Prediction and Prevention of Recurrent Preeclampsia

Prognostic risk factors for early diagnosing of Preeclampsia in Nulliparas

Background:

Preeclampsia is of major complications of pregnancy that is associated with maternal morbidity and mortality. Therefore, prediction and early diagnosis of preeclampsia would be helpful for better controlling of related complications. Our study aimed to investigate risk factors helping to predict and early diagnose of preeclampsia.

Materials and Methods:

A total of 739 nulliparous women at their 24-28^th weeks of the first pregnancy were enrolled in this multi-center cohort study. Incidence or absence of preeclampsia in this population was evaluated up to the end of pregnancy period. For each case, a record sheet was assigned that contained information about haematocrit level in weeks 24-28^th of pregnancy, blood pressure, result of roll-over test in weeks 24-28^th of pregnancy and the presence of disease up to end of the study. Diagnosis of preeclampsia was made based on gold standard.

Results:

Overall, 3.9 % of all cases developed preeclampsia. The mean maternal age, body mass index (BMI), years of education and positive roll-over test were significantly higher in preeclampsia group (P < 0.001). However, the mean gestational age and changes in the levels of haematocrit were significantly higher in normotensive cases (P < 0.001). Our combined model could predict preeclampsia with a sensitivity of 93% and a specificity of 80%.

Conclusion:

Simple combined model of demographic characteristics including maternal age, BMI, years of education and positive roll-over tests can predict preeclampsia without any cost for the patients.

Contemporary clinical management of the cerebral complications of preeclampsia

The neurological complications of preeclampsia and eclampsia are responsible for a major proportion of the morbidity and mortality arising from these conditions, for women and their infants alike. This paper outlines the evidence base for contemporary management principles pertaining to the neurological sequelae of preeclampsia, primarily from the maternal perspective, but with consideration of fetal and neonatal aspects as well. It concludes with a discussion regarding future directions in the management of this potentially lethal condition.

First trimester maternal characteristics, Doppler parameters and serum analytes after preeclampsia

OBJECTIVE

To evaluate the impact of prior preeclampsia on first trimester assessment in subsequent pregnancy.

METHODS

A total of 1283 parous patients were prospectively enrolled at 9-14 weeks of gestation. Maternal biophysical characteristics, ultrasound parameters and placental analytes were compared between women with and without prior preeclampsia.

RESULTS

There is no association between prior preeclampsia and the first trimester ultrasound parameters or placental analytes studied. The effects of prior preeclampsia in subsequent pregnancy are exaggerated by increasing parity and are predominantly blood pressure-related, independent of other cardiovascular risk factors.

CONCLUSION

There is a potential role for lifestyle modification and stricter pregnancy blood pressure control in patients with prior preeclampsia.

Associations of personal and family preeclampsia history with the risk of early-, intermediate- and late-onset preeclampsia

Preeclampsia encompasses multiple conditions of varying severity. We examined the recurrence and familial aggregation of preeclampsia by timing of onset, which is a marker for severity. We ascertained personal and family histories of preeclampsia for women who delivered live singletons in Denmark in 1978-2008 (almost 1.4 million pregnancies). Using log-linear binomial regression, we estimated risk ratios for the associations between personal and family histories of preeclampsia and the risk of early-onset (before 34 weeks of gestation, which is typically the most severe), intermediate-onset (at 34-36 weeks of gestation), and late-onset (after 36 weeks of gestation) preeclampsia. Previous early-, intermediate-, or late-onset preeclampsia increased the risk of recurrent preeclampsia with the same timing of onset 25.2 times (95% confidence interval (CI): 21.8, 29.1), 19.7 times (95% CI: 17.0, 22.8), and 10.3 times (95% CI: 9.85, 10.9), respectively, compared with having no such history. Preeclampsia in a woman's family was associated with a 24%-163% increase in preeclampsia risk, with the strongest associations for early- and intermediate-onset preeclampsia in female relatives. Preeclampsia in the man's family did not affect a woman's risk of early-onset preeclampsia and was only weakly associated with her risks of intermediate- and late-onset preeclampsia. Early-onset preeclampsia appears to have the largest genetic component, whereas environmental factors likely contribute most to late-onset preeclampsia. The role of paternal genes in the etiology of preeclampsia appears to be limited.

Recurrence of preeclampsia in northern Tanzania: a registry-based cohort study

OBJECTIVE

Preeclampsia occurs in about 4 per cent of pregnancies worldwide, and may have particularly serious consequences for women in Africa. Studies in western countries have shown that women with preeclampsia in one pregnancy have a substantially increased risk of preeclampsia in subsequent pregnancies. We estimate the recurrence risks of preeclampsia in data from Northern Tanzania.

METHODS

A prospective cohort study was designed using 19,811 women who delivered singleton infants at a hospital in Northern Tanzania between 2000 and 2008. A total of 3,909 women were recorded with subsequent deliveries in the hospital with follow up through 2010. Adjusted recurrence risks of preeclampsia were computed using regression models.

RESULTS

The absolute recurrence risk of preeclampsia was 25%, which was 9.2-fold (95% CI: 6.4 - 13.2) compared with the risk for women without prior preeclampsia. When there were signs that the preeclampsia in a previous pregnancy had been serious either because the baby was delivered preterm or had died in the perinatal period, the recurrence risk of preeclampsia was even higher. Women who had preeclampsia had increased risk of a series of adverse pregnancy outcomes in future pregnancies. These include perinatal death (RR= 4.3), a baby with low birth weight (RR= 3.5), or a preterm birth (RR= 2.5). These risks were only partly explained by recurrence of preeclampsia.

CONCLUSIONS

Preeclampsia in one pregnancy is a strong predictor for preeclampsia and other adverse pregnancy outcomes in subsequent pregnancies in Tanzania. Women with previous preeclampsia may benefit from close follow-up during their pregnancies.

