Adverse maternal and perinatal outcomes in women with previous preeclampsia: a prospective study

Development, validation, and clinical utility of a risk prediction model for recurrent preeclampsia

OBJECTIVES

We aim to establish a predictive model for recurrent preeclampsia.

METHODS

A retrospective review of medical records from three hospitals between 2010 and 2021 was conducted. The study included women who had two consecutive singleton deliveries at the same hospital, with the first delivery complicated by preeclampsia. A multivariable logistic regression model was constructed using a training cohort, and subsequently cross-validated and tested using an independent cohort. The model's performance was assessed in terms of discrimination and calibration, and its clinical utility was evaluated using decision curve analysis (DCA).

RESULTS

Among 296 405 deliveries, 694 women met the inclusion criteria, with 151 (21.8%) experiencing recurrent preeclampsia. The predictive model incorporated 10 risk factors from previous preeclampsia, including gestational weeks with elevated blood pressure, gestational diabetes mellitus (GDM), pericardial effusion, heart failure, limb edema, serum creatinine, white blood cell count, low platelet counts within one week before delivery, SBP on the first postpartum day, and postpartum antihypertensive use. Additionally, one risk factor from the index pregnancy was included, which was antihypertensive use before 20 weeks. The model demonstrated better discrimination, calibration, and a net benefit across a wide range of recurrent preeclampsia risk thresholds. Furthermore, the model has been translated into a clinical risk calculator, enabling clinicians to calculate individualized risks of recurrent preeclampsia.

CONCLUSION

Our study demonstrates that a predictive tool utilizing routine clinical and laboratory factors can accurately estimate the risk of recurrent preeclampsia. This predictive model has the potential to facilitate shared decision-making by providing personalized and risk-stratified care.

Chance of healthy versus adverse outcome in subsequent pregnancy after previous loss beyond 16 weeks: data from a specialized follow-up clinic

PURPOSE

Women with a previous fetal demise have a 2-20 fold increased risk of another stillbirth in a subsequent pregnancy when compared to those who have had a live birth. Despite this, there is limited research regarding the management and outcomes of subsequent pregnancies. This study was conducted to accurately quantify the chances of a woman having a healthy subsequent pregnancy after a pregnancy loss.

METHODS

A retrospective study was conducted at a tertiary-level unit between March 2019 and April 2021. We collected data on all women with a history of previous fetal demise attending a specialized perinatal history clinic and compared the risk of subsequent stillbirth to those with a normal pregnancy outcome. Outcome data included birth outcome, obstetric and medical complications, gestational age and birth weight and mode of delivery. Those who had healthy subsequent pregnancies were compared with those who experienced adverse outcomes.

RESULTS

A total of 101 cases were reviewed. Ninety-six women with subsequent pregnancies after a history of fetal demise from 16 weeks were included. Seventy-nine percent of women (n = 76) delivered a baby at term, without complications. Overall, 2.1% had repeat pregnancy losses (n = 2) and 2.1% delivered babies with fetal growth restriction (n = 2). There were no cases of abruption in a subsequent pregnancy. Eighteen neonates were delivered prematurely (18.4%), 15 of these (83.3%) were due to iatrogenic causes and three (16.7%) were spontaneous. In univariable logistic regression analyses, those with adverse outcomes in subsequent pregnancies had greater odds of pre-eclampsia (Odds ratio *(OR) = 3.89, 95% CI = 1.05-14.43, p = .042) and fetal growth restriction (OR = 4.58, 95% CI = 1.41-14.82, p = 0.011) in previous pregnancies compared to those with healthy outcomes. However, in multivariable logistic regression analyses, neither variable had a significant odds ratio (OR = 2.03, 95% CI = 0.44-9.39, p = .366 and OR = 3.42, 95% CI = 0.90 - 13.09, p = .072 for pre-eclampsia and FGR, respectively).

CONCLUSION

Four in five women had a healthy subsequent pregnancy. This is a reassuring figure for women when contemplating another pregnancy, particularly if cared for in a specialist clinic.

Association between inter-pregnancy interval and risk of adverse birth outcomes in subsequent pregnancy: A retrospective study from Jordan

BACKGROUND

Adverse birth outcomes, such as preterm birth and low birth weight (LBW), are leading causes of neonatal morbidity and mortality. In this study, we aimed to estimate the association between inter-pregnancy interval (IPI) and the risks of adverse birth outcomes in a subsequent pregnancy.

METHODS

We conducted a retrospective analysis involving 630 mothers who delivered a singleton live infant at a leading tertiary hospital in northern Jordan from March to August 2021. Outcome variables were preterm birth (<37 weeks of gestation) and LBW (<2.5 kg). Using multivariable logistic regression, the association between IPI and these two adverse birth outcomes was investigated.

RESULTS

The rates of preterm birth and LBW were 12.4% and 16.8%, respectively. Compared with an optimal IPI (24-36 months), a short IPI (<24 months) was positively associated with preterm birth (aOR: 4.09; 95% CI: 1.48-6.55) and LBW (aOR: 3.58; 95% CI: 1.57-5.15). Infants conceived after a long IPI (≥ 60 months) had increased odds of preterm birth (aOR: 3.78; 95% CI: 1.12-5.78) and LBW (aOR: 2.65; 95% CI: 1.67-4.03). Preterm delivery was also significantly associated with the mother's age (aOR: 1.10; 95% CI: 1.04-1.17), history of multiple cesarean births (aOR: 2.67; 95% CI: 1.14-4.29), prolonged rupture of membranes (aOR: 2.46; 95% CI: 1.10-5.52), and perinatal death (aOR: 3.42; 95% CI: 1.10-5.49). A mother's history of prior LBW (aOR: 4.39; 95% CI: 1.08-6.80), hypertensive disorders (aOR: 1.95; 95% CI: 1.03-3.89), and multiple cesarean births (aOR: 4.35; 95% CI: 2.10-6.99) was associated with LBW.

CONCLUSIONS

Both short and long IPIs were related to preterm delivery and LBW. Optimal birth spacing is recommended to improve birth outcomes and must be considered when designing effective family planning programs.

Pregnancy in Living Kidney Donors: An Evidence-Based Review

Purpose of review

To review the current studies and guidelines on the risk of adverse pregnancy outcomes in female kidney donors.

Recent findings

Living kidney donors include a significant amount of young women of child-bearing age. Safety and possible risks of pregnancy after donation are a concern for female kidney donor candidates. Many current studies indicate a higher risk of preeclampsia in women after kidney donation. Considering the increasing number of living kidney donors, the maternal outcomes of living kidney donation is an active area of research.

Summary

Guidelines and consensus statements on the risk of pregnancy in living kidney donors recommend close monitoring of blood pressure, weight gain, and proteinuria during pregnancy. Current studies indicate an increased risk of hypertensive disorders of pregnancy in living kidney donors. Counseling and informing donor candidates about the possible risks is important.

Pre-eclampsia: a Scoping Review of Risk Factors and Suggestions for Future Research Direction

Abstract

Most of maternal deaths are preventable, and one-quarter of maternal deaths are due to pre-eclampsia and eclampsia. Prenatal screening is essential for detecting and managing pre-eclampsia. However, pre-eclampsia screening is solely based on maternal risk factors and has low (< 5% in the USA) detection rates. This review looks at pre-eclampsia from engineering, public health, and medical points of view. First, pre-eclampsia is defined clinically, and the biological basis of established risk factors is described. The multiple theories behind pre-eclampsia etiology should serve as the scientific basis behind established risk factors for pre-eclampsia; however, African American race does not have sufficient evidence as a risk factor. We then briefly describe predictive statistical models that have been created to improve screening detection rates, which use a combination of biophysical and biochemical biomarkers, as well as aspects of patient medical history as inputs. Lastly, technologies that aid in advancing pre-eclampsia screening worldwide are explored. The review concludes with suggestions for more robust pre-eclampsia research, which includes diversifying study sites, improving biomarker analytical tools, and for researchers to consider studying patients before they become pregnant to improve pre-eclampsia detection rates. Additionally, researchers must acknowledge the systemic racism involved in using race as a risk factor and include qualitative measures in study designs to capture the effects of racism on patients.

Lay Summary

Pre-eclampsia is a pregnancy-specific hypertensive disorder that can affect almost every organ system and complicates 2-8% of pregnancies globally. Here, we focus on the biological basis of the risk factors that have been identified for the condition. African American race currently does not have sufficient evidence as a risk factor and has been poorly studied. Current clinical methods poorly predict a patient's likelihood of developing pre-eclampsia; thus, researchers have made statistical models that are briefly described in this review. Then, low-cost technologies that aid in advancing pre-eclampsia screening are discussed. The review ends with suggestions for research direction to improve pre-eclampsia screening in all settings.Overall, we suggest that the future of pre-eclampsia screening should aim to identify those at risk before they become pregnant. We also suggest that the clinical standard of assessing patient risk solely on patient characteristics needs to be reevaluated, that study locations of pre-eclampsia research need to be expanded beyond a few high-income countries, and that low-cost technologies should be developed to increase access to prenatal screening.

