The classification, diagnosis and management of the hypertensive disorders of pregnancy: A revised statement from the ISSHP

Pre-eclampsia is associated with a twofold increase in diabetes: a systematic review and meta-analysis

AIMS/HYPOTHESIS

Pre-eclampsia is a pregnancy-specific multisystem disorder and a state of physiological insulin resistance. Our aim was to systematically evaluate and quantify the evidence on the relationship between pre-eclampsia and the future risk of diabetes.

METHODS

We conducted a systematic review and meta-analysis of studies that evaluated diabetes in women with and without pre-eclampsia. We performed a systematic search of MEDLINE and EMBASE to identify relevant studies. Independent double data extractions were conducted by four reviewers. Random-effects meta-analysis was used to estimate the risk of future diabetes following pre-eclampsia.

RESULTS

A total of 21 studies were identified with more than 2.8 million women, including more than 72,500 women with pre-eclampsia. Meta-analysis of studies that adjusted for potential confounders demonstrated that pre-eclampsia was independently associated with an increased risk of future diabetes (RR 2.37 [95% CI 1.89, 2.97]). This risk appeared in studies that followed women from less than 1 year postpartum (RR 1.97 [95% CI 1.35, 2.87]) and persisted to more than 10 years postpartum (RR 1.95 [95% CI 1.28, 2.97]). After adjusting for BMI or gestational diabetes, pre-eclampsia remained linked with an increased risk of future diabetes (RR 2.38 [95% CI 1.74, 3.24] and RR 2.36 [95% CI 1.94, 2.88], respectively).

CONCLUSIONS/INTERPRETATION

Pre-eclampsia is independently associated with a twofold increase in future diabetes. Our study highlights the importance of clinical risk assessment for the future development of diabetes in women with pre-eclampsia. We recommend detailed evaluation of a screening programme for diabetes in this high-risk population.

Hyperemesis gravidarum and placental dysfunction disorders

Background

Evidence about the consequence of hyperemesis gravidarum (HG) on pregnancy outcomes is still inconclusive. In this study, we evaluated if occurrence of hyperemesis gravidarum is associated with placental dysfunction disorders and neonatal outcomes.

Methods

A prospective cohort study was conducted in a maternal and child health primary care referral center, Budi Kemuliaan Hospital and its branch, in Jakarta, Indonesia. 2252 pregnant women visiting the hospital for regular antenatal care visits from July 2012 until October 2014 were included at their first clinic visit. For women without, with mild and with severe hyperemesis, placental dysfunction disorders (gestational hypertension, preeclampsia (PE), stillbirth, miscarriage), neonatal outcomes (birth weight, small for gestational age (SGA), low birth weight (LBW), Apgar score at 5 min, gestational age at delivery) and placental outcomes (placental weight and placental-weight-to-birth-weight ratio (PW/BW ratio)) were studied.

Results

Compared to newborns of women without hyperemesis, newborns of women with severe hyperemesis had a 172 g lower birth weight in adjusted analysis (95%CI -333.26; -10.18; p = 0.04). There were no statistically significant effects on placental dysfunction disorders or other neonatal outcome measures.

Conclusions

The results of our study suggest that hyperemesis gravidarum does not seem to induce placental dysfunction disorders, but does, if severe lead to lower birth weight.

A randomised controlled demonstration trial of multifaceted nutritional intervention and or probiotics: the healthy mums and babies (HUMBA) trial

Background

Maternal obesity is associated with adverse pregnancy outcomes and has lifelong negative implications for offspring health. The Institute of Medicine recommends limited gestational weight gain (GWG) in obese women for optimal maternal and infant outcomes. However, there is a gap regarding an effective and sustainable intervention strategy to achieve this goal. The aim of the healthy mums and babies (HUMBA) demonstration trial is to assess whether a multifaceted nutritional intervention and/or an oral probiotic treatment in obese pregnant women can reduce excessive GWG and optimise pregnancy outcomes.

Methods and design

The study is a two by two factorial randomised controlled demonstration trial conducted in Counties Manukau health region, New Zealand, a multi-ethnic region with a high prevalence of obesity. A total of 220 non-diabetic obese women with a singleton pregnancy will be recruited between 12⁰ and 17⁶ weeks. At recruitment, women are randomised to receive either a culturally tailored multifaceted dietary intervention or routine dietary advice, and either an oral probiotic or placebo capsule. Randomisation is undertaken via a web-based protocol, randomize.net, with a 1:1 ratio using stratification by body mass index (BMI) category (BMI of 30–34.9 or BMI ≥35 kg/m²). The dietary intervention includes 4 customised nutrition education visits by a trained community health worker combined with motivational text messaging. Probiotic capsules consist of Lactobacillus rhamnosus GG and Bifidobacterium lactis BB12 at a dose of 7 × 10⁹ colony-forming units one per day until birth. Probiotic and placebo capsules are identically pre-packed and labelled by a third party, and are prescribed in a double blinded fashion. Research assessments are conducted at enrolment, 28 weeks, 36 weeks, at birth and at 5 months post-delivery. The primary outcomes for the study are proportion of women with excessive GWG and infant birthweight.

Discussion

The HUMBA demonstration trial will assess the efficacy of a culturally tailored multifaceted dietary intervention and probiotic treatment in limiting excessive GWG and optimising birthweight in a multiethnic sample of obese pregnant women. If successful, either one or both of the interventions may be incorporated into future studies powered to investigate important pregnancy outcomes.

