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Demirer S, Hocaoglu M, Turgut A, Karateke A, Komurcu-Bayrak E. Expression profiles of candidate microRNAs in the peripheral blood leukocytes of patients with early- and late-onset preeclampsia versus normal pregnancies. Pregnancy Hypertens 2020; 19:239-245. [PMID: 31899190 DOI: 10.1016/j.preghy.2019.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/12/2019] [Accepted: 11/09/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES Maternal leucocytes play an important role in the pathogenesis of preeclampsia (PE). Circulating microRNAs (miRNAs) are small, noncoding RNA molecules. The purpose of this study was to investigate miR-518b, miR-155-5p, and miR-21-3p in the peripheral blood leukocytes of patients with PE, compared to controls. STUDY DESIGN Using real-time quantitative PCR method, the selected miRNAs which have been associated with PE were examined from early- onset PE (EOPE) (<34 weeks) (n = 48), late- onset PE (LOPE) (≥34 weeks) (n = 48), total cases of PE (n = 96), and healthy controls (n = 52). MAIN OUTCOME MEASURES The relative expression of the target miR in patient samples was compared to the calibrator and the results were expressed as relative quantification values. RESULTS Gestational age (GA) was significantly different between PE and controls. Univariate logistic regression analysis adjusted for GA at blood draw were fit to compare miR-518b, miR-155-5p, and miR-21-3p between PE and controls. The expression of miR-518b, miR-155-5p, and miR-21-3p were not significantly different in PE, compared to controls. The expression of miR-518b was upregulated in the EOPE and LOPE group, compared to controls, and the area under the receiver operating characteristic curve (AUC) of miR-518b was 0.65 and 0.62, respectively. miR-518b was positively correlated with WBC count, platelet count, serum levels of AST, ALT, LDH in EOPE. miR-21-3p expression level was negatively correlated with body mass index at blood draw and systolic blood pressure in the LOPE group. CONCLUSIONS Increased miR-518b expression levels were found to be associated with EOPE and LOPE.
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Affiliation(s)
- Selin Demirer
- Department of Genetics, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey
| | - Meryem Hocaoglu
- Department of Obstetrics and Gynecology, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey.
| | - Abdulkadir Turgut
- Department of Obstetrics and Gynecology, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey; Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ateş Karateke
- Department of Obstetrics and Gynecology, Goztepe Training and Research Hospital, Istanbul Medeniyet University, Istanbul, Turkey; Department of Obstetrics and Gynecology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Evrim Komurcu-Bayrak
- Department of Genetics, Aziz Sancar Institute of Experimental Medicine, Istanbul University, Istanbul, Turkey.
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Li JY, Wang PH, Vitale SG, Chen SN, Marranzano M, Cianci A, Lin LT, Tsui KH. Pregnancy-induced hypertension is an independent risk factor for meconium aspiration syndrome: A retrospective population based cohort study. Taiwan J Obstet Gynecol 2019; 58:396-400. [PMID: 31122532 DOI: 10.1016/j.tjog.2018.11.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/19/2018] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Meconium aspiration syndrome (MAS), possibly resulting from fetal hypoxia, is a respiratory distress disorder in the infant. Pregnancy-induced hypertension (PIH) can cause placental dysfunction and lead to fetal hypoxia, which may induce the development of MAS. Therefore, the aim of this study was to determine the association between PIH and MAS and to identify the predictive risk factors. MATERIALS AND METHODS This was a retrospective cohort study. We selected patients with newly diagnosed PIH and a matched cohort group from the Taiwan National Health Insurance Research Database (NHIRD), from January 1, 2000 till December 31, 2013. For each patient in the PIH cohort, 4 subjects without PIH, matched for age and year of delivery, were randomly selected as the comparison cohort. The incidence of meconium aspiration syndrome was assessed in both groups. RESULTS Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. Patients who experienced PIH had a higher incidence of MAS than did those without PIH. According to a multivariate analysis, PIH (odds ratio [OR] = 1.70, 95% confidence interval [CI] = 1.49-1.93, p < 0.0001) was independently associated with increased risk of MAS. Additionally, age ≥30 years (OR = 1.26, 95% CI = 1.12-1.42, p = 0.0001), nulliparity (OR = 1.13, 95% CI = 1.01-1.27, p = 0.0367) and patients with diabetes mellitus (OR = 3.09, 95% CI = 1.35-7.09, p = 0.0078) were also independent risk factors of MAS. CONCLUSION Patients with PIH obtained higher subsequent risk for the development of MAS than those without PIH. Besides, age ≥30 years, nulliparity and patients with diabetes mellitus are the independent risk factors of developing MAS.
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Affiliation(s)
- Ju-Yueh Li
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Peng-Hui Wang
- Department of Obstetrics and Gynecology, Taipei Veterans General Hospital, Taipei, Taiwan, ROC; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Medical Research, China Medical University Hospital, Taichung, Taiwan, ROC
| | - Salvatore Giovanni Vitale
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - San-Nung Chen
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
| | - Marina Marranzano
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Catania, Italy
| | - Antonio Cianci
- Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - Li-Te Lin
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Biological Science, National Sun Yat-sen University, Kaohsiung City, Taiwan.
| | - Kuan-Hao Tsui
- Department of Obstetrics and Gynecology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan; Department of Obstetrics and Gynecology, National Yang-Ming University, Taipei, Taiwan, ROC; Department of Pharmacy and Graduate Institute of Pharmaceutical Technology, Tajen University, Pingtung County, Taiwan.
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53
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Graham N, Heazell AEP. When the Fetus Goes Still and the Birth Is Tragic: The Role of the Placenta in Stillbirths. Obstet Gynecol Clin North Am 2019; 47:183-196. [PMID: 32008668 DOI: 10.1016/j.ogc.2019.10.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Because of the critical role that placental structure and function plays during pregnancy, abnormal placental structure and function is closely related to stillbirth: when an infant dies before birth. However, understanding the role of the placental and specific lesions is incomplete, in part because of the variation in definitions of lesions and in classifying causes of stillbirths. Nevertheless, placental abnormalities are seen more frequently in stillbirths than live births, with placental abruption, chorioamnionitis, and maternal vascular malperfusion most commonly reported. Critically, some placental lesions affect the management of subsequent pregnancies. Histopathological examination of the placenta is recommended following stillbirth.
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Affiliation(s)
- Nicole Graham
- Faculty of Biological, Medical and Human Sciences, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, 5th Floor (Research), Oxford Road, Manchester M13 9WL, UK
| | - Alexander E P Heazell
- Faculty of Biological, Medical and Human Sciences, Maternal and Fetal Health Research Centre, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, St. Mary's Hospital, Central Manchester University Hospitals NHS Foundation Trust, 5th Floor (Research), Oxford Road, Manchester M13 9WL, UK.
