Current best practice in the management of hypertensive disorders in pregnancy

An augmented illness-death model for semi-competing risks with clinically immediate terminal events

Preeclampsia is a pregnancy-associated condition posing risks of both fetal and maternal mortality and morbidity that can only resolve following delivery and removal of the placenta. Because in its typical form preeclampsia can arise before delivery, but not after, these two events exemplify the time-to-event setting of "semi-competing risks" in which a non-terminal event of interest is subject to the occurrence of a terminal event of interest. The semi-competing risks framework presents a valuable opportunity to simultaneously address two clinically meaningful risk modeling tasks: (i) characterizing risk of developing preeclampsia, and (ii) characterizing time to delivery after onset of preeclampsia. However, some people with preeclampsia deliver immediately upon diagnosis, while others are admitted and monitored for an extended period before giving birth, resulting in two distinct trajectories following the non-terminal event, which we call "clinically immediate" and "non-immediate" terminal events. Though such phenomena arise in many clinical contexts, to-date there have not been methods developed to acknowledge the complex dependencies between such outcomes, nor leverage these phenomena to gain new insight into individualized risk. We address this gap by proposing a novel augmented frailty-based illness-death model with a binary submodel to distinguish risk of immediate terminal event following the non-terminal event. The model admits direct dependence of the terminal event on the non-terminal event through flexible regression specification, as well as indirect dependence via a shared frailty term linking each submodel. We develop an efficient Bayesian sampler for estimation and corresponding model fit metrics, and derive formulae for dynamic risk prediction. In an extended example using pregnancy outcome data from an electronic health record, we demonstrate the proposed model's direct applicability to address a broad range of clinical questions.

Evaluation of Pregnant Women's Knowledge About Preeclampsia in the Kurdistan Region of Iraq: A Cross-Sectional Study

INTRODUCTION

Iraqi pregnant women have a higher prevalence of preeclampsia (PE) compared to pregnant women in neighboring developing nations. Several maternal characteristics, such as gestational weight gain (GWG), mode of delivery, and neonatal complications, have been linked to PE. The aim of this study is to evaluate the level of knowledge of pregnant women about PE.

METHODS

This cross-sectional study was conducted in the Kurdistan region in Iraq from 2022 to 2023. Data on women's knowledge was collected using a structured questionnaire consisting of 12 questions. The collected data was then analyzed using statistical methods such as the Mann-Whitney U test, Kruskal-Wallis test, and linear regression.

RESULTS

A total of 200 pregnant women diagnosed with PE and hypertension were included in the present study. The majority of participants (n=85; 42.5%) were between the ages of 28 and 37. Additionally, most participants (n=129; 64.5%) were from urban areas, with 45% (n=90) of them being obese. As for the participants' knowledge about PE, only 24.55% (n=49) were unaware of the correct answer, while 61% (n=122) stated that family history is not a risk factor for PE. On the other hand, 60% (n=120) of the participants were aware that previous PE is a risk factor for the current pregnancy, and 58.5% (n=117) indicated the importance of urine tests for pregnant women. Overall, the majority (n=144; 72%) had a low level of knowledge, while a small proportion (n=21; 10.5%) had good and high knowledge about PE.

CONCLUSION

The present study provides a comprehensive assessment of the knowledge of PE among Kurdish women, highlighting specific areas where intervention and education could potentially yield significant impact.

Validation of a new kit for preeclampsia screening: A comprehensive analysis

Objectives

Preeclampsia is a common pregnancy complication that significantly contributes to maternal mortality, perinatal mortality, and preterm delivery. The sFlt-1/PlGF (fms-like tyrosine kinase-1/placental growth factor) ratio has demonstrated robust diagnostic value for preeclampsia. This study assessed the analytical performance and diagnostic accuracy of a novel quantitative determination kit for sFlt-1 and PlGF for the diagnosis of preeclampsia.

Methods

The detection performance of the test kit was validated using the Center for Medical Device Evaluation (CMDE) and Clinical and Laboratory Standards Institute (CLSI) documents. The test results were compared to those of the Elecsys immunoassay (Roche Diagnostics). Independent discovery and validation sets were used to analyze the diagnostic efficacy of the preeclampsia kit. The area under the curve (AUC) for preeclampsia at different gestational ages was calculated.

Results

Correlation analysis between the test and Roche kits revealed a strong concordance (sFlt-1: r = 0.9966, P < 0.0001; PlGF: r = 0.9935, P < 0.0001). The AUCs for sFlt-1, PlGF, and the sFlt-1/PlGF ratio in diagnosing preeclampsia were 0.749, 0.795, and 0.834, respectively, in the discovery set and 0.729, 0.811, and 0.831, respectively, in the validation set. The corresponding results from the Roche kit were 0.741, 0.795, and 0.829, respectively, and 0.761, 0.864, and 0.844, respectively.

Conclusions

Quantitative sFlt-1 and PlGF kits exhibited high levels of consistency with the Roche kits in terms of quantitative outcomes and diagnostic performance for preeclampsia.

The Protective Effect of Abortion on Preeclampsia: An Analysis of Current Research

A review of the current literature on preeclampsia (PE) confirms that this pregnancy complication remains a common cause of maternal mortality. Within the last several decades, obstetric and gynecological researchers worldwide have indicated an association between prior abortions and the development of PE. Different studies have debated whether abortion is a protective or risk factor for PE. However, the most current literature demonstrates a stronger likelihood that a positive history of abortions will offer a protective effect against PE. This association has been supported by advancements in the reproductive immunology literature, which states complex fetal and paternal pathological mechanisms help to build maternal immunological tolerance, thus protecting expectant mothers from pregnancy complications. This literature review will compare studies supporting prior abortions offering a protective effect against PE with those stating prior abortions are a risk factor for the development of PE. Additionally, this critical review will discuss the advancements and current understanding of reproductive immunology and how it pertains to this association between positive abortion history and PE.

Relationship between the hemodynamic profile and resistant hypertension in pregnant patients with hypertensive crisis

OBJECTIVE

Reducing maternal morbidity and mortality has been a challenge for low and middle-income countries, especially in the setting of hypertensive disorders of pregnancy. Improved strategies for treating obstetric patients with resistant hypertension are needed. We sought to explore whether hemodynamic parameters may be used to identify patients that develop resistant hypertension in pregnancy.

METHODS

Retrospective cohort study among pregnant patients with gestational hypertension or preeclampsia that experienced severe blood pressure elevations. Hemodynamic variables were evaluated, including cardiac output (CO), and total peripheral resistance (TPR). The primary endpoint was resistant hypertension. An exploratory logistic regression was performed to evaluate the association between the hemodynamic profile and the development of resistant hypertension. Adverse maternal and fetal outcomes were additionally described according to the presence of resistant hypertension.

RESULTS

Fifty-seven patients with severe pregnancy hypertension were included, of whom 34 developed resistant hypertension (59.7%). The resistant hypertension group, in comparison to those without resistant hypertension, presented with a hypodynamic profile characterized by reduced CO < 5 L/min (41.2% vs. 8.7%, p: 0.007), and increased TPR > 1400 dyn-s/cm5 (64.7% vs. 39.1%, p: 0.057). Logistic regression analysis revealed an association between a hypodynamic profile and resistant hypertension (OR 3.252, 95% CI 1.079-9.804; p = 0.035). Newborns of the resistant hypertension group had more frequent low birth weight (<2500 g), low Apgar scores, ICU admissions, and acute respiratory distress syndrome.

CONCLUSION

Patients experiencing hypertensive crisis during pregnancy and exhibiting a hypodynamic profile (TPR ≥1400 dyn·s/cm5 and CO ≤ 5 L/min) developed higher rates of resistant hypertension.