Trial registration

Australian New Zealand Clinical Trials Registry registration number: ACTRN12615000400561, Universal Trial Number: U1111-1155-0409. Date registered: 29^th April 2015.

Enoxaparin for the prevention of preeclampsia and intrauterine growth restriction in women with a prior history - an open-label randomised trial (the EPPI trial): study protocol

BACKGROUND

Preeclampsia and intrauterine fetal growth restriction (IUGR) are two of the most common causes of maternal and perinatal morbidity and mortality. Current methods of predicting those at most risk of these conditions remain relatively poor, and in clinical practice past obstetric history remains the most commonly used tool. Aspirin and, in women at risk of preeclampsia only, calcium have been demonstrated to have a modest effect on risk reduction. Several observational studies and randomised trials suggest that low molecular weight heparin (LMWH) therapy may confer some benefit.

METHODS/DESIGN

This is a multicentre open label randomised controlled trial to determine the effect of the LMWH, enoxaparin, on the prevention of recurrence of preeclampsia and/or IUGR in women at high risk due to their past obstetric history in addition to standard high risk care for all participants.

INCLUSION CRITERIA

A singleton pregnancy >6+0 and <16+0 weeks gestation with most recent prior pregnancy with duration >12 weeks having; (1) preeclampsia delivered <36+0 weeks, (2) Small for gestational age (SGA) infant <10th customised birthweight centile delivered <36+0 weeks or, (3) SGA infant ≤3rd customised birthweight centile delivered at any gestation. Randomisation is stratified for maternal thrombophilia status and women are randomly assigned to 'standard high risk care' or 'standard high risk care' plus enoxaparin 40 mg from recruitment until 36+0 weeks or delivery, whichever occurs sooner. Standard high risk care includes the use of aspirin 100 mg daily and calcium 1000-1500 mg daily (unless only had previous SGA with no preeclampsia). The primary outcome is preeclampsia and/or SGA <5th customised birthweight centile. Analysis will be by intention to treat.

DISCUSSION

The EPPI trial has more focussed and clinically relevant inclusion criteria than other randomised trials with a more restricted composite primary outcome. The inclusion of standard use of aspirin (and calcium) for all participants will help to ensure that any differences observed in outcome are likely to be related to enoxaparin use. These data will make a significant contribution to future meta-analyses and systematic reviews on the use of LMWH for the prevention of placental mediated conditions.

TRIAL REGISTRATION

ACTRN12609000699268 Australian New Zealand Clinical Trials Registry. Date registered 13/Aug/2009 (prospective registration).

Risk of hypertensive disorders in pregnancy following assisted reproductive technology: overview and meta-analysis

The extent of the increased risk of pregnancy hypertensive disorders following assisted reproductive technology (ART) was investigated. PubMed and the Cochrane Collaboration Library were used as data sources to identify and select longitudinal cohorts comparing pregnancies following ART with spontaneously conceived pregnancies, between 1978 and June 2016. Risk ratios and 95% confidence intervals (CIs) of three outcomes, ie, gestational hypertension (GH), preeclampsia (PE), and their sum (PHD), were calculated. Stratification of results by gestation order (singletons and nonsingletons) was pursued, but a separate "all orders" mixed stratification was considered. Sixty-six longitudinal studies (7 038 029 pregnancies; 203 375 following any ART) were eligible. All outcomes independent of gestation order ("all orders") were increased following any invasive ART: GH (+79% [95% CI, 24%-157%]) and PE (+75% [95% CI, 50%-103%]) to a greater extent, with smaller increases in PHD (+54% [95% CI, 39%-70%]). The risk of PHD following ART steadily increased independent of gestation order.

Defining a Reference Range for Vital Signs in Healthy Term Pregnant Women Undergoing Caesarean Section

Early warning systems (EWS), used to identify deteriorating hospitalised patients, are based on measurement of vital signs. When the patients are pregnant, most EWS still use non-pregnant reference ranges of vital signs to determine trigger thresholds. There are no published reference ranges for all vital signs in pregnancy. We aimed to define vital signs reference ranges for term pregnancy in the preoperative period, and to determine the appropriateness of EWS trigger criteria in pregnancy. We conducted a one-year retrospective study in a tertiary referral obstetric hospital. The study sample was healthy term women undergoing planned caesarean section (CS). Systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), oxygen saturation (SpO2) and temperature were all measured automatically and data was extracted from the medical record. Two hundred and fifty-eight women met inclusion criteria. Results were (mean ± SD [standard deviation]) SBP 118 ± 11.2 mmHg, DBP 75 ± 10.3 mmHg, HR 84 ± 10.2 /minute, respiratory rate 18 ± 1.5 /minute, SpO2 99% ± 1.0% and temperature 36.4°C ± 0.43°C. The reference ranges (mean ± 2SD) determined were SBP 96–140 mmHg, DBP 54–96 mmHg, HR 64-104 /minute, RR 15–21 /minute, SpO2 97%–100% and temperature 35.5°C–37.3°C. This study defined a reference range for vital signs in healthy term pregnant women undergoing CS. Study findings suggest that currently used criteria for EWS triggers, based on non-pregnant values, may be too extreme for timely detection of deteriorating pregnant patients. Further research examining the modified HR triggers of ≤50 and ≥110 /minute in pregnant women and their relationship to clinical outcomes is required.