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54
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Steurer MA, Peyvandi S, Baer RJ, Oltman SP, Chambers CD, Norton ME, Ryckman KK, Moon-Grady AJ, Keller RL, Shiboski SC, Jelliffe-Pawlowski LL. Impaired Fetal Environment and Gestational Age: What Is Driving Mortality in Neonates With Critical Congenital Heart Disease? J Am Heart Assoc 2019; 8:e013194. [PMID: 31726960 PMCID: PMC6915289 DOI: 10.1161/jaha.119.013194] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Background Infants with critical congenital heart disease (CCHD) are more likely to be small for gestational age (SGA) or born to mothers with maternal placental syndrome. The objective of this study was to investigate the relationship between maternal placental syndrome, SGA, and gestational age (GA) on 1‐year mortality in infants with CCHD. Methods and Results In a population‐based administrative database of all live‐born infants in California (2007–2012) we identified all infants with CCHD without chromosomal anomalies. Our primary predictor was an impaired fetal environment (IFE), defined as presence of maternal placental syndrome or SGA. We calculated hazard ratios to quantify the association between different components of IFE and 1‐year mortality and conducted a causal mediation analysis to assess GA at birth as a mediator. We identified 6863 infants with CCHD. IFE was present in 25.1%. Infants with IFE were more likely to die than infants without IFE (16.6% versus 11.1%; hazard ratios 1.55, 95% CI 1.34–1.78). Only SGA (hazard ratios 1.76, 95% CI 1.50–2.05) and placental abruption (hazard ratios 1.70, 95% CI 1.17–2.48) were significantly associated with mortality; preeclampsia and gestational hypertension had no significant association with mortality. The mediation analysis showed that 32.8% (95% CI 24.9–47.0%) of the relationship between IFE and mortality is mediated through GA. Conclusions IFE is a significant contributor to outcomes in the CCHD population. SGA and placental abruption are the main drivers of postnatal mortality while other maternal placental syndrome components had much less of an impact. Only one third of the effect between IFE and mortality is mediated through GA.
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Affiliation(s)
- Martina A Steurer
- Department of Pediatrics University of California San Francisco San Francisco CA.,Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
| | - Shabnam Peyvandi
- Department of Pediatrics University of California San Francisco San Francisco CA.,Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
| | - Rebecca J Baer
- Department of Pediatrics University of California San Diego La Jolla CA.,Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco San Francisco CA
| | - Scott P Oltman
- Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
| | | | - Mary E Norton
- Department of Obstetrics, Gynecology, and Reproductive Sciences University of California San Francisco San Francisco CA
| | - Kelli K Ryckman
- Department of Epidemiology College of Public Health University of Iowa Iowa City IA
| | - Anita J Moon-Grady
- Department of Pediatrics University of California San Francisco San Francisco CA
| | - Roberta L Keller
- Department of Pediatrics University of California San Francisco San Francisco CA
| | - Stephen C Shiboski
- Department of Epidemiology and Biostatistics University of California San Francisco San Francisco CA
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55
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Abstract
Gestational hypertension, preeclampsia, and peripartum cardiomyopathy are among the most common and often severe pregnancy-specific cardiovascular diseases (CVDs) and causes of complications in pregnancy. This clinical review provides nurses with an overview of pregnancy-specific CVDs, outlines their pathophysiology, and discusses risk factors and assessment. It describes management interventions according to timing: the antepartum, intrapartum, and postpartum phases are each addressed.
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56
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Tan CMJ, Lewandowski AJ. The Transitional Heart: From Early Embryonic and Fetal Development to Neonatal Life. Fetal Diagn Ther 2019; 47:373-386. [PMID: 31533099 DOI: 10.1159/000501906] [Citation(s) in RCA: 108] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Accepted: 07/04/2019] [Indexed: 12/12/2022]
Abstract
Formation of the human heart involves complex biological signals, interactions, specification of myocardial progenitor cells, and heart tube looping. To facilitate survival in the hypoxemic intrauterine environment, the fetus possesses structural, physiological, and functional cardiovascular adaptations that are fundamentally different from the neonate. At birth, upon separation from the placental circulation, the neonatal cardiovascular system takes over responsibility of vital processes for survival. The transition from the fetal to neonatal circulation is considered to be a period of intricate physiological, anatomical, and biochemical changes in the cardiovascular system. With a successful cardiopulmonary transition to the extrauterine environment, the fetal shunts are functionally modified or eliminated, enabling independent life. Investigations using medical imaging tools such as ultrasound and magnetic resonance imaging have helped to define normal and abnormal patterns of cardiac remodeling both in utero and ex utero. This has not only allowed for a better understanding of how congenital cardiac malformations alter the hemodynamic transition to the extrauterine environment but also how other more common complications during pregnancy including intrauterine growth restriction, preeclampsia, and preterm delivery adversely affect offspring cardiac remodeling during this early transitional period. This review article describes key cardiac progenitors involved in embryonic heart development; the cellular, physiological, and anatomical changes during the transition from fetal to neonatal circulation; as well as the unique impact that different pregnancy complications have on cardiac remodeling.
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Affiliation(s)
- Cheryl Mei Jun Tan
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Adam James Lewandowski
- Oxford Cardiovascular Clinical Research Facility, Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Oxford, United Kingdom,
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Bian X, Biswas A, Huang X, Lee KJ, Li TKT, Masuyama H, Ohkuchi A, Park JS, Saito S, Tan KH, Yamamoto T, Dietl A, Grill S, Verhagen-Kamerbeek WDJ, Shim JY, Hund M. Short-Term Prediction of Adverse Outcomes Using the sFlt-1 (Soluble fms-Like Tyrosine Kinase 1)/PlGF (Placental Growth Factor) Ratio in Asian Women With Suspected Preeclampsia. Hypertension 2019; 74:164-172. [PMID: 31188674 PMCID: PMC6587370 DOI: 10.1161/hypertensionaha.119.12760] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Supplemental Digital Content is available in the text. Current diagnostic criteria have limited clinical value for prediction of preeclampsia and fetal adverse outcomes. The prediction of short-term outcome in pregnant women with suspected preeclampsia study in Asia (PROGNOSIS Asia) was a prospective, multicenter study designed to investigate the value of the sFlt-1 (soluble fms-like tyrosine kinase 1)/PlGF (placental growth factor) ratio for predicting adverse outcomes in pregnant Asian women with suspected preeclampsia. Seven hundred sixty-four pregnant women at gestational week 20+0 days (18+0 days in Japan) to 36+6 days were enrolled at 25 sites in Asia. The primary objectives were to demonstrate the value of the sFlt-1/PlGF ratio for ruling out preeclampsia within 1 week and ruling in preeclampsia within 4 weeks. The value of the ratio for predicting fetal adverse outcomes was also assessed. Seven hundred patients were evaluable for primary end point analysis. The prevalence of preeclampsia was 14.4%. An sFlt-1/PlGF ratio of ≤38 had a negative predictive value of 98.6% (95% CI, 97.2%–99.4%) for ruling out preeclampsia within 1 week, with 76.5% sensitivity and 82.1% specificity. The positive predictive value of a ratio of >38 for ruling in preeclampsia within 4 weeks was 30.3% (95% CI, 23.0%–38.5%), with 62.0% sensitivity and 83.9% specificity. An sFlt-1/PlGF ratio of ≤38 had a negative predictive value of 98.9% (95% CI, 97.6%–99.6%) for ruling out fetal adverse outcomes within 1 week and a ratio of >38 had a positive predictive value of 53.5% (95% CI, 45.0%–61.8%) for ruling in fetal adverse outcomes within 4 weeks. The sFlt-1/PlGF ratio cutoff of 38 demonstrated clinical value for the short-term prediction of preeclampsia in Asian women with suspected preeclampsia, potentially helping to prevent unnecessary hospitalization and intervention.