Endostatin and Cystatin C as Potential Biomarkers for Early Prediction of Preeclampsia

Preeclampsia (PE) is characterized by new onset hypertension and proteinuria. Undoubtedly, some individuals do not fit precisely into this description, and it could be challenging to spot newly developed PE in females who already have hypertension or renal illness. Monitoring the disease's progression enables the optimization of delivery time while minimizing premature births. The current study explores the diagnostic benefits of serum endostatin and cystatin C in addition to serum and urinary magnesium (Mg) and fractional excretion magnesium (FEMg) for early prediction of PE. The population sample included 82 pregnant women divided into 3 groups: normal pregnancy group served as a control (n = 26), nonpreeclampsia (NPE, n = 34) group included pregnant women with one or more risk factors but did not progress to PE, and pregnant women who developed preeclampsia (PE, n = 22) group. Blood samples were withdrawn at two sampling times: at 12th to 16th and 24th to 26th weeks of gestation. Compared to normal pregnancy, results (X̅ ± SD) indicated a significant increase in serum endostatin in NPE at the first sample (10.78 ± 3.63 ng/mL) and the second sample (28.03 ± 3.79 ng/mL), while cystatin C was at the first sample (0.68 ± 0.06 mg/dL) and the second sample (0.71 ± 0.07 mg/dL). In the PE group, the serum endostatin was 18.86 ± 4.37 ng/mL at the first sampling time and 53.56 ± 9.76 ng/mL for the second sample. Serum cystatin C was also elevated in PE with X̅ ± SD equivalent to 0.73 ± 0.08 and 0.89 ± 0.08 mg/dL at the first and second samples, respectively. On the other hand, serum and urinary Mg in addition to FEMg levels did not significantly differ across the groups under study. Receiver operating characteristic (ROC) curve analysis proved that both endostatin and cystatin C could be good indicators for PE. The findings imply that measuring endostatin and cystatin C at early pregnancy and before progression to PE may be effective in detecting the likelihood of PE. Endostatin could be more precise and sensitive in assessing the probability of PE than cystatin C; however, coupling of the two parameters may be promising.

VASCULAR AND RENAL MECHANISMS OF PREECLAMPSIA

Preeclampsia (PE) is a multisystem obstetric disorder that affects 2-10% of pregnancies worldwide and it is a leading cause of maternal and fetal morbidity and mortality. The etiology of PE development is not clearly delineated, but since delivery of the fetus and placenta often leads to symptom resolution in the most cases of PE, it is hypothesized that the placenta is the inciting factor of the disease. Current management strategies for PE focus on treating the maternal symptoms to stabilize the mother in an attempt to prolong the pregnancy. However, the efficacy of this management strategy is limited. Therefore, identification of novel therapeutic targets and strategies is needed. Here, we provide a comprehensive overview of the current state of knowledge regarding mechanisms of vascular and renal pathophysiology during PE and discuss potential therapeutic targets directed at improving maternal vascular and renal function.

Literature Review: The sFlt1/PlGF Ratio and Pregestational Maternal Comorbidities: New Risk Factors to Predict Pre-Eclampsia

One of the main causes of maternal and neonatal morbidity and mortality is pre-eclampsia. It is characterized by a high sFlt1/PlGF ratio, according to prior research. Pregestational diseases in mothers may increase the risk of developing pre-eclampsia. Only a few studies have looked at the connection between maternal comorbidities before conception and the sFlt1/PlGF ratio. The most recent information regarding the association between maternal pregestational diseases and the ratio of sFlt1/PlGF is described in this review. The paper also examines current research suggesting that changes in pregnancy hormones and metabolites are related to a high sFlt1/PlGF ratio. Certain maternal disorders have been found to dramatically raise sFlt-1 and sFlt1/PlGF levels, according to an analysis of the literature. There is still debate about the data on the association between the sFlt1/PlGF ratio and maternal disorders such as HIV, acute coronary syndromes, cardiovascular function in the mother between 19 and 23 weeks of pregnancy, thyroid hormones, diabetes, and cancer. Additional research is needed to confirm these findings.

Awareness of Preeclampsia among Antenatal Clinic Attendees in Northwestern Nigeria

Background  Preeclampsia (PE) is among the five main causes of maternal mortality in low resource countries. This study was designed to assess PE awareness and its socioeconomic determinants among antenatal clinic attendees in northwestern Nigeria. Methods  Two hundred twenty-one antenatal clinic attendees in northwestern Nigeria were selected through systematic random sampling for this quantitative study. Women who were 9 months pregnant and had consented to participate were included; those with chronic illnesses such as diabetes mellitus were excluded. Data on respondents' sociodemographic variables, and PE awareness were collected using a validated questionnaire. Associations between variables were tested using chi-square test and multiple regression analysis. Results  Ninety-one percent of respondents were aged 20 to 40 years, 53.9% were multiparous, 27% had no or low level of formal education, and 52% had attended antenatal care (ANC) at least four times in the index pregnancy. Only 37% ( N  = 83) were aware of PE. Women with formal education were 3.8 times more likely (odds ratio [OR] = 3.8, 95% confidence interval [CI] = 1.4-10.3) to be aware of PE compared with those with no formal education ( p  < 0.05). Also, women who experienced hypertension in their previous pregnancies were 2.8 times more likely (OR = 2.8, 95% CI = 1.37-5.71) to be aware of PE than those women who had not ( p  < 0.05). Conclusion  There was a low level of PE awareness among pregnant women in this study; being formally educated and having had hypertension in a previous pregnancy were positively associated with PE awareness. PE education should be part of ANC.

Patients' understanding of long-term cardiovascular risks and associated health-seeking behaviours after pre-eclampsia

OBJECTIVE

The lifelong risks of cardiovascular disease following hypertensive disorders of pregnancy are well described. Awareness of these risks and associated health-seeking behaviours among affected individuals remains unclear. We aimed to assess participants' knowledge of their cardiovascular disease risk and relevant health-seeking behaviours following a pregnancy affected by preeclampsia or gestational hypertension.

METHODS

We undertook a single-site, cross-sectional cohort study. The target population included individuals who birthed at a large tertiary referral centre in Melbourne, Australia, between 2016 and 2020, and were diagnosed with gestational hypertension or pre-eclampsia. Participants completed a survey assessing pregnancy details, medical comorbidities, knowledge of future risks and health-seeking behaviours post-pregnancy.

RESULTS

1526 individuals met inclusion criteria and 438 (28.6%) completed the survey. Of these, 62.6% (n=237) were unaware of their increased risk of cardiovascular disease following a hypertensive disorder of pregnancy. Participants who reported awareness of their increased risk were more likely to have annual blood pressure monitoring (54.6% vs 38.1%, p<0.01), and at least one assessment of blood cholesterol (p<0.01), blood glucose (p=0.03) and renal function (p=0.01). Participants who were aware were more likely to be taking antihypertensive medication (24.5% vs 6.6%, p<0.01) since pregnancy, compared with those who were unaware. There were no differences between groups in diet, exercise or smoking habits.

CONCLUSION

Among our study cohort, risk awareness was associated with increased health-seeking behaviours. Participants who were aware of their increased risk of cardiovascular disease were more likely to have regular cardiovascular risk factor assessments. They were also more likely to be taking antihypertensive medication.

Maternal Steroids on Fetal Doppler Indices, in Growth-Restricted Fetuses with Abnormal Umbilical Flow from Pregnancies Complicated with Early-Onset Severe Preeclampsia

Corticoids are largely used for fetal interest in expected preterm deliveries. This study went further, evaluating the effect of maternal administration of dexamethasone (Dex) on the umbilical artery (UA), middle cerebral artery (MCA), and ductus venous (DV) spectrum, in growth-restricted fetuses, with the absent end-diastolic flow (AEDF) in UA, from singleton early-onset severe preeclamptic pregnancies. Supplementary, the impact on both uterine arteries (UTAs) flow was also evaluated. In 68.7% of cases, the EDF was transiently restored (trAEDF group), in the rest of 31.2% remained persistent absent (prAEDF group). UA-PI significantly decreased in the first day after Dex (day 1/0; p < 0.05), reaching its minimum during day 2 (day 2/1; p > 0.05), revealing a significant recovery to day 4 (day 4/2; p < 0.05), in both groups. The MCA-PI decreased from day 1 until day 3 in both groups, but significantly only in the trAEDF group (p = 0.030 vs. p = 0.227. The DV-PI's decrease (during day 1) and the CPR's increase (between days 0 and 2) were not significant in both groups. UTAs-PIs did not vary. The prAEDF group had a significantly increased rate of antenatal worsening Doppler and a poorer perinatal outcome compared with the trAEDF group. In conclusion, Dex transiently restored the AEDF in UA in the majority of cases, a "positive" effect being a useful marker for better perinatal prognosis. UA-PI significantly decreased in all cases. The improvement in umbilical circulation probably was responsible for the short but not significant DV-PI reduction. MCA-PI decreased only in sensitive cases, probably due to an already cerebral "full" vasodilation in the prAEDF group. Furthermore, the CPR's nonsignificant improvement was the result of a stronger effect of Dex on UA-PI than on MCA-PI. Finally, despite the same etiology, it was only a weak correlation between the severity of the umbilical and uterine abnormal spectrum.