Triggers for Preeclampsia Onset: a Case-Crossover Study

BACKGROUND

Risk factors for preeclampsia are well established, whereas, the triggers associated with timing of preeclampsia onset are not. The aim of this study was to establish whether recent infection or other triggers were associated with timing of preeclampsia onset.

METHODS

We used a case-crossover design with preeclampsia cases serving as their own controls. Women with singleton pregnancies of ≥20 weeks gestation presenting at three hospitals were eligible for inclusion. Exposures to potential triggers were identified via guided questionnaire. Infective episodes included symptoms lasting >24 h. Preeclampsia was defined as hypertension (BP ≥140 mmHg and/or ≥90 mmHg) and proteinuria (protein/creatinine ratio ≥30 mg/mmol). Conditional logistic regression was used to compare the odds of exposure to potential triggers in the case windows (1-7 days preceding diagnosis of preeclampsia) and control windows (8-14 days prior to diagnosis); unadjusted odds ratios (ORs) are reported.

RESULTS

Among 286 recruited women, 25 (8.7%) reported a new infection in the 7 days prior to preeclampsia onset and 21 (7.3%) in the 8-14 days prior. There was no significant association between onset of infection in the 7 days prior and preeclampsia diagnosis (OR 1.24, 95% CI 0.65, 2.34). Consumption of caffeine (OR 0.51, 95% CI 0.33, 0.77), spicy food (OR 0.49, 95% CI 0.30, 0.81), and alcohol (OR 0.26, 95% CI 0.10, 0.71) were strongly inversely associated with preeclampsia onset.

CONCLUSION

Recent infection does not appear to trigger preeclampsia. Decreased consumption of caffeine, spicy food, and alcohol may be prodromal markers. Such behaviours may be early markers of imminent preeclampsia.

Preeclampsia; short and long-term consequences for mother and neonate

Preeclampsia is a common pregnancy specific disease, that presents with hypertension and a variety of organ failures, including malfunction of kidneys, liver and lungs. At present, the only definitive treatment of preeclampsia is end the pregnancy and deliver the neonate and placenta. For women with mild preeclampsia in the preterm phase of pregnancy, expectant management is generally indicated to improve fetal maturity, often requiring maternal medical treatment. Last decades, more evidence is available that the underlying mechanism of preeclampsia, endothelial disease, is not limited to pregnancy but increases cardiovascular risk in later life. In this review, we present the most recent insight in preeclampsia with focus on impact on the fetus, short and long-term outcome of offspring's, and long-term outcome of women with a history of preeclampsia.

Elevated levels of protein AMBP in cerebrospinal fluid of women with preeclampsia compared to normotensive pregnant women

PURPOSE

To investigate the cerebrospinal fluid (CSF) proteome of patients with preeclampsia (PE) and normotensive pregnant women, in order to provide a better understanding of brain involvement in PE.

EXPERIMENTAL DESIGN

Ninety-eight CSF samples (43 women with PE and 55 normotensive controls) were analyzed by LC-MS/MS proteome profiling. CSF was obtained during the spinal puncture before caesarean delivery.

RESULTS

Eight proteins were higher abundant and 17 proteins were lower abundant in patients with PE. The most significantly differentially abundant protein was protein AMBP (alpha-1-microglobulin/bikunin precursor). This finding was validated by performing an ELISA experiment (p = 0.002).

CONCLUSIONS AND CLINICAL RELEVANCE

The current study showed a clear difference between the protein profiles of CSF from patients with PE and normotensive pregnant women. Protein AMBP is a precursor of a heme-binding protein that counteracts the damaging effects of free hemoglobin, which may be related to the presence of free hemoglobin in CSF. Protein levels showed correlations with clinical symptoms during pregnancy and postpartum. To our knowledge, this is the first LC-MS/MS proteome profiling study on a unique set of CSF samples from (severe) preeclamptic patients and normotensive pregnant women.

Pregnancy in the liver transplant recipient

During gestation, the woman's body undergoes various changes, and the line between physiology and pathology is very thin even in healthy women. Today, many of the liver transplant recipients are young women, who at one point in their lives may consider the possibility of pregnancy. Clinicians have to counsel them about the time of conception, the risk of miscarriage, the deterioration of the mother's health status, and the risk of birth defects. This review, based on our 20 years of clinical experience and up-to-date literature, provides comprehensive guidelines on pregnancy management in liver transplant recipients. Pregnancy in liver transplant recipients is possible but never physiological. Proper management and pharmacotherapy lowers the incidence of complications and birth defects. Critical factors for perinatal success include stable graft function before pregnancy, proper preparation for pregnancy, and cautious observation during its course. Liver Transplantation 22 1408-1417 2016 AASLD.

Predictive value of miR-210 as a novel biomarker for pre-eclampsia: a systematic review protocol

INTRODUCTION

Pre-eclampsia (PE) is a serious condition affecting 3-5% of all pregnancies worldwide. However, underlying molecular pathogenesis of this disease has largely remained unknown. Recently, several studies have indicated the possibility role of microRNAs, especially miR-210, in the aetiology of PE. The aim of this systematic review is to assess the possible role of miR-210 as a novel biomarker for the prediction of PE.

