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Aspirin use during pregnancy and the risk of bleeding complications: a Swedish population-based cohort study. Am J Obstet Gynecol 2021; 224:95.e1-95.e12. [PMID: 32687818 DOI: 10.1016/j.ajog.2020.07.023] [Citation(s) in RCA: 71] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aspirin is offered to pregnant women to prevent preeclampsia, a severe obstetrical complication. Large studies of nonpregnant populations have consistently shown that aspirin prophylaxis increases the risk of hemorrhagic complications. However, there have not been any population-based studies investigating this in a pregnant population. OBJECTIVE This study aimed to investigate whether aspirin use during pregnancy is associated with an increased risk of bleeding complications. STUDY DESIGN We performed a register-based cohort study using the Swedish Pregnancy Register wherein we examined 313,624 women giving birth between January 2013 and July 2017. Logistic regression was used to assess the risk of antepartum, intrapartum, and postpartum hemorrhage. A propensity score and inverse probability treatment weighting was used to generate an odds ratio that corrects for differences in baseline characteristics. RESULTS Aspirin use was registered in 4088 (1.3%) women during pregnancy. Compared with women who did not take aspirin, aspirin use was not associated with bleeding complications during the antepartum period (adjusted odds ratio, 1.22; 95% confidence interval, 0.97-1.54). However, aspirin users had a higher incidence of intrapartum bleeding (2.9% aspirin users vs 1.5% nonusers; adjusted odds ratio, 1.63; 95% confidence interval, 1.30-2.05), postpartum hemorrhage (10.2% vs 7.8%; adjusted odds ratio, 1.23; 95% confidence interval, 1.08-1.39), and postpartum hematoma (0.4% vs 0.1%; adjusted odds ratio, 2.21; 95% confidence interval, 1.13-4.34). The risk of a neonatal intracranial hemorrhage was also increased (0.07% vs 0.01%; adjusted odds ratio, 9.66; 95% confidence interval, 1.88-49.48). After stratifying by mode of birth, a higher incidence of bleeding among aspirin users was present for those who had a vaginal birth but not those who had a cesarean delivery. CONCLUSION Using aspirin during pregnancy is associated with increased postpartum bleeding and postpartum hematoma. It may also be associated with neonatal intracranial hemorrhage. When offering aspirin during pregnancy, these risks need to be weighed against the potential benefits.
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Tomsett KI, Barrett HL, Dekker EE, Callaway LK, McIntyre DH, Dekker Nitert M. Dietary Fiber Intake Alters Gut Microbiota Composition but Does Not Improve Gut Wall Barrier Function in Women with Future Hypertensive Disorders of Pregnancy. Nutrients 2020; 12:nu12123862. [PMID: 33348731 PMCID: PMC7766248 DOI: 10.3390/nu12123862] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/15/2020] [Indexed: 01/14/2023] Open
Abstract
Pregnancy alters the inflammatory state, metabolic hormones, and gut microbiota composition. It is unclear if the lower abundance of dietary fiber-fermenting, short-chain fatty acid-producing bacteria observed in hypertension also occurs in hypertensive disorders of pregnancy (HDP). This study investigated the relationship between dietary fiber intake and the gut microbiota profile at 28 weeks gestation in women who developed HDP in late pregnancy (n = 22) or remained normotensive (n = 152) from the Study of PRobiotics IN Gestational diabetes (SPRING). Dietary fiber intake was classified as above or below the median of 18.2 g/day. Gut microbiota composition was examined using 16S rRNA gene amplicon sequencing. The gut permeability marker zonulin was measured in a subset of 46 samples. In women with future HPD, higher dietary fiber intake was specifically associated with increased abundance of Veillonella, lower abundance of Adlercreutzia, Anaerotruncus and Uncl. Mogibacteriaceae and higher zonulin levels than normotensive women. Fiber intake and zonulin levels were negatively correlated in women with normotensive pregnancies but not in pregnancies with future HDP. In women with normotensive pregnancies, dietary fiber intake may improve gut barrier function. In contrast, in women who develop HDP, gut wall barrier function is impaired and not related to dietary fiber intake.
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Affiliation(s)
- Kate I. Tomsett
- School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia, QLD 4072, Australia;
| | - Helen L. Barrett
- Mater Medical Research Institute, The University of Queensland, South Brisbane, QLD 4001, Australia; (H.L.B.); (D.H.M.)
| | - Evelyn E. Dekker
- Queensland Academy for Science, Mathematics and Technology, Toowong, QLD 4066, Australia;
| | - Leonie K. Callaway
- Women’s and Newborns, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia;
| | - David H. McIntyre
- Mater Medical Research Institute, The University of Queensland, South Brisbane, QLD 4001, Australia; (H.L.B.); (D.H.M.)
| | - Marloes Dekker Nitert
- School of Chemistry and Molecular Biosciences, The University of Queensland, St Lucia, QLD 4072, Australia;
- Correspondence: ; Tel.: +61-7-3365-4633
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103
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Roth H, Homer CSE, LeMarquand G, Roberts LM, Hanley LI, Brown M, Henry A. Assessing Australian women's knowledge and knowledge preferences about long-term health after hypertensive disorders of pregnancy: a survey study. BMJ Open 2020; 10:e042920. [PMID: 33334841 PMCID: PMC7747529 DOI: 10.1136/bmjopen-2020-042920] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/02/2020] [Accepted: 11/27/2020] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To (1) assess women's current knowledge regarding long-term cardiovascular health after hypertensive disorders of pregnancy (2) elicit women's preferred educational content and format regarding health after hypertensive disorders of pregnancy. DESIGN AND SETTING A custom-created online survey exploring Australian women's knowledge about long-term health after hypertensive disorders of pregnancy, distributed through consumer groups and social media. PARTICIPANTS 266 women with (n=174) or without (n=92) a history of hypertensive disorders of pregnancy. PRIMARY AND SECONDARY OUTCOME MEASURES: (1) Proportion of women identifying long-term health risks after hypertensive disorder of pregnancy using a 10-point risk knowledge score with 0-4 'low', 4.1-7.0 'moderate' and 7.1-10 'high'. (2) Exploration of preferred content, format and distribution of educational material post hypertensive disorder of pregnancy. RESULTS Knowledge scores about health after hypertensive disorder of pregnancy were moderate in groups with and without a history of the disorder. Knowledge was highest regarding risk of recurrent hypertensive disorders in a subsequent pregnancy, 'moderate' for chronic hypertension and heart attack, 'moderate' and 'low' regarding risk of heart disease and 'low' for diabetes and renal disease. Only 36% of all participants were aware that risks start within 10 years after the affected pregnancy. The majority of respondents with a history of hypertensive disorder of pregnancy (76%) preferred receiving information about long-term health 0-6 months post partum from a healthcare provider (80%), key organisations (60%), social media (47%) and brochures/flyers (43%). CONCLUSIONS Women's knowledge regarding health risks after hypertensive disorder of pregnancy was 'moderate', although with important disease-specific gaps such as increased risk of diabetes. Most women wanted to be informed about their long-term health from a healthcare provider.
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Affiliation(s)
- Heike Roth
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Caroline S E Homer
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Maternal, Child and Adolescent Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Grace LeMarquand
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Lynne M Roberts
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Women's and Children's Health, Saint George Hospital, Sydney, New South Wales, Australia
| | - LIsa Hanley
- Maternity Consumer, Saint George Hospital, Sydney, New South Wales, Australia
| | - Mark Brown
- Renal Medicine, Saint George Hospital, Sydney, New South Wales, Australia
- St George & Sutherland Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Amanda Henry
- Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Women's and Children's Health, Saint George Hospital, Sydney, New South Wales, Australia
- The George Institute, Sydney, New South Wales, Australia
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104
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Roth H, Homer CSE, Arnott C, Roberts L, Brown M, Henry A. Assessing knowledge of healthcare providers concerning cardiovascular risk after hypertensive disorders of pregnancy: an Australian national survey. BMC Pregnancy Childbirth 2020; 20:717. [PMID: 33228597 PMCID: PMC7684922 DOI: 10.1186/s12884-020-03418-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 11/12/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) affect 5-10% of pregnant women. Women after HDP have 2-3 times increased risk of heart attack, stroke and diabetes, as soon as 5-10 years after pregnancy. Australian healthcare providers' knowledge of cardiovascular disease (CVD) risks for women after HDP is unknown, and this study aimed to explore their current knowledge and practice regarding long-term cardiovascular health after HDP, as a precursor to producing targeted healthcare provider education on health after HDP. METHODS A custom-created, face-validated online survey explored knowledge about long-term risks after HDP. Distribution occurred from February to July 2019 via professional colleges, key organisations and social media. The objective was to assess current knowledge and knowledge gaps amongst a group of healthcare providers (HCP) in Australia, regarding long-term cardiovascular health after hypertensive disorders of pregnancy (HDP), specifically gestational hypertension or preeclampsia. RESULTS Of 492 respondents, 203 were midwives, 188 obstetricians, 75 general practitioners (GP), and 26 cardiologists. A risk knowledge score was computed with 0-6 considered low, 6.1-8.9 moderate and 9-12 high. Most participants (85%) were aware of increased cardiovascular disease after preeclampsia and gestational hypertension (range 76% midwives to 100% cardiologists). There were significant differences in average knowledge scores regarding health after preeclampsia; high for cardiologists (9.3), moderate for GPs and obstetricians (8.2 and 7.6 respectively) and low for midwives (5.9). Average knowledge scores were somewhat lower for gestational hypertension (9.0 for cardiologists, 7.4 for obstetricians and GPs, 5.1 for midwives). Knowledge was highest regarding risk of chronic hypertension, moderate to high regarding risk of ischaemic heart disease, stroke and recurring HDP, and low for diabetes and peripheral vascular disease. Only 34% were aware that risks start < 10 years after the affected pregnancy. CONCLUSION(S) Participants were aware there is increased cardiovascular risk after HDP, although less aware of risks after gestational hypertension and some specific risks including diabetes. Findings will inform the development of targeted education.
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Affiliation(s)
- Heike Roth
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.
| | - Caroline S E Homer
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Burnet Institute, Maternal and Child Health, Melbourne, Victoria, Australia
| | - Clare Arnott
- The George Institute, Sydney, NSW, Australia.,Department of Cardiology, RPA, Sydney, NSW, Australia
| | - Lynne Roberts
- St George Hospital, Sydney, NSW, Australia.,St George & Sutherland Clinical School, UNSW, Sydney, NSW, Australia
| | - Mark Brown
- St George Hospital, Sydney, NSW, Australia.,St George & Sutherland Clinical School, UNSW, Sydney, NSW, Australia
| | - Amanda Henry
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,The George Institute, Sydney, NSW, Australia.,St George Hospital, Sydney, NSW, Australia.,School of Women's and Children's Health, UNSW Medicine, University of NSW, Sydney, NSW, Australia
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105
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Rudland VL, Price SAL, Hughes R, Barrett HL, Lagstrom J, Porter C, Britten FL, Glastras S, Fulcher I, Wein P, Simmons D, McIntyre HD, Callaway L. ADIPS 2020 guideline for pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:E18-E52. [PMID: 33200400 DOI: 10.1111/ajo.13265] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Accepted: 09/14/2020] [Indexed: 02/07/2023]
Abstract
This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The guideline encompasses the management of women with pre-existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis-related diabetes in relation to pregnancy is also discussed.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Victoria, Australia.,Mercy Hospital for Women, Melbourne, Victoria, Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | - Ruth Hughes
- Department of Obstetrics and Gynaecology, University of Otago, Christchurch, New Zealand
| | - Helen L Barrett
- Department of Endocrinology, Mater Health, Brisbane, Queensland, Australia.,Mater Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Janet Lagstrom
- Green St Specialists Wangaratta, Wangaratta, Victoria, Australia.,Denis Medical Yarrawonga, Yarrawonga, Victoria, Australia.,Corowa Medical Clinic, Corowa, New South Wales, Australia.,NCN Health, Numurkah, Victoria, Australia
| | - Cynthia Porter
- Geraldton Diabetes Clinic, Geraldton, Western Australia, Australia
| | - Fiona L Britten
- Department of Obstetric Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Mater Private Hospital and Mater Mother's Private Hospital, Brisbane, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Sarah Glastras
- Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.,Department of Diabetes, Endocrinology and Metabolism, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Ian Fulcher
- Liverpool Hospital, Sydney, New South Wales, Australia
| | - Peter Wein
- Mercy Hospital for Women, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, Victoria, Australia
| | - David Simmons
- Western Sydney University, Sydney, New South Wales, Australia.,Campbelltown Hospital, Sydney, New South Wales, Australia
| | - H David McIntyre
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Mater Health, Brisbane, Queensland, Australia
| | - Leonie Callaway
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Queensland, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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106
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Rudland VL, Price SAL, Callaway L. ADIPS position paper on pre-existing diabetes and pregnancy. Aust N Z J Obstet Gynaecol 2020; 60:831-839. [PMID: 33135798 DOI: 10.1111/ajo.13266] [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: 08/10/2020] [Accepted: 09/14/2020] [Indexed: 01/17/2023]
Abstract
This is an executive summary of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre-existing diabetes and pregnancy. The summary focuses on the main clinical practice points for the management of women with type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The full guideline is available at https://doi.org/10.1111/ajo.13265.
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Affiliation(s)
- Victoria L Rudland
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Sarah A L Price
- Department of Diabetes and Endocrinology, Royal Melbourne Hospital, Melbourne, Vic., Australia.,Department of Diabetes, Royal Women's Hospital, Melbourne, Vic., Australia.,Mercy Hospital for Women, Melbourne, Vic., Australia.,Faculty of Medicine, University of Melbourne, Melbourne, Vic., Australia
| | - Leonie Callaway
- Women's and Children's Services, Metro North Hospital and Health Service District, Brisbane, Qld, Australia.,Women's and Newborn Services, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Qld, Australia
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107
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Gleeson S, Lightstone L. Glomerular Disease and Pregnancy. Adv Chronic Kidney Dis 2020; 27:469-476. [PMID: 33328063 DOI: 10.1053/j.ackd.2020.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/04/2020] [Accepted: 08/04/2020] [Indexed: 12/28/2022]
Abstract
Nephrologists are routinely involved in the care of pregnant women with glomerulonephritis. Prepregnancy counseling is vital to inform women of the potential risks of pregnancy and to reduce those risks by optimizing clinical status and medications. In general, for all glomerulonephritides, the best pregnancy outcomes are achieved when the disease is in remission and the woman has preserved renal function with no proteinuria or hypertension. Each glomerulonephritis has specific considerations, for example in lupus nephritis, mycophenolate is teratogenic and must be stopped at least 6 weeks before conception, hydroxychloroquine is recommended for all pregnant women, and flares are frequently encountered and must be treated appropriately. De novo glomerulonephritis should be considered when significant proteinuria is found early in pregnancy or an acute kidney injury with active urine is encountered. Biopsy can be safely undertaken in the first trimester. Treatment is often with corticosteroids, azathioprine, and/or tacrolimus. Rituximab is increasingly used for severe disease. Women with glomerulonephritis should ideally be managed in a joint renal-obstetric clinic. This review details the approach to the care of women with glomerulonephritis from prepregnancy counseling, through antenatal care and delivery, to the postpartum period. Special attention is given to medications and treatment of glomerulonephritis in pregnancy.
