Pre-eclampsia: Fetal assessment and neonatal outcomes

Pregnancy in women with congenital heart disease: New insights into neonatal risk prediction

BACKGROUND

Advances in managing adult congenital heart disease (ACHD) have led to an increased number of women with CHD reaching childbearing age. This demographic shift underscores the need for improved understanding and prediction of complications during pregnancy in this specific ACHD population. Despite progress in maternal cardiac risk assessment, the prediction of neonatal outcomes for ACHD pregnancies remains underdeveloped. Therefore, the aims of this study are to assess neonatal outcomes in a CHD women population, to identify their predictive factors and to propose a new risk score for predicting neonatal complications.

METHODS

This registry study included all women born between 1975 and 1996 diagnosed with ACHD who underwent at least one cardiology consultation for ACHD in Cliniques Universitaires Saint-Luc. A multivariate analysis was performed to identify predictors of neonatal complications and these were incorporated into a new risk index. Its validity was assessed using bootstrap method. This score was then compared with scores adapted from the ZAHARA and CARPREG studies for offspring events prediction.

RESULTS

Analysis of 491 pregnancies revealed 31.4% of neonatal complications. Four significant predictors of adverse neonatal outcomes were identified: cardiac treatment during pregnancy (OR 14.8, 95%CI [3.4-66]), hypertensive disorders of pregnancy (OR 11.4, 95%CI [3.4-39.0]), smoking during pregnancy (OR 10.6, 95%CI [2.8-40.6]), and pre-pregnancy BMI <18.5 kg/m² (OR 6.5, 95%CI [2.5-16.5]). The risk model demonstrated an AUC of 0.70 (95%CI [0.65-0.75]), which remained stable after bootstrap validation. This model significantly outperformed the scores adapted from ZAHARA and CARPREG data. Based on the regression coefficients, a risk score was subsequently developed comprising five risk categories.

CONCLUSIONS

One third of ACHD pregnancies are complicated by poor neonatal outcome. These complications are determined by four independent factors relating to the cardiac and non-cardiac status of the patients, which have been incorporated into a risk score. Our study is one of the first to propose a predictive risk score of neonatal outcomes in ACHD pregancies, and paves the way for other validation and confirmation studies.

Sex-specific alterations in cognitive control following moderate prenatal alcohol exposure and transient systemic hypoxia ischemia in the rat

BACKGROUND

Prenatal alcohol exposure (PAE) continues to be a worldwide problem. Affected offspring display impaired neurodevelopment, including difficulties with executive control. Although PAE has also been associated with decreased blood flow to fetuses, the relationship between PAE and altered blood flow is not well understood.

METHODS

We used preclinical models of PAE, transient systemic hypoxia ischemia (TSHI), and PAE + TSHI combined to assess the effects on neurodevelopmental outcomes using translationally relevant touchscreen operant platform testing. Twenty-eight Long-Evans (Blue Spruce, Strain HsdBlu:LE) dams were randomly assigned to one of four experimental groups: Saccharin Control (Sham), 5% Ethanol (PAE), TSHI, or 5% Ethanol and TSHI (PAE + TSHI). Dams consumed either saccharin or 5% ethanol during gestation. TSHI was induced on Embryonic Day 19 (E19) during an open laparotomy where the uterine arteries were transiently occluded for 1 h. Pups were born normally and, after weaning, were separated by sex. A total of 80 offspring, 40 males and 40 females, were tested on the 5-Choice Continuous Performance paradigm (5C-CPT).

RESULTS

Female offspring were significantly impacted by TSHI, but not PAE, with an increase in false alarms and a decrease in hit rates, omissions, accuracy, and correct choice latencies. In contrast, male offspring were mildly affected by PAE, but not TSHI, showing decreases in premature responses and increases in accuracy. No significant interactions between PAE and TSHI were detected on any measure.

CONCLUSION

Transient systemic hypoxia ischemia impaired performance on the 5C-CPT in females, leading to a bias toward stimulus responsivity regardless of stimulus type. In contrast, TSHI did not affect male offspring, and only slight effects of PAE were seen. Together, these data suggest that TSHI in females may cause alterations in cortical structures that override alterations caused by moderate PAE.

Childhood growth outcomes 2 years after hypertensive versus normotensive pregnancy: a P4 study

BACKGROUND

Intrauterine exposure to hypertensive disorders of pregnancy, including gestational hypertension (GH) and preeclampsia (PE), may influence infant growth and have long-term health implications. This study aimed to compare growth outcomes of infants exposed to a normotensive pregnancy (NTP), GH, or PE from birth to 2 years.

METHODS

Infants were children of women enroled in the prospective Postpartum Physiology, Psychology and Paediatric (P4) cohort study who had NTP, GH or PE. Birth, 6-month (age-corrected) and 2-year (age-corrected) weight z-scores, change in weight z-scores, rapid weight gain (≥0.67 increase in weight z-score) and conditional weight gain z-scores were calculated to assess infant growth (NTP = 240, GH = 19, PE = 66).

RESULTS

Infants exposed to PE compared to NTP or GH had significantly lower birth weight and length z-scores, but there were no differences in growth outcomes at 6 months or 2 years. GH and PE-exposed infants had significantly greater weight z-score gain [95% CI] (PE = 0.93 [0.66-1.18], GH = 1.03 [0.37-1.68], NTP = 0.45 [0.31-0.58], p < 0.01) and rapid weight gain (GH = 63%, PE = 59%, NTP = 42%, p = 0.02) from birth to 2 years, which remained significant for PE-exposed infants after confounder adjustment.

CONCLUSION

In this cohort, GH and PE were associated with accelerated infant weight gain that may increase future cardiometabolic disease risk.

IMPACT

Preeclampsia exposed infants were smaller at birth, compared with normotensive pregnancy and gestational hypertension exposed infants, but caught up in growth by 2 years of age. Both preeclampsia and gestational hypertension exposed infants had significantly accelerated weight gain from birth to 2 years, which remained significant for preeclampsia exposed infants after adjustment for confounders including small for gestational age. Monitoring of growth patterns in infants born following exposure to a hypertensive disorder of pregnancy may be indicated to prevent accelerated weight gain trajectories and obesity.

Dynamic changes in blood lipid levels and their associations with hypertensive disorders of pregnancy in twin pregnancy: A retrospective study

BACKGROUND

Little knowledge on the association of blood lipid levels with hypertensive disorders of pregnancy (HDP) in twin pregnancy.

OBJECTIVE

To investigate the association of blood lipid levels with HDP in twin pregnancy.

METHODS

This is a retrospective study in the Beijing Birth Cohort on patients followed between January 2014 and November 2021. A total of 2628 women pregnant with twins were included and divided into HDP (n = 565) and normal blood pressure (NBP, n = 2063) groups. HDP subtypes included gestational hypertension (GH, n = 190) and preeclampsia (PE, n = 375). Dynamic changes in blood lipid profiles and their associations with HDP were assessed.

RESULTS

Compared to NBP group, higher triglyceride (TG) and low-density lipoprotein  cholesterol (LDL-c) in the first (T1) and second trimesters (T2) existed in women with PE. In addition, TG increased significantly from T1 to T2, and high-density lipoprotein cholesterol (HDL-c) decreased significantly since T2 in women with PE, especially in women with early-onset PE and severe PE. Elevated TG and LDL-c were associated with HDP, mainly PE. In a subgroup analysis, higher TG or LDL-c increased the risk of HDP for underweight, overweight and primipara women.

CONCLUSIONS

In twin pregnancy, women with PE had higher TG and LDL-c, and elevated TG and LDL-c were associated with PE. A significant increase in TG or decrease in HDL-c were more prone to PE, especially early-onset PE and severe PE. It is helpful to monitor blood lipid levels in women pregnant with twins, especially in underweight, overweight, and primipara women.

Preterm and term pre-eclampsia: Relative burdens of maternal and perinatal complications

OBJECTIVE

To determine the relative burdens of maternal and perinatal complications for preterm and term pre-eclampsia.

DESIGN

Prospective observational cohort study.

SETTING

Two English maternity units.

POPULATION

Unselected women with singleton pregnancies who developed pre-eclampsia (International Society for the Study of Hypertension in Pregnancy definition).

METHODS

Outcomes were ascertained by health record review and compared between pregnancies with preterm (versus term) pre-eclampsia.

MAIN OUTCOME MEASURES

Severe maternal hypertension, maternal mortality or major maternal morbidity, perinatal mortality or major neonatal morbidity, neonatal unit (NNU) admission ≥48 hours, and birthweight <3rd percentile.