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Affiliation(s)
- Xuming Bian
- From the Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, Beijing, China (X.B.)
| | - Arijit Biswas
- Department of Obstetrics and Gynecology, Yong Loo Lin School of Medicine, National University Health System, National University of Singapore, Singapore (A.B.)
| | - Xianghuang Huang
- Department of Obstetrics and Gynecology, The Second Hospital of Hebei Medical University, Shijiazhuang, China (X.H.)
| | - Kyoung Jin Lee
- Department of Obstetrics and Gynecology, CHA Gangnam Medical Center, CHA University, Seoul, South Korea (K.J.L.)
| | - Thomas Kwok-To Li
- Department of Obstetrics and Gynecology, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China (T.K.-T.L.)
| | - Hisashi Masuyama
- Department of Obstetrics and Gynecology, Okayama University Hospital, Okayama, Japan (H.M.)
| | | | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, South Korea (J.S.P.)
| | | | - Kok Hian Tan
- Department of Obstetrics and Gynecology, KK Women's and Children's Hospital, Singapore (K.H.T., K.K.H.)
| | - Tatsuo Yamamoto
- Department of Obstetrics and Gynecology, Nihon University Itabashi Hospital, Tokyo, Japan (T.Y.)
| | - Angela Dietl
- Roche Diagnostics GmbH, Penzberg, Germany (A.D., S.G.)
| | - Sonja Grill
- Roche Diagnostics GmbH, Penzberg, Germany (A.D., S.G.)
| | | | - Jae-Yoon Shim
- Department of Obstetrics and Gynecology, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea (J.-Y.S.)
| | - Martin Hund
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland (W.D.J.V.-K, M.H.)
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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Nahum Sacks K, Friger M, Shoham-Vardi I, Sergienko R, Spiegel E, Landau D, Sheiner E. Long-term neuropsychiatric morbidity in children exposed prenatally to preeclampsia. Early Hum Dev 2019; 130:96-100. [PMID: 30711915 DOI: 10.1016/j.earlhumdev.2019.01.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/17/2019] [Accepted: 01/22/2019] [Indexed: 01/22/2023]
Abstract
INTRODUCTION There are contradicting findings in the current literature regarding the association between in-utero exposure to preeclampsia and the long-term neuropsychiatric health of the offspring. The objective of this study is to assess whether prenatal exposure to preeclampsia increases the risk of long-term neuropsychiatric morbidity. METHODS A retrospective population-based cohort study compared neuropsychiatric morbidity between singletons exposed and unexposed to preeclampsia. The study included all the singletons that were born between 1991 and 2014 in a single regional tertiary medical center. A generalized estimating equation (GEE) model was used to control for confounders and maternal clusters. RESULTS Of the 253,808 singletons that met the inclusion criteria; 3.0% were born to mothers diagnosed with mild preeclampsia (n = 7660), 0.9% with severe preeclampsia (n = 2366) and 0.03% with eclampsia (n = 81). A significant linear association was noted between the severity of the preeclampsia (no preeclampsia, mild, severe preeclampsia and eclampsia) and the incidence of neuropsychiatric morbidity of the offspring (1.0%, vs. 1.2% vs. 1.9% vs. 1.2% respectively, p = 0.003). In a GEE model which was used to control for maternal clusters, gestational diabetes, maternal age, gestational age and time-to-event preeclampsia was found to be an independent risk factor for neuropsychiatric morbidity in the offspring (adjusted OR = 1.36; 95% CI 1.14-1.63). CONCLUSION Offspring exposed prenatally to preeclampsia have a significantly higher risk of developing a neuropsychiatric morbidity during childhood.
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Affiliation(s)
- Kira Nahum Sacks
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer- Sheva, Israel.
| | - Michael Friger
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer- Sheva, Israel
| | - Ilana Shoham-Vardi
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer- Sheva, Israel
| | - Ruslan Sergienko
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, P.O.B. 653, Beer- Sheva, Israel
| | - Efrat Spiegel
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O.B. 151, Beer-Sheva, Israel
| | - Daniella Landau
- Department of Pediatrics, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O.B. 151, Beer-Sheva, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, P.O.B. 151, Beer-Sheva, Israel
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Pacora P, Romero R, Jaiman S, Erez O, Bhatti G, Panaitescu B, Benshalom-Tirosh N, Jung Jung E, Hsu CD, Hassan SS, Yeo L, Kadar N. Mechanisms of death in structurally normal stillbirths. J Perinat Med 2019; 47:222-240. [PMID: 30231013 PMCID: PMC6349478 DOI: 10.1515/jpm-2018-0216] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 07/20/2018] [Indexed: 01/05/2023]
Abstract
Objectives To investigate mechanisms of in utero death in normally formed fetuses by measuring amniotic fluid (AF) biomarkers for hypoxia (erythropoietin [EPO]), myocardial damage (cardiac troponin I [cTnI]) and brain injury (glial fibrillary acidic protein [GFAP]), correlated with risk factors for fetal death and placental histopathology. Methods This retrospective, observational cohort study included intrauterine deaths with transabdominal amniocentesis prior to induction of labor. Women with a normal pregnancy and an indicated amniocentesis at term were randomly selected as controls. AF was assayed for EPO, cTnI and GFAP using commercial immunoassays. Placental histopathology was reviewed, and CD15-immunohistochemistry was used. Analyte concentrations >90th centile for controls were considered "raised". Raised AF EPO, AF cTnI and AF GFAP concentrations were considered evidence of hypoxia, myocardial and brain injury, respectively. Results There were 60 cases and 60 controls. Hypoxia was present in 88% (53/60), myocardial damage in 70% (42/60) and brain injury in 45% (27/60) of fetal deaths. Hypoxic fetuses had evidence of myocardial injury, brain injury or both in 77% (41/53), 49% (26/53) and 13% (7/53) of cases, respectively. Histopathological evidence for placental dysfunction was found in 74% (43/58) of these cases. Conclusion Hypoxia, secondary to placental dysfunction, was found to be the mechanism of death in the majority of fetal deaths among structurally normal fetuses. Ninety-one percent of hypoxic fetal deaths sustained brain, myocardial or both brain and myocardial injuries in utero. Hypoxic myocardial injury was an attributable mechanism of death in 70% of the cases. Non-hypoxic cases may be caused by cardiac arrhythmia secondary to a cardiac conduction defect.