Impaired effect of relaxin on vasoconstrictor reactivity in spontaneous hypertensive rats

Relaxin is thought to be involved in vasodilation to pregnancy by increasing endothelium-dependent vasodilation and compliance, and decreasing myogenic reactivity. Primary (essential) hypertension predisposes to circulatory maladaptation and subsequent gestational hypertensive disease. This study aimed to determine that vascular responses to chronic exposure to relaxin are impaired in young female rats with primary hypertension. In 10-12 weeks old Wistar-Hannover rats (WHR) and spontaneous hypertensive rats (SHR), we determined vascular responses in isolated kidney and mesenteric arteries after 5-days of chronic exposure to relaxin (4 μg/h) or placebo. SHR show decreased sensitivity to phenylephrine (by 67%, p<0.01) and renal perfusion flow (RPFF, by 19%, p<0.01), but no changes in flow-mediated vasodilation, myogenic reactivity or vascular compliance. In WHR, relaxin stimulated flow-mediated vasodilation (2.67 fold, from 48 ± 9 to 18 ± 4 μl/min, p = 0.001), inhibited myogenic reactivity (from -1 ± 2 to 7 ± 3 μm/10 mmHg, p = 0.01), and decreased sensitivity to phenylephrine (28%, from 1.39 ± 0.08 to 1.78 ± 0.10 μM, p<0.01), but left compliance and RPFF unchanged. NO-blockade by L-NAME diminished most relaxin-mediated responses. In SHR, the vasodilator effects of relaxin were blunted for myogenic reactivity and sensitivity to phenylephrine, with similar effects on flow-mediated vasodilation, compliance, RPFF and equal Rxfp1 (relaxin family peptide receptor) gene expression, as compared to WHR. Primary hypertension blunts both the relaxin-induced inhibition of myogenic reactivity and α-adrenergic vasoconstrictor response, independent from Rxfp1 gene expression, while the relaxin-dependent enhanced flow-mediated vasodilation remains intact. This implies selective resistance to relaxin in young subjects suffering from primary hypertension.

DNA methylation as a biomarker for preeclampsia

BACKGROUND

Preeclampsia contributes significantly to pregnancy-associated morbidity and mortality as well as future risk of cardiovascular disease in mother and offspring, and preeclampsia in offspring. The lack of reliable methods for early detection limits the opportunities for prevention, diagnosis, and timely treatment.

PURPOSE

The purpose of this study was to explore distinct DNA methylation patterns associated with preeclampsia in both maternal cells and fetal-derived tissue that represent potential biomarkers to predict future preeclampsia and inheritance in children.

METHOD

A convenience sample of nulliparous women (N = 55) in the first trimester of pregnancy was recruited for this prospective study. Genome-wide DNA methylation was quantified in first-trimester maternal peripheral white blood cells and placental chorionic tissue from normotensive women and those with preeclampsia (n = 6/group).

RESULTS

Late-onset preeclampsia developed in 12.7% of women. Significant differences in DNA methylation were identified in 207 individual linked cytosine and guanine (CpG) sites in maternal white blood cells collected in the first trimester (132 sites with gain and 75 sites with loss of methylation), which were common to approximately 75% of the differentially methylated CpG sites identified in chorionic tissue of fetal origin.

CONCLUSION

This study is the first to identify maternal epigenetic targets and common targets in fetal-derived tissue that represent putative biomarkers for early detection and heritable risk of preeclampsia. Findings may pave the way for diagnosis of preeclampsia prior to its clinical presentation and acute damaging effects, and the potential for prevention of the detrimental long-term sequelae.

Preeclampsia is associated with increased maternal body weight in a northeastern Brazilian population

Background

Preeclampsia is a disease with great variability in incidence across the world. The mortality is higher in lower income countries, where it is the leading cause of maternal mortality. This study aimed to determine the frequency of and risk factors for preeclampsia in a low income population from an urban area of Brazil.

Methods

A prospective case control study of 242 women of which 30 developed preeclampsia, 4 had gestational hypertension, 2 had superimposed hypertension, 11 had spontaneous abortion, 13 were lost to follow up and 192 had normal pregnancy. This latter group was considered the normotensive controls. The rate of preeclampsia and the risk of cardiovascular disease, after onset of preeclampsia, were determined.

Results

Of the 218 women who completed the study, the frequency of hypertensive disorder of pregnancy was 16.5% (36 of 218) and of preeclampsia was 13.8% (30 of 218). Women with preeclampsia had a higher body mass index (BMI), mean of 25.3 ± 4.8 compared to 23.5 ± 3.7 for the normotensive controls, p = 0.02. The risk of preeclampsia increased with BMI [Odds ratio (OR) 1.12, 95% Confidence Interval (CI = 1.02;1.24, p-value = 0.023)]. Women with preeclampsia developed chronic hypertension more often than normotensive controls (p = 0.043) and their systolic and ambulatory blood pressure monitoring was elevated (p = 0.034). Women with preeclampsia had higher BMI even 5 years post-pregnancy (p = 0.008).

Conclusions

Women who are overweight or older have an increased risk of preeclampsia. Previous history of preeclampsia increases the risk of early onset of chronic hypertension. Therefore, effective preventive measures are needed, particularly women at lower social economic stratum who have less access to proper medical care and adequate nutrition.

Social representations of mothers about gestational hypertension and premature birth

OBJECTIVE

To identify the meanings attributed by mothers to hypertensive disorders of pregnancy (HDPs) and their consequences, such as premature birth and hospitalization of the infant in the neonatal intensive care unit (NICU).

METHOD

A qualitative study, based on the Central Nucleus Theory, with 70 women who had hypertensive disorders of pregnancy and preterm delivery. We used the technique of free word association (FWAT) with three stimuli: high blood pressure during pregnancy, prematurity and NICU.

RESULTS

We obtained 1007 evocations, distributed as follows: high blood pressure during pregnancy (335) prematurity (333) and NICU (339). These constituted three thematic units: representation of HDPs, prematurity and the NICU. The categories death and negative aspects were inherent to the three units analyzed, followed by coping strategies and needs for care present in HDPs and prematurity.

CONCLUSION

The study had death as its central nucleus, and highlighted the subjective aspects present in the high risk pregnancy and postpartum cycle. It is hoped that this research will contribute to qualifying nursing care for women confronting the problem of HDPs, so that they can cope with less impacts from the adverse effects of high risk pregnancy and birth.

A complicated role for the renin-angiotensin system during pregnancy: highlighting the importance of drug discovery

INTRODUCTION

Blood pressure management is recommended to avoid maternal cerebrovascular or cardiovascular compromise during pregnancy. Current antihypertensive treatment during pregnancy with positive safety profiles includes labetalol, hydralazine, methyldopa and nifedipine.

