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Sepúlveda-Martínez A, Conrads T, Guiñez R, Guiñez J, Llancaqueo M, Parra-Cordero M. Perinatal outcomes of pregestational hypertension according to blood pressure range at 11-14 week scan: Impact of the 2017 ACC/AHA guidelines. Front Med (Lausanne) 2022; 9:994386. [PMID: 36313988 PMCID: PMC9613962 DOI: 10.3389/fmed.2022.994386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Accepted: 09/21/2022] [Indexed: 11/20/2022] Open
Abstract
Objective The aim of this study was to evaluate the impact on perinatal outcomes related to placental insufficiency with the application of the new 2017 ACC/AHA guidelines to a group of chronic hypertensive pregnancies during their first-trimester assessment. Study design This retrospective cohort study included pregnancies with preconceptional hypertension and known perinatal outcomes. In the first trimester, a combined screening for preterm preeclampsia (p-PE) was performed, including blood pressure (BP), mean uterine artery Doppler, and maternal characteristics. Patients were divided, according to the 2017 ACC/AHA consensus, into the following groups: elevated or less, Stage 1, and Stage 2. For adverse perinatal outcome assessment, univariate and multivariate regression analyses were performed, considering the “elevated or less” group as a reference. Odds ratios (OR) were compared with linear trend analysis. The main outcomes measured were preterm PE and FGR < 3rd percentile. Results Of the 130 included patients, 59 (45.4%) were classified as elevated or less, 47 (36.2%) as Stage 1, and 24 (18.4%) as Stage 2. p-PE showed a significant increase according to BP range [7% (OR = 1.0), 19.6% (OR = 3.2), and 21.7% (OR = 3.7)]; trend p = 0.02, for elevated or less, Stage 1, and Stage 2, respectively. There was a non-significant increased trend of FGR < 3rd percentile according to the BP stage. The best multivariate predictive model for p-PE included a previous PE background (OR = 15) and mean arterial pressure in mmHg (OR = 1.1). Conclusion The use of the 2017 ACC/AHA consensus in pregnancies with chronic hypertension identifies an intermediate risk group for placental-mediated diseases.
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Affiliation(s)
- Alvaro Sepúlveda-Martínez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico San Borja Arriarán, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Universidad del Desarrollo y Clínica Alemana de Santiago, Santiago, Chile,*Correspondence: Alvaro Sepúlveda-Martínez,
| | - Tomas Conrads
- Critical Care Unit, Department of Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Rodolfo Guiñez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Javiera Guiñez
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Marcelo Llancaqueo
- Cardiology Unit, Department of Internal Medicine, Hospital Clínico de la Universidad de Chile, Santiago, Chile
| | - Mauro Parra-Cordero
- Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico de la Universidad de Chile, Santiago, Chile,Maternal and Fetal Medicine Unit, Department of Obstetrics and Gynecology, Hospital Clínico San Borja Arriarán, Santiago, Chile
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Anness AR, Clark A, Melhuish K, Leone FMT, Osman MW, Webb D, Robinson T, Walkinshaw N, Khalil A, Mousa HA. Maternal hemodynamics and neonatal birth weight in pregnancies complicated by gestational diabetes: new insights from novel causal inference analysis modeling. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:215-222. [PMID: 35061298 PMCID: PMC9541284 DOI: 10.1002/uog.24864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 12/23/2021] [Accepted: 01/07/2022] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Normal pregnancy is characterized by significant changes in maternal hemodynamics that are associated with fetal growth. Pregnancies complicated by gestational diabetes mellitus (GDM) are associated with large-for-gestational age and macrosomia, but the relationship between maternal hemodynamic parameters and birth weight (BW) among women with GDM has not been established. Our objective was to investigate the influence of maternal hemodynamics on neonatal BW in healthy pregnancies and in those complicated by GDM. METHODS This was a prospective, cross-sectional