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Morris RK, Johnstone E, Lees C, Morton V, Smith G. Investigation and Care of a Small-for-Gestational-Age Fetus and a Growth Restricted Fetus (Green-top Guideline No. 31). BJOG 2024; 131:e31-e80. [PMID: 38740546 DOI: 10.1111/1471-0528.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Key recommendations
All women should be assessed at booking (by 14 weeks) for risk factors for fetal growth restriction (FGR) to identify those who require increased surveillance using an agreed pathway [Grade GPP]. Findings at the midtrimester anomaly scan should be incorporated into the fetal growth risk assessment and the risk assessment updated throughout pregnancy. [Grade GPP]
Reduce smoking in pregnancy by identifying women who smoke with the assistance of carbon monoxide (CO) testing and ensuring in‐house treatment from a trained tobacco dependence advisor is offered to all pregnant women who smoke, using an opt‐out referral process. [Grade GPP]
Women at risk of pre‐eclampsia and/or placental dysfunction should take aspirin 150 mg once daily at night from 12+0–36+0 weeks of pregnancy to reduce their chance of small‐for‐gestational‐age (SGA) and FGR. [Grade A]
Uterine artery Dopplers should be carried out between 18+0 and 23+6 weeks for women at high risk of fetal growth disorders [Grade B]. In a woman with normal uterine artery Doppler and normal fetal biometry at the midtrimester scan, serial ultrasound scans for fetal biometry can commence at 32 weeks. Women with an abnormal uterine artery Doppler (mean pulsatility index > 95th centile) should commence ultrasound scans at 24+0–28+6 weeks based on individual history. [Grade B]
Women who are at low risk of FGR should have serial measurement of symphysis fundal height (SFH) at each antenatal appointment after 24+0 weeks of pregnancy (no more frequently than every 2 weeks). The first measurement should be carried out by 28+6 weeks. [Grade C]
Women in the moderate risk category are at risk of late onset FGR so require serial ultrasound scan assessment of fetal growth commencing at 32+0 weeks. For the majority of women, a scan interval of four weeks until birth is appropriate. [Grade B]
Maternity providers should ensure that they clearly identify the reference charts to plot SFH, individual biometry and estimated fetal weight (EFW) measurements to calculate centiles. For individual biometry measurements the method used for measurement should be the same as those used in the development of the individual biometry and fetal growth chart [Grade GPP]. For EFW the Hadlock three parameter model should be used. [Grade C]
Maternity providers should ensure that they have guidance that promotes the use of standard planes of acquisition and calliper placement when performing ultrasound scanning for fetal growth assessment. Quality control of images and measurements should be undertaken. [Grade C]
Ultrasound biometry should be carried out every 2 weeks in fetuses identified to be SGA [Grade C]. Umbilical artery Doppler is the primary surveillance tool and should be carried out at the point of diagnosis of SGA and during follow‐up as a minimum every 2 weeks. [Grade B]
In fetuses with an EFW between the 3rd and 10th centile, other features must be present for birth to be recommended prior to 39+0 weeks, either maternal (maternal medical conditions or concerns regarding fetal movements) or fetal compromise (a diagnosis of FGR based on Doppler assessment, fetal growth velocity or a concern on cardiotocography [CTG]) [Grade C]. For fetuses with an EFW or abdominal circumference less than the 10th centile where FGR has been excluded, birth or the initiation of induction of labour should be considered at 39+0 weeks after discussion with the woman and her partner/family/support network. Birth should occur by 39+6 weeks. [Grade B]
Pregnancies with early FGR (prior to 32+0 weeks) should be monitored and managed with input from tertiary level units with the highest level neonatal care. Care should be multidisciplinary by neonatology and obstetricians with fetal medicine expertise, particularly when extremely preterm (before 28 weeks) [Grade GPP]. Fetal biometry in FGR should be repeated every 2 weeks [Grade B]. Assessment of fetal wellbeing can include multiple modalities but must include computerised CTG and/or ductus venous. [Grade B]
In pregnancies with late FGR, birth should be initiated from 37+0 weeks to be completed by 37+6 weeks [Grade A]. Decisions for birth should be based on fetal wellbeing assessments or maternal indication. [Grade GPP]
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Fuenzalida B, Yañez MJ, Mueller M, Mistry HD, Leiva A, Albrecht C. Evidence for hypoxia-induced dysregulated cholesterol homeostasis in preeclampsia: Insights into the mechanisms from human placental cells and tissues. FASEB J 2024; 38:e23431. [PMID: 38265294 PMCID: PMC10953329 DOI: 10.1096/fj.202301708rr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 01/25/2024]
Abstract
Preeclampsia (PE) poses a considerable risk to the long-term cardiovascular health of both mothers and their offspring due to a hypoxic environment in the placenta leading to reduced fetal oxygen supply. Cholesterol is vital for fetal development by influencing placental function. Recent findings suggest an association between hypoxia, disturbed cholesterol homeostasis, and PE. This study investigates the influence of hypoxia on placental cholesterol homeostasis. Using primary human trophoblast cells and placentae from women with PE, various aspects of cholesterol homeostasis were examined under hypoxic and hypoxia/reoxygenation (H/R) conditions. Under hypoxia and H/R, intracellular total and non-esterified cholesterol levels were significantly increased. This coincided with an upregulation of HMG-CoA-reductase and HMG-CoA-synthase (key genes regulating cholesterol biosynthesis), and a decrease in acetyl-CoA-acetyltransferase-1 (ACAT1), which mediates cholesterol esterification. Hypoxia and H/R also increased the intracellular levels of reactive oxygen species and elevated the expression of hypoxia-inducible factor (HIF)-2α and sterol-regulatory-element-binding-protein (SREBP) transcription factors. Additionally, exposure of trophoblasts to hypoxia and H/R resulted in enhanced cholesterol efflux to maternal and fetal serum. This was accompanied by an increased expression of proteins involved in cholesterol transport such as the scavenger receptor class B type I (SR-BI) and the ATP-binding cassette transporter G1 (ABCG1). Despite these metabolic alterations, mitogen-activated-protein-kinase (MAPK) signaling, a key regulator of cholesterol homeostasis, was largely unaffected. Our findings indicate dysregulation of cholesterol homeostasis at multiple metabolic points in both the trophoblast hypoxia model and placentae from women with PE. The increased cholesterol efflux and intracellular accumulation of non-esterified cholesterol may have critical implications for both the mother and the fetus during pregnancy, potentially contributing to an elevated cardiovascular risk later in life.