AREAS COVERED

Many earlier animal and human studies indicate that angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are associated with fetopathy; therefore, these drugs are contraindicated during pregnancy, especially if these medications were taken during the second and third trimesters. The role of the RAS is quite complex, with fetal development heavily dependent on its appropriate expression and function. New findings indicate that the placental unit expresses its own RAS in order to regulate angiogenesis. Multiple studies have shown that women with abnormal uterine doppler sonography produce an agonistic autoantibody to the angiotensin I receptor, implicating a role for RAS function and regulation in abnormal pregnancies. Importantly, interruption of a normal RAS compromises fetal development.

EXPERT OPINION

Traditional medications that inhibit components of RAS for long-term hypertension control are not appropriate for use before or during pregnancy. Further study and drug discovery are needed to find alternative pathways for treatment of hypertensive disorders when pregnancy is present or a possibility.

Digoxin antibody fragment, antigen binding (Fab), treatment of preeclampsia in women with endogenous digitalis-like factor: a secondary analysis of the DEEP Trial

OBJECTIVE

Endogenous digitalis-like factors (EDLFs) are elevated in women with preeclampsia, and the use of an anti-digoxin antibody Fab (DIF) in women with preeclampsia who were remote from term reduced maternal blood pressure and preserved renal function. The objective was to determine whether DIF treatment in women with severe preeclampsia in association with positive EDLFs in maternal serum improves maternal-perinatal outcomes.

STUDY DESIGN

This was a planned secondary analysis from a randomized, placebo-controlled, double-blind study of DIF in women with severe preeclampsia with positive EDLF status that was managed expectantly between 23 weeks 5 days and 34 weeks' gestation (19 women received placebo, and 17 women received DIF). Primary outcome variables were a change in creatinine clearance and the use of antihypertensives. Secondary outcomes were maternal and perinatal complications.

RESULTS

Women with positive EDLFs who received DIF had an attenuated decline in creatinine clearance from baseline compared with placebo (-4.5 ± 12.9 vs -53.2 ± 12.6 mL/min; P = .005). In this same group, the use of antihypertensives (the other primary outcome) was lower but not significantly so (41% vs 63%; P = .12). However, women who were treated with DIF had a lower rate of pulmonary edema (1/17 vs 6/19 women; P = .035) and lower rates of neonatal intraventricular hemorrhage (DIF: 0/17 women vs placebo: 5/19 women; P = .015).

CONCLUSION

In women with severe preeclampsia who were remote from term who were EDLF positive, the use of DIF was associated with improved maternal and neonatal outcome. These findings suggest the need for a large multicenter trial that would evaluate the benefits of DIF in the treatment of women with severe preeclampsia who are remote from term and with positive EDLF status.

Individual risk assessment of adverse pregnancy outcome by multivariate regression analysis may serve as basis for drug intervention studies: retrospective analysis of 426 high-risk patients including ethical aspects

OBJECTIVE

To identify patients at very high risk for adverse pregnancy outcome (APO) at the 20- to 23-week scan and to assess the effectiveness of Aspirin (ASS) and low molecular weight heparin (LMWH) starting after this examination.

PATIENTS AND METHODS

By applying an algorithm based on multivariate logistic regression analysis using the parameters maternal age, parity, body mass index (BMI), mean pulsatility index of both uterine arteries (meanPI), presence of uni- or bilateral notch, and depth of notch (mean notch index (meanNI), we retrospectively calculated the individual risk for APO of 21,302 singleton pregnancies. We isolated a subgroup of 426 patients with the highest calculated probability for APO (cpAPO > 27.8 %). 147 had been treated with ASS; 73 with LMWH, 15 patients with a combination of ASS and LMWH, and 191 patients had not received anticoagulants.

RESULTS

Administration of ASS starting after 20 gestational weeks in comparison to non-treated patients significantly reduced the frequency of intrauterine/neonatal death (IUD/NND), preeclampsia <33 weeks (PE < 33), and preterm delivery <33 weeks (PD < 33), while the frequency of IUGR showed a tendency to be elevated (P = 0.061). The subgroup of high-risk patients treated with LMWH was characterised by a higher a priori risk for APO and showed no significant reduction of any form of APO but an increased frequency of PE.

CONCLUSION

Individual assessment of risk for APO by applying a simple algorithm based on biometrical/biographical as well as sonographic parameters may serve as basis for drug intervention studies. The administration of ASS in high-risk patients starting after 20 gestational weeks reduced the frequency of most of the severe forms of adverse pregnancy outcome in high-risk patients. A complication-reducing effect of LMWH starting after 20 weeks of gestation in patients could not be proven. From an ethical point of view, it may not be justified any more to preclude high-risk patients from administration of ASS or to perform studies of ASS against placebo.

Effects of pravastatin on angiogenic and placental hypoxic imbalance in a mouse model of preeclampsia

In order to determine the effects of pravastatin (Pra) on angiogenic and placental hypoxic imbalance in a model of preeclampsia induced by overexpression of soluble fms-like tyrosine kinase 1 (sFlt-1), we randomly allocated pregnant CD1 mice to injection with adenovirus-carrying sFlt-1 or mFc (control). The sFlt-1 group received either Pra (sFlt-1 + Pra) or water (sFlt-1). Mice were sacrificed at day 18, and serum levels of sFlt-1 and soluble endoglin (sEng) were measured. Placental expression of placental (PLGF) and vascular endothelial (VEGF) growth factors and other markers of angiogenesis and hypoxia were assayed. We observed that Pra treatment in sFlt-1 mice reduced sFlt-1 and sEng concentrations at day 18 to levels similar to control group. Placental PLGF and VEGF expression were upregulated, and markers of hypoxia downregulated to levels similar to control group. Hence, Pra prevents the rise in circulating antiangiogenic factors in a mouse model of preeclampsia. Statins may represent a novel approach to prevention of preeclampsia.

New developments in the pathogenesis of preeclampsia

Preeclampsia affects 3% to 5% of all pregnancies and is a major cause of maternal and perinatal morbidity and mortality worldwide. This disorder is characterized by a constellation of signs and symptoms, most notably new-onset hypertension and proteinuria during the last trimester of pregnancy. In this review, the molecular mechanisms of preeclampsia with an emphasis on the role of circulating antiangiogenic proteins in the pathogenesis of preeclampsia and its complications will be discussed.