Chronic kidney disease and adverse pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

Limited evidence exists on the role that the cause of chronic kidney disease plays in determining pregnancy outcomes. The aim of this systematic review and meta-analysis was to examine the association between chronic kidney disease and adverse pregnancy outcomes by the cause and severity of chronic kidney disease where reported. The protocol was registered under the International Prospective Register of Systematic Reviews (CRD42020211925).

DATA SOURCES

PubMed, Embase, and Web of Science were searched until May 24, 2021, supplemented with reference list checking.

STUDY ELIGIBILITY CRITERIA

Studies that compared the pregnancy outcomes in women with or without chronic kidney disease were included. Two reviewers independently screened titles, abstracts, and full-text articles according to a priori defined inclusion criteria.

METHODS

Data extraction and quality appraisal were performed independently by 3 reviewers. The grading of recommendations, assessment, development, and evaluation approach was used to assess the overall certainty of the evidence. Random-effects meta-analyses were used to calculate the pooled estimates using the generic inverse variance method. The primary outcomes included preeclampsia, cesarean delivery, preterm birth (<37 weeks' gestation), and small for gestational age babies.

RESULTS

Of 4076 citations, 31 studies were included. Prepregnancy chronic kidney disease was significantly associated with a higher odds of preeclampsia (pooled crude odds ratio, 8.13; [95% confidence interval, 4.41-15], and adjusted odds ratio, 2.58; [1.33-5.01]), cesarean delivery (adjusted odds ratio, 1.65; [1.21-2.25]), preterm birth (adjusted odds ratio, 1.73; [1.31-2.27]), and small for gestational age babies (adjusted odds ratio, 1.93; [1.06-3.52]). The association with stillbirth was not statistically significant (adjusted odds ratio, 1.67; [0.96-2.92]). Subgroup analyses indicated that different causes of chronic kidney disease might confer different risks and that the severity of chronic kidney disease is associated with a risk of adverse pregnancy outcomes, as pregnancies with later stages of chronic kidney disease had higher odds of preeclampsia, preterm birth, and small for gestational age babies than those at earlier stages. The grading of recommendations, assessment, development, and evaluation certainty of the evidence overall was "very low".

CONCLUSION

This meta-analysis quantified the associations between prepregnancy chronic kidney disease and adverse pregnancy outcomes, both overall and according to the cause and severity of the disease. These findings might support the clinicians aiming to counsel women having chronic kidney disease by allowing them to tailor their advice according to cause and severity of the chronic kidney disease. We identified the gaps in the literature, and further studies examining the effect of specific kidney diseases and other clinical characteristics (eg, proteinuria, hypertension) on adverse pregnancy outcomes are warranted.

Hypertensive Disorders of Pregnancy: Common Clinical Conundrums

Importance

Hypertensive complications of pregnancy comprise 16% of maternal deaths in developed countries and 7.4% of deaths in the United States. Rates of preeclampsia increased 25% from 1987 to 2004, and rates of severe preeclampsia have increased 6.7-fold between 1980 and 2003.

Objective

The aim of this study was to review current and available evidence for common clinical questions regarding the management of hypertensive disorders of pregnancy.

Evidence Acquisition

Original research articles, review articles, and guidelines on hypertension in pregnancy were reviewed.

Results

Severe gestational hypertension should be managed as preeclampsia with severe features. Serum uric acid levels can be useful in predicting development of superimposed preeclampsia for women with chronic hypertension. When presenting with preeclampsia with severe features before 34 weeks, expectant management should be considered only when both maternal and fetal conditions are stable. In the setting of hypertensive disorders of pregnancy, oral antihypertensive medications should be initiated when systolic blood pressure is greater than 160 mm Hg or when diastolic blood pressure is greater than 110 mm Hg, with the most ideal agents being labetalol or nifedipine. Furthermore, although risk of preeclampsia recurrence in future pregnancy is low, women with a history of preeclampsia should be managed with 81 mg aspirin daily for preeclampsia prevention.

Conclusions and Relevance

Despite the frequency with which hypertensive disorders of pregnancy are encountered clinically, situations arise frequently with limited evidence to guide providers in their management. An urgent need exists to better understand this disease to optimize outcomes for impacted patients.

Interconception Care for Primary Care Providers: Consensus Recommendations on Preconception and Postpartum Management of Reproductive-Age Patients With Medical Comorbidities

Severe maternal morbidity and mortality continue to increase in the United States, largely owing to chronic and newly diagnosed medical comorbidities. Interconception care, or care and management of medical conditions between pregnancies, can improve chronic disease control before, during, and after pregnancy. It is a crucial and time-sensitive intervention that can decrease maternal morbidity and mortality and improve overall health. Despite these potential benefits, interconception care has not been well implemented by the primary care community. Furthermore, there is a lack of guidelines for optimizing preconception chronic disease, risk stratifying postpartum chronic diseases, and recommending general collaborative management principles for reproductive-age patients in the period between pregnancies. As a result, many primary care providers, especially those without obstetric training, are unclear about their specific role in interconception care and may be unsure of effective methods for collaborating with obstetric care providers. In particular, internal medicine physicians, the largest group of primary care physicians, may lack sufficient clinical exposure to medical conditions in the obstetric population during their residency training and may feel uncomfortable in caring for these patients in their subsequent practice.

The objective of this article is to review concepts around interconception care, focusing specifically on preconception care for patients with chronic medical conditions (eg, chronic hypertension, chronic diabetes mellitus, chronic kidney disease, venous thromboembolism, and obesity) and postpartum care for those with medically complicated pregnancies (eg, hypertensive disorders of pregnancy, gestational diabetes mellitus, excessive gestational weight gain, peripartum cardiomyopathy, and peripartum mood disorders). We also provide a pragmatic checklist for preconception and postpartum management.

The interval between births and the risk of recurrent preeclampsia among predominantly high risk women in urban tertiary care center

INTRODUCTION

Women with a history of preeclampsia have a higher risk of recurrent preeclampsia. This study sought to ascertain the relationship between the interbirth interval and the risk of recurrent preeclampsia and difference in angiogenic markers between the two groups.

METHODS

Data was collected from an ongoing cohort study of women with hypertensive disorders of pregnancy (HDP) enrolled at the admission to the labor and delivery floor. From this dataset, multigravida women with a prior diagnosis of preeclampsia were identified and compared to women with no prior history of preeclampsia.

RESULTS

Of the 375 women with HDP who were predominantly African American, 245 were multigravida and 44 (18.0%) had a prior history of preeclampsia. Women with prior preeclampsia had an earlier gestational age of delivery, higher rates of preterm delivery and a higher incidence of preeclampsia with severe features (56.8% vs 29.8%) in the index pregnancy (p-values ≤ 0.001) than those without. The median number of years between history of preeclampsia in previous pregnancy and current pregnancy was 6 years (IQR 3, 8). Among patients with a prior history of preeclampsia, the interbirth interval was not associated with severe preeclampsia (p = 0.60) and there was no difference in angiogenic factors between patients with a prior history of preeclampsia compared to those without.

CONCLUSIONS

In this study, the duration of the interbirth interval was not identified as a risk factor of developing severe preeclampsia in a subsequent pregnancy and angiogenic factors are not a reflection of maternal predisposition to recurrent preeclampsia.

Angiogenic factors and prediction for ischemic placental disease in future pregnancies

OBJECTIVES

Ischemic placental disease (IPD), including preeclampsia, abruption, and fetal growth restriction, often recurs in subsequent pregnancies. Angiogenic factors of placental origin have been implicated in the pathogenesis of preeclampsia, but have not been studied as predictors of IPD in subsequent pregnancies. We hypothesized that elevated angiogenic factors in an index pregnancy would be associated with recurrence of IPD.

STUDY DESIGN

We conducted a retrospective cohort study of patients undergoing evaluation for preeclampsia who had angiogenic factors measured in an index pregnancy and experienced a subsequent pregnancy at the same institution. Patients with IPD in the index pregnancy were included. A high ratio of soluble fms-like tyrosine kinase 1 (sFlt1) and placental growth factor (PlGF) was defined as greater than or equal to 85.

MAIN OUTCOME MEASURES

The primary outcome was IPD in a subsequent pregnancy.