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Affiliation(s)
- Barbara Fuenzalida
- Institute of Biochemistry and Molecular Medicine, Faculty of MedicineUniversity of BernBernSwitzerland
| | - Maria Jose Yañez
- School of Medical Technology, Faculty of Medicine and ScienceUniversidad San SebastiánSantiagoChile
| | - Martin Mueller
- Division of Gynecology and ObstetricsLindenhofgruppeBernSwitzerland
- Department for BioMedical ResearchUniversity of BernBernSwitzerland
| | - Hiten D. Mistry
- Department of Women and Children's HealthSchool of Life Course and Population Health Sciences, King's College LondonLondonUK
| | - Andrea Leiva
- School of Medical Technology, Faculty of Medicine and ScienceUniversidad San SebastiánSantiagoChile
| | - Christiane Albrecht
- Institute of Biochemistry and Molecular Medicine, Faculty of MedicineUniversity of BernBernSwitzerland
- Swiss National Center of Competence in Research, NCCR TransCureUniversity of BernBernSwitzerland
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3
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Wei X, Yang X. The central role of natural killer cells in preeclampsia. Front Immunol 2023; 14:1009867. [PMID: 36865565 PMCID: PMC9972679 DOI: 10.3389/fimmu.2023.1009867] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 01/31/2023] [Indexed: 02/16/2023] Open
Abstract
Preeclampsia (PE) is a disease that is unique to pregnancy and affects multiple systems. It can lead to maternal and perinatal mortality. The precise etiology of PE is unclear. Patients with PE may have systemic or local immune abnormalities. A group of researchers has proposed that the immune communication between the fetus and mother is primarily moderated by natural killer (NK) cells as opposed to T cells, since NK cells are the most abundant immune cells in the uterus. This review examines the immunological roles of NK cells in the pathogenesis of PE. Our aim is to provide obstetricians with a comprehensive and updated research progress report on NK cells in PE patients. It has been reported that decidual NK (dNK) cells contribute to the process of uterine spiral artery remodeling and can modulate trophoblast invasion. Additionally, dNK cells can stimulate fetal growth and regulate delivery. It appears that the count or proportion of circulating NK cells is elevated in patients with or at risk for PE. Changes in the number or function of dNK cells may be the cause of PE. The Th1/Th2 equilibrium in PE has gradually shifted to an NK1/NK2 equilibrium based on cytokine production. An improper combination of killer cell immunoglobulin-like receptor (KIR) and human leukocyte antigen (HLA)-C may lead to insufficient activation of dNK cells, thereby causing PE. In the etiology of PE, NK cells appear to exert a central effect in both peripheral blood and the maternal-fetal interface. To maintain immune equilibrium both locally and systemically, it is necessary to take therapeutic measures directed at NK cells.
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Affiliation(s)
- Xiaoqi Wei
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
| | - Xiuhua Yang
- Department of Obstetrics, The First Hospital of China Medical University, Shenyang, China
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4
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Simons NE, Leeuw M, van’t Hooft J, Limpens J, Roseboom TJ, Oudijk MA, Pajkrt E, Finken MJJ, Painter RC. The long-term effect of prenatal progesterone treatment on child development, behaviour and health: a systematic review. BJOG 2021; 128:964-974. [PMID: 33112462 PMCID: PMC8246867 DOI: 10.1111/1471-0528.16582] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 10/17/2020] [Accepted: 10/22/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Progesterone is widely used in prenatal care. However, long-term effects of prenatal progesterone treatment on child development are unclear. OBJECTIVES To evaluate long-term outcomes in children after prenatal progesterone treatment. SEARCH STRATEGY MEDLINE, Embase and Cochrane Central Register of Controlled Trials from inception to 24 May 2020. SELECTION CRITERIA Randomised controlled trials (RCTs) reporting outcomes in children born to women who received progesterone treatment (compared with placebo or another intervention) during any trimester in pregnancy. DATA COLLECTION AND ANALYSIS Two authors independently selected and extracted data. We used the Cochrane Risk of Bias tool for randomised trials and Quality In Prognosis Studies. MAIN RESULTS Of 388 papers, we included seven articles based on five RCTs, comprising 4222 measurements of children aged 6 months to 8 years. All studies compared progesterone to placebo in second and/or third trimester for the prevention of preterm birth. Meta-analysis (two studies, n = 890 children) showed no difference in neurodevelopment as assessed by the Bayley-III Cognitive Composite score at 2 years between children exposed to progesterone versus placebo (Standardised Mean Difference -0.04, 95% Confidence Interval -0.26 to 0.19), I2 = 22%. Heterogeneity prohibited additional meta-analyses. Other long-term outcomes showed no differences. CONCLUSIONS Our systematic review comprising a multitude of developmental measurements with a broad age range did not find evidence of benefit or harm in offspring prenatally exposed to progesterone treatment for the prevention of preterm birth. We identified an urgent need for follow-up studies of prenatal progesterone administration in early pregnancy and effects in offspring beyond early childhood. TWEETABLE ABSTRACT Progesterone to prevent preterm birth: no effect on child development. Outcomes after first trimester progesterone are unclear.
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Affiliation(s)
- NE Simons
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - M Leeuw
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J van’t Hooft
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - J Limpens
- Medical LibraryResearch SupportAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - TJ Roseboom
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
- Department of Epidemiology and Data ScienceAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - MA Oudijk
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - E Pajkrt
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
| | - MJJ Finken
- Department of Paediatric EndocrinologyEmma Children’s HospitalAmsterdam UMCAmsterdamThe Netherlands
| | - RC Painter
- Department of ObstetricsAmsterdam Reproduction and Development Research InstituteAmsterdam UMCUniversity of AmsterdamAmsterdamThe Netherlands
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Ota E, da Silva Lopes K, Middleton P, Flenady V, Wariki WM, Rahman MO, Tobe-Gai R, Mori R. Antenatal interventions for preventing stillbirth, fetal loss and perinatal death: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2020; 12:CD009599. [PMID: 33336827 PMCID: PMC8078228 DOI: 10.1002/14651858.cd009599.pub2] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Stillbirth is generally defined as a death prior to birth at or after 22 weeks' gestation. It remains a major public health concern globally. Antenatal interventions may reduce stillbirths and improve maternal and neonatal outcomes in settings with high rates of stillbirth. There are several key antenatal strategies that aim to prevent stillbirth including nutrition, and prevention and management of infections. OBJECTIVES To summarise the evidence from Cochrane systematic reviews on the effects of antenatal interventions for preventing stillbirth for low risk or unselected populations of women. METHODS We collaborated with Cochrane Pregnancy and Childbirth's Information Specialist to identify all their published reviews that specified or reported stillbirth; and we searched the Cochrane Database of Systematic Reviews (search date: 29 Feburary 2020) to identify reviews published within other Cochrane groups. The primary outcome measure was stillbirth but in the absence of stillbirth data, we used perinatal mortality (both stillbirth and death in