METHODS AND ANALYSIS

Using a combination of mesh terms 'preeclampsia', 'microRNA' and their equivalents, an electronic search will be performed for all observational studies (cross sectional, case-control and cohort) in PubMed, Web of Science, Scopus, Embase, Cochrane, LILACS and OvidSP MEDLINE from January 2005 to December 2015. Furthermore, other sources are searched, including grey literature, reference lists of relevant primary studies as well as key journals. Study selection, data extraction and quality assessment of studies will be performed independently by 2 reviewers, and any disagreement will be resolved by consensus. If sufficient data are available, it will be combined by either fixed or random effects models. We will investigate the source)s(and degree of heterogeneity using 'Heterogeneity χ2' and I2. Heterogeneity would be investigated through either subgroup analysis or metaregression. Stata V.11.1 will be used for data analysis.

ETHICS AND DISSEMINATION

The results of this study are disseminated in peer-reviewed journal articles and academic presentations. Formal ethical approval is not required, since the secondary data will be collected.

TRIAL REGISTRATION NUMBER

CRD42015032345.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal extracellular vesicles and platelets promote preeclampsia via inflammasome activation in trophoblasts

Preeclampsia (PE) is a placenta-induced inflammatory disease associated with maternal and fetal morbidity and mortality. The mechanisms underlying PE remain enigmatic and delivery of the placenta is the only known remedy. PE is associated with coagulation and platelet activation and increased extracellular vesicle (EV) formation. However, thrombotic occlusion of the placental vascular bed is rarely observed and the mechanistic relevance of EV and platelet activation remains unknown. Here we show that EVs induce a thromboinflammatory response specifically in the placenta. Following EV injection, activated platelets accumulate particularly within the placental vascular bed. EVs cause adenosine triphosphate (ATP) release from platelets and inflammasome activation within trophoblast cells through purinergic signaling. Inflammasome activation in trophoblast cells triggers a PE-like phenotype, characterized by pregnancy failure, elevated blood pressure, increased plasma soluble fms-like tyrosine kinase 1, and renal dysfunction. Intriguingly, genetic inhibition of inflammasome activation specifically in the placenta, pharmacological inhibition of inflammasome or purinergic signaling, or genetic inhibition of maternal platelet activation abolishes the PE-like phenotype. Inflammasome activation in trophoblast cells of women with preeclampsia corroborates the translational relevance of these findings. These results strongly suggest that EVs cause placental sterile inflammation and PE through activation of maternal platelets and purinergic inflammasome activation in trophoblast cells, uncovering a novel thromboinflammatory mechanism at the maternal-embryonic interface.

Long-term follow-up of psychosocial distress after early onset preeclampsia: the Preeclampsia Risk EValuation in FEMales cohort study

OBJECTIVE

To examine long-term psychosocial distress in women with a history of early onset preeclampsia (PE) compared to a comparison group.

METHODS

Women with and without a history of early onset PE participating in the 'Preeclampsia Risk EValuation in FEMales' (PREVFEM) study were sent questionnaires, on average 14.1 years (SD = 3.2, range 5-23 years) after the index pregnancy. In total 265 (77%) women with PE and 268 (78%) age-matched women without PE returned questionnaires (mean age 43.5, SD =4.6 years). Group differences were examined on indicators of psychosocial distress, depressive symptoms, anxiety, fatigue, loneliness, marital quality, trait optimism and Type D personality, and unadjusted and adjusted for a priori chosen and study-specific covariates. In secondary analyses, the effect of previously detected hypertension was examined, as well as pregnancy-related events within the PE group.

RESULTS

Women with a history of PE reported more subsequent depressive symptoms (B = 0.70, 95% CI 0.09-1.32, p = 0.026) and more fatigue (B = 1.12, 95% CI 0.07-2.18, p = 0.037) compared to the non-PE group, but the differences explained less than 1% of the variance. The differences remained after adjustment for age, BMI and education level, and additional adjustment for partner, being unemployed and physical activity. No significant differences were observed for anxiety, loneliness, marital quality, optimism, or Type D personality. These differences were not explained by four-year previously measured elevated blood pressure in the PE group. Having had a stillborn child or early neonatal death during the index pregnancy was associated with higher depressive symptoms, anxiety, fatigue, and loneliness in the PE group, but these factors explained only a small proportion of the variance in these psychosocial distress factors.

CONCLUSION

A history of early PE is associated with slightly higher levels of depressive symptoms and fatigue on average 14 years later, but this is unlikely to be of clinical relevance.

Placental exosomes and pre-eclampsia: Maternal circulating levels in normal pregnancies and, early and late onset pre-eclamptic pregnancies

INTRODUCTION AND AIM

Exosomes are a subtype of extracellular vesicle (20-130 nm) released by biological cells under normal and pathological conditions. Although there have been reports of circulating exosomes in normal pregnancy, the relevance of placental-derived exosomes in normal and abnormal pregnancies still needs to be elucidated. The aim of this study was to quantify total and placental-derived exosomes in maternal plasma from normal (N), early onset- and late onset-preeclampsia (PE).

METHOD

Plasma samples were obtained from pregnant women in the third trimester, for the isolation of exosomes by differential ultracentrifugation. Total exosomes were quantified using nanoparticle tracking analysis and immuno-reactive exosomal CD63 quantification. Placental-derived exosomes were quantified using placental alkaline phosphatase (PLAP) as a specific marker. The contribution of placental-derived exosomes to total exosomes in maternal plasma was determined by the ratio of PLAP⁺ exosomes to CD63⁺ exosomes.

