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Para R, Romero R, Gomez-Lopez N, Tarca AL, Panaitescu B, Done B, Hsu R, Pacora P, Hsu CD. Maternal circulating concentrations of soluble Fas and Elabela in early- and late-onset preeclampsia. J Matern Fetal Neonatal Med 2022; 35:316-329. [PMID: 32008387 PMCID: PMC10544759 DOI: 10.1080/14767058.2020.1716720] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 12/17/2019] [Accepted: 01/13/2020] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The Fas/Fas ligand (FASL) system and Elabela-apelin receptor signaling pathways are implicated in the pathophysiology of preeclampsia. The aim of the current study was to investigate whether a model combining the measurement of sFas and Elabela in the maternal circulation may serve as a clinical biomarker for early- and/or late-onset preeclampsia more effectively than measures of each biomarker individually. METHODS Blood samples were collected from 214 women in the following groups: (1) normal pregnancy sampled <34 weeks of gestation (n = 56); (2) patients who developed early-onset preeclampsia (n = 54); (3) normal pregnancy sampled ≥34 weeks of gestation (n = 52); (4) patients who developed late-onset preeclampsia (n = 52). Maternal circulating soluble Fas and Elabela concentrations were determined using sensitive and validated immunoassays. Two sample t-tests, multivariate logistic regression, and receiver operating characteristic curves were used for analyses. RESULTS (1) Women with early-onset preeclampsia, and those with late-onset preeclampsia with placental lesions of maternal vascular malperfusion, had increased concentrations of sFas compared to their gestational age-matched normal controls; (2) women with late-onset preeclampsia, but not those with early-onset preeclampsia, had increased concentrations of Elabela compared to their gestational age-matched counterparts; and (3) an increase in both Elabela and sFas concentrations was more strongly associated with late-onset preeclampsia than early-onset preeclampsia relative to models including either of the markers alone. CONCLUSIONS A combined model of maternal sFas and Elabela concentrations provides a stronger association with late-onset preeclampsia than either protein alone. This finding demonstrates the possibility to improve the classification of late-onset preeclampsia by combining the results of both molecular biomarkers.
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Affiliation(s)
- Robert Para
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Roberto Romero
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, Michigan, USA
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
- Center for Molecular Medicine and Genetics, Wayne State University, Detroit, Michigan, USA
- Detroit Medical Center, Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Florida International University, Miami, Florida, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Biochemistry, Microbiology and Immunology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Adi L. Tarca
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Computer Science, Wayne State University College of Engineering, Detroit, Michigan, USA
| | - Bogdan Panaitescu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Bogdan Done
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Richard Hsu
- Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Percy Pacora
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Chaur-Dong Hsu
- Perinatology Research Branch, Division of Obstetrics and Maternal-Fetal Medicine, Division of Intramural Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, U.S. Department of Health and Human Services, Bethesda, Maryland, and Detroit, Michigan, USA
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, Detroit, Michigan, USA
- Department of Physiology, Wayne State University School of Medicine, Detroit, Michigan, USA
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Johnston A, Tseung V, Dancey SR, Visintini SM, Coutinho T, Edwards JD. Use of Race, Ethnicity, and National Origin in Studies Assessing Cardiovascular Risk in Women With a History of Hypertensive Disorders of Pregnancy. CJC Open 2021; 3:S102-S117. [PMID: 34993440 PMCID: PMC8712581 DOI: 10.1016/j.cjco.2021.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/10/2021] [Indexed: 11/06/2022] Open
Abstract
Women with a history of hyperBtensive disorders of pregnancy (HDP) are at particularly high risk for cardiovascular disease (CVD) and CVD-related death, and certain racial and ethnic subpopulations are disproportionately affected by these conditions. We examined the use of race, ethnicity, and national origin in observational studies assessing CVD morbidity and mortality in women with a history of HDP. A total of 124 studies, published between 1976 and 2021, were reviewed. We found that white women were heavily overrepresented, encompassing 53% of all participants with HDP. There was limited and heterogeneous reporting of race and ethnicity information across studies and only 27 studies reported including race and/or ethnicity variables in at least 1 statistical analysis. Only 2 studies mentioned the use of these variables as a strength; several others (k = 18) reported a lack of diversity among participants as a study limitation. Just over half of included articles (k = 68) reported at least 1 sociodemographic variable other than race and ethnicity (eg, marital status and income); however, none investigated how they might have worked synergistically or antagonistically with race and/or ethnicity to influence participants' risk of CVD. These findings highlight significant areas for improvement in cardiovascular obstetrics research, including the need for more robust and standardized methods for collecting, reporting, and using sociodemographic information. Future studies of CVD risk in women with a history of HDP should explicitly examine racial and ethnic differences and use an intersectional approach.
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Affiliation(s)
- Amy Johnston
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Victrine Tseung
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sonia R. Dancey
- School of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Sarah M. Visintini
- Berkman Library, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Thais Coutinho
- Division of Cardiac Prevention and Rehabilitation, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Canadian Women’s Heart Health Centre, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jodi D. Edwards
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Brain and Heart Nexus Research Program, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- IC/ES, Ottawa, Ontario, Canada
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Abstract
Hypertensive disorders of pregnancy are common and can result in maternal and fetal morbidity and mortality. Women may have chronic hypertension, or develop hypertension during pregnancy. Management involves close maternal and fetal surveillance. If an antihypertensive drug is needed, prescribe one that is safe in pregnancy. Pre-eclampsia is a hypertensive disorder of pregnancy. Women at high risk of pre-eclampsia should start aspirin 150 mg daily at 12-16 weeks gestation and continue until 36 weeks gestation, to reduce the risk of preterm delivery. There are long-term cardiovascular and mortality risks associated with pregnancies complicated by gestational hypertension and pre-eclampsia. Ongoing cardiovascular and metabolic risk surveillance should be undertaken by the woman's general practitioner.
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Affiliation(s)
| | - George Mangos
- St George and Sutherland Clinical School, St George Hospital, UNSW Sydney
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Defective Uteroplacental Vascular Remodeling in Preeclampsia: Key Molecular Factors Leading to Long Term Cardiovascular Disease. Int J Mol Sci 2021; 22:ijms222011202. [PMID: 34681861 PMCID: PMC8539609 DOI: 10.3390/ijms222011202] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/15/2021] [Accepted: 10/16/2021] [Indexed: 12/12/2022] Open
Abstract
Preeclampsia is a complex hypertensive disorder in pregnancy which can be lethal and is responsible for more than 70,000 maternal deaths worldwide every year. Besides the higher risk of unfavorable obstetric outcomes in women with preeclampsia, another crucial aspect that needs to be considered is the association between preeclampsia and the postpartum cardiovascular health of the mother. Currently, preeclampsia is classified as one of the major risk factors of cardiovascular disease (CVD) in women, which doubles the risk of venous thromboembolic events, stroke, and ischemic heart disease. In order to comprehend the pathophysiology behind the linkage between preeclampsia and the development of postpartum CVD, a thorough understanding of the abnormal uteroplacental vascular remodeling in preeclampsia is essential. Therefore, this review aims to summarize the current knowledge of the defective process of spiral artery remodeling in preeclampsia and how the resulting placental damage leads to excessive angiogenic imbalance and systemic inflammation in long term CVD. Key molecular factors in the pathway-including novel findings of microRNAs-will be discussed with suggestions of future management strategies of preventing CVD in women with a history of preeclampsia.