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Affiliation(s)
- Percy Pacora
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan,Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan,Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan
| | - Sunil Jaiman
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Offer Erez
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Gaurav Bhatti
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Bogdan Panaitescu
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Neta Benshalom-Tirosh
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Obstetrics and Gynecology, Soroka University Medical Center, School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Eun Jung Jung
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Chaur-Dong Hsu
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Sonia S. Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan,Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan
| | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
| | - Nicholas Kadar
- Perinatology Research Branch, NICHD/NIH/DHHS, Bethesda, Maryland, and Detroit, Michigan,Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan
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Vogtmann R, Kühnel E, Dicke N, Verkaik-Schakel RN, Plösch T, Schorle H, Stojanovska V, Herse F, Köninger A, Kimmig R, Winterhager E, Gellhaus A. Human sFLT1 Leads to Severe Changes in Placental Differentiation and Vascularization in a Transgenic hsFLT1/rtTA FGR Mouse Model. Front Endocrinol (Lausanne) 2019; 10:165. [PMID: 30949132 PMCID: PMC6437783 DOI: 10.3389/fendo.2019.00165] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 02/27/2019] [Indexed: 12/24/2022] Open
Abstract
The anti-angiogenic soluble fms-like tyrosine kinase 1 (sFLT1) is one of the candidates in the progression of preeclampsia, often associated with fetal growth restriction (FGR). Therapeutic agents against preeclampsia with/without FGR, as well as adequate transgenic sFLT1 mouse models for testing such agents, are still missing. Much is known about sFLT1-mediated endothelial dysfunction in several tissues; however, the influence of sFLT1 on placental and fetal development is currently unknown. We hypothesize that sFLT1 is involved in the progression of FGR by influencing placental differentiation and vascularization and is a prime candidate for interventional strategies. Therefore, we generated transgenic inducible human sFLT1/reverse tetracycline-controlled transactivator (hsFLT1/rtTA) mice, in which hsFLT1 is ubiquitously overexpressed during pregnancy in dams and according to the genetics in hsFLT1/rtTA homozygous and heterozygous fetuses. Induction of hsFLT1 led to elevated hsFLT1 levels in the serum of dams and on mRNA level in all placentas and hetero-/homozygous fetuses, resulting in FGR in all fetuses at term. The strongest effects in respect to FGR were observed in the hsFLT1/rtTA homozygous fetuses, which exhibited the highest hsFLT1 levels. Only fetal hsFLT1 expression led to impaired placental morphology characterized by reduced placental efficiency, enlarged maternal sinusoids, reduced fetal capillaries, and impaired labyrinthine differentiation, associated with increased apoptosis. Besides impaired placental vascularization, the expression of several transporter systems, such as glucose transporter 1 and 3 (Glut-1; Glut-3); amino acid transporters, solute carrier family 38, member one and two (Slc38a1; Slc38a2); and most severely the fatty acid translocase Cd36 and fatty acid binding protein 3 (Fabp3) was reduced upon hsFLT1 expression, associated with an accumulation of phospholipids in the maternal serum. Moreover, the Vegf pathway showed alterations, resulting in reduced Vegf, Vegfb, and Plgf protein levels and increased Bad and Caspase 9 mRNA levels. We suggest that hsFLT1 exerts an inhibitory influence on placental vascularization by reducing Vegf signaling, which leads to apoptosis in fetal vessels, impairing placental differentiation, and the nutrient exchange function of the labyrinth. These effects were more pronounced when both the dam and the fetus expressed hsFLT1 and ultimately result in FGR and resemble the preeclamptic phenotype in humans.
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Affiliation(s)
- Rebekka Vogtmann
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Elisabeth Kühnel
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nikolai Dicke
- Department of Developmental Pathology, Institute of Pathology, University Medical School, Bonn, Germany
| | - Rikst Nynke Verkaik-Schakel
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Torsten Plösch
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Hubert Schorle
- Department of Developmental Pathology, Institute of Pathology, University Medical School, Bonn, Germany
| | - Violeta Stojanovska
- Department of Obstetrics and Gynecology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Florian Herse
- Experimental and Clinical Research Center, Charité Medical Faculty, and the Max Delbrück Center for Molecular Medicine in the Helmholtz Association, Berlin, Germany
| | - Angela Köninger
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Rainer Kimmig
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Elke Winterhager
- EM Unit, Imaging Center Essen, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alexandra Gellhaus
- Department of Gynecology and Obstetrics, University Hospital Essen, University Duisburg-Essen, Essen, Germany
- *Correspondence: Alexandra Gellhaus
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Mayo JA, Lu Y, Stevenson DK, Shaw GM, Eisenberg ML. Parental age and stillbirth: a population-based cohort of nearly 10 million California deliveries from 1991 to 2011. Ann Epidemiol 2018; 31:32-37.e2. [PMID: 30642694 DOI: 10.1016/j.annepidem.2018.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 11/15/2018] [Accepted: 12/01/2018] [Indexed: 12/27/2022]
Abstract
PURPOSE Parental age at delivery in the United States has been rising. Advanced maternal and paternal ages have been associated with adverse pregnancy outcomes including stillbirth. However, these relationships come from studies that often do not present results for both mother and father concurrently. The purpose of this study was to estimate the risk of stillbirth for maternal and paternal age in the same cohort of deliveries. METHODS This is a population-based cohort study of all live birth and stillbirth deliveries in California from 1991 to 2011. The individual associations between maternal and paternal ages and stillbirth were estimated with hazard ratios from Cox proportional hazard models. Age was modeled continuously with restricted cubic splines to account for nonlinear relationships. Mean parental age was used as the referent group. RESULTS J-shaped associations between maternal and paternal ages were observed in crude models where older mothers and fathers had the highest hazard ratios for stillbirth. In maternal models, after adjusting for maternal and paternal covariates, young maternal age no longer showed increased hazard ratio for stillbirth, whereas the association with older mothers remained. In adjusted paternal models, the relationship between young paternal age and stillbirth was unchanged while the hazard ratio for older fathers was slightly smaller. CONCLUSIONS After adjusting for both parents' age, education, race/ethnicity, along with parity, older mothers and fathers were independently associated with elevated hazard ratios for stillbirth.
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Affiliation(s)
- Jonathan A Mayo
- March of Dimes Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA.
| | - Ying Lu
- Department of Biomedical Data Science, Stanford University School of Medicine, Stanford, CA
| | - David K Stevenson
- March of Dimes Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Gary M Shaw
- March of Dimes Prematurity Research Center, Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Michael L Eisenberg
- Departments of Urology and Obstetrics/Gynecology, Stanford University School of Medicine, Stanford, CA
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Nahum Sacks K, Friger M, Shoham-Vardi I, Spiegel E, Sergienko R, Landau D, Sheiner E. Prenatal exposure to preeclampsia as an independent risk factor for long-term cardiovascular morbidity of the offspring. Pregnancy Hypertens 2018; 13:181-186. [PMID: 30177050 DOI: 10.1016/j.preghy.2018.06.013] [Citation(s) in RCA: 81] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Revised: 06/13/2018] [Accepted: 06/16/2018] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Preeclampsia is a leading cause of maternal and fetal morbidity and mortality. Regarding the offspring, little is known about the long-term complications. The objective of the current study is to assess whether in utero exposure to preeclampsia increases the risk of long-term cardiovascular morbidity in the offspring. MATERIALS AND METHODS A population-based cohort study compared the incidence of cardiovascular disease between singletons exposed and unexposed to preeclampsia. Deliveries occurred between 1991 and 2014 in a regional tertiary medical center. A Cox proportional hazard model was used to control for confounders. RESULTS During the study period 231,298 deliveries met the inclusion criteria; 4.1% of the births were to mothers diagnosed with preeclampsia, of which 3.2% with mild preeclampsia (n = 7286), 0.9% with severe preeclampsia (n = 2174) and 0.03% with eclampsia (n = 73). A significant linear association was noted between preeclampsia (no preeclampsia, mild preeclampsia, severe preeclampsia and eclampsia) and cardiovascular disease of the offspring (0.24%, vs. 0.33% vs. 0.51% vs. 2.73% respectively, p < 0.001 using the chi-square test for trends). In the offspring born at term, severe preeclampsia was found to be an independent risk factor for cardiovascular morbidity (adjusted HR = 2.32; 95% CI 1.15-4.67). In offspring born preterm, neither severe preeclampsia (adjusted HR = 1.36; 95% CI 0.53-3.48) nor mild preeclampsia (adjusted HR = 0.37; 95% CI 0.52-2.71) were associated with cardiovascular morbidity of the offspring. CONCLUSION Exposure to severe maternal preeclampsia is an independent risk factor for long-term cardiovascular morbidity in the offspring born at term.