RESULTS

The concentration of total exosomes significantly increased in early onset-PE and late onset-PE compared to N (≤33 weeks) and N (≥34 weeks). The relative concentration of placental-derived exosomes significantly increased in early onset-PE but decreased in late onset-PE compared to N. The ratio of PLAP⁺ exosomes to total number of exosomes significantly decreased in early onset-PE and late onset-PE. A positive correlation between total and placental-derived exosomes were obtained in N (≤33 weeks: Pearson's r = 0.60, ≥34 weeks: Pearson's r = 0.67) and early onset-PE (Pearson's r = 0.51, p < 0.05) with the inverse in late onset-PE (Pearson's r = -0.62, p < 0.01).

CONCLUSION

The differences in the contribution of placental-derived exosomes to total exosomes in maternal circulation suggests a possible pathophysiological role of placental-derived exosomes in pre-eclampsia.

Prediction and prevention of hypertensive disorders of pregnancy

The most common classifications of hypertensive disorders of pregnancy consist of chronic hypertension, gestational hypertension, preeclampsia (PE) and superimposed PE. A common final pathophysiology of PE is endothelial dysfunction. The most successful translational research model for explaining the cause-effect relationship in the genesis of PE is the angiogenic/angiostatic balance theory, involving soluble fms-like tyrosine kinase 1 (sFlt-1), placental growth factor (PlGF) and soluble endoglin (sEng). In a systematic review of articles on the prediction of early-onset PE using angiogenesis-related factors, we revealed that the prediction of early-onset PE in the first trimester is clinically possible, but the prediction of early-onset PE in the early third trimester might be ideal. In addition, an onset threshold or a serial approach appeared to be clinically useful for predicting the imminent onset of PE, with onset at <4 weeks after blood sampling in the second and early third trimesters, because the positive likelihood ratio was >10 and the positive predictive value was >20%. The National Institute for Health and Care Excellence guidelines state that the Triage PlGF testing and Elecsys immunoassay for the sFlt-1/PlGF ratio could help to exclude PE in women with suspected PE at 20-34 weeks of gestation. Until now, we have not found any effective therapies to prevent PE. However, low-dose aspirin treatment starting at ⩽16 weeks of gestation might be associated with a marked reduction in PE. In addition, early statin treatment might prevent the occurrence of PE. Currently, a clinical trial using pravastatin for the prevention of PE is ongoing.

The diagnosis of pre-eclampsia using two revised classifications in the Finnish Pre-eclampsia Consortium (FINNPEC) cohort

Background

The Finnish Pre-eclampsia Consortium (FINNPEC) case-control cohort consisting of 1447 pre-eclamptic and 1068 non-pre-eclamptic women was recruited during 2008–2011 to study genetic background of pre-eclampsia and foetal growth. Pre-eclampsia was defined by hypertension and proteinuria according to the American College of Obstetricians and Gynecologists (ACOG) 2002 classification. The ACOG Task Force Report on Hypertension in Pregnancy (2013) and The International Society for the Study of Hypertension in Pregnancy (ISSHP) (2014) have published new classifications, in which proteinuria is not necessary for diagnosis when specific symptoms are present. For diagnoses based on proteinuria, the ISSHP 2014 criteria raised its threshold to 2+ on dipstick. We studied how the new classifications would affect pre-eclampsia diagnoses in the FINNPEC cohort.

Methods

We re-evaluated pre-eclampsia diagnosis using the ACOG 2013 and the ISSHP 2014 classifications in pre-eclamptic women whose proteinuria did not exceed 1+ on dipstick (n = 68), in women with gestational hypertension (n = 138) and in women with chronic hypertension (n = 66).

Results

The number of women with pre-eclampsia increased 0.8 % (1459/1447) according to the ACOG 2013 criteria and 0.6 % (1455/1447) according to the ISSHP 2014 criteria. All 68 women with the amount of proteinuria not exceeding 1+ on dipstick diagnosed originally pre-eclamptic met the ACOG 2013 criteria but only 20 women (29.4 %) met the ISSHP 2014 criteria. Seven (5.1 %) and 35 (25.4 %) women with gestational hypertension were diagnosed with pre-eclampsia according to the ACOG 2013 and the ISSHP 2014 criteria, respectively. Correspondingly five (7.6 %) and 21 (31.8 %) women with chronic hypertension were diagnosed with pre-eclampsia according to the ACOG 2 013 and the ISSHP 2014 criteria.

Conclusions

Only minor changes were observed in the total number of pre-eclamptic women in the FINNPEC cohort when comparing the ACOC 2002 classification with the ACOG 2013 and ISSHP 2014 classifications.

Does pre-pregnancy BMI determine blood pressure during pregnancy? A prospective cohort study

OBJECTIVES

To evaluate if pre-pregnancy body mass index (BMI) determines blood pressure throughout pregnancy and to explore the role of gestational weight gain in this association. In addition, the effects of pre-pregnancy BMI and gestational weight gain on the occurrence of gestational hypertension and pre-eclampsia were investigated.

DESIGN

Prospective cohort study.

SETTING

Maternal and child health primary care referral centre, Jakarta, Indonesia.