Association between maternal serum uric acid and preeclampsia

OBJECTIVE

The aim of this study is to compare the changes in serum uric acid levels among preeclamptic pregnant women and healthy pregnant women.

METHODS

Two hundred and twenty-four (224) pregnant women were enrolled. Serum uric acid levels were analysed in the two groups at the time of referral and prior to the delivery.

RESULTS

The mean uric acid in all pregnant women was 5.61 mg/dL. The mean uric acid in women with preeclampsia was 6.51 ± 1.53 and in normotensive women was 4.72 ± 1.58, which was seen significant. The mean age of the mother, gestational age and BMI were not significant with the levels of uric acid. The elevation in serum levels of uric acid increased the risk of preeclampsia by 1.98 folds.

CONCLUSION

There is a significant increase in the serum levels of uric acid in pregnant women with preeclampsia as compared to normotensive women. This can be one of a significant indicator of preeclampsia.

Maternal tumour necrosis factor-alpha levels in preeclamptic pregnancies in Lagos, South-West Nigeria

OBJECTIVE

This study aimed to assess the association between maternal serum levels of TNF-α and preeclampsia.

METHODS

An analytical cross-sectional study involving 45 women diagnosed with preeclampsia and 45 healthy normotensive pregnant women matched for age, and gestational age at enrolment. Venous samples were collected from each participant after informed consent was obtained. Serum TNF-α level was determined using the human TNF-α competitive enzyme-linked immunosorbent assay (ELISA) technique with ELISA Kit. Hypothesis testing was done using the Chi-square test for categorical variables, the independent samples t-test and the Kruskal-Wallis test for numerical variables. All significances were reported at P < 0.05.

RESULTS

The median concentrations of TNF-α in women with preeclampsia of varying severity were significantly higher than those with normotensive pregnancies (P = 0.001). The median level of TNF-α was also significantly higher in patients with severe features of preeclampsia than in those without. The estimated cut-off levels of serum TNF-α were 15.6 ng/mL and 26.4 ng/mL respectively for the development and severity of preeclampsia. Maternal serum TNF-α level in preeclamptic patients is strongly correlated with systolic and diastolic BP, serum uric acid and alkaline phosphatase levels, proteinuria, and platelet count (P < 0.05).

CONCLUSION

We can infer from this study that increased maternal serum levels of TNF-α may play a significant role in the pathogenesis of preeclampsia. We recommend further validation of these findings with a more robust longitudinal characterization of maternal serum TNF-α profiles in pregnancy through a well-designed prospective cohort study.

Comparison of Intravenous Anti-hypertensives for Preoperative Blood Pressure Control in Hypertensive Disorders of Pregnancy and Effect of Oral Labetalol

BACKGROUND AND AIMS

Intravenous hydralazine and labetalol are recommended as first-line anti-hypertensives for controlling severe hypertension in pregnancy. Our study aimed at identifying the most effective drug with minimum side effects for preoperative management of severe hypertension in parturients scheduled for Caesarean delivery (CD). We also studied the effect of these drugs on patients already on oral labetalol in the antenatal period.

METHODS

A prospective observational study was done on 162 hypertensive parturients scheduled to undergo emergency CD who received hydralazine or labetalol in the preoperative period. Demographic data, booking status, hemodynamic data, time taken to reach adequate control of blood pressure (BP), drug efficacy, the incidence of persistent hypertension, adverse effects associated with the drugs, and maternal and fetal outcomes were noted.

RESULTS

The time taken for the control of BP was similar with both drugs (p-value = 0.425). The mean number of doses required to achieve target BP was significantly less with hydralazine compared to labetalol (p-value = 0.009). Patients on tablet labetalol in the antenatal period were poorly controlled when put on the same drug intravenously but had better control with hydralazine (p-value = 0.005). The incidence of persistent hypertension was lower in patients treated with hydralazine compared with labetalol (p-value = 0.008).

CONCLUSION

Both drugs took a similar time for BP control. However, hydralazine was more efficacious, produced adequate control of BP in a higher number of patients, and had a lower incidence of persistent hypertension.

The effect of preeclampsia on adverse maternal outcomes in Sidama region, Ethiopia: a prospective open cohort study

Ethiopia has made improvements in the reduction of maternal mortality; the high burden of preeclampsia remains a concern in the Sidama region. This study aimed to measure the effect of preeclampsia on adverse maternal outcomes and identify risk factors among women with preeclampsia in Sidama region. A prospective open cohort study was conducted from August 8, 2019, to October 1, 2020. We enrolled a total of 1015 the pregnant women who had preeclampsia and normotensive women at ≥ 20 weeks of gestation and followed them until 42 days after delivery. A log-binomial logistic regression model was used to estimate the incidence of adverse maternal outcomes and its risk factors. There were 276 adverse maternal outcomes observed in the preeclampsia group compared to 154 adverse maternal outcomes in the normotensive group (P < 0.001). Women with severe features of preeclampsia had a 43% (aRR = 1.43, 95% CI 1.3-1.58) higher risk for adverse maternal outcomes compared to women without severe features of preeclampsia. Women without severe features of preeclampsia had a 39% (aRR = 1.39, 95% CI 1.2-1.76) higher risk for adverse maternal outcomes compared to women in the normotensive group. More adverse maternal outcomes occurred among women with preeclampsia after controlling for confounders.

Review: Influence of 25(OH)D Blood Concentration and Supplementation during Pregnancy on Preeclampsia Development and Neonatal Outcomes

Briefly, 25-hydroxyvitamin D (25(OH)D) plays an essential role in embryogenesis and the course of intra- and postnatal periods and is crucially involved in the functioning of the mother-placenta-fetus system. The low quantity of 25(OH)D during pregnancy can lead to an elevated risk for preeclampsia occurrence. Despite the numerous studies on the association of 25(OH)D deficiency and preeclampsia development, the current research on this theme is contradictory. In this review, we summarize and analyze study data on the effects of 25(OH)D deficiency and supplementation on pregnancy, labor, and fetal and neonatal outcomes.

Incidence of adverse perinatal outcomes and risk factors among women with pre-eclampsia, southern Ethiopia: a prospective open cohort study

BACKGROUND

In Ethiopia, in 2021, more than 80% of all newborn deaths were caused by preventable and treatable conditions. This study aimed to measure the incidence of adverse perinatal outcomes and risk factors among women with pre-eclampsia in the Sidama region of southern Ethiopia.

METHODS

A prospective open cohort study was conducted from 8 August 2019 to 1 October 2020. We enrolled 363 women with pre-eclampsia and 367 normotensive women at ≥20 weeks of gestation and followed them until the 37th week. We then followed them until the seventh day after delivery up to the last perinatal outcome status was ascertained. A log-binomial logistic regression model was used to estimate the incidence of adverse perinatal outcomes and its risk factors among women with pre-eclampsia. Relative risk (RR) with a 95% CI was reported. A p<0.05 was considered statistically significant.