RESULTS

We included 109 patients in the analysis. The sFlt1/PlGF ratio was elevated in 30% of participants. Those with an elevated ratio were more likely to be nulliparous in the index pregnancy, and less likely to have chronic hypertension. The recurrence of IPD in the study was 27%, with a non-significant difference in risk based on a high sFlt-1/P1GF ratio RR 0.58 (95% CI 0.21 - 1.6) compared to a low ratio.

CONCLUSIONS

A high sFlt1/P1GF ratio in an index pregnancy is not associated with a higher risk of IPD in a subsequent pregnancy. These data suggest placental angiogenic biomarkers are specific to the pregnancy and not a reflection of maternal predisposition to IPD.

Decidual Natural Killer Cells: A Good Nanny at the Maternal-Fetal Interface During Early Pregnancy

Decidual natural killer (dNK) cells are the tissue-resident and major subpopulation of NK cells at the maternal-fetal interface. It has been demonstrated that dNK cells play pivotal roles in pregnancy, including keeping maternal-fetal immune tolerance, promoting extravillous trophoblast (EVT) cell invasion, and driving uterine spiral artery remodeling. However, the molecular mechanisms haven't been elucidated until recent years. In this review, we systemically introduce the generation, subsets, and surface or soluble molecules of dNK cells, which are critical for maintaining the functions of dNK cells. Further, new functions of dNK cells including well-controlled cytotoxicity, immunosurveillance and immunotrophism supporting via the cell-cell interaction between dNK cells and EVT cells are mainly focused. The molecular mechanisms involved in these functions are also illustrated. Moreover, pregnancy-associated diseases caused by the dNK cells abnormalities are discussed. It will be important for future investigations about the mechanism of maintenance of pregnancy and parturition and potential clinical applications of dNK cells.

Maternal risk factors and neonatal outcomes associated with low birth weight in a secondary referral hospital in Ghana

INTRODUCTION

Over the past decade, the incidence of low birth weight (LBW) in sub-Saharan Africa has not seen any decline and this is a matter of grave concern for healthcare providers, policymakers, and researchers. Therefore, this study aimed to assess the incidence of LBW and related maternal risk factors (during pregnancy or delivery) as well as neonatal outcomes.

METHODS

An institutional-based retrospective cross-sectional study design was employed to select 1,017 mothers who delivered in the study hospital from January to December 2017 with singleton newborn babies without congenital diseases. Data were analysed using STATA version 14.1 (StataCorp. 2015. Stata Statistical Software: Release 14. College Station, TX: Stata Corp LP). Chi-square test of independence was used to test the association between the dependent variable (LBW) and risk factors of LBW. Bivariate and multivariable unconditional logistic regression was used to determine the factors associated with LBW.

RESULTS

The incidence of LBW was 23.7%. The findings show that being married has a protective effect on LBW [AOR = 0.60 (95%CI: 0.40-0.90), p = 0.013] compared to single mothers. Neonates born between gestational age of 37-42 weeks had 85% lower odds of LBW [AOR = 0.15, (95%CI: 0.10-0.24), p < 0.001)]. Neonates with LBW had a higher risk of low Apgar score in the first minute compared to neonates with normal birth weight [AOR = 0.52 (95%CI: 0.37-0.73), p < 0.001]. Female neonates had 64% higher odds of LBW compared to their male counterparts [AOR = 1.64 (95%CI: 1.19-2.24), p = 0.002].

CONCLUSION

This study revealed a high incidence of LBW. Women's marital status (single mothers), gestational age (<37 weeks), neonatal sex (female), are independent risk factors associated with LBW, while a higher risk of an Apgar score of less than 7 in the first minute was an independent outcome of low birth weight births. The current study findings contribute to the growing literature on the influence of maternal and neonatal factors on LBW in resource-constrained settings. These findings could guide healthcare providers, hospital administrators, stakeholders, and policymakers to develop and implement appropriate clinical and public health strategies aimed at reducing LBW.

Preeclampsia Among African American Pregnant Women: An Update on Prevalence, Complications, Etiology, and Biomarkers

Importance

Preeclampsia is a devastating disease of pregnancy associated with increased risk of fetal and maternal complications. African American pregnant women have a high prevalence of preeclampsia, but there is a need of systemic analyses of this high-risk group regarding complications, etiology, and biomarkers.

Objective

The aim of this study was to provide a synopsis of current research of preeclampsia specifically related to African American women.

Evidence Acquisition

A comprehensive search was performed in the bibliographic database PubMed with keywords "preeclampsia" and "African American."

Results

African American women with preeclampsia were at an increased risk of preterm birth, which resulted in low-birth-weight infants. Intrauterine fetal death among African American preeclamptic patients occurs at twice the rate as in other races. On the maternal side, African American mothers with preeclampsia have more severe hypertension, antepartum hemorrhage, and increased mortality. Those who survive preeclampsia have a high risk of postpartum cardiometabolic disease. Preexisting conditions (eg, systemic lupus erythematosus) and genetic mutations (eg, sickle cell disease in the mother, FVL or APOL1 mutations in the fetus) may contribute to the higher prevalence and worse outcomes in African American women. Many blood factors, for example, the ratio of proteins sFlt/PlGF, hormones, and inflammatory factors, have been studied as potential biomarkers for preeclampsia, but their specificity needs further investigation.

Conclusions

Further studies of preeclampsia among African American women addressing underlying risk factors and etiologies, coupled with identification of preeclampsia-specific biomarkers allowing early detection and intervention, will significantly improve the clinical management of this devastating disease.

The impact of pregnancy induced hypertension on low birth weight in Ethiopia: systematic review and meta-analysis

Background

Even though neonatal mortality reduction is the major goal needed to be achieved by 2030, it is still unacceptably high especially in Ethiopia. In the other hand, low birth weight is the major cause of neonatal mortality and morbidity. More than 10 millions of low birth weight infants occurred as a result of pregnancy induced hypertension. However, in Ethiopia the association between low birth weight and pregnancy induced hypertension was represented with un-updated, inconclusive and different studies. Therefore, this review aimed to estimate the overall pooled impact of pregnancy induced hypertension on low birth weight and its association in Ethiopia.

Methods

articles searched on PubMed/Medline, EMBASE, CINAHL, Cochrane library, Google, Google Scholar and local shelves. Joanna Briggs Institute Meta-Analysis of Statistics Assessment and Review Instrument (JBI-MAStARI) was applied for critical appraisal. The I² statistic was computed to check the presence of heterogeneity. Publication bias was evaluated using funnel plot asymmetry and Egger’s test. A random effect model was used to estimate the pooled prevalence of low birth weight.

Result

From the total 131 identified original articles, 25 were eligible and included for the final analysis. The overall pooled prevalence of low birth weight among women who had pregnancy induced hypertension in Ethiopia was 39.7% (95% CI: 33.3, 46.2). But, I² statistic estimation evidenced significant heterogeneity across included studies (I² = 89.4, p < 0.001). In addition, the odds of having low birth weight newborns among women who had pregnancy induced hypertension was 3.89 times higher compared to their counterparts (OR = 3.89, 95% CI: 2.66, 5.69).

Conclusion

The pooled prevalence of low birth weight among women who had pregnancy induced hypertension was more than two times higher than the pooled estimate of low birth weight among all reproductive aged women. The odds of low birth weight also increased nearly four times among women with pregnancy induced hypertension than normotensive women. Therefore, health policies which provide better and quality antenatal care with more oriented on importance of early detection and management of pregnancy induced hypertension should be implemented.

Preeclampsia before 26 weeks of gestation: Obstetrical prognosis for the subsequent pregnancy

INTRODUCTION

Gestational age at delivery seems to be a risk factor of recurrence of preeclampsia. The objective of this study was to analyze adverse pregnancy outcomes and recurrence of preeclampsia during the subsequent pregnancy in women with a history of pre-eclampsia delivered before 26 weeks of gestation.

MATERIAL AND METHOD

We performed a retrospective study in two French tertiary care hospitals between 2000 and 2018. Patients with a history of pre-eclampsia delivered before 26 weeks of gestation were analyzed. Information on the immediate subsequent pregnancy was collected. Adverse composite outcome was defined as recurrent preeclampsia, HELLP syndrome, placental abruption, fetal growth restriction <3rd percentile or <10^e percentile with Doppler abnormalities, maternal death and fetal death.

RESULTS

Among the 107 patients who met the criteria, 48 were analyzed for a subsequent pregnancy. Seventeen women (35.4 %) developed an adverse composite outcome, occurring for 15 women (31.2 %) before 34 weeks. Ten women (20.8 %) developed a recurrent preeclampsia occurring for 5 women (10.4 %) before 34 weeks. We related 3 HELLP syndromes, 1 placental abruption, 9 fetal growth restrictions, 3 fetal deaths and no maternal death. Compared to baseline normotensive women, chronic hypertension was significantly associated with an increased risk of adverse composite outcome (19.3 vs 58.8 %, p-value 0.014).