POPULATION AND MEASUREMENTS

2252 pregnant women visiting Budi Kemuliaan Hospital and its branch for regular antenatal care visits from July 2012 to April 2015. Pre-pregnancy BMI (kg/m(2)) was based on self-reported pre-pregnancy weight and measured height at first visit. Gestational weight gain was calculated as weight at the day of delivery minus the pre-pregnancy weight. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured during pregnancy at every visit. Linear mixed models were used to analyse this relation with repeated blood pressure measures as the outcome and pre-pregnancy BMI as the predictor. When looking at gestational hypertension and pre-eclampsia as outcomes, (multiple) logistic regression was used in the analysis.

RESULTS

Independent of pre-pregnancy BMI, SBP and DBP increased by 0.99 mm Hg/month and 0.46 mm Hg/month, respectively. Higher pre-pregnancy BMI was associated with higher pregnancy SBP (0.25 mm Hg/kg/m(2); 95% CI 0.17 to 0.34; p<0.01) and DBP (0.18 mm Hg/kg/m(2); 0.13 to 0.24; p<0.01) in adjusted analysis. Every 1 kg/m(2) higher pre-pregnancy BMI was associated with 6% and 9% higher odds for gestational hypertension (adjusted OR (aOR) 1.06; 95% CI 1.03 to 1.09; p<0.01) and pre-eclampsia (aOR 1.09; 1.04 to 1.14; p<0.01). Accounting for gestational weight gain did not attenuate these associations.

CONCLUSIONS

Pre-pregnancy BMI determines the level, but not the change, of blood pressure in pregnancy and is linked to higher odds for gestational hypertension and pre-eclampsia, independent of gestational weight gain.

Current best practice in the management of hypertensive disorders in pregnancy

Preeclampsia is a potentially serious complication of pregnancy with increasing significance worldwide. Preeclampsia is the cause of 9%–26% of global maternal mortality and a significant proportion of preterm delivery, and maternal and neonatal morbidity. Incidence is increasing in keeping with the increase in obesity, maternal age, and women with medical comorbidities entering pregnancy. Recent developments in the understanding of the pathophysiology of preeclampsia have opened new avenues for prevention, screening, and management of this condition. In addition it is known that preeclampsia is a risk factor for cardiovascular disease in both the mother and the child and presents an opportunity for early preventative measures. New tools for early detection, prevention, and management of preeclampsia have the potential to revolutionize practice in the coming years. This review presents the current best practice in diagnosis and management of preeclampsia and the hypertensive disorders of pregnancy.

Pregnancy in Women With CKD: A Success Story

In women with chronic kidney disease (CKD), pregnancy outcomes have improved over the last 50 years, particularly in the developed world. Maternal mortality is now extremely low, fetal survival has markedly increased (even in women with CKD stages 4-5), and it is now the exception for women with CKD to be advised against embarking on a pregnancy. However, pregnancies are rarely free from complications, and there are unanswered questions about the longer term effects on maternal and infant health. The developments have led to a more optimistic attitude to pregnancy in women with CKD not requiring renal replacement treatment. The remaining problems are described in this World Kidney Forum.

Immunology of hepatic diseases during pregnancy

The mother's immune system has to adapt to pregnancy accepting the semi-allograft fetus and preventing harmful effects to the developing child. Aberrations in feto-maternal immune adaptation may result in disease of the mother, such as liver injury. Five pregnancy-associated liver disorders have been described so far, however, little is known concerning immune alterations promoting the respective disease. These liver disorders are pre-eclampsia, hemolysis, elevated liver enzymes, low platelet count (HELLP), acute fatty liver, hyperemesis gravidarum, and intrahepatic cholestasis of pregnancy. On the other hand, pre-existing autoimmune liver injury of the mother can be affected by pregnancy. This review intends to summarize current knowledge linking feto-maternal immunology and liver inflammation with a special emphasis on novel potential biomarkers.

Neonatal haemodynamic effects following foetal exposure to labetalol in hypertensive disorders of pregnancy

OBJECTIVE

Hypertensive disorders of pregnancy (HDP) affect foetal outcome. Labetalol is frequently used to lower maternal blood pressure and prolong pregnancy. Conflicting evidence exists for specific neonatal side effects described after maternal labetalol treatment. Our aim was to investigate neonatal effects of foetal exposure to labetalol on cerebral oxygenation and extraction.

METHODS

In a prospective observational study, clinical characteristics, vital parameters and cerebral oxygen delivery and extraction were collected during the first 24 h of life in labetalol-exposed preterm neonates and compared with two control groups.

RESULTS

Twenty-two infants with a mean gestational age of 28.9 weeks, born from labetalol-treated mothers with HDP were included and matched with 22 infants with non-labetalol-treated mothers with HDP and 22 infants without maternal HDP. No significant differences between groups were found neither in heart rate, blood pressure and inotropic support, nor in mean regional cerebral oxygen saturation and fractional tissue oxygen extraction.

CONCLUSION

Foetal labetalol exposure associated effects on preterm heart rate, blood pressure, cerebral oxygenation and extraction are not demonstrated. Maternal disease severity seems to play a more important role in neonatal cerebral haemodynamics. Maternal labetalol treatment has no clinically important short term side effects in the preterm neonate.