RESULTS

There were 224 adverse perinatal outcomes observed in the 363 women with pre-eclampsia compared with 136 adverse perinatal outcomes in the 367 normotensive women (p<0.001). There were 23 early neonatal deaths in the pre-eclampsia group compared with six deaths in the normotensive group (p<0.001). There were 35 perinatal deaths in the pre-eclampsia group compared with 16 deaths in the normotensive group (p<0.05). Women with severe features of pre-eclampsia had a 46% (adjusted RR 1.46, 95% CI 1.38 to 2.77) higher risk for adverse perinatal outcomes compared with women without severe features of pre-eclampsia.

CONCLUSIONS

In this study, more adverse perinatal outcomes occurred among women with pre-eclampsia after controlling for confounders. A higher perinatal outcome observed among women with pre-eclampsia, especially among women with severe features of pre-eclampsia, and those admitted to hospital at <34 weeks. This paper highlights the significantly elevated perinatal risks associated with pre-eclampsia, especially when it has severe features.

Macro- and Micronutrient of Junk Food and Preeclampsia on Pregnant Women

BACKGROUND: Preeclampsia (PE) is still a global public health issue in developed and developing countries. It is a major contributor to maternal and fetal morbidity and mortality. The pathophysiology of preeclampsia during pregnancy is unclear, but the WHO reported that PE is higher in developing countries than developed ones due to lifestyle and nutritional status. AIM: This study aimed to describe the influence of macro- and micronutrients of junk food on PE. METHODS: This case–control study was carried out on 148 samples, including pregnant women with preeclampsia (n = 74) and normal pregnant women (n = 74) with gestational age > 20 weeks. Data on junk food intake were collected using the SQ-FFQ form and then estimated using the Nutri Survey. Data were analyzed in SPSS version 17 using descriptive statistics. Pearson correlation coefficient was used to observe the correlation between variables with p < 0.05 and 95% confidence interval. RESULTS: Binary logistic regression revealed that the intake of fat (p = 0.005), vitamin C (p = 0.002), and sodium (p = 0.036) contained in the junk food were significantly associated with PE. The frequency of consumption of junk food also had a significant effect on the incidence of preeclampsia (p = 0.013). CONCLUSION: Intake of fat, vitamin C, and sodium were associated with PE, and they were risk factors of PE. The frequency of consuming junk food gave more risk to have PE.

Urinary Protein-to-Creatinine Ratio: An Indicator of Adverse Clinical Outcomes in Preeclampsia With Proteinuria

Background and objective

Preeclampsia is a major contributor to morbidity and mortality among pregnant women and leads to poor fetomaternal outcomes. Predicting fetal and maternal health outcomes will enable early interventions so as to reduce further damage. Various biochemical tests like beta-human chorionic gonadotropin (β-HCG), inhibin A, activin A, pregnancy-associated plasma protein-A (PAPP-A), fetal DNA, and color Doppler have been studied for their ability to predict fetal and maternal health outcomes; however, most of these tests are complex and costly. Among the many variables that indicate the severity of outcomes in hypertensive disorders of pregnancy, the urinary protein-to-creatinine ratio (UPCR) is an important index. The aim of the study was to find out the association between UPCR and fetomaternal outcomes in preeclampsia.

Material and methods

A prospective observational study was conducted among 141 women with preeclampsia presenting with proteinuria, who were divided into two groups: 11% with UPCR <0.3 and 89% with UPCR ≥0.3. These patients were followed up till delivery to look for maternal and fetal outcomes.

Results

The sensitivity of UPCR for predicting adverse maternal outcomes was 79.37% (95% CI: 71.25-86.06), specificity was 46.67% (95% CI: 21.27-73.41), positive predictive value (PPV) was 92.59% (95% CI: 88.53-95.29), negative predictive value (NPV) was 21.21% (95% CI: 12.43-33.81), and the accuracy was 75.79% (95% CI: 67.97-82.69); for adverse fetal outcomes, the sensitivity was 76.98% (95% CI: 68.65-84.01), specificity was 13.33% (95% CI: 1.66-40.46), PPV was 88.18% (95% CI: 85.69-90.29), NPV was 6.45% (95% CI: 1.79-20.67), and the accuracy was 70.21% (95% CI: 61.94-77.62).

Conclusion

Based on our findings, UPCR is a simple laboratory tool that can help predict abnormal fetomaternal outcomes in preeclampsia with good sensitivity and PPV and can be used as an adjunct to assist in clinical decisions.

Optimising Cardiometabolic Risk Factors in Pregnancy: A Review of Risk Prediction Models Targeting Gestational Diabetes and Hypertensive Disorders

Cardiovascular disease, especially coronary heart disease and cerebrovascular disease, is a leading cause of mortality and morbidity in women globally. The development of cardiometabolic conditions in pregnancy, such as gestational diabetes mellitus and hypertensive disorders of pregnancy, portend an increased risk of future cardiovascular disease in women. Pregnancy therefore represents a unique opportunity to detect and manage risk factors, prior to the development of cardiovascular sequelae. Risk prediction models for gestational diabetes mellitus and hypertensive disorders of pregnancy can help identify at-risk women in early pregnancy, allowing timely intervention to mitigate both short- and long-term adverse outcomes. In this narrative review, we outline the shared pathophysiological pathways for gestational diabetes mellitus and hypertensive disorders of pregnancy, summarise contemporary risk prediction models and candidate predictors for these conditions, and discuss the utility of these models in clinical application.

Maternal Adverse Outcomes in Hypertensive Disorders of Pregnancy and Their Association with Serum Adiponectin and Redox Markers

Background: Premature termination of pregnancy because of unmanageable maternal complications in hypertensive disorders of pregnancy (HDP) results in adverse neonatal outcome. Identification of biochemical derangements associated with maternal complications may help in the better medical management of the mother resulting in better neonatal outcomes. Method: Healthy pregnant women (C); pregnant women with gestational hypertension (GH), and preeclampsia (late [LP] and early [EP] onset) were studied. Maternal serum redox markers and adipokines were evaluated for their association with maternal complications. Results: Adiponectin levels were significantly raised in preeclampsia groups when compared with control and GH groups. Univariate and multivariate analysis confirmed that malondialdehyde (MDA) and total antioxidant status (TAS) were associated with eclampsia; adiponectin and TAS with HELLP syndrome; adiponectin, MDA and TAS with severe preeclampsia; and adiponectin with impaired renal function. Conclusion: We identified that increased serum adiponectin, MDA, and TAS were associated with adverse maternal outcomes.

Dysregulated BMP2 in the Placenta May Contribute to Early-Onset Preeclampsia by Regulating Human Trophoblast Expression of Extracellular Matrix and Adhesion Molecules

Many pregnancy disorders, including early-onset preeclampsia (EOPE), are associated with defects in placental trophoblast cell invasion and differentiation during early placental development. Bone morphogenetic protein 2 (BMP2) belongs to the TGF-β superfamily and controls various physiological and developmental processes. However, the expression of BMP2 in the placenta and underlying molecular mechanisms of how BMP2 regulates trophoblast function remain unclear. In this study, we analyzed several publicly available microarray and RNA-seq datasets and revealed differences in expression of TGF-β superfamily members between gestational age-matched non-preeclamptic control and EOPE placentas. Importantly, BMP2 levels were significantly reduced in EOPE placentas compared with controls, and RNAscope in situ hybridization further demonstrated BMP2 expression was disrupted in EOPE placental villi. To explore the molecular mechanisms of BMP2-regulated early trophoblast differentiation, we examined BMP2 expression in first-trimester human placenta and found it to be localized to all subtypes of trophoblasts and the decidua. RNA-seq analysis on control and BMP2-treated primary human trophoblast cells identified 431 differentially expressed genes, including several canonical TGF-β/BMP signaling targets (BAMBI, ID1, INHBA, IGFBP3). Gene ontology annotations revealed that differentially expressed genes were involved in cell adhesion and extracellular matrix organization. Furthermore, we identified adhesion molecule with IgG-like domain 2 (AMIGO2) as a novel target for BMP2 that contributed to BMP2-induced trophoblast invasion and endothelial-like tube formation. Overall, our findings provide insight into the molecular processes controlled by BMP2 during early placental development that may contribute to the pathogenesis of EOPE.