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108
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Hogg P, Thompson M, Burgess J. The clinical expression and impact of multiple endocrine neoplasia 1 during pregnancy. Clin Endocrinol (Oxf) 2020; 93:429-438. [PMID: 32419214 DOI: 10.1111/cen.14252] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 04/29/2020] [Accepted: 05/08/2020] [Indexed: 01/18/2023]
Abstract
CONTEXT Multiple endocrine neoplasia type 1 (MEN 1) is characterized by multisystem neoplasia including primary hyperparathyroidism and pituitary adenoma. Despite the adolescent onset of endocrinopathies, information regarding the impact of maternal MEN 1 on pregnancy is limited to case reports. OBJECTIVE To explore pregnancy outcomes in MEN 1 positive women. METHODS Retrospective case series of maternofoetal outcomes MEN 1 positive mothers managed at the Royal Hobart Hospital between 1967 and 2018. Data were retrieved from medical records and Australian averages calculated based on the Australian Institute of Health and Welfare data. RESULTS Twenty-six women with MEN 1 were identified accounting for 96 pregnancies and 76 live born infants. Hyperparathyroidism was evident in 16 pregnancies. A significant increase in serum calcium in the second trimester (β = 0.14, P < .001) occurred that was not mediated by parathyroid hormone. Hypercalcaemia was mild-moderate with parathyroidectomy or medical management required in one and four pregnancies, respectively. Compared to the Australian average, women with MEN 1 were more likely to develop gestational diabetes (56% vs 8.9%, P = .001), hypertensive disorders (25.9% vs 7.6, P = .018), have shorter gestations (38.1 vs 38.7 weeks, P = .015) and have low birthweight infants (30.1% vs 6.5%, P = .001). However, emergency caesarean deliveries (63.2% vs 52.3%) and miscarriage rate (20.8% vs 20%) were not significantly different. CONCLUSION Maternal MEN 1 is associated with an increased risk of gestational diabetes, hypertensive disorders and low neonatal birthweight, but not with an increased miscarriage rate. Whilst hypercalcaemia worsens during the second trimester, most pregnancies progressed without overt complications or requirement for intervention.
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Affiliation(s)
- Prudence Hogg
- Department of General Medicine, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Michael Thompson
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
| | - John Burgess
- Department of Diabetes and Endocrinology, Royal Hobart Hospital, Hobart, Tasmania, Australia
- School of Medicine, University of Tasmania, Hobart, Tasmania, Australia
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109
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Tamanna S, Clifton VL, Rae K, van Helden DF, Lumbers ER, Pringle KG. Angiotensin Converting Enzyme 2 (ACE2) in Pregnancy: Preeclampsia and Small for Gestational Age. Front Physiol 2020; 11:590787. [PMID: 33101066 PMCID: PMC7554608 DOI: 10.3389/fphys.2020.590787] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 09/09/2020] [Indexed: 01/14/2023] Open
Abstract
Introduction An imbalance in angiotensin (Ang) peptides could contribute to the pathophysiology of preeclampsia (PE) and poor fetal growth. Methods We measured maternal plasma levels of Ang peptides and converting enzymes in non-pregnant women (n = 10), in normal pregnant women (n = 59), women delivering small for gestational age babies (SGA, n = 25) across gestation (13–36 weeks) and in women with PE (n = 14) in their third trimester. Results Plasma ACE, ACE2, and Ang-(1-7) levels, and ACE2 activity were significantly higher in normal pregnant women compared with non-pregnant women; neprilysin (NEP) levels were not changed. In SGA pregnancies, ACE and ACE2 levels were higher in early-mid pregnancy compared with normal pregnant women. In women with PE, plasma ACE, ACE2, NEP, and Ang-(1-7) levels and ACE2 activity were lower than levels in normal pregnant women. Conclusion The higher plasma ACE2 levels and activity in pregnancy could be driving the higher Ang-(1-7) levels. The early gestation increases in ACE and ACE2 levels in SGA pregnancies highlights the possibility that these enzymes could be used as potential early biomarkers of poor fetal growth. In women with PE, the reduced ACE2 and NEP levels at term, could be contributing to the reduction in Ang-(1-7) levels. These findings suggest that dysfunctional relationships between two key enzymes in the circulating RAS are involved in the pathogenesis of PE and SGA. Since soluble ACE2 can prevent binding of the novel coronavirus, SARS-CoV-2, to membrane bound ACE2, the interplay between ACE2 and the coronavirus and its impact in pregnancy requires further investigation.
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Affiliation(s)
- Sonia Tamanna
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle, NSW, Australia.,School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Pregnancy and Reproduction Program, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Vicki L Clifton
- Robinson Research Institute, School of Medicine, University of Adelaide, Adelaide, SA, Australia.,Mater Medical Research Institute and Translational Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Kym Rae
- Mater Medical Research Institute and Translational Research Institute, University of Queensland, Brisbane, QLD, Australia
| | - Dirk F van Helden
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Eugenie R Lumbers
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle, NSW, Australia.,School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Pregnancy and Reproduction Program, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Kirsty G Pringle
- Priority Research Centre for Reproductive Sciences, University of Newcastle, Newcastle, NSW, Australia.,School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia.,Pregnancy and Reproduction Program, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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110
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Garti I, Gray M, Tan JY, Bromley A. Midwives' knowledge of pre-eclampsia management: A scoping review. Women Birth 2020; 34:87-104. [PMID: 32928690 DOI: 10.1016/j.wombi.2020.08.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 08/31/2020] [Accepted: 08/31/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Pre-eclampsia is a multi-organ disease affecting pregnant women from the second trimester onwards resulting in multiple adverse outcomes. Sub-optimal treatment of pre-eclampsia is linked with unfavorable outcomes. It is critical for midwives as primary providers to be competent in the diagnosis and management of pre-eclampsia especially in low-and middle-income countries. AIM To identify what midwives' around the world know about pre-eclampsia management. METHODS A scoping review using the JBI three-step search strategy was used to identify relevant research articles and grey literature on the subject. Database searches in PubMed, CINAHL, Cochrane Databases, Web of Science, and Scopus yielded twenty papers in addition to nine guidelines from Google Scholar. The findings were synthesised using a metasynthesis approach and presented as themes. FINDINGS Four themes were identified from the extracted data: Foundational knowledge of pre-eclampsia; Knowledge and management of a woman with pre-eclampsia according to guidelines; Knowledge of being prepared for emergency procedures and management of emergencies; Factors influencing knowledge. The first three themes addressed diagnosis and management whilst the last theme described how contextual factors led to either increased or decreased knowledge of pre-eclampsia. CONCLUSION Worldwide, practicing midwives lack knowledge on several aspects of pre-eclampsia diagnosis and care. Policies on in-service training should be oriented to include innovative non-traditional methods that have the potential to increase midwives' knowledge.
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Affiliation(s)
- Isabella Garti
- College of Nursing and Midwifery, Charles Darwin University, Darwin, Australia.
| | - Michelle Gray
- College of Nursing and Midwifery, Charles Darwin University, Darwin, Australia
| | - Jing-Yu Tan
- College of Nursing and Midwifery, Charles Darwin University, Darwin, Australia
| | - Angela Bromley
- College of Nursing and Midwifery, Charles Darwin University, Darwin, Australia
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111
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Yuan N, Sun J, Li Z, Chai S, Zhang X, Ji L. Relationship between anti-thyroid peroxidase antibody positivity and pregnancy-related and fetal outcomes in Euthyroid women: a single-center cohort study. BMC Pregnancy Childbirth 2020; 20:491. [PMID: 32847542 PMCID: PMC7449005 DOI: 10.1186/s12884-020-03176-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Thyroid autoimmunity (TAI) and subclinical hypothyroidism (SCH) have been associated with poor pregnancy and fetal outcomes. However, whether euthyroid women with anti-thyroid peroxidase antibody (TPOAb) positivity have a higher risk of poor pregnancy and fetal outcomes is debatable. Therefore, this study aimed to investigate the association between TPOAb positivity and pregnancy-related and fetal outcomes in euthyroid women. METHODS In total, 938 pregnant women participated in this prospective cohort study. The euthyroid group included 837 pregnant women and the TPOAb-positive group included 101 euthyroid pregnant women. Serum TPOAb, thyroglobulin antibody (TGAb), thyroid-stimulating hormone (TSH), and free thyroxine (FT4) levels were assessed. Pregnancy and fetal outcomes included gestational diabetes mellitus, spontaneous abortion, premature rupture of membranes, hypertensive disorders of pregnancy, preterm birth, fetal distress, low birth weight, fetal macrosomia, and small for gestational age infant. RESULTS Logistic regression analysis showed TPOAb positivity was not associated with an increased risk of poor pregnancy or fetal outcomes in euthyroid women. However, TPOAb-positive euthyroid women pregnant with a female fetus were independently associated with preterm births (OR: 4.511, 95% CI: 1.075-18.926) after adjustment for potential confounding factors. CONCLUSIONS TPOAb positivity was not found to be associated with poor pregnancy-related or fetal outcomes in euthyroid women. However, in euthyroid women with a female fetus, TPOAb positivity was strongly associated with preterm births. The risk of preterm birth in the euthyroid women with TPOAb positivity should be emphasized in clinical practice. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02966405 . Registered on October 24th 2016 - Retrospectively registered.
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Affiliation(s)
- Ning Yuan
- Department of Endocrinology, Peking University People's Hospital, Beijing, 100044, China
| | - Jianbin Sun
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China
| | - Zhi Li
- Department of gynaecology and obstetrics, Peking University International Hospital, Beijing, 102206, China
| | - Sanbao Chai
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China
| | - Xiaomei Zhang
- Department of Endocrinology, Peking University International Hospital, Beijing, 102206, China.
| | - Linong Ji
- Department of Endocrinology, Peking University People's Hospital, Beijing, 100044, China.
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112
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Meazaw MW, Chojenta C, Muluneh MD, Loxton D. Factors associated with hypertensive disorders of pregnancy in sub-Saharan Africa: A systematic and meta-analysis. PLoS One 2020; 15:e0237476. [PMID: 32813709 PMCID: PMC7437911 DOI: 10.1371/journal.pone.0237476] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 07/27/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy (HDP) are common complications of pregnancy globally, including sub-Saharan African (SSA) countries. Although it has a high burden of maternal and neonatal mortality and morbidity, evidence on the risk of the problem is limited. Therefore, the aim of this review was to systematically examine factors associated with HDP among women in SSA countries. METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was followed. Articles conducted in SSA and published in English from January 2000 to May 2020 from electronic databases including MEDLINE, EMBASE, PubMed, and CINAHL were included. Articles, which focused on HDP and found to be relevant through the reference check, were included. Additional articles found through a hand search of reference lists were also included. The quality of papers was appraised using the Critical Appraisal Skills Programme (CASP) scale. Two reviewers independently screened, extracted, and assessed the quality of the articles. STATA 16 software was used to compute the pooled estimated odds ratios for each of the identified associated factor. Both random and fixed effect models were used for analysis. Heterogeneity of the studies and small study bias were checked by I2 and asymmetric test, respectively. RESULTS Twenty-seven studies met the inclusion criteria and included in the systematic review and meta-analysis. Significant associations with HDP were identified through meta-analysis for the following variables: being primiparous (OR: 1.78; 95% CI: 1.11, 2.44), having previous HDP (OR: 3.75; 95% CI: 2.05, 5.45), family history of HDP (OR: 2.73; 95% CI: 1.85, 3.6), and lower maternal educational level (OR: 1.65; 95% CI: 1.17, 2.13). Due to the limited number of studies found specific to each variable, there was inconclusive evidence for a relationship with a number of factors, such as maternal nutrition, antenatal care visits, birth spacing, multiple birth, physical activity during pregnancy, use of contraceptives, place of residency, family size, and other related associated factors. CONCLUSIONS The risk of developing HDP is worse among women who have a history of HDP (either themselves or their family), are primiparous, or have a lower maternal educational level. Therefore, investment in women's health needs considered to reduce the problem, and health service providers need to give due attention to women with at increased risk to HDP. Additionally, interventions need to focus on increasing women's access to education and their awareness of potential associated factors for HDP.
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Affiliation(s)
- Maereg Wagnew Meazaw
- Federal Ministry of Health, Addis Ababa, Ethiopia
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Catherine Chojenta
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
| | - Muluken Dessalegn Muluneh
- School of Nursing and Midwifery, Western Sydney University, Parramatta, Australia
- Amref Health Africa in Ethiopia, Addis Ababa, Ethiopia
| | - Deborah Loxton
- Research Centre for Generational Health and Ageing, School of Medicine and Public Health, Faculty of Health and Medicine, University of Newcastle, Newcastle, Australia
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113
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Hutchesson MJ, Taylor R, Shrewsbury VA, Vincze L, Campbell LE, Callister R, Park F, Schumacher TL, Collins CE. Be Health e for Your Heart: A Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women with a History of Preeclampsia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17165779. [PMID: 32785044 PMCID: PMC7459885 DOI: 10.3390/ijerph17165779] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/06/2020] [Accepted: 08/07/2020] [Indexed: 01/07/2023]
Abstract
This pilot randomized controlled trial (RCT) aimed to determine the acceptability and preliminary efficacy of a web-based cardiovascular disease (CVD) prevention intervention for women following preeclampsia. Australian women with a recent history (≤4 years post diagnosis) of preeclampsia were randomized into two study arms: (1) Be Healthe for your Heart, a web-based behavioral intervention or; (2) Control, access to the National Heart Foundation website. Assessments were conducted at baseline, and after three months. Intervention acceptability and impact on absolute CVD 30-year risk score, CVD risk markers and health behaviors were assessed. Twenty-four of 31 (77.4%) women completed the three-month assessment. Eleven out of 13 intervention participants (84.6%) agreed/strongly agreed they were satisfied with the program, with a mean score of 4.2 ± 0.9 (maximum of five). There were no significant between or within group differences in absolute CVD risk, CVD risk markers or health behaviors from baseline to three months. Women with a history of preeclampsia were successfully recruited and retained and they reported high levels of acceptability with the Be Healthe for your Heart program. Further research is therefore needed from powered trials to determine the impact of web-based lifestyle interventions on CVD risk in this at-risk group.
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Affiliation(s)
- Melinda J. Hutchesson
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
- Correspondence:
| | - Rachael Taylor
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
| | - Vanessa A. Shrewsbury
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
| | - Lisa Vincze
- School of Allied Health Sciences & Menzies Health Institute Queensland, Griffith University, Gold Coast, QLD 4222, Australia;
| | - Linda E. Campbell
- School of Psychology, Faculty of Science, The University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Robin Callister
- Priority Research Centre for Physical Activity and Nutrition, School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia;
| | - Felicity Park
- Department of Maternal Foetal Medicine, John Hunter Hospital, Newcastle, NSW 2305, Australia;
| | - Tracy L. Schumacher
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
- Priority Research Centre for Health Behaviours, Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW 2340, Australia
| | - Clare E. Collins
- Priority Research Centre for Physical Activity and Nutrition, School of Health Sciences, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia; (R.T.); (V.A.S.); (T.L.S.); (C.E.C.)
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114
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Liu X, Gong Y. The Potential Protective Role of Aspirin Against Migraine in Pregnant Women. Med Sci Monit 2020; 26:e923959. [PMID: 32740647 PMCID: PMC7431385 DOI: 10.12659/msm.923959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Females are highly predisposed to the occurrence of migraine, a recurrent neurovascular headache disorder. Although migraine improves or disappears during pregnancy, a significant association between migraine and hypertension (i.e., pre-eclampsia) or vascular complications (i.e., stroke) during gestation has been determined. Low-dose aspirin exerts an antithrombotic effect and can improve vascular resistance by regulating endothelial function, which are implicated in the pathogenesis of migraine, pre-eclampsia, and other vascular complications during pregnancy. Low-dose aspirin is widely used prophylactically in the general population who are at higher risk of developing stroke or in pregnant women at higher risk of pre-eclampsia. In this paper we discuss the recent trends in research on the relationship between migraine and pre-eclampsia, an issue of paramount importance in obstetric care, and the potential relationship between migraine and vascular complications in pregnant women. In addition, the potential validity of low-dose aspirin prophylaxis in pregnant women with migraine is explored.