RESULTS

Among 40 241 singleton pregnancies, 298 (0.7%, 95% confidence interval [CI] 0.66-0.83) and 1194 (3.0%, 95% CI 2.8-3.1) developed preterm and term pre-eclampsia, respectively. Women with preterm (versus term) pre-eclampsia more commonly experienced adverse maternal or perinatal events: severe hypertension 18.5% (95% CI 14.5-23.3) versus 13.6% (95% CI 11.7-15.6); maternal mortality/major morbidity 7.4% (95% CI 4.9-10.9) versus 2.2% (95% CI 1.5-3.2); perinatal mortality/major neonatal morbidity 29.5% (95% CI 24.6-34.9) versus 2.2% (95% CI 1.5-3.2); and birthweight <3rd percentile 54.4% (95% CI 48.7-59.9) versus 14.2% (95% CI 12.4-16.3). However, in absolute terms, most maternal complications occurred in women with term pre-eclampsia, as did a large proportion of perinatal complications: severe hypertension 74.7% (95% CI 68.5-80.0); maternal mortality/major morbidity 54.2% (95% CI 40.3-67.4); perinatal mortality/major neonatal morbidity 22.8% (95% CI 16.1-31.3); NNU admission ≥48 hours 38.1% (95% CI 32.4-44.1); and birthweight <3rd percentile 51.2% (95% CI 45.8-56.5).

CONCLUSIONS

Although adverse event risks are greater with preterm (versus term) pre-eclampsia, term disease is associated with at least equivalent total numbers of maternal, and a significant proportion of perinatal, adverse events. Increased efforts should be made to decrease the incidence of term pre-eclampsia.

Consequences of early-onset preeclampsia on neonatal morbidity and mortality

Preterm birth is the leading cause of perinatal morbidity and mortality in developed countries. Common reasons for indicated preterm births include pre-eclampsia. The increase in incidences of morbidity and mortality observed in neonates resulting from pregnancies complicated by preeclampsia is also due to alterations in angiogenic and pro-inflammatory factors that directly affect the neonatal health. This review was prepared with the aim of gathering the information available at PubMed/MEDLINE, in the years from 2011 to 2021, on the consequences of neonatal morbidity and mortality of early-onset preeclampsia. There is great controversy in the literature and paucity of studies. Early onset pre-eclampsia has been linked to fetal growth restriction (FGR). Most studies support its association with respiratory distress syndrome (RDS). Most studies point to an association between preeclampsia and bronchopulmonary dysplasia (BPD), with the highest risk in FGR. The association between preeclampsia, patent ductus arteriosus (PDA) and sepsis is not supported by the literature. The association to necrotizing enterocolitis (NEC) is controversial. The risk of spontaneous intestinal perforation (SIP) seems to be increased with preeclampsia. The association between intraventricular hemorrhage (IVH) and preeclampsia is controversial, however, preeclampsia seems to have a protective effect on periventricular leukomalacia (PVL). Most of the evidence points to the non-association between preeclampsia and retinopathy of prematurity (ROP). Hematological changes such as neutropenia, thrombocytopenia and increased nucleated red blood cell counts have been shown to be associated with preeclampsia. The evidence is still quite controversial regarding mortality. The early installation of preeclampsia will have direct consequences on neonatal morbidity. Gestational age at preterm birth is the main risk factor on neonatal morbidity. Obstetricians should aim to prolong the pregnancies complicated by early-onset severe preeclampsia as far as maternal conditions allow. This policy may contribute to improve the neonatal outcomes.

A review of infant growth and psychomotor developmental outcomes after intrauterine exposure to preeclampsia

Preeclampsia is a hypertensive disorder of pregnancy with serious health implications for mother and their offspring. The uteroplacental vascular insufficiency caused by preeclampsia is associated with epigenetic and pathological changes in the mother and fetus. However, the impact of preeclampsia in infancy (birth to 2 years), a time of rapid development influenced by pre- and postnatal factors that can predict future health outcomes, remains inconclusive. This narrative review of 23 epidemiological and basic science studies assessed the measurement and impact of preeclampsia exposure on infant growth and psychomotor developmental outcomes from birth to 2 years. Studies assessing infant growth report that preeclampsia-exposed infants have lower weight, length and BMI at 2 years than their normotensive controls, or that they instead experience accelerated weight gain to catch up in growth by 2 years, which may have long-term implications for their cardiometabolic health. In contrast, clear discrepancies remain as to whether preeclampsia exposure impairs infant motor and cognitive development, or instead has no impact. It is additionally unknown whether any impacts of preeclampsia are independent of confounders including shared genetic factors that predispose to both preeclampsia and childhood morbidity, perinatal factors including small for gestational age or preterm birth and their sequelae, and postnatal environmental factors such childhood nutrition. Further research is required to account for these variables in larger cohorts born at term, to help elucidate the independent pathophysiological impact of this clinically heterogenous and dangerous disease.

Association of Prenatal Acetaminophen Exposure Measured in Meconium With Adverse Birth Outcomes in a Canadian Birth Cohort

BACKGROUND

The small number of studies examining the association of prenatal acetaminophen with birth outcomes have all relied on maternal self-report. It remains unknown whether prenatal acetaminophen exposure measured in a biological specimen is associated with birth outcomes.

OBJECTIVES

To investigate the association of acetaminophen measured in meconium with birthweight, gestational age, preterm birth, size for gestational age, gestational diabetes, preeclampsia, and high blood pressure.

METHODS

This birth cohort from Sherbrooke, QC, Canada, included 773 live births. Mothers with no thyroid disease enrolled at their first prenatal care visit or delivery. Acetaminophen was measured in meconium for 393 children at delivery. We tested associations of prenatal acetaminophen with birthweight, preterm birth, gestational age, small and large for gestational age, gestational diabetes, preeclampsia, and high blood pressure. We imputed missing data via multiple imputation and used inverse probability weighting to account for confounding and selection bias.

RESULTS

Acetaminophen was detected in 222 meconium samples (56.5%). Prenatal acetaminophen exposure was associated with decreased birthweight by 136 g (β = -136; 95% CI [-229, -43]), 20% increased weekly hazard of delivery (hazard ratio = 1.20; 95% CI [1.00, 1.43]), and over 60% decreased odds of being born large for gestational age (odds ratio = 0.38; 95% CI [0.20, 0.75]). Prenatal acetaminophen was not associated with small for gestational age, preterm birth, or any pregnancy complications.

CONCLUSION

Prenatal acetaminophen was associated with adverse birth outcomes. Although unobserved confounding and confounding by indication are possible, these results warrant further investigation into adverse perinatal effects of prenatal acetaminophen exposure.

Management and perinatal outcomes of hypertensive disorders of pregnancy in a low-resource setting in Indonesia

Objectives:

To provide up-to-date data concerning hypertensive disorders of pregnancy on maternal and neonatal profiles in Indonesia.

Methods:

Retrospective clinical audit on all pregnancy-associated hypertensive women between 1 January 2020 and 31 March 2020 at Cianjur General District Hospital.

Results:

Preeclampsia accounts for 66.8% (235/352) of hypertensive disorders of pregnancy, gestational hypertension 29% (102/352) and chronic hypertension 4.3% (15/352). Compared to other pregnant women, those with preeclampsia, on average, had higher systolic and diastolic blood pressures and poorer kidney (ureum and creatinine) and liver function (aspartate transaminase enzyme and alanine transaminase enzyme) profiles (p < 0.001, < 0.001, < 0.001, 0.003, 0.033 and 0.002, respectively), and required more intensive care admission. Neonates from women with severe forms of preeclampsia (eclampsia and HELLP syndrome (haemolysis, elevated liver enzymes, low platelets)) had, on average, lower birthweight (p = 0.015 and 0.048, respectively) and birth length (p = 0.021, 0.017). Neonates from eclamptic mothers had poorer APGAR (appearance, pulse, grimace, activity and respiration) scores (p = 0.006 and 0.005, respectively).

Conclusion:

Hypertensive disorders of pregnancy exerts adverse maternal and neonatal outcomes, particularly among eclampsia and HELLP-syndrome neonates. Various challenges remain for optimal management.

Gestational Hypertension and Preeclampsia: An Overview of National and International Guidelines

Importance

Gestational hypertension and preeclampsia are leading causes of maternal and perinatal morbidity and mortality worldwide. Τhe lack of effective screening and management policies appears to be one of the main reasons.

Objective

The aim of this study was to review and compare recommendations from published guidelines on these common pregnancy complications.