CONCLUSION

In our population, preeclampsia with delivery before 26 weeks is associated with 35.4 % of adverse composite outcomes and 20.8 % of recurrent preeclampsia during the immediate subsequent pregnancy. These results justify the importance of an ongoing monitoring of these patients during subsequent pregnancy.

Probability and outcomes of second pregnancy after HELLP syndrome in the first: A population-based registry study

INTRODUCTION

Some studies have suggested that women may avoid further pregnancies after experiencing a pregnancy affected by a hypertensive disorder. Large population-based studies are needed to better understand the outcomes of later pregnancies among women who have a history of hypertensive disorders of pregnancy. The aims of the study were to assess outcomes of the second pregnancy and second delivery rate among women experiencing Hemolysis, elevated liver enzymes and low platelet count (HELLP) syndrome in their first pregnancy.

MATERIAL AND METHODS

This population-based registry study included all women with a first delivery registered in the Medical Birth Registry of Norway from 1999 to 2014 (n = 418 897). Logistic regression was used to estimate odds ratios (ORs) with 95% confidence intervals (CIs) for adverse outcomes of the second delivery and the probability of no second delivery among women with HELLP syndrome in first pregnancy compared with women without HELLP syndrome. We also compared outcomes in the first and second pregnancies among women with HELLP syndrome in first.

RESULTS

HELLP syndrome occurred in 0.24% of first pregnancies (n = 1006). Among women with HELLP syndrome in their first pregnancy, adverse outcomes were substantially less frequent in the second pregnancy: preterm deliveries declined from 56.0% to 14.2%, and small for gestational age from 6.6% to 2.8%. More than 75% had no hypertensive disorder in their second pregnancy. Still, compared with women without a history of HELLP syndrome, ORs for adverse outcomes in second pregnancies were increased: preterm birth (OR 3.7, 95% CI 2.8-4.8), small for gestational age (OR 2.7, 95% CI 1.6-4.8), perinatal death (OR 3.1, 95% CI 1.4-7.0), placental abruption (OR 4.2, 95% CI 1.8-9.4) and hypertensive complication (OR 8.3, 95% CI 6.7-10.3). HELLP syndrome did not influence the probability of a second delivery.

CONCLUSIONS

Among women with HELLP syndrome in their first pregnancy, the occurrence of adverse pregnancy outcomes was substantially reduced in the second pregnancy. However, compared with unaffected women, they were still at greater risk of pregnancy complications.

The Roles of Uterine Natural Killer (NK) Cells and KIR/HLA-C Combination in the Development of Preeclampsia: A Systematic Review

Preeclampsia (PE) is termed as a systemic disease that involves multiple organs; however, the exact etiology is still quite unclear. It is believed that the poor remodeling of uterine spiral arteries triggers PE, thereby causing failed placentation and producing inflammatory factors. The decline of blood flow results in lowering the nutrients and oxygen received by the fetus and augmenting the placental pressure in PE. Decidual immune cells, especially uterine natural killer (uNK) cells, are involved in the process of placentation. Decidual NK (dNK) cells significantly contribute to the vascular remodeling through the secretion of cytokines and angiogenic mediators in normal placental development. The abnormal activation of NK cells in both the peripheral blood and the decidua was counted among the causes leading to PE. The correlation existing between maternal killer cell immunoglobulin-like receptor (KIR) and HLA-C in trophoblast cells constitutes a robust evidence for the genetic etiology of PE. The combinations of the two kinds of gene systems, together with the KIR genotype in the mother and the HLA-C group in her fetus, are likely to exactly decide the pregnancy outcome. The women, who have the inappropriate match of KIR/HLA-C, are likely to be prone to the augmented risk of PE. However, the combinations of KIR/HLA-C in PE undergo ethnic changes. The extensive prospective research works in Europe, Asia, and Africa are required for providing more findings in PE patients.

Altered growth trajectory in children born to mothers with gestational diabetes mellitus and preeclampsia

PURPOSE

Gestational diabetes mellitus (GDM) and preeclampsia are leading causes of mortality and morbidity in mothers and children. High childhood body mass index (BMI) is among their myriad of negative outcomes. However, little is known about the trajectory of the child BMI exposed to GDM and co-occurring preeclampsia from early to mid-childhood. This study examined the independent and joint impact of GDM and preeclampsia on childhood BMI trajectory.

METHODS

A population-based sample of 356 mothers were recruited from OB/GYN clinics in New York. Their children were then followed annually from 18 to 72 months. Maternal GDM and preeclampsia status were obtained from medical records. Child BMI was calculated based on their height and weight at annual visits.

RESULTS

Hierarchical Linear Modeling was used to evaluate the trajectories of child BMI exposed to GDM and preeclampsia. BMI trajectory by GDM decreased (t ratio = - 2.24, [Formula: see text]0.45, 95% CI - 0.05-0.95, p = 0.07), but the trajectory by preeclampsia increased over time (t ratio = 3.153,[Formula: see text]0.65, 95% CI 0.11-1.18, p = 0.002). Moreover, there was a significant interaction between the two (t ratio = -2.24, [Formula: see text]- 1.244, 95% CI 0.15-2.33, p = 0.02), such that the BMI of children born to mothers with both GDM and preeclampsia showed consistent increases over time.

CONCLUSIONS

GDM and preeclampsia could be used as a marker for childhood obesity risk and the identification of a high-risk group, providing potential early intervention. These findings highlight the importance of managing obstetric complications, as an effective method of child obesity prevention.

Maternal and perinatal outcomes of hypertensive disorders of pregnancy in Ethiopia: systematic review and meta-analysis

BACKGROUND

Hypertensive disorders of pregnancy complicate around 6% of pregnancies and accounts for 19% of maternal death in Ethiopia. The current review aimed to assess maternal and perinatal outcomes of pregnancies complicated by hypertension in Ethiopia.

METHODS

A systematic review and meta-analysis was done on the outcome of hypertensive disorder among pregnant women in Ethiopia. Literature search was made in five databases and Statistical analyses were carried out by using Stata 14 software. The pooled prevalence of maternal death, HELLP syndrome, perinatal death, and low birth weight was calculated using a random-effects model. Egger's test and funnel plot were used to evaluate publication bias. The Cochran Q test and I2 test statistics were used to test the heterogeneity of studies.

RESULT

Thirteen studies included in the review, with an overall sample size of 5894 women diagnosed to have hypertensive disorder of pregnancy. The pooled prevalence of maternal death was estimated to be 4% (95% CI: 2, 6%). The pooled prevalence of HELLP syndrome was 13% (95% CI: 10, 16%). Other complications such as pulmonary edema, kidney injury, hepatic injury, placental abruption, and aspiration pneumonia were also reported. Perinatal death was observed in one-fourth of women with HDP 25% (95% CI: 18, 32%). The pooled prevalence of low birth weight neonate in a woman with HDP is 37% (95% CI, 27, 48%).

CONCLUSIONS

In Ethiopia, the prevalence of perinatal and maternal mortality among pregnant women with one of the hypertensive disorders were found to be higher than rates reported from high income as well as most of the low and middle income countries. For instance, one in four of pregnancies complicated by hypertensive disorder end up in perinatal death in Ethiopia. HELLP syndrome, placental abruption, pulmonary edema, renal damage, prematurity, perinatal asphyxia, and low birth weight were also commonly reported. To improve the health outcomes of hypertensive disorders of pregnancy, it is recommended to improve utilization of maternal health service; early detection and early referral of pregnant women with hypertensive disorder; advocating policies and strategies that improves the quality of health care that a pregnant woman and her newborn receive.

Uterine and umbilical artery doppler in women with pre-eclampsia and their pregnancy outcomes

Background

Pre-eclampsia (PE) is an important public health menace in both developed and developing countries with high maternal and perinatal morbidity and mortality globally. A major goal towards improving antenatal management of PE is to develop accurate prediction models that identify women at high risk of this disease for appropriate interventions.

Methodology

In a longitudinal cohort study, high-risk singleton pregnant women enroled between April 2015 and February 2016 had uterine and umbilical artery Doppler sonography at 22-24 weeks and 32-34 weeks gestation and had their delivery outcomes documented by the obstetrician and gynaecologist. The peak systolic velocity (PSV), end-diastolic velocity (EDV), Resistivity Index (RI), Pulsatility Index (PI) and the systolic-diastolic ratio (S/D) were recorded.