Dexamethasone on absent end-diastolic flow in umbilical artery, in growth restricted fetuses from early-onset preeclamptic pregnancies and the perinatal outcome

BACKGROUND

Absent end-diastolic flow (AEDF) in the umbilical artery (UA) worsens the already poor prognosis of growth-restricted fetuses (GRFs) in pregnancies complicated by early-onset preeclampsia with severe features (ESP).

METHOD

We assessed the correlation between the effect of maternal dexamethasone (Dex) on AEDF in the UA and perinatal outcomes, in 59 GRFs from EPS-complicated pregnancies. The maternal outcome was also evaluated.

RESULTS

The mean maternal age at inclusion was 22.4 ± 5.9 years. Dex transiently restored EDF in the UA in 38 (64.4%) cases (trAEDF group), but in 21 (35.6%) patients, the flow was persistently absent (prAEDF group). The effect lasted up to the 4th day.The gestational age at diagnosis, number of days from admission until delivery, and fetal weight were significantly lower in the prAEDF group than in the trAEDF group (p < .05). The same group had a significantly increased rate of fetal proximal deterioration, low APGAR scores, neonatal hypoxia, assisted ventilation, mild intraventricular haemorrhage (I/II), and respiratory distress syndrome, as well as maternal deterioration, especially in cases of resistant hypertension (p < .05). Although the rates of fetal acidemia and perinatal mortality in the prAEDF group were respectively three times and two times higher, the differences were not significant (p > .05).

CONCLUSIONS

The Dex no-effect on UA Doppler in GRFs with AEDF in the UA, in EPS-complicated pregnancies, can be a useful marker for a higher risk of proximal fetal deterioration, poor state at delivery, neonatal hypoxic complications, and worsening maternal condition, but not for perinatal mortality. The findings also highlight the alarmingly younger age of patients with EPS. Finally, all these pregnancies should be monitored in a complex multidisciplinary manner in tertiary referral units.Key messageThe effect of dexamethasone on absent end-diastolic flow in the umbilical artery in growth-restricted fetuses from pregnancies complicated by early-onset preeclampsia with severe features can be a useful prognostic factor for perinatal outcomes.

Comparison of Maternal Serum Levels and Placental mRNA Levels of Dickkopf-1 in Preeclamptic and Normal Pregnant Women at Delivery

Background Preeclampsia remains a major cause of perinatal and maternal mortality and morbidity worldwide. Wnt/β-catenin signaling is known to be critically involved in placenta development processes. Dickkopf-1 (DKK1) is a key regulator of this transduction pathway. The aim of this study is to compare maternal serum DKK1 levels and placental mRNA levels of DKK1 and β-catenin in preeclamptic and normal pregnant women at delivery.

Methods The present study included 30 women with preeclampsia and 30 women with normal pregnancy. Maternal serum DKK1 levels were measured by ELISA. Placental mRNA levels of DKK1 and β-catenin were detected using RT-PCR.

Results Decreased maternal serum DKK1 levels were associated with worse maternal and fetal complications including HELLP syndrome, determination of one or more pathological symptom and IUGR diagnosis. No significant difference in maternal serum DKK1 levels was reported between preeclamptic women and women with normal pregnancy. Placental mRNA DKK1 levels were lower in preeclamptic women compared with normal pregnant women. Placental mRNA β-catenin levels showed no significant difference between two groups.

Conclusions Our findings reported the aberrant placental mRNA DKK1 levels in patients with preeclampsia. In addition, worse preeclampsia features were associated with decreased maternal serum DKK1 levels. Hence, aberrant Wnt/β-catenin signaling might present a plausible mechanism in preeclampsia pathogenicity. Dysregulated expression of DKK1 at gene level in the placenta but not at protein level in the maternal serum might confirm the notion that preeclampsia is a type of placenta-derived disease.

A pattern of platelet indices as a potential marker for prediction of pre-eclampsia among pregnant women attending a Tertiary Hospital, Ethiopia: A case-control study

INTRODUCTION

Preeclampsia is the most serious health risk during pregnancy for both the mother and the fetus. Even though platelet parameters are among the proposed biomarkers for the prediction of preeclampsia, the use of its indices in the diagnosis of preeclampsia is not increasing in Ethiopia. There is little information on platelet patterns in preeclampsia and normal pregnancy. The purpose of this study was to determine the pattern of platelet indices in women with preeclampsia in our study setting.

METHODS

A case-control study was conducted among 180 pregnant women who attended anti-natal follow-ups from January 1 to April 3, 2019. An Ethylene Diamine Tetra Acetic Acid anti-coagulated venous blood was collected and analyzed using a hematology analyzer (MINDRAY®-BC-300Plus, Shenzhen China). The SPSS software version 26 was used to run the Mann Whitney U test, Kruskal-Wallis H test, and Kolmogorov-Smirnov normality test, Post-hock test augmented with Benforeni, receiver operating characteristics curve, and Spear Man rank-order correlation. A P-value of <0.05 was considered statistically significant.

RESULTS

A total of 180 pregnant women were included in the study. Platelet count and platelet crit levels tend to decrease as pre-eclampsia becomes more severe. In contrast, the mean platelet volume and platelet distribution widths were significantly increased with the severity of preeclampsia (P<0.001). Platelet distribution width (rho = 0.731, p<0.001) and mean platelet volume (rho = 0.674, p<0.001) had statistically significant positive relationships with mean arterial pressure. The best metric for predicting preeclampsia was platelet distribution width (AUC = 0.986; 95%CI; 0.970, 1).

CONCLUSIONS

Platelet indices, including platelet count, mean platelet volume, platelet distribution width, and Platelet crit, have been identified as promising candidate markers for predicting preeclampsia in pregnant women. In the future, a serial examination of these indicators during several trimesters of pregnancy should be conducted.

The burden of severe hypertensive disorders of pregnancy on perinatal outcomes: a nationwide case-control study in Suriname

BACKGROUND

Latin America and the Caribbean is the region with the highest prevalence of hypertensive disorders of pregnancy worldwide. In Suriname, where the stillbirth rate is the second highest in the region, it is not yet known which maternal factors contribute most substantially.

OBJECTIVE

The aims of this study in Suriname were to (1) study the impact of different types of maternal morbidity on adverse perinatal outcomes and (2) study perinatal birth outcomes among women with severe hypertensive disorders of pregnancy.

STUDY DESIGN

A case-control study was conducted between March 2017 and February 2018 during which time all hospital births (86% of total) in Suriname were included. We identified babies with adverse perinatal outcomes (perinatal death or neonatal near miss) and women with severe maternal morbidity (according to the World Health Organization Near Miss tool). Stillbirths and early neonatal deaths (<7 days) were considered perinatal death. We defined a neonatal near miss as a birthweight below 1750 g, gestational age <33 weeks, 5-minute Apgar score <7, and preterm intrauterine growth restriction <p3. Descriptive statistics and multivariate binary logistic regression analyses were conducted.

RESULTS

In the 1-year study period, adverse perinatal outcomes were reported for 638 singleton births of which 120 (18.8%) involved women with severe maternal morbidity. In most of these cases, the mother suffered severe hypertensive disorders of pregnancy (n=95/120, 79.2%). Severe hypertensive disorders of pregnancy were strongly associated with adverse perinatal outcomes (adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9). The prevalence of severe hypertensive disorders of pregnancy in Suriname was 2.5% (234/9197). Of the 215 singleton pregnancies complicated by severe hypertensive disorders, adverse perinatal outcomes were reported for 44.2% of them (n=95/215; adjusted odds ratio, 11.1; 95% confidence interval, 8.3–14.9); perinatal death accounted for 18.1% of these cases (n=39/215; adjusted odds ratio, 8.6; 95% confidence interval, 5.8–12.7) and neonatal near miss accounted for another 26.0% (n=56/215). Women with severe hypertensive disorders of pregnancy had a preterm birth (<37 weeks) in 67.1% of the cases (n=143/215; adjusted odds ratio, 14.1; 95% confidence interval, 10.5–19.0), a baby with a low birthweight (<2500 g) in 62.2% of the cases (n=130/215; adjusted odds ratio, 10.8; 95% confidence interval, 8.1–14.5), and a baby with a low 5-minute Apgar score in 20.5% of the cases (n=43/215; adjusted odds ratio, 6.9; 95% confidence interval, 4.8–10.0).