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Affiliation(s)
- Kira Nahum Sacks
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel
| | - Michael Friger
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel
| | - Ilana Shoham-Vardi
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel
| | - Efrat Spiegel
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Israel
| | - Ruslan Sergienko
- Department of Public Health, Faculty of Health Sciences, Ben Gurion University of the Negev, Israel
| | - Daniella Landau
- Department of Pediatrics, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Israel
| | - Eyal Sheiner
- Department of Obstetrics and Gynecology, Faculty of Health Sciences, Soroka University Medical Center, Ben-Gurion University of the Negev, Israel.
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Xiong T, Mu Y, Liang J, Zhu J, Li X, Li J, Liu Z, Qu Y, Wang Y, Mu D. Hypertensive disorders in pregnancy and stillbirth rates: a facility-based study in China. Bull World Health Organ 2018; 96:531-539. [PMID: 30104793 PMCID: PMC6083384 DOI: 10.2471/blt.18.208447] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2018] [Revised: 03/24/2018] [Accepted: 05/01/2018] [Indexed: 01/27/2023] Open
Abstract
Objective To assess the association between hypertensive disorders in pregnancy and the stillbirth rate. Methods We obtained all data from China's National Maternal Near Miss Surveillance System for 2012 to 2016. Associations between hypertensive disorders in pregnancy and stillbirths, stratified by fetus number and gestational age, were assessed using Poisson regression analysis with a robust variance estimator. Findings For the period, 6 970 032 births, including 66 494 stillbirths, were reported to the surveillance system. The weighted stillbirth rate in women with a hypertensive disorder in pregnancy was 21.9 per 1000 births. The risk was higher in those who had received few antenatal care visits or who were poorly educated. For singleton pregnancies, the adjusted risk ratio (aRR) for a stillbirth among women with hypertensive disorders in pregnancy compared with normotensive women was 3.1 (95% confidence interval, CI: 2.85-3.37). The aRR for hypertensive disorder subtypes was: 6.66 (95% CI: 5.57-7.96) for superimposed preeclampsia; 4.15 (95% CI: 3.81-4.52) for preeclampsia or eclampsia; 2.32 (95% CI: 1.87-2.88) for chronic hypertension; and 1.21 (95% CI: 1.08-1.36) for gestational hypertension. For multiple pregnancies, the association between stillbirths and hypertensive disorders in pregnancy was not significant, except for superimposed preeclampsia (aRR: 1.95; 95% CI: 1.28-2.97). Conclusion To minimize the incidence of stillbirths, more attention should be paid to chronic hypertension and superimposed preeclampsia in singleton pregnancies and to superimposed preeclampsia in multiple pregnancies. Better quality antenatal care and improved guidelines are needed in China.
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Affiliation(s)
- Tao Xiong
- Department of Paediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Mu
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Juan Liang
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Jun Zhu
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Xiaohong Li
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Jinke Li
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Zheng Liu
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Yi Qu
- Department of Paediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yanping Wang
- National Office for Maternal and Child Health Surveillance Sichuan University, Chengdu, China
| | - Dezhi Mu
- Department of Paediatrics, Key Laboratory of Birth Defects and Related Diseases of Women and Children of the Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
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Folk DM. Hypertensive Disorders of Pregnancy: Overview and Current Recommendations. J Midwifery Womens Health 2018; 63:289-300. [PMID: 29764001 DOI: 10.1111/jmwh.12725] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 11/12/2017] [Accepted: 11/15/2017] [Indexed: 11/29/2022]
Abstract
Hypertensive disorders of pregnancy include chronic hypertension, gestational hypertension, preeclampsia-eclampsia, and chronic hypertension with superimposed preeclampsia. These disorders are an important cause of maternal and fetal morbidity and mortality. Although advances in effective treatments have been made, current research has yet to identify a biochemical or diagnostic imaging marker to reliably predict preeclampsia. Despite current guidelines that address diagnosis and management of hypertensive disorders in pregnancy, health care providers may overlook or be unaware of signs that require immediate evaluation and treatment. This article reviews the definitions of hypertensive disorders of pregnancy, diagnosis, pathophysiology of preeclampsia, indications for treatment, neurologic sequelae, and counseling about the implications of hypertension in pregnancy for subsequent health.
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Suarez EA, Landi SN, Conover MM, Jonsson Funk M. Bias from restricting to live births when estimating effects of prescription drug use on pregnancy complications: A simulation. Pharmacoepidemiol Drug Saf 2018; 27:307-314. [DOI: 10.1002/pds.4387] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2017] [Revised: 11/17/2017] [Accepted: 12/16/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Elizabeth A. Suarez
- Department of Epidemiology, Gillings School of Global Public Health; University of North Carolina; Chapel Hill NC USA
| | - Suzanne N. Landi
- Department of Epidemiology, Gillings School of Global Public Health; University of North Carolina; Chapel Hill NC USA
| | - Mitchell M. Conover
- Department of Epidemiology, Gillings School of Global Public Health; University of North Carolina; Chapel Hill NC USA
| | - Michele Jonsson Funk
- Department of Epidemiology, Gillings School of Global Public Health; University of North Carolina; Chapel Hill NC USA
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Goldenberg RL, Griffin JB, Kamath-Rayne BD, Harrison M, Rouse DJ, Moran K, Hepler B, Jobe AH, McClure EM. Clinical interventions to reduce stillbirths in sub-Saharan Africa: a mathematical model to estimate the potential reduction of stillbirths associated with specific obstetric conditions. BJOG 2018; 125:119-129. [PMID: 27704677 DOI: 10.1111/1471-0528.14304] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Stillbirths are among the most common adverse pregnancy outcomes, with 98% occurring in low-income countries. More than one-third occur in sub-Saharan Africa (SSA). However, the medical conditions causing stillbirths and interventions to reduce stillbirths from these conditions are not well documented. We estimated the reductions in stillbirths possible with combinations of interventions. DESIGN We developed a computerised model to estimate the impact of various interventions on stillbirths caused by the most common conditions. The model considered the location of obstetric care (home, clinic or hospital) and each intervention's efficacy, penetration and utilisation. Maternal transfers were also considered. SETTING AND POPULATION Pregnancies in SSA in 2012. METHODS For each condition, we created a series of scenarios involving different combinations of interventions and modelled their impact on stillbirth rates. MAIN OUTCOME MEASURES Stillbirths associated with various maternal and fetal conditions and the percentage reduction with various interventions. RESULTS Eight to ten maternal and fetal conditions were responsible for most stillbirths, but none for more than 15%. The most common conditions causing stillbirths in SSA include obstructed labour and uterine rupture, fetal distress and umbilical cord complications, fetal growth restriction, pre-eclampsia/eclampsia, and placental abruption/placenta praevia. Syphilis and malaria contribute smaller numbers. Reducing stillbirths requires appropriate diagnosis and management of each condition, usually including hospital care for monitoring and delivery, often by caesarean section. Maternal syphilis and malaria were the only conditions for which outpatient management alone reduced stillbirth. CONCLUSIONS Most stillbirths in low-income countries occur at term and during labour and therefore are preventable by appropriate obstetric care. Management focused on the maternal and fetal conditions that cause stillbirths is necessary to achieve stillbirth rates approaching those found in high-income countries. TWEETABLE ABSTRACT Reducing stillbirth incidence requires appropriate management of each causative condition and often caesarean delivery.