Emerging new biomarkers of preeclampsia

Preeclampsia continues to plague some of the most vulnerable women and fetuses. It is surprisingly prevalent in developing and developed nations. According to the World Health Organization, hypertension during pregnancy is a leading cause of maternal mortality in industrialized countries at 16% and up to 25% in developing countries. As the pathogenesis of this disease is being unraveled, we are afforded new opportunities to develop novel biomarkers for early identification and prevention of disease. The angiogenic markers including soluble fms-like tyrosine kinase 1, placental growth factor, and soluble endoglin have demonstrated to be the most promising, perhaps in conjunction with traditional markers such as plasma protein-13 and uterine artery Doppler studies. There is also increasing evidence that the podocyte is shed during the course of preeclampsia, which may be useful for diagnosis. Systems biology approaches to biomarker discovery such as proteomics and metabolomics are also gaining more attention and will most certainly open new avenues of research. In this review, we present the best studied biomarkers of preeclampsia to date.

Preterm severe preeclampsia in singleton and twin pregnancies

OBJECTIVE

We aimed to evaluate rates of delivery and clinical manifestations of preterm severe preeclampsia in singleton and twin gestations.

STUDY DESIGN

This retrospective cohort study included 86 765 deliveries from 2000 to 2009, including 3244 twins. Rates of delivery for severe preeclampsia among infants born 24 to 31+6, and 32 to 36+6 weeks gestation were calculated, and diagnostic criteria were compared.

RESULT

Re-term severe preeclampsia was more common in twin pregnancies (2.4% vs 0.4%, P<0.001, relative risk 5.70 (95% confidence interval 4.47 to 7.26)). This was also true for deliveries from 24 to 31+6 (0.8% vs 0.2%, P<0.001) and 32 to 36+6 weeks (1.7% vs 0.3%, P<0.001). Diagnostic criteria and disease manifestation including hemolysis elevated liver enzymes low platelet count syndrome, abruption and growth restriction were similar between groups.

CONCLUSION

Twin pregnancies are significantly more likely than singletons to be delivered preterm for severe preeclampsia. Diagnostic criteria and disease manifestation were similar in singletons and twins, at all gestational ages.

Vitamin D and pregnancy: skeletal effects, nonskeletal effects, and birth outcomes

The function and requirement of vitamin D during pregnancy for both mother and fetus have remained a mystery. This fact was highlighted by The Cochrane Review in 2000, which reported a lack of randomized controlled trials (RCTs) with respect to vitamin D requirements during pregnancy. Unfortunately, during the past decade only a single RCT has been performed with respect to vitamin D requirements during pregnancy. In this review we will discuss vitamin D metabolism during pregnancy as well as the consequences of vitamin D deficiency on skeletal, nonskeletal, and birth outcomes using birth observational data and data from our recent RCT. New RCT data strongly support previous observational studies in that improving nutritional vitamin D status will improve birth outcomes. The new RCT data indicate that 4,000 IU/day vitamin D(3) during pregnancy will "normalize" vitamin D metabolism and improve birth outcomes including primary cesarean section and comorbidities of pregnancy with no risk of side effects.

Prediction of preeclampsia: liver function tests during the first 20 gestational weeks

OBJECTIVE

To examine whether plasma levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) during the first 20 weeks of pregnancy can predict preeclampsia in the second half of pregnancy.

METHODS

The study population included 150,10 registered births. Receiver operating characteristic (ROC) curve analysis was used to describe the relationship between different values of AST and ALT during the first 20 weeks of pregnancy in the prediction of preeclampsia.

RESULTS

Using ROC curve analyses, elevated ALT levels were significantly associated with both mild preeclampsia (p < 0.001) and severe preeclampsia (p = 0.032). However, an ALT level of 50 IU/L had a sensitivity of only 3.3% (despite a specificity of 97%) in the prediction of severe preeclampsia. While no significant association was noted between AST levels and mild preeclampsia (p = 0.669), elevated levels of AST during this period were significantly associated with severe preeclampsia (p = 0.027). However, AST of 50I U/L had a sensitivity of only 2.0% (despite a specificity of 98%) in the prediction of severe preeclampsia.

CONCLUSIONS

Higher levels of the liver enzymes AST and ALT during the first 20 weeks of pregnancy are associated with higher risk for the development of severe preeclampsia in the second half of the pregnancy. Nevertheless, there is no clinical cutoff value that can be practically used for the prediction of preeclampsia.

Brain damage in preterm newborns and maternal medication: the ELGAN Study

OBJECTIVE

We sought to evaluate the association between maternal medication use during pregnancy and cerebral white matter damage and cerebral palsy (CP) among very preterm infants.

STUDY DESIGN

This analysis of data from the Extremely Low Gestational Age Newborns (ELGAN) Study included 877 infants born <28 weeks' gestation. Mothers were interviewed, charts were reviewed, placentas were cultured and assessed histologically, and children were evaluated at 24 months corrected age. A diagnostic algorithm classified neurologic findings as quadriparetic CP, diparetic CP, hemiparetic CP, or no CP.

RESULTS

After adjustment for the potential confounding of disorders for which medications might have been indicated, the risk of quadriparetic CP remained elevated among the infants of mothers who consumed aspirin (odds ratio [OR], 3.0; 95% confidence interval [CI], 1.3-6.9) and nonsteroidal antiinflammatory drugs (NSAIDs) (OR, 2.4; 95% CI, 1.04-5.8). The risk of diparetic CP was also associated with maternal consumption of an NSAID, but only if the consumption was not approved by a physician (OR, 3.5; 95% CI 1.1-11.0).

CONCLUSION

The possibility that aspirin and NSAID use in pregnancy could lead to perinatal brain damage cannot be excluded.

Calcium supplementation and prevention of preeclampsia: a meta-analysis

BACKGROUND

Since the early 1980s, epidemiological evidence has suggested a connection between low calcium intake and preeclampsia The purpose of this meta-analysis is to summarize current evidence regarding calcium supplementation during pregnancy in predicting preeclampsia and associated maternal-fetal complications.