CONCLUSION

In Suriname, severe hypertensive disorders of pregnancy are strongly associated with adverse perinatal outcomes, with an increased risk for preterm birth, low birthweight, low Apgar score, and perinatal mortality. Prevention, early diagnosis, and management of hypertensive disorders of pregnancy are expected to reduce perinatal deaths substantially. Recommendations to reduce perinatal deaths in Suriname include the establishment of a national health plan for the management of severe hypertensive disorders of pregnancy and the introduction of perinatal death and neonatal near miss reviews.

The effect of preexisting medical comorbidities on the preeclamptic phenotype: a retrospective cohort study

Objective:To compare the effect of comorbidities on the phenotype and outcomes of preeclampsia.Methods: A matched retrospective cohort study of women delivering at a tertiary maternity center following a diagnosis of preeclampsia. We collected data on signs and symptoms, biochemical markers, and maternal and perinatal outcomes.Results:We studied 474 women; 158 women with and 316 without comorbidities. Compared to women without comorbidities, women with comorbidities delivered earlier. They suffered fewer maternal but more neonatal complications.Conclusion: Women with comorbidities receive earlier intervention than women without comorbidities, which may lead to fewer maternal complications but worse neonatal outcomes.

Long non-coding RNA myocardial infarction associated transcript expression and clinical significance in patients with hypertension during pregnancy

OBJECTIVE

This study aimed to investigate the expression level of lncRNA myocardial infarction associated transcript (MIAT) in serum of pregnant women with hypertensive disorders in pregnancy (HDP) and its clinical significance.

METHODS

A total of 135 pregnant women with HDP were selected, including 69 pregnant women with gestational hypertension (GH) and 66 pregnant women with preeclampsia (PE). Sixty-eight normal pregnant women were selected as healthy control group (HC). The expression level of serum MIAT of all subjects was detected by quantitative real-time polymerase chain reaction (qRT-PCR), and the diagnostic value of MIAT for GH was evaluated by constructing receiver operating characteristic (ROC) curve. Pearson correlation coefficient was used to analyze the correlation between MIAT and patients' clinical indicators. Logistics regression analysis evaluated the influencing factors of GH development into PE.

RESULTS

The level of MIAT in GH group was significantly higher than that in HC group, while MIAT level in PE group was more significantly upregulated than that in GH group and HC group. ROC curve showed that MIAT had the ability to distinguish between GH patients and healthy controls. Pearson correlation coefficient suggested that HOTAIR expression was positively correlated with systolic blood pressure (SBP) and diastolic blood pressure (DPB). Logistic regression analysis showed that MIAT was an independent influencing factor for the development of GH to PE.

CONCLUSION

The expression of MIAT in serum of HDP patients was increased and positively correlated with the severity of the disease. The abnormal expression of MIAT has certain diagnostic value for GH.

Course and outcomes of pregnancy in women treated for acromegaly: Discerning a contemporary cohort

OBJECTIVE

To analyze pregnancy course and outcomes in women treated for acromegaly and compare outcomes based on disease activity at the time of conception.

DESIGN

Retrospective study.

PATIENTS

Women with acromegaly diagnosed prior to or during pregnancy from 2010 to 2019, representing cases (14 pregnancies in 12 cases), were later stratified based on active (n = 5) or controlled disease (n = 9) at time of conception. Female acromegalic patients over the same period constituted the 'acromegaly cohort' (AC) (n = 75).

RESULTS

All cases had macroadenomas with nadir GH of 15.06 ng/ml (IQR 9-30), IGF-I index of 3.04 (1.96-3.82), for which they had undergone pituitary surgery; except two patients diagnosed during pregnancy, who received pharmacotherapy followed by surgery 4 months postpartum. Adjuvant pharmacotherapy was required in 71.4% patients and radiotherapy in 35.7%. Pregnancy occurred at a median of 2 (0.8-5.1) years after surgery and 21.4% required assisted reproduction. All had term delivery with normal APGAR except one case with gestational hypertension, who delivered a preterm baby. None had congenital malformations. Despite higher baseline IGF-I, GH and tumor volume in those with pre-conceptional active acromegaly, materno-fetal outcomes were not different from those with controlled disease (p > 0.05). Similar or greater proportion of cases had normal GH and no residual tumor postpartum, even in those with pre-conceptional active acromegaly.

CONCLUSION

The current study showed conducive outcomes of gestation in women treated for acromegaly and no higher rates of pregnancy parameters or complications than non-acromegaly pregnancies in the same population. Active acromegaly does not seem to have an adverse bearing on outcomes.

Factors associated with severe maternal outcomes in patients with eclampsia in an obstetric intensive care unit: A cohort study

To describe the clinical profile, management, maternal outcomes and factors associated with severe maternal outcome (SMO) in patients admitted for eclampsia.A retrospective cohort study was carried out. All women admitted to the Obstetric Intensive Care Unit (ICU) at Instituto de Medicina Integral Prof. Fernando Figueira (IMIP), Recife, Northeast of Brazil, from April 2012 to December 2019 were considered for inclusion and patients with the diagnosis of eclampsia were selected. Patients who, after reviewing their medical records, did not present a diagnosis of eclampsia were excluded from the study. Severe maternal outcome (SMO) was defined as all cases of near miss maternal mortality (MNM) plus all maternal deaths during the study period. The Risk Ratio (RR) and its 95% confidence interval (95% CI) were calculated as a measure of the relative risk. Multiple logistic regression analysis was performed to control confounding variables. The institute's internal review board and the board waived the need of the informed consent.Among 284 patients with eclampsia admitted during the study period, 67 were classified as SMO (23.6%), 63 of whom had MNM (22.2%) and 5 died (1.8%). In the bivariate analysis, the following factors were associated with SMO: age 19 years or less (RR = 0.57 95% CI 0.37-0.89, P = .012), age 35 years or more (RR = 199 95% CI 1.18-3.34, P = .019), the presence of associated complications such as acute kidney injury (RR = 3.85 95% CI 2.69-5.51, P < .001), HELLP syndrome (RR = 1.81 95% CI 1.20-2.75, P = .005), puerperal hemorrhage (PPH) (RR = 2.15 95% CI 1.36-3.40, P = .003) and acute pulmonary edema (RR = 2.78 95% CI 1.55-4.96, P = .008). After hierarchical multiple logistic regression analysis, the factors that persisted associated with SMO were age less than or equal to 19 years (ORa = 0.46) and having had PPH (ORa = 3.33).Younger age was a protective factor for developing SMO, while those with PPH are more likely to have SMO.

A Detailed Review of Critical Care Considerations for the Pregnant Cardiac Patient

Maternal cardiovascular disease is a leading cause of maternal death worldwide and recently, maternal mortality has increased secondary to cardiovascular causes. Maternal admissions to critical care encompass 1%-2% of all critical care admissions, and although not common, the management of the critically ill pregnant patient is complex. Caring for the critically ill pregnant cardiac patient requires integration of pregnancy-associated physiologic changes, understanding pathophysiologic disease states unique to pregnancy, and a multidisciplinary approach to timing around delivery as well as antenatal and postpartum care. Herein we describe cardiorespiratory changes that occur during pregnancy and the differential diagnosis for cardiorespiratory failure in pregnancy. Cardiorespiratory diseases that are either associated or exacerbated by pregnancy are highlighted with emphasis on perturbations secondary to pregnancy and appropriate management strategies. Finally, we describe general management of the pregnant cardiac patient admitted to critical care.