the first week of life), fetal loss or fetal death as outcomes. Two review authors independently evaluated reviews for inclusion, extracted data and assessed quality of evidence using AMSTAR (A Measurement Tool to Assess Reviews) and GRADE tools. We assigned interventions to categories with graphic icons to classify the effectiveness of interventions as: clear evidence of benefit or harm; clear evidence of no effect or equivalence; possible benefit or harm; or unknown benefit or harm or no effect or equivalence. MAIN RESULTS We identified 43 Cochrane Reviews that included interventions in pregnant women with the potential for preventing stillbirth; all of the included reviews reported our primary outcome 'stillbirth' or in the absence of stillbirth, 'perinatal death' or 'fetal loss/fetal death'. AMSTAR quality was high in 40 reviews with scores ranging from 8 to 11 and moderate in three reviews with a score of 7. Nutrition interventions Clear evidence of benefit: balanced energy/protein supplementation versus no supplementation suggests a probable reduction in stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94, 5 randomised controlled trials (RCTs), 3408 women; moderate-certainty evidence). Clear evidence of no effect or equivalence for stillbirth or perinatal death: vitamin A alone versus placebo or no treatment; and multiple micronutrients with iron and folic acid versus iron with or without folic acid. Unknown benefit or harm or no effect or equivalence: for all other nutrition interventions examined the effects were uncertain. Prevention and management of infections Possible benefit for fetal loss or death: insecticide-treated anti-malarial nets versus no nets (RR 0.67, 95% CI 0.47 to 0.97, 4 RCTs; low-certainty). Unknown evidence of no effect or equivalence: drugs for preventing malaria (stillbirth RR 1.02, 95% CI 0.76 to 1.36, 5 RCTs, 7130 women, moderate certainty in women of all parity; perinatal death RR 1.24, 95% CI 0.94 to 1.63, 4 RCTs, 5216 women, moderate-certainty in women of all parity). Prevention, detection and management of other morbidities Clear evidence of benefit: the following interventions suggest a reduction: midwife-led models of care in settings where the midwife is the primary healthcare provider particularly for low-risk pregnant women (overall fetal loss/neonatal death reduction RR 0.84, 95% CI 0.71 to 0.99, 13 RCTs, 17,561 women; high-certainty), training versus not training traditional birth attendants in rural populations of low- and middle-income countries (stillbirth reduction odds ratio (OR) 0.69, 95% CI 0.57 to 0.83, 1 RCT, 18,699 women, moderate-certainty; perinatal death reduction OR 0.70, 95% CI 0.59 to 0.83, 1 RCT, 18,699 women, moderate-certainty). Clear evidence of harm: a reduced number of antenatal care visits probably results in an increase in perinatal death (RR 1.14 95% CI 1.00 to 1.31, 5 RCTs, 56,431 women; moderate-certainty evidence). Clear evidence of no effect or equivalence: there was evidence of no effect in the risk of stillbirth/fetal loss or perinatal death for the following interventions and comparisons: psychosocial interventions; and providing case notes to women. Possible benefit: community-based intervention packages (including community support groups/women's groups, community mobilisation and home visitation, or training traditional birth attendants who made home visits) may result in a reduction of stillbirth (RR 0.81, 95% CI 0.73 to 0.91, 15 RCTs, 201,181 women; low-certainty) and perinatal death (RR 0.78, 95% CI 0.70 to 0.86, 17 RCTs, 282,327 women; low-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. Screening and management of fetal growth and well-being Clear evidence of benefit: computerised antenatal cardiotocography for assessing infant's well-being in utero compared with traditional antenatal cardiotocography (perinatal mortality reduction RR 0.20, 95% CI 0.04 to 0.88, 2 RCTs, 469 women; moderate-certainty). Unknown benefit or harm or no effect or equivalence: the effects were uncertain for other interventions examined. AUTHORS' CONCLUSIONS While most interventions were unable to demonstrate a clear effect in reducing stillbirth or perinatal death, several interventions suggested a clear benefit, such as balanced energy/protein supplements, midwife-led models of care, training versus not training traditional birth attendants, and antenatal cardiotocography. Possible benefits were also observed for insecticide-treated anti-malarial nets and community-based intervention packages, whereas a reduced number of antenatal care visits were shown to be harmful. However, there was variation in the effectiveness of interventions across different settings, indicating the need to carefully understand the context in which these interventions were tested. Further high-quality RCTs are needed to evaluate the effects of antenatal preventive interventions and which approaches are most effective to reduce the risk of stillbirth. Stillbirth (or fetal death), perinatal and neonatal death need to be reported separately in future RCTs of antenatal interventions to allow assessment of different interventions on these rare but important outcomes and they need to clearly define the target populations of women where the intervention is most likely to be of benefit. As the high burden of stillbirths occurs in low- and middle-income countries, further high-quality trials need to be conducted in these settings as a priority.
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Affiliation(s)
- Erika Ota
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University , Tokyo, Japan
| | | | - Philippa Middleton
- Healthy Mothers, Babies and Children, South Australian Health and Medical Research Institute, Adelaide, Australia
| | - Vicki Flenady
- NHMRC Centre of Research Excellence in Stillbirth, Mater Research Institute - The University of Queensland (MRI-UQ), Brisbane, Australia
| | - Windy Mv Wariki
- Faculty of Medicine, Sam Ratulangi University, Manado, Indonesia
| | - Md Obaidur Rahman
- Global Health Nursing, Graduate School of Nursing Science, St. Luke's International University, Tokyo, Japan
| | | | - Rintaro Mori
- Graduate School of Medicine, Kyoto University, Kyoto, Japan
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17-Hydroxyprogesterone caproate improves T cells and NK cells in response to placental ischemia; new mechanisms of action for an old drug. Pregnancy Hypertens 2019; 19:226-232. [PMID: 31806502 DOI: 10.1016/j.preghy.2019.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 11/11/2019] [Accepted: 11/15/2019] [Indexed: 11/22/2022]
Abstract
Preeclampsia (PE) is new onset hypertension during pregnancy associated with increased uterine artery resistance (UARI) and an imbalance among CD4 + T lymphocytes and natural killer (NK) cells. We have shown an important role for 17-hydroxyprogesterone caproate (17-OHPC) to improve hypertension and fetal demise in the RUPP rat model of PE. However we have not examined a role for 17-OHPC to improve NK cells and CD4+TH2 cells as possible mechanisms for improved fetal weight and hypertension. Therefore, we hypothesized that 17-OHPC lowers NK cells while improving the T cell ratio in the RUPP rat. RUPP was surgically induced on gestational day 14 in pregnant rats. 17-OHPC (3.32 mg/kg) was administered intraperitoneal on day 15, UARI was measured on day 18. Blood pressure (MAP), blood and tissues were collected on GD 19. MAP in NP rats (n = 9) was 100 ± 2, 104 ± 6 in Sham rats (n = 8), 128 ± 2 in RUPP (n = 11) and 115 ± 3 mmHg in RUPP + 17-OHPC (n = 10), p < 0.05. Pup weight and UARI were improved after 17-OHPC. Total and cytolytic placental NK cells were 38 ± 5, and 12 ± 2% gate in RUPP rats which decreased to 1.6 ± 0.5 and 0.4 ± 0.2% gate in RUPP + 17OHPC rats. CD4+ T cells were 40 ± 3 in RUPP rats, which significantly decreased to 7 ± 1 RUPP + 17-OHPC rats. Circulating and placental TH2 cells were 6.0 ± 1, 0.3 ± 0.1% gate in RUPP rats and 12 ± 1%, 2 ± 0.5% gate in RUPP + 17-OHPC rats, p < 0.05 This study identifies new mechanisms whereby 17-OHPC improves outcomes in response to placental ischemia.