Evidence Acquisition

A descriptive review of guidelines from the National Institute for Health and Care Excellence, the Society of Obstetric Medicine of Australia and New Zealand, the International Society of Hypertension, the International Society for the Study of Hypertension in Pregnancy, the European Society of Cardiology, the International Federation of Gynecology and Obstetrics, the Society of Obstetricians and Gynaecologists of Canada, the American College of Obstetricians and Gynecologists, the International Society of Ultrasound in Obstetrics and Gynecology, the World Health Organization, and the US Preventive Services Task Force on gestational hypertension and preeclampsia was carried out.

Results

There is an overall agreement that, in case of suspected preeclampsia or new-onset hypertension, blood and urine tests should be carried out, including dipstick test for proteinuria, whereas placental growth factor-based testing is only recommended by the National Institute for Health and Care Excellence and the European Society of Cardiology. In addition, there is a consensus on the recommendations for the medical treatment of severe and nonsevere hypertension, the management of preeclampsia, the appropriate timing of delivery, the optimal method of anesthesia and the mode of delivery, the administration of antenatal corticosteroids and the use of magnesium sulfate for the treatment of eclamptic seizures, the prevention of eclampsia in cases of severe preeclampsia, and the neuroprotection of preterm neonates. The reviewed guidelines also state that, based on maternal risk factors, pregnant women identified to be at high risk for preeclampsia should receive low-dose aspirin starting ideally in the first trimester until labor or 36 to 37 weeks of gestation, although the recommended dose varies between 75 and 162 mg/d. Moreover, most guidelines recommend calcium supplementation for the prevention of preeclampsia and discourage the use of other agents. However, controversy exists regarding the definition and the optimal screening method for preeclampsia, the need for treating mild hypertension, the blood pressure treatment targets, and the postnatal blood pressure monitoring.

Conclusions

The development and implementation of consistent international protocols will allow clinicians to adopt effective universal screening, as well as preventive and management strategies with the intention of improving maternal and neonatal outcomes.

Quantifying Fetal Reprogramming for Biomarker Development in the Era of High-Throughput Sequencing

Gestational hypertensive disorders continue to threaten the well-being of pregnant women and their offspring. The only current definitive treatment for gestational hypertensive disorders is delivery of the fetus. The optimal timing of delivery remains controversial. Currently, the available clinical tools do not allow for assessment of fetal stress in its early stages. Placental insufficiency and fetal growth restriction secondary to gestational hypertensive disorders have been shown to have long-term impacts on offspring health even into their adulthood, becoming one of the major focuses of research in the field of developmental origins of health and disease. Fetal reprogramming was introduced to describe the long-lasting effects of the toxic intrauterine environment on the growing fetus. With the advent of high-throughput sequencing, there have been major advances in research attempting to quantify fetal reprogramming. Moreover, genes that are found to be differentially expressed as a result of fetal reprogramming show promise in the development of transcriptional biomarkers for clinical use in detecting fetal response to placental insufficiency. In this review, we will review key pathophysiology in the development of placental insufficiency, existing literature on high-throughput sequencing in the study of fetal reprogramming, and considerations regarding research design from our own experience.

Maternal BMI at the time of birth and selected risk factors associated with severe neonatal outcomes: a secondary analysis of the WHO Better Outcomes in Labour Difficulty (BOLD) project

The main objective of this secondary analysis was to describe the nutritional status of the Better Outcomes in Labour Difficulty (BOLD) project study population and determine possible associations between maternal nutritional status (as reflected by maternal BMI at the time of birth) and severe neonatal outcomes (SNO). We also analysed previous and index maternal pathologies to determine associations with neonatal outcomes. We used the classification designed by Atalah for maternal BMI and compared with the Hyperglycaemia and Adverse Pregnancy Outcome study one. To describe the nutritional status of this population, figures of distribution and test of normality related to weight and BMI were presented for the women and their babies. To explore the association between maternal BMI data and SNO, the χ2 test was performed. To identify a maternal characteristic or a group of characteristics that could predict SNO, we used Fisher's exact test using previous maternal pathology collected in the BOLD project as well as that in the index pregnancy. In this study, BMI at the time of birth was not associated with neonatal near miss or death. We found that previous maternal obesity, diabetes and chronic hypertension were associated with SNO. Maternal pathology in the index pregnancy such as other obstetric haemorrhage, pre-eclampsia, anaemia and gestational diabetes was associated with SNO.

Perinatal outcome in gestational hypertension: Which role for developing preeclampsia. A population-based cohort study

OBJECTIVE

To analyze perinatal outcome in singleton pregnancies complicated by gestational hypertension (GH), to investigate the rate of women developing preeclampsia (PE) and to describe maternal features associated with progression to PE.

STUDY DESIGN

This is a population-based retrospective cohort-study involving 514 singleton pregnancies with a diagnosis of GH at admission.

RESULTS

In pregnancies with GH, a poorer pregnancy outcome in comparison to healthy controls was observed in terms of gestational age at delivery, birthweight and birthweight percentile. The observed overall rate of developing PE was 11.7 %. Of all pregnancies with GH at admission, two different groups were identified based on the diagnosis at delivery: GHPE, i.e. women who developed PE (60/514; 11.7 %), and GHnoPE, i.e. women who did not develop PE (454/514; 88.3 %). In the GHPE group it was observed that the 62 % of the women with diagnosis of GH earlier than 28 weeks developed PE while only 2% developed PE if the diagnosis of GH was performed later than 36 weeks. The observed rate of developing PE was 14.7 % in pharmacologically treated hypertensive women, whereas the diagnosis of PE has been made in only 3% of non-treated women.

CONCLUSION

Pregnant women with raised blood pressure are at risk of having a less favourable perinatal outcome. The risk is mainly associated with the progression to PE. Major determinants of the risk of developing PE are the earlier gestational age at diagnosis of GH, the necessity of treatment and the number of anti-hypertensive drugs needed for controlling blood pressure.

Melhoria da qualidade do cuidado à hipertensão gestacional em terapia intensiva

Objetivo: avaliar o efeito de um ciclo de melhoria da qualidade na implementação de práticas baseadas em evidências no tratamento de mulheres com doenças hipertensivas gestacionais admitidas em Unidade de Terapia Intensiva Materna (UTIM).Métodos: estudo quase-experimental, sem grupo de controle, realizado numa UTIM de um hospital universitário que seguiu as etapas de um ciclo de melhoria da qualidade. Avaliaram-se nove critérios de processo em todas as mulheres admitidas com diagnóstico de doenças hipertensivas gestacionais nos períodos anterior (n = 50) e posterior à intervenção (n = 50) em 2015. Estimou-se a conformidade com intervalo de confiança de 95 %, as não conformidades com gráficos de Pareto e a significância da melhoria com teste do valor Z unilateral (α = 5 %).Resultados: o nível de qualidade inicial foi alto em seis dos nove critérios (amplitude: 94-100 %), as práticas com menor adesão foram a “manutenção de sulfato de magnésio” (54 %), “solicitação de ultrassom fetal” (72 %) e “restrição hídrica intravenosa” (78 %). Houve melhoria absoluta em cinco dos nove critérios (amplitude: 2-16 %), que foi significativa para a solicitação de ultrassom fetal (melhoria absoluta: 16 %; p = 0,023) e para o total de critérios (4 %; p = 0,01).Conclusão: a intervenção de melhoria da qualidade proposta aumentou a adesão às recomendações baseadas em evidência para o tratamento de pacientes com doenças hipertensivas gestacionais admitidas em uma UTIM.

Intravenous magnesium sulfate in the management of severe pre-eclampsia: A randomized study of 12-hour versus 24-hour maintenance dose

OBJECTIVE

To assess the effectiveness of a 12-hour versus 24-hour intravenous maintenance dose of magnesium sulfate (MgSO₄ ) in women with pre-eclampsia, and the maternal and fetal outcomes.

METHODS

This was a randomized controlled trial conducted at the labor ward complex of University College Hospital, Ibadan, Nigeria between May and August 2014. Pregnant women with severe pre-eclampsia were randomized to receive a 12-hour versus 24-hour maintenance dose of MgSO₄ . Study outcomes were occurrence of seizures, adverse maternal effects, neonatal survival, and admission to the intensive care unit. Data analysis involved descriptive statistics and bivariate analysis using Statistical Package for Social Science (SPSS) version 20.