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Affiliation(s)
- Xijing Liu
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) of Ministry of Education, Chengdu, Sichuan, China (mainland)
| | - Yunhui Gong
- Department of Obstetrics and Gynecology, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China (mainland).,Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) of Ministry of Education, Chengdu, Sichuan, China (mainland)
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115
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Ngene NC, Moodley J. Pre-eclampsia with severe features: management of antihypertensive therapy in the postpartum period. Pan Afr Med J 2020; 36:216. [PMID: 32963682 PMCID: PMC7490136 DOI: 10.11604/pamj.2020.36.216.19895] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 02/21/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction there is variance in both the types and combinations of antihypertensive drugs used for managing pre-eclampsia in the postpartum period. Knowledge of the most common and suitable single or combination antihypertensive drug therapies in the postpartum period will minimize harmful effects, promote adherence to medications, overcome any fears that lactating mothers may have about these drugs and will assist in healthcare planning. Objective: to determine the types of antihypertensive drug therapies used in managing pre-eclampsia with severe features (sPE) in the postpartum period in a regional hospital in South Africa. Methods fifty consecutively presenting pregnant women with sPE were followed up prospectively from the pre-delivery period (within 48 hours before delivery) until day 3 postpartum. The antihypertensive drug therapies administered to the participants were observed. Their blood pressures were measured daily at 04: 00, 08: 00, 14: 00 and 22: 00 hours. Results nifedipine was the commonest rapid-acting agent used for severe hypertension. Prepartum, 9 different combinations of antihypertensive drugs were prescribed; alpha-methyldopa was the commonest single long-acting agent used. Postpartum, the number of different drug combinations administered were 15, 18, 22 and 16 on days 0, 1, 2 and 3 respectively. Alpha-methyldopa was the commonest single agent used on postpartum days 0 - 2 while hydrochlorothiazide was the most frequently used single agent on postpartum day 3. Postpartum, the commonest combination therapy was alpha-methyldopa and amlodipine on day 0; alpha-methyldopa and amlodipine as a regimen as well as alpha-methyldopa, amlodipine and hydrochlorothiazide as another regimen on day 1; alpha-methyldopa and amlodipine on day 2; and many amlodipine-based regimens on day 3. Conclusion a variety of antihypertensive drug combinations were used in the postpartum period indicating the need for standardised guidelines; however, detailed studies are required to evaluate their efficacies completely.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa.,Department of Obstetrics and Gynaecology, Klerksdorp Hospital, North West Province, Klerksdorp, South Africa.,Department of Obstetrics and Gynaecology, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jagidesa Moodley
- Department of Obstetrics and Gynaecology, University of KwaZulu-Natal, Durban, South Africa
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116
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Henry A, Arnott C, Makris A, Davis G, Hennessy A, Beech A, Pettit F, Se Homer C, Craig ME, Roberts L, Hyett J, Chambers G, Fitzgerald O, Gow M, Mann L, Challis D, Gale M, Ruhotas A, Kirwin E, Denney-Wilson E, Brown M. Blood pressure postpartum (BP 2) RCT protocol: Follow-up and lifestyle behaviour change strategies in the first 12 months after hypertensive pregnancy. Pregnancy Hypertens 2020; 22:1-6. [PMID: 32679537 DOI: 10.1016/j.preghy.2020.07.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 07/02/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Women who had hypertensive disorders of pregnancy (HDP) are twice as likely to experience maternal cardiovascular disease later in life. The primary aim of this study (BP2) is to compare outcomes of 3 different management strategies, including lifestyle behaviour change (LBC), in the first 12 months postpartum in women who had HDP in their preceding pregnancy. Secondary aims include assessing the effects on other cardiometabolic parameters. STUDY DESIGN Three-arm multicentre randomised trial in metropolitan Australian hospitals, (registration: ACTRN12618002004246) target sample size 480. Participants are randomised to one of three groups: 1) Optimised usual care: information package and family doctor follow-up 6 months postpartum 2) Brief intervention: information package as per group 1, plus assessment and brief LBC counselling at a specialised clinic with an obstetric physician and dietitian 6 months postpartum 3) Extended intervention: as per group 2 plus enrolment into a 6 month telephone-based LBC program from 6 to 12 months postpartum. All women have an outcome assessment at 12 months. MAIN OUTCOME MEASURES Primary outcomes: (a) BP change or (b) weight change and/or waist circumference change. SECONDARY OUTCOMES maternal health-related quality of life, engagement and retention in LBC program, biochemical markers, vascular function testing, infant weight trajectory, incremental cost-effectiveness ratios. The study is powered to detect a 4 mmHg difference in systolic BP between groups, or a 4 kg weight loss difference/2cm waist circumference change. CONCLUSIONS BP2 will provide evidence regarding the feasibility and effectiveness of postpartum LBC interventions and structured clinical follow-up in improving cardiovascular health markers after HDP.
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Affiliation(s)
- Amanda Henry
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia; Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia; The George Institute for Global Health, Sydney, Australia.
| | - Clare Arnott
- The George Institute for Global Health, Sydney, Australia; Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Faculty of Medicine, University of New South Wales, Sydney, Australia; Sydney Medical School, University of Sydney, Australia
| | - Angela Makris
- Faculty of Medicine, University of New South Wales, Sydney, Australia; School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Gregory Davis
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia; Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia
| | - Annemarie Hennessy
- School of Medicine, Western Sydney University, Campbelltown, New South Wales, Australia
| | - Amanda Beech
- Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Franziska Pettit
- Department of Renal Medicine, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Caroline Se Homer
- Burnet Institute, Melbourne, Victoria, Australia; Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Maria E Craig
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia; Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia
| | - Lynne Roberts
- Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia
| | - Jon Hyett
- Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia; Sydney Medical School, University of Sydney, Australia
| | - Georgina Chambers
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health and Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Oisin Fitzgerald
- National Perinatal Epidemiology and Statistics Unit, School of Women's and Children's Health and Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW, Australia
| | - Megan Gow
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Linda Mann
- General Practitioner, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Daniel Challis
- School of Women's and Children's Health, UNSW Medicine, University of New South Wales, Sydney, Australia; Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Marianne Gale
- New South Wales Ministry of Health, North Sydney, New South Wales, Australia
| | - Annette Ruhotas
- Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia
| | - Emilee Kirwin
- Women's and Children's Health, St George Hospital, Kogarah, New South Wales, Australia
| | | | - Mark Brown
- Department of Renal Medicine, St George Hospital, Kogarah, New South Wales, Australia; St George and Sutherland Clinical School, UNSW Medicine, University of New South Wales, Sydney, Australia
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117
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Fyfe R, Burton A, McLennan A, McCudden L, Gordon A, Hyett J. Factors affecting cord blood leptin levels in a consecutive birth cohort. J Matern Fetal Neonatal Med 2020; 35:884-889. [PMID: 32594793 DOI: 10.1080/14767058.2020.1733518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Introduction: The fetus that fails to meet its ideal growth trajectory has increased risks of poor health outcomes throughout life. "Gold standard" methods of anthropometric assessment such as measurement of percentage body fat can be difficult to apply across populations and other biomarkers such as serum concentration of umbilical cord blood leptin may be more effective for screening. This study reports cord blood leptin levels in a large prospective consecutive birth cohort and assesses the relationship between leptin and neonatal and maternal factors.Methods: Venous umbilical cord blood samples were collected from a prospective consecutive cohort of pregnancies at the time of delivery. Maternal and neonatal characteristics and details of delivery were collated. Serum leptin levels were measured, associations with demographic features were identified, and a normal range was established. The association between cord leptin level and neonatal outcome was tested.Results: Umbilical cord leptin and maternal and neonatal characteristics were collected at 1275 births. The median leptin value was 10.8 ng/ml (IQR: 6.4, 17.8 ng/ml). Log10 leptin was significantly associated with gestation at delivery, birthweight (BWt), infant sex, plurality, and maternal body mass index (BMI) (p < .001). Observed leptin values were expressed as multiples of the median (MoM). The mean leptin MoM was significantly lower in infants admitted to NICU following delivery (0.85; 95% confidence interval [CI]: 0.78-0.91 versus 1.05; 95% CI: 1.03-1.06 (controls), p < .001). There was no significant association between leptin MoM values and 5-min Apgar scores.Conclusions: Neonatal cord leptin levels are influenced by a number of maternal and fetal characteristics. Absolute levels can be adjusted to account for normal population variation. Infants requiring admission to NICU have lower mean leptin MoM levels. Further studies are needed to see whether the identification of fetuses with polarized leptin levels (<5th or >95th centile) will benefit from further surveillance or intervention in infancy.
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Affiliation(s)
- Rina Fyfe
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia.,Department of Obstetrics and Gynaecology, University of Newcastle, Newcastle, Australia
| | - Alice Burton
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia
| | - Andrew McLennan
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Lucy McCudden
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia
| | - Adrienne Gordon
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, Australia
| | - Jon Hyett
- Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia.,Discipline of Obstetrics, Gynaecology and Neonatology, Faculty of Medicine, University of Sydney, Sydney, Australia
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118
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Comparisons of Dipstick Test, Urine Protein-to-Creatine Ratio, and Total Protein Measurement for the Diagnosis of Preeclampsia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124195. [PMID: 32545523 PMCID: PMC7344421 DOI: 10.3390/ijerph17124195] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/05/2020] [Accepted: 06/10/2020] [Indexed: 01/21/2023]
Abstract
Preeclampsia affects 2–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality. We aimed to extensively evaluate proteinuria in women with preeclampsia and to determine the analytical sensitivity and specificity of and the cutoff values for urine protein-to-creatinine ratio (UPCR) and total protein in 24 h urine samples. This study included 88 women. We used the urine dipstick test, UPCR, and total protein measurement in a 24 h urine sample. The patients were divided in gestational hypertension (GH, n = 44) and preeclampsia (PE, n = 44) groups. In the GH group, 25% (11/44) of the patients presented incidentally positive results. UPCR and total protein in 24 h urine specimens were increased in the GH group compared to the PE group. Receiver operating characteristic analysis showed a UPCR cutoff of 30 mg/mmol as significant for preeclampsia, while the sensitivity and specificity were 89% (95% CI, 75–97) and 100% (95% CI, 87–100), respectively. In the 24 h urine protein test, sensitivity and specificity were 80% (95% CI, 61–92) and 100% (95% CI, 88–100), respectively, for the cutoff value of 0.26 g/24 h. In comparison to the other commonly used tests here considered, UPCR determination is a reliable, relatively faster, and equally accurate method for the quantitation of proteinuria, correlates well with 24 h urine protein estimations, and could be used as an alternative to the 24 h proteinuria test for the diagnosis of preeclampsia.
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119
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Reddy M, Rolnik DL, Harris K, Li W, Mol BW, Da Silva Costa F, Wallace EM, Palmer K. Challenging the definition of hypertension in pregnancy: a retrospective cohort study. Am J Obstet Gynecol 2020; 222:606.e1-606.e21. [PMID: 31954700 DOI: 10.1016/j.ajog.2019.12.272] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND In routine antenatal care, blood pressure is used as a screening tool for preeclampsia and its associated adverse outcomes. As such women with a blood pressure greater than 140/90 mm Hg undergo further investigation and closer follow-up, whereas those with lower blood pressures receive no additional care. In the nonpregnant setting, the American College of Cardiology now endorses lower hypertensive thresholds and it remains unclear whether these lower thresholds should also be considered in pregnancy. OBJECTIVE (1) To examine the association between lower blood pressure thresholds (as per the American College of Cardiology guidelines) and pregnancy outcomes and (2) to determine whether there is a continuous relationship between blood pressure and pregnancy outcomes and identify the point of a change at which blood pressure is associated with an increased risk of such outcomes. STUDY DESIGN This was a retrospective study of singleton pregnancies at Monash Health, Australia. Data were obtained with regards to maternal characteristics and blood pressure measurements at varying gestational ages. Blood pressures were then categorized as (1) mean arterial pressure and (2) normal, elevated, stage 1 and stage 2 hypertension, as per the American College of Cardiology guidelines. Multivariable regression analysis was performed to identify associations between blood pressure categories and pregnancy outcomes. RESULTS This study included 18,243 singleton pregnancies. We demonstrated a positive dose-response relationship between mean arterial pressure and the development of preeclampsia in later pregnancy. Across all gestational ages, the risk of preeclampsia was greater in those with "elevated blood pressure" and "stage 1 hypertension" in comparison with the normotensive group (adjusted risk ratio; 2.45, 95% confidence interval, 1.74-3.44 and adjusted risk ratio, 6.60; 95% confidence interval, 4.98-8.73 respectively, at 34-36 weeks' gestation). There was also an association between stage 1 hypertension, preterm birth, and adverse perinatal outcomes. CONCLUSION This study demonstrated that preeclampsia and the associated adverse outcomes are not exclusive to those with blood pressures greater than 140/90 mm Hg. As such, those with prehypertensive blood pressures may also benefit from closer monitoring. Further research is essential to determine whether lowering the blood pressure threshold in pregnancy would improve detection and outcomes.
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Affiliation(s)
- Maya Reddy
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia; Monash Women's, Monash Health, Melbourne, Victoria, Australia.
| | - Daniel Lorber Rolnik
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia; Monash Women's, Monash Health, Melbourne, Victoria, Australia
| | - Katrina Harris
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Wentao Li
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Ben Willem Mol
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Fabricio Da Silva Costa
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia; Department of Gynecology and Obstetrics, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Euan M Wallace
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia
| | - Kirsten Palmer
- Ritchie Centre, Department of Obstetrics and Gynaecology, School of Clinical Sciences, Monash University, Victoria, Australia; Monash Women's, Monash Health, Melbourne, Victoria, Australia
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120
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Unger T, Borghi C, Charchar F, Khan NA, Poulter NR, Prabhakaran D, Ramirez A, Schlaich M, Stergiou GS, Tomaszewski M, Wainford RD, Williams B, Schutte AE. 2020 International Society of Hypertension Global Hypertension Practice Guidelines. Hypertension 2020; 75:1334-1357. [PMID: 32370572 DOI: 10.1161/hypertensionaha.120.15026] [Citation(s) in RCA: 1643] [Impact Index Per Article: 410.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Thomas Unger
- From the CARIM - School for Cardiovascular Diseases, Maastricht University, the Netherlands (T.U.)
| | - Claudio Borghi
- Department of Medical and Surgical Sciences, University of Bologna, Italy (C.B.)
| | - Fadi Charchar
- Federation University Australia, School of Health and Life Sciences, Ballarat, Australia (F.C.).,University of Melbourne, Department of Physiology, Melbourne, Australia (F.C.).,University of Leicester, Department of Cardiovascular Sciences, United Kingdom (F.C.)
| | - Nadia A Khan
- University of British Columbia, Vancouver, Canada (N.A.K.).,Center for Health Evaluation and Outcomes Sciences, Vancouver, Canada (N.A.K.)
| | - Neil R Poulter
- Imperial Clinical Trials Unit, Imperial College London, United Kingdom (N.R.P.)
| | - Dorairaj Prabhakaran
- Public Health Foundation of India, New Delhi, India (D.P.).,Centre for Chronic Disease Control, New Delhi, India (D.P.).,London School of Hygiene and Tropical Medicine, United Kingdom (D.P.)
| | - Agustin Ramirez
- Hypertension and Metabolic Unit, University Hospital, Favaloro Foundation, Buenos Aires, Argentina (A.R.)
| | - Markus Schlaich
- Dobney Hypertension Centre, School of Medicine, Royal Perth Hospital Unit, University of Western Australia, Perth (M.S.).,Neurovascular Hypertension & Kidney Disease Laboratory, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia (M.N.)
| | - George S Stergiou
- Hypertension Center STRIDE-7, School of Medicine, Third Department of Medicine, Sotiria Hospital, National and Kapodistrian University of Athens, Greece (G.S.S.)
| | - Maciej Tomaszewski
- Division of Cardiovascular Sciences, Faculty of Medicine, Biology and Health, University of Manchester, United Kingdom (M.T.).,Division of Medicine and Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust Manchester, United Kingdom (M.T.)