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Affiliation(s)
- R L Goldenberg
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - J B Griffin
- Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA
| | - B D Kamath-Rayne
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - M Harrison
- Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA
| | - D J Rouse
- Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA
| | - K Moran
- Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA
| | - B Hepler
- Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA
| | - A H Jobe
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - E M McClure
- Statistical, Social and Environmental Health Sciences, RTI International, Durham, NC, USA
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Bauer AE, Weinberg CR, Engel SM. Response to Commentary: Genetic Association Family-Based Studies and Preeclampsia. Paediatr Perinat Epidemiol 2018; 32:16-18. [PMID: 29096049 DOI: 10.1111/ppe.12425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Anna E Bauer
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Clarice R Weinberg
- Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, Research Triangle Park, NC
| | - Stephanie M Engel
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Nepomuceno TC, De Gregoriis G, de Oliveira FMB, Suarez-Kurtz G, Monteiro AN, Carvalho MA. The Role of PALB2 in the DNA Damage Response and Cancer Predisposition. Int J Mol Sci 2017; 18:ijms18091886. [PMID: 28858227 PMCID: PMC5618535 DOI: 10.3390/ijms18091886] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/21/2017] [Accepted: 08/26/2017] [Indexed: 01/01/2023] Open
Abstract
The deoxyribonucleic acid (DNA) damage response (DDR) is a major feature in the maintenance of genome integrity and in the suppression of tumorigenesis. PALB2 (Partner and Localizer of Breast Cancer 2 (BRCA2)) plays an important role in maintaining genome integrity through its role in the Fanconi anemia (FA) and homologous recombination (HR) DNA repair pathways. Since its identification as a BRCA2 interacting partner, PALB2 has emerged as a pivotal tumor suppressor protein associated to hereditary cancer susceptibility to breast and pancreatic cancers. In this review, we discuss how other DDR proteins (such as the kinases Ataxia Telangiectasia Mutated (ATM) and ATM- and Rad3-Related (ATR), mediators BRCA1 (Breast Cancer 1)/BRCA2 and effectors RAD51/DNA Polymerase η (Polη) interact with PALB2 to orchestrate DNA repair. We also examine the involvement of PALB2 mutations in the predisposition to cancer and the role of PALB2 in stimulating error-free DNA repair through the FA/HR pathway.
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Affiliation(s)
- Thales C Nepomuceno
- Programa de Pesquisa Clínica, Instituto Nacional de Câncer, Rio de Janeiro 20231-050, Brazil.
| | - Giuliana De Gregoriis
- Programa de Pesquisa Clínica, Instituto Nacional de Câncer, Rio de Janeiro 20231-050, Brazil.
| | | | - Guilherme Suarez-Kurtz
- Programa de Pesquisa Clínica, Instituto Nacional de Câncer, Rio de Janeiro 20231-050, Brazil.
| | - Alvaro N Monteiro
- Cancer Epidemiology Program, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL 33612, USA.
| | - Marcelo A Carvalho
- Programa de Pesquisa Clínica, Instituto Nacional de Câncer, Rio de Janeiro 20231-050, Brazil.
- Instituto Federal do Rio de Janeiro-IFRJ, Rio de Janeiro 20270-021, Brazil.
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Bokslag A, van Weissenbruch M, Mol BW, de Groot CJM. Preeclampsia; short and long-term consequences for mother and neonate. Early Hum Dev 2016; 102:47-50. [PMID: 27659865 DOI: 10.1016/j.earlhumdev.2016.09.007] [Citation(s) in RCA: 268] [Impact Index Per Article: 33.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Anouk Bokslag
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Mirjam van Weissenbruch
- Department of Pediatrics, Division of Neonatology, VU University Medical Center, Amsterdam, The Netherlands.
| | - Ben Willem Mol
- The Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, Australia; The South Australian Health and Medical Research Institute, Adelaide, Australia.
| | - Christianne J M de Groot
- Department of Obstetrics and Gynaecology, VU University Medical Center, Amsterdam, The Netherlands.
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Preterm preeclampsia in relation to country of birth. J Perinatol 2016; 36:718-22. [PMID: 27149056 PMCID: PMC5007604 DOI: 10.1038/jp.2016.73] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To examine the association between maternal country of birth and the risk of preeclampsia+preterm birth (PTB). STUDY DESIGN We completed a population-based study in the entire province of Ontario, where there is universal access to obstetrical care. We included 881 700 singleton livebirths among Canadian-born mothers and 305 547 births among immigrant mothers. Adjusted risk ratios (aRRs) were adjusted for maternal age, parity and income quintile. RESULTS Compared with a rate of preeclampsia+PTB of 4.0 per 1000 among Canadian-born mothers, the aRR of preeclampsia+PTB at 24 to 36 weeks was significantly higher for immigrant women from Nigeria (1.79, 95% confidence interval (CI) 1.12 to 2.84), the Philippines (1.54, 95% CI 1.30 to 1.86), Colombia (1.68, 95% CI 1.04 to 2.73), Jamaica (2.06, 95% CI 1.66 to 2.57) and Ghana (2.12, 95% CI 1.40 to 3.21). The aRRs generally followed a similar pattern for secondary outcomes. Specifically, women from Ghana were at highest risk of preeclampsia+very PTB (4.55, 95% CI 2.57 to 8.06), and women from Jamaica at the highest risk of preeclampsia+indicated PTB (1.89, 95% CI 1.43 to 2.50). CONCLUSION The risk of preeclampsia+PTB is highest among women from a select number of countries. This information can enhance initiatives aimed at reducing the risk of PTB related to preeclampsia.
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Abstract
Stillbirths are among the most common pregnancy-related adverse outcomes but are more common in low-income and middle-income countries than in high-income countries. In high-income countries, most stillbirths occur early in the preterm period, whereas in low-income and middle-income countries, most occur in term or in late preterm births. In low-income and middle-income countries, conditions, such as prolonged or obstructed labor, placental abruption, preeclampsia/eclampsia, fetal growth restriction, fetal distress, breech and other abnormal presentations, and multiple births, are associated with stillbirth. In high-income countries, placental abnormalities are the most common associations. Globally, fetal asphyxia is likely the most common final pathway to stillbirth.