RESULTS

There were 80 patients randomized to the 12-hour (n=40) and 24-hour (n=40) groups. The participants in the two groups had comparable demographic features. There was no significant difference (P>0.999) between the satisfactory maternal outcome following the 12-hour maintenance dose and the standard 24-hour regimen (95.0% vs 97.5%). Similarly, there was no significant difference (P=0.276) in perinatal mortality in the 12-hour versus 24-hour arm (17.5% vs 12.5%, respectively). No case of eclampsia and maternal death was recorded.

CONCLUSION

A 12-hour maintenance dose of intravenous MgSO₄ in the management of severe pre-eclampsia is effective and safe when compared with the 24-hour maintenance dose.

Hyperferritinemia worsens the perinatal outcomes of conceptions of pregnancies with preeclampsia

BACKGROUND AND AIMS

To analyze the prevalence of hyperferritinemia in pregnant women with preeclampsia and its association with adverse perinatal outcomes.

METHODS

A cross-sectional study carried out in 2017 with a convenience sample of pregnant women with preeclampsia attended at a high-risk maternity hospital in Alagoas, Brazil. Socioeconomic, lifestyle, clinical and biochemical data were collected through a structured questionnaire. Type of delivery, gestational age, weight and length at birth, and Apgar score were analyzed as outcome variables. Women were dichotomized according to the serum ferritin level (150 ng/mL). Poisson regression models were used to analyze the effect of hyperferritinemia on the outcome variables. Estimates were presented as prevalence ratio with 95% confidence intervals (PR [95% CI]).

RESULTS

Based on the Fisher's exact statistical teste and in the proportions of the neonatal outcome (birth weight), with a statistical significance of 5%, the statistical power of the sample studied was 83%. Two hundred six pregnant women with preeclampsia were recruited, which 8.74% presented hyperferritinemia. Except for ferritin level, there were no differences in C-reactive protein (CRP), hemoglobin, Glutamate Oxaloacetate Transaminase (GOT) and Pyruvic Glutamic Transaminase (PGT) levels between women with or without hyperferritinemia. After adjusting for potential confounders, hyperferritinemia was associated with low birth weight (2.19 [2.13-3.89 95%CI]), low birth length (7.76 [2.52-23.8 95% CI]) and being born small for gestational age (3.14 [1.36-7.28 95% CI]).

CONCLUSION

In the presence of hyperferritinemia, preeclampsia patients were associated with a higher rate of unfavorable neonatal outcomes.

Fetal chronic hypoxia and oxidative stress in diabetic pregnancy. Could fetal erythropoietin improve offspring outcomes?

Oxidative stress is responsible for microvascular complications (hypertension, nephropathy, retinopathy, peripheral neuropathy) of diabetes, which during pregnancy increase both maternal and fetal complications. Chronic hypoxia and hyperglycemia result in increased oxidative stress and decreased antioxidant enzyme activity. However, oxidative stress induces also anti-oxidative reactions both in pregnant diabetes patients and in their fetuses. Not all type 1 diabetes patients with long-lasting disease develop microvascular complications, which suggests that some of these patients have protective mechanisms against these complications. Fetal erythropoietin (EPO) is the main regulator of red cell production in the mother and in the fetus, but it has also protective effects in various maternal and fetal tissues. This dual effect of EPO is based on EPO receptor (EPO-R) isoforms, which differ structurally and functionally from the hematopoietic EPO-R isoform. The tissue protective effects of EPO are based on its anti-apoptotic, anti-oxidative, anti-inflammatory, cell proliferative and angiogenic properties. Recent experimental and clinical studies have shown that EPO has also positive metabolic effects on hyperglycemia and diabetes, although these have not yet been fully delineated. Whether the tissue protective and metabolic effects of EPO could have clinical benefits, are important topics for future research in diabetic pregnancies.

Robust increases in erythropoietin production by the hypoxic fetus is a response to protect the brain and other vital organs

Fetal erythropoietin (EPO), in addition to regulating erythropoiesis, has also tissue-protective properties based on its anti-inflammatory, anti-apoptotic, antioxidant, and neurotrophic effects. Notably, EPO concentrations needed for tissue protection are 100-1000 times higher than concentrations needed for regulating erythropoiesis. This dual effect of EPO is based on EPO-receptor (EPO-R) isoforms, which differ structurally and functionally. We hypothesize in this Integrated Mechanism Review that during severe fetal hypoxia the observed, but poorly understood, marked increases of fetal plasma EPO concentrations occur to protect the brain, heart, and other vital fetal organs. We further hypothesize that the concurrent marked increases of EPO in the amniotic fluid during fetal hypoxia, occur to protect newborn infants from necrotizing enterocolitis. This review presents experimental and clinical evidence in support of these hypotheses and points out unknown or poorly understood functions of EPO in the fetus. If these novel hypotheses are correct, the importance of fetal EPO as an antenatal hypoxia biomarker will become apparent. It will also likely point the way to important diagnostic and therapeutic fetal and neonatal interventions.

Pre-eclampsia onset and SPARC: A possible involvement in placenta development

Pre-eclampsia (PE) is a multisystem disorder commonly diagnosed in the latter half of pregnancy and it is a leading cause of intrauterine fetal growth retardation (IUGR). The aim of this study was to investigate the localization and the role of SPARC, secreted protein acidic, and rich in cysteine, in PE and PE-IUGR placentas in comparison with normal placentas. SPARC was mainly expressed in the villous and extravillous cytotrophoblastic cells in first trimester, whereas in PE, PE-IUGR and at term placentas, SPARC immunostaining was visible in both cytotrophoblastic cells and syncytiotrophoblast. SPARC expression significantly decreased in normal placenta from first to third trimester and a further significant reduction was demonstrated in PE and PE-IUGR. The latter downregulation of SPARC depends on hypoxic condition as shown by in vitro models. In conclusion, SPARC can play a pivotal role in PE and PE-IUGR onset and it should be considered as a key molecule for future investigations in such pathologies.

Maternal pregnancy-induced hypertension increases subsequent neonatal necrotizing enterocolitis risk: A nationwide population-based retrospective cohort study in Taiwan

The utero-placental ischemia induced by pregnancy-induced hypertension (PIH) could lead to fetal hypoxia and proinflammatory cytokine release, which are associated with the development of neonatal necrotizing enterocolitis (NEC). However, a few studies have investigated the relationship between PIH and neonatal NEC and have produced controversial results. Therefore, we attempted to assess the relationship between PIH and the subsequent neonatal NEC risk and identify predictive risk factors.Patients with newly diagnosed PIH were recruited from the Taiwan National Health Insurance Research Database (NHIRD). For each participant, 4 age- and delivery-year-matched participants without PIH were randomly selected. A multivariable logistic regression was performed for the identification of the predictive risk factors for neonatal NEC.Among the 23.3 million individuals registered in the NHIRD, 29,013 patients with PIH and 116,052 matched controls were identified. For the multivariable analysis, maternal PIH was associated with an increased risk of subsequent neonatal NEC development (odds ratio [OR] 1.86, 95% confidence interval [CI] 1.08-3.21, P = .026). Furthermore, single parity (OR 2.06, 95% CI 1.12-3.77, P = .019), preterm birth (OR 5.97, 95% CI 3.49-10.20, P < .001), multiple gestations (OR 2.25, 95% CI 1.22-4.14, P = .010), and intrauterine growth restriction (IUGR) (OR 3.59, 95% CI 2.06-6.24, P < .001) were independent risk factors for the development of subsequent neonatal NEC.Maternal PIH increases the risk for developing neonatal NEC. Furthermore, primiparity, preterm birth, multiple gestations, and IUGR were independent risk factors for neonatal NEC.

Prenatal and perinatal risk factors and the clinical implications on autism spectrum disorder

Prenatal and perinatal factors may increase the risk of autism spectrum disorder. However, little is known about whether unaffected siblings of probands with autism spectrum disorder also share the phenomenon and whether the prenatal/perinatal factors are related to the clinical severity of autistic symptoms. We compared the frequency of prenatal and perinatal factors among 323 probands with autism spectrum disorder (mean age ± standard deviation, 10.7 ± 3.5 years; males, 91.0%), 257 unaffected siblings (11.7 ± 4.5; 42.8%), and 1504 typically developing controls (8.9 ± 1.6 years; 53.1%); and investigated their effects on the severity of autistic symptoms. We found that probands with autism spectrum disorder and their unaffected siblings had more prenatal/perinatal events than typically developing controls with higher numbers of prenatal/perinatal factors in probands than in unaffected siblings. The prenatal/perinatal events were associated with greater stereotyped behaviors, social-emotional problems, socio-communication deficits, and overall severity. We also found that six prenatal/perinatal factors (i.e. preeclampsia, polyhydramnios, oligoamnios, placenta previa, umbilical cord knot, and gestational diabetes) were associated with the severity of autistic symptoms, particularly stereotyped behaviors and socio-communication deficits. Our findings suggest that prenatal and perinatal factors may potentially moderate the clinical expression of autism spectrum disorder. The underlying mechanism warrants further research.