| | - Richard D Wainford
- Department of Pharmacology and Experimental Therapeutics, Boston University School of Medicine, MA (R.D.W.).,The Whitaker Cardiovascular Institute, Boston University, MA (R.D.W.).,Department of Health Sciences, Boston University Sargent College, MA (R.D.W.)
| | - Bryan Williams
- University College London, NIHR University College London, Hospitals Biomedical Research Centre, London, United Kingdom (B.W.)
| | - Aletta E Schutte
- Faculty of Medicine, University of New South Wales, Sydney, Australia (A.E.S.).,The George Institute for Global Health, Sydney, Australia (A.E.S.).,Hypertension in Africa Research Team (A.E.S.), North-West University, Potchefstroom, South Africa.,South African MRC Unit for Hypertension and Cardiovascular Disease (A.E.S.), North-West University, Potchefstroom, South Africa
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Li P, Xiong T, Hu Y. Hypertensive disorders of pregnancy and risk of asthma in offspring: protocol for a systematic review and meta-analysis. BMJ Open 2020; 10:e035145. [PMID: 32276955 PMCID: PMC7170635 DOI: 10.1136/bmjopen-2019-035145] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 03/21/2020] [Accepted: 03/23/2020] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP), one of the most common obstetrical complications, has been reported to have a controversial relationship with the increased risk of asthma in offspring. No systematic review of this topic has been performed. The aim of this systematic review will be to summarise the available evidence examining the association between HDP and the risk of asthma in offspring. METHODS AND ANALYSIS We will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Meta-analysis of Observational Studies in Epidemiology guidelines. A systematic search of the PubMed, Embase, Cochrane and Web of Science databases will be performed using a detailed search strategy from database inception through 31 December 2019. Cohort, case-control and cross-sectional studies that report a diagnosis of maternal HDP and asthma in offspring will be included. Studies will be limited to the English language and include only human participants. Two independent reviewers will conduct the study selection, data extraction and risk of bias assessments using a standardised data extraction form. A meta-analysis will be performed to calculate overall pooled estimates using the generic inverse variance method. The data will be synthesised by either fixed-effect or random effects models according to heterogeneity tests. All analyses will be performed in Stata 14 and RevMan 5.3. High-quality evidence of the relationship between HDP and the risk of asthma in exposed offspring will be identified through the synthesis of current studies. In addition, the results of subgroup analyses and related secondary outcomes will be reported. The following will be concluded: (i) whether HDP increases the risk of asthma in offspring, (ii) whether HDP affects the severity of asthma in exposed offspring and (iii) whether possible differences in the risk of asthma among different HDP subgroups exist. ETHICS AND DISSEMINATION There is no requirement for ethics approval because the meta-analysis and systematic review will be based on published data. It is anticipated that the dissemination of results will take place at conferences and through publication in a peer-reviewed journal.
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Affiliation(s)
- Ping Li
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
| | - Tao Xiong
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
- Deep Underground Space Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yong Hu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University) Ministry of Education, Chengdu, China
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122
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Mönckeberg M, Arias V, Fuenzalida R, Álvarez S, Toro V, Calvo A, Kusanovic JP, Monteiro LJ, Schepeler M, Nien JK, Martinez J, Illanes SE. Diagnostic Performance of First Trimester Screening of Preeclampsia Based on Uterine Artery Pulsatility Index and Maternal Risk Factors in Routine Clinical Use. Diagnostics (Basel) 2020; 10:E182. [PMID: 32225087 PMCID: PMC7235780 DOI: 10.3390/diagnostics10040182] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/26/2020] [Accepted: 03/04/2020] [Indexed: 01/18/2023] Open
Abstract
Preeclampsia is a pregnancy-specific disorder defined by new onset of hypertension and proteinuria after 20 weeks of gestation. The early detection of patients at risk of developing preeclampsia is crucial, however, predictive models are still controversial. We aim to evaluate the diagnostic performance of a predictive algorithm in the first trimester of pregnancy, in order to identify patients that will subsequently develop preeclampsia, and to study the effect of aspirin on reducing the rate of this complication in patients classified as high risk by this algorithm. A retrospective cohort including 1132 patients attending prenatal care at Clínica Dávila in Santiago, Chile, was conceived. The risk of developing preeclampsia (early and late onset) was calculated using algorithms previously described by Plasencia et al. Patients classified as high risk, in the first trimester of pregnancy, by these algorithms, were candidates to receive 100 mg/daily aspirin as prophylaxis at the discretion of the attending physician. The overall incidence of preeclampsia in this cohort was 3.5% (40/1132), and the model for early onset preeclampsia prediction detected 33% of patients with early onset preeclampsia. Among the 105 patients considered at high risk of developing preeclampsia, 56 received aspirin and 49 patients did not. Among those who received aspirin, 12% (7/56) developed preeclampsia, which is equal to the rate of preeclampsia (12% (6/49)) of those who did not receive this medication. Therefore, the diagnostic performance of an algorithm combining uterine artery Doppler and maternal factors in the first trimester predicted only one third of patients that developed preeclampsia. Among those considered at high risk for developing the disease using this algorithm, aspirin did not change the incidence of preeclampsia, however, this could be due either to the small study sample size or the type of the study, a retrospective, non-interventional cohort study.
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Affiliation(s)
- Max Mönckeberg
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (M.S.); (J.K.N.)
| | - Valentina Arias
- Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (V.A.); (R.F.); (V.T.); (A.C.)
| | - Rosario Fuenzalida
- Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (V.A.); (R.F.); (V.T.); (A.C.)
| | - Santiago Álvarez
- Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (V.A.); (R.F.); (V.T.); (A.C.)
| | - Victoria Toro
- Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (V.A.); (R.F.); (V.T.); (A.C.)
| | - Andrés Calvo
- Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (V.A.); (R.F.); (V.T.); (A.C.)
| | - Juan P. Kusanovic
- Center for Research and Innovation in Maternal-Fetal Medicine (CIMAF), Hospital Sótero del Río, Santiago 8207257, Chile;
- Division of Obstetrics and Gynecology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8331150, Chile
| | - Lara J. Monteiro
- Centre for Biomedical Research, Laboratory of Reproductive Biology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile;
| | - Manuel Schepeler
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (M.S.); (J.K.N.)
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago 8420384, Chile;
| | - Jyh K. Nien
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (M.S.); (J.K.N.)
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago 8420384, Chile;
| | - Jaime Martinez
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago 8420384, Chile;
| | - Sebastián E. Illanes
- Department of Obstetrics and Gynecology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile; (M.M.); (M.S.); (J.K.N.)
- Centre for Biomedical Research, Laboratory of Reproductive Biology, Faculty of Medicine, Universidad de Los Andes, Santiago 7620001, Chile;
- Department of Obstetrics and Gynecology, Clínica Dávila, Santiago 8420384, Chile;
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123
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Tamargo J. Selecting emergency therapy for patients with pre-eclampsia. Expert Opin Pharmacother 2020; 21:1119-1122. [PMID: 32133877 DOI: 10.1080/14656566.2020.1727444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Juan Tamargo
- Department of Pharmacology and Toxicology, School of Medicine, Instituto De Investigación Sanitaria Gregorio Marañón, Universidad Complutense , Madrid, Spain
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124
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Shanmugalingam R, Mengesha Z, Notaras S, Liamputtong P, Fulcher I, Lee G, Kumar R, Hennessy A, Makris A. Factors that influence adherence to aspirin therapy in the prevention of preeclampsia amongst high-risk pregnant women: A mixed method analysis. PLoS One 2020; 15:e0229622. [PMID: 32106237 PMCID: PMC7046289 DOI: 10.1371/journal.pone.0229622] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 02/10/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Non-adherence with medications in pregnancy is increasingly recognized and often results in a higher rate of preventable maternal and fetal morbidity and mortality. Non-adherence with prophylactic aspirin amongst high-risk pregnant women is associated with higher incidence of preeclampsia, preterm delivery and intrauterine growth restriction. Yet, the factors that influences adherence with aspirin in pregnancy, from the women's perspective, remains poorly understood. OBJECTIVE The study is aimed at understanding the factors, from the women's perspective, that influenced adherence with prophylactic aspirin in their pregnancy. STUDY DESIGN A sequential-exploratory designed mixed methods quantitative (n = 122) and qualitative (n = 6) survey of women with recent high-risk pregnancy necessitating antenatal prophylactic aspirin was utilized. Women recruited underwent their antenatal care in one of three high-risk pregnancy clinics within the South Western Sydney Local Health District, Australia. The quantitative study was done through an electronic anonymous survey and the qualitative study was conducted through a face-to-face interview. Data obtained was analysed against women's adherence with aspirin utilizing phi correlation (φ) with significance set at <0.05. RESULTS Two key themes, from the women's perspective, that influenced their adherence with aspirin in pregnancy were identified; (1) pill burden and non-intention omission (2) communication and relationship with health care provider (HCP). Pill burden and its associated non-intentional omission, both strongly corelated with reduced adherence (Φ = 0.8, p = 0.02, Φ = 0.8, p<0.01) whilst the use of reminder strategies minimized accidental omission and improved adherence (Φ = 0.9, p<0.01). Consistent communication between HCPs and a good patient-HCP relationship was strongly associated with improved adherence (Φ = 0.7, p = 0.04, Φ = 0.9, p = <0.01) and more importantly was found to play an important role in alleviating factors that had potentials to negatively influence adherence with aspirin in pregnancy. CONCLUSION This study identified factors that both positively and negatively influenced adherence with aspirin amongst high-risk pregnant women. Is highlights the importance in recognizing the impact of pill burden in pregnancy and the need to counsel women on the utility of reminder strategies to minimize non-intentional omission. Importantly, it emphasizes on the importance of a positive patient-HCP relationship through effective and consistent communication to achieve the desired maternal and fetal outcomes.
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Affiliation(s)
- Renuka Shanmugalingam
- Department of Renal Medicine, South Western Sydney Local Health District, Liverpool, NSW, Australia
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Vascular Immunology Group, Heart Research Institute, University of Sydney, Newtown, NSW, Australia
- Women’s Health Initiative Translational Unit (WHITU), Ingham Institute For Applied Medical Research and South Western Sydney Local Health District, Liverpool, NSW, Australia
| | - Zelalem Mengesha
- Research and Social Policy Team, Uniting Australia, Sydney, NSW, Australia
| | - Stephanie Notaras
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Pranee Liamputtong
- School of Health Sciences and Translational Health Research Institute, Western Sydney University, Penrith, NSW, Australia
| | - Ian Fulcher
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Gaksoo Lee
- Women’s Health Initiative Translational Unit (WHITU), Ingham Institute For Applied Medical Research and South Western Sydney Local Health District, Liverpool, NSW, Australia
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Roshika Kumar
- Department of Obstetrics and Gynaecology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Annemarie Hennessy
- Department of Renal Medicine, South Western Sydney Local Health District, Liverpool, NSW, Australia
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Vascular Immunology Group, Heart Research Institute, University of Sydney, Newtown, NSW, Australia
- Women’s Health Initiative Translational Unit (WHITU), Ingham Institute For Applied Medical Research and South Western Sydney Local Health District, Liverpool, NSW, Australia
| | - Angela Makris
- Department of Renal Medicine, South Western Sydney Local Health District, Liverpool, NSW, Australia
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
- Vascular Immunology Group, Heart Research Institute, University of Sydney, Newtown, NSW, Australia
- Women’s Health Initiative Translational Unit (WHITU), Ingham Institute For Applied Medical Research and South Western Sydney Local Health District, Liverpool, NSW, Australia
- School of Medicine, University of New South Wales, Sydney, NSW, Australia
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Turner JM, Robertson NT, Hartel G, Kumar S. Impact of low-dose aspirin on adverse perinatal outcome: meta-analysis and meta-regression. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2020; 55:157-169. [PMID: 31479546 DOI: 10.1002/uog.20859] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 08/18/2019] [Accepted: 08/21/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To perform a meta-analysis and meta-regression of randomized controlled trials (RCTs) to evaluate the impact of low-dose aspirin (LDA) on perinatal outcome, independent of its effect on pre-eclampsia (PE), preterm birth and low birth weight. METHODS An electronic search of EMBASE, PubMed, CENTRAL, PROSPERO and Google Scholar databases was performed to identify RCTs assessing the impact of LDA in pregnancy, published in English prior to May 2019, which reported perinatal outcomes of interest (placental abruption, delivery mode, low 5-min Apgar score, neonatal acidosis, neonatal intensive care unit admission, periventricular hemorrhage and perinatal death). Risk ratios (RR) and 95% CI were calculated and pooled for analysis. Analysis was stratified according to gestational age at commencement of treatment (≤ 16 weeks vs > 16 weeks) and subgroup analysis was performed to assess the impact of aspirin dose (< 100 mg vs ≥ 100 mg). Meta-regression was used to assess the impact of LDA on perinatal outcome, independent of the reduction in PE, preterm birth and low birth weight. RESULTS Forty studies involving 34 807 participants were included. When LDA was commenced ≤ 16 weeks' gestation, it was associated with a significant reduction in the risk of perinatal death (RR, 0.47; 95% CI, 0.25-0.88; P = 0.02; number needed to treat, 92); however, this risk reduction was only seen when a daily dose of ≥ 100 mg was administered. If commenced > 16 weeks' gestation, LDA was associated with a significant reduction in 5-min Apgar score < 7 (RR, 0.75; 95% CI, 0.58-0.96; P = 0.02) and periventricular hemorrhage (RR, 0.68; 95% CI, 0.47-0.99; P = 0.04), but a trend towards an increase in the risk of placental abruption (RR, 1.20; 95% CI, 1.00-1.46; P = 0.06) was also noted. LDA was not associated with any significant increase in adverse events if commenced ≤ 16 weeks gestation. LDA had no effect on delivery mode, irrespective of the gestational age at which it was started. Meta-regression confirmed that the effect of LDA on perinatal death, when treatment was started ≤ 16 weeks' gestation, was independent of any reduction in the rate of PE and preterm birth. CONCLUSION LDA improves some important perinatal outcomes, without increasing adverse events such as placental abruption or periventricular hemorrhage, and its utility, if commenced prior to 16 weeks' gestation, may be considered in a wider context beyond the prevention of PE or fetal growth restriction. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- J M Turner
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
| | - N T Robertson
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
| | - G Hartel
- Division of Biostatistics, QIMR Berghofer Institute of Medical Research, University of Queensland, Herston, Queensland, Australia
| | - S Kumar
- Mater Research Institute, University of Queensland, South Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, South Brisbane, Queensland, Australia
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126
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Ekawati FM, Emilia O, Brennecke S, Gunn J, Licqurish S, Lau P. Opportunities for improving hypertensive disorders of pregnancy (HDP) management in primary care settings: A review of international published guidelines in the context of pregnancy care in Indonesia. Pregnancy Hypertens 2020; 19:195-204. [PMID: 32078932 DOI: 10.1016/j.preghy.2020.01.012] [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: 07/21/2019] [Revised: 01/19/2020] [Accepted: 01/19/2020] [Indexed: 10/25/2022]
Abstract
Almost all of global maternal mortality caused by HDP occurs in low to middle-income countries (LMIC). However, limited guidance is available to local primary care practitioners who are usually the main health care providers. This review examined existing international practice guidelines to identify potential practices to improve HDP management in Indonesian primary care settings. We performed structured literature search strategies and snowballing searches in six databases (MEDLINE, Web of Science, EMBASE, CINAHL, Cochrane reviews and Google Scholar) for guidelines that were published between 2007 and 2018 using relevant keywords and phrases of 'guidelines', 'hypertensive disorders of pregnancy' or 'preeclampsia' and 'primary care'. The AGREE II instrument was used to assess quality and reporting of the eligible guidelines. Thematic analysis was performed on all of the guidelines and the results were discussed among the project investigators. Sixteen international practice guidelines or similar management recommendations were reviewed. Almost all of them were partially applicable, with some managements potentially able to be adopted to Indonesian primary care settings. Three main themes for improving HDP management were identified, namely clinical management, care planning, and professional communication. These potential improvements in managing women with HDP in Indonesia may also be relevant in other LMIC. Further contextualisation is required to facilitate their adoption in practice settings.