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Haruna M, Matsuzaki M, Ota E, Shiraishi M, Hanada N, Mori R. Guided imagery for treating hypertension in pregnancy. Cochrane Database Syst Rev 2019; 4:CD011337. [PMID: 31032884 PMCID: PMC6487386 DOI: 10.1002/14651858.cd011337.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Hypertension (high blood pressure) in pregnancy carries a high risk of maternal morbidity and mortality. Although antihypertensive drugs are commonly used, they have adverse effects on mothers and fetuses. Guided imagery is a non-pharmacological technique that has the potential to lower blood pressure among pregnant women with hypertension. Guided imagery is a mind-body therapy that involves the visualisation of various mental images to facilitate relaxation and reduction in blood pressure. OBJECTIVES To determine the effect of guided imagery as a non-pharmacological treatment of hypertension in pregnancy and its influence on perinatal outcomes. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register, and two trials registers (October 2018). We also searched relevant conference proceedings and journals, and scanned the reference lists of retrieved studies. SELECTION CRITERIA We included randomised controlled trials (RCTs). We would have included RCTs using a cluster-randomised design, but none were identified. We excluded quasi-RCTs and cross-over trials.We sought intervention studies of various guided imagery techniques performed during pregnancy in comparison with no intervention or other non-pharmacological treatments for hypertension (e.g. quiet rest, music therapy, aromatherapy, relaxation therapy, acupuncture, acupressure, massage, device-guided slow breathing, hypnosis, physical exercise, and yoga). DATA COLLECTION AND ANALYSIS Three review authors independently assessed the trials for inclusion, extracted data, and assessed risk of bias for the included studies. We checked extracted data for accuracy, and resolved differences in assessments by discussion. We assessed the certainty of the evidence using the GRADE approach. MAIN RESULTS We included two small trials (involving a total of 99 pregnant women) that compared guided imagery with quiet rest. The trials were conducted in Canada and the USA. We assessed both trials as at high risk of performance bias, and low risk of attrition bias; one trial was at low risk for selection, detection, and reporting bias, while the other was at unclear risk for the same domains.We could not perform a meta-analysis because the two included studies reported different outcomes, and the frequency of the intervention was slightly different between the two studies. One study performed guided imagery for 15 minutes at least twice daily for four weeks, or until the baby was born (whichever came first). In the other study, the intervention included guided imagery, self-monitoring of blood pressure, and thermal biofeedback-assisted relaxation training for four total hours; the participants were instructed to practice the procedures twice daily and complete at least three relief relaxation breaks each day. The control groups were similar - one was quiet rest, and the other was quiet rest as bed rest.None of our primary outcomes were reported in the included trials: severe hypertension (either systolic blood pressure of 160 mmHg or higher, or diastolic blood pressure of 110 mmHg or higher); severe pre-eclampsia, or perinatal death (stillbirths plus deaths in the first week of life). Only one of the secondary outcomes was measured.Low-certainty evidence from one trial (69 women) suggests that guided imagery may make little or no difference in the use of antihypertensive drugs (risk ratio 1.27, 95% confidence interval 0.72 to 2.22). AUTHORS' CONCLUSIONS There is insufficient evidence to inform practice about the use of guided imagery for hypertension in pregnancy.The available evidence for this review topic is sparse, and the effect of guided imagery for treating hypertension during pregnancy (compared with quiet rest) remains unclear. There was low-certainty evidence that guided imagery made little or no difference to the use of antihypertensive drugs, downgraded because of imprecision.The two included trials did not report on any of the primary outcomes of this review. We did not identify any trials comparing guided imagery with no intervention, or with another non-pharmacological method for hypertension.Large and well-designed RCTs are needed to identify the effects of guided imagery on hypertension during pregnancy and on other relevant outcomes associated with short-term and long-term maternal and neonatal health. Trials could also consider utilisation and costs of health service.
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Affiliation(s)
- Megumi Haruna
- The University of TokyoDepartment of Midwifery and Women’s Health, Division of Health Sciences & Nursing, Graduate School of Medicine7‐3‐1 HongoTokyoJapan113‐0033
| | - Masayo Matsuzaki
- Osaka University Graduate School of MedicineDepartment of Children and Women's Health1‐7 YamadaokaSuitaOsakaJapan565‐0871
| | - Erika Ota
- St. Luke's International UniversityGlobal Health Nursing, Graduate School of Nursing Sciences10‐1 Akashi‐choChuo‐KuTokyoMSJapan104‐0044
| | - Mie Shiraishi
- Osaka UniversityDepartment of Children and Women's Health1‐7 YamadaokaSuitaOsakaJapan565‐0871
| | - Nobutsugu Hanada
- National Center for Child Health and DevelopmentDepartment of Health Policy2‐10‐1 OkuraTokyoJapan166‐0014
| | - Rintaro Mori
- National Center for Child Health and DevelopmentDepartment of Health Policy2‐10‐1 OkuraTokyoJapan166‐0014
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Robertson SA, Green ES, Care AS, Moldenhauer LM, Prins JR, Hull ML, Barry SC, Dekker G. Therapeutic Potential of Regulatory T Cells in Preeclampsia-Opportunities and Challenges. Front Immunol 2019; 10:478. [PMID: 30984163 PMCID: PMC6448013 DOI: 10.3389/fimmu.2019.00478] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 02/21/2019] [Indexed: 12/26/2022] Open
Abstract
Inflammation is a central feature and is implicated as a causal factor in preeclampsia and other hypertensive disorders of pregnancy. Inflammatory mediators and leukocytes, which are elevated in peripheral blood and gestational tissues, contribute to the uterine vascular anomalies and compromised placental function that characterize particularly the severe, early onset form of disease. Regulatory T (Treg) cells are central mediators of pregnancy tolerance and direct other immune cells to counteract inflammation and promote robust placentation. Treg cells are commonly perturbed in preeclampsia, and there is evidence Treg cell insufficiency predates onset of symptoms. A causal role is implied by mouse studies showing sufficient numbers of functionally competent Treg cells must be present in the uterus from conception, to support maternal vascular adaptation and prevent later placental inflammatory pathology. Treg cells may therefore provide a tractable target for both preventative strategies and treatment interventions in preeclampsia. Steps to boost Treg cell activity require investigation and could be incorporated into pregnancy planning and preconception care. Pharmacological interventions developed to target Treg cells in autoimmune conditions warrant consideration for evaluation, utilizing rigorous clinical trial methodology, and ensuring safety is paramount. Emerging cell therapy tools involving in vitro Treg cell generation and/or expansion may in time become relevant. The success of preventative and therapeutic approaches will depend on resolving several challenges including developing informative diagnostic tests for Treg cell activity applicable before conception or during early pregnancy, selection of relevant patient subgroups, and identification of appropriate windows of gestation for intervention.
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Affiliation(s)
- Sarah A. Robertson
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Ella S. Green
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Alison S. Care
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Lachlan M. Moldenhauer
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | | | - M. Louise Hull
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Women's and Children's Hospital, Adelaide, SA, Australia
| | - Simon C. Barry
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Gustaaf Dekker
- Robinson Research Institute and Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
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Abstract
BACKGROUND Pre-eclampsia is a pregnancy-specific multi-organ disorder, which is characterised by hypertension and multisystem organ involvement and which has significant maternal and fetal morbidity and mortality. Failure of the placental vascular remodelling and reduced uteroplacental flow form the etiopathological basis of pre-eclampsia. There are several established therapies for pre-eclampsia including antihypertensives and anticonvulsants. Most of these therapies aim at controlling the blood pressure or preventing complications of elevated blood pressure, or both. Epidural therapy aims at blocking the vasomotor tone of the arteries, thereby increasing uteroplacental blood flow. This review was aimed at evaluating the available evidence about the possible benefits and risks of epidural therapy in the management of severe pre-eclampsia, to define the current evidence level of this therapy, and to determine what (if any) further evidence is required. OBJECTIVES To assess the effectiveness, safety and cost of the extended use of epidural therapy for treating severe pre-eclampsia in non-labouring women. This review aims to compare the use of extended epidural therapy with other methods, which include intravenous magnesium sulphate, anticonvulsants other than magnesium sulphate, with or without use of the antihypertensive drugs and adjuncts in the treatment of severe pre-eclampsia.This review only considered the use of epidural anaesthesia in the management of severe pre-eclampsia in the antepartum period and not as pain relief in labour. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) (13 July 2017) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials (RCTs) or quasi-RCTs comparing epidural therapy versus traditional therapy for pre-eclampsia in the form of antihypertensives, anticonvulsants, magnesium sulphate, low-dose dopamine, corticosteroids or a combination of these, were eligible for inclusion. Trials using a cluster design, and studies published in abstract form only are also eligible for inclusion in this review. Cross-over trials were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS The two review authors independently assessed trials for inclusion and trial quality. There were no relevant data available for extraction. MAIN RESULTS We included one small study (involving 24 women). The study was a single-centre randomised trial conducted in Mexico. This study compared a control group who received antihypertensive therapy, anticonvulsant therapy, plasma expanders, corticosteroids and dypyridamole with an intervention group that received epidural block instead of the antihypertensives, as well as all the other four drugs. Lumbar epidural block was given using 0.25% bupivacaine, 10 mg bolus and 5 mg each hour on continuous epidural infusion for six hours. This study was at low risk of bias in three domains but was assessed to be high risk of bias in two domains due to lack of allocation concealment and blinding of women and staff, and unclear for random sequence generation and outcome assessor blinding.The included study did not report on any of this review's important outcomes. Meta-analysis was not possible.For the mother, these were: maternal death (death during pregnancy or up to 42 days after the end of the pregnancy, or death more than 42 days after the end of the pregnancy); development of eclampsia or recurrence of seizures; stroke; any serious morbidity: defined as at least one of stroke, kidney failure, liver failure, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), disseminated intravascular coagulation, pulmonary oedema.For the baby, these were: death: stillbirths (death in utero at or after 20 weeks' gestation), perinatal deaths (stillbirths plus deaths in the first week of life), death before discharge from the hospital, neonatal deaths (death within the first 28 days after birth), deaths after the first 28 days; preterm birth (defined as the birth before 37 completed weeks' gestation); and side effects of the intervention. Reported outcomesThe included study only reported on a single secondary outcome of interest to this review: the Apgar score of the baby at birth and after five minutes and there was no clear difference between the intervention and control groups.The included study also reported a reduction in maternal diastolic arterial pressure. However, the change in maternal mean arterial pressure and systolic arterial pressure, which were the other reported outcomes of this trial, were not significantly different between the two groups. AUTHORS' CONCLUSIONS Currently, there is insufficient evidence from randomised controlled trials to evaluate the effectiveness, safety or cost of using epidural therapy for treating severe pre-eclampsia in non-labouring women.High-quality randomised controlled trials are needed to evaluate the use of epidural agents as therapy for treatment of severe pre-eclampsia. The rationale for the use of epidural is well-founded. However there is insufficient evidence from randomised controlled trials to show that the effect of epidural translates into improved maternal and fetal outcomes. Thus, there is a need for larger, well-designed studies to come to an evidence-based conclusion as to whether the lowering of vasomotor tone by epidural therapy results in better maternal and fetal outcomes and for how long that could be maintained. Another important question that needs to be answered is how long should extended epidural be used to ensure any potential clinical benefits and what could be the associated side effects and costs. Interactions with other modalities of treatment and women's satisfaction could represent other avenues of research.