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Rezende KBDC, Bornia RG, Esteves APVDS, Cunha AJLAD, Amim Junior J. Preeclampsia: Prevalence and perinatal repercussions in a University Hospital in Rio de Janeiro, Brazil. Pregnancy Hypertens 2016; 6:253-255. [PMID: 27939461 DOI: 10.1016/j.preghy.2016.08.229] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
Preeclampsia (PE) prevalence studies in Brazil are both scarce and not divided in accordance with gestational age at delivery. We accessed PE prevalence according to delivery before 34, 37 and 42weeks in a cross-sectional study including 4464 single deliveries. PE was diagnosed in 301 cases (6.74%); Prevalence of PE was 0.78%; 1.92% and 6.74% according to deliveries before 34, 37 and 42weeks. PE was associated with fetal death, prematurity and small for gestational age newborns.
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Affiliation(s)
| | - Rita Guérios Bornia
- Maternidade Escola da Universidade Federal do Rio de Janeiro, Professional Masters Program in Perinatal Health, Brazil
| | | | | | - Joffre Amim Junior
- Maternidade Escola da Universidade Federal do Rio de Janeiro, Professional Masters Program in Perinatal Health, Brazil
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Stillbirth, hypertensive disorders of pregnancy, and placental pathology. Placenta 2016; 43:61-8. [PMID: 27324101 DOI: 10.1016/j.placenta.2016.04.020] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/22/2016] [Accepted: 04/28/2016] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Stillbirth, preeclampsia, and gestational hypertension (PE/GH) have similar clinical risk factors and redundant placental pathology. We aim to discern if stillbirth with PE/GH has a particular phenotype by comparing stillbirths with and without PE/GH. METHODS Secondary analysis of the Stillbirth Collaborative Research Network, a population-based cohort study of all stillbirths and a sample of live births from 2006 to 2008 in five catchment areas. We compared placental pathology between stillbirths and with and without PE/GH, stratified by term or preterm. We also compared placental pathology between stillbirths and live births with PE/GH. RESULTS 79/518 stillbirths and 140/1200 live births had PE/GH. Amongst preterm stillbirths, there was higher feto-placental ratio in PE/GH pregnancies (OR 1.24 [1.11, 1.37] per unit increase), and there were more parenchymal infarctions (OR 5.77 [3.18, 10.47]). Among PE/GH pregnancies, stillbirths had increased maternal and fetal vascular lesions, including retroplacental hematoma, parenchymal infarction, fibrin deposition, fetal vascular thrombi, and avascular villi. DISCUSSION Stillbirth pregnancies are overwhelmingly associated with placental lesions. Parenchymal infarctions are more common in PE/GH preterm stillbirths, but there is significant overlap in lesions found in stillbirths and PE/GH.
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Triunfo S, Crovetto F, Crispi F, Rodriguez-Sureda V, Dominguez C, Nadal A, Peguero A, Gratacos E, Figueras F. Association of first-trimester angiogenic factors with placental histological findings in late-onset preeclampsia. Placenta 2016; 42:44-50. [PMID: 27238713 DOI: 10.1016/j.placenta.2016.04.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Revised: 04/04/2016] [Accepted: 04/05/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To explore in women with late-onset preeclampsia (PE) the association between maternal levels of angiogenic/antiangiogenic factors in the first trimester of pregnancy and histological findings attributable to placental underperfusion (PUP). METHODS A nested case-control cohort study was conducted in 73 women with pregnancies complicated by late-onset PE (>34 weeks at delivery) matched with controls. First trimester uterine artery Doppler (UtA); maternal levels of placental growth factor (PlGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) were retrieved. Placentas were histologically evaluated using a hierarchical and standardized classification system. One-way ANOVA with linear polynomial contrast or linear-by-linear association test was performed to test the hypothesis of a linear association across study groups (controls, PE without PUP and PE with PUP). RESULTS In 54 (74%) placentas, 89 placental histological findings qualifying for PUP were found. Across study groups, significant values were observed in maternal levels of decreased PlGF (MoM values: 1.53, 1.41 and 1.37; p < 0.001), increased sFlt-1 (MoM values: 3.11, 3.11 and 3.22; p = 0.002), increased sFlt-1/PlGF ratio (MoM values: 2.3, 2.3 and 2.44; p < 0.001), abnormal UtA Doppler (MoM values: 1, 1.26 and 1.32; p < 0.001), and worse perinatal outcomes in terms of gestational age at delivery, cesarean section for not reassuring fetal status, birth weight and neonatal acidosis. DISCUSSION In late-onset PE an imbalance of circulating angiogenic and anti-angiogenic factors already present at 8-10 weeks of pregnancy was associated with histological findings reflecting placental insufficiency. An early first trimester screening by angiogenic factors might help to identify patients with placental involvement among late-onset PE cases. CONCLUSION In late-onset preeclampsia, first-trimester uterine Doppler and circulating levels of angiogenic/antiangiogenic factors are associated with placental underperfusion.
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Affiliation(s)
- Stefania Triunfo
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain.
| | - Francesca Crovetto
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain; Ca' Granda, Ospedale Maggiore Policlinico, Dipartimento Ostetricia e Ginecologia, Università degli Studi di Milano, Milan, Italy
| | - Fatima Crispi
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Victor Rodriguez-Sureda
- Biochemistry and Molecular Biology Research Centre for Nanomedicine, Hospital Univeritari Vall d'Hebron, Centre for Biomedical Research on Rare Disease (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Carmen Dominguez
- Biochemistry and Molecular Biology Research Centre for Nanomedicine, Hospital Univeritari Vall d'Hebron, Centre for Biomedical Research on Rare Disease (CIBERER), Instituto de Salud Carlos III, Barcelona, Spain
| | - Alfons Nadal
- Department of Pathology, Hospital Clinic-IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Anna Peguero
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Eduard Gratacos
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - Francesc Figueras
- BCNatal - Barcelona Center for Maternal-Fetal and Neonatal Medicine (Hospital Clínic and Hospital Sant Joan de Deu), IDIBAPS, University of Barcelona, Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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Luque-Fernandez MA, Zoega H, Valdimarsdottir U, Williams MA. Deconstructing the smoking-preeclampsia paradox through a counterfactual framework. Eur J Epidemiol 2016; 31:613-23. [PMID: 26975379 DOI: 10.1007/s10654-016-0139-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 03/08/2016] [Indexed: 02/04/2023]
Abstract
Although smoking during pregnancy may lead to many adverse outcomes, numerous studies have reported a paradoxical inverse association between maternal cigarette smoking during pregnancy and preeclampsia. Using a counterfactual framework we aimed to explore the structure of this paradox as being a consequence of selection bias. Using a case-control study nested in the Icelandic Birth Registry (1309 women), we show how this selection bias can be explored and corrected for. Cases were defined as any case of pregnancy induced hypertension or preeclampsia occurring after 20 weeks' gestation and controls as normotensive mothers who gave birth in the same year. First, we used directed acyclic graphs to illustrate the common bias structure. Second, we used classical logistic regression and mediation analytic methods for dichotomous outcomes to explore the structure of the bias. Lastly, we performed both deterministic and probabilistic sensitivity analysis to estimate the amount of bias due to an uncontrolled confounder and corrected for it. The biased effect of smoking was estimated to reduce the odds of preeclampsia by 28 % (OR 0.72, 95 %CI 0.52, 0.99) and after stratification by gestational age at delivery (<37 vs. ≥37 gestation weeks) by 75 % (OR 0.25, 95 %CI 0.10, 0.68). In a mediation analysis, the natural indirect effect showed and OR > 1, revealing the structure of the paradox. The bias-adjusted estimation of the smoking effect on preeclampsia showed an OR of 1.22 (95 %CI 0.41, 6.53). The smoking-preeclampsia paradox appears to be an example of (1) selection bias most likely caused by studying cases prevalent at birth rather than all incident cases from conception in a pregnancy cohort, (2) omitting important confounders associated with both smoking and preeclampsia (preventing the outcome to develop) and (3) controlling for a collider (gestation weeks at delivery). Future studies need to consider these aspects when studying and interpreting the association between smoking and pregnancy outcomes.