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Hiersch L, Ray JG, Barrett J, Berger H, Geary M, McDonald SD, Diong C, Gandhi S, Guan J, Murray-Davis B, Melamed N. Maternal cardiovascular disease after twin pregnancies complicated by hypertensive disorders of pregnancy: a population-based cohort study. CMAJ 2021; 193:E1448-E1458. [PMID: 34544783 PMCID: PMC8476218 DOI: 10.1503/cmaj.202837] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 12/15/2022] Open
Abstract
Background: People whose singleton pregnancy is affected by hypertensive disorders of pregnancy (HDP) are at risk of future cardiovascular disease. It is unclear, however, whether this association can be extrapolated to twin pregnancies. We aimed to compare the association between HDP and future cardiovascular disease after twin and singleton pregnancies. Methods: We conducted a population-based retrospective cohort study that included nulliparous people in Ontario, Canada, 1992–2017. We compared the future risk of cardiovascular disease among pregnant people from the following 4 groups: those who delivered a singleton without HDP (referent) and with HDP, and those who delivered twins either with or without HDP. Results: The populations of the 4 groups were as follows: 1 431 651 pregnant people in the singleton birth without HDP group; 98 631 singleton birth with HDP; 21 046 twin birth without HDP; and 4283 twin birth with HDP. The median duration of follow-up was 13 (interquartile range 7–20) years. The incidence rate of cardiovascular disease was lowest among those with a singleton or twin birth without HDP (0.72 and 0.74 per 1000 person-years, respectively). Compared with people with a singleton birth without HDP, the risk of cardiovascular disease was highest among those with a singleton birth and HDP (1.47 per 1000 person-years; adjusted hazard ratio [HR] 1.81 [95% confidence interval (CI) 1.72–1.90]), followed by people with a twin pregnancy and HDP (1.07 per 1000 person-years; adjusted HR 1.36 [95% CI 1.04–1.77]). The risk of the primary outcome after a twin pregnancy with HDP was lower than that after a singleton pregnancy with HDP (adjusted HR 0.74 [95% CI 0.57–0.97]), when compared directly. Interpretation: In a twin pregnancy, HDP are weaker risk factors for postpartum cardiovascular disease than in a singleton pregnancy.
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Affiliation(s)
- Liran Hiersch
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont.
| | - Joel G Ray
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Jon Barrett
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Howard Berger
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Michael Geary
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Sarah D McDonald
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Christina Diong
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Sima Gandhi
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Jun Guan
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Beth Murray-Davis
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
| | - Nir Melamed
- Division of Maternal-Fetal Medicine (Hiersch, Barrett, Melamed), Department of Obstetrics and Gynecology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont.; Departments of Obstetrics and Gynaecology (Hiersch), Lis Maternity Hospital and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Departments of Medicine and Obstetrics and Gynaecology (Ray), St. Michael's Hospital, University of Toronto; ICES Central (Ray, Diong, Gandhi, Guan); Division of Maternal-Fetal Medicine (Berger, Geary), Department of Obstetrics and Gynecology, St. Michael's Hospital, University of Toronto, Toronto, Ont.; Division of Maternal-Fetal Medicine (McDonald, Murray-Davis), Departments of Obstetrics and Gynecology, Radiology, and Research Methods, Evidence & Impact, McMaster University, Hamilton, Ont
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Brown MA, Roberts L, Hoffman A, Henry A, Mangos G, O'Sullivan A, Pettit F, Youssef G, Xu L, Davis GK. Recognizing Cardiovascular Risk After Preeclampsia: The P4 Study. J Am Heart Assoc 2020; 9:e018604. [PMID: 33170079 PMCID: PMC7763721 DOI: 10.1161/jaha.120.018604] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background There is increased risk of hypertension, early cardiovascular disease, and premature mortality in women who have had preeclampsia. This study was undertaken to determine the upper limit of normal blood pressure (BP) 6 months postpartum and the frequency of women with prior preeclampsia who had BP above these limits, as part of the P4 (Post‐Partum Physiology, Psychology and Pediatric) follow‐up study. Methods and Results BP was measured by sphygmomanometer, 24‐hour ambulatory BP monitoring, and non‐invasive central BP at 6 months postpartum in 302 women who had normotensive pregnancy and 90 who had preeclampsia. The upper limit of normal BP (mean+2 SD) for women with normotensive pregnancy was 122/79 mm Hg for routine BP, 115/81 mm Hg for central BP, and 121/78 mm Hg for 24‐hour ambulatory BP monitoring. Traditional normal values detected only 3% of women who had preeclampsia as having high BP 6 months postpartum whereas these new values detected between 13% and 19%. Women with preeclampsia had greater body mass index (27.8 versus 25.0, P<0.001) and left ventricular wall thickness but similar augmentation index. They also had lower high‐density lipoprotein (59±15 versus 65±16 mg/dL, P=0.002), higher triglycerides (77±51 versus 61±35 mg/dL, P=0.005), and higher homeostatic model assessment score (2.1±1.8 versus 1.3±1.9, P<0.001). Conclusions Clinicians wishing to detect high BP in these women should be aware of the lower than usual upper limit of normal for this young cohort and where possible should use 24‐hour ambulatory BP monitoring to detect these changes. This may define a subgroup of women who had preeclampsia for whom targeted BP lowering therapy would be successful. Registration URL: https://anzctr.org.au/Trial/Registration/TrialReview.aspx?id=365295&isReview=true; Unique identifier: ACTRN12613001260718.