METHODS

Literature revision of all RCT (random allocation of calcium versus placebo) available in MEDLINE/PUBMED up to 2/29/2012 regarding calcium supplementation during pregnancy for preventing preeclampsia. We used the Mantel-Haenszel's Method for four subgroup of patients: Adequate calcium intake; Low calcium intake; Low risk of preeclampsia; High risk of preeclampsia. We considered p < 0.05 as significant.

RESULTS

There is no consensus in Literature about: (1) the efficacy of calcium supplementation in the prevention of preeclampsia, (2) other/adverse/long-term effects of calcium supplementation in pregnancy.

CONCLUSIONS

Preeclampsia is likely to be a multifactorial disease. However, inadequate calcium intake represents a factor associated with an increased incidence of hypertensive disease. The results of our meta-analysis demonstrate that the additional intake of calcium during pregnancy is an effective measure to reduce the incidence of preeclampsia, especially in populations at high risk of preeclampsia due to ethnicity, gender, age, high BMI and in those with low baseline calcium intake.

Comparative Study of Endothelial Function and Uterine Artery Doppler Velocimetry between Pregnant Women with or without Preeclampsia Development

Background. Poor placentation and systemic endothelial dysfunction have been identified as main events in Preeclampsia (PE). The relationship and chronology of these phenomena are important if we are to understand the pathophysiological mechanisms underlying this major clinical problem. Objectives. To compare the evolution of placentation and endothelial function in normotensive and preeclamptic pregnancies. Patients and methods. In a prospective cohort study, 59 pregnant women with a high risk of developing PE were subjected to flow-mediated dilation (FMD) and to Doppler velocimetry of uterine arteries in order to obtain their Pulsatility Index (UtA-PI). The variations in the FMD and UtA-PI values, between 16⁺⁰ and 19⁺⁶ and 24⁺⁰ and 27⁺⁶ weeks of gestation, were compared, taking PE development into consideration. Results. Nine patients developed PE and the other 50 women remained normotensive. At 16⁺⁰ to 19⁺⁶ weeks of pregnancy, patients that developed PE presented higher values of UtA-PI than the normotensive group, but there was no difference in FMD results between them. At 24⁺⁰ to 27⁺⁶ weeks, the patients that developed PE presented higher values of UtA-PI and lower values of FMD than the women that remained normotensive. Conclusions. These results corroborate the evidence that endothelial injury is secondary to poor placentation.

FOLATE METABOLISM AND PREECLAMPSIA

Preeclampsia (PE) is a multisystem disorder of human pregnancy, affecting about 6% of all pregnancies worldwide, and is one of the leading causes of maternal and infant morbidity and mortality. Despite decades of research into the pathogenesis of this complex disease, the underlying mechanisms remain unclear. As a result, the options for prevention and management of PE are limited. In recent years, there has been a growing body of evidence suggesting that folate deficiency is associated with PE, and folic acid supplementation may reduce the risk of developing PE in certain populations. Folate contributes to cell division and growth, and folate metabolism is involved in a large number of physiological and pathophysiological processes in human development. Sufficient supply of folate is therefore particularly important during pregnancy. Nevertheless, the exact mechanisms of folic acid deficiency increasing the risk of developing PE are still unclear. This article reviews what is understood about the aetiology of PE and the relationship between folate metabolism and PE so as to enhance further discussions on the subject.

Dynamic proteome in enigmatic preeclampsia: an account of molecular mechanisms and biomarker discovery

The coevolution of genomics and proteomics has led to advancements in the field of diagnosis and molecular mechanisms of disease. Proteomics is now stepping into the field of obstetrics, where early diagnosis of pregnancy complication such as preeclampsia (PE) is imperative. PE is a multifactorial disease characterized by hypertension with proteinuria, which is a leading cause of maternal and neonatal morbidity and mortality occurring in 5-7% of pregnancies worldwide. This review discusses the probable molecular mechanisms that lead to PE and summarizes the proteomics research carried out in understanding the pathogenicity of PE, and for identifying the candidate biomarker for diagnosis of the disease.

Association of uric acid with progression to preeclampsia and development of adverse conditions in gestational hypertensive pregnancies

BACKGROUND

Preeclampsia is a serious pregnancy complication. Gestational hypertension is a common first clinical presentation of preeclampsia. Little is known about which clinical risk factors are associated with the progression from gestational hypertension to preeclampsia.

METHODS

In a retrospective cohort study of 249 singleton pregnant women with an initial presentation of gestational hypertension in an obstetric hospital, we assessed which routinely available clinical risk factors are associated with the progression to preeclampsia and the development of adverse maternal or infant conditions.

RESULTS

The mean serum uric acid level at the initial presentation of gestational hypertension was significantly higher comparing patients who later progressed to preeclampsia to those who did not (5.06 vs. 4.59 mg/dl, P < 0.01). Lower gestational age and higher serum uric acid level at the initial presentation of gestational hypertension and subsequent need for antihypertensive drug treatment for blood pressure (BP) control were associated with significantly increased risks of progression to preeclampsia, and development of adverse maternal or infant conditions. One standard deviation (s.d.) increase in serum uric acid level was associated with 2.3-fold increased odds of progression to preeclampsia (adjusted odds ratio (aORs) 2.33 (95% confidence interval (CI) 1.45-3.74)), and 1.5-fold increased odds of developing clinically significant adverse maternal or infant conditions (aOR 1.49 (1.03-2.17)) irrespective of the progression to preeclampsia.

CONCLUSIONS

Higher serum uric acid levels at the initial presentation of gestational hypertension may indicate heightened risk of progression to preeclampsia and development of adverse maternal/infant conditions.

Evaluation of kisspeptin levels in obese pregnancy as a biomarker for pre-eclampsia

OBJECTIVES

Circulating concentrations of the peptide kisspeptin have been proposed as a novel biomarker for early detection of pre-eclampsia. Our aims were to assess analytical and clinical performance characteristics of a commercial kisspeptin assay and to determine sensitivity and specificity of the test for pre-eclampsia.

DESIGN

Prospective, longitudinal study in a United Kingdom tertiary referral Antenatal Metabolic Clinic.

PATIENTS

Severely obese (body mass index, BMI > 40 kg/m(2), n = 194) and lean (BMI < 25 kg/m(2), n = 78) pregnant women.