Preeclampsia: Updates in Pathogenesis, Definitions, and Guidelines

Preeclampsia is becoming an increasingly common diagnosis in the developed world and remains a high cause of maternal and fetal morbidity and mortality in the developing world. Delay in childbearing in the developed world feeds into the risk factors associated with preeclampsia, which include older maternal age, obesity, and/or vascular diseases. Inadequate prenatal care partially explains the persistent high prevalence in the developing world. In this review, we begin by presenting the most recent concepts in the pathogenesis of preeclampsia. Upstream triggers of the well described angiogenic pathways, such as the heme oxygenase and hydrogen sulfide pathways, as well as the roles of autoantibodies, misfolded proteins, nitric oxide, and oxidative stress will be described. We also detail updated definitions, classification schema, and treatment targets of hypertensive disorders of pregnancy put forth by obstetric and hypertensive societies throughout the world. The shift has been made to view preeclampsia as a systemic disease with widespread endothelial damage and the potential to affect future cardiovascular diseases rather than a self-limited occurrence. At the very least, we now know that preeclampsia does not end with delivery of the placenta. We conclude by summarizing the latest strategies for prevention and treatment of preeclampsia. A better understanding of this entity will help in the care of at-risk women before delivery and for decades after.

Long-term renal and cardiovascular risk after preeclampsia: towards screening and prevention

Preeclampsia (PE) is a hypertensive pregnancy disorder complicating up to 1-5% of pregnancies, and a major cause of maternal and fetal morbidity and mortality. In recent years, observational studies have consistently shown that PE carries an increased risk for the mother to develop cardiovascular and renal disease later in life. Women with a history of PE experience a 2-fold increased risk of long-term cardiovascular disease (CVD) and an approximate 5-12-fold increased risk of end-stage renal disease (ESRD). Recognition of PE as a risk factor for renal disease and CVD allows identification of a young population of women at high risk of developing of cardiovascular and renal disease. For this reason, current guidelines recommend cardiovascular screening and treatment for formerly preeclamptic women. However, these recommendations are based on low levels of evidence due to a lack of studies on screening and prevention in formerly preeclamptic women. This review lists the incidence of premature CVD and ESRD observed after PE and outlines observed abnormalities that might contribute to the increased CVD risk with a focus on kidney-related disturbances. We discuss gaps in current knowledge to guide optimal screening and prevention strategies. We emphasize the need for research on mechanisms of late disease manifestations, and on effective screening and therapeutic strategies aimed at reducing the late disease burden in formerly preeclamptic women.

Randomized Trial of a Lifestyle Program in Obese Infertile Women

BACKGROUND

Small lifestyle-intervention studies suggest that modest weight loss increases the chance of conception and may improve perinatal outcomes, but large randomized, controlled trials are lacking.

METHODS

We randomly assigned infertile women with a body-mass index (the weight in kilograms divided by the square of the height in meters) of 29 or higher to a 6-month lifestyle intervention preceding treatment for infertility or to prompt treatment for infertility. The primary outcome was the vaginal birth of a healthy singleton at term within 24 months after randomization.

RESULTS

We assigned women who did not conceive naturally to one of two treatment strategies: 290 women were assigned to a 6-month lifestyle-intervention program preceding 18 months of infertility treatment (intervention group) and 287 were assigned to prompt infertility treatment for 24 months (control group). A total of 3 women withdrew consent, so 289 women in the intervention group and 285 women in the control group were included in the analysis. The discontinuation rate in the intervention group was 21.8%. In intention-to-treat analyses, the mean weight loss was 4.4 kg in the intervention group and 1.1 kg in the control group (P<0.001). The primary outcome occurred in 27.1% of the women in the intervention group and 35.2% of those in the control group (rate ratio in the intervention group, 0.77; 95% confidence interval, 0.60 to 0.99).

CONCLUSIONS

In obese infertile women, a lifestyle intervention preceding infertility treatment, as compared with prompt infertility treatment, did not result in higher rates of a vaginal birth of a healthy singleton at term within 24 months after randomization. (Funded by the Netherlands Organization for Health Research and Development; Netherlands Trial Register number, NTR1530.).

Translational studies for exercise in high-risk pregnancy: Pre-eclampsia model

OBJECTIVE

Reviewed literature regarding exercise effects on pregnancy-related hypertensive disorders, analyzing basic science perspectives and clinical studies.

METHODS

Scientific databases were accessed by research strategy combining Medical Subject Headings terms. Studies published between 2000 and 2015, in English, Portuguese, and Spanish language, were considered.

RESULTS

Studies were classified into: recommendations for exercise on high-risk pregnancy; animal models for hypertension in pregnancy; exercise on hypertensive disorders in animal models and pregnant women.

CONCLUSION

There are several animal models to mimic hypertensive disorders in pregnancy; however, clinical studies are still needed for exercise recommendation in pregnant women with hypertensive disorders.

Pregnancy and liver disease

Pregnancy associated liver diseases affect up to 3% of pregnant women and are the most frequent cause of liver dysfunction in pregnancy. When severe, they are associated with significant morbidity and mortality for both mother and infant. A rapid evaluation to distinguish them from non-pregnancy related liver dysfunction is essential, in order to facilitate appropriate management. Liver disease unrelated to pregnancy can present de novo in pregnancy, or pregnancy can occur in women with preexisting liver pathology (Table 1). Research and subsequent advances in medical care have resulted in improved but still not satisfactory maternal and fetal outcomes. In this review we provide an overview of the liver diseases specific to the pregnant state and an update on their pathogenesis, treatment and outcomes. The risks of pregnancy in women with pre-existent liver pathology is detailed and recent advances in our understanding of specific risks and outcomes are discussed.

