Pre-eclampsia: pathogenesis, novel diagnostics and therapies

Epidemiology and maternal prognosis of hypertension disorders of pregnancy in French Guiana

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are responsible for high maternal mortality and morbidity worldwide.

OBJECTIVE

Our primary objective was to report the epidemiological and clinical features of HDP in Cayenne General Hospital. Our secondary objectives were to search for factors associated to preeclampsia (PE) and to severe PE in patients with HDP.

METHODS

Our study was observational and non-interventional. It was conducted over 4-month period (January to April 2019) in the Obstetrics and Gynaecology Unit of the Cayenne General Hospital. We included all pregnant women after 20 weeks of gestation (WG), who gave birth and who presented HDP and/or PE.

RESULTS

During the study period 1243 patients gave birth in our unit. Among them, 156 were diagnosed with HDP (12.6%). The median age was 33 years (IQR 28 - 38 years). The most frequent medical histories were diabetes (27.5%) and chronic hypertension (23.5%). The socioeconomic status was low in 31% of patients. Ninety-four patients (61.4%) developed PE with a severe form in 80.9% of cases. HELLP syndrome was diagnosed in 6.5% and nephropathy in 3.3% of cases. Delivery was by cesarean in 49.7% of cases. The median gestational age at delivery was 37 WG (IQR: 35-39). Multivariate analysis showed no independent factors associated with the occurrence of PE or severe PE in patients with HDP.

CONCLUSION

Our study shows a high prevalence of PE in patients with HDP. Hospitalization and repeated clinical evaluation are needed to screen for women exposed to develop PE or severe PE.

Upregulated LncZBTB39 in pre-eclampsia and its effects on trophoblast invasion and migration via antagonizing the inhibition of miR-210 on THSD7A expression

OBJECTIVE

Pre-eclampsia (PE) is a major cause of maternal morbidity and mortality, but its etiology remains to be elucidated. Accumulating evidence suggests that placental long noncoding RNAs (lncRNAs) might contribute to the pathogenesis of pre-eclampsia.

STUDY DESIGN

In the present study, the expression levels of lncRNAs in human placenta were first determined by microarray analysis and then validated by secondary RT-qPCR and FISH. LncZBTB39 expression manipulation in HTR8/SVneo trophoblast cells was achieved by shRNA and plasmid transfection. Then, the invasion and migration of lncZBTB39-deficient and lncZBTB39-overexpressing trophoblast cells were evaluated by transwell assays and wound-healing assays, respectively. MMP2 activity was measured by gelatin zymography. The downstream target genes of lncZBTB39 were then identified by a transcriptomic microarray, followed by RT-qPCR validation.

RESULTS

We found that lncZBTB39 was upregulated in PE-complicated human placentas, and overexpression of lncZBTB39 inhibited invasion and migration, as well as MMP2 activity in HTR8/SVneo cells, while downregulation of lncZBTB39 enhanced invasion, migration and MMP2 activity. In addition, THSD7A expression was elevated by lncZBTB39 overexpression but reduced in lncZBTB39-deficient cells; moreover, lncZBTB39 antagonized the inhibitory effects of miR-210 on THSD7A expression.

CONCLUSION

PE-complicated placentas are associated with upregulated lncZBTB39, which negatively regulates trophoblast invasion and migration, most likely by preserving the expression of THSD7A mRNA through sponging miR-210. The results of this study not only provide novel evidence that lncRNAs regulate trophoblastic activities but also suggest that lncZBTB39 may be a potential interventional target for PE.

Down-regulated lncRNA AGAP2-AS1 contributes to pre-eclampsia as a competing endogenous RNA for JDP2 by impairing trophoblastic phenotype