Mechanisms of the effect of magnesium salts in preeclampsia

Preeclampsia is a heterogeneous pregnancy-specific syndrome associated with abnormal trophoblast invasion and endothelial dysfunction. Magnesium (Mg²⁺) level may be normal or decreased in women with preeclampsia. However, the use of Mg²⁺ salts, such as Mg²⁺ sulphate, are useful in reducing the pathophysiological consequences of preeclampsia with severe features and eclampsia. Although the mechanism of action of this Mg²⁺ salt is not well understood, the available evidence suggests a beneficial effect of Mg²⁺ for the mother and foetus. The mechanisms include a lower level of soluble fms-like tyrosine kinase 1 and endoglin, blockage of brain N-methyl-D-aspartate receptors, decreased inflammation mediators, activation of nitric oxide synthases, blockage of arginases, and reduced free radicals level. The maintenance of Mg²⁺ homeostasis in pregnancy is crucial for an appropriate pregnancy progression. Oral Mg²⁺ salts can be used for this purpose which could result in mitigating the deleterious consequences of this syndrome to the mother, foetus, and newborn.

Evaluating pre-pregnancy dietary diversity vs. dietary quality scores as predictors of gestational diabetes and hypertensive disorders of pregnancy

Background

Dietary diversity scores (DDS) are considered as metrics for monitoring the implementation of the UN’s Sustainable Development Goals, but they need to be rigorously evaluated.

Objective

To examine two DDS, the Food Groups Index (FGI), and the Minimum Dietary Diversity-Women (MDD-W), alongside two dietary quality scores, the Alternate Healthy Eating Index (AHEI-2010) and the Prime Diet Quality Score (PDQS), with risks of gestational diabetes mellitus (GDM) and hypertensive disorders of pregnancy (HDPs).

Design

The analysis included 21,312 (GDM) and 19,917 (HDPs) singleton births reported in the Nurses’ Health Study II cohort (1991–2001), among women without major chronic disease or GDM/HDPs. Scores were derived using prepregnancy diet collected by a comprehensive food frequency questionnaire. Multivariable models were utilized to calculate relative risks (RR) and confidence intervals (95%CIs).

Results

Incident GDM (n = 916) and HDPs (n = 1,421) were reported. The MDD-W and FGI were not associated with risk of GDM or HDPs, but the AHEI-2010 and PDQS were associated with a lower risk of GDM and marginally lower risk of HDP. The RR’s of GDM comparing the highest vs. lowest quintiles were 1.00 (95%CI: 0.79, 1.27; p-trend = 0.82) for MDD-W, 0.96 (95%CI: 0.76, 1.22; p-trend = 0.88) for FGI, 0.63 (95%CI: 0.50, 0.81; p-trend <0.0001) for the AHEI-2010 and 0.68 (95%CI: 0.54, 0.86; p-trend = 0.003) for the PDQS. Similarly, the RR’s of HDPs were 0.92 (95%CI: 0.75, 1.12, p-trend = 0.94) for MDD-W, 0.97 (95%CI: 0.79, 1.17; p-trend = 0.83) for FGI, 0.84 (95%CI: 0.70, 1.02; p-trend = 0.07) for AHEI-2010 and 0.89 (95%CI: 0.74, 1.09; p-trend = 0.07) for PDQS.

Conclusions

MDD-W and FGI did not predict the risk of GDM and HDPs. These DDS should not be widely used as metrics for achieving dietary goals in their present form. The Prime Diet Quality Score warrants further testing as a promising measure of a sustainable and healthy diet on a global scale.

What Do We Know about Risk Factors for Fetal Growth Restriction in Africa at the Time of Sustainable Development Goals? A Scoping Review

BACKGROUND

The reduction in the under-5 year mortality rate to at least as low as 25 per 1000 livebirths by 2030 has been implemented as one of the new Sustainable Development Goals. Fetal growth restriction (FGR) is one of the most important determinants of infant mortality in developing countries. In this review, we assess the extent of the literature and summarize its findings on the main preventable factors of FGR in Africa.

METHODS

A scoping review was conducted using the Arksey and O'Malley framework. Five bibliographic databases and grey literature were used to identify studies assessing at least one risk factor for FGR. Aggregate risk estimates for the main factors associated with FGR were calculated.

RESULTS

Forty-five of a total of 671 articles were selected for the review. The prevalence of FGR varied between 2.6 and 59.2% according to both the African region and the definition of FGR. The main preventable factors reported were a low maternal nutritional status (aggrerate odds ratio [OR]: 2.28, 95% confidence interval [CI] 1.59, 3.25), HIV infection (aOR 1.86, 95% CI 1.38, 2.50), malaria (aOR 1.95, 95% CI 1.04, 3.66), and gestational hypertension (aOR 2.61, 95% CI 2.42, 2.82).

CONCLUSION

FGR is, to a large extent, preventable through existing efficacious interventions dedicated to malaria, HIV and nutrition. Further studies are still needed to assess the influence of risk factors most commonly documented in high-income countries. Improving research on FGR in Africa requires a consensual and standardized definition of FGR-for a higher comparability-between studies and settings.

Heme oxygenase-1 is a potent inhibitor of placental ischemia-mediated endothelin-1 production in cultured human glomerular endothelial cells

Preeclampsia is a pregnancy-specific disorder of maternal hypertension and reduced renal hemodynamics linked to reduced endothelial function. Placental ischemia is thought to be the culprit of this disease, as it causes the release of factors like tumor necrosis factor (TNF)-α that induce vascular endothelin-1 (ET-1) production. Interestingly, placental ischemia-induced hypertension in rats [reduced uterine perfusion pressure (RUPP) model] is abolished by ETA receptor blockade, suggesting a critical role for ET-1. Although it has been found that systemic induction of heme oxygenase (HO)-1 is associated with reduced ET-1 production and attenuated hypertension, it is unclear whether HO-1 directly modulates the increased ET-1 response to placental factors. We tested the hypothesis that HO-1 or its metabolites inhibit ET-1 production in human glomerular endothelial cells induced by serum of RUPP rats or TNF-α. Serum (5%) from RUPP hypertensive (mean arterial blood pressure 119 ± 9 mmHg) vs. normotensive pregnant (NP, 101 ± 6 mmHg, P < 0.001) rats increased ET-1 production (RUPP 168.8 ± 18.1 pg/ml, NP 80.3 ± 22.7 pg/ml, P < 0.001, n = 12/group). HO-1 induction [25 µM cobalt photoporphyrin (CoPP)] abolished RUPP serum-induced ET-1 production (1.6 ± 0.8 pg/ml, P < 0.001), whereas bilirubin (10 µM) significantly attenuated ET-1 release (125.3 ± 5.2 pg/ml, P = 0.005). Furthermore, TNF-α-induced ET-1 production (TNF-α 31.0 ± 8.4 vs. untreated 7.5 ± 0.4 pg/ml, P < 0.001) was reduced by CoPP (1.5 ± 0.8 pg/ml, P < 0.001) and bilirubin (10.5 ± 4.3 pg/ml, P < 0.001). These results suggest that circulating factors released during placental ischemia target the maternal glomerular endothelium to increase ET-1, and that pharmacological induction of HO-1 or bilirubin could be a treatment strategy to block this prohypertensive pathway in preeclampsia.

Meta-Prediction of MTHFR Gene Polymorphisms and Air Pollution on the Risk of Hypertensive Disorders in Pregnancy Worldwide

Hypertensive disorders in pregnancy (HDP) are devastating health hazards for both women and children. Both methylenetetrahydrofolate reductase (MTHFR) gene polymorphisms and air pollution can affect health status and result in increased risk of HDP for women. The major objective of this study was to investigate the effect of MTHFR polymorphisms, air pollution, and their interaction on the risk of HDP by using meta-predictive analytics. We searched various databases comprehensively to access all available studies conducted for various ethnic populations from countries worldwide, from 1997 to 2017. Seventy-one studies with 8064 cases and 13,232 controls for MTHFR C677T and 11 studies with 1425 cases and 1859 controls for MTHFR A1298C were included. MTHFR C677T homozygous TT (risk ratio (RR) = 1.28, p < 0.0001) and CT plus TT (RR = 1.07, p = 0.0002) were the risk genotypes, while wild-type CC played a protective role (RR = 0.94, p = 0.0017) for HDP. The meta-predictive analysis found that the percentage of MTHFR C677T TT plus CT (p = 0.044) and CT (p = 0.043) genotypes in the HDP case group were significantly increased with elevated levels of air pollution worldwide. Additionally, in countries with higher air pollution levels, the pregnant women with wild-type CC MTHFR 677 had a protection effect against HDP (p = 0.014), whereas, the homozygous TT of MTHFR C677T polymorphism was a risk genotype for developing HDP. Air pollution level is an environmental factor interacting with increased MTHFR C677T polymorphisms, impacting the susceptibility of HDP for women.