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Affiliation(s)
- Amita Ray
- DM Wayanad Institute of Medical SciencesDepartment of Obstetrics and GynaecologyNaseera Nagar ,Meppadi (PO)WayanadWayanadKeralaIndia673577
| | - Sujoy Ray
- St. John's Medical College and HospitalDepartment of PsychiatrySarjapur RoadBangaloreKarnatakaIndia560008
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Kehl S, Dötsch J, Hecher K, Schlembach D, Schmitz D, Stepan H, Gembruch U. Intrauterine Growth Restriction. Guideline of the German Society of Gynecology and Obstetrics (S2k-Level, AWMF Registry No. 015/080, October 2016). Geburtshilfe Frauenheilkd 2017; 77:1157-1173. [PMID: 29375144 PMCID: PMC5784232 DOI: 10.1055/s-0043-118908] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2017] [Revised: 08/19/2017] [Accepted: 08/25/2017] [Indexed: 12/12/2022] Open
Abstract
AIMS The aim of this official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG) was to provide consensus-based recommendations obtained by evaluating the relevant literature for the diagnostic treatment and management of women with fetal growth restriction. METHODS This S2k guideline represents the structured consensus of a representative panel of experts with a range of different professional backgrounds commissioned by the Guideline Committee of the DGGG. RECOMMENDATIONS Recommendations for diagnostic treatment, management, counselling, prophylaxis and screening are presented.
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Affiliation(s)
- Sven Kehl
- Frauenklinik, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Jörg Dötsch
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Köln, Köln, Germany
| | - Kurt Hecher
- Klinik für Geburtshilfe und Pränatalmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Dagmar Schmitz
- Institut für Geschichte, Theorie und Ethik der Medizin, Uniklinik RWTH Aachen, Aachen, Germany
| | - Holger Stepan
- Abteilung für Geburtsmedizin, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Ulrich Gembruch
- Abteilung für Geburtshilfe und Pränatale Medizin, Universitätsklinikum Bonn, Bonn, Germany
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Amaral LM, Faulkner JL, Elfarra J, Cornelius DC, Cunningham MW, Ibrahim T, Vaka VR, McKenzie J, LaMarca B. Continued Investigation Into 17-OHPC: Results From the Preclinical RUPP Rat Model of Preeclampsia. Hypertension 2017; 70:1250-1255. [PMID: 29084881 DOI: 10.1161/hypertensionaha.117.09969] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 07/31/2017] [Accepted: 09/25/2017] [Indexed: 12/24/2022]
Abstract
Preeclampsia is characterized by elevated TNF-α (tumor necrosis factor-α), antiangiogenic factors, such as sFlt-1 (soluble vascular endothelial growth factor receptor 1), increased uterine artery resistance index, and decreased of NO during pregnancy. Previously we showed that 17-hydroxyprogesterone caproate (17-OHPC) administered into reduced uterine perfusion pressure (RUPP) rats on day 18 of gestation improved hypertension without improving pup weight. We hypothesized that earlier administration of 17-OHPC on day 15 of gestation could improve pathophysiology of preeclampsia and fetal outcomes in response to placental ischemia. Carotid catheters were inserted on day 18, and mean arterial blood pressure and samples were collected on day 19. Mean arterial blood pressure in normal pregnant rats was 102±2, 105±2 in normal pregnant+day 15 of gestation (GD15) 17-OHPC, 127±2 in RUPP and 112±1 mm Hg in RUPP+GD15 17-OHPC, P<0.05. Pup weight and litter size were improved from 1.9±0.05, 10.1±1.4 in RUPP to 2.1±0.07 g and 13.2±0.6 in RUPP+GD15 17-OHPC, P<0.05. Uterine artery resistance index was 0.8±0.03 in RUPP, which was decreased to 0.6±0.04 in RUPP+GD15 17-OHPC, P<0.05. Plasma TNF-α levels were 164±34 in RUPP and blunted to 29±9 pg/mL in RUPP+GD15 17-OHPC, P<0.05. Plasma nitrate-nitrite levels were 10.8±2.3 in RUPP rats and significantly increased to 25.5±5.2 µmol/L in RUPP+GD15 17-OHPC, P<0.05. sFlt-1 levels were 386±141 in RUPP rats, which were reduced to 110.2±11 in RUPP+17-OHPC, P<0.05. These data indicate that GD15 17-OHPC improves pathophysiology in RUPP rats, possibly via improving sFlt-1 reduced NO during pregnancy.
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Affiliation(s)
- Lorena M Amaral
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Jessica L Faulkner
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Jamil Elfarra
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Denise C Cornelius
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Mark W Cunningham
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Tarek Ibrahim
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Venkata Ramana Vaka
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Jessica McKenzie
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.)
| | - Babbette LaMarca
- From the Department of Pharmacology (L.M.A., M.W.C., T.I., V.R.V., B.L.), Department of Obstetrics and Gynecology (J.E.), and Departments of Emergency Medicine and Pharmacology (D.C.C.), University of Mississippi Medical Center, Jackson; Department of Vascular Biology Center, Augusta University, GA (J.L.F.); and Department of Biological Sciences, Mississippi College, Clinton (J.M.).