Recently, growing evidence has shown that aberrant long non‐coding RNA (lncRNA) expression in conjunction with an impaired trophoblastic phenotype could implicate the pathological process of pre‐eclampsia (PE). However, only a small portion of lncRNAs has been characterized with regard to the function and molecular mechanisms involved in PE. There are still gaps in the available knowledge; as a result, there are currently only a few applicable treatments for PE in the context of lncRNA. Here, we found that lncRNA AGAP2‐AS1 is abnormally down‐regulated in severe PE placenta tissues. Using human trophoblasts, we established that AGAP2‐AS1 knockdown could inhibit trophoblasts proliferation and invasion and promote cell apoptosis. Further, we showed that overexpression of AGAP2‐AS1 substantially stimulated the development of the trophoblastic phenotype. Through high‐throughput sequencing analysis, we demonstrated that silencing of AGAP2‐AS1 favourably regulated various genes which are relevant to trophoblastic growth and invasion. Mechanistically, AGAP2‐AS1 promoted the suppressor protein, Jun dimerization protein 2 (JDP2), by sponging miR‐574‐5p. Resultantly, further impairment of the trophoblastic phenotype was achieved by way of inhibiting cell growth, apoptosis and invasion. We also determined that the expression of AGAP2‐AS1 could be mediated by FOXP1. Our results showed that the down‐regulated expression of lncRNA AGAP2‐AS1 might serve as a key suppressor in PE via inhibition of JDP2 at the post‐transcriptional level by competing for miR‐574; thus, this presents a novel therapeutic strategy for PE.

The Role of NFκB in Healthy and Preeclamptic Placenta: Trophoblasts in the Spotlight

The NFκB protein family regulates numerous pathways within the cell-including inflammation, hypoxia, angiogenesis and oxidative stress-all of which are implicated in placental development. The placenta is a critical organ that develops during pregnancy that primarily functions to supply and transport the nutrients required for fetal growth and development. Abnormal placental development can be observed in numerous disorders during pregnancy, including fetal growth restriction, miscarriage, and preeclampsia (PE). NFκB is highly expressed in the placentas of women with PE, however its contributions to the syndrome are not fully understood. In this review we discuss the molecular actions and related pathways of NFκB in the placenta and highlight areas of research that need attention.

The Renin-Angiotensin System in Hypertension, a Constantly Renewing Classic: Focus on the Angiotensin AT2-Receptor

It is common knowledge that the renin-angiotensin system (RAS), in particular angiotensin II acting through the angiotensin AT₁-receptor (AT₁R), is pivotal for the regulation of blood pressure (BP) and extracellular volume. More recent findings have revealed that the RAS is far more complex than initially thought and that it harbours additional mediators and receptors, which are able to counteract and thereby fine-tune AT₁R-mediated actions. This review will focus on the angiotensin AT₂-receptor (AT₂R), which is one of the "counter-regulatory" receptors within the RAS. It will review and discuss data related to the role of the AT₂R in regulation of BP and focus on the following 3 questions: Do peripheral AT₂R have an impact on BP regulation, and, if so, does this effect become apparent only under certain conditions? Are central nervous system AT₂R involved in regulation of BP, and, if so, which brain areas are involved and what are the mechanisms? Does dysfunction of AT₂R contribute to the pathogenesis of hypertension in preeclampsia?

Pre-Eclampsia: Microbiota possibly playing a role

Pre-eclampsia (PE) is a complication of pregnancy that is associated with mortality and morbidity in mothers and fetuses worldwide. Oxygen dysregulation in the placenta, abnormal remodeling of the spiral artery, defective placentation, oxidative stress at the fetal-maternal border, inflammation and angiogenic impairment in the maternal circulation are the main causes of this syndrome. These events result in a systemic and diffuse endothelial cell dysfunction, an essential pathophysiological feature of PE. The impact of bacteria on the multifactorial pathway of PE is the recent focus of scientific inquiry since microbes may cause each of the aforementioned features. Microbes and their derivatives by producing antigens and other inflammatory factors may trigger infection and inflammatory responses. A mother's bacterial communities in the oral cavity, gut, vagina, cervix and uterine along with the placenta and amniotic fluid microbiota may be involved in the development of PE. Here, we review the mechanistic and pathogenic role of bacteria in the development of PE. Then, we highlight the impact of alterations in a set of maternal microbiota (dysbiosis) on the pathogenesis of PE.

Aspirin for prevention of preeclampsia and fetal growth restriction

For the past decades, growing attention has been given to aspirin use during pregnancy. It favors placentation by its proangiogenic, antithrombotic, and anti-inflammatory effects. Therefore, low doses of aspirin are prescribed in the prevention of placenta-mediated complications, mainly preeclampsia and fetal growth restriction. However, questions regarding its clinical application are still debated. Aspirin is effective in preventing preeclampsia in a high-risk population. Most guidelines recommend that risk stratification should rely on medical history. Nevertheless, screening performances dramatically improve if biochemical and biophysical markers are included. Concerning the appropriate timing and dose, latest studies suggest aspirin should be started before 16 weeks of pregnancy and at a daily dose of 100 mg or more. Further studies are needed to improve the identification of patients likely to benefit from prophylactic aspirin. Besides, the role of aspirin in the prevention of fetal growth restriction is still questioned.