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Affiliation(s)
- Mark A Brown
- Department of Renal Medicine St George Hospital Sydney New South Wales Australia.,Department of Medicine St George and Sutherland Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Lynne Roberts
- Department of Medicine St George and Sutherland Clinical SchoolUNSW Medicine Sydney New South Wales Australia.,Department of Women's and Children's Health St George Hospital Sydney New South Wales Australia
| | - Anna Hoffman
- Department of Renal Medicine St George Hospital Sydney New South Wales Australia
| | - Amanda Henry
- Department of Women's and Children's Health St George Hospital Sydney New South Wales Australia.,School of Women's and Children's Health UNSW Medicine Sydney New South Wales Australia.,The George Institute for Global Health Sydney New South Wales Australia
| | - George Mangos
- Department of Renal Medicine St George Hospital Sydney New South Wales Australia.,Department of Medicine St George and Sutherland Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Anthony O'Sullivan
- Department of Medicine St George and Sutherland Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - Franziska Pettit
- Department of Renal Medicine St George Hospital Sydney New South Wales Australia.,Department of Medicine St George and Sutherland Clinical SchoolUNSW Medicine Sydney New South Wales Australia
| | - George Youssef
- Department of Cardiology St George Hospital Sydney New South Wales Australia
| | - Lily Xu
- Department of Women's and Children's Health St George Hospital Sydney New South Wales Australia
| | - Gregory K Davis
- Department of Women's and Children's Health St George Hospital Sydney New South Wales Australia.,School of Women's and Children's Health UNSW Medicine Sydney New South Wales Australia
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Wu R, Wang T, Gu R, Xing D, Ye C, Chen Y, Liu X, Chen L. Hypertensive Disorders of Pregnancy and Risk of Cardiovascular Disease-Related Morbidity and Mortality: A Systematic Review and Meta-Analysis. Cardiology 2020; 145:633-647. [PMID: 32841945 DOI: 10.1159/000508036] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 04/15/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Several studies have demonstrated that there is a higher risk of cardiovascular disease (CVD) in women with a history of hypertensive disorders of pregnancy (HDP). However, effect sizes varied greatly between these studies, and a complete overview of the existing data in the literature is lacking. We aimed to evaluate the association between HDP and the risk of CVD-related morbidity and mortality. METHODS Systematic literature searches were conducted in several electronic databases from inception to July 2019. Exposure of interest was any type of HDP. Outcomes of interest included any CVD, CVD-related mortality, and hypertension. RESULTS Sixty-six cohort and 7 case-control studies involving >13 million women were included. The overall combined relative risks (RRs) for women with a history of HDP compared with the reference group were 1.80 (95% confidence interval [CI] 1.67-1.94) for any CVD, 1.66 (1.49-1.84) for coronary artery heart disease, 2.87 (2.14-3.85) for heart failure, 1.60 (1.29-2.00) for peripheral vascular disease, 1.72 (1.50-1.97) for stroke, 1.78 (1.58-2.00) for CVD-related mortality, and 3.16 (2.74-3.64) for hypertension. Significant heterogeneity was partially explained by all or part of the variables including type of exposure, follow-up time, geographic region, and sample source. CONCLUSIONS Women with a history of HDP are at an increased risk of future CVD-related morbidity and mortality. Our study highlights the importance of life-long monitoring of cardiovascular risk factors in women with a history of HDP.
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Affiliation(s)
- Rong Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Tingting Wang
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Runhui Gu
- School of Public Health, Nanjing Medical University, Jiangsu, China
| | - Dexiu Xing
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Changxiang Ye
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Yan Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Xiaoling Liu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China
| | - Lizhang Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Hunan, China,
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Hu H, Zhao J, Savitz DA, Prosperi M, Zheng Y, Pearson TA. An external exposome-wide association study of hypertensive disorders of pregnancy. ENVIRONMENT INTERNATIONAL 2020; 141:105797. [PMID: 32413622 PMCID: PMC7336837 DOI: 10.1016/j.envint.2020.105797] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 04/22/2020] [Accepted: 05/03/2020] [Indexed: 05/11/2023]
Abstract
It is widely recognized that exogenous factors play an important role in the development of hypertensive disorders of pregnancy (HDP). However, only a few external environmental factors have been studied, often separately, with no attempt to examine the totality of the external environment, or the external exposome. We conducted an external exposome-wide association study (ExWAS) using the Florida Vital Statistics Birth Records including 819,399 women with live births in 2010-2013. A total of 5784 factors characterizing women's surrounding natural, built, and social environment during pregnancy from 10 data sources were collected, harmonized, integrated, and spatiotemporally linked to the women based on pregnancy periods using 250 m buffers around their geocoded residential addresses. A random 50:50 split divided the data into discovery and replication sets, and a 3-phase procedure was used. In phase 1, associations between HDP and individual factors were examined, and Bonferroni adjustment was performed. In phase 2, an elastic net model was used to perform variable selection among significant variables from phase 1. In phase 3, a multivariable logistic regression model including all variables selected by the elastic net model was fitted. Variables that were significant in both the discovery and replication sets were retained. Among the 528 and 490 variables identified in Phase 1, 232 and 224 were selected by the elastic net model in Phase 2, and 67 and 48 variables remained statistically significant in Phase 3 in the discovery and replication sets, respectively. A total of 12 variables were significant in both the discovery and replication sets, including air toxicants (e.g., 2,2,4-trimethylpentane), meteorological factors (e.g., omega or vertical velocity at 125mb pressure level), neighborhood crime and safety (e.g., burglary rate), and neighborhood sociodemographic status (e.g., urbanization). This is the first large external exposome study of HDP. It confirmed some of the previously reported associations and generated unexpected predictors within the environment that may warrant more focused evaluation.
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Affiliation(s)
- Hui Hu
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA.
| | - Jinying Zhao
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - David A Savitz
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Mattia Prosperi
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Yi Zheng
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
| | - Thomas A Pearson
- Department of Epidemiology, College of Public Health and Health Professions and College of Medicine, University of Florida, Gainesville, FL, USA
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9
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Smith CA, Tuson A, Thornton C, Dahlen HG. The safety and effectiveness of mind body interventions for women with pregnancy induced hypertension and or preeclampsia: A systematic review and meta-analysis. Complement Ther Med 2020; 52:102469. [PMID: 32951719 DOI: 10.1016/j.ctim.2020.102469] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 06/02/2020] [Accepted: 06/03/2020] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To undertake a systematic review of the safety and effectiveness of mind body approaches for women with hypertensive disorders in pregnancy (HDP). DESIGN A search was undertaken of databases from inception to 2019 for randomised and quasi randomised controlled trials. MAIN OUTCOME MEASURES The primary outcome was a reduction in systolic and / or diastolic blood pressure for women with hypertension and or preeclampsia in pregnancy. RESULTS 121 studies were identified and eight studies were included in this review. These included mind body interventions examining yoga, guided imagery, relaxation, music, and acupuncture for HDP. Two studies of relaxation found a reduction in systolic (MD -11.3, 95%CI -13.23 to -9.39) and diastolic blood pressure (MD -6.59, 95%CI -9.43 to -3.75) and reduced stress (MD -11.4, 95%CI -16.5 to -6.3). In one study of yoga, the risk of developing HDP was reduced (RR 0.28, 95% CI 0.09 to 0.91, 59 women) and a second study found a reduction in stress at the end of the intervention of yoga. One trial of guided imagery found a reduction in mean arterial blood pressure compared to the control (4.35, 95% -8.04 to -0.66, p=0.02). Overall there was no effect on the development of preeclampsia, use of anti-hypertensive medication and any neonatal outcomes from the interventions evaluated. Few trials reported on safety outcomes, one trial of acupuncture reported one case of placental abruption and three cases of acupuncture related side effects. CONCLUSION Few high quality trials have examined the effectiveness and safety of mind body interventions to manage HDP. Relaxation, yoga, guided imagery and music may have some potential benefit. Safety issues are completely unclear and thus the risk-benefit ratio of all interventions could not be determined. Further research is recommended.
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Affiliation(s)
- C A Smith
- NICM Health Research Institute, Western Sydney University, Penrith, 2751, Australia.
| | - A Tuson
- Registered Midwife and Western Sydney University Summer Scholar, Western Sydney University Penrith, 2751, Australia.
| | - Charlene Thornton
- College of Nursing and Health Sciences, Flinders University, Bedford Park, 5042, Australia.
| | - Hannah G Dahlen
- School of Nursing and Midwifery, Western Sydney University, Penrith, 2751, Australia.