Results

Among the ninety-eight high-risk pregnant women, 61 (62.2%) developed PE and 32 (32.8%) did not have PE. In the PE cases, 15 (24.5%) were mild and 46 (74.5%) were severe PE. The uterine artery PI was significantly associated with PE. A unit increase in uterine PI in high-risk pregnancies, increases the odd of PE by 37.37 times (95% confidence interval; odds ratio = 6.09, 241.9; P < 0.001). The combination of the uterine and umbilical PSV predicted 80.3% of severe PE. All three spontaneous abortions were in women who developed PE, more caesarean section (48.4%) and 69.2% of 45 pre-term deliveries occurred in women with severe PE.

Conclusion

The findings from this study show significantly lower uterine and umbilical arteries PSV and EDV but higher RI, PI and S/D in cases that developed PE. The uterine artery PI is the best predictor of PE, whereas the combinations of uterine and umbilical arteries PSV best predict severity of PE among high-risk pregnant Nigeria women.

Management of pregnancy blood pressure increase in the emergency room: role of PlGF-based biochemical markers and relative economic impact

INTRODUCTION

To evaluate the clinical and economic impact of healthcare management of pregnant women with blood pressure increase (BPI) accessing emergency room (ER) and the utility of the introduction of a PlGF-based test in clinical practice.

MATERIALS AND METHODS

This retrospective cohort study included women with single pregnancies who performed at least 1 ER access for BPI after the 20th gestational week in 2016. BPI was subsequently classified as significant if associated with preeclampsia (PE) or Fetal Growth Restriction (FGR) and not significant otherwise. Two experts evaluated potential changes in patients' management with the introduction of a PlGF-based test. The direct healthcare cost was estimated.

RESULTS

We enrolled 107 patients, of which 30% showed significant BPI (17 PE cases, 13 FGR, and 2 both pathologies). Anamnestic, clinical, and laboratory evaluations were not effective in differentiating between significant and not significant BPI (p-values: .8320, .2856, and .2297, respectively). The introduction of a PlGF-based test would have reduced overtreatment and undertreatment. The test would have avoided 18% of all hospitalizations, 35% of hospitalizations for BPI, 43% of outpatient referrals, and 13% of ER accesses. The number of avoidable accesses was higher in women with not significant BPI. Overall, the mean total cost (from first ER access until delivery) was €2634 per woman and €401 would have been avoidable.

CONCLUSION

The clinical integration of PlGF-based tests is advantageous in diagnostic, prognostic and economic terms, as an objective marker of placental dysfunction.

Risk factors for adverse maternal and perinatal outcomes in women with preeclampsia: analysis of 1396 cases

Preeclampsia is a major cause of adverse maternal and perinatal outcomes, but how to identify women and fetuses at increased risk for later adverse events is a challenge. This study aimed to investigate the risk factors for adverse maternal and perinatal outcomes in women with preeclampsia. Data from 1396 women with preeclampsia were retrospectively collected and analyzed. Eighteen candidate risk factors and 12 adverse outcomes were investigated. The following factors were found to be significantly associated with at least one adverse outcome: maternal age 35 years or older, multiple birth, the usage of assisted reproductive technology, living in a rural area, history of pregnancy-induced hypertension, male fetus, multigravida, or having polycystic ovary syndrome, hemolysis, elevated liver enzymes, and low platelet count syndrome, intrahepatic cholestasis of pregnancy, cardiovascular disease, gestational diabetes mellitus, systemic lupus erythematosus, thyroid disease, or liver disease. Compared with patients without any identified risk factors, patients with preeclampsia with three or more risk factors were at increased risk for severe adverse outcomes. Those findings demonstrated that maternal risk factors could be used as indicators supplementary to clinical symptoms and laboratory test results for the risk assessment in women with preeclampsia.

Placental growth factor (alone or in combination with soluble fms-like tyrosine kinase 1) as an aid to the assessment of women with suspected pre-eclampsia: systematic review and economic analysis

BACKGROUND

Pre-eclampsia (PE) prediction based on blood pressure, presence of protein in the urine, symptoms and laboratory test abnormalities can result in false-positive diagnoses. This may lead to unnecessary antenatal admissions and preterm delivery. Blood tests that measure placental growth factor (PlGF) or the ratio of soluble fms-like tyrosine kinase 1 (sFlt-1) to PlGF could aid prediction of PE if either were added to routine clinical assessment or used as a replacement for proteinuria testing.

OBJECTIVES

To evaluate the diagnostic accuracy and cost-effectiveness of PlGF-based tests for patients referred to secondary care with suspected PE in weeks 20-37 of pregnancy.

DESIGN

Systematic reviews and an economic analysis.

DATA SOURCES

Bibliographic databases including MEDLINE, EMBASE, Web of Science and The Cochrane Library and Database of Abstracts of Reviews of Effects were searched up to July 2015 for English-language references. Conferences, websites, systematic reviews and confidential company submissions were also accessed.

REVIEW METHODS

Systematic reviews of test accuracy and economic studies were conducted to inform an economic analysis. Test accuracy studies were required to include women with suspected PE and report quantitatively the accuracy of PlGF-based tests; their risk of bias was assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) criteria. The economic studies review had broad eligibility criteria to capture any types of economic analysis; critical appraisal employed standard checklists consistent with National Institute for Health and Care Excellence criteria. Study selection, critical appraisal and data extraction in both reviews were performed by two reviewers.

ECONOMIC ANALYSIS

An independent economic analysis was conducted based on a decision tree model, using the best evidence available. The model evaluates costs (2014, GBP) from a NHS and Personal Social Services perspective. Given the short analysis time horizon, no discounting was undertaken.

RESULTS

Four studies were included in the systematic review of test accuracy: two on Alere's Triage^® PlGF test (Alere, Inc., San Diego, CA, USA) for predicting PE requiring delivery within a specified time and two on Roche Diagnostics' Elecsys^® sFlt-1 to PlGF ratio test (Roche Diagnostics GmbH, Mannheim, Germany) for predicting PE within a specified time. Three studies were included in the systematic review of economic studies, and two confidential company economic analyses were assessed separately. Study heterogeneity precluded meta-analyses of test accuracy or cost-analysis outcomes, so narrative syntheses were conducted to inform the independent economic model. The model predicts that, when supplementing routine clinical assessment for rule-out and rule-in of PE, the two tests would be cost-saving in weeks 20-35 of gestation, and marginally cost-saving in weeks 35-37, but with minuscule impact on quality of life. Length of neonatal intensive care unit stay was the most influential parameter in sensitivity analyses. All other sensitivity analyses had negligible effects on results.

LIMITATIONS

No head-to-head comparisons of the tests were identified. No studies investigated accuracy of PlGF-based tests when used as a replacement for proteinuria testing. Test accuracy studies were found to be at high risk of clinical review bias.

CONCLUSIONS

The Triage and Elecsys tests would save money if added to routine clinical assessment for PE. The magnitude of savings is uncertain, but the tests remain cost-saving under worst-case assumptions. Further research is required to clarify how the test results would be interpreted and applied in clinical practice.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015017670.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Previable Preeclampsia Diagnosed by Renal Biopsy in Setting of Novel Diagnosis of C4 Glomerulopathy

Background

Preeclampsia diagnosed before 20 weeks' gestational age is a rare entity, particularly without any predisposing factors. We report a case of preeclampsia occurring prior to 20 weeks' gestational age in the setting of a novel diagnosis of C4 glomerulopathy.

Case

A G3P0020 at 18 weeks presented with new onset hypertension and proteinuria, requiring multiple antihypertensive agents to maintain control. Renal biopsy demonstrated thrombotic microangiopathic lesions and glomerular endotheliosis. C4-dominant staining and numerous subendothelial and mesangial electron dense deposits were found within the glomerulus. With no other definable etiologies, preeclampsia was diagnosed. She developed posterior reversible encephalopathic syndrome and pregnancy termination was recommended.

Conclusion

The lectin complement pathway may play a role in the pathophysiology of severe, early onset preeclampsia. Renal biopsy may play an integral role in diagnosis.

Factors associated with maternal mortality at advanced maternal age: a population-based case-control study

OBJECTIVE

This study aimed to examine the factors associated with maternal mortality among women aged ≥35 years.

DESIGN

Unmatched population based case-control study.

SETTING

United Kingdom.

POPULATION

Between 2009 and 2012, 105 cases of maternal deaths aged ≥35 years were extracted from the surveillance database of the MBRRACE-UK confidential enquiries into maternal deaths in the UK. In addition, 766 controls aged ≥35 years were identified from the UK Obstetric Surveillance System (2005-2012).

METHODS

Risk factors known to be associated with maternal mortality and morbidity and for which data were available were examined for their association with maternal mortality among women ≥35 years using logistic regression analysis.

MAIN OUTCOME MEASURES

Odds ratios and 95% confidence intervals associated with maternal death.