MEASUREMENTS

A commercial kisspeptin ELISA (Phoenix Pharmaceuticals) was assessed for analytical sensitivity, specificity, precision, linearity, recovery and stability in maternal plasma samples at 16, 28 and 36 weeks gestation. Pre-eclampsia, defined using International Society for the Study of Hypertension in Pregnancy guidelines; blood pressure; delivery gestation; birthweight.

RESULTS

Kisspeptin concentrations were lower in early pregnancy in obese women (P < 0.001), and in women who later developed pre-eclampsia (P < 0.05), compared with women with uncomplicated pregnancies. For 16-week plasma kisspeptin in prediction of pre-eclampsia, area under the receiver-operator characteristic curve was 0.80 (P < 0.01), positive and negative likelihood ratios were 3.0 and 0.2, and test sensitivity and specificity were 85.7 and 71.4%, respectively. In regression analyses, kisspeptin (16 weeks) associated positively with delivery gestation (P < 0.05) and birthweight (P < 0.0001), and negatively with 28- and 36-week blood pressure (P < 0.0001).

CONCLUSIONS

Kisspeptin concentration in early pregnancy is a promising biomarker for pre-eclampsia and low birthweight but cannot be recommended, in isolation, for universal screening because of inadequate test sensitivity and specificity. Large-scale studies are required to assess its potential in a panel of biomarkers.

A comprehensive review of hypertension in pregnancy

Hypertension is the most common medical disorder encountered during pregnancy. Hypertensive disorders are one of the major causes of pregnancy-related maternal deaths in the United States. We will present a comprehensive update of the literature pertinent to hypertension in pregnancy. The paper begins by defining and classifying hypertensive disorders in pregnancy. The normal vascular and renal physiological changes which occur during pregnancy are detailed. We will summarize the intriguing aspects of pathophysiology of preeclampsia, emphasizing on recent advances in this field. The existing diagnostic tools and the tests which have been proposed for screening preeclampsia are comprehensively described. We also highlight the short- and long-term implications of preeclampsia. Finally, we review the current management guidelines, goals of treatment and describe the potential risks and benefits associated with various antihypertensive drug classes. Preeclampsia still remains an enigma, and the present management focuses on monitoring and treatment of its manifestations. We are hopeful that this in depth critique will stimulate the blossoming research in the field and assist practitioners to identify women at risk and more effectively treat affected individuals.

Twenty-four-hour ambulatory blood pressure monitor heart rate: a potential marker for gestational hypertension in at-risk women

We prospectively correlated the 24-hour ambulatory blood pressure measurements (ABPM) to conventional sphygmomanometer blood pressure measurements (CSM) in women at risk for gestational hypertensive disorders (GHTNDs) and identified predictive factors from ABPM for GHTND. We analyzed 73 women with ≥ 1 risk factor for developing a GHTND. Using both the CSM and ABPM, the systolic blood pressure, diastolic blood pressure, mean arterial pressure (MAP), and heart rate (HR) were measured for 24 hours during three periods (14 to 24 weeks; 24 to 32 weeks; and 33 weeks to delivery). Correlation between the CSM and ABPM lessened as pregnancy progressed. Seventeen (25%) of women developed a GHTND. MAP variability increased in the GHTND group versus those without a GHTND. The odds of developing a GHTND increased 1.5 times for every 1 beat per minute increase in the ABPM 24-hour HR at visit 1 and reversed by visit 3. In women at risk for a GHTND, CSM and ABPM correlate less well as pregnancy advances. HR changes in at-risk women may be a marker for the development of a GHTND and may reflect increased sympathetic activity and/or decreased baroreceptor sensitivity.

Microarray screening for novel preeclampsia biomarker candidates

INTRODUCTION

Our aim was to identify novel biomarker candidates for the near-term prediction of preeclampsia in a homogenous collective. In this study, we screened at the genome-wide level for gene expression in placental villous tissue from patients with severe preeclampsia in comparison to normal healthy pregnancies.

MATERIAL AND METHODS

Total RNA was extracted from placental villous tissue from 9 preeclamptic patients and 7 normotensive controls after scheduled cesarean sections. After sample pooling, gene expression analysis was performed using six Affymetrix Human Gene 1.0 ST arrays, followed by quantitative RT-PCR and validation of selected markers in the serum of patients at the protein level.

RESULTS

In total, 896 significantly differentially expressed genes were identified (p ≤ 0.05). After restricting these to molecules present in the circulation, 9 upregulated and 5 downregulated genes were selected. Four of them (β-hCG, HTRA4, LHB1, all upregulated; and NOX4, downregulated) were validated by quantitative real-time RT-PCR. Finally, the maternal plasma protein levels of 2 of these genes (LHB and β-hCG) were confirmed to be significantly different between preeclampsia cases and controls.

DISCUSSION

We identified 14 potential new biomarker candidates for preeclampsia and validated 4 of them by quantitative RT-PCR and 2 of them with subsequent serum protein analyses. Further studies will assess the optimal marker combination for the imminent prediction of impending preeclampsia.

Male sex bias in placental dysfunction

Several reports suggest a male fetal preponderance in a variety of complications of pregnancy attributable to severe placental dysfunction (SPD). However, the underlying mechanisms remain unknown. Our primary objective was to explore the relationship between fetal sex and the spectrum of conditions implicated in abnormal placentation. We identified singleton pregnancies with a fetus delivered between 20 + 0 and 32 + 6 weeks of gestation with one or more pregnancy complications attributed to SPD (severe pre-eclampsia, intra-uterine fetal death, intra-uterine growth restriction, abnormal Doppler studies, abruption) at a single institution between 1999 and 2007. Pedigrees of index cases were created to define the relationship between fetal sex and the risk of SPD. We identified 132 index cases, 97/132 (73%) were male. Eighty-four index cases had a total of 133 sibs, of which 37/133 (28%) were affected with SPD (22 male, 15 female). A male sex preponderance persisted across all manifestations of PD in index cases with sibs. In families with the absence of maternal chronic hypertension (cHTN; n = 70), the index case was 5.9 (95% CI 2.28-16.15; P <0.001) times more likely to be male and most (12/14) affected sibs of male index cases were male, while female index cases had no affected sibs. Our results confirm a male fetal sex preponderance in SPD. In a subgroup analysis of families without cHTN, a significant male bias was found to extend to sibs of index cases. This suggests a potential genetic mechanism predisposing the male fetus to abnormal placental development.