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10
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Perry H, Binder J, Gutierrez J, Thilaganathan B, Khalil A. Maternal haemodynamic function differs in pre-eclampsia when it is associated with a small-for-gestational-age newborn: a prospective cohort study. BJOG 2020; 128:167-175. [PMID: 32314535 DOI: 10.1111/1471-0528.16269] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/14/2020] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To describe maternal haemodynamic differences in gestational hypertension with small-for-gestational-age babies (HDP + SGA), gestational hypertension with appropriate-for-gestational-age babies (HDP-only) and control pregnancies. DESIGN Prospective cohort study. SETTING Tertiary Hospital, UK. POPULATION Women with gestational hypertension and healthy pregnant women. METHODS Maternal haemodynamic indices were measured using a non-invasive Ultrasound Cardiac Output Monitor (USCOM-1A® ) and corrected for gestational age and maternal characteristics using device-specific reference ranges. MAIN OUTCOME MEASURES Maternal cardiac output, stroke volume, systemic vascular resistance. RESULTS We included 114 HDP + SGA, 202 HDP-only and 401 control pregnancies at 26-41 weeks of gestation. There was no significant difference in the mean arterial blood pressure (110 versus 107 mmHg, P = 0.445) between the two HDP groups at presentation. Pregnancies complicated by HDP + SGA had significantly lower median heart rate (76 versus 85 bpm versus 83 bpm), lower cardiac output (0.85 versus 0.98 versus 0.97 MoM) and higher systemic vascular resistance (1.4 versus 1.0 versus 1.2 MoM) compared with control and HDP-only pregnancies, respectively (all P < 0.05). CONCLUSION Women with HDP + SGA present with more severe haemodynamic dysfunction than HDP-only. Even HDP-only pregnancies exhibit impaired haemodynamic indices compared with normal pregnancies, supporting a role of the maternal cardiovascular system in gestational hypertension irrespective of fetal size. Central haemodynamic changes may play a role in the pathogenesis of pre-eclampsia and should be considered alongside placental aetiology. TWEETABLE ABSTRACT Hypertensive disorders of pregnancy are associated with worse maternal haemodynamic function when associated with small-for-gestational-age birth.
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Affiliation(s)
- H Perry
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - J Binder
- Department of Obstetrics and Feto-maternal Medicine, Medical University of Vienna, Vienna, Austria.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Medical University of Vienna, Vienna, Austria
| | - J Gutierrez
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - B Thilaganathan
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - A Khalil
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St George's University Hospitals NHS Foundation Trust, London, UK
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11
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Barrett PM, McCarthy FP, Kublickiene K, Cormican S, Judge C, Evans M, Kublickas M, Perry IJ, Stenvinkel P, Khashan AS. Adverse Pregnancy Outcomes and Long-term Maternal Kidney Disease: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e1920964. [PMID: 32049292 DOI: 10.1001/jamanetworkopen.2019.20964] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
IMPORTANCE Adverse pregnancy outcomes, such as hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, are associated with increased risk of maternal cardiovascular disease. Little is known about whether adverse pregnancy outcomes are associated with increased risk of maternal chronic kidney disease (CKD) and end-stage kidney disease (ESKD). OBJECTIVE To review and synthesize the published literature on adverse pregnancy outcomes (hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery) and subsequent maternal CKD and ESKD. DATA SOURCES PubMed, Embase, and Web of Science were searched from inception to July 31, 2019, for cohort and case-control studies of adverse pregnancy outcomes and maternal CKD and ESKD. STUDY SELECTION Selected studies included the following: a population of pregnant women, exposure to an adverse pregnancy outcome of interest, and at least 1 primary outcome (CKD or ESKD) or secondary outcome (hospitalization or death due to kidney disease). Adverse pregnancy outcomes included exposure to hypertensive disorders of pregnancy (preeclampsia, gestational hypertension, or chronic hypertension), preterm delivery (<37 weeks), and gestational diabetes. Three reviewers were involved in study selection. Of 5656 studies retrieved, 23 were eligible for inclusion. DATA EXTRACTION AND SYNTHESIS The Meta-analyses of Observational Studies in Epidemiology (MOOSE) guidelines were followed throughout. Three reviewers extracted data and appraised study quality. Random-effects meta-analyses were used to calculate overall pooled estimates using the generic inverse variance method. MAIN OUTCOMES AND MEASURES Primary outcomes included CKD and ESKD diagnosis, defined using established clinical criteria (estimated glomerular filtration rate or albuminuria values) or hospital records. The protocol for this systematic review was registered on PROSPERO (CRD42018110891). RESULTS Of 23 studies included (5 769 891 participants), 5 studies reported effect estimates for more than 1 adverse pregnancy outcome. Preeclampsia was associated with significantly increased risk of CKD (pooled adjusted risk ratio [aRR], 2.11; 95% CI, 1.72-2.59), ESKD (aRR, 4.90; 95% CI, 3.56-6.74), and kidney-related hospitalization (aRR, 2.65; 95% CI, 1.03-6.77). Gestational hypertension was associated with increased risk of CKD (aRR, 1.49; 95% CI, 1.11-2.01) and ESKD (aRR, 3.64; 95% CI, 2.34-5.66). Preterm preeclampsia was associated with increased risk of ESKD (aRR, 5.66; 95% CI, 3.06-10.48); this association with ESKD persisted for women who had preterm deliveries without preeclampsia (aRR, 2.09; 95% CI, 1.64-2.66). Gestational diabetes was associated with increased risk of CKD among black women (aRR, 1.78; 95% CI, 1.18-2.70), but not white women (aRR, 0.81; 95% CI, 0.58-1.13). CONCLUSIONS AND RELEVANCE In this meta-analysis, exposure to adverse pregnancy outcomes, including hypertensive disorders of pregnancy, gestational diabetes, and preterm delivery, was associated with higher risk of long-term kidney disease. The risk of ESKD was highest among women who experienced preeclampsia. A systematic approach may be warranted to identify women at increased risk of kidney disease, particularly after hypertensive disorders of pregnancy, and to optimize their long-term follow-up.
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Affiliation(s)
- Peter M Barrett
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
| | - Fergus P McCarthy
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
- Department of Obstetrics & Gynaecology, Cork University Maternity Hospital, Cork, Ireland
| | - Karolina Kublickiene
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Sarah Cormican
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - Conor Judge
- Department of Nephrology, University Hospital Galway, Galway, Ireland
| | - Marie Evans
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Marius Kublickas
- Department of Obstetrics & Gynaecology, Karolinska University Hospital, Stockholm, Sweden
| | - Ivan J Perry
- School of Public Health, University College Cork, Cork, Ireland
| | - Peter Stenvinkel
- Division of Renal Medicine, Department of Clinical Intervention, Science and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Ali S Khashan
- School of Public Health, University College Cork, Cork, Ireland
- Irish Centre for Maternal & Child Health, University College Cork, Cork, Ireland
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12
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Vermunt JV, Kennedy SH, Garovic VD. Blood Pressure Variability in Pregnancy: an Opportunity to Develop Improved Prognostic and Risk Assessment Tools. Curr Hypertens Rep 2020; 22:10. [PMID: 32008117 PMCID: PMC7259977 DOI: 10.1007/s11906-019-1014-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE OF REVIEW This review discusses the mortality and morbidity of hypertensive disorders of pregnancy (HDP) and the current diagnostic thresholds. It then explores measurement of variability in blood pressure (BP) during pregnancy as an opportunity to identify women at high risk of cardiovascular disease (CVD) later in life. RECENT FINDINGS HDP is known to be associated with increased risk of long-term CVD. Current CVD prognostic tools do not incorporate a history of HDP given a lack of improved risk discrimination. However, HDP diagnostic criteria are currently based on a binary threshold, and there is some evidence for the use of variability in BP throughout gestation as a marker of CVD risk. HDP increases long-term risk of CVD. Future studies investigating changes in diagnostic criteria, including the use of BP variability, may improve long-term CVD risk prediction and be incorporated into future risk assessment tools.