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Affiliation(s)
- Fitriana Murriya Ekawati
- Department of Family and Community Medicine, Universitas Gadjah Mada, Yogyakarta, Indonesia; Department of General Practice, University of Melbourne, Victoria, Australia.
| | - Ova Emilia
- Department of Obstetrics and Gynaecology, Universitas Gadjah Mada/Sardjito Hospital, Yogyakarta, Indonesia
| | - Shaun Brennecke
- Department of Obstetrics and Gynaecology, University of Melbourne/Royal Women's Hospital, Parkville, Victoria, Australia; Pregnancy Research Centre, Department of Maternal-Fetal Medicine, Royal Women's Hospital, Parkville, Victoria, Australia
| | - Jane Gunn
- Department of General Practice, University of Melbourne, Victoria, Australia
| | - Sharon Licqurish
- School of Nursing and Midwifery, Monash University, Victoria, Australia
| | - Phyllis Lau
- Department of General Practice, University of Melbourne, Victoria, Australia
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Pollock W, Peek MJ, Wang A, Li Z, Ellwood D, Homer CSE, Jackson Pulver L, McLintock C, Vaughan G, Knight M, Sullivan EA. Eclampsia in Australia and New Zealand: A prospective population-based study. Aust N Z J Obstet Gynaecol 2019; 60:533-540. [PMID: 31840809 DOI: 10.1111/ajo.13100] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/10/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Eclampsia is a serious consequence of pre-eclampsia. There are limited data from Australia and New Zealand (ANZ) on eclampsia. AIM To determine the incidence, management and perinatal outcomes of women with eclampsia in ANZ. MATERIALS AND METHODS A two-year population-based descriptive study, using the Australasian Maternity Outcomes Surveillance System (AMOSS), carried out in 263 sites in Australia, and all 24 New Zealand maternity units, during a staggered implementation over 2010-2011. Eclampsia was defined as one or more seizures during pregnancy or postpartum (up to 14 days) in any woman with clinical evidence of pre-eclampsia. RESULTS Of 136 women with eclampsia, 111 (83%) were in Australia and 25 (17%) in New Zealand. The estimated incidence of eclampsia was 2.2 (95% confidence interval (CI) 1.9-2.7) per 10 000 women giving birth. Aboriginal and Torres Strait Islander women were over-represented in Australia (n = 9; 8.1%). Women with antepartum eclampsia (n = 58, 42.6%) were more likely to have a preterm birth (P = 0.04). Sixty-three (47.4%) women had pre-eclampsia diagnosed prior to their first eclamptic seizure of whom 19 (30.2%) received magnesium sulphate prior to the first seizure. Nearly all women (n = 128; 95.5%) received magnesium sulphate post-seizure. No woman received prophylactic aspirin during pregnancy. Five women had a cerebrovascular haemorrhage, and there were five known perinatal deaths. CONCLUSIONS Eclampsia is an uncommon consequence of pre-eclampsia in ANZ. There is scope to reduce the incidence of this condition, associated with often catastrophic morbidity, through the use of low-dose aspirin and magnesium sulphate in women at higher risk.
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Affiliation(s)
- Wendy Pollock
- Maternal Critical Care, Melbourne, Victoria, Australia.,Department of Nursing, The University of Melbourne, Melbourne, Victoria, Australia.,School of Nursing and Midwifery, La Trobe University, Melbourne, Victoria, Australia
| | - Michael J Peek
- Obstetrics and Gynaecology, ANU Medical School, College of Health and Medicine, The Australian National University, Canberra, Australian Capital Territory, Australia
| | - Alex Wang
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Zhuoyang Li
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - David Ellwood
- Department of Obstetrics and Gynaecology, Griffiths University, Southport, Queensland, Australia
| | - Caroline S E Homer
- Maternal and Child Health, Burnet Institute, Melbourne, Victoria, Australia
| | - Lisa Jackson Pulver
- Indigenous Strategy and Services, The University of Sydney, Sydney, New South Wales, Australia
| | - Claire McLintock
- National Women's Health, Auckland City Hospital, University of Auckland, Auckland, New Zealand
| | - Geraldine Vaughan
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Marian Knight
- Maternal and Child Population Health, National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elizabeth A Sullivan
- The Australian Centre for Public and Population Health Research, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,Faculty of Health and Medicine, University of Newcastle, Newcastle, New South Wales, Australia
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128
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Roth H, LeMarquand G, Henry A, Homer C. Assessing Knowledge Gaps of Women and Healthcare Providers Concerning Cardiovascular Risk After Hypertensive Disorders of Pregnancy-A Scoping Review. Front Cardiovasc Med 2019; 6:178. [PMID: 31850374 PMCID: PMC6895842 DOI: 10.3389/fcvm.2019.00178] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 11/15/2019] [Indexed: 12/14/2022] Open
Abstract
Background: A history of a Hypertensive Disorder of Pregnancy (HDP) at least doubles a woman's risk of cardiovascular disease (CVD). The risk increases within 10 years after HDP and continues for life, making long-term health after HDP of major public health importance. Understanding knowledge gaps in health care professionals and women regarding cardiovascular health after HDP is an important component in addressing these risks. Objectives: The primary aim was to examine what women and healthcare providers (HCP) know about cardiovascular risks after HDP. The secondary aims were to identify enablers and barriers to knowledge and action on knowledge. Methods: A scoping review was conducted. This was a narrative synthesis, using PRISMA-ScR guidelines, of English-language full text articles that included assessment of knowledge of women, and/or HCP, on long term cardiovascular risk after HDP. The databases Embase, Medline, Scopus, ProQuest, Cochrane, and PsycInfo were searched from 01 January 2005 to 31 May 2019. Results: Twelve studies were included, six addressing women's knowledge, five addressing HCP knowledge, and one addressing both. The studies included 402 women and 1,215 HCP from seven countries. Regarding women's knowledge, six of seven studies found women had limited or no knowledge about the link between HDP and CVD. Where women were aware of the link, the majority had sourced their own information, rather than obtaining it through their HCP. In five of six studies, HCP also mostly had limited knowledge about HDP-CVD links. Primary enablers for HCP acquisition of knowledge and counseling were the availability and knowledge of guidelines. Where comparisons between HCP groups were made, obstetricians had greater knowledge than family physicians, internal medical specialists, or midwives. Conclusion: There was a low level of knowledge amongst HCP and women about increased CVD risk after HDP. Where women had higher levels of knowledge, the information was often obtained informally rather than from HCP. There were variations in knowledge of HCP, with obstetricians generally more aware than other professions. Further country and context-specific research on current status of women's and HCP's knowledge is therefore necessary when creating educational strategies to address knowledge gaps after HDP.
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Affiliation(s)
- Heike Roth
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Grace LeMarquand
- School of Women's and Children's Health, UNSW Medicine, University of NSW, Sydney, NSW, Australia
| | - Amanda Henry
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,School of Women's and Children's Health, UNSW Medicine, University of NSW, Sydney, NSW, Australia.,Global Women's Health Program, The George Institute for Global Health, Sydney, NSW, Australia.,Department of Women's and Children's Health, St George Hospital, Sydney, NSW, Australia
| | - Caroline Homer
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia.,Burnet Institute, Maternal and Child Health, Melbourne, VIC, Australia
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129
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Lui NA, Jeyaram G, Henry A. Postpartum Interventions to Reduce Long-Term Cardiovascular Disease Risk in Women After Hypertensive Disorders of Pregnancy: A Systematic Review. Front Cardiovasc Med 2019; 6:160. [PMID: 31803757 PMCID: PMC6873287 DOI: 10.3389/fcvm.2019.00160] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Accepted: 10/21/2019] [Indexed: 01/04/2023] Open
Abstract
Introduction: Hypertensive disorders (HDP) affect ~7% of pregnancies. Epidemiological evidence strongly suggests HDP independently increases that individual's risk of later cardiovascular disease (CVD). Focus on reduction or mitigation of this risk has been limited. This review seeks to identify trialed interventions to reduce cardiovascular risk after HDP. Methods: Online medical databases were searched to identify full-text published results of randomized controlled trials (RCT) in women <10 years postpartum after HDP that trialed interventions to reduce cardiovascular risk. Outcomes sought included cardiovascular disease events, chronic hypertension, and other measures of cardiovascular risk such as obesity, smoking status, diet, and physical activity. Publications from January 2008 to July 2019 were included. Results: Two RCTs were identified. One, a trial of calcium vs. placebo in 201 women with calcium commenced from the first follow-up visit outside of pregnancy and continued until 20 weeks' gestation if another pregnancy occurred. A non-significant trend toward decreased blood pressure was noted. The second RCT of 151 women tested an online education programme (vs. general information to control group) to increase awareness of risk factors and personalized phone-based lifestyle coaching in women who had a preeclampsia affected pregnancy in the 5 years preceding enrolment. Significant findings included increase in knowledge of CVD risk factors, reported healthy eating and decreased physical inactivity, however adoption of a promoted heart healthy diet and physical activity levels did not differ significantly between groups. Several observational studies after HDP, and one meta-analysis of studies of lifestyle interventions not performed specifically after HDP but used to extrapolate likely benefits of lifestyle interventions, were identified which supported the use of lifestyle interventions. Several ongoing RCTs were also noted. Discussion: There is a paucity of intervention trials in the early years after HDP to guide evidence-based cardiovascular risk reduction in affected women. Limited evidence suggests lifestyle intervention may be effective, however degree of any risk reduction remains uncertain. Conclusion: Sufficiently powered randomized controlled trials of appropriate interventions (e.g., lifestyle behavior change, pharmacological) are required to assess the best method of reducing the risk of cardiovascular disease in this at-risk population of women.
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Affiliation(s)
- Nicla A. Lui
- Department of Women's and Children's Health, St. George Hospital, Sydney, NSW, Australia
| | - Gajana Jeyaram
- Department of Women's and Children's Health, St. George Hospital, Sydney, NSW, Australia
| | - Amanda Henry
- Department of Women's and Children's Health, St. George Hospital, Sydney, NSW, Australia
- School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
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Umapathy A, Chamley LW, James JL. Reconciling the distinct roles of angiogenic/anti-angiogenic factors in the placenta and maternal circulation of normal and pathological pregnancies. Angiogenesis 2019; 23:105-117. [DOI: 10.1007/s10456-019-09694-w] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 10/26/2019] [Indexed: 01/03/2023]
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Thayaparan AS, Said JM, Lowe SA, McLean A, Yang Y. Pre-eclampsia and long-term cardiac dysfunction: A review of asymptomatic cardiac changes existing well beyond the post-partum period. Australas J Ultrasound Med 2019; 22:234-244. [PMID: 34760564 PMCID: PMC8411796 DOI: 10.1002/ajum.12173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 04/08/2019] [Accepted: 06/03/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Pre-eclampsia is a disease of pregnancy characterised by the manifestations of multi-organ dysfunction. The recent use of transthoracic echocardiography in the assessment of women with pre-eclampsia has allowed the detection of cardiac systolic and diastolic dysfunction in the acute phase. Women with a history of pre-eclampsia also have increased lifelong risks of cardiovascular disease and mortality that persists well beyond the post-partum period. These developments raise the possibility that pre-eclampsia may be an early marker of cardiovascular disease and the potential role for echocardiography in guiding the detection and management of this. This review aims to summarise the existing evidence of echocardiographic cardiac assessment of women with a history of pre-eclampsia performed more than 12 weeks post-partum. METHODS A systematic search of PubMed and OVID EMBASE databases was performed to identify studies featuring assessment of cardiac function performed after 12 weeks post-partum in women with a history of pre-eclampsia. Studies without post-partum cardiac assessment or with other documented causes for cardiomyopathy were excluded. RESULTS Thirteen studies were identified that measured cardiac function by transthoracic echocardiography between 6 months and 18 years following a pregnancy complicated by pre-eclampsia. Common findings across the studies were of increased diastolic dysfunction, increased left ventricular mass index (LVMI) and concentric hypertrophy in women with a history of pre-eclampsia, as compared to women with uncomplicated pregnancy histories. This was predominantly seen in those with a history of early or preterm pre-eclampsia. CONCLUSIONS Women with a history of early or preterm pre-eclampsia have an increased prevalence of diastolic dysfunction. This review demonstrates that the cardiac dysfunction associated with previous pre-eclampsia is quantifiable and persistent. Progression of heart failure from asymptomatic to symptomatic stages carries a fivefold increase in mortality. The use of echocardiography could detect cardiac dysfunction in the asymptomatic stage and guide more intensive risk factor modification in these women.
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Affiliation(s)
| | - Joanne M Said
- Joan Kirner Women's and Childrens HospitalSt AlbansVictoriaAustralia
| | - Sandra A Lowe
- Royal Hospital for WomenRandwickNew South WalesAustralia
| | | | - Yang Yang
- Western Health, Eastern HealthEpworth HospitalVictoriaAustralia
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132
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Wei LL, Pan YS, Tang Q, Yang ZJ, Song WQ, Gao YF, Li J, Zhang L, Liu SG. Decreased ALCAM expression and promoter hypermethylation is associated with preeclampsia. Hypertens Res 2019; 43:13-22. [PMID: 31601971 DOI: 10.1038/s41440-019-0337-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/15/2019] [Accepted: 08/19/2019] [Indexed: 01/27/2023]
Abstract
Preeclampsia (PE) is a major obstetrical complication that results in maternal and fetal morbidity and mortality. Aberrant epigenetic modifications are widely involved in the pathogenesis of PE. Previously, the activated leukocyte cell adhesion molecule (ALCAM) was reported to be required for blastocyst implantation but has not been described in the context of pathological pregnancy. This study explored the expression of ALCAM and its methylation levels in the placentas and peripheral venous blood of patients with PE from a Chinese Han population. The mRNA and protein expression levels of ALCAM were downregulated in the PE placentas compared with the control placentas (P < 0.05). The methylation rate of the ALCAM gene promoter was considerably elevated in the placentas (P = 0.003, odds ratio (OR) = 0.264, 95% confidence interval (95% CI) [0.108-0.647], cases n = 47, controls n = 53) and peripheral blood (P = 0.007, OR = 0.455, 95% CI [0.256-0.806], cases n = 100, controls n = 100) of the PE patients compared with those of the normotensive women, suggesting a negative relationship between ALCAM methylation and gene transcription. Moreover, the transcriptional expression of ALCAM was dramatically increased by demethylating treatment in trophoblastic cells. ALCAM is expected to be involved in the pathogenesis of PE through methylation regulation.