RESULTS

Five factors were found to be significantly associated with increased odds of death among women aged ≥35 years: smoking during pregnancy (adjusted odds ratio (aOR) 2.06, 95% CI 1.13-3.75), inadequate use of antenatal care (aOR 23.62, 95% CI 8.79-63.45), medical co-morbidities (aOR 5.92, 95% CI 3.56-9.86) and previous pregnancy problems (aOR 2.06, 95% CI 1.23-3.45). The odds associated with death increased by 12% per year increase in age (aOR 1.12, 95% CI 1.02-1.22).

CONCLUSION

Age was associated with maternal mortality even after adjusting for other known risk factors. Importantly, this study showed an association between maternal mortality and smoking among women aged 35 years or older. It emphasises the importance of public health action to reduce smoking levels and address trends in rising maternal age.

TWEETABLE ABSTRACT

Smoking is a risk factor for maternal death for those aged over 35 years.

Enoxaparin and Aspirin Compared With Aspirin Alone to Prevent Placenta-Mediated Pregnancy Complications: A Randomized Controlled Trial

OBJECTIVE

To evaluate whether daily enoxaparin, added to low-dose aspirin, started before 14 weeks of gestation reduces placenta-mediated complications in pregnant women with previous severe preeclampsia diagnosed before 34 weeks of gestation.

METHODS

In this open-label multicenter randomized trial, we enrolled consenting pregnant women with previous severe preeclampsia diagnosed before 34 weeks of gestation, gestational age at randomization of 7-13 weeks, singleton pregnancy, and no plan for anticoagulation. Eligible patients were randomly assigned to a one-to-one ratio to receive daily either 4,000 international units enoxaparin plus 100 mg aspirin or 100 mg aspirin alone. Randomization was done by a web-based randomization system. The primary composite outcome comprised maternal death, perinatal death, preeclampsia, small for gestational age (less than the 10th percentile), and placental abruption. A sample size of 232 women equally divided into two groups was needed to detect a significant reduction in primary outcome from 55% in the aspirin group to 36.7% in the enoxaparin-aspirin group (α: 0.05, β: 0.8, two-sided).

RESULTS

Between November 14, 2009, and February 21, 2015, 257 participants were enrolled. Baseline demographic and clinical factors were similar between groups. Eight women were excluded after randomization (six in the enoxaparin-aspirin group and two in the aspirin group), leaving 124 participants assigned to enoxaparin-aspirin and 125 to aspirin. Five participants were lost to follow-up (two in the enoxaparin-aspirin group and three in the aspirin group). There was no significant difference between the groups in the primary outcome: enoxaparin-aspirin 42 of 122 (34.4%) compared with aspirin alone 50 of 122 (41%) (relative risk 0.84, 95% confidence interval 0.61-1.16, P=.29). The occurrence of complications did not differ between the two groups.

CONCLUSION

Antepartum prophylactic enoxaparin does not significantly reduce placenta-mediated complications in women receiving low-dose aspirin for previous severe preeclampsia diagnosed before 34 weeks of gestation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, https://clinicaltrials.gov, NCT00986765.

Neurodevelopmental consequences in offspring of mothers with preeclampsia during pregnancy: underlying biological mechanism via imprinting genes

PURPOSE

Preeclampsia is known to be a leading cause of mortality and morbidity among mothers and their infants. Approximately 3-8% of all pregnancies in the US are complicated by preeclampsia and another 5-7% by hypertensive symptoms. However, less is known about its long-term influence on infant neurobehavioral development. The current review attempts to demonstrate new evidence for imprinting gene dysregulation caused by hypertension, which may explain the link between maternal preeclampsia and neurocognitive dysregulation in offspring.

METHOD

Pub Med and Web of Science databases were searched using the terms "preeclampsia," "gestational hypertension," "imprinting genes," "imprinting dysregulation," and "epigenetic modification," in order to review the evidence demonstrating associations between preeclampsia and suboptimal child neurodevelopment, and suggest dysregulation of placental genomic imprinting as a potential underlying mechanism.

RESULTS

The high mortality and morbidity among mothers and fetuses due to preeclampsia is well known, but there is little research on the long-term biological consequences of preeclampsia and resulting hypoxia on the fetal/child neurodevelopment. In the past decade, accumulating evidence from studies that transcend disciplinary boundaries have begun to show that imprinted genes expressed in the placenta might hold clues for a link between preeclampsia and impaired cognitive neurodevelopment. A sudden onset of maternal hypertension detected by the placenta may result in misguided biological programming of the fetus via changes in the epigenome, resulting in suboptimal infant development.

CONCLUSION

Furthering our understanding of the molecular and cellular mechanisms through which neurodevelopmental trajectories of the fetus/infant are affected by preeclampsia and hypertension will represent an important first step toward preventing adverse neurodevelopment in infants.

Cluster analysis to estimate the risk of preeclampsia in the high-risk Prediction and Prevention of Preeclampsia and Intrauterine Growth Restriction (PREDO) study

Objectives

Preeclampsia is divided into early-onset (delivery before 34 weeks of gestation) and late-onset (delivery at or after 34 weeks) subtypes, which may rise from different etiopathogenic backgrounds. Early-onset disease is associated with placental dysfunction. Late-onset disease develops predominantly due to metabolic disturbances, obesity, diabetes, lipid dysfunction, and inflammation, which affect endothelial function. Our aim was to use cluster analysis to investigate clinical factors predicting the onset and severity of preeclampsia in a cohort of women with known clinical risk factors.

Methods

We recruited 903 pregnant women with risk factors for preeclampsia at gestational weeks 12⁺⁰–13⁺⁶. Each individual outcome diagnosis was independently verified from medical records. We applied a Bayesian clustering algorithm to classify the study participants to clusters based on their particular risk factor combination. For each cluster, we computed the risk ratio of each disease outcome, relative to the risk in the general population.

Results

The risk of preeclampsia increased exponentially with respect to the number of risk factors. Our analysis revealed 25 number of clusters. Preeclampsia in a previous pregnancy (n = 138) increased the risk of preeclampsia 8.1 fold (95% confidence interval (CI) 5.7–11.2) compared to a general population of pregnant women. Having a small for gestational age infant (n = 57) in a previous pregnancy increased the risk of early-onset preeclampsia 17.5 fold (95%CI 2.1–60.5). Cluster of those two risk factors together (n = 21) increased the risk of severe preeclampsia to 23.8-fold (95%CI 5.1–60.6), intermediate onset (delivery between 34⁺⁰–36⁺⁶ weeks of gestation) to 25.1-fold (95%CI 3.1–79.9) and preterm preeclampsia (delivery before 37⁺⁰ weeks of gestation) to 16.4-fold (95%CI 2.0–52.4). Body mass index over 30 kg/m² (n = 228) as a sole risk factor increased the risk of preeclampsia to 2.1-fold (95%CI 1.1–3.6). Together with preeclampsia in an earlier pregnancy the risk increased to 11.4 (95%CI 4.5–20.9). Chronic hypertension (n = 60) increased the risk of preeclampsia 5.3-fold (95%CI 2.4–9.8), of severe preeclampsia 22.2-fold (95%CI 9.9–41.0), and risk of early-onset preeclampsia 16.7-fold (95%CI 2.0–57.6). If a woman had chronic hypertension combined with obesity, gestational diabetes and earlier preeclampsia, the risk of term preeclampsia increased 4.8-fold (95%CI 0.1–21.7). Women with type 1 diabetes mellitus had a high risk of all subgroups of preeclampsia.

Conclusion

The risk of preeclampsia increases exponentially with respect to the number of risk factors. Early-onset preeclampsia and severe preeclampsia have different risk profile from term preeclampsia.

Influence of random urine albumin-creatinine ratio of pregnant women with hypertension during the gestation period on perinatal outcome

The aim of the present study was to investigate the influence of the random urine albumin-creatinine ratio (ACR) of pregnant women with hypertension during the gestation period on perinatal outcome. A total of 6,758 pregnant women with pregnancy-induced hypertension and proteinuria were randomly selected between September, 2009 and June, 2015 for the study. Kidney function, blood pressure, history of gravidity and parity, embryo number and the birth weight of the participants was determined. Logistic regression and paired data correlation analyses were carried out with kidney function, blood pressure, history of gravidity and parity, embryo number, birth weight, maternal age, labor presentation and other risk factors as the independent variables and the newborn APGAR score as the dependent variable. The results showed that random urine ACR was increased and negatively correlated with the APGAR score (OR=−0.095, P=0.017). In conclusion, the increased random urine ACR can influence the postpartum outcome. Early intervention of women of childbearing age in early pregnancy or before pregnancy can minimize the adverse complications of infants and mothers such as pregnancy hypertension syndrome, and improve the outcome of the pregnancy.