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Affiliation(s)
- Jane V Vermunt
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
- Division of Nephrology and Hypertension, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Stephen H Kennedy
- Nuffield Department of Women's & Reproductive Health, University of Oxford, Oxford, UK
| | - Vesna D Garovic
- Division of Nephrology and Hypertension, Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA.
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13
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Aldridge E, Verburg PE, Sierp S, Andraweera P, Dekker GA, Roberts CT, Arstall MA. A Protocol for Nurse-Practitioner Led Cardiovascular Follow-Up After Pregnancy Complications in a Socioeconomically Disadvantaged Population. Front Cardiovasc Med 2020; 6:184. [PMID: 31970161 PMCID: PMC6960097 DOI: 10.3389/fcvm.2019.00184] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 12/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background: Women who experience pregnancy complications have an increased risk of future cardiovascular disease when compared to their healthy counterparts. Despite recommendations, there is no standardized cardiovascular follow-up in the postpartum period for these women, and the Australian follow-up protocols that have been previously described are research-based. This study proposes a new model of care for a nurse practitioner-led postpartum intervention clinic for women who experience severe hypertensive disorders of pregnancy, gestational diabetes mellitus requiring medication, severe intrauterine growth restriction, idiopathic preterm delivery, or placental abruption, in a socioeconomically disadvantaged population. Methods: All women receiving antenatal care or who deliver at the Lyell McEwin Hospital, a tertiary acute care facility located in the northern Adelaide metropolitan area, following a severe complication of pregnancy are referred to the intervention clinic for review at 6 months postpartum. A comprehensive assessment is conducted from demographics, medical history, diet and exercise habits, psychosocial information, health literacy, pathology results, and physical measurements. Subsequently, patient-specific education and clinical counseling are provided by a specialized nurse practitioner. Clinic appointments are repeated at 18 months and 5 years postpartum. All data is also collated into a registry, which aims to assess the efficacy of the intervention at improving modifiable cardiovascular risk factors and reducing cardiovascular risk. Discussion: There is limited information on the efficacy of postpartum intervention clinics in reducing cardiovascular risk in women who have experienced pregnancy complications. Analyses of the data collected in the registry will provide essential information about how best to reduce cardiovascular risk in women in socioeconomically disadvantaged and disease-burdened populations.
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Affiliation(s)
- Emily Aldridge
- Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.,Department of Cardiology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Petra E Verburg
- Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, Rijnstate Hospital, Arnhem, Netherlands
| | - Susan Sierp
- Department of Cardiology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Prabha Andraweera
- Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Gustaaf A Dekker
- Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.,Department of Obstetrics and Gynaecology, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Claire T Roberts
- Adelaide Medical School, Robinson Research Institute, University of Adelaide, Adelaide, SA, Australia.,Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Margaret A Arstall
- Faculty of Health and Medical Sciences, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.,Department of Cardiology, Lyell McEwin Hospital, Adelaide, SA, Australia
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14
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Grandi SM, Filion KB, Yoon S, Ayele HT, Doyle CM, Hutcheon JA, Smith GN, Gore GC, Ray JG, Nerenberg K, Platt RW. Cardiovascular Disease-Related Morbidity and Mortality in Women With a History of Pregnancy Complications. Circulation 2019; 139:1069-1079. [PMID: 30779636 DOI: 10.1161/circulationaha.118.036748] [Citation(s) in RCA: 317] [Impact Index Per Article: 63.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Women with a history of certain pregnancy complications are at higher risk for cardiovascular (CVD) disease. However, most clinical guidelines only recommend postpartum follow-up of those with a history of preeclampsia, gestational diabetes mellitus, or preterm birth. This systematic review was undertaken to determine if there is an association between a broader array of pregnancy complications and the future risk of CVD. METHODS We systematically searched PubMed, MEDLINE and EMBASE (via Ovid), CINAHL, and the Cochrane Library from inception to September 22, 2017, for observational studies of the association between the hypertensive disorders of pregnancy, placental abruption, preterm birth, gestational diabetes mellitus, low birth weight, small-for-gestational-age birth, stillbirth, and miscarriage and subsequent CVD. Likelihood ratio meta-analyses were performed to generate pooled odds ratios (OR) and 95% intrinsic confidence intervals (ICI). RESULTS Our systematic review included 84 studies (28 993 438 patients). Sample sizes varied from 250 to 2 000 000, with a median follow-up of 7.5 years postpartum. The risk of CVD was highest in women with gestational hypertension (OR 1.7; 95% ICI, 1.3-2.2), preeclampsia (OR 2.7; 95% ICI, 2.5-3.0), placental abruption (OR 1.8; 95% ICI, 1.4-2.3), preterm birth (OR 1.6; 95% ICI, 1.4-1.9), gestational diabetes mellitus (OR 1.7; 95% ICI, 1.1-2.5), and stillbirth (OR 1.5; 95% ICI, 1.1-2.1). A consistent trend was seen for low birth weight and small-for-gestational-age birth weight but not for miscarriage. CONCLUSIONS Women with a broader array of pregnancy complications, including placental abruption and stillbirth, are at increased risk of future CVD. The findings support the need for assessment and risk factor management beyond the postpartum period.
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Affiliation(s)
- Sonia M Grandi
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Kristian B Filion
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Department of Medicine, McGill University, Montreal, QC, Canada (K.F.)
| | - Sarah Yoon
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Henok T Ayele
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Carla M Doyle
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.)
| | - Jennifer A Hutcheon
- Department of Obstetrics and Gynaecology, Faculty of Medicine, University of British Columbia, Canada (J.H.)
| | - Graeme N Smith
- Department of Obstetrics and Gynaecology, School of Medicine, Queen's University, Kingston, ON, Canada (G.S.)
| | - Genevieve C Gore
- Schulich Library of Science and Engineering, McGill University, Montreal, QC, Canada (G.G.)
| | - Joel G Ray
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, ON, Canada (J.R.)
| | - Kara Nerenberg
- University of Calgary, Department of Medicine, Cumming School of Medicine, AB, Canada (K.N.)
| | - Robert W Platt
- Department of Epidemiology, Biostatisticcs and Occupational Health, McGill University, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,Centre for Clinical Epidemiology, Lady Davis Institute, Jewish General Hospital, Montreal, QC, Canada (S.G., K.F., S.Y., H.A., C.D., R.P.).,McGill University Health Center Research Institute and Department of Pediatrics, McGill University, Montreal, QC, Canada (R.P.)