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12
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Zabul P, Wozniak M, Slominski AT, Preis K, Gorska M, Korozan M, Wieruszewski J, Zmijewski MA, Zabul E, Tuckey R, Kuban-Jankowska A, Mickiewicz W, Knap N. A Proposed Molecular Mechanism of High-Dose Vitamin D3 Supplementation in Prevention and Treatment of Preeclampsia. Int J Mol Sci 2015; 16:13043-64. [PMID: 26068234 PMCID: PMC4490485 DOI: 10.3390/ijms160613043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 05/31/2015] [Accepted: 06/01/2015] [Indexed: 12/02/2022] Open
Abstract
A randomized prospective clinical study performed on a group of 74 pregnant women (43 presenting with severe preeclampsia) proved that urinary levels of 15-F(2t)-isoprostane were significantly higher in preeclamptic patients relative to the control (3.05 vs. 2.00 ng/mg creatinine). Surprisingly enough, plasma levels of 25-hydroxyvitamin D3 in both study groups were below the clinical reference range with no significant difference between the groups. In vitro study performed on isolated placental mitochondria and placental cell line showed that suicidal self-oxidation of cytochrome P450scc may lead to structural disintegration of heme, potentially contributing to enhancement of oxidative stress phenomena in the course of preeclampsia. As placental cytochrome P450scc pleiotropic activity is implicated in the metabolism of free radical mediated arachidonic acid derivatives as well as multiple Vitamin D3 hydroxylations and progesterone synthesis, we propose that Vitamin D3 might act as a competitive inhibitor of placental cytochrome P450scc preventing the production of lipid peroxides or excess progesterone synthesis, both of which may contribute to the etiopathogenesis of preeclampsia. The proposed molecular mechanism is in accord with the preliminary clinical observations on the surprisingly high efficacy of high-dose Vitamin D3 supplementation in prevention and treatment of preeclampsia.
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Affiliation(s)
- Piotr Zabul
- Department of Obstetrics & Gynecology, the Sw. Wojciech Specialist Hospital, Independent Public Complex of Integrated Health Care Units in Gdansk, 50 Al. Jana Pawła II St., Gdansk 80-462, Poland; E-Mail:
| | - Michal Wozniak
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
| | - Andrzej T. Slominski
- Department of Dermatology, University of Alabama at Birmingham, VA Medical Center, Birmingham, AL 35294, USA; E-Mail:
| | - Krzysztof Preis
- Department of Obstetrics & Gynecology, Medical University of Gdansk, 1A Kliniczna St., Gdansk 80-402, Poland; E-Mail:
| | - Magdalena Gorska
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
| | - Marek Korozan
- Department of Obstetrics & Gynecology, the Sw. Wojciech Specialist Hospital, Independent Public Complex of Integrated Health Care Units in Gdansk, 50 Al. Jana Pawła II St., Gdansk 80-462, Poland; E-Mail:
| | - Jan Wieruszewski
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
| | - Michal A. Zmijewski
- Department of Histology, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mail:
| | - Ewa Zabul
- Department of Anesthesiology & Intensive Care, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mail:
| | - Robert Tuckey
- School of Chemistry and Biochemistry, the University of Western Australia, 35 Stirling Highway, Crawley, WA 6009, Australia; E-Mail:
| | - Alicja Kuban-Jankowska
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
| | - Wieslawa Mickiewicz
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
| | - Narcyz Knap
- Department of Medical Chemistry, Medical University of Gdansk, 1 Debinki St., Gdansk 80-211, Poland; E-Mails: (M.W.); (M.G.); (J.W.); (A.K.-J.); (W.M.)
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Amaral LM, Cornelius DC, Harmon A, Moseley J, Martin JN, LaMarca B. 17-hydroxyprogesterone caproate significantly improves clinical characteristics of preeclampsia in the reduced uterine perfusion pressure rat model. Hypertension 2014; 65:225-31. [PMID: 25368030 DOI: 10.1161/hypertensionaha.114.04484] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Preeclampsia is characterized by increased uterine artery resistance index, chronic immune activation, and decreased circulating nitric oxide levels. 17-α-Hydroxyprogesterone caproate (17-OHPC) is a synthetic metabolite of progesterone used for the prevention of recurrent preterm birth. We hypothesized that 17-OHPC could reduce mean arterial pressure by decreasing inflammation, whereas improving vasodilation by increasing nitric oxide bioavailability and uterine artery resistance index during late gestation in the reduced uterine perfusion pressure (RUPP) rat model of preeclampsia. 17-OHPC (3.32 mg/kg) was intraperitoneally administered on gestation day 18 into RUPP rats, carotid catheters inserted, and mean arterial pressure, blood, and tissues were collected on day 19. Mean arterial pressure in normal pregnant (NP; n=13) was 92±2.0 and increased to123±2.0 in RUPP (n=18; P<0.0001), which was improved to 116±1.5 mm Hg in RUPP+17-OHPC (n=10; P<0.05). Circulating CD4+ T cells were 1.19%±1.0% of gated cells in NP (n=7), which increased to 8.52%±2.4% in RUPP rats (n=10; P<0.05) but was reduced to 2.72%±0.87% (n=14; P<0.05) in RUPP+17-OHPC. Circulating nitrate/nitrite was 26.34±3.5 µmol/L in NP (n=12) but was reduced to14.58±3.1 in RUPP rats (n=8; P=0.03) and increased to 22.69±1.62 in RUPP+17-OHPC (n=7; P=0.05). Endothelial nitric oxide synthase expression was 0.65±0.11 AU in NP (n=4), which decreased to 0.33±0.01 in RUPP rats (n=4; P=0.05) but increased to 0.57±0.01 in RUPP+17-OHPC (n=5; P=0.03). Uterine artery resistance index was 0.54±0.02 in NP (n=3), 0.78±0.03 in RUPP (n=4), and 0.63±0.038 in RUPP+17-OHPC (n=8; both P<0.05). Our findings demonstrate that even though modest, lowering blood pressure with 17-OHPC could be a viable treatment option for suppressing inflammation, uterine artery vasoconstriction while improving litter size.
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Affiliation(s)
- Lorena M Amaral
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson
| | - Denise C Cornelius
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson
| | - Ashlyn Harmon
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson
| | - Janae Moseley
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson
| | - James N Martin
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson
| | - Babbette LaMarca
- From the Departments of Pharmacology (L.M.A., D.C.C., A.H., J.N.M., B.L.) and Obstetrics and Gynecology (J.N.M.), University of Mississippi Medical Center, Jackson.