Interleukin 11 is upregulated in preeclampsia and leads to inflammation and preeclampsia features in mice

Preeclampsia is a dangerous pregnancy complication, which is often associated with fetal growth restriction and can have serious life-long effects for both mother and baby. While the establishment of the placenta in the first trimester is the sentinel event in the development of preeclampsia little is known of the critical mechanisms of placentation that lead to the syndrome. Locally produced inflammatory cytokines are thought to play a role in the development of preeclampsia. This review summarizes the evidence that interleukin 11 is dysregulated in preeclampsia and contributes to the initiation of preeclampsia via effects on placentation. It discusses the benefits and drawbacks of targeting IL11 as a novel treatment option for preeclampsia.

Promoter Methylation Status of WNT2 in Placenta from Patients with Preeclampsia

Background

Preeclampsia is a serious multisystem disorder of human gestation, affecting up to 10% of pregnant women worldwide, and results in maternal morbidity and mortality. The aim of this study was to determine the gene expression pattern and methylation status of the promoter of the WNT2 gene in placentas from patients with preeclampsia and to evaluate the potential role of the WNT2 pathway in the pathogenesis of preeclampsia.

Material/Methods

Real-time quantitative polymerase chain reaction (PT-PCR) was used to determine the WNT2 gene expression level. Western blot analysis was used to identify alterations in wnt2 protein expression.

Results

The mRNA and protein expression levels of the WNT2 gene were reduced in placentas from patients with preeclampsia when compared with placentas from healthy women. The average methylation level of the promoter of the WNT2 gene was elevated in the placentas from patients with preeclampsia compared with the controls placentas from healthy women.

Conclusions

The findings of this study have shown that molecular mechanisms, including aberrant activation of the WNT2 gene signaling pathway, may be involved in the pathogenesis of preeclampsia. Promoter hypermethylation and reduced expression of the WNT2 gene requires further study to determine a potential role in the diagnosis and treatment of preeclampsia.

Understanding the Implications of Birth Weight

Neonatal growth parameters include birth weight, length, and head circumference. Weight, as it relates to gestational age, is monitored closely during pregnancy to assess the appropriate growth of the fetus. At birth, it becomes an important parameter to assess the health and well-being of the newborn. Birth weight carries implications for nursing care and monitoring of the newborn's transition to extrauterine life. The importance of birth weight assessment and its interpretation will be reviewed, along with the implications for immediate neonatal care and potential long-term effects on an infant's health outcomes.

Fetal hemoglobin in umbilical cord blood in preeclamptic and normotensive pregnancies: A cross-sectional comparative study

Preeclampsia (PE) is associated with increased fetal hemoglobin (HbF) in the maternal circulation but its source is unknown. To investigate whether excessive HbF is produced in the placenta or the fetus, the concentration of HbF (cHbF) in the arterial and venous umbilical cord blood (UCB) was compared in 15825 normotensive and 444 PE pregnancies. The effect of fetal gender on cHbF was also evaluated in both groups. Arterial and venous UCB sampled immediately after birth at 36-42 weeks of gestation were analyzed for total Hb concentration (ctHb) (g/L) and HbF% using a Radiometer blood gas analyzer. Non-parametric tests were used for statistical comparison and P values < 0.05 were considered significant. Our results indicated higher cHbF in venous compared to arterial UCB in both normotensive (118.90 vs 117.30) and PE (126.75 vs 120.12) groups. In PE compared to normotensive pregnancies, a significant increase was observed in arterial and venous ctHb (171.00 vs 166.00 and 168.00 vs 163.00, respectively) while cHbF was only significantly increased in venous UCB (126.75 vs 118.90). The pattern was similar in both genders. These results indicate a substantial placental contribution to HbF levels in UCB, which increases in PE and is independent of fetal gender, suggesting the elevated cHbF evident in PE results from placental dysfunction.

Interleukin 11: similar or opposite roles in female reproduction and reproductive cancer?

During placental development and carcinogenesis, cell invasion and migration are critical events in establishing a self-supporting vascular supply. Interleukin (IL)-11 is a pleiotropic cytokine that affects the invasive and migratory capabilities of trophoblast cells that form the placenta during pregnancy, as well as various malignant cell types. The endometrium is the site of embryo implantation during pregnancy; conversely, endometrial carcinoma is the most common gynaecological malignancy. Here, we review what is known about the role of IL-11 in trophoblast function and in gynaecological malignancies, focusing primarily on the context of the uterine environment.

Preventing deaths due to the hypertensive disorders of pregnancy

In this chapter, taking a life cycle and both civil society and medically oriented approach, we will discuss the contribution of the hypertensive disorders of pregnancy (HDPs) to maternal, perinatal and newborn mortality and morbidity. Here we review various interventions and approaches to preventing deaths due to HDPs and discuss effectiveness, resource needs and long-term sustainability of the different approaches. Societal approaches, addressing sustainable development goals (SDGs) 2.2 (malnutrition), 3.7 (access to sexual and reproductive care), 3.8 (universal health coverage) and 3c (health workforce strengthening), are required to achieve SDGs 3.1 (maternal survival), 3.2 (perinatal survival) and 3.4 (reduced impact of non-communicable diseases (NCDs)). Medical solutions require greater clarity around the classification of the HDPs, increased frequency of effective antenatal visits, mandatory responses to the HDPs when encountered, prompt provision of life-saving interventions and sustained surveillance for NCD risk for women with a history of the HDPs.

Preeclampsia: Prevalence and perinatal repercussions in a University Hospital in Rio de Janeiro, Brazil

Preeclampsia (PE) prevalence studies in Brazil are both scarce and not divided in accordance with gestational age at delivery. We accessed PE prevalence according to delivery before 34, 37 and 42weeks in a cross-sectional study including 4464 single deliveries. PE was diagnosed in 301 cases (6.74%); Prevalence of PE was 0.78%; 1.92% and 6.74% according to deliveries before 34, 37 and 42weeks. PE was associated with fetal death, prematurity and small for gestational age newborns.

Intake of antioxidant nutrients and coefficients of variation in pregnant women with preeclampsia

INTRODUCTION AND OBJECTIVE

Oxidative stress appears to play a critical role in the pathogenesis of preeclampsia. Evidence suggests that adequate intake of antioxidants can modulate this condition. The objective of this study was to assess the intake of antioxidant nutrients and coefficients of variation in pregnant women with preeclampsia.

METHODS

In a cross-sectional study in the public health network of the city of Maceió, Brazil, a dietary survey was performed consisting of 24-hour food recalls, with subsequent adjustment of nutrients using the estimated average requirement as the cutoff point, and a questionnaire on frequency of consumption of antioxidants.

RESULTS

We studied 90 pregnant women with preeclampsia (PWP) and 90 pregnant women without preeclampsia (PWoP) with mean ages of 25.8±6.7 years and 24.1±6.2 years (p=0.519), respectively. A low mean intake of antioxidants (vitamin A, selenium, zinc and copper) was observed in both PWP and PWoP, although intakes of vitamin A (p=0.045) and selenium (p=0.008) were higher in PWoP. In addition, we observed high coefficients of variation in nutrient intakes in both groups, which were higher for vitamin C (p<0.001), vitamin A (p=0.006) and copper (p=0.005) in PWP.

CONCLUSIONS

Consumption of antioxidant nutrients by pregnant women with preeclampsia is inadequate, with considerable daily variations in intake, which points to a need for nutrition education strategies aimed at improving intakes, because diet is without doubt a key factor in the modulation of oxidative stress caused by preeclampsia.

Maternal Factors and Adverse Perinatal Outcomes in Women with Preeclampsia in Maceió, Alagoas

Background

Preeclampsia has been associated with several risk factors and events. However, it still deserves further investigation, considering the multitude of related factors that affect different populations.

Objective

To evaluate the maternal factors and adverse perinatal outcomes in a cohort of pregnant women with preeclampsia receiving care in the public health network of the city of Maceió.