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15
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Ling HZ, Guy GP, Bisquera A, Poon LC, Nicolaides KH, Kametas NA. The effect of parity on longitudinal maternal hemodynamics. Am J Obstet Gynecol 2019; 221:249.e1-249.e14. [PMID: 30951684 DOI: 10.1016/j.ajog.2019.03.027] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Revised: 03/24/2019] [Accepted: 03/27/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Parous women have a lower risk for pregnancy complications, such as preeclampsia or delivery of small-for-gestational-age neonates. However, parous women are a heterogeneous group of patients because they contain a low-risk cohort with previously uncomplicated pregnancies and a high-risk cohort with previous pregnancies complicated by preeclampsia and/or small for gestational age. Previous studies examining the effect of parity on maternal hemodynamics, including cardiac output and peripheral vascular resistance, did not distinguish between parous women with and without a history of preeclampsia or small for gestational age and reported contradictory results. OBJECTIVE The objective of the study was to compare maternal hemodynamics in nulliparous women and in parous women with and without previous preeclampsia and/or small for gestational age. STUDY DESIGN This was a prospective, longitudinal study of maternal hemodynamics, assessed by a bioreactance method, measured at 11+0 to 13+6, 19+0 to 24+0, 30+0 to 34+0, and 35+0 to 37+0 weeks' gestation in 3 groups of women. Group 1 was composed of parous women without a history of preeclampsia and/or small for gestational age (n = 632), group 2 was composed of nulliparous women (n = 829), and group 3 was composed of parous women with a history of preeclampsia and/or small for gestational age (n = 113). A multilevel linear mixed-effects model was performed to compare the repeated measures of hemodynamic variables controlling for maternal characteristics, medical history, and development of preeclampsia or small for gestational age in the current pregnancy. RESULTS In groups 1 and 2, cardiac output increased with gestational age to a peak at 32 weeks and peripheral vascular resistance showed a reversed pattern with its nadir at 32 weeks; in group 1, compared with group 2, there was better cardiac adaptation, reflected in higher cardiac output and lower peripheral vascular resistance. In group 3 there was a hyperdynamic profile of higher cardiac output and lower peripheral vascular resistance at the first trimester followed by an earlier sharp decline of cardiac output and increase of peripheral vascular resistance from midgestation. The incidence of preeclampsia and small for gestational age was highest in group 3 and lowest in group 1. CONCLUSION There are parity-specific differences in maternal cardiac adaptation in pregnancy.
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16
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Tamargo J, Caballero R, Delpón E. Pharmacotherapy for hypertension in pregnant patients: special considerations. Expert Opin Pharmacother 2019; 20:963-982. [PMID: 30943045 DOI: 10.1080/14656566.2019.1594773] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Hypertensive disorders of pregnancy (HDP) represent a major cause of maternal, fetal and neonatal morbidity and mortality and identifies women at risk for cardiovascular and other chronic diseases later in life. When antihypertensive drugs are used during pregnancy, their benefit and harm to both mother and fetus should be evaluated. AREAS COVERED This review summarizes the pharmacological characteristics of the recommended antihypertensive drugs and their impact on mother and fetus when administered during pregnancy and/or post-partum. Drugs were identified using MEDLINE and the main international Guidelines for the management of HDP. EXPERT OPINION Although there is a consensus that severe hypertension should be treated, treatment of mild hypertension without end-organ damage (140-159/90-109 mmHg) remains controversial and there is no agreement on when to initiate therapy, blood pressure targets or recommended drugs in the absence of robust evidence for the superiority of one drug over others. Furthermore, the long-term outcomes of in-utero antihypertensive exposure remain uncertain. Therefore, evidence-based data regarding the treatment of HDP is lacking and well designed randomized clinical trials are needed to resolve all these controversial issues related to the management of HDP.
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Affiliation(s)
- Juan Tamargo
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Ricardo Caballero
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
| | - Eva Delpón
- a Department of Pharmacology and Toxicology, School of Medicine , Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, CIBERCV , Madrid , Spain
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17
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Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, Hall DR, Warren CE, Adoyi G, Ishaku S. Hypertensive Disorders of Pregnancy: ISSHP Classification, Diagnosis, and Management Recommendations for International Practice. Hypertension 2019; 72:24-43. [PMID: 29899139 DOI: 10.1161/hypertensionaha.117.10803] [Citation(s) in RCA: 1060] [Impact Index Per Article: 212.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Mark A Brown
- From the Departments of Renal Medicine and Medicine, St. George Hospital and University of New South Wales, Sydney, Australia (M.A.B.)
| | - Laura A Magee
- Faculty of Life Sciences and Medicine, King's College London, United Kingdom (L.A.M.)
| | - Louise C Kenny
- Faculty of Health and Life Sciences, University of Liverpool, United Kingdom (L.C.K.).,INFANT Centre, Cork University Maternity Hospital, Ireland (L.C.K., F.P.M.)
| | - S Ananth Karumanchi
- Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA (S.A.K.)
| | - Fergus P McCarthy
- INFANT Centre, Cork University Maternity Hospital, Ireland (L.C.K., F.P.M.)
| | - Shigeru Saito
- Department of Obstetrics and Gynecology, Graduate School of Medicine and Pharmaceutical Science for Research, University of Toyama, Japan (S.S.)
| | - David R Hall
- Department Obstetrics and Gynecology, Stellenbosch University and Tygerberg Hospital, South Africa (D.R.H.)
| | - Charlotte E Warren
- Reproductive Health Program, Population Council, Washington, DC (C.E.W.)
| | - Gloria Adoyi
- Reproductive Health Program, Population Council-Nigeria, West Africa (G.A., S.I.)
| | - Salisu Ishaku
- Reproductive Health Program, Population Council-Nigeria, West Africa (G.A., S.I.)