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Affiliation(s)
- Miguel Angel Luque-Fernandez
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK. .,Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Helga Zoega
- Faculty of Medicine, Center of Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Unnur Valdimarsdottir
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Faculty of Medicine, Center of Public Health Sciences, University of Iceland, Reykjavik, Iceland
| | - Michelle A Williams
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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A risk of waiting: the weekly incidence of hypertensive disorders and associated maternal and neonatal morbidity in low-risk term pregnancies. Am J Obstet Gynecol 2016; 214:389.e1-389.e12. [PMID: 26440691 DOI: 10.1016/j.ajog.2015.09.095] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Revised: 09/18/2015] [Accepted: 09/28/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Elective induction of labor (eIOL) prior to 39 weeks' gestation is discouraged because of presumed fetal benefits. However, few data exist on the maternal risks of expectant management. To date, no study has evaluated the maternal risk of developing a hypertensive disorder of pregnancy with expectant management of a low-risk gravid at term. OBJECTIVE We sought to evaluate the development of hypertensive disorders in term low-risk expectantly managed patients. STUDY DESIGN This is a retrospective cross-sectional study from 19 US hospitals, from 2002 to 2008 (Safe Labor Consortium) including all nonanomalous, cephalic, singleton pregnancies at 37-41 weeks. Women with a history of hypertension, diabetes mellitus, cardiovascular disease, or planned cesarean delivery or from centers with incomplete hypertensive data were excluded. Women with eIOL in each week were compared with women managed expectantly until the next week of gestation or beyond. The primary outcome was the frequency of hypertensive complications. RESULTS Of 114,651 low-risk deliveries, 12,772 (11.1%) had eIOL. The cohort was 49.2% nulliparous, 51.1% white, and obese (mean body mass index 30.2 kg/m(2)). The risk of developing any hypertension in expectantly managed women was 4.1% after 37 weeks, 3.5% after 38 weeks, 3.2% after 39 weeks, and 2.6% after 40 weeks. Compared with eIOL, women with hypertensive disorders had significantly higher rates of cesarean delivery and maternal morbidities (intensive care unit admission or death, third- or fourth-degree lacerations, maternal infections, and bleeding complications) at each week of gestation and the composite neonatal morbidity at 38 and 39 weeks of gestation. CONCLUSION For women at low risk expectantly managed at term, there is a risk of developing hypertensive complications for each additional week of pregnancy, with associated increases in maternal and neonatal morbidities.
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McKinney D, Boyd H, Langager A, Oswald M, Pfister A, Warshak CR. The impact of fetal growth restriction on latency in the setting of expectant management of preeclampsia. Am J Obstet Gynecol 2016; 214:395.e1-7. [PMID: 26767794 DOI: 10.1016/j.ajog.2015.12.050] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Revised: 12/01/2015] [Accepted: 12/29/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Fetal growth restriction is a common complication of preeclampsia. Expectant management for qualifying patients has been found to have acceptable maternal safety while improving neonatal outcomes. Whether fetal growth restriction influences the duration of latency during expectant management of preeclampsia is unknown. OBJECTIVE The objective of the study was to determine whether fetal growth restriction is associated with a reduced interval to delivery in women with preeclampsia being expectantly managed prior to 34 weeks. STUDY DESIGN We performed a retrospective cohort of singleton, live-born, nonanomalous deliveries at the University of Cincinnati Medical Center between 2008 and 2013. Patients were included in our analysis if they were diagnosed with preeclampsia prior to 34 completed weeks and if the initial management plan was to pursue expectant management beyond administration of steroids for fetal lung maturity. Two study groups were determined based on the presence or absence of fetal growth restriction. Patients were delivered when they developed persistent neurological symptoms, severe hypertension refractory to medical therapy, renal insufficiency, nonreassuring fetal status, pulmonary edema, or hemolysis elevated liver low platelet syndrome or when they reached 37 weeks if they remained stable without any other indication for delivery. Our primary outcome was the interval from diagnosis of preeclampsia to delivery, measured in days. Secondary outcomes included indications for delivery, rates of induction and cesarean delivery, development of severe morbidities of preeclampsia, and select neonatal outcomes. We performed a multivariate logistic regression analysis comparing those with fetal growth restriction with those with normally grown fetuses to determine whether there is an association between fetal growth restriction and a shortened interval to delivery, neonatal intensive care unit admission, prolonged neonatal stay, and neonatal mortality. RESULTS A total of 851 patients met the criteria for preeclampsia, of which 199 met inclusion criteria, 139 (69%) with normal growth, and 60 (31%) with fetal growth restriction. Interval to delivery was significantly shorter in women with fetal growth restriction, median (interquartile range) of 3 (1.6) days vs normal growth, 5 (2.12) days, P < .001. The association between fetal growth restriction and latency less than 7 days remained significant, even after post hoc analysis controlling for confounding variables (adjusted odds ratio, 1.66 [95% confidence interval, 1.12-2.47]). There were no differences in the development of severe disease (85.9 vs 91.7%, P = .26), need for intravenous antihypertensive medications (47.1 vs 46.7%, P = .96), and the development of severe complications of preeclampsia (51.1 vs 42.9%, P = .30) in normally grown and growth-restricted fetuses, respectively. Fewer women with fetal growth restriction attained their scheduled delivery date, 3 of 60 (5.0%), compared with normally grown fetuses,12 of 139 (15.7%), P = .03. Admission to the neonatal intensive care unit, neonatal length of stay, and neonatal mortality were higher when there was fetal growth restriction; however, after a logistic regression analysis, these associations were no longer significant. CONCLUSION Fetal growth restriction is associated with a shortened interval to delivery in women undergoing expectant management of preeclampsia when disease is diagnosed prior to 34 weeks. These data may be helpful in counseling patients regarding the expected duration of pregnancy, guiding decision making regarding administration of steroids and determining the need for maternal transport.
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In Reply. Obstet Gynecol 2015; 126:1311. [PMID: 26595572 DOI: 10.1097/aog.0000000000001178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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