Inter-pregnancy interval and risk of recurrent pre-eclampsia: systematic review and meta-analysis

BACKGROUND

Women with a history of pre-eclampsia have a higher risk of developing pre-eclampsia in subsequent pregnancies. However, the role of the inter-pregnancy interval on this association is unclear.

OBJECTIVE

To explore the effect of inter-pregnancy interval on the risk of recurrent pre-eclampsia or eclampia.

SEARCH STRATEGY

MEDLINE, EMBASE and LILACS were searched (inception to July 2015).

SELECTION CRITERIA

Cohort studies assessing the risk of recurrent pre-eclampsia in the immediate subsequent pregnancy according to different birth intervals.

DATA COLLECTION AND ANALYSIS

Two reviewers independently performed screening, data extraction, methodological and quality assessment. Meta-analysis of adjusted odds ratios (aOR) with 95 % confidence intervals (CI) was used to measure the association between various interval lengths and recurrent pre-eclampsia or eclampsia.

MAIN RESULTS

We identified 1769 articles and finally included four studies with a total of 77,561 women. The meta-analysis of two studies showed that compared to inter-pregnancy intervals of 2-4 years, the aOR for recurrent pre-eclampsia was 1.01 [95 % CI 0.95 to 1.07, I(2) 0 %] with intervals of less than 2 years and 1.10 [95 % CI 1.02 to 1.19, I(2) 0 %] with intervals longer than 4 years.

CONCLUSION

Compared to inter-pregnancy intervals of 2 to 4 years, shorter intervals are not associated with an increased risk of recurrent pre-eclampsia but longer intervals appear to increase the risk. The results of this review should be interpreted with caution as included studies are observational and thus subject to possible confounding factors.

Preeclampsia: Short-term and Long-term Implications

Preeclampsia is a hypertensive disorder that affects 4% of pregnancies and has a high risk of maternal, fetal, and neonatal morbidity and mortality, as well as long-term cardiovascular risk. Recent updates in the definition, diagnosis, and management guidelines for preeclampsia warrant review by general obstetrician-gynecologists. Screening and prevention algorithms for preeclampsia are available, but ultimately the cure remains delivery of the fetus and placenta. Close monitoring for the development and worsening of preeclampsia during pregnancy is essential to optimize both maternal and fetal/neonatal outcomes.

Multicenter impact analysis of a model for predicting recurrent early-onset preeclampsia: A before-after study

OBJECTIVE

This study aims to determine the impact of using a prediction model for recurrent preeclampsia to customize antenatal care in subsequent pregnancies.

METHODS

We compared care consumption, pregnancy outcomes, and self-reported health state of two risk-based subgroups, and compared these to a reference group receiving standard care.

RESULTS

We included a total of 311 women from 12 hospitals. Compared to standard care, recurrence-risk guided care did not lead to different outcomes or self-perceived health.

CONCLUSION

Our study exemplifies that recurrence-risk-based stratification of antenatal care in former preeclampsia patients is feasible; it does not lead to worse pregnancy outcomes.

Clustering of retrospectively reported and prospectively observed time-to-pregnancy

PURPOSE

Given reportedly high clustering but limited validity of retrospectively reported time-to-pregnancy (TTP), we assessed within-woman clustering for retrospectively reported TTPs alone and including gold-standard prospectively observed TTPs among women with 2 or more retrospectively reported and 1 or more prospectively observed TTPs. We further investigated whether past trying times inform future trying time among women with 1 or more retrospectively reported and 1 or more prospectively observed TTPs.

METHODS

Five hundred one couples attempting pregnancy were prospectively observed until human chorionic gonadotropin pregnancy or 12 months of trying. Women reported TTP for past planned pregnancies. Clustering as measured by the frailty variance was estimated using discrete Cox frailty models, adjusted for age, body mass index, smoking at each attempt. Utility of past attempts to inform future attempts was assessed with discrete Cox models and relative risk regression, adjusted for enrollment age, body mass index, smoking.

RESULTS

Seventy-five women with 2 or more prior pregnancies contributed 180 retrospective and 91 prospective TTPs for frailty modeling. Retrospectively reported TTP clustering was high (frailty variance = 0.89) but substantially lower when including prospectively observed TTPs (frailty variance = 0.42). Among 202 women with 1 or more prior pregnancies, past trying times did not inform future trying time.

CONCLUSIONS

TTP recall rather than TTP may account for clustering. Past trying times may not inform future trying times.

First-trimester screening for preeclampsia: impact of maternal parity on modeling and screening effectiveness

OBJECTIVE

The impact of maternal parity on screening efficiency for preeclampsia (PE) has been poorly studied. Our objective was to investigate the effect of maternal parity on models for screening for PE in the first-trimester and their effectiveness.

STUDY DESIGN

A secondary analysis of a prospective cohort study of women present between 11 and 14 weeks gestation. Maternal risk factors, uterine artery Doppler, mean arterial pressure (MAP) and serum markers including PAPP-A, ADAM12, PP13 in the first-trimester were used to create multi-parameter screening models for PE. The best models for screening in nulliparous versus parous women were developed using backward stepwise logistic regression approach. The area under the receiver operating characteristic curves (AUC) and the sensitivity for fixed false positive rates of 10% and 20%, respectively, were compared using non-parametric statistics.

RESULTS

Among 1177 women with complete outcome data (503 (42.7%) nulliparous and 674 (57.3%) multiparous), PE occurred in 102 (8.7%). There were significant differences in predicting variables in the final optimal models when stratified by parity; and screening performance also varied by parity. The AUC for the model for nulliparous women was 0.88(95% CI 0.80-0.95); and for multiparous was 0.84 (95% CI, 0.75-0.91). For fixed false positive rate of 10%, the sensitivity for predicting PE was 70% and 68% for nulliparous and multiparous, respectively. The screening performance for the models were however not statistically or clinically significantly different.

CONCLUSION

We found significant differences in prediction model parameters between nulliparous and multiparous women, but these did not significantly impact screening performance for PE in the first-trimester.

Successive time to pregnancy among women experiencing pregnancy loss

STUDY QUESTION

Is time to pregnancy (TTP) similar across successive pregnancy attempts among women experiencing pregnancy loss?

SUMMARY ANSWER

TTP after a loss may be longer compared with TTP before a loss.

WHAT IS KNOWN ALREADY

Two pregnancy cohort studies have reported that TTP is similar across pregnancy attempts in fertile women. However, this has not been investigated among women experiencing pregnancy losses.

STUDY DESIGN, SIZE, DURATION

Data for this analysis come from the Longitudinal Investigation of Fertility and the Environment Study, a population-based, preconception cohort of couples attempting pregnancy. During 2005-2009, recruitment was targeted to 16 counties in Michigan and Texas with reported exposures to persistent environmental chemicals. A total of 501 couples were recruited and followed for up to 12 months of pregnancy attempts allowing for continued participation of women with pregnancy losses until censoring.

PARTICIPANTS, SETTING, METHODS

We assessed TTP among 70 couples recruited upon discontinuing contraception for purposes of becoming pregnant and experiencing ≥1 prospectively observed pregnancy losses during 12 months of trying. There were 61 couples who contributed two pregnancy attempts and 9 who contributed three. Women were instructed in the use of urine-based home fertility monitors to time intercourse relative to ovulation and recorded their bleeding patterns in daily journals. TTP was defined as the number of menstrual cycles taken to achieve pregnancy. Women were also instructed in the use of home digital pregnancy tests and asked to begin pregnancy testing on the day of expected menses. Women recorded the results of their pregnancy tests in a daily journal with a single positive pregnancy test result indicating an hCG-confirmed pregnancy. Pregnancy losses were ascertained from a subsequent recorded negative pregnancy test or clinically confirmed loss. We estimated fecundability odds ratios (FORs) comparing subsequent to first TTP using discrete Cox models with robust standard errors, accounting for cycles off contraception before study entry and adjusting for maternal age, body mass index, reproductive history and time-varying cigarette, alcohol and caffeine usage while trying.

MAIN RESULTS AND THE ROLE OF CHANCE

The mean female age was 30.3 ± 4.3 years; 21% had a prior pregnancy loss before study entry. Of the second and third attempts, 59 and 43%, respectively, were longer compared with the first attempt. FORs <1 suggest reduced fecundability or a longer TTP when comparing the second with the first attempt (0.42, 95% confidence interval (CI): 0.28, 0.65), and similarly for the third relative to the first attempt (0.64, 95% CI: 0.18, 2.36). TTP in the second attempt was a median of 1 cycle longer (interquartile range: 0, 3 cycles) compared with TTP in the first attempt.