Circulating endocan and preeclampsia: a meta-analysis

Background: Endocan, a novel protein involved in inflammation and endothelial dysfunction, has been suggested to be related to preeclampsia, although the results of previous studies were not consistent. The aim of the study was to evaluate the potential difference of circulating endocan in women with preeclampsia and those with normal pregnancy.

Methods: Matched case–control studies evaluating the difference of circulating endocan between women with preeclampsia and those with normal pregnancy were identified via systematic search of PubMed and Embase databases. A random-effect model or a fixed-effect model was used to pool the results according to the heterogeneity. Subgroup analysis was performed to evaluate whether the timing of preeclampsia onset affected the outcome.

Results: Overall, eight matched case–control studies, including 451 women with preeclampsia and 442 women with normal pregnancy were included. Significant heterogeneity was detected among the included studies (P for Cochrane’s Q test = 0.006, I² = 65%). Meta-analysis with a random-effect model showed that women with preeclampsia had significantly higher circulating level of endocan compared with women with normal pregnancy (standardized mean difference = 0.37, 95% confidence interval: 0.13–0.62, P = 0.003). Subsequent subgroup analyses showed that the difference of circulating endocan between women with early onset preeclampsia and those with normal pregnancy was not statistically different from that between women with late-onset preeclampsia and those with normal pregnancy (P for subgroup difference = 0.81).

Conclusions: Women with preeclampsia have higher circulating endocan than those with normal pregnancy.

Maternal Serum Placental Growth Factor, Soluble Fms-Like Tyrosine Kinase-1, and Soluble Endoglin in Twin Gestations and the Risk of Preeclampsia-A Systematic Review

Multiple gestation is one of the key risk factors for the occurrence of preeclampsia (PE). Soluble fms-like tyrosine kinase-1, placental growth factor, and soluble endoglin are molecules involved in the process of angiogenesis with a proven role in the pathogenesis of PE. The aim of the review was to summarize available data on maternal serum levels of the above-mentioned factors and their usefulness in predicting PE in twin pregnancies. Only original research articles written in English were considered eligible. Reviews, chapters, case studies, conference papers, experts’ opinions, editorials, and letters were excluded from the analysis. No publication date limitations were imposed. The systematic literature search using PubMed/MEDLINE, Scopus, Embase, and Cochrane Library databases identified 338 articles, 10 of which were included in the final qualitative analyses. The included studies showed significant differences in maternal serum levels of the discussed factors between women with twin pregnancies with PE and those who did not develop PE, and their promising performance in predicting PE, alone or in combination with other factors. The identification of the most effective algorithms, their prompt introduction to the clinical practice, and further assessment of the real-life performance should become a priority.

Differential Role of Smad2 and Smad3 in the Acquisition of an Endovascular Trophoblast-Like Phenotype and Preeclampsia

During placental development, cytotrophoblast progenitor cells differentiate into the syncytiotrophoblast and invasive extravillous trophoblasts (EVTs). Some EVTs further differentiate into endovascular trophoblasts (enEVTs) which exhibit endothelial-like properties. Abnormal placental development, including insufficient enEVT-mediated remodeling of the uterine spiral arteries, is thought to be a precipitating factor in the onset of preeclampsia (PE), a pregnancy-related hypertensive disorder. Several members of the transforming growth factor-β (TGF-β) superfamily, such as TGF-βs, Nodal, and Activin have been reported to either promote or inhibit the invasive EVT pathway. These ligands signal through serine/threonine receptor complexes to activate downstream signaling mediators, Smad2 and Smad3. In this study, we determined Smad2 and Smad3 expression pattern in placenta and their effects on trophoblast invasion and differentiation. Total Smad2/3 levels were relatively constant across gestation while the ratio of active phosphorylated forms to their total levels varied with gestational stages, with a higher pSmad2/total Smad2 in later gestation and a higher pSmad3/total Smad3 in early gestation. Immunofluorescent staining revealed that pSmad3 was localized in nuclei of EVTs in anchoring villi. On the other hand, pSmad2 was mostly absent in this invasive EVT population. In addition, pSmad3/total Smad3, but not pSmad2/total Smad2, was significantly lower in both early onset and late onset PE cases, as compared to gestational age-matched controls. Functional studies carried out using a first trimester trophoblast cell line, HTR-8/SVneo, and first trimester human placental explants showed that Smad2 and Smad3 had differential roles in the invasive pathway. Specifically, siRNA-mediated knockdown of Smad2 resulted in an increase in trophoblast invasion and an upregulation of mRNA levels of enEVT markers while the opposite was observed with Smad3 knockdown. In addition, Smad2 siRNA accelerated the EVT outgrowth in first trimester placental explants while the Smad3 siRNA reduced the outgrowth of EVTs when compared to the control. Furthermore, knockdown of Smad2 enhanced, whereas overexpression of Smad2 suppressed, the ability of trophoblasts to form endothelial-like networks. Conversely, Smad3 had opposite effects as Smad2 on network formation. These findings suggest that Smad2 and Smad3 have opposite functions in the acquisition of an enEVT-like phenotype and defects in Smad3 activation are associated with PE.