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Affiliation(s)
- Li-Li Wei
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yue-Shuai Pan
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Qian Tang
- Prenatal Diagnosis Center, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zong-Jun Yang
- Department of Clinical Laboratory, Qingdao Women and Children's Hospital, Qingdao, China
| | - Wei-Qing Song
- Department of Clinical Laboratory, Qingdao Municipal Hospital, Qingdao, China
| | - Yu-Fang Gao
- Department of Nursing, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Jing Li
- Clinical Laboratory, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Lu Zhang
- Prenatal Diagnosis Center, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Shi-Guo Liu
- Prenatal Diagnosis Center, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Preeclampsia: Risk Factors, Diagnosis, Management, and the Cardiovascular Impact on the Offspring. J Clin Med 2019; 8:jcm8101625. [PMID: 31590294 PMCID: PMC6832549 DOI: 10.3390/jcm8101625] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 09/22/2019] [Accepted: 10/02/2019] [Indexed: 12/20/2022] Open
Abstract
Hypertensive disorders of pregnancy affect up to 10% of pregnancies worldwide, which includes the 3%–5% of all pregnancies complicated by preeclampsia. Preeclampsia is defined as new onset hypertension after 20 weeks’ gestation with evidence of maternal organ or uteroplacental dysfunction or proteinuria. Despite its prevalence, the risk factors that have been identified lack accuracy in predicting its onset and preventative therapies only moderately reduce a woman’s risk of preeclampsia. Preeclampsia is a major cause of maternal morbidity and is associated with adverse foetal outcomes including intra-uterine growth restriction, preterm birth, placental abruption, foetal distress, and foetal death in utero. At present, national guidelines for foetal surveillance in preeclamptic pregnancies are inconsistent, due to a lack of evidence detailing the most appropriate assessment modalities as well as the timing and frequency at which assessments should be conducted. Current management of the foetus in preeclampsia involves timely delivery and prevention of adverse effects of prematurity with antenatal corticosteroids and/or magnesium sulphate depending on gestation. Alongside the risks to the foetus during pregnancy, there is also growing evidence that preeclampsia has long-term adverse effects on the offspring. In particular, preeclampsia has been associated with cardiovascular sequelae in the offspring including hypertension and altered vascular function.
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Taylor R, Shrewsbury VA, Vincze L, Campbell L, Callister R, Park F, Schumacher T, Collins C, Hutchesson M. Be Healthe for Your Heart: Protocol for a Pilot Randomized Controlled Trial Evaluating a Web-Based Behavioral Intervention to Improve the Cardiovascular Health of Women With a History of Preeclampsia. Front Cardiovasc Med 2019; 6:144. [PMID: 31616675 PMCID: PMC6775183 DOI: 10.3389/fcvm.2019.00144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/05/2019] [Indexed: 01/07/2023] Open
Abstract
Background: Women with a history of preeclampsia are at greater risk of cardiovascular disease (CVD) related morbidity. Despite this knowledge, there is a lack of interventions available for women with a history of preeclampsia for the prevention of CVD. The aim of this pilot randomized controlled trial (RCT) is to determine the acceptability and preliminary efficacy of a web-based behavioral intervention targeted to women with a history of preeclampsia (Be Healthe for your Heart). Method: Australian women aged 18-45 years, with a recent history (≤4 years post diagnosis) of preeclampsia will be recruited for a 3-months, 2-arm parallel group pilot RCT. Participants will be randomized into 2 study arms: (1) Be Healthe for your Heart or; (2) Control, with assessments conducted at baseline, and after 3-months. Be Healthe for your Heart is an intervention delivered online via the program website, with weekly emails to support changes in modifiable CVD risk factors (excess body weight, physical inactivity, poor diet, and stress), using behavior change techniques (e.g., self-monitoring, goal setting). Intervention acceptability (satisfaction, usability, appropriateness, and usage) and impact on absolute full CVD 30-years risk score, CVD risk markers, and modifiable risk factors will be assessed. Discussion: No studies to date have evaluated acceptability and preliminary efficacy of a web-based intervention for the prevention of CVD in this high-risk population with preeclampsia. This pilot trial will inform development of a fully powered RCT if acceptability and preliminary efficacy are demonstrated.
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Affiliation(s)
- Rachael Taylor
- School of Health Sciences, Priority Research Centre for Physical Activity and Nutrition, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Vanessa A. Shrewsbury
- School of Health Sciences, Priority Research Centre for Physical Activity and Nutrition, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Lisa Vincze
- School of Allied Health Sciences, Griffith University, Gold Coast, QLD, Australia
| | - Linda Campbell
- School of Psychology, Faculty of Science, The University of Newcastle, Newcastle, NSW, Australia
| | - Robin Callister
- School of Biomedical Sciences and Pharmacy, Priority Research Centre for Physical Activity and Nutrition, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Felicity Park
- Department of Maternal Fetal Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Tracy Schumacher
- Department of Rural Health, Faculty of Health and Medicine, University of Newcastle, Tamworth, NSW, Australia
| | - Clare Collins
- School of Health Sciences, Priority Research Centre for Physical Activity and Nutrition, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
| | - Melinda Hutchesson
- School of Health Sciences, Priority Research Centre for Physical Activity and Nutrition, Faculty of Health and Medicine, The University of Newcastle, Newcastle, NSW, Australia
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Shanmugalingam R, Wang X, Münch G, Fulcher I, Lee G, Chau K, Xu B, Kumar R, Hennessy A, Makris A. A pharmacokinetic assessment of optimal dosing, preparation, and chronotherapy of aspirin in pregnancy. Am J Obstet Gynecol 2019; 221:255.e1-255.e9. [PMID: 31051121 DOI: 10.1016/j.ajog.2019.04.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 04/16/2019] [Accepted: 04/24/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND The benefit of aspirin in preventing preeclampsia is well established; however, studies over the years have demonstrated variability in outcomes with its use. Potential contributing factors to this variation in efficacy include dosing, time of dosing, and preparation of aspirin. OBJECTIVE We aimed to compare the difference in pharmacokinetics of aspirin, through its major active metabolite, salicylic acid, in pregnant women and nonpregnant women, and to examine the effect of dose (100 mg vs 150 mg), preparation (enteric coated vs non-enteric-coated), and chronotherapy of aspirin (morning vs evening) between the 2 groups. MATERIALS AND METHODS Twelve high-risk pregnant women and 3 nonpregnant women were enrolled in this study. Pregnant women were in 1 of 4 groups (100 mg enteric coated, 100 mg non-enteric-coated, 150 mg non-enteric-coated morning dosing, and 150 mg non-enteric-coated evening dosing), whereas nonpregnant women undertook each of the 4 dosing schedules with at least a 30-day washout period. Blood samples were collected at baseline (before ingestion) and at 1, 2, 4, 6, 12, and 24 hours after ingestion of aspirin. Plasma obtained was analyzed for salicylic acid levels by means of liquid chromatography-mass spectrometry. Pharmacokinetic values of area under the curve from time point 0 to 24 hours point of maximum concentration, time of maximum concentration, volume of distribution, clearance, and elimination half-life were analyzed for statistical significance with SPSS v25 software. RESULTS Pregnant women had a 40% ± 4% reduction in area under the curve from time point 0 to 24 hours (P < .01) and 29% ± 3% reduction in point of maximum concentration (P < .01) with a 44% ± 8% increase in clearance (P < .01) in comparison to that in nonpregnant women when 100 mg aspirin was administered. The reduction in the area under the curve from time point 0 to 24 hours, however, was minimized with the use of 150 mg aspirin in pregnant women, with which the area under the curve from time point 0 to 24 hours was closer to that achieved with the use of 100 mg aspirin in nonpregnant women. There was a 4-hour delay (P < .01) in the time of maximum concentration, a 47% ± 3% reduction in point of maximum concentration (P < .01) and a 48% ± 1% increase in volume of distribution (P < .01) with the use of 100 mg enteric-coated aspirin compared to non-enteric-coated aspirin, with no difference in the overall area under the curve. There was no difference in the pharmacokinetics of aspirin between morning and evening dosing. CONCLUSION There is a reduction in the total drug metabolite concentration of aspirin in pregnancy, and therefore a dose adjustment is potentially required in pregnant women. This is likely due to the altered pharmacokinetics of aspirin in pregnancy, with an increase in clearance. There was no difference in the total drug metabolite concentration of aspirin between enteric-coated and non-enteric-coated aspirin and between morning and evening dosing of aspirin. Further pharmacodynamic and clinical studies are required to examine the clinical relevance of these pharmacokinetic findings.
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Affiliation(s)
- Renuka Shanmugalingam
- School of Medicine, Western Sydney University, NSW, Australia; Department of Renal Medicine, South Western Sydney Local Health District, NSW, Australia; Heart Research Institute, University of Sydney, NSW, Australia; Women's Health Initiative Translational Unit (WHITU), South Western Sydney Local Health District, NSW, Australia.
| | - XiaoSuo Wang
- Bosch Mass Spectrometry Facility, Bosch Institute, Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Gerald Münch
- Pharmacology Unit, School of Medicine, Western Sydney University, NSW, Australia
| | - Ian Fulcher
- Department of Obstetrics and Gynaecology, Liverpool Hospital, NSW, Australia
| | - Gaksoo Lee
- Department of Renal Medicine, South Western Sydney Local Health District, NSW, Australia; Women's Health Initiative Translational Unit (WHITU), South Western Sydney Local Health District, NSW, Australia
| | - Katrina Chau
- Heart Research Institute, University of Sydney, NSW, Australia
| | - Bei Xu
- Heart Research Institute, University of Sydney, NSW, Australia
| | - Roshika Kumar
- Department of Obstetrics and Gynaecology, Liverpool Hospital, NSW, Australia
| | - Annemarie Hennessy
- School of Medicine, Western Sydney University, NSW, Australia; Department of Renal Medicine, South Western Sydney Local Health District, NSW, Australia; Heart Research Institute, University of Sydney, NSW, Australia; Women's Health Initiative Translational Unit (WHITU), South Western Sydney Local Health District, NSW, Australia
| | - Angela Makris
- School of Medicine, Western Sydney University, NSW, Australia; Department of Renal Medicine, South Western Sydney Local Health District, NSW, Australia; Heart Research Institute, University of Sydney, NSW, Australia; Women's Health Initiative Translational Unit (WHITU), South Western Sydney Local Health District, NSW, Australia
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136
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Frawley N, East C, Brennecke S. Women's experiences of preeclampsia: a prospective survey of preeclamptic women at a single tertiary centre. J OBSTET GYNAECOL 2019; 40:65-69. [PMID: 31455184 DOI: 10.1080/01443615.2019.1615040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Preeclampsia (PE) can suddenly disrupt a normal pregnancy experience. This project aimed to see how PE was experienced close to the time of birth, in a group of hospital patients. Women with PE who gave birth at The Royal Women's Hospital, Melbourne, Australia, from October 2010 to May 2012 were asked to complete a survey designed with consumer input. There was a 74% response rate. Regarding diagnosis, 90% experienced PE, 2.5% experienced eclampsia and 7.5% experienced HELLP. For 60% of women, their baby was born earlier than expected. Although 67.5% of women knew little about PE prior to pregnancy and diagnosis, 67.5% believed PE was serious or life threatening. Fifty-five percent were afraid that their baby might die. The women in the study identified the need to obtain more information about PE (97.5%), and 60% indicated that their PE experience would either delay or contribute to the decision to not undertake a future pregnancy. This project details that PE can have a substantial psychological effect on patients around the time of birth. Maternity caregivers can direct counselling to address the specific vulnerabilities raised in PE and thus improve the care of women with PE.Impact StatementWhat is already known on this subject? Qualitative research from New Zealand showed that women experiencing preeclampsia (PE) can have a number of psychological issues with their pregnancy experience, including feeling no longer in control of their pregnancy, dealing with an unexpected medicalised preterm birth, and feeling fear for themselves and their baby's life, even if no formal psychiatric issues are identified. A PE support group surveyed their own members and found that these psychological issues are present in most of their members who had PE.What the results of this study add? This study was a survey of 40 women experiencing PE around the time of birth in a tertiary hospital in Melbourne, Australia, to see if these themes could be applied to a general hospital group. There was a 74% response rate. For 60% of women, the baby was born earlier than expected. Although most women knew little about PE prior to diagnosis, 67.5% believed PE was serious or life threatening at diagnosis. More than half (55%) were afraid their baby might die and 47.5% of women identified that separation from their baby impaired their ability to bond. Most women planned to obtain more information about PE (97.5%) and 50% indicated that their PE experience meant they would either delay or not undertake future pregnancy.What the implications are of these findings for clinical practice and/or further clinical research? This study demonstrates the significance of psychological factors in the care of women with pre-eclampsia or eclampsia and offers a range of issues that the health care provider can use in discussions with women in the early postnatal period, in the inter-pregnancy interval and in subsequent pregnancies. Further research would ideally involve a large sample in a range of hospital settings (primary through tertiary) to further consider the prevalence and enduring nature of themes identified in the present study.
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Affiliation(s)
- Natasha Frawley
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Australia.,The Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Australia
| | - Christine East
- School of Nursing and Midwifery, Monash University and Monash Maternity Services, Clayton, Australia
| | - Shaun Brennecke
- Department of Obstetrics and Gynaecology, The University of Melbourne, Parkville, Australia.,The Department of Maternal-Fetal Medicine, The Royal Women's Hospital, Parkville, Australia
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137
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Benschop L, Duvekot JJ, Roeters van Lennep JE. Future risk of cardiovascular disease risk factors and events in women after a hypertensive disorder of pregnancy. Heart 2019; 105:1273-1278. [PMID: 31175138 PMCID: PMC6678044 DOI: 10.1136/heartjnl-2018-313453] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 05/10/2019] [Accepted: 05/13/2019] [Indexed: 02/06/2023] Open
Abstract
Hypertensive disorders of pregnancy (HDP), such as gestational hypertension and pre-eclampsia, affect up to 10% of all pregnancies. These women have on average a twofold higher risk to develop cardiovascular disease (CVD) later in life as compared with women with normotensive pregnancies. This increased risk might result from an underlying predisposition to CVD, HDP itself or a combination of both. After pregnancy women with HDP show an increased risk of classical cardiovascular risk factors including chronic hypertension, renal dysfunction, dyslipidemia, diabetes and subclinical atherosclerosis. The prevalence and onset of cardiovascular risk factors depends on the severity of the HDP and the coexistence of other pregnancy complications. At present, guidelines addressing postpartum cardiovascular risk assessment for women with HDP show a wide variation in their recommendations. This makes cardiovascular follow-up of women with a previous HDP confusing and non-coherent. Some guidelines advise to initiate cardiovascular follow-up (blood pressure, weight and lifestyle assessment) 6-8 weeks after pregnancy, whereas others recommend to start 6-12 months after pregnancy. Concurrent blood pressure monitoring, lipid and glucose assessment is recommended to be repeated annually to every 5 years until the age of 50 years when women will qualify for cardiovascular risk assessment according to all international cardiovascular prevention guidelines.
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Affiliation(s)
- Laura Benschop
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Johannes J Duvekot
- Department of Obstetrics and Gynaecology, Erasmus MC, Rotterdam, The Netherlands
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Affiliation(s)
- Renee Eslick
- Clinical and Laboratory Haematologist, Haematology Department, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Claire McLintock
- Clinical and Laboratory Haematologist, Obstetric Physician, National Women’s Health, Auckland City Hospital, Auckland, New Zealand
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139
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Gamble DT, Brikinns B, Myint PK, Bhattacharya S. Hypertensive Disorders of Pregnancy and Subsequent Cardiovascular Disease: Current National and International Guidelines and the Need for Future Research. Front Cardiovasc Med 2019; 6:55. [PMID: 31157237 PMCID: PMC6533460 DOI: 10.3389/fcvm.2019.00055] [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] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Accepted: 04/16/2019] [Indexed: 11/13/2022] Open
Abstract
Background: It is well-established that hypertensive disorders of pregnancy (HDP) are associated with an increased risk of cardiovascular disease (CVD) in later life. National and International guidelines recognize this but due to a lack of research in this area few details are provided on how best to risk stratify or when and how to monitor these women. Objectives: This article aims to summarize current guidelines in this area in order to raise awareness of need for further research in this important clinical area. Search Strategy: A review of the published literature was carried out in August 2018 using the databases EMBASE and Medline and the websites of professional societies were searched manually using the search terms "pre-eclampsia," "hypertensive disorders of pregnancy," "management," "guidelines," "long term follow up" and "cardiovascular risk." Guidelines published in English were included and articles that provided guidance on follow up post-partum of women with HDP. Main Results: The search identified 360 records. Of these, 16 guidelines mentioned the follow up of women with HDP; their reported years ranges from 2010 to 2018. Only 8 (50%) provided some level of recommendation for follow up beyond the immediate post-partum period. These recognized the future risk of CVD to women from HDP and provide detailed recommendations for the management of these conditions during pregnancy and in the immediate post-partum period. Guidelines recommended that women and primary care clinicians are made aware of this risk and some suggest yearly BP monitoring, and at least 5 yearly monitoring of renal functions, urinalysis and lipid profile testing alongside lifestyle modifications and control of CVD risk factors. Guidelines used a combination of meta-analysis, individual cohort studies and expert opinions to inform their recommendations. Conclusions: There is a need for future studies of women with a history of HDP to define their trajectory for the development of CVD and candidate biomarkers in order to develop screening, risk stratification, and preventive measures to reduce the significant CV burden associated with HDP in women.