LIMITATIONS, REASONS FOR CAUTION

As this is the first study to investigate successive TTP exclusively among women experiencing pregnancy loss, our findings await corroboration since most losses occurred early in gestation. As such, the generalizability of our findings for all pregnancy losses awaits further research. We also had limited power to detect a reduction in fecundability for the third compared with first pregnancy attempt.

WIDER IMPLICATIONS OF THE FINDINGS

Unlike fertile women, TTP in women experiencing early pregnancy losses may trend towards longer subsequent attempts. If the findings are corroborated, women experiencing losses may benefit from counselling regarding trying times.

STUDY FUNDING/COMPETING INTERESTS

This research was supported by the Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development (contracts N01-HD-3-3355, N01-HD-3-3356 and NOH-HD-3-3358). K.J.S. was supported by an Intramural Research Training Award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Division of Intramural Population Health Research. The authors have no conflicts of interest to declare.

Association of maternal KIR and fetal HLA-C genes with the risk of preeclampsia in the Chinese Han population

INTRODUCTION

This study is to investigate the distribution of inhibitory and activating killer-cell immunoglobulin-like receptors (KIRs) and the combination of KIR/human leukocyte antigen (HLA)-C in women with preeclampsia in the Chinese Han population.

METHODS

A total of 271 patients and 295 controls were enrolled in our study. The inhibitory/activating KIR and HLA-C genes were detected using the PCR-SSP (polymerase chain reaction with sequence-specific primers) method.

RESULTS

Our result showed that decreased numbers of individual activating KIR genes (2DS2, 2DS3, and 2DS5) were observed in women with preeclampsia. Furthermore, the gene frequency of total activating KIRs was significantly lower in patients compared with that of the controls (P = 0.03). The frequency of the KIR2DL1 gene was increased in women with preeclampsia when a homozygous HLA-C2 allele appeared in the fetus.

CONCLUSION

The results suggest that a KIR genetic variation might influence the risk of preeclampsia. The lack of activating KIRs could possibly lower uterine natural killer (uNK) cell activation, thereby contributing to the pathogenesis of preeclampsia. Moreover, the imbalance of the inhibitory or activating signals at the maternal-fetal interface seems to play a regulatory role in the occurrence of preeclampsia.

The Effects of Preeclampsia on Perinatal Risks and Infant Temperaments Among Mothers With Antenatal Depression

IMPORTANCE

Preeclampsia and depression are two most prevalent disorders known to affect pregnant women and unborn infant. However, few studies have prospectively examined the adverse influence of the in-utero exposures to the two disorders on the optimal development in their offspring, including mortality, adverse birth outcomes, and infant temperament styles.

OBJECTIVES

(1) To examine whether exposures to preeclampsia and antenatal depression were associated with developmental indices of offspring at birth and temperament at 3 months; and (2) To evaluate how preeclampsia and antenatal depression associated with offspring temperamental style.

DESIGN

Prospective cohort study with regular assessment of mother's blood pressure at each prenatal visit: offspring were followed till 3 months.

SETTING

Two prenatal clinics, New York City, USA.

PARTICIPANTS

A cohort of 233 pregnant women was followed throughout pregnancy. Of those, 141 provided ratings of infant temperament at three months.

EXPOSURES

Diagnostic outcome of maternal depression by clinical interviewers blind to preeclampsia status, were ascertained using the Structured Clinical Interview for DSM-IV Axis I Disorders. The development of preeclampsia, defined by the onset of hypertension (> 140/90 mm HG) after 20 weeks' gestation, accompanied by 300 mg of protein, monitored via electronic medical records.

MAIN OUTCOME MEASURES

Birth outcomes were assessed via standardized ratings at delivery. Infant temperament was reported by the mother at three months, using 91-item IBQ-R (Infant Behavioral Questionnaire-Revised).

RESULTS

Preeclampsia was associated with an over 5-fold increased risk for fetal/infant mortality, a 3- to 7-fold increased risk for poorer birth outcomes, and flatter affect and distress in infants. Furthermore, infants born to preeclamptic mothers with co-occurring depression displayed lower levels of smile/laughter, high-intensity pleasure seeking behavior, perceptual sensitivity, and approach behavior.

CONCLUSION

Preeclampsia was associated with a few difficult temperament styles in the first three months after birth. Moreover, its negative impact was amplified by mother's antenatal depression. Our findings regarding additive risk for negative infant outcomes in babies exposed to preeclampsia and antenatal depression suggests that the development of early detection programs to identify and monitor women who are at heightened risk for these conditions can potentially have a positive influence on long-term infant neurobehavioral development.

Pregnancy, parturition and preeclampsia in women of African ancestry

Maternal and associated neonatal mortality rates in sub-Saharan Africa remain unacceptably high. In Mulago Hospital (Kampala, Uganda), 2 major causes of maternal death are preeclampsia and obstructed labor and their complications, conditions occurring at the extremes of the birthweight spectrum, a situation encapsulated as the obstetric dilemma. We have questioned whether the prevalence of these disorders occurs more frequently in indigenous African women and those with African ancestry elsewhere in the world by reviewing available literature. We conclude that these women are at greater risk of preeclampsia than other racial groups. At least part of this susceptibility seems independent of socioeconomic status and likely is due to biological or genetic factors. Evidence for a genetic contribution to preeclampsia is discussed. We go on to propose that the obstetric dilemma in humans is responsible for this situation and discuss how parturition and birthweight are subject to stabilizing selection. Other data we present also suggest that there are particularly strong evolutionary selective pressures operating during pregnancy and delivery in Africans. There is much greater genetic diversity and less linkage disequilibrium in Africa, and the genes responsible for regulating birthweight and placentation may therefore be easier to define than in non-African cohorts. Inclusion of African women into research on preeclampsia is an essential component in tackling this major disparity of maternal health.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Maternal and Perinatal Outcomes of Exercise in Pregnant Women with Chronic Hypertension and/or Previous Preeclampsia: A Randomized Controlled Trial

Objectives. To evaluate the association between physical exercise supervised in pregnant women with chronic hypertension and/or previous preeclampsia and maternal and neonatal outcomes. Method. Randomized controlled trial, which included 116 pregnant women with chronic hypertension and/or previous preeclampsia, considered risk of preeclampsia development. They were divided into two groups: study group that performed physical exercise with a stationary bicycle once a week, for 30 minutes; the intensity was controlled (heart rate 20% above resting values), under professional supervision and a control group that was not engaged in any physical exercise. The data was retrieved from medical charts. Significance level assumed was 5%. Results. Women from study group performed 9.24 ± 7.03 of physical exercise sessions. There were no differences between groups comparing type of delivery and maternal outcomes, including maternal morbidity and hospitalization in intensive unit care, and neonatal outcomes, including birth weight, adequacy of weight to gestational age, prematurity, Apgar scale at first and fifth minutes, hospitalization in intensive unit care, and neonatal morbidity. Conclusions. Physical exercise using a stationary bicycle in pregnant women with chronic hypertension and/or previous preeclampsia, once a week, under professional supervision, did not interfere in the delivery method and did not produce maternal and neonatal risks of the occurrence of morbidity. This trial is registered with ClinicalTrials.gov NCT01395342.

Echocardiographic and Doppler assessment of maternal cardiovascular function in normal and abnormal canine pregnancies

The objective was to verify maternal hemodynamic differences between normal and abnormal pregnancies in dogs. Brucella-negative pregnant bitches (n = 31) were retrospectively classified into abnormal (which had either their pregnancy interrupted between Days 52 and 60 or perinatal death of more than 50% of the litter; n = 14) and normal (which had delivered healthy puppies at term; n = 17). These dogs were evaluated with echocardiography every 10 days from Days 0 to 60 of gestation (Day 0 = estimated day of LH peak). Systolic blood pressure was also assessed. At Day 50 of gestation, left ventricular free wall in systole increased in the normal but not in the abnormal group (P < 0.01). In contrast, end systolic stress (P < 0.01) and systolic blood pressure (P < 0.01) diminished only in normal animals. We concluded that signs of altered maternal cardiovascular adaptation to pregnancy may be predictors of obstetrical complications in dogs.

Correlation of biochemical parameters and neonatal outcome in patients with gestational hypertension

Hypertensive disorders in pregnancy are one of the leading causes of maternal death in the world and one of the major causes of perinatal mortality. The incidence of hypertensive disorders in pregnancy is 8%-15%. Significant changes of biochemical parameters in cases of hypertensive disorders in pregnancy are increased levels of blood glucose, urea, creatinine, uric acid (hyperuricemia), transaminases, and LDH. The most increased is the level of proteinuria. Bad laboratory results and the intensification of clinical signs, with multiorgan dysfunction, are indications for termination of pregnancy.