Key Infections in the Placenta

Congenital infections are an important cause of morbidity and mortality worldwide, especially in low-income settings. This review discusses the main pathways of infections and associated adverse maternal and fetal outcomes, considering the TORCH pathogens, including Zika virus; the acronym stands for Toxoplasma gondii infection, other (Listeria monocytogenes, Treponema pallidum, and parvovirus B19, among others, including Zika virus), rubella virus, cytomegalovirus, and herpes simplex viruses type 1 and type 2.

Riboflavin and pyrroloquinoline quinone generate carbon monoxide in the presence of tissue microsomes or recombinant human cytochrome P-450 oxidoreductase: implications for possible roles in gasotransmission

Carbon monoxide (CO), an endogenously produced gasotransmitter, regulates inflammation and vascular tone, suggesting that delivery of CO may be therapeutically useful for pathologies like preeclampsia where CO insufficiency is implicated. Our strategy is to identify chemicals that increase the activity of endogenous CO-producing enzymes, including cytochrome P-450 oxidoreductase (CPR). Realizing that both riboflavin and pyrroloquinoline quinone (PQQ) are relatively nontoxic, even at high doses, and that they share chemical properties with toxic CO activators that we previously identified, our goal was to determine whether riboflavin or PQQ could stimulate CO production. Riboflavin and PQQ were incubated in sealed vessels with rat and human tissue extracts and CO generation was measured with headspace-gas chromatography. Riboflavin and PQQ increased CO production ∼60% in rat spleen microsomes. In rat brain microsomes, riboflavin and PQQ increased respective CO production approximately fourfold and twofold compared to baseline. CO production by human placenta microsomes increased fourfold with riboflavin and fivefold with PQQ. In the presence of recombinant human CPR, CO production was threefold greater with PQQ than with riboflavin. These observations demonstrate for the first time that riboflavin and PQQ facilitate tissue-specific CO production with significant contributions from CPR. We propose a novel biochemical role for these nutrients in gastransmission.

Pyroptosis is a critical inflammatory pathway in the placenta from early onset preeclampsia and in human trophoblasts exposed to hypoxia and endoplasmic reticulum stressors

Systemic manifestation of preeclampsia (PE) is associated with circulating factors, including inflammatory cytokines and damage-associated molecular patterns (DAMPs), or alarmins. However, it is unclear whether the placenta directly contributes to the increased levels of these inflammatory triggers. Here, we demonstrate that pyroptosis, a unique inflammatory cell death pathway, occurs in the placenta predominantly from early onset PE, as evidenced by elevated levels of active caspase-1 and its substrate or cleaved products, gasdermin D (GSDMD), IL-1β, and IL-18. Using cellular models mimicking pathophysiological conditions (e.g., autophagy deficiency, hypoxia, and endoplasmic reticulum (ER) stress), we observed that pyroptosis could be induced in autophagy-deficient human trophoblasts treated with sera from PE patients as well as in primary human trophoblasts exposed to hypoxia. Exposure to hypoxia elicits excessive unfolded protein response (UPR) and ER stress and activation of the NOD-like receptor pyrin-containing 3 (NLRP3) inflammasome in primary human trophoblasts. Thioredoxin-interacting protein (TXNIP), a marker for hyperactivated UPR and a crucial signaling molecule linked to NLRP3 inflammasome activation, is significantly increased in hypoxia-treated trophoblasts. No evidence was observed for necroptosis-associated events. Importantly, these molecular events in hypoxia-treated human trophoblasts are significantly observed in placental tissue from women with early onset PE. Taken together, we propose that placental pyroptosis is a key event that induces the release of factors into maternal circulation that possibly contribute to severe sterile inflammation and early onset PE pathology.