Molecular mechanisms of preeclampsia

Preeclampsia is one of the leading causes of maternal morbidity/mortality. The pathogenesis of preeclampsia is still under investigation. The aim of this paper is to present the molecular mechanisms implicating in the pathway leading to preeclampsia.

Preconception counseling

The preconception counseling visit is an ideal time to evaluate the patient and her future expectations regarding pregnancy. In fact at every patient encounter, whether for acute or chronic care, consideration should be given to any woman who, although not pregnant, may become pregnant, and what effect each ordered procedure, laboratory examination, or medication prescription might have on her or her fetus. If the primary reason for the office visit is preconception counseling there are a few specific components that should be discussed besides a complete history and physical examination.

[The meanings that postpartum women assign to gestational hypertension and premature birth]

The objective of this study was to understand the meanings that postpartum women assign to gestational hypertension that resulted in premature birth. Participants were 70 women, with a mean age of 28 years, 85.7% of whom delivered between the 32nd and 36th gestational week. A questionnaire with subjective questions was applied to identify the meanings of gestational hypertension and premature delivery for postpartum women. Results were analyzed based on the Theory of Social Representations. We observed the construction of a negative social representation, with death as the central nucleus and negative aspects as the peripheral nuclei. The latter derive from the risks the mother and fetus were exposed to during pregnancy and later in the postpartum period with the hospitalization of the child in the neonatal intensive care unit.

Age at menarche, menstrual characteristics, and risk of preeclampsia

We examined associations of age at menarche and menstrual characteristics with the risk of preeclampsia among participants (n = 3,365) of a pregnancy cohort study. Data were collected using in-person interviews and medical record abstraction. Logistic regression was used to estimate adjusted odds ratio (OR) and 95% confidence interval (95% CI). There was a significant inverse association between age at menarche and risk of preeclampsia (P value for trend < 0.05). Association of long cycle length (>36 days) with higher risk of preeclampsia was present only among women who had prepregnancy body mass index <25 kg/m(2) (interaction P value = 0.04). Early menarche is associated with higher risk of preeclampsia. Prepregnancy weight may modify associations of long menstrual cycles with risk of preeclampsia.

Evaluation of 7 serum biomarkers and uterine artery Doppler ultrasound for first-trimester prediction of preeclampsia: a systematic review

Preeclampsia (PE) affects 1% to 2% of pregnant women and is a leading cause of maternal and perinatal morbidity and mortality worldwide. The clinical syndrome of PE arises in the second half of pregnancy. However, many underlying factors including defective placentation may already be apparent in the first and early second trimester in many patients. In clinical practice, there is currently no reliable screening method in the first trimester of pregnancy with sufficient accuracy to identify women at high risk to develop PE. Early identification of high-risk pregnancy may facilitate the development of new strategies for antenatal surveillance or prevention and thus improve maternal and perinatal outcome. The aim of this systematic review was to study the literature on the predictive potential of first-trimester serum markers and of uterine artery Doppler velocity waveform assessment (Ut-A Doppler). Literature on the 7 most studied serum markers (ADAM12, fβ-hCG, Inhibin A, Activin A, PP13, PlGF, and PAPP-A) and Ut-A Doppler was primarily selected. In the selected literature, a combination of these markers was analyzed, and where relevant, the value of maternal characteristics was added. Measurements of serum markers and Ut-A Doppler were performed between week 8 + 0 and 14 + 0 GA. Low levels of PP13, PlGF, and PAPP-A and elevated level of Inhibin A have been found to be significantly associated with the development of PE later in pregnancy. The detection rates of single markers, fixed at 10% false-positive rate, in the prediction of early-onset PE were relatively low, and ranged from 22% to 83%. Detection rates for combinations of multiple markers varied between 38% and 100%. Therefore, a combination of multiple markers yields high detection rates and is promising to identify patients at high risk of developing PE. However, large scale prospective studies are required to evaluate the power of this integrated approach in clinical practice.

TARGET AUDIENCE

Obstetricians and Gynecologists, Family physicians Learning Objectives: After completion of this article, the reader should be better able to appraise the recent literature on the development of preeclampsia in the first-trimester, evaluate the predictive value of first-trimester markers and use first-trimester markers, either individually or in combination, to assess the risk of preeclampsia.

Identification of high-risk patients for adverse pregnancy outcome based on multivariate logistic regression analysis at 20-23 gestational weeks

AIMS

To establish and test a multivariate approach for identification of patients with high risk for adverse pregnancy outcome (APO) by a combination of sonographic (20+0-23+6 weeks) and biometrical data in a test group and to prove its effectiveness in a validation group.

METHODS

In order to develop a multivariate approach for identifying patients at high risk for APO, data from 15,855 non-treated singleton pregnancies (test group A), with well-known outcomes, were analysed retrospectively. Registered parameters were parity, body mass index (BMI), mean of pulsatility index of both uterine arteries (meanPI), presence of notch, and depth of notch described as the mean of the notch index of both uterine arteries (meanNI). In a second step, the model was validated in 3678 subsequent non-treated singleton pregnancies (validation group B).

RESULTS

In test group A, the calculated probabilities of APO were found between 1.3% and 82.8%, with the 95th centile at 11.2% and the 99th centile at 28.3%. In validation group B, in patients with a low calculated risk for APO <10%, complications were found in 4.4%. In patients with an intermediate risk of APO between 10% and 28%, complications were found in 10.7%. In patients from group B who were identified to be at high risk with a calculated probability of APO >28%, complications were found in 39.1%.

CONCLUSION

A multivariate approach toward risk-assessment of APO seems to be a promising method for identifying patients who are at high risk for APO. Besides the individual consequence of intensive surveillance, the identification of groups of patients at high risk for APO might serve as a basis for interventional studies.

Effects of pravastatin on mediators of vascular function in a mouse model of soluble Fms-like tyrosine kinase-1-induced preeclampsia

OBJECTIVE

We sought to investigate the mechanisms of action by which pravastatin improves vascular reactivity in a mouse model of preeclampsia induced by overexpression of soluble Fms-like tyrosine kinase-1 (sFlt)-1.