case-control study of women aged ≥ 16 years with a singleton viable pregnancy, recruited between January 2016 and February 2021 at Leicester Royal Infirmary, Leicester, UK. GDM was defined as a fasting glucose level ≥ 5.3 mmol/L and/or serum glucose level ≥ 7.8 mmol/L, 2 h following a 75-g oral glucose load. We collected data on maternal characteristics and pregnancy outcome, including body mass index (BMI) at booking and BW centile adjusted for gestational age at delivery. Maternal hemodynamic parameters were assessed at 34-42 weeks' gestation using the Arteriograph® and bioreactance techniques. Graphical causal inference methodology was used to identify causal effects of the measured variables on neonatal BW centile. RESULTS Included in the analysis were 141 women with GDM and 136 normotensive non-diabetic pregnant controls. 62% of the women with GDM were managed pharmacologically, with metformin and/or insulin. Variables included in the final model were cardiac output (CO), mean arterial pressure (MAP), total peripheral resistance (TPR), aortic augmentation index (AIx), aortic pulse wave velocity (PWV) and BMI at booking. Among the controls, maternal BMI, CO and aortic PWV were significantly associated with neonatal BW. Each SD increase in booking BMI produced an increase of 8.4 BW centiles (P = 0.002), in CO produced an increase of 9.4 BW centiles (P = 0.008) and in aortic PWV produced an increase of 7.1 BW centiles (P = 0.017). We found no significant relationship between MAP, TPR or aortic AIx and neonatal BW. Maternal hemodynamics influenced neonatal BW among the women with GDM in a similar manner to that in the control group, but only the relationship between maternal BMI and neonatal BW reached statistical significance, with a 1-SD increase in BMI producing an increase of 6.1 BW centiles (P = 0.019). CONCLUSIONS Maternal BMI, CO and PWV were determinants of BW in our control group. The relationship between maternal hemodynamics and neonatal BW was similar between women with GDM and healthy controls. Our findings therefore suggest that fetal growth restriction in pregnancies complicated by GDM may indicate maternal cardiovascular dysfunction. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. R. Anness
- Maternal and Fetal Medicine UnitUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | - A. Clark
- Department of Computer ScienceUniversity of SheffieldSheffieldUK
| | - K. Melhuish
- Maternal and Fetal Medicine UnitUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | - F. M. T. Leone
- Maternal and Fetal Medicine UnitUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | - M. W. Osman
- Maternal and Fetal Medicine UnitUniversity Hospitals of Leicester NHS TrustLeicesterUK
| | - D. Webb
- Diabetes Research CentreCollege of Life Sciences, University of LeicesterLeicesterUK
| | - T. Robinson
- College of Life SciencesUniversity of LeicesterLeicesterUK
| | - N. Walkinshaw
- Department of Computer ScienceUniversity of SheffieldSheffieldUK
| | - A. Khalil
- Fetal Medicine UnitSt George's University Hospitals NHS Foundation Trust, University of LondonLondonUK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research InstituteSt George's University of LondonLondonUK
| | - H. A. Mousa
- Maternal and Fetal Medicine UnitUniversity Hospitals of Leicester NHS TrustLeicesterUK
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Lovell H, Mitchell A, Ovadia C, Pitrelli N, Briley A, Singh C, Marschall HU, Cruickshank K, Murphy H, Seed P, Williamson C. A multi-centered trial investigating gestational treatment with ursodeoxycholic acid compared to metformin to reduce effects of diabetes mellitus (GUARD): a randomized controlled trial protocol. Trials 2022; 23:571. [PMID: 35854327 PMCID: PMC9295112 DOI: 10.1186/s13063-022-06462-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/09/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Each year in the UK, approximately 35,000 women develop gestational diabetes mellitus (GDM). The condition increases the risk of obstetric and neonatal complications for mother and child, including preeclampsia, preterm birth, and large for gestational age babies. Biochemical consequences include maternal hyperglycemia, neonatal hypoglycemia, and dyslipidemia. Metformin is the most