An Analysis of Cellular Communication Network Factor Proteins as Candidate Mediators of Postpartum Psychosis Risk

Postpartum (or puerperal) psychosis (PP) is a severe psychiatric condition associated with hallucinations, delusions, cognitive disorganization, and mood problems, which affects approximately 1-2 out of every 1,000 mothers shortly after childbirth. While the risk factors for, and co-morbidities of, PP are relatively well-defined, currently, the pathophysiology underlying the disorder is very poorly-specified. Here, I argue, on the basis of multiple lines of new evidence, that altered expression of the Cellular Communication Network (CCN) factor proteins (and of the heterodimerizing CCN2 and CCN3 proteins in particular), may be associated with, and possibly causal for, increased PP risk. Future preclinical and clinical studies should aim to test this hypothesis as empirical support for it would provide much-needed clues regarding the biological substrates of PP, and could point to predictive biomarkers for the condition.

Maternal plasma proteomics in a rat model of pregnancy complications reveals immune and pro-coagulant gene pathway activation

PROBLEM

The Brown Norway (BN) rat is a model of T-helper 2 immune diseases, and also a model of pregnancy disorders that include placental insufficiency, fetal loss, and pre-eclampsia-like symptoms. The aim of this study was to investigate the plasma proteomic/cytokine profile of pregnant BN rats in comparison to that of the Lewis (LEW) rat strain.

METHOD OF STUDY

Plasma proteomics differences were studied at day 13 of pregnancy in pooled plasma samples by differential in-gel electrophoresis, and protein identification was performed by mass spectrometry. Key protein findings and predicted cytokine differences were validated by ELISA using plasma from rats at various pregnancy stages. Proteomics data were used for ingenuity pathway analysis (IPA).

RESULTS

In-gel analysis revealed 74 proteins with differential expression between BN and LEW pregnant dams. ELISA studies confirmed increased maternal plasma levels of complement 4, prothrombin, and C-reactive protein in BN compared to LEW pregnancies. LEW pregnancies showed higher maternal plasma levels of transthyretin and haptoglobin than BN pregnancies. Ingenuity pathway analysis revealed that BN pregnancies are characterized by activation of pro-coagulant, reactive oxygen species, and immune-mediated chronic inflammation pathways, and suggested increased interleukin 6 and decreased transforming growth factor-β1 as potential upstream events. Plasma cytokine analysis revealed that pregnant BN dams have a switch from anti- to pro-inflammatory cytokines with the opposite switch observed in pregnant LEW dams.

CONCLUSION

Brown Norway rats show a maternal pro-inflammatory response to pregnancy that likely contributes to the reproductive outcomes observed in this rat strain.

Thrombocytopenia in pregnancy: Diagnosis and approach to management

Thrombocytopenia during pregnancy presents unique challenges for the hematologist. Obstetricians generally manage many of the pregnancy-specific etiologies, ranging from the benign (gestational thrombocytopenia) to the life-threatening (preeclampsia; hemolysis, elevated liver enzymes and low platelets syndrome; and acute fatty liver of pregnancy). However, hematologists may be consulted for atypical and severe presentations and to help manage non-pregnancy specific etiologies, including immune thrombocytopenia, thrombotic thrombocytopenic purpura, hemolytic uremic syndrome and antiphospholipid syndrome, among others, in which maternal and fetal risks must be considered. This review provides a general approach to the diagnosis and management of thrombocytopenia in pregnancy for the consulting hematologist.

The apelinergic system: a perspective on challenges and opportunities in cardiovascular and metabolic disorders

The apelinergic pathway has been generating increasing interest in the past few years for its potential as a therapeutic target in several conditions associated with the cardiovascular and metabolic systems. Indeed, preclinical and, more recently, clinical evidence both point to this G protein-coupled receptor as a target of interest in the treatment of not only cardiovascular disorders such as heart failure, pulmonary arterial hypertension, atherosclerosis, or septic shock, but also of additional conditions such as water retention/hyponatremic disorders, type 2 diabetes, and preeclampsia. While it is a peculiar system with its two classes of endogenous ligand, the apelins and Elabela, its intricacies are a matter of continuing investigation to finely pinpoint its potential and how it enables crosstalk between the vasculature and organ systems of interest. In this perspective article, we first review the current knowledge on the role of the apelinergic pathway in the above systems, as well as the associated therapeutic indications and existing pharmacological tools. We also offer a perspective on the challenges and potential ahead to advance the apelinergic system as a target for therapeutic intervention in several key areas.