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Haruna M, Matsuzaki M, Ota E, Shiraishi M, Hanada N, Mori R. Guided imagery for treating hypertension in pregnancy. Hippokratia 2014. [DOI: 10.1002/14651858.cd011337] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Megumi Haruna
- The University of Tokyo; Department of Midwifery and Women's Health; 7-3-1 Hongo Bunkyo-ku Tokyo Japan 113-0033
| | - Masayo Matsuzaki
- The University of Tokyo; Department of Midwifery and Women's Health; 7-3-1 Hongo Bunkyo-ku Tokyo Japan 113-0033
| | - Erika Ota
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
| | - Mie Shiraishi
- The University of Tokyo; Department of Midwifery and Women's Health; 7-3-1 Hongo Bunkyo-ku Tokyo Japan 113-0033
| | - Nobutsugu Hanada
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
| | - Rintaro Mori
- National Center for Child Health and Development; Department of Health Policy; 2-10-1 Okura, Setagaya-ku Tokyo Japan 157-8535
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Piso B, Zechmeister-Koss I, Winkler R. Antenatal interventions to reduce preterm birth: an overview of Cochrane Systematic Reviews. BMC Res Notes 2014; 7:265. [PMID: 24758148 PMCID: PMC4021758 DOI: 10.1186/1756-0500-7-265] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 04/04/2014] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Several factors are associated with an increased risk of preterm birth (PTB); therefore, various interventions might have the potential to influence it. Due to the large number of interventions that address PTB, the objective of this overview is to summarise evidence from Cochrane reviews regarding the effects and safety of these different interventions. METHODS We conducted a systematic literature search in the Cochrane Database of Systematic Reviews. Included reviews should be based on randomised controlled trials comparing antenatal non-pharmacological and pharmacological interventions that directly or indirectly address PTB with placebo/no treatment or routine care in pregnant women at less than 37 completed weeks of gestation without signs of threatened preterm labour. We considered PTB at less than 37 completed weeks of gestation as the primary outcome. RESULTS We included 56 Cochrane systematic reviews. Three interventions increased PTB risk significantly. Twelve interventions led to a statistically significant lower incidence of PTBs. However, this reduction was mostly observed in defined at-risk subgroups of pregnant women. The remaining antenatal interventions failed to prove a significant effect on PTB < 37 weeks, but some of them at least showed a positive effect in secondary outcomes (e.g., reduction in early PTBs). As an unintended result of this review, we identified 28 additional Cochrane reviews which intended to report on PTB < 37 weeks, but were not able to find any RCTs reporting appropriate data. CONCLUSIONS The possible effects of a diverse range of interventions on PTB have been evaluated in Cochrane systematic reviews. Few interventions have been demonstrated to be effective and a small number have been found to be harmful. For around half of the interventions evaluated, the Cochrane review concluded that there was insufficient evidence to provide sound recommendations for clinical practice. No RCT evidence is available for a number of potentially relevant interventions.
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Affiliation(s)
- Brigitte Piso
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090 Wien, Austria
| | - Ingrid Zechmeister-Koss
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090 Wien, Austria
| | - Roman Winkler
- Ludwig Boltzmann Institute for Health Technology Assessment, Garnisongasse 7/20, 1090 Wien, Austria
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Progesterone blunts vascular endothelial cell secretion of endothelin-1 in response to placental ischemia. Am J Obstet Gynecol 2013; 209:44.e1-6. [PMID: 23545163 DOI: 10.1016/j.ajog.2013.03.032] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2012] [Revised: 02/19/2013] [Accepted: 03/27/2013] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Preeclampsia (PE) is associated with hypertension and elevated endothelin (ET-1), an indicator of endothelial cell activation and dysfunction. Reduction of uteroplacental perfusion (RUPP) in the pregnant rat model of PE is characterized by elevated mean arterial pressure, inflammatory cytokines, and activation of the ET-1 system. We aim to determine whether 17-alpha-hydroxyprogesterone caproate (17-OHPC) or progesterone suppresses these pathways. STUDY DESIGN Plasma progesterone was purified from normal pregnant (NP) and PE patients and measured via enzyme-linked immunosorbent assay. Human umbilical vein endothelial cells were exposed to the sera with or without progesterone added and ET-1 was measured. Pregnant rats underwent the RUPP procedure with or without intraperitoneal 17-OHPC. Mean arterial pressure was compared in RUPP vs NP rats. Human umbilical vein endothelial cells were exposed to NP or RUPP sera, with and without progesterone and ET-1 measured. RESULTS Progesterone was significantly decreased in PE women compared with NP women. In response to human sera, ET-1 was elevated in PE women compared to NP women, and decreased with addition of progesterone. Mean arterial pressure was significantly elevated in RUPP vs NP rats but was attenuated by 17-OHPC. ET-1 secretion was stimulated significantly by RUPP compared to NP rat sera, but attenuated by progesterone. CONCLUSION Circulating progesterone is significantly lower in PE women compared to controls. 17-OHPC attenuates hypertension in response to placental ischemia in RUPP rats. Progesterone blunts vascular ET-1 stimulated at cellular level by sera from PE women or RUPP rats. Decreased circulating progesterone is associated with stimulation of ET-1. 17-OHPC supplementation blunts hypertension and progesterone blunts endothelial cell ET-1 secretion in response to placental ischemia.
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Abstract
Preeclampsia (PE) affects around 2–5% of pregnant women. It is a major cause of maternal and perinatal morbidity and mortality. In an attempt to prevent preeclampsia, many strategies based on antenatal care, change in lifestyle, nutritional supplementation, and drugs have been studied. The aim of this paper is to review recent evidence about primary and secondary prevention of preeclampsia.
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Kaore SN, Langade DK, Yadav VK, Sharma P, Thawani VR, Sharma R. Novel actions of progesterone: what we know today and what will be the scenario in the future? J Pharm Pharmacol 2012; 64:1040-62. [DOI: 10.1111/j.2042-7158.2012.01464.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Abstract
Objectives
This article is aimed to review the novel actions of progesterone, which otherwise is considered as a female reproductive hormone. The article focuses on its important physiological actions in males too and gives an overview of its novel perspectives in disorders of central and peripheral nervous system.
Key findings
Progesterone may have a potential benefit in treatment of traumatic brain injury, various neurological disorders and male related diseases like benign prostatic hypertrophy (BPH), prostate cancer and osteoporosis. Norethisterone (NETA), a progesterone derivative, decreases bone mineral loss in male castrated mice suggesting its role in osteoporosis. In the future, progesterone may find use as a male contraceptive too, but still needs confirmatory trials for safety, tolerability and acceptability. Megestrol acetate, a progesterone derivative is preferred in prostatic cancer. Further, it may find utility in nicotine addiction, traumatic brain injury (recently entered Phase III trial) and Alzheimer's disease, diabetic neuropathy and crush injuries. Studies also suggest role of progesterone in stroke, for which further clinical trials are needed. The non genomic actions of progesterone may be in part responsible for these novel actions.
Summary
Although progesterone has shown promising role in various non-hormonal benefits, further clinical studies are needed to prove its usefulness in conditions like stroke, traumatic brain injury, neuropathy and crush injury. In male related illnesses like BPH and prostatic Ca, it may prove a boon in near future. New era of hormonal male contraception may be initiated by use of progesterone along with testosterone.