commonly used firstline pharmacological treatment. However, there are concerns about its widespread use during pregnancy, due to its limited efficacy and potential safety concerns. Therefore, there is a need for additional therapies that improve both maternal-fetal glucose and lipid metabolism. Ursodeoxycholic acid (UDCA) is not currently used for treatment for GDM. However, it can improve glucose control in type 2 diabetes, and it improves fetal lipid profiles in gestational cholestasis. Consequentially, it is hypothesized that treatment with UDCA for women with GDM may improve both maternal metabolism and neonatal outcomes. The primary outcome of this trial is to assess the efficacy of UDCA compared with metformin to improve glucose levels in women with GDM. METHODS The trial is a two-armed, open-label, multi-center, randomized controlled trial. Women are eligible if they have been diagnosed with GDM by an oral glucose tolerance test between 24 + 0 and 30 + 6 weeks' gestation, and if they require pharmacological intervention. In total, 158 pregnant women will be recruited across seven NHS Trusts in England and Wales. Women who consent will be recruited and randomized to either metformin or UDCA, which will be taken daily until the birth of their baby. Maternal and neonatal blood samples will be taken to evaluate the impact of the treatments on maternal glucose control, and maternal and neonatal lipid metabolism. Maternal and fetal outcomes will be evaluated, and acceptability of UDCA compared with metformin will be assessed. DISCUSSION This trial has the potential to identify a potential new treatment for women with GDM. If successful, a future large multi-center trial will be designed to investigate where decisions can be personalized to identify which women will respond more effectively to UDCA than alternatives to improve maternal and baby outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT04407650.
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Affiliation(s)
- Holly Lovell
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| | | | | | | | - Annette Briley
- Caring Futures Institute, Flinders University South Australia, Adelaide, Australia
| | | | | | | | - Helen Murphy
- University of East Angela/ Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Yuan M, Bedell S, de Vrijer B, Eastabrook G, Frisbee JC, Frisbee SJ. Highlighting the Mechanistic Relationship Between Perinatal Depression and Preeclampsia: A Scoping Review. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2022; 3:850-866. [PMID: 36340477 PMCID: PMC9629976 DOI: 10.1089/whr.2022.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/31/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although there is scientific literature supporting an association between depression and preeclampsia (PE), little is known about the underlying mechanistic pathways that may explain these observed associations. Thus, this study aimed to outline the relationship between depression and PE, and to highlight the underlying cardiovascular and metabolic risk factors that are common to both. METHODS A scoping review of the literature was conducted in Medline, Scopus, and Web of Science. RESULTS From 706 articles initially identified, 23 articles met the inclusion criteria and were included in this review. Although some studies reported a positive association between PE and postpartum depressive symptoms, challenges comparing different methodologies, measurement instruments and when measurements were administered, and patient populations do not permit a decisive conclusion. In addition, very few studies addressed potential underlying mechanisms that may be contributing to observed associations; thus, a secondary search was conducted to identify cardiovascular and metabolic risk factors that are common to both depression and PE. CONCLUSION The cardiovascular and metabolic risk factors (i.e., increased inflammation and oxidative stress and decreased vascular and endothelial function) common to both depression and PE suggest that these factors may contribute as underlying mechanisms in both conditions. These similarities underscore the importance to better understand these mechanisms so preventative and therapeutic strategies could be developed to improve maternal health.
