PCL, with it the highest in patients with HELLP syndrome. Further studies are needed for evaluating the utility of this technique in hypertensive disorders of pregnancy and, particularly, in HELLP syndrome.

Hypertension in pregnancy is associated with elevated homocysteine levels later in life

OBJECTIVE

Hyperhomocysteinemia is associated with an elevated cardiovascular disease risk. We examined whether women with a history of hypertension in pregnancy are more likely to have a high level of serum homocysteine decades after pregnancy.

STUDY DESIGN

Serum homocysteine was measured at a mean age of 60 years in nulliparous women (n = 216), and women with a history of normotensive (n = 1825) or hypertensive (n = 401) pregnancies who participated in the Genetic Epidemiology Network of Arteriopathy (GENOA) study. Relationships between homocysteine and pregnancy history were examined by linear and logistic regression, controlling for multiple covariates including personal and family history of hypertension, diabetes, obesity, tobacco use, and demographics.

RESULTS

A history of hypertension in pregnancy, when compared with normotensive pregnancy, was associated with a 4.5% higher serum homocysteine level (P = .015) and 1.60-fold increased odds of having an elevated homocysteine (95% confidence interval, 1.15-2.21; P = .005) after adjusting for potentially confounding covariates. In contrast, a history of normotensive pregnancy, as compared with nulliparity, was associated with a 6.1% lower serum homocysteine level (P = .005) and a 0.49-fold reduced odds of elevated homocysteine levels (95% confidence interval, 0.32-0.74; P < .001).

CONCLUSION

Homocysteine levels decades after pregnancy are higher in women with a history of pregnancy hypertension, even after controlling for potential confounders. Thus, pregnancy history may prompt homocysteine assessment and risk modification in an attempt at primary prevention of cardiovascular disease.