MicroRNAs in Uteroplacental Vascular Dysfunction

Pregnancy complications of preeclampsia and intrauterine growth restriction (IUGR) are major causes of maternal and perinatal/neonatal morbidity and mortality. Although their etiologies remain elusive, it is generally accepted that they are secondary to placental insufficiency conferred by both failure in spiral artery remodeling and uteroplacental vascular malfunction. MicroRNAs (miRNAs) are small no-coding RNA molecules that regulate gene expression at the post-transcriptional level. Increasing evidence suggests that miRNAs participate in virtually all biological processes and are involved in numerous human diseases. Differentially expressed miRNAs in the placenta are typical features of both preeclampsia and IUGR. Dysregulated miRNAs target genes of various signaling pathways in uteroplacental tissues, contributing to the development of both complications. In this review, we provide an overview of how aberrant miRNA expression in preeclampsia and IUGR impacts the expression of genes involved in trophoblast invasion and uteroplacental vascular adaptation.

Serum amphiregulin and cerebellin-1 levels in severe preeclampsia

PURPOSE

Preeclampsia is a form of hypertensive disorders of pregnancy and defined as the presence of new-onset hypertension and proteinuria or other end organ damage occurring after 20-week gestation. Preeclampsia can be a destructive process that can cause maternal and infant mortality. The exact etiopathogenesis of preeclampsia is still undefined. We aimed to compare serum amphiregulin and cerebellin-1 levels of severe preeclampsia patients with healthy pregnant women and healthy control subjects.

MATERIALS AND METHODS

A total of 88 women were enrolled in this study. Patients diagnosed with severe preeclampsia were group 1 (n = 28), healthy non-pregnant normotensive women group 2 (n = 30), and healthy pregnant women group 3 (n = 30). The participants in each group were matched for age. Pregnant women in groups 1 and 3 were also matched for gestational age. Serum amphiregulin and cerebellin-1 levels were measured using ELISA.

RESULTS

Serum amphiregulin levels were 3413 ± 1.38 ng/ml (1748-7739), 8510 ± 7213 ng/ml (2019-24,000), and 6580 ± 5360 ng/ml (2484-24,000) in preeclampsia patients, controls and healthy pregnant women, respectively. Amphiregulin levels were significantly lower in preeclampsia patients than healthy pregnant women (p=.008) and controls (p = .015). Amphiregulin levels were similar between healthy controls and healthy pregnant women (p  =  1.00). Cerebellin-1 levels were 222.039 ± 92.681 pg/ml (138,580-557,757) in preeclamptic patients, 537.043 ± 525.117 pg/ml (150,432-1,600,000) in controls and 415.091 ± 436.580 pg/ml (137,284-1,600,000) in healthy pregnant women. Cerebellin-1 levels were similar among groups (p = .272). Serum amphiregulin and cerebellin-1 levels were significantly and positively correlated with each other in preeclampsia patients (r  =  0.693, p < .001), controls (r  =  0.882, p < .001), and healthy pregnant women (r  =  0.591, p = .001). Serum level of amphiregulin ≤3590 pg/ml had a sensitivity of 67.9% and specificity of 63.3% in the diagnosis of preeclampsia (AUC: 0.751; p = .001).

CONCLUSIONS

Serum amphiregulin decreases in severe preeclampsia patients.

Increased BMI has a linear association with late-onset preeclampsia: A population-based study

Background

To investigate the ongoing controversy on the effect of BMI (body mass index) on EOP (early onset preeclampsia) vs LOP (late onset), especially focusing on diabetes and maternal booking/pre-pregnancy BMI as possible independent variables.

Methods

18 year-observational cohort study (2001–2018). The study population consisted of all consecutive births delivered at the Centre Hospitalier Universitaire Hospitalier Sud Reunion’s maternity (ap. 4,300 birth per year, only level 3 maternity in the south of Reunion Island, sole allowed to follow and deliver all preeclampsia cases of the area). History of pregnancies, deliveries and neonatal outcomes have been collected in standardized fashion into an epidemiological perinatal data base.