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Affiliation(s)
- Shilpa N Kaore
- Department of Pharmacology, Peoples College of Medical Sciences & Research Center, Bhopal, Madhya Pradesh, India
| | - Deepak Kumar Langade
- Department of Pharmacology, Peoples College of Medical Sciences & RC, Bhopal, Madhya Pradesh, India
| | - Vijay Kumar Yadav
- Department of Pharmacology, Peoples College of Medical Sciences & RC, Bhopal, Madhya Pradesh, India
| | - Parag Sharma
- Department of Pharmacology, Peoples College of Medical Sciences & RC, Bhopal, Madhya Pradesh, India
| | - Vijay R Thawani
- Department of Pharmacology, VCSG GMSRI, Srinagar and Pauri Garhwal, Uttarakhand, India
| | - Raj Sharma
- Department of Pharmacology, Govt medical College, Jagdalpur, Chhatisgarh, India
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Dutta D, Sule M, Ray A. Epidural therapy for the treatment of severe pre-eclampsia in non labouring women. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2012. [DOI: 10.1002/14651858.cd009540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Debarati Dutta
- Norfolk and Norwich University Hospital; Department of Obstetrics and Gynaecology; 9 Mornington Road Norwich Norfolk UK NR2 3NA
| | - Medha Sule
- Norfolk and Norwich University Hospital; Department of Obstetrics and Gynaecology; 9 Mornington Road Norwich Norfolk UK NR2 3NA
| | - Amita Ray
- Father Muller Medical College; Department of Obstetrics and Gynaecology; Father Muller Road, Kankanady Mangalore Karnataka India 575002
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Ronsmans C, Campbell O. Quantifying the fall in mortality associated with interventions related to hypertensive diseases of pregnancy. BMC Public Health 2011; 11 Suppl 3:S8. [PMID: 21501459 PMCID: PMC3231914 DOI: 10.1186/1471-2458-11-s3-s8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In this paper we review the evidence of the effect of health interventions on mortality reduction from hypertensive diseases in pregnancy (HDP). We chose HDP because they represent a major cause of death in low income countries and evidence of effect on maternal mortality from randomised studies is available for some interventions. METHODS We used four approaches to review the evidence of the effect of interventions to prevent or treat HDP on mortality reduction from HDP. We first reviewed the Cochrane Library to identify systematic reviews and individual trials of the efficacy of single interventions for the prevention or treatment of HDP. We then searched the literature for articles quantifying the impact of maternal health interventions on the reduction of maternal mortality at the population level and describe the approaches used by various authors for interventions related to HDP. Third, we examined levels of HDP-specific mortality over time or between regions in an attempt to quantify the actual or potential reduction in mortality from HDP in these regions or over time. Lastly, we compared case fatality rates in women with HDP-related severe acute maternal morbidity with those reported historically in high income countries before any effective treatment was available. RESULTS The Cochrane review identified 5 effective interventions: routine calcium supplementation in pregnancy, antiplatelet agents during pregnancy in women at risk of pre-eclampsia, Magnesium sulphate (MgS04) for the treatment of eclampsia, MgS04 for the treatment of pre-eclampsia, and hypertensive drugs for the treatment of mild to moderate hypertension in pregnancy.We found 10 studies quantifying the effect of maternal health interventions on reducing maternal mortality from HDP, but the heterogeneity in the methods make it difficult to draw uniform conclusions for effectiveness of interventions at various levels of the health system. Most authors include a health systems dimension aimed at separating interventions that can be delivered at the primary or health centre level from those that require hospital treatment, but definitions are rarely provided and there is no consistency in the types of interventions that are deemed effective at the various levels.The low levels of HDP related mortality in rural China and Sri Lanka suggest that reductions of 85% or more are within reach, provided that most women give birth with a health professional who can refer them to higher levels of care when necessary. Results from studies of severe acute maternal morbidity in Indonesia and Bolivia also suggest that mortality in women with severe pre-eclampsia or eclampsia in hospital can be reduced by more than 84%, even when the women arrive late. CONCLUSIONS The increasing emphasis on the rating of the quality of evidence has led to greater reliance on evidence from randomised controlled trials to estimate the effect of interventions. Yet evidence from randomised studies is often not available, the effects observed on morbidity may not translate in to mortality, and the distinction between efficacy and effectiveness may be difficult to make. We suggest that more use should be made of observational evidence, particularly since such data represent the actual effectiveness of packages of interventions in various settings.
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Affiliation(s)
- Carine Ronsmans
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
| | - Oona Campbell
- Infectious Disease Epidemiology Unit, London School of Hygiene and Tropical Medicine, London, UK
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East C, Conway K, Pollock W, Frawley N, Brennecke S. Women's experiences of preeclampsia: Australian action on preeclampsia survey of women and their confidants. J Pregnancy 2011; 2011:375653. [PMID: 21547089 PMCID: PMC3087153 DOI: 10.1155/2011/375653] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2010] [Accepted: 01/18/2011] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The experience of normal pregnancy is often disrupted for women with preeclampsia (PE). MATERIALS AND METHODS Postal survey of the 112 members of the consumer group, Australian Action on Pre-Eclampsia (AAPEC). RESULTS Surveys were returned by 68 women (61% response rate) and from 64 (57%) partners, close relatives or friends. Respondents reported experiencing pre-eclampsia (n = 53), eclampsia (n = 5), and/or Hemolysis, Elevated Liver enzymes, and Low Platelets (HELLP syndrome) (n = 26). Many women had no knowledge of PE prior to diagnosis (77%) and, once diagnosed, did not appreciate how serious or life threatening it was (50%). Women wanted access to information about PE. Their experience contributed substantial anxiety towards future pregnancies. Partners/friends/relatives expressed fear for the woman and/or her baby and had no prior understanding of PE. CONCLUSIONS The PE experience had a substantial effect on women, their confidants, and their babies and affected their approach to future pregnancies. Access to information about PE was viewed as very important.
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Affiliation(s)
- C East
- Department of Obstetrics & Gynaecology, University of Melbourne and Department of Perinatal Medicine, Royal Women's Hospital, 20 Flemington Road, Parkville, VIC 3052, Australia.
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Turner TJ, Barnes H, Reid J, Garrubba M. Evidence for perinatal and child health care guidelines in crisis settings: can Cochrane help? BMC Public Health 2010; 10:170. [PMID: 20350326 PMCID: PMC3091544 DOI: 10.1186/1471-2458-10-170] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2009] [Accepted: 03/29/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND It is important that healthcare provided in crisis settings is based on the best available research evidence. We reviewed guidelines for child and perinatal health care in crisis situations to determine whether they were based on research evidence, whether Cochrane systematic reviews were available in the clinical areas addressed by these guidelines and whether summaries of these reviews were provided in Evidence Aid. METHODS Broad internet searches were undertaken to identify relevant guidelines. Guidelines were appraised using AGREE and the clinical areas that were relevant to perinatal or child health were extracted. We searched The Cochrane Database of Systematic Reviews to identify potentially relevant reviews. For each review we determined how many trials were included, and how many were conducted in resource-limited settings. RESULTS Six guidelines met selection criteria. None of the included guidelines were clearly based on research evidence. 198 Cochrane reviews were potentially relevant to the guidelines. These reviews predominantly addressed nutrient supplementation, breastfeeding, malaria, maternal hypertension, premature labour and prevention of HIV transmission. Most reviews included studies from developing settings. However for large portions of the guidelines, particularly health services delivery, there were no relevant reviews. Only 18 (9.1%) reviews have summaries in Evidence Aid. CONCLUSIONS We did not identify any evidence-based guidelines for perinatal and child health care in disaster settings. We found many Cochrane reviews that could contribute to the evidence-base supporting future guidelines. However there are important issues to be addressed in terms of the relevance of the available reviews and increasing the number of reviews addressing health care delivery.
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Affiliation(s)
- Tari J Turner
- Monash Institute of Health Services Research, Monash University, Locked Bag 29, Clayton 3168 Australia
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Hayley Barnes
- previously of the Australasian Cochrane Centre, Monash University, Locked Bag 29, Clayton 3168 Australia
| | - Jane Reid
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
| | - Marie Garrubba
- Centre for Clinical Effectiveness, Southern Health, Locked Bag 29, Clayton 3168 Australia
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Duley L, Henderson-Smart DJ, Walker GJA. Interventions for treating pre-eclampsia and its consequences: generic protocol. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2009. [DOI: 10.1002/14651858.cd007756] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Lelia Duley
- University of Leeds; Centre for Epidemiology and Biostatistics; Bradford Royal Infirmary, Bradford Institute of Health Research Temple Bank House, Duckworth Lane Bradford West Yorkshire UK BD9 6RJ
| | - David J Henderson-Smart
- Queen Elizabeth II Research Institute; NSW Centre for Perinatal Health Services Research; Building DO2 University of Sydney Sydney NSW Australia 2006
| | - Godfrey JA Walker
- The University of Liverpool; C/o Cochrane Pregnancy and Childbirth Group, School of Reproductive and Developmental Medicine, Division of Perinatal and Reproductive Medicine; First Floor, Liverpool Women's NHS Foundation Trust Crown Street Liverpool UK L8 7SS
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