Methods

Prospective cohort study carried out in 2014 in the public health network of the city with a sample of pregnant women calculated based on a prevalence of preeclampsia of 17%, confidence level of 90%, power of 80%, and ratio of 1:1. We applied a questionnaire to collect socioeconomic, personal, and anthropometric data, and retrieved perinatal variables from medical records and certificates of live birth. The analysis was performed with Poisson regression and chi-square test considering p values < 0.05 as significant.

Results

We evaluated 90 pregnant women with preeclampsia (PWP) and 90 pregnant women without preeclampsia (PWoP). A previous history of preeclampsia (prevalence ratio [PR] = 1.57, 95% confidence interval [95% CI] 1.47 - 1.67, p = 0.000) and black skin color (PR = 1.15, 95% CI 1.00 - 1.33, p = 0.040) were associated with the occurrence of preeclampsia. Among the newborns of PWP and PWoP, respectively, 12.5% and 13.1% (p = 0.907) were small for gestational age and 25.0% and 23.2% (p = 0.994) were large for gestational age. There was a predominance of cesarean delivery.

Conclusion

Personal history of preeclampsia and black skin color were associated with the occurrence of preeclampsia. There was a high frequency of birth weight deviations and cesarean deliveries.

Perinatal outcomes after hypertensive disorders in pregnancy in a low resource setting

OBJECTIVE

The objective of this study was to evaluate perinatal outcomes of pregnancies complicated by hypertensive disorders in pregnancy in an urban sub-Saharan African setting.

METHODS

A prospective cohort study of 1010 women of less than 17 weeks of gestation was conducted at two antenatal clinics in Accra, Ghana, between July 2012 and March 2014. Information about hypertensive disorders was available for analysis on 789 pregnancies. The main outcomes were pre-term birth, birthweight, Apgar scores, small for gestational age and mortality. Relative risk (RR, 95% confidence interval (CI)) for the association between hypertensive disorders of pregnancy and perinatal outcomes was assessed using logistic regression adjusting for potential confounders.

RESULTS

A total of 88.7% of women remained normotensive, 7.5% developed pregnancy-induced hypertension, 2.0% had chronic hypertension, and 1.7% developed (pre-)eclampsia. No adverse effects were observed in women with pregnancy-induced hypertension. Women with chronic hypertension were more likely to have a lower gestational age at delivery (38.0 ± 2.3 weeks vs. 39.0 ± 1.9 weeks, P = 0.04) and higher risk of pre-term delivery (aRR 4.63, 95% CI 1.35-15.91). Women with pre-eclampsia had emergency Caesarean section significantly more often (88.9% vs. 50%, P = 0.04), with a higher risk for low birthweight infants (aRR 7.95, 95% CI 1.41-44.80) and a higher risk of neonatal death (aRR 18.41, 95% CI 1.20-283.22).

CONCLUSION

Comparable to high-income countries, in Accra hypertensive disorders during pregnancy were associated with increased risk of adverse perinatal outcomes necessitating maternal and newborn care.

Chronic hyperleptinemia results in the development of hypertension in pregnant rats

Despite the fact that obesity is a major risk factor for preeclampsia (PE), the pathophysiological mechanisms whereby obesity and metabolic factors such as leptin increase this risk are unclear. While human data have shown that hyperleptinemia is associated with PE, the long-term effect of hyperleptinemia on blood pressure during pregnancy is unknown. Thus we tested the hypothesis whether chronic circulating leptin elevations in pregnant rats increase blood pressure and placental factors known to play a role in PE. On gestational day (GD)14, rats were assigned to the normal pregnant group with food intake ad libitum (control), leptin-treated (0.5 μg·kg(-1)·min(-1) ip) pregnant group with food intake ad libitum (pregnant+LEP), and normal pregnant group with food intake adjusted to the food intake of pregnant+LEP rats (pregnant-FR). On GD19, mean arterial pressure (MAP) was assessed and tissues were collected. Serum leptin concentration was elevated in pregnant+LEP compared with control and pregnant-FR (18.0 ± 2.8 vs. 0.8 ± 0.1 vs. 0.3 ± 0.1 ng/ml; P < 0.05), which was associated with increased MAP (121.3 ± 8.1 vs. 102.4 ± 2.4 vs. 101.3 ± 1.8 mmHg; P < 0.05). Food intake and body weight were reduced in pregnant+LEP and pregnant-FR by the end of gestation. Additionally, placentas and fetuses of these groups were lighter than those of control. However, placental expression of tumor necrosis factor-α was significantly greater in pregnant+LEP compared with controls (1.6 ± 0.1 vs. 1.1 ± 0.1 pg/mg; P < 0.05). In conclusion, leptin increases blood pressure and placental tumor necrosis factor-α during pregnancy despite its effect of reducing food intake and body weight, and represents a mechanism whereby obesity can promote the development of hypertension in PE.

Pre-eclampsia: an update

Pre-eclampsia remains the second leading direct cause of maternal death, >99 % of which occurs in less developed countries. Over 90 percent of the observed reduction in pre-eclampsia-related maternal deaths in the UK (1952-2008) occurred with antenatal surveillance and timed delivery. In this review, we discuss the pathogenesis, diagnostic criteria, disease prediction models, prevention and management of pre-eclampsia. The Pre-eclampsia Integrated Estimate of RiSk (PIERS) models and markers of angiogenic imbalance identify women at incremental risk for severe pre-eclampsia complications. For women at high risk of developing pre-eclampsia, low doses of aspirin (especially if started <17 weeks) and calcium are evidence-based preventative strategies; heparin is less so. Severe hypertension must be treated and the Control of Hypertension In Pregnancy (CHIPS) Trial (reporting: 2014) will guide non-severe hypertension management. Magnesium sulfate prevents and treats eclampsia; there is insufficient evidence to support alternative regimens. Pre-eclampsia predicts later cardiovascular disease; however, at this time we do not know what to do about it.

External validity of first-trimester algorithms in the prediction of pre-eclampsia disease severity

OBJECTIVE

To compare disease features in women with pre-eclampsia between those who are correctly identified (true positive) and those who are missed (false negative) when applying first-trimester prediction algorithms for pre-eclampsia to a prospectively enrolled population.

METHOD

Six first-trimester early (requiring delivery < 34 weeks' gestation) pre-eclampsia algorithms were applied to a prospective cohort of singleton pregnancies enrolled at first-trimester screening. Maternal outcomes, neonatal outcomes and severity parameters for pre-eclampsia were compared between true-positive and false-negative predictions.

RESULTS

Twenty of 2446 (0.8%) women developed early pre-eclampsia, with 65% of these developing severe features and 20% HELLP syndrome. At enrollment, true-positive cases were more likely to be African-American and chronically hypertensive, while false-negative cases were more likely to be Caucasian. At delivery, true-positive cases were more likely to have pre-eclampsia superimposed on hypertension, severely elevated blood pressure and creatinine level > 1.1 mg/dL. False-negative cases were more likely to have HELLP syndrome (all P < 0.05).

CONCLUSION

In an urban population with a high prevalence of chronic hypertension, patients who are correctly identified by first-trimester screening models are more likely to develop pre-eclampsia superimposed on chronic hypertension with severely elevated blood pressure and evidence of renal failure. In contrast, patients who are missed by these algorithms are more likely to have HELLP syndrome. Further research is needed to confirm these findings and the algorithm adjustments that may be necessary to better predict pre-eclampsia phenotypes.

Uterine vasculature remodeling in human pregnancy involves functional macrochimerism by endothelial colony forming cells of fetal origin

The potency of adult-derived circulating progenitor endothelial colony forming cells (ECFCs) is drastically surpassed by their fetal counterparts. Human pregnancy is associated with robust intensification of blood flow and vascular expansion in the uterus, crucial for placental perfusion and fetal supply. Here, we investigate whether fetal ECFCs transmigrate to maternal bloodstream and home to locations of maternal vasculogenesis, primarily the pregnant uterus. In the first instance, endothelial-like cells, originating from mouse fetuses expressing paternal eGFP, were identified within uterine endothelia. Subsequently, LacZ or enhanced green fluorescent protein (eGFP)-labeled human fetal ECFCs, transplanted into immunodeficient (NOD/SCID) fetuses on D15.5 pregnancy, showed similar integration into the mouse uterus by term. Mature endothelial controls (human umbilical vein endothelial cells), similarly introduced, were unequivocally absent. In humans, SRY was detected in 6 of 12 myometrial microvessels obtained from women delivering male babies. The copy number was calculated at 175 [IQR 149-471] fetal cells per millimeter square endothelium, constituting 12.5% of maternal vessel lumina. Cross-sections of similar human vessels, hybridized for Y-chromosome, positively identified endothelial-associated fetal cells. It appears that through ECFC donation, fetuses assist maternal uterine vascular expansion in pregnancy, potentiating placental perfusion and consequently their own fetal supply. In addition to fetal growth, this cellular mechanism holds implications for materno-fetal immune interactions and long-term maternal vascular health.