Persistent Hypertension Up to One Year Postpartum among Women with Hypertensive Disorders in Pregnancy in a Low-Resource Setting: A Prospective Cohort Study

Background

Hypertensive disorders in pregnancy (HDPs) are associated with lifelong cardiovascular disease risk. Persistent postpartum hypertension in HDPs could suggest progression to chronic hypertension. This phenomenon has not been well examined in low- and middle-income countries (LIMCs), and most previous follow-ups typically last for maximally six weeks postpartum. We assessed the prevalence of persistent hypertension up to one year in women with HDPs in a low resource setting and determined associated risk factors.

Methodology

A prospective cohort study of women conducted at eight tertiary health care facilities in seven states of Nigeria. Four hundred and ten women with any HDP were enrolled within 24 hours of delivery and followed up at intervals until one year postpartum. Descriptive statistics were performed to express the participants' characteristics. Univariable and multivariable logistic regressions were conducted to identify associated risk factors.

Results

Of the 410 women enrolled, 278 were followed up to one year after delivery (follow-up rate 68%). Among women diagnosed with gestational hypertension and pre-eclampsia/eclampsia, 22.3% (95% CI; 8.3-36.3) and 62.1% (95% CI; 52.5-71.9), respectively, had persistent hypertension at six months and this remained similar at one year 22.3% (95% CI; 5.6-54.4) and 61.2% (95% CI; 40.6-77.8). Maternal age and body mass index were significant risk factors for persistent hypertension at one year [aORs = 1.07/year (95% CI; 1.02-1.13) and 1.06/kg/m2 (95% CI; 1.01-1.10)], respectively.

Conclusion

This study showed a substantial prevalence of persistent hypertension beyond puerperium. Health systems in LMICs need to be organized to anticipate and maintain postpartum monitoring until blood pressure is normalized, or women referred or discharged to family physicians as appropriate. In particular, attention should be given to women who are obese, and or of higher maternal age.

Acute neurological conditions during pregnancy and their management: a review

Less vascular resistance, higher vascular permeability and improved cardiac output include anatomical and physiological changes related to pregnancy. These are needed to accommodate an increase in plasma volume and ensure significant organ infusion. Nevertheless, increases in oestrogen levels may lead to an increase in the risk of coagulation and thrombosis. Increased levels of progesterone increase the risk of thrombosis due to vasodilation, vascular stasis and edoema in these situations. The increased resistance in preeclampsia maternal systemic blood arteries can create high blood pressure that can interfere with blood flow in numerous organs (including liver, kidneys, brain and placenta). The risk of issues such as pulmonary edoema, placental abruption, pneumonia of aspiration, renal failure, hepatic failure and stroke in pregnant women is increased by Preeclampsia and eclampsia. Some peripheral neuropathies (carpal tunnel syndrome, peripheral facial palsy) and central neurological conditions (seizure, migraine, stroke, epilepsy) may become more common during pregnancy because of the exacerbation of the pre-existing neurologic condition or the onset of neurological disturbance caused by pregnancy physiological changes (such as headache or vascular disorders). During the three trimesters of pregnancy, neurological disorders are both peripheral and central. Therefore, an early and correct diagnosis is required to improve pregnancy care, treatment and perinatal outcomes. The aims of this paper are to identify, define and manage the most prevalent peripheral and centrally occurring neurological disorders in the pregnancy.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Maternal and perinatal outcomes in women with eclampsia by mode of delivery at Riley mother baby hospital: a longitudinal case-series study

Background

Eclampsia, considered as serious complication of preeclampsia, remains a life-threatening condition among pregnant women. It accounts for 12% of maternal deaths and 16–31% of perinatal deaths worldwide. Most deaths from eclampsia occurred in resource-limited settings of sub-Saharan Africa. This study was performed to determine the optimum mode of delivery, as well as factors associated with the mode of delivery, in women admitted with eclampsia at Riley Mother and Baby Hospital.

Methods

This was a hospital-based longitudinal case-series study conducted at the largest and busiest obstetric unit of the tertiary hospital of western Kenya. Maternal and perinatal variables, such as age, parity, medications, initiation of labour, mode of delivery, admission to the intensive care unit, admission to the newborn care unit, organ injuries, and mortality, were analysed using the Statistical Package for the Social Sciences software version 20.0. Quantitative data were described using frequencies and percentages. The significance of the obtained results was judged at the 5% level. The chi-square test was used for categorical variables, and Fisher’s exact test or the Monte Carlo correction was used for correction of the chi-square test when more than 20% of the cells had an expected count of less than 5.

Results

During the study period, 53 patients diagnosed with eclampsia were treated and followed up to 6 weeks postpartum. There was zero maternal mortality; however, perinatal mortality was reported in 9.4%. Parity was statistically associated with an increased odds of adverse perinatal outcomes (p = 0.004, OR = 9.1, 95% CI = 2.0–40.8) and caesarean delivery (p = 0.020, OR = 4.7, 95% CI = 1.3–17.1). In addition, the induction of labour decreased the risk of adverse outcomes (p = 0.232, OR = 0.3, 95% CI = 0.1–2.0).

Conclusion

There is no benefit of emergency caesarean section for women with eclampsia. This study showed that induction of labour and vaginal delivery can be successfully achieved in pregnant women with eclampsia. Maternal and perinatal mortality from eclampsia can be prevented through prompt and effective care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03875-6.

Are Essential Women's Healthcare Services Fully Covered? A Comparative Analysis of Policy Documents in Shanghai and New York City from 1978-2017

This study aimed to analyze the changes in the 10 major categories of women's healthcare services (WHSs) in Shanghai (SH) and New York City (NYC) from 1978 to 2017, and examine the relationship between these changes and maternal mortality ratio (MMR). Content analysis of available public policy documents concerning women's health was conducted. Two indicators were designed to represent the delivery of WHSs: The essential women's healthcare service coverage rate (ESCR) and the assessable essential healthcare service coverage rate (AESCR). Spearman correlation was used to analyze the relationship between the two indicators and MMR. In SH, the ESCR increased from 10% to 90%, AESCR increased from 0% to 90%, and MMR decreased from 24.0/100,000 to 1.01/100,000. In NYC, the ESCR increased from 0% to 80%, the AESCR increased from 0% to 60%, and the MMR decreased from 24.7/100,000 to 21.4/100,000. The MMR significantly decreased as both indicators increased (p < 0.01). Major advances have been made in women's healthcare in both cities, with SH having a better improvement effect. A common shortcoming for both was the lack of menopausal health service provision. The promotion of women's health still needs to receive continuous attention from governments of SH and NYC. The experiences of the two cities showed that placing WHSs among policy priorities is effective in improving service status.

Pregnancy-Related Hormones Increase UGT1A1-Mediated Labetalol Metabolism in Human Hepatocytes

Pregnancy-related hormones (PRH) are recognized as important regulators of hepatic cytochrome P450 enzyme expression and function. However, the impact of PRH on the hepatic expression and function of uridine diphosphate glucuronosyltransferases (UGTs) remains unclear. Using primary human hepatocytes, we evaluated the effect of PRH exposure on mRNA levels and protein concentrations of UGT1A1, UGT2B7, and other key UGT enzymes, and on the metabolism of labetalol (a UGT1A1 and UGT2B7 substrate commonly prescribed to treat hypertensive disorders of pregnancy). Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to the PRH estradiol, estriol, estetrol, progesterone, and cortisol individually or in combination. We quantified protein concentrations of UGT1A1, UGT2B7, and four additional UGT1A isoforms in SCHH membrane fractions and evaluated the metabolism of labetalol to its glucuronide metabolites in SCHH. PRH exposure increased mRNA levels and protein concentrations of UGT1A1 and UGT1A4 in SCHH. PRH exposure also significantly increased labetalol metabolism to its UGT1A1-derived glucuronide metabolite in a concentration-dependent manner, which positively correlated with PRH-induced changes in UGT1A1 protein concentrations. In contrast, PRH did not alter UGT2B7 mRNA levels or protein concentrations in SCHH, and formation of the UGT2B7-derived labetalol glucuronide metabolite was decreased following PRH exposure. Our findings demonstrate that PRH alter expression and function of UGT proteins in an isoform-specific manner and increase UGT1A1-mediated labetalol metabolism in human hepatocytes by inducing UGT1A1 protein concentrations. These results provide mechanistic insight into the increases in labetalol clearance observed in pregnant individuals.