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Affiliation(s)
- David T Gamble
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Bolanle Brikinns
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Phyo Kyaw Myint
- Ageing Clinical and Experimental Research Team, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
| | - Sohinee Bhattacharya
- Obstetric Epidemiology Group, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom
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140
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Poon LC, Shennan A, Hyett JA, Kapur A, Hadar E, Divakar H, McAuliffe F, da Silva Costa F, von Dadelszen P, McIntyre HD, Kihara AB, Di Renzo GC, Romero R, D’Alton M, Berghella V, Nicolaides KH, Hod M. The International Federation of Gynecology and Obstetrics (FIGO) initiative on pre-eclampsia: A pragmatic guide for first-trimester screening and prevention. Int J Gynaecol Obstet 2019; 145 Suppl 1:1-33. [PMID: 31111484 PMCID: PMC6944283 DOI: 10.1002/ijgo.12802] [Citation(s) in RCA: 519] [Impact Index Per Article: 103.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Pre‐eclampsia (PE) is a multisystem disorder that typically affects 2%–5% of pregnant women and is one of the leading causes of maternal and perinatal morbidity and mortality, especially when the condition is of early onset. Globally, 76 000 women and 500 000 babies die each year from this disorder. Furthermore, women in low‐resource countries are at a higher risk of developing PE compared with those in high‐resource countries. Although a complete understanding of the pathogenesis of PE remains unclear, the current theory suggests a two‐stage process. The first stage is caused by shallow invasion of the trophoblast, resulting in inadequate remodeling of the spiral arteries. This is presumed to lead to the second stage, which involves the maternal response to endothelial dysfunction and imbalance between angiogenic and antiangiogenic factors, resulting in the clinical features of the disorder. Accurate prediction and uniform prevention continue to elude us. The quest to effectively predict PE in the first trimester of pregnancy is fueled by the desire to identify women who are at high risk of developing PE, so that necessary measures can be initiated early enough to improve placentation and thus prevent or at least reduce the frequency of its occurrence. Furthermore, identification of an “at risk” group will allow tailored prenatal surveillance to anticipate and recognize the onset of the clinical syndrome and manage it promptly. PE has been previously defined as the onset of hypertension accompanied by significant proteinuria after 20 weeks of gestation. Recently, the definition of PE has been broadened. Now the internationally agreed definition of PE is the one proposed by the International Society for the Study of Hypertension in Pregnancy (ISSHP). According to the ISSHP, PE is defined as systolic blood pressure at ≥140 mm Hg and/or diastolic blood pressure at ≥90 mm Hg on at least two occasions measured 4 hours apart in previously normotensive women and is accompanied by one or more of the following new‐onset conditions at or after 20 weeks of gestation: 1.Proteinuria (i.e. ≥30 mg/mol protein:creatinine ratio; ≥300 mg/24 hour; or ≥2 + dipstick); 2.Evidence of other maternal organ dysfunction, including: acute kidney injury (creatinine ≥90 μmol/L; 1 mg/dL); liver involvement (elevated transaminases, e.g. alanine aminotransferase or aspartate aminotransferase >40 IU/L) with or without right upper quadrant or epigastric abdominal pain; neurological complications (e.g. eclampsia, altered mental status, blindness, stroke, clonus, severe headaches, and persistent visual scotomata); or hematological complications (thrombocytopenia–platelet count <150 000/μL, disseminated intravascular coagulation, hemolysis); or 3.Uteroplacental dysfunction (such as fetal growth restriction, abnormal umbilical artery Doppler waveform analysis, or stillbirth). It is well established that a number of maternal risk factors are associated with the development of PE: advanced maternal age; nulliparity; previous history of PE; short and long interpregnancy interval; use of assisted reproductive technologies; family history of PE; obesity; Afro‐Caribbean and South Asian racial origin; co‐morbid medical conditions including hyperglycemia in pregnancy; pre‐existing chronic hypertension; renal disease; and autoimmune diseases, such as systemic lupus erythematosus and antiphospholipid syndrome. These risk factors have been described by various professional organizations for the identification of women at risk of PE; however, this approach to screening is inadequate for effective prediction of PE. PE can be subclassified into: 1.Early‐onset PE (with delivery at <34+0 weeks of gestation); 2.Preterm PE (with delivery at <37+0 weeks of gestation); 3.Late‐onset PE (with delivery at ≥34+0 weeks of gestation); 4.Term PE (with delivery at ≥37+0 weeks of gestation). These subclassifications are not mutually exclusive. Early‐onset PE is associated with a much higher risk of short‐ and long‐term maternal and perinatal morbidity and mortality. Obstetricians managing women with preterm PE are faced with the challenge of balancing the need to achieve fetal maturation in utero with the risks to the mother and fetus of continuing the pregnancy longer. These risks include progression to eclampsia, development of placental abruption and HELLP (hemolysis, elevated liver enzyme, low platelet) syndrome. On the other hand, preterm delivery is associated with higher infant mortality rates and increased morbidity resulting from small for gestational age (SGA), thrombocytopenia, bronchopulmonary dysplasia, cerebral palsy, and an increased risk of various chronic diseases in adult life, particularly type 2 diabetes, cardiovascular disease, and obesity. Women who have experienced PE may also face additional health problems in later life, as the condition is associated with an increased risk of death from future cardiovascular disease, hypertension, stroke, renal impairment, metabolic syndrome, and diabetes. The life expectancy of women who developed preterm PE is reduced on average by 10 years. There is also significant impact on the infants in the long term, such as increased risks of insulin resistance, diabetes mellitus, coronary artery disease, and hypertension in infants born to pre‐eclamptic women. The International Federation of Gynecology and Obstetrics (FIGO) brought together international experts to discuss and evaluate current knowledge on PE and develop a document to frame the issues and suggest key actions to address the health burden posed by PE. FIGO's objectives, as outlined in this document, are: (1) To raise awareness of the links between PE and poor maternal and perinatal outcomes, as well as to the future health risks to mother and offspring, and demand a clearly defined global health agenda to tackle this issue; and (2) To create a consensus document that provides guidance for the first‐trimester screening and prevention of preterm PE, and to disseminate and encourage its use. Based on high‐quality evidence, the document outlines current global standards for the first‐trimester screening and prevention of preterm PE, which is in line with FIGO good clinical practice advice on first trimester screening and prevention of pre‐eclampsia in singleton pregnancy.1 It provides both the best and the most pragmatic recommendations according to the level of acceptability, feasibility, and ease of implementation that have the potential to produce the most significant impact in different resource settings. Suggestions are provided for a variety of different regional and resource settings based on their financial, human, and infrastructure resources, as well as for research priorities to bridge the current knowledge and evidence gap. To deal with the issue of PE, FIGO recommends the following: Public health focus: There should be greater international attention given to PE and to the links between maternal health and noncommunicable diseases (NCDs) on the Sustainable Developmental Goals agenda. Public health measures to increase awareness, access, affordability, and acceptance of preconception counselling, and prenatal and postnatal services for women of reproductive age should be prioritized. Greater efforts are required to raise awareness of the benefits of early prenatal visits targeted at reproductive‐aged women, particularly in low‐resource countries. Universal screening: All pregnant women should be screened for preterm PE during early pregnancy by the first‐trimester combined test with maternal risk factors and biomarkers as a one‐step procedure. The risk calculator is available free of charge at https://fetalmedicine.org/research/assess/preeclampsia. FIGO encourages all countries and its member associations to adopt and promote strategies to ensure this. The best combined test is one that includes maternal risk factors, measurements of mean arterial pressure (MAP), serum placental growth factor (PLGF), and uterine artery pulsatility index (UTPI). Where it is not possible to measure PLGF and/or UTPI, the baseline screening test should be a combination of maternal risk factors with MAP, and not maternal risk factors alone. If maternal serum pregnancy‐associated plasma protein A (PAPP‐A) is measured for routine first‐trimester screening for fetal aneuploidies, the result can be included for PE risk assessment. Variations to the full combined test would lead to a reduction in the performance screening. A woman is considered high risk when the risk is 1 in 100 or more based on the first‐trimester combined test with maternal risk factors, MAP, PLGF, and UTPI. Contingent screening: Where resources are limited, routine screening for preterm PE by maternal factors and MAP in all pregnancies and reserving measurements of PLGF and UTPI for a subgroup of the population (selected on the basis of the risk derived from screening by maternal factors and MAP) can be considered. Prophylactic measures: Following first‐trimester screening for preterm PE, women identified at high risk should receive aspirin prophylaxis commencing at 11–14+6 weeks of gestation at a dose of ~150 mg to be taken every night until 36 weeks of gestation, when delivery occurs, or when PE is diagnosed. Low‐dose aspirin should not be prescribed to all pregnant women. In women with low calcium intake (<800 mg/d), either calcium replacement (≤1 g elemental calcium/d) or calcium supplementation (1.5–2 g elemental calcium/d) may reduce the burden of both early‐ and late‐onset PE.
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Affiliation(s)
- Liona C. Poon
- Department of Obstetrics and Gynaecology, The Chinese
University of Hong Kong
| | - Andrew Shennan
- Department of Women and Children’s Health, FoLSM,
Kings College London
| | | | | | - Eran Hadar
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
| | | | - Fionnuala McAuliffe
- Department of Obstetrics and Gynaecology, National
Maternity Hospital Dublin, Ireland
| | - Fabricio da Silva Costa
- Department of Gynecology and Obstetrics, Ribeirão
Preto Medical School, University of São Paulo, Ribeirão Preto,
São Paulo, Brazil
| | | | | | - Anne B. Kihara
- African Federation of Obstetrics and Gynaecology,
Africa
| | - Gian Carlo Di Renzo
- Centre of Perinatal & Reproductive Medicine
Department of Obstetrics & Gynaecology University of Perugia, Perugia,
Italy
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and
Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy
Shriver National Institute of Child Health and Human Development,
National Institutes of Health, U. S. Department of Health and Human Services,
Bethesda, Maryland, and Detroit, Michigan, USA
| | - Mary D’Alton
- Society for Maternal-Fetal Medicine, Washington, DC,
USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of
Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson
University, Philadelphia, PA, USA
| | | | - Moshe Hod
- Helen Schneider Hospital for Women, Rabin Medical Center,
Petach Tikva, and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv
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Ngene NC, Moodley J, Naicker T. The performance of pre-delivery serum concentrations of angiogenic factors in predicting postpartum antihypertensive drug therapy following abdominal delivery in severe preeclampsia and normotensive pregnancy. PLoS One 2019; 14:e0215807. [PMID: 31022243 PMCID: PMC6485032 DOI: 10.1371/journal.pone.0215807] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Accepted: 04/09/2019] [Indexed: 01/07/2023] Open
Abstract
Background The imbalance between circulating concentrations of anti- and pro-angiogenic
factors is usually intense in preeclampsia with severe features (sPE). It is
possible that pre-delivery circulating levels of angiogenic factors in sPE
may be associated with postpartum antihypertensive drug requirements. Objective To determine the predictive association between maternal pre-delivery serum
concentrations of angiogenic factors and the use of ≥3 slow- and/or a
rapid-acting antihypertensive drug therapy in sPE on postpartum days zero to
three following caesarean delivery. Study design Women with sPE (n = 50) and normotensive pregnancies (n = 90) were recruited
prior to childbirth. Serum samples were obtained from each participant <
48 hours before delivery to assess the concentrations of placental growth
factor (PIGF) and soluble fms-like tyrosine kinase-1 (sFlt-1) using the
Roche Elecsys platform. Each participant was followed up on postpartum days
zero, one, two and three to monitor BP and confirm antihypertensive
treatment. The optimal cut-off thresholds of sFlt-1/PIGF ratio from receiver
operating characteristic curve predictive of the antihypertensive therapy
were subjected to diagnostic accuracy assessment. Results The majority 58% (29/50) of sPE had multiple severe features of preeclampsia
in the antenatal period with the commonest presentation being severe
hypertension in 88% (44/50) of this group, followed by features of impending
eclampsia which occurred in 42% (21/50). The median gestational age at
delivery was 38 (Interquartile range, IQR 1) vs 36 (IQR 6)
weeks, p < 0.001 in normotensive and sPE groups
respectively. Notably, the median sFlt-1/PIGF ratio in normotensive and sPE
groups were 7.3 (IQR 17.9) and 179.1 (IQR 271.2) respectively,
p < 0.001. Of the 50 sPE participants, 34% (17/50)
had early-onset preeclampsia. The median (IQR) of sFlt-1/PIGF in the early-
and late-onset preeclampsia groups were 313.52 (502.25), and 166.59(195.37)
respectively, p = 0.006. From postpartum days zero to
three, 48% (24/50) of sPE received ≥ 3 slow- and/or a rapid-acting
antihypertensive drug. However, the daily administration of ≥ 3 slow- and/or
a rapid-acting antihypertensive drug in sPE were pre-delivery 26% (13/50),
postpartum day zero 18% (9/50), postpartum day one 34% (17/50), postpartum
day two 24% (12/50) and postpartum day three 20% (10/50). In sPE, the
pre-delivery sFlt-1/PIGF ratio was predictive of administration of ≥3 slow-
and/or a rapid-acting antihypertensive drug on postpartum days zero, one and
two with the optimal cut-off ratio being ≥315.0, ≥181.5 and ≥ 267.8
respectively (sensitivity 72.7–75.0%, specificity 64.7–78.6%, positive
predictive value 40.0–50.0% and negative predictive value 84.6% - 94.3%).
The predictive performance of sFlt-1/PIG ratio on postpartum day 3 among the
sPE was not statistically significant (area under receiver operating
characteristic curve, 0.6; 95% CI, 0.3–0.8). Conclusion A pre-delivery sFlt-1/PIGF ratio (< 181.5) is a promising predictor for
excluding the need for ≥3 slow- and/or a rapid-acting antihypertensive drug
therapy in the immediate postpartum period in sPE.