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Affiliation(s)
- Mei Yuan
- Department of Pathology and Laboratory Medicine, Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Samantha Bedell
- Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Barbra de Vrijer
- Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Genevieve Eastabrook
- Maternal-Fetal Medicine, Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lawson Health Research Institute, London, Canada
| | - Jefferson C. Frisbee
- Department of Medical Biophysics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
| | - Stephanie J. Frisbee
- Department of Pathology and Laboratory Medicine, Department of Obstetrics and Gynaecology, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Lawson Health Research Institute, London, Canada
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, Canada
- Address correspondence to: Stephanie J. Frisbee, PhD, MSc, Department of Pathology and Laboratory Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario, 1151 Richmond Street, Dental Sciences Building, Room 4041, London N6A 5C1, Canada,
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Forrest M, Bourgeois S, Pichette É, Caughlin S, Kuate Defo A, Hales L, Labos C, Daskalopoulou SS. Arterial stiffness measurements in pregnancy as a predictive tool for hypertensive disorders of pregnancy and preeclampsia: Protocol for a systematic review and meta-analysis. Eur J Obstet Gynecol Reprod Biol X 2022; 13:100141. [PMID: 35118371 PMCID: PMC8792469 DOI: 10.1016/j.eurox.2022.100141] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Revised: 12/24/2021] [Accepted: 01/06/2022] [Indexed: 11/18/2022] Open
Abstract
Hypertensive disorders of pregnancy (HDPs) are a leading cause of maternal morbidity and mortality worldwide. Unfortunately, accurate early clinical screening methods for the development of these disorders are lacking. Arterial stiffness (AS) is an important hemodynamic indicator of vascular health that has shown promising results for the prediction of HDP onset. Past systematic reviews in the field have reported an increase in AS indices in women who develop HDPs and have highlighted the potential of AS measurements as a predictive tool early in pregnancy. The most recent systematic review, including papers up to 2015, assessed the differences in AS parameters between women with and without pregnancy complications. Since then, there has been a substantial influx of published research on the topic and a growing interest in the incorporation of AS measurements into clinical practice. Thus, we propose a systematic review and meta-analysis that is more inclusive to all HDP subsets and various hemodynamic indices of vascular health to provide a comprehensive overview of the current state of evidence. Specifically, we aim to evaluate these measures in women who develop HDPs compared to normotensive pregnancies to determine which measures are most associated with and/or can predict the development of HDPs. Major databases (Medline, Embase, The Cochrane Library, Web of Science, PubMed, and CINAHL), grey literature (Google Scholar) and clinical trials (clinicaltrials.gov) will be searched to identify studies that report AS and hemodynamic measurements in pregnant women with and without HDPs. No restrictions will be made on study type or year. Articles will be independently evaluated by three authors to determine eligibility based on inclusion and exclusion criteria. Methodological quality of included studies will be assessed. Pooled analyses will be conducted using a random-effects model. Publication bias and between-study heterogeneity will also be assessed. Sources of heterogeneity will be explored by sensitivity, subgroup, and/or meta-regression analyses. Results from this study will be shared through scientific conferences and publications in scientific journals. The analysis of potential AS and hemodynamic markers for HDP onset will help inform the development of screening guidelines and clinically relevant cut-off values of AS and hemodynamic markers for HDP risk, guiding future research. There are no applicable ethical considerations to the writing of this protocol.
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Key Words
- AIx, Augmentation Index
- AIx75, AIx adjusted to a heart rate of 75 beats per minute
- AS, Arterial stiffness
- Arterial stiffness
- CBP, Central blood pressure
- CO, Cardiac output
- CVD, Cardiovascular disease
- FMD, Flow-mediated dilation
- HDP, Hypertensive disorder of pregnancy
- Hemodynamics
- Hypertension
- MAP, Mean arterial pressure
- PWA, Pulse wave analysis
- PWV, Pulse wave velocity
- PrE, Preeclampsia
- Preeclampsia
- Pregnancy complications
- Pulse wave velocity
- SEVR, subendocardial viability ratio
- T1R, Time to wave reflection
- cfPWV, carotid-femoral pulse wave velocity
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Affiliation(s)
- Mekayla Forrest
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Sophia Bourgeois
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Émilie Pichette
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Sarah Caughlin
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Alvin Kuate Defo
- Vascular Health Unit, Research Institute of McGill University Health Centre, Department of Medicine, Faculty of Medicine, McGill University, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Lindsay Hales
- Medical Library, McGill University Health Centre, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
| | - Christopher Labos
- Queen Elizabeth Health Complex, 2100 Marlowe Suite 236, Montreal, Quebec H4A 3L5, Canada
| | - Stella S. Daskalopoulou
- Medical Library, McGill University Health Centre, 1001 Décarie Blvd, Montreal, Quebec H4A 3J1, Canada
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