The cost implications of continuous glucose monitoring in pregnant women with type 1 diabetes in 3 Canadian provinces: a posthoc cost analysis of the CONCEPTT trial

BACKGROUND

The Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy Trial (CONCEPTT) found improved health outcomes for mothers and their infants among those randomized to self-monitoring of blood glucose (SMBG) with continuous glucose monitoring (CGM) compared with SMBG alone. In this study, we evaluated whether CGM or standard SMBG was more or less costly from the perspective of a third-party payer.

METHODS

We conducted a posthoc analysis of data from the CONCEPTT trial (Mar. 25, 2013, to Mar. 22, 2016). Health care resource data from 215 pregnant women, randomized to CGM or SMBG, were collected from 31 hospitals in 7 countries. We determined resource costs posthoc based on prices from hospitals in 3 Canadian provinces (Ontario, British Columbia, Alberta). The primary outcome was the difference between groups in the mean total cost of care for mother and infant dyads, paid by each government (i.e., the third-party payer) from randomization to hospital discharge (time horizon). The secondary outcome included CGM and SMBG costs not paid by governments (e.g., glucose monitoring devices and supplies).

RESULTS

The mean total cost of care was lower in the CGM group compared with the SMBG group in each province (Ontario: $13 270.25 v. $18 465.21, difference in mean total cost [DMT] -$5194.96, 95% confidence interval [CI] -$9841 to -$1395; BC: $13 480.57 v. $18 762.17, DMT -$5281.60, 95% CI -$9964 to -$1382; Alberta: $13 294.39 v. $18 674.45, DMT -$5380.06, 95% CI -$10 216 to -$1490). There was no difference in the secondary outcome.

INTERPRETATION

Government health care costs are lower when CGM is paid by the patient, driven by lower costs from reduced use of the neonatal intensive care unit in the CGM group; however, when governments pay for CGM equipment, there is no overall cost difference between CGM and SMBG. Governments should consider paying for CGM, as it results in improved maternal and neonatal outcomes with no added overall cost.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01788527.

Diagnostic Potential of MicroRNAs as Biomarkers in the Detection of Preeclampsia

Preeclampsia is a multisystemic disorder that occurs in 5-8% of pregnant women and remains a leading cause of both maternal and fetal morbidity and mortality. The disease is characterized by the abnormal vascular response to placentation, but the exact pathophysiology and pathogenesis of preeclampsia remain unknown. Risk factors for preeclampsia include increased maternal age, obesity, multiple gestations, and a history of preeclampsia. Several studies have suggested that altered expression of some microRNAs (miRNAs) in placental tissue, and maternal circulation, may be associated with several types of pregnancy complications such as preeclampsia, preterm birth, and spontaneous abortion. It is assumed that these miRNAs play an important role in various cellular processes important for maintaining a healthy pregnancy, including promoting angiogenesis and the differentiation of trophoblast cells. In this review, we discuss the role of miRNAs as potential biomarkers of preeclampsia.

Knowledge and attitude of pregnant women towards preeclampsia and its associated factors in South Gondar Zone, Northwest Ethiopia: a multi-center facility-based cross-sectional study

BACKGROUND

Preeclampsia has the greatest impact on maternal mortality which complicates nearly a tenth of pregnancies worldwide. It is one of the top five maternal mortality causes and responsible for 16 % of direct maternal death in Ethiopia. Little is known about the level of knowledge and attitude towards preeclampsia in Ethiopia. This study was designed to assess the knowledge and attitude towards preeclampsia and its associated factors in South Gondar, Northwest Ethiopia.

METHODS

A multicenter facility-based cross-sectional study was implemented in four selected hospitals of South Gondar Zone among 423 pregnant women. Multistage random sampling and systematic random sampling techniques were used to select the study sites and the study participants respectively. Data were entered in EpiData version 3.1 while cleaned and analyzed by Statistical Package for Social Sciences (SPSS) version 23. Descriptive and inferential statistics were performed. Adjusted odds ratio with 95 % confidence interval were used to identify the significance of the association between the level of knowledge on preeclampsia and its predictors.

RESULTS

In this study, 118 (28.8 %), 120 (29.3 %) of the study participants had good knowledge and a positive attitude towards preeclampsia respectively. The likelihood of having good knowledge on preeclampsia was found to be low among women with no education (AOR = 0.22, 95 % CI (0.06, 0.85)), one antenatal care visit (ANC) (AOR = 0.13, 95 % CI (0.03, 0.59)). Whereas, those who booked for ANC in the first trimester (AOR = 6.59, 95 % CI (1.43, 30.33)), gave the last birth at a health facility (AOR = 2.61, 955 CI (1.03, 6.61)), and experienced a complication during previous births (AOR = 3.67, 95 % CI (1.78, 7.57)) were more likely to be knowledgeable on preeclampsia.

CONCLUSIONS

No formal education and not attending four ANC visits were associated with poor knowledge of preeclampsia. While participants who visited health facilities during the first trimester, who gave birth at health facilities, and those who experienced a complication in previous births were more likely to be knowledgeable on preeclampsia. Improving the numbers of ANC visits and encouraging facility delivery are important measures to improve women's knowledge on preeclampsia. Health education regarding preeclampsia risk factors, symptoms, and complications shall be emphasized.

The endogenous exposome of the pregnant mother: Placental extracellular vesicles and their effect on the maternal system

During pregnancy, there is an intense crosstalk between mother and placenta. During the entire time of pregnancy, the maternal system deals with a huge amount of foreign (fetal) material released from the placenta, which can be referred to as placental exposome. Besides the release of hormones and growth factors, the placenta releases a variety of extracellular vesicles into maternal blood. These vesicles contain specific molecules including proteins, lipids, DNA as well as miRNA, all of which may have specific sites and modes of action on maternal cells. During normal pregnancy, the fine-tuning of factors and vesicles helps maintaining a viable and healthy pregnancy. However, in pregnancy pathologies such as preeclampsia, quantity and quality of the placenta-derived vesicles are altered leading to a deleterious effect on the maternal vascular system. This review focuses on the different types of placenta-derived extracellular vesicles in pregnancy with special emphasis on the interplay between these placental vesicles and the maternal system. Additionally, it displays new techniques and ideas for the analysis of the placental exposome with placental extracellular vesicles as a key aspect.

Pregnancy-Related Hormones Increase Nifedipine Metabolism in Human Hepatocytes by Inducing CYP3A4 Expression

Pregnancy-related hormones (PRH) have emerged as key regulators of hepatic cytochrome P450 (CYP) enzyme expression and function. The impact of PRH on protein levels of CYP3A4 and other key CYP enzymes, and the metabolism of nifedipine (a CYP3A4 substrate commonly prescribed during pregnancy), was evaluated in primary human hepatocytes. Sandwich-cultured human hepatocytes (SCHH) from female donors were exposed to PRH (estradiol, estriol, estetrol, progesterone, and cortisol), individually or in combination as a cocktail. Absolute protein concentrations of twelve CYP isoforms in SCHH membrane fractions were quantified by nanoLC-MS/MS, and metabolism of nifedipine to dehydronifedipine in SCHH was evaluated. PRH significantly increased CYP3A4 protein concentrations and nifedipine metabolism to dehydronifedipine in a concentration-dependent manner. CYP3A4 mRNA levels in hepatocyte-derived exosomes positively correlated with CYP3A4 protein levels and dehydronifedipine formation in SCHH. PRH also increased CYP2B6, CYP2C8 and CYP2A6 levels. Our findings demonstrate that PRH increase nifedipine metabolism in SCHH by inducing CYP3A4 expression and alter expression of other key CYP proteins in an isoform-specific manner, and suggest that hepatocyte-derived exosomes warrant further investigation as biomarkers of hepatic CYP3A4 metabolism. Together, these results offer mechanistic insight into the increases in nifedipine metabolism and clearance observed in pregnant women.