Aleitamento materno na primeira hora de vida em um Hospital Amigo da Criança: prevalência, fatores associados e razões para sua não ocorrência

Objetivos: identificar a prevalência do aleitamento materno na primeira hora de vida, os fatores associados e as razões para sua não ocorrência em um Hospital Amigo da Criança. Métodos: estudo transversal com 562 mães e recém-nascidos. Os dados foram obtidos entre outubro a novembro de 2011 mediante formulários de entrevista e consulta a prontuários. Modelo de Poisson foi ajustado para analisar a prevalência do aleitamento materno na primeira hora de vida em função das variáveis de exposição. Resultados: a prevalência do aleitamento materno na primeira hora de vida foi de 31%. Apenas o parto normal permaneceu no modelo final, apresentando razão de prevalência de 27% a mais em relação ao parto cesáreo (p=0,020). As razões para que 388 crianças não tenham sido amamentadas na primeira hora de vida foram classificadas em: problemas de saúde da criança (328, 84,5%), da mãe (241, 62,1%) e atraso no resultado do teste rápido anti-HIV (199, 51,2%), 11 (2,8%) não apresentaram nenhuma justificativa. Conclusões: os resultados relatados ainda estão bem abaixo das recomendações da Organização Mundial da Saúde (OMS), o que em grande parte pode ser atribuído às condições próprias de um hospital de nível terciário, cuja demanda é constituída predominantemente por casos de pacientes de médio e elevado risco obstétrico.

Diagnosis, evaluation, and management of the hypertensive disorders of pregnancy

OBJECTIVE

This guideline summarizes the quality of the evidence to date and provides a reasonable approach to the diagnosis, evaluation and treatment of the hypertensive disorders of pregnancy (HDP).

EVIDENCE

The literature reviewed included the previous Society of Obstetricians and Gynaecologists of Canada (SOGC) HDP guidelines from 2008 and their reference lists, and an update from 2006. Medline, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Registry of Controlled Trials (CCRCT) and Database of Abstracts and Reviews of Effects (DARE) were searched for literature published between January 2006 and March 2012. Articles were restricted to those published in French or English. Recommendations were evaluated using the criteria of the Canadian Task Force on Preventive Health Care and GRADE.

Maternal morbidity and preterm birth in 22 low- and middle-income countries: a secondary analysis of the WHO Global Survey dataset

Background

Preterm birth (PTB) (<37weeks) complicates approximately 15 million deliveries annually, 60% occurring in low- and middle-income countries (LMICs). Several maternal morbidities increase the risk of spontaneous (spPTB) and provider-initiated (piPTB) preterm birth, but there is little data from LMICs.

Method

We used the WHO Global Survey to analyze data from 172,461 singleton deliveries in 145 facilities across 22 LMICs. PTB and six maternal morbidities (height <145 cm, malaria, HIV/AIDS, pyelonephritis/UTI, diabetes and pre-eclampsia) were investigated. We described associated characteristics and developed multilevel models for the risk of spPTB/piPTB associated with maternal morbidities. Adverse perinatal outcomes (Apgar <7 at 5 minutes, NICU admission, stillbirth, early neonatal death and low birthweight) were determined.

Results

8.2% of deliveries were PTB; one-quarter of these were piPTB. 14.2% of piPTBs were not medically indicated. Maternal height <145 cm (AOR 1.30, 95% CI 1.10–1.52), pyelonephritis/UTI (AOR 1.16, 95% CI 1.01–1.33), pre-gestational diabetes (AOR 1.41, 95% CI 1.09–1.82) and pre-eclampsia (AOR 1.25, 95% CI 1.05–1.49) increased odds of spPTB, as did malaria in Africa (AOR 1.67, 95%CI 1.32-2.11) but not HIV/AIDS (AOR 1.17, 95% CI 0.79-1.73). Odds of piPTB were higher with maternal height <145 cm (AOR 1.47, 95% CI 1.23-1.77), pre-gestational diabetes (AOR 2.51, 95% CI 1.81-3.47) and pre-eclampsia (AOR 8.17, 95% CI 6.80-9.83).

Conclusions

Maternal height <145 cm, diabetes and pre-eclampsia significantly increased odds of spPTB and piPTB, while pyelonephritis/UTI and malaria increased odds of spPTB only. Strategies to reduce PTB and associated newborn morbidity/mortality in LMICs must prioritize antenatal screening/treatment of these common conditions and reducing non-medically indicated piPTBs where appropriate.

Evaluating the fetus at risk for cardiopulmonary compromise

The in-utero environment is relatively hypoxic, but fetal physiologic adaptation assures adequate tissue oxygen supply. Fetal reactions to acute or chronic hypoxia are different and are modified by the preceding fetal condition. Acute fetal hypoxia episodes are often not preventable. By contrast, good obstetric care during labor may prevent poor fetal outcome in many cases of acute fetal hypoxia. The pathophysiology of chronic fetal hypoxia caused by placental insufficiency differs from chronic fetal hypoxia seen during the last weeks of diabetic pregnancies. The efficacy of antenatal fetal surveillance methods in preventing perinatal complications is different in these two conditions. Electronic fetal heart rate testing and Doppler flow assessment methods have been successful in detecting chronic fetal hypoxia caused by placental insufficiency. However, these methods have been unable to prevent chronic fetal hypoxia complications in diabetic pregnancies. Therefore, research to find new strategies and early and reliable biomarkers is necessary to assess fetal well-being and to decide when to deliver the fetus.

DNA methylation as a biomarker for preeclampsia

BACKGROUND

Preeclampsia contributes significantly to pregnancy-associated morbidity and mortality as well as future risk of cardiovascular disease in mother and offspring, and preeclampsia in offspring. The lack of reliable methods for early detection limits the opportunities for prevention, diagnosis, and timely treatment.

PURPOSE

The purpose of this study was to explore distinct DNA methylation patterns associated with preeclampsia in both maternal cells and fetal-derived tissue that represent potential biomarkers to predict future preeclampsia and inheritance in children.

METHOD

A convenience sample of nulliparous women (N = 55) in the first trimester of pregnancy was recruited for this prospective study. Genome-wide DNA methylation was quantified in first-trimester maternal peripheral white blood cells and placental chorionic tissue from normotensive women and those with preeclampsia (n = 6/group).

RESULTS

Late-onset preeclampsia developed in 12.7% of women. Significant differences in DNA methylation were identified in 207 individual linked cytosine and guanine (CpG) sites in maternal white blood cells collected in the first trimester (132 sites with gain and 75 sites with loss of methylation), which were common to approximately 75% of the differentially methylated CpG sites identified in chorionic tissue of fetal origin.

CONCLUSION

This study is the first to identify maternal epigenetic targets and common targets in fetal-derived tissue that represent putative biomarkers for early detection and heritable risk of preeclampsia. Findings may pave the way for diagnosis of preeclampsia prior to its clinical presentation and acute damaging effects, and the potential for prevention of the detrimental long-term sequelae.

A complicated role for the renin-angiotensin system during pregnancy: highlighting the importance of drug discovery

INTRODUCTION

Blood pressure management is recommended to avoid maternal cerebrovascular or cardiovascular compromise during pregnancy. Current antihypertensive treatment during pregnancy with positive safety profiles includes labetalol, hydralazine, methyldopa and nifedipine.

AREAS COVERED

Many earlier animal and human studies indicate that angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) are associated with fetopathy; therefore, these drugs are contraindicated during pregnancy, especially if these medications were taken during the second and third trimesters. The role of the RAS is quite complex, with fetal development heavily dependent on its appropriate expression and function. New findings indicate that the placental unit expresses its own RAS in order to regulate angiogenesis. Multiple studies have shown that women with abnormal uterine doppler sonography produce an agonistic autoantibody to the angiotensin I receptor, implicating a role for RAS function and regulation in abnormal pregnancies. Importantly, interruption of a normal RAS compromises fetal development.

EXPERT OPINION

Traditional medications that inhibit components of RAS for long-term hypertension control are not appropriate for use before or during pregnancy. Further study and drug discovery are needed to find alternative pathways for treatment of hypertensive disorders when pregnancy is present or a possibility.