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18
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Ying W, Catov JM, Ouyang P. Hypertensive Disorders of Pregnancy and Future Maternal Cardiovascular Risk. J Am Heart Assoc 2018; 7:e009382. [PMID: 30371154 PMCID: PMC6201430 DOI: 10.1161/jaha.118.009382] [Citation(s) in RCA: 132] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Accepted: 07/24/2018] [Indexed: 12/18/2022]
Affiliation(s)
- Wendy Ying
- Division of CardiologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMD
| | - Janet M. Catov
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Epidemiology and CTSIUniversity of Pittsburgh School of MedicinePittsburghPA
| | - Pamela Ouyang
- Division of CardiologyDepartment of MedicineJohns Hopkins University School of MedicineBaltimoreMD
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19
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Panaitescu B, Romero R, Gomez-Lopez N, Pacora P, Erez O, Vadillo-Ortega F, Yeo L, Hassan SS, Hsu CD. ELABELA plasma concentrations are increased in women with late-onset preeclampsia. J Matern Fetal Neonatal Med 2018; 33:5-15. [PMID: 29890874 DOI: 10.1080/14767058.2018.1484089] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Objective: ELABELA is a newly discovered peptide hormone that appears to be implicated in the mechanisms leading to preeclampsia, independently of angiogenic factors. The aim of the current study was to investigate whether women with early- or late-onset preeclampsia have altered ELABELA plasma concentrations compared to gestational-age-matched normal pregnant women.Methods: This retrospective cross-sectional study focused on the maternal plasma samples collected from 232 women with a singleton pregnancy who were allocated into the following groups: (1) early-onset preeclampsia (<34 weeks of gestation, N = 56); (2) late-onset preeclampsia (≥34 weeks of gestation, N = 57); and (3) gestational-age-matched controls with a normal pregnancy [(<34 weeks of gestation, N = 59); (≥34 weeks of gestation, N = 60)]. ELABELA plasma concentrations were determined using a validated enzyme immunoassay.Results: (1) ELABELA plasma concentrations are higher in patients with late-onset preeclampsia compared with those from gestational-age-matched controls with a normal pregnancy [median: 7.99 ng/mL (IQR, 5.3-13.95 ng/mL) versus median: 4.17 ng/mL (IQR, 3-11.19 ng/mL), p =.001]; (2) ELABELA plasma concentrations in patients with early-onset preeclampsia do not differ from those of normal pregnant women [median: 6.09 ng/mL (IQR, 2.8-10.66 ng/mL) versus median: 4.02 ng/mL (IQR, 3.26-7.49), p = .32]; and (3) ELABELA plasma concentrations are higher in patients with late-onset preeclampsia compared to those with early-onset preeclampsia [median: 7.99 ng/mL (IQR, 5.3-13.95 ng/mL) versus median: 6.09 ng/mL (IQR, 2.8-10.66 ng/mL), p = .01].Conclusion: ELABELA plasma concentrations are higher in patients with late-onset preeclampsia than in those with a normal pregnancy. However, women with early-onset preeclampsia have similar ELABELA plasma concentrations to those with a normal pregnancy. These findings provide insight into the ELABELA axis during the human syndrome of preeclampsia. In addition, these data support the concept that different pathophysiologic mechanisms are implicated in early- and late-onset preeclampsia.
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Affiliation(s)
- Bogdan Panaitescu
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Roberto Romero
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, University of Michigan, Ann Arbor, MI, USA.,Department of Epidemiology & Biostatistics, Michigan State University, East Lansing, MI, USA.,Center for Molecular Medicine & Genetics, Wayne State University, Detroit, MI, USA
| | - Nardhy Gomez-Lopez
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Immunology, Microbiology & Biochemistry, Wayne State University School of Medicine, Detroit, MI, USA
| | - Percy Pacora
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Offer Erez
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | | | - Lami Yeo
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Sonia S Hassan
- Perinatology Research Branch, NICHD/NIH/DHHS, Detroit, MI, USA.,Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA.,Department of Physiology, Wayne State University School of Medicine, Detroit, MI, USA
| | - Chaur-Dong Hsu
- Department of Obstetrics & Gynecology, Wayne State University School of Medicine, Detroit, MI, USA
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20
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Brown MA, Magee LA, Kenny LC, Karumanchi SA, McCarthy FP, Saito S, Hall DR, Warren CE, Adoyi G, Ishaku S. The hypertensive disorders of pregnancy: ISSHP classification, diagnosis & management recommendations for international practice. Pregnancy Hypertens 2018; 13:291-310. [DOI: 10.1016/j.preghy.2018.05.004] [Citation(s) in RCA: 470] [Impact Index Per Article: 78.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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21
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Cui Y, Zhu B, Zheng F. Low-dose aspirin at ≤16 weeks of gestation for preventing preeclampsia and its maternal and neonatal adverse outcomes: A systematic review and meta-analysis. Exp Ther Med 2018; 15:4361-4369. [PMID: 29725376 PMCID: PMC5920352 DOI: 10.3892/etm.2018.5972] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Accepted: 02/08/2018] [Indexed: 12/13/2022] Open
Abstract
The aim of the present meta-analysis study was to evaluate the efficacy of low-dose aspirin, commenced at ≤16 weeks of gestation, in preventing preterm and term preeclampsia, as well as associated maternal and neonatal adverse events in women at risk of preeclampsia. The Embase, PubMed, Cochrane Central Register of Controlled Trials and the Web of Science databases were searched for relevant random controlled trials (RCTs) published between January 1979 and October 2017. After quality assessment and data extraction, a meta-analysis was performed using RevMan 5.3 software. Outcomes of interest were preeclampsia with subgroups of preterm preeclampsia (delivery at <37 weeks) and term preeclampsia, as well as maternal adverse outcomes, including gestational hypertension, postpartum hemorrhage and preterm birth, and neonatal adverse outcomes, including intrauterine growth retardation (IUGR) or small for gestation age infant (SGA), stillbirth or death, and newborn weight. A total of 10 RCTs involving 3,168 participants were included. The meta-analysis demonstrated that, compared with placebo or no treatment, low-dose aspirin was associated with a significant reduction in the overall risk ratio (RR) of preeclampsia regardless of the time to delivery [RR=0.67; 95% confidence interval (CI)=0.57-0.80]. This was apparent for preterm preeclampsia (RR=0.35; 95% CI=0.13-0.94) but not for term preeclampsia (RR=1.01; 95% CI=0.60-1.70). Except for postpartum hemorrhage, low-dose aspirin also significantly reduced the risk of maternal and neonatal adverse outcomes. In conclusion, low-dose aspirin in women at risk of preeclampsia, commenced at ≤16 weeks of gestation, was associated with a reduced risk of preterm preeclampsia, and of adverse maternal and neonatal outcomes.
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Affiliation(s)
- Yuechong Cui
- Department of Human Health and Human Services, Yiwu Maternity and Children Health Care Hospital, Yiwu, Zhejiang 322000, P.R. China
| | - Bin Zhu
- Department of Obstetrics and Gynecology, Yiwu Maternity and Children Health Care Hospital, Yiwu, Zhejiang 322000, P.R. China
| | - Fei Zheng
- Department of Obstetrics and Gynecology, Yiwu Maternity and Children Health Care Hospital, Yiwu, Zhejiang 322000, P.R. China
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22
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Magee LA, Kenny L, Ananth Karumanchi S, McCarthy F, Saito S, Hall DR, Warren CE, Adoyi G, Mohammed SI. TEMPORARY REMOVAL: The hypertensive disorders of pregnancy: ISSHP classification, diagnosis and management recommendations for international practice 2018. Pregnancy Hypertens 2018. [DOI: 10.1016/j.preghy.2018.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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23
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Logue OC, Mahdi F, Chapman H, George EM, Bidwell GL. A Maternally Sequestered, Biopolymer-Stabilized Vascular Endothelial Growth Factor (VEGF) Chimera for Treatment of Preeclampsia. J Am Heart Assoc 2017; 6:e007216. [PMID: 29629873 PMCID: PMC5779036 DOI: 10.1161/jaha.117.007216] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 10/30/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Preeclampsia is a hypertensive syndrome that complicates 3% to 5% of pregnancies in the United States. Preeclampsia originates from an improperly vascularized and ischemic placenta that releases factors that drive systemic pathophysiology. One of these factors, soluble fms-like tyrosine kinase-1, is believed to sequester vascular endothelial growth factor (VEGF), leading to systemic endothelial dysfunction and hypertension. With the goal of targeting soluble fms-like tyrosine kinase-1 while simultaneously preventing fetal exposure to VEGF, we fused VEGF to elastin-like polypeptide, a biopolymer carrier that does not cross the placental barrier (ELP-VEGF). METHODS AND RESULTS ELP-VEGF restored in vitro endothelial cell tube formation in the presence of plasma from placental ischemic rats. Long-term administered ELP-VEGF in pregnant rats accumulated in maternal kidneys, aorta, liver, and placenta, but the protein was undetectable in the pups when administered at therapeutic doses in dams. Long-term administration of ELP-VEGF in a placental ischemia rat model achieved dose-dependent attenuation of hypertension, with blood pressure equal to sham controls at a dose of 5 mg/kg per day. ELP-VEGF infusion increased total plasma soluble fms-like tyrosine kinase-1 levels but dramatically reduced free plasma soluble fms-like tyrosine kinase-1 and induced urinary excretion of nitrate/nitrite, indicating enhanced renal nitric oxide signaling. ELP-VEGF at up to 5 mg/kg per day had no deleterious effect on maternal or fetal body weight. However, dose-dependent adverse events were observed, including ascites production and neovascular tissue encapsulation around the minipump. CONCLUSIONS ELP-VEGF has the potential to treat the preeclampsia maternal syndrome, but careful dosing and optimization of the delivery route are necessary.