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Affiliation(s)
- Nnabuike Chibuoke Ngene
- Department of Obstetrics and Gynaecology, University of KwaZulu-Natal,
South Africa
- * E-mail:
| | - Jagidesa Moodley
- Women’s Health and HIV Research Group, Department of Obstetrics and
Gynaecology, University of KwaZulu-Natal, South Africa
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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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MacDonald EJ, Lepine S, Pledger M, Geller SE, Lawton B, Stone P. Pre‐eclampsia causing severe maternal morbidity – A national retrospective review of preventability and opportunities for improved care. Aust N Z J Obstet Gynaecol 2019; 59:825-830. [DOI: 10.1111/ajo.12971] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/19/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Evelyn Jane MacDonald
- Women's Health Research CentreFaculty of HealthVictoria University of Wellington Wellington New Zealand
| | - Sam Lepine
- Wellington Regional Hospital Wellington New Zealand
| | - Megan Pledger
- Health Services Research CentreFaculty of HealthVictoria University of Wellington Wellington New Zealand
| | - Stacie E. Geller
- Centre for Research on Women and GenderUniversity of Illinois Chicago Illinois USA
| | - Bev Lawton
- Women's Health Research CentreFaculty of HealthVictoria University of Wellington Wellington New Zealand
| | - Peter Stone
- Department of Obstetrics and GynaecologyUniversity of Auckland Auckland New Zealand
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Ellis R, Katerelos M, Choy SW, Cook N, Lee M, Paizis K, Pell G, Walker S, Power DA, Mount PF. Increased expression and phosphorylation of 6-phosphofructo-2-kinase/fructose-2,6-bisphosphatase isoforms in urinary exosomes in pre-eclampsia. J Transl Med 2019; 17:60. [PMID: 30819197 PMCID: PMC6394033 DOI: 10.1186/s12967-019-1806-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 02/21/2019] [Indexed: 12/13/2022] Open
Abstract
Background Glycolysis is altered in various kidney diseases, but little is known about glycolysis in pre-eclampsia, a multi-system disorder with major pathological effects on the kidney. Urinary exosomes provide a non-invasive alternative for studying changes in kidney metabolism. This study aims to characterise the expression and phosphorylation of isozymes of the key glycolytic regulatory protein, 6-phosphofructokinase-2-kinase/fructose-2,6-bisphosphatase (PFK-2/FBPase-2), in urinary exosomes of subjects with pre-eclampsia (PE), compared to normotensive non-pregnant (NC) and normotensive pregnant (NP) controls. Methods A cross-sectional study of NC (n = 19), NP (n = 23) and PE (n = 29) subjects was performed. Exosomes were isolated from urine samples by differential ultracentrifugation, and then analyzed by Western blot and densitometry for expression of PFK-2/FBPase-2 isozymes (PFKFB2, PFKFB3 and PFKFB4) and phosphorylation of PFKFB2 at residues Ser483 and Ser466 and PFKFB3 at Ser461. Results PFKFB2 expression was increased 4.7-fold in PE compared to NP (p < 0.001). PFKFB2 phosphorylation at Ser483 was increased 2.6-fold in PE compared to NP (p = 0.002). Expression of phosphorylated PFKFB2/PFKFB3 at Ser466/Ser461 was increased in PE, being present in 77.4% (95% CI 59.9–88.9%) of PE and 8.3% (95% CI 1.2–27.0%) of NP samples (p < 0.001). PFKFB3 was more commonly expressed in PE, detected in 90.3% (95% CI 74.3–97.4%) of PE and 8.3% (95% CI 1.2–27.0%) of NP samples (p < 0.001). PFKFB4 had a 7.2-fold increase in expression in PE compared to NP (p < 0.001). No significant differences between NP and NC groups were observed. Conclusion Regulatory proteins that increase glycolysis are increased in the urinary exosomes of subjects with pre-eclampsia, suggesting that renal glycolysis may be increased in this condition.
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Affiliation(s)
- R Ellis
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia.,Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - M Katerelos
- Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Kidney Laboratory, Institute for Breathing and Sleep, Heidelberg, Australia
| | - S W Choy
- Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - N Cook
- Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - M Lee
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia.,Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Kidney Laboratory, Institute for Breathing and Sleep, Heidelberg, Australia
| | - K Paizis
- Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia
| | - G Pell
- Mercy Hospital for Women, Heidelberg, Australia
| | - S Walker
- Mercy Hospital for Women, Heidelberg, Australia
| | - D A Power
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia.,Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.,Kidney Laboratory, Institute for Breathing and Sleep, Heidelberg, Australia
| | - P F Mount
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Parkville, Australia. .,Department of Nephrology, Austin Health, Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia. .,Kidney Laboratory, Institute for Breathing and Sleep, Heidelberg, Australia.
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145
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Developing management pathways for hypertensive disorders of pregnancy (HDP) in Indonesian primary care: a study protocol. Reprod Health 2019; 16:12. [PMID: 30709408 PMCID: PMC6359831 DOI: 10.1186/s12978-019-0674-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 01/20/2019] [Indexed: 01/15/2023] Open
Abstract
Background National and international guidelines for the management of hypertensive disorders of pregnancy (HDP) are available in developing countries. However, more detailed clinical pathways for primary care settings are limited. This study focuses on Indonesia, where 72% of women who died from HDP and its complications had received less appropriate treatment according to international guidelines. There is an urgent need to develop primary care focused pathways that enable general practitioners (GPs), midwives and other relevant providers to manage HDP better. Objectives This paper describes a study protocol for the development of HDP management pathways for Indonesian primary care settings. Methods This study design is informed by Implementation Science theories and consists of three phases. The exploratory phase will involve conducting semi-structured interviews with key Indonesian primary care stakeholders to explore their experiences and views on HDP management. The development phase will apply evidence from the literature review and results of the exploratory phase to develop HDP management pathways contextualised to Indonesian primary care settings. Consensus will be sought from approximately 50 experts, consist of general practitioners (GPs), midwives, obstetricians, nurses and policy makers using Delphi technique survey. The evaluation phase will involve a pilot study to evaluate the pathways’ acceptability and feasibility in a sample of Indonesian primary care practices using mixed methods. Discussion The implementation science frameworks inform and guide the phases in this study. Qualitative interviews in the exploratory phase are conducive to eliciting opinions from key stakeholders. Using Delphi technique at the development phase is suitable to seek participants’ consensus on HDP management in primary care. Observations, focus group discussions, interviews as well as analysis of patients’ medical records at the evaluation phase are expected to provide a comprehensive investigation of the implementation of the pathways in practice settings.
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146
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Cox AG, Marshall SA, Palmer KR, Wallace EM. Current and emerging pharmacotherapy for emergency management of preeclampsia. Expert Opin Pharmacother 2019; 20:701-712. [PMID: 30707633 DOI: 10.1080/14656566.2019.1570134] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Preeclampsia is a disease specific to pregnancy characterised by new onset hypertension with maternal organ dysfunction and/or fetal growth restriction. It remains a major cause of maternal and perinatal morbidity and mortality. For fifty years, antihypertensives have been the mainstay of treating preeclampsia, reducing maternal morbidity and mortality. With increased knowledge of the mechanisms underlying the disease has come opportunities for novel therapies that complement antihypertensives by protecting the maternal vasculature. Areas covered: In this review, the authors consider, in detail, the antihypertensives commonly used today in the emergency care of women with severe preeclampsia. They also review less common anti-hypertensive agents and discuss the role of magnesium sulphate in the management of preeclampsia and the prevention of eclampsia. Finally, they explore novel therapeutics for the acute management of preeclampsia. Expert opinion: The rapid control of maternal hypertension will, and must, remain the mainstay of emergency treatment for women with severe preeclampsia. The role of magnesium sulphate as a primary prevention for eclampsia is context dependant and should not displace a focus on correcting blood pressure safely. The exploration of novel adjuvant therapies will likely allow us to prolong pregnancy longer and improve perinatal outcomes safely for the mother.
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Affiliation(s)
- Annie G Cox
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Sarah A Marshall
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
| | - Kirsten R Palmer
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia
| | - Euan M Wallace
- a Ritchie Centre, Department of Obstetrics and GynaecologySchool of Clinical Sciences , Monash University , Clayton , Australia.,b The Ritchie Centre , Hudson Institute of Medical Research , Clayton , Australia
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147
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Cao Y, Wang M, Yuan Y, Li C, Bai Q, Li M. Arterial blood gas and acid-base balance in patients with pregnancy-induced hypertension syndrome. Exp Ther Med 2019; 17:349-353. [PMID: 30651802 PMCID: PMC6307481 DOI: 10.3892/etm.2018.6893] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 10/11/2018] [Indexed: 12/29/2022] Open
Abstract
This study aimed to investigate the expression of arterial blood gas and acid-base balance in patients with pregnancy-induced hypertension syndrome and their influence on newborns. A total of 348 patients with pregnancy-induced hypertension syndrome (research group) admitted and treated in the First People's Hospital of Jining from March 2013 to March 2016 were retrospectively analyzed, and another 156 cases of healthy pregnant women who were physically examined were selected as the control group. Blood gas analysis was performed on pregnant women, and pH value, partial pressure of oxygen (PO2), partial pressure of carbon dioxide (PCO2), bicarbonate radical (HCO3-) and base excess (BE) were included as test indexes. Apgar score was made for newborns for neonatal asphyxia. The evaluation was performed at 1, 5, and 10 min after birth to analyze the correlation between the maternal arterial blood pH and the neonatal Apgar score. The pH value, and PO2 and HCO3- levels in the research group were lower than those in the control group (p<0.05). PCO2 and BE levels in the research group were higher than those in the control group (p<0.05). The incidence of neonatal mild asphyxia (Apgar score, 4-6 points) and neonatal severe asphyxia (Apgar score, <4 points) in the research group were higher than that in the control group (p<0.05). The Apgar score of newborns was positively correlated with the pH value of the arterial blood of pregnant women. Blood gas analysis in patients with pregnancy-induced hypertension syndrome is useful to a certain extent to evaluate the condition of the patient. The combination of the pH value of the patient and the Apgar score of the newborns may help improve the judgement rate of neonatal asphyxia so as to improve the quality of childbirth by early monitoring and intervention of the newborns.
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Affiliation(s)
- Yali Cao
- Department of Obstetrics, The First People's Hospital of Jining, Jining, Shandong 272011, P.R. China
| | - Meichun Wang
- Department of Clinical Laboratory, Yantaishan Hospital of Yantai, Yantai, Shandong 264025, P.R. China
| | - Yuchao Yuan
- Department of Ultrasound, People's Hospital of Zhangqiu District, Jinan, Shandong 250000, P.R. China
| | - Cong Li
- Department of Otolaryngology, People's Hospital of Zhangqiu District, Jinan, Shandong 250000, P.R. China
| | - Qinglin Bai
- Department of Operating Room, People's Hospital of Zhangqiu District, Jinan, Shandong 250000, P.R. China
| | - Min Li
- Department of Obstetrics, The First People's Hospital of Jining, Jining, Shandong 272011, P.R. China
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Galbally M, Frayne J, Watson SJ, Snellen M. Psychopharmacological prescribing practices in pregnancy for women with severe mental illness: A multicentre study. Eur Neuropsychopharmacol 2019; 29:57-65. [PMID: 30497841 DOI: 10.1016/j.euroneuro.2018.11.1103] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/26/2018] [Accepted: 11/09/2018] [Indexed: 01/26/2023]
Abstract
There is little known about real world psychopharmacological prescribing practices in managing pregnant women with severe mental illness (SMI). This study utilised a sample of 535 women with a SMI across two hospitals in Australia. This included women with psychotic disorders, bipolar disorder and a range of non-psychotic disorders. The majority of women with a SMI in pregnancy were prescribed psychotropic medication as part of their management. Furthermore, more than one class of agent was prescribed for 31% of women with psychotic disorders and 30% of women with bipolar disorder. Differences between sites were identified in prescribing practices across the mental disorders. This included the variation in rates of use of multiple agents and pattern of use across pregnancy. This study also identified that women with a SMI had elevated rates of gestational hypertension, gestational diabetes mellitus, smoking and obesity in pregnancy and neonates admitted following delivery compared with the Australian average. These findings suggest that studies that examine associated risks for severe mental disorders or their treatments on pregnancy and infant outcomes should take into account the prescribing practices including the likelihood of exposure to polypharmacy and a range of potential confounding co-morbidities and exposures. The discrepancies in reported findings for pregnancy and infant outcomes following use of antipsychotic and mood stabiliser agents such as lithium may be at least partially accounted for by the complexity of multiple exposures that includes use of multiple psychopharmacological agents, co-exposures such as smoking and co-morbid conditions such as obesity.
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Affiliation(s)
- Megan Galbally
- School of Psychology and Exercise Science, Murdoch University, 90 South Street, Murdoch, WA 6150, Australia; School of Medicine, University of Notre Dame, Australia; King Edward Memorial Hospital, Australia.
| | - Jacqueline Frayne
- King Edward Memorial Hospital, Australia; School of Medicine, Division of General Practice, The University of Western Australia, Australia
| | - Stuart J Watson
- School of Psychology and Exercise Science, Murdoch University, 90 South Street, Murdoch, WA 6150, Australia; School of Medicine, University of Notre Dame, Australia
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149
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Marshall SA, Cox AG, Parry LJ, Wallace EM. Targeting the vascular dysfunction: Potential treatments for preeclampsia. Microcirculation 2018; 26:e12522. [PMID: 30556222 DOI: 10.1111/micc.12522] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Revised: 11/22/2018] [Accepted: 12/10/2018] [Indexed: 12/18/2022]
Abstract
Preeclampsia is a pregnancy-specific disorder, primarily characterized by new-onset hypertension in combination with a variety of other maternal or fetal signs. The pathophysiological mechanisms underlying the disease are still not entirely clear. Systemic maternal vascular dysfunction underlies the clinical features of preeclampsia. It is a result of oxidative stress and the actions of excessive anti-angiogenic factors, such as soluble fms-like tyrosine kinase, soluble endoglin, and activin A, released by a dysfunctional placenta. The vascular dysfunction then leads to impaired regulation and secretion of relaxation factors and an increase in sensitivity/production of constrictors. This results in a more constricted vasculature rather than the relaxed vasodilated state associated with normal pregnancy. Currently, the only effective "treatment" for preeclampsia is delivery of the placenta and therefore the baby. Often, this means a preterm delivery to save the life of the mother, with all the attendant risks and burdens associated with fetal prematurity. To lessen this burden, there is a pressing need for more effective treatments that target the maternal vascular dysfunction that underlies the hypertension. This review details the vascular effects of key drugs undergoing clinical assessment as potential treatments for women with preeclampsia.
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Affiliation(s)
- Sarah A Marshall
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Annie G Cox
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
| | - Laura J Parry
- School of BioSciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Euan M Wallace
- Departments of Obstetrics and Gynaecology and Medicine, School of Clinical Sciences, The Ritchie Centre, Monash University, Clayton, Victoria, Australia
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Kahsay HB, Gashe FE, Ayele WM. Risk factors for hypertensive disorders of pregnancy among mothers in Tigray region, Ethiopia: matched case-control study. BMC Pregnancy Childbirth 2018; 18:482. [PMID: 30522444 PMCID: PMC6282279 DOI: 10.1186/s12884-018-2106-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 11/20/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Hypertensive disorders of pregnancy are a global public health concern both in developed and developing countries. However, evidences regarding the risk factors of hypertensive disorders of pregnancy are limited particularly in Ethiopia. The aim of the study was to assess risk factors associated with hypertensive disorders of pregnancy among mothers in public hospitals of Tigray. METHODS The study was conducted in seven public hospitals of Tigray region, Ethiopia from June 2017 to November 2017. A facility based matched case-control study was employed to select 110 cases and 220 controls who were pregnant women. Cases and controls were matched by parity status. A case was a mother diagnosed to have hypertensive disorders of pregnancy by an obstetrician in the antenatal period while a control was a mother who did not have a diagnosis of hypertensive disorders of pregnancy. Data were collected by face to face interview technique using a pretested questionnaire and a checklist. Conditional logistic regression analysis was used to identify the independent predictor variables. Adjusted matched odds ratio with its corresponding 95% confidence interval was used and significance was claimed at P-value less than 0.05. Overall findings were presented in texts and tables. RESULTS Rural residents were at greater odds of suffering from hypertensive disorders (OR = 3.7, 95% CI; 1.9, 7.1). Similarly, mothers who consume less amount of fruits in their diet had 5 times higher odds of developing hypertensive disorders than those who consume fruits regularly (OR = 5.1, 95% CI; 2.4, 11.15). Overweight (BMI > 25 Kg/m2) mothers were also at risk of developing hypertensive disorders of pregnancy as compared with the normal and underweight mothers (AOR = 5.5 95% CI; 1.12, 27.6). The risk of developing hypertensive disorders of pregnancy was 5.4 times higher among diabetic mothers. CONCLUSION Rural residence, less fruit consumption, multiple pregnancy, presence of gestational diabetes mellitus and pre-pregnancy overweight were identified as independent risk factors in this study. It is recommended that health care givers may use these factors as a screening tool for the prediction, early diagnoses as well as timely interventions of hypertensive disorders of pregnancy.
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