Trial protocol to compare the efficacy of a smartphone-based blood glucose management system with standard clinic care in the gestational diabetic population

INTRODUCTION

The prevalence of gestational diabetes mellitus (GDM) is rising in the UK. Good glycaemic control improves maternal and neonatal outcomes. Frequent clinical review of patients with GDM by healthcare professionals is required owing to the rapidly changing physiology of pregnancy and its unpredictable course. Novel technologies that allow home blood glucose (BG) monitoring with results transmitted in real time to a healthcare professional have the potential to deliver good-quality healthcare to women more conveniently and at a lower cost to the patient and the healthcare provider compared to the conventional face-to-face or telephone-based consultation. We have developed an integrated GDm-health management system and aim to test the impact of using this system on maternal glycaemic control, costs, patient satisfaction and maternal and neonatal outcomes compared to standard clinic care in a single large publicly funded (National Health Service (NHS)) maternity unit.

METHODS AND ANALYSIS

Women with confirmed gestational diabetes in a current pregnancy are individually randomised to either the GDm-health system and half the normal clinic visits or normal clinic care. Primary outcome is mean BG in each group from recruitment to delivery calculated, with adjustments made for number of BG measurements, proportion of preprandial and postprandial readings and length of time in study, and compared between the groups. The secondary objective will be to compare the two groups for compliance to the allocated BG monitoring regime, maternal and neonatal outcomes, glycaemic control using glycated haemoglobin (HbA1c) and other BG metrics, and patient attitudes to care assessed using a questionnaire and resource use.

ETHICS AND DISSEMINATION

Thresholds for treatment, dietary advice and clinical management are the same in both groups. The results of the study will be published in a peer-reviewed journal and disseminated electronically and in print.

TRIAL REGISTRATION NUMBER

NCT01916694; Pre-results.

Pre-eclampsia

Pre-eclampsia affects 3-5% of pregnancies and is traditionally diagnosed by the combined presentation of high blood pressure and proteinuria. New definitions also include maternal organ dysfunction, such as renal insufficiency, liver involvement, neurological or haematological complications, uteroplacental dysfunction, or fetal growth restriction. When left untreated, pre-eclampsia can be lethal, and in low-resource settings, this disorder is one of the main causes of maternal and child mortality. In the absence of curative treatment, the management of pre-eclampsia involves stabilisation of the mother and fetus, followed by delivery at an optimal time. Although algorithms to predict pre-eclampsia are promising, they have yet to become validated. Simple preventive measures, such as low-dose aspirin, calcium, and diet and lifestyle interventions, show potential but small benefit. Because pre-eclampsia predisposes mothers to cardiovascular disease later in life, pregnancy is also a window for future health. A collaborative approach to discovery and assessment of the available treatments will hasten our understanding of pre-eclampsia and is an effort much needed by the women and babies affected by its complications.

Calcium Supplementation to Prevent Preeclampsia: Translating Guidelines into Practice in Low-Income Countries

The WHO issued a strong recommendation that pregnant women be provided calcium supplements to prevent preeclampsia. This is the first recommended nutritional intervention to prevent this condition, a leading cause of maternal mortality globally. As health systems seek to implement this new intervention, a number of issues require further clarification and guidance, including dosage regimen, supplement formulation, and alignment with other antenatal nutritional interventions. We summarize key evidence on the above points and offer our views on good practices. Most developing countries have low calcium intake, so where habitual calcium intake is unknown, calcium supplements are likely beneficial. In our view, policymakers and program planners should consider adopting doses between 1.0 and 1.5 g elemental calcium/d, depending on the local average and variation in dietary calcium intake, logistical feasibility, and acceptability in the target population. Prudent practice would entail daily administration as calcium carbonate administered in divided doses of not >500 mg elemental calcium per dose. For ease of prescribing and adherence, calcium [as with iron and folic acid (IFA)] should be administered routinely to pregnant women from the earliest contact in pregnancy until delivery. Calcium's acute inhibitory effect on iron absorption translates to minimal effects in clinical studies. Therefore, to simplify the regimen and facilitate adherence, providers should not counsel that calcium and IFA pills must be taken separately. Although further research will shed more light on clinical and programmatic issues, policies can be implemented with ongoing revision as we continue to learn what works to improve maternal and newborn health.

Hypertension in pregnancy

PURPOSE OF REVIEW

Hypertension in pregnancy contributes substantially to perinatal mortality and morbidity of both the mother and her child. High blood pressure is mainly responsible for this adverse outcome, in particular when associated with preeclampsia. Although preeclampsia is nowadays a well-known clinical-obstetrical entity, and screening for this complication has been part of routine care during pregnancy for nearly 100 years, its cause is still enigmatic.

RECENT FINDINGS

Profound changes of the demographic development of our society, the worldwide rising prevalence of obesity and metabolic disorders, and progress in reproductive medicine will inevitably modify the prevalence of many medical problems in pregnancy. Complications such as gestational diabetes mellitus, chronic hypertension, and preeclampsia will rise and an interdisciplinary approach is necessary to handle these women during pregnancy and also after delivery. Indeed, it is now well established that these women and their offspring born large or small-for-gestational age are at increased risk for severe cardiovascular and metabolic complications later in life.

SUMMARY

Knowledge of the pregnancy course is not only important for an obstetrician but also increasingly inevitable for the general practitioner. Recognition, classification, and adequate management of hypertensive pregnancy disorders and associated complications may considerably reduce perinatal death and morbidity.