STUDY DESIGN

Pregnant CD-1 mice were randomly allocated to tail vein injection with adenovirus carrying sFlt-1 or murine immunoglobulin G2 Fc (control), and thereafter to receive pravastatin (5 mg/kg/d) or water. Mice were sacrificed at gestational day 18. Protein expression of endothelial nitric oxide synthase (eNOS), vascular endothelial growth factor receptor-1, and hemeoxygenase-1 were assayed by Western blot in aorta, liver, and kidneys. Serum total cholesterol concentrations were measured.

RESULTS

Pravastatin up-regulated eNOS expression in the aorta of sFlt-1 mice by nearly 2-fold (P = .005) to levels similar to control mice. Total cholesterol levels, vascular endothelial growth factor receptor-1, and hemeoxygenase-1 protein expression were similar across groups.

CONCLUSION

Pravastatin prevents vascular dysfunction in part by up-regulation of eNOS in the vasculature. Our data support a role for statins in preeclampsia prevention.

Management of late preterm and early-term pregnancies complicated by mild gestational hypertension/pre-eclampsia

Gestational hypertension/pre-eclampsia is the most frequent obstetrical complication, complicating 26%-29% of all gestations in nulliparous women. In general, the diagnosis of mild gestational hypertension/pre-eclampsia is made at 38 weeks or more in approximately 80% of cases. For many years, the optimal timing of delivery for patients with mild gestational hypertension/pre-eclampsia at 37-0/7 to 39-6/7 weeks was unclear. Recently, investigators of the HYPITAT (Pregnancy-induced hypertension and pre-eclampsia after 36 weeks: induction of labor versus expectant monitoring: A comparison of maternal and neonatal outcome, maternal quality of life and costs) randomized trial evaluated maternal and neonatal complications in patients at 36-40 weeks' gestation who were randomized to either induction of labor or expectant monitoring. The results of this trial revealed that induction of labor at or after 37-0 weeks was associated with lower rate of maternal complications without increased rates of either cesarean delivery or neonatal complications. In contrast, the optimum management for those with mild hypertension/pre-eclampsia with stable maternal and fetal conditions at 34-0/7 to 36-6/7 weeks remains uncertain. Therefore, there is urgent need for research to evaluate the reasons for late preterm birth in such women as well as for a randomized trial to evaluate the optimal timing for delivery in such patients.

Symptoms of post-traumatic stress after preeclampsia

This study describes the prevalence of postpartum post-traumatic stress disorder (PTSD) based on the DSM-IV criteria, including its symptoms of intrusion, avoidance and hyperarousal after pregnancies complicated by preeclampsia, and examines which variables are associated with PTSD and its symptoms. Women whose pregnancies were complicated by preeclampsia completed the Self-Rating Inventory for PTSD at 6 and 12 weeks postpartum: 149 women completed this questionnaire on at least one time point. Logistic regression analyses were used to examine associations with PTSD and its symptoms. Results showed that the prevalence of PTSD was 8.6% at 6 weeks, and 5.1% at 12 weeks postpartum; 21.9% of the study sample experienced postpartum symptoms of intrusion at 6 weeks postpartum (11.7% at 12 weeks), 9.4% symptoms of avoidance (8.0% at 12 weeks), and 28.9% symptoms of hyperarousal (20.4% at 12 weeks). Younger age, severe preeclampsia, cesarean section, lower gestational age, lower birth weight, admission to the neonatal intensive care unit, and perinatal death were found to be associated with PTSD and its symptoms. There was a relatively high prevalence of postpartum symptoms of PTSD among women after preeclampsia. The prevalence was highest among younger women who experienced more adverse pregnancy outcomes.

Postpartum depression after mild and severe preeclampsia

OBJECTIVE

To describe the prevalence of postpartum depressive symptoms after preeclampsia, to assess the extent to which the prevalence of postpartum depressive symptoms differs after mild and severe preeclampsia, and to investigate which factors contribute to such differences.

METHODS

Women diagnosed with preeclampsia (n=161) completed the Edinburgh Postnatal Depression Scale (EPDS) at 6, 12, or 26 weeks postpartum. Multiple logistic regression analysis was used to investigate the association between severity of preeclampsia, contributing factors and postpartum depression (PPD) (1) at any time during the first 26 weeks postpartum and (2) accounting for longitudinal observations at three time points.

RESULTS

After mild preeclampsia, 23% reported postpartum depressive symptoms at any time up to 26 weeks postpartum compared to 44% after severe preeclampsia (unadjusted odds ratio [OR] 2.65, 95% confidence interval [CI] 1.16-6.05) for depression at any time up to 26 weeks postpartum (unadjusted OR 2.57, 95% CI, 1.14-5.76) while accounting for longitudinal observations. Admission to the neonatal intensive care unit (NICU) (adjusted OR 3.19, 95% CI 1.15-8.89) and perinatal death (adjusted OR 2.96, 95% CI 1.09-8.03) contributed to this difference.

CONCLUSIONS

It appears that not the severity of preeclampsia itself but rather the consequences of the severity of the disease (especially admission to the NICU and perinatal death) cause postpartum depressive symptoms. Obstetricians should be aware of the high risk of postpartum depressive symptoms after severe preeclampsia, particularly among women whose infant has been admitted to the NICU or has died.

Pre-eclampsia: pathophysiology, diagnosis, and management

The incidence of pre-eclampsia ranges from 3% to 7% for nulliparas and 1% to 3% for multiparas. Pre-eclampsia is a major cause of maternal mortality and morbidity, preterm birth, perinatal death, and intrauterine growth restriction. Unfortunately, the pathophysiology of this multisystem disorder, characterized by abnormal vascular response to placentation, is still unclear. Despite great polymorphism of the disease, the criteria for pre-eclampsia have not changed over the past decade (systolic blood pressure > 140 mmHg or diastolic blood pressure ≥ 90 mmHg and 24-hour proteinuria ≥ 0.3 g). Clinical features and laboratory abnormalities define and determine the severity of pre-eclampsia. Delivery is the only curative treatment for pre-eclampsia. Multidisciplinary management, involving an obstetrician, anesthetist, and pediatrician, is carried out with consideration of the maternal risks due to continued pregnancy and the fetal risks associated with induced preterm delivery. Screening women at high risk and preventing recurrences are key issues in the management of pre-eclampsia.