Results

Chronic hypertension and, history of preeclampsia in multigravidas, were the strongest risk factors for EOP. Primiparity, age over 35 years and BMI ≥ 35 kg/m² were rather associated with LOP. In a multivariate analysis with EOP or LOP as outcome variables compared with controls (normotensive), maternal age and pre-pregnancy BMI were independent risk factors for both EOP and LOP (p < 0.001). However, analyzing by increment of 5 (years of age, kg/m² for BMI) rising maternal ages and incidence of preeclampsia were strictly parallel for EOP and LOP, while increment of BMI was only associated with LOP. Controlling for maternal ages and booking/pre-pregnancy BMI, diabetes was not an independent risk factor neither for EOP or LOP.

Conclusions

Metabolic factors, other than diabetes, associated with pre-pregnancy maternal corpulence are specifically associated with LOP. This may be a direction for future researches on the maternal preeclamptic syndrome. This may explain the discrepancy we are facing nowadays where high-income countries report 90% of their preeclampsia being LOP, while it is only 60–70% in medium-low income countries.

Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring

Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.

Selective feticide as a treatment of severe preeclampsia in discordant twins

Multifetal gestation is often complicated by the development of preeclampsia. In some twin gestations, preeclampsia develops in association with restricted fetal growth of only one fetus. Instead of termination of the entire pregnancy, we investigated an alternative approach to the management of such pregnancies that might allow unharmed survival of the normal twin. We present a case of preeclampsia in twin discordance with severe fetal growth restriction at 25 weeks of gestation. Preeclampsia was linked to a lethal condition in one twin and was treated with selective feticide in an effort to reverse preeclampsia. Inasmuch as the fetal prognosis was extremely poor for the abnormal fetus, selective feticide was a reasonable therapeutic option. Maternal symptoms resolved, allowing continuation of the pregnancy for 4 weeks before delivery of the healthy fetus. We maintain that selective termination induced a decrease in the release of substances involved in the physiopathology of preeclampsia, which allowed the continuation of the pregnancy with close follow-up. This report highlights the link between placental pathology and the disease process of preeclampsia and further supports selective termination as a reasonable management strategy in carefully selected cases of discordant twins.

Preeclampsia: Maternal Systemic Vascular Disorder Caused by Generalized Endothelial Dysfunction Due to Placental Antiangiogenic Factors

Preeclampsia, a systemic vascular disorder characterized by new-onset hypertension and proteinuria after 20 weeks of gestation, is the leading cause of maternal and perinatal morbidity and mortality. Maternal endothelial dysfunction caused by placental factors has long been accepted with respect to the pathophysiology of preeclampsia. Over the past decade, increased production of placental antiangiogenic factors has been identified as a placental factor leading to maternal endothelial dysfunction and systemic vascular dysfunction. This review summarizes the recent advances in understanding the molecular mechanisms of endothelial dysfunction caused by placental antiangiogenic factors, and the novel clinical strategies based on these discoveries.

Association between Vascular Endothelial Growth Factor Gene Polymorphisms and Pre-Eclampsia Susceptibility: An Updated Meta-Analysis

Objectives: The aim of this study was to assess the genetic association between vascular endothelial growth factor (VEGF) gene polymorphisms and the risk of pre-eclampsia (PE).Methods: A systematic literature search of several databases (PubMed, Embase, and the China National Knowledge Infrastructure (CNKI)) was conducted for case-control trials comparing VEGF polymorphisms (+936C/T, -634G/C, -2578C/A, and -1154G/A) with the risk of PE. Meta-analysis was performed using the Stata 12.0 software.Results: Twenty-three case-control studies on a total of 2597 PE patients and 3075 controls were included in our meta-analysis. The +936C/T polymorphism was observed to be associated with the risk of PE in the overall population (T vs. C: odds ratios (OR) = 1.434, 95% confidence interval (CI) = 1.120-1.836, P = .004). However, the -634G/C, -2578C/A, and -1154G/A polymorphisms showed no association with the risk of PE. A subgroup analysis based on ethnicity found that the +936C/T polymorphism was associated with the risk of PE in both Europeans and Asians. Furthermore, the -634G/C polymorphism was found to be associated with the risk of PE in Europeans (C vs. G: OR = 1.428, 95% CI = 1.141-1.778, P = .002). The polymorphisms at other loci were not associated with the risk of PE.Conclusion: This meta-analysis suggests that VEGF +936C/T polymorphism, rather than -634G/C, -2578C/A, or -1154G/A polymorphisms, is associated with the risk of PE in the overall study population. However, the -634G/C polymorphism may be associated with the risk of developing PE in Europeans.