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Affiliation(s)
- Omar C Logue
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
| | - Fakhri Mahdi
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
| | - Heather Chapman
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
| | - Eric M George
- Department of Physiology and Biophysics, University of Mississippi Medical Center, Jackson, MS
- Department of Biochemistry, University of Mississippi Medical Center, Jackson, MS
| | - Gene L Bidwell
- Department of Neurology, University of Mississippi Medical Center, Jackson, MS
- Department of Biochemistry, University of Mississippi Medical Center, Jackson, MS
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24
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The role of aspirin dose on the prevention of preeclampsia and fetal growth restriction: systematic review and meta-analysis. Am J Obstet Gynecol 2017; 216:110-120.e6. [PMID: 27640943 DOI: 10.1016/j.ajog.2016.09.076] [Citation(s) in RCA: 373] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 08/25/2016] [Accepted: 09/07/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Preeclampsia and fetal growth restriction are major causes of perinatal death and handicap in survivors. Randomized clinical trials have reported that the risk of preeclampsia, severe preeclampsia, and fetal growth restriction can be reduced by the prophylactic use of aspirin in high-risk women, but the appropriate dose of the drug to achieve this objective is not certain. OBJECTIVE We sought to estimate the impact of aspirin dosage on the prevention of preeclampsia, severe preeclampsia, and fetal growth restriction. STUDY DESIGN We performed a systematic review and meta-analysis of randomized controlled trials comparing the effect of daily aspirin or placebo (or no treatment) during pregnancy. We searched MEDLINE, Embase, Web of Science, and Cochrane Central Register of Controlled Trials up to December 2015, and study bibliographies were reviewed. Authors were contacted to obtain additional data when needed. Relative risks for preeclampsia, severe preeclampsia, and fetal growth restriction were calculated with 95% confidence intervals using random-effect models. Dose-response effect was evaluated using meta-regression and reported as adjusted R2. Analyses were stratified according to gestational age at initiation of aspirin (≤16 and >16 weeks) and repeated after exclusion of studies at high risk of biases. RESULTS In all, 45 randomized controlled trials included a total of 20,909 pregnant women randomized to between 50-150 mg of aspirin daily. When aspirin was initiated at ≤16 weeks, there was a significant reduction and a dose-response effect for the prevention of preeclampsia (relative risk, 0.57; 95% confidence interval, 0.43-0.75; P < .001; R2, 44%; P = .036), severe preeclampsia (relative risk, 0.47; 95% confidence interval, 0.26-0.83; P = .009; R2, 100%; P = .008), and fetal growth restriction (relative risk, 0.56; 95% confidence interval, 0.44-0.70; P < .001; R2, 100%; P = .044) with higher dosages of aspirin being associated with greater reduction of the 3 outcomes. Similar results were observed after the exclusion of studies at high risk of biases. When aspirin was initiated at >16 weeks, there was a smaller reduction of preeclampsia (relative risk, 0.81; 95% confidence interval, 0.66-0.99; P = .04) without relationship with aspirin dosage (R2, 0%; P = .941). Aspirin initiated at >16 weeks was not associated with a risk reduction or a dose-response effect for severe preeclampsia (relative risk, 0.85; 95% confidence interval, 0.64-1.14; P = .28; R2, 0%; P = .838) and fetal growth restriction (relative risk, 0.95; 95% confidence interval, 0.86-1.05; P = .34; R2, not available; P = .563). CONCLUSION Prevention of preeclampsia and fetal growth restriction using aspirin in early pregnancy is associated with a dose-response effect. Low-dose aspirin initiated at >16 weeks' gestation has a modest or no impact on the risk of preeclampsia, severe preeclampsia, and fetal growth restriction. Women at high risk for those outcomes should be identified in early pregnancy.
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25
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Cheng SB, Sharma S. Preeclampsia and health risks later in life: an immunological link. Semin Immunopathol 2016; 38:699-708. [PMID: 27339196 DOI: 10.1007/s00281-016-0579-8] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/16/2016] [Indexed: 12/11/2022]
Abstract
Pregnancy represents a period of physiological stress, and although this stress is experienced for a very modest portion of life, it is now recognized as a window to women's future health, often by unmasking predispositions to conditions that only become symptomatic later in life. In normal pregnancy, the mother experiences mild metabolic syndrome-like condition through week 20 of gestation. A pronounced phenotype of metabolic syndrome may program pregnancy complications such as preeclampsia. Preeclampsia is a serious complication with a myriad of manifestations for mother and offspring. This pregnancy syndrome is a polygenic disease and has been now linked to higher incidence of cardiovascular disease, diabetes, and several other disorders associated with vulnerable organs. Furthermore, the offspring born to preeclamptic mothers also exhibit an elevated risk of cardiovascular disease, stroke, and mental disorders during adulthood. This suggests that preeclampsia not only exposes the mother and the fetus to complications during pregnancy but also programs chronic diseases in later life. The etiology of preeclampsia is thought to be primarily associated with poor placentation and entails excessive maternal inflammation and endothelial dysfunction. It is well established now that the maternal immune system and the placenta are involved in a highly choreographed cross-talk that underlies adequate spiral artery remodeling required for uteroplacental perfusion and free flow of nutrients to the fetus. Since normal pregnancy is associated with a sequence of events represented by temporal events of inflammation (implantation), anti-inflammation (gestation), and inflammation (parturition), it is quite possible that unscheduled alterations in these regulatory responses may lead to pathologic consequences. Although it is not clear whether immunological alterations occur early in pregnancy, it is proposed that dysregulated systemic and placental immunity contribute to impaired angiogenesis and the onset of preeclampsia. This review will focus on important aspects of the immune system that coordinate with placental dysfunction to program preeclampsia and influence health in later life.
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Affiliation(s)
- Shi-Bin Cheng
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA
| | - Surendra Sharma
- Department of Pediatrics, Women and Infants' Hospital of Rhode Island, Warren Alpert Medical School of Brown University, 101 Dudley Street, Providence, RI, 02905, USA.
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