The usefulness of melatonin in the field of obstetrics and gynecology

Disorders of the female reproductive system, including those associated with hormone regulation, fertility rate and fetal health, are issues of great concern worldwide. More recently, melatonin supplementation has been suggested as a therapeutic approach in gynecological practice. In both animal models and in women, melatonin supplementation suggests a therapeutic and preventative potential, effects attributed mainly to its antioxidant properties and action as hormone modulator. The aim of this literature review is to further investigate the evidence available on the effects of melatonin supplementation in animal and human studies, focusing on its potential application to gynecology. Melatonin-containing supplements are easily found in online and high street retailers, and despite its supplementation deemed to be relatively safe, no consensus has been reached on effective dosage and supplementation period. Short term supplementation studies, of up to six months, suggest that a daily posology of 2-18 mg of melatonin may have the potential to improve fertility rate, oocyte quality, maturation and number of embryos. However, the evidence available so far on the effects of melatonin supplementation covering gestational age and gestational outcomes is very scarce. Clinical trials and longer-term supplementation studies are required to assess any clinical outcome associated with melatonin supplementation in the field of gynecology.

Exosomes-Associated DNA-New Marker in Pregnancy Complications?

Despite a large number of studies, the etiology of pregnancy complications remains unknown. The involvement of cell-free DNA or fetal cell-free DNA in the pathogenesis of pregnancy complications is currently being hypothesized. Cell-free DNA occurs in different forms-free; part of neutrophil extracellular traps; or as recently discovered, carried by extracellular vesicles. Cell-free DNA is believed to activate an inflammatory pathway, which could possibly cause pregnancy complications. It could be hypothesized that DNA in its free form could be easily degraded by nucleases to prevent the inflammatory activation. However, recently, there has been a growing interest in the role of exosomes, potential protectors of cell-free DNA, in pregnancy complications. Most of the interest from recent years is directed towards the micro RNA carried by exosomes. However, exosome-associated DNA in relation to pregnancy complications has not been truly studied yet. DNA, as an important cargo of exosomes, has been so far studied mostly in cancer research. This review collects all the known information on the topic of not only exosome-associated DNA but also some information on vesicles-associated DNA and the studies regarding the role of exosomes in pregnancy complications from recent years. It also suggests possible analysis of exosome-associated DNA in pregnancy from plasma and emphasizes the importance of such analysis for future investigations of pregnancy complications. A major obstacle to the advancement in this field is the proper uniformed technique for exosomes isolation. Similarly, the sensitivity of methods analyzing a small fraction of DNA, potentially fetal DNA, carried by exosomes is variable.

Neurological manifestations and neuroimaging presentations in patients with severe preeclampsia: predisposing factors and clinical implications

BACKGROUND AND PURPOSE

Neurological manifestations and neuroimaging abnormalities are common in patients with severe preeclampsia; however, the differences between these abnormal features occurring during early- and late-onset severe preeclampsia are unclear, and the factors associated with abnormal imaging changes in patients with neurological manifestations have not yet been fully elucidated.

MATERIALS AND METHODS

A retrospective study was conducted on 172 patients with severe preeclampsia from January 2017 to June 2018 in the Department of Neurology and Obstetrics, Shengjing Hospital of China Medical University. The neurological manifestations, clinical parameters, laboratory, and neuroimaging findings were analyzed.

RESULTS

Early- and late-onset preeclampsia were diagnosed in 83 and 89 patients, respectively. Headache and dizziness were more common in patients with early-onset preeclampsia than in patients with late-onset preeclampsia (p = 0.013, p = 0.004, respectively). Serum uric acid, creatinine, and urea nitrogen were significantly elevated in the patients with early-onset preeclampsia (p < 0.001, p = 0.004, and p = 0.005, respectively). Neuroimaging was performed in 81 patients, of which 57 were positive. Findings indicating cerebral edema were the most common neuroimaging abnormality. Gestational weeks (p = 0.014), headache (p < 0.001), and blood urea nitrogen level (p = 0.027) may be associated with positive imaging findings. By multiple logistic regression, headache (OR = 10.2, 95% CI, 2.4-42.7; p = 0.002) proved to be an independent factor associated with neuroimaging abnormality.

CONCLUSIONS

Neurological symptoms such as headache and dizziness were more common in patients with early-onset preeclampsia. Renal dysfunction may also associate with early-onset severe preeclampsia. Cerebral edema was the most common neuroimaging abnormality, and headache might be independently associated with abnormal imagine changes.