Secular Trends in Preeclampsia Incidence and Outcomes in a Large Canada Database: A Longitudinal Study Over 24 Years

"Understanding knowledge and attitudes regarding hypertensive disorders of pregnancy among expectant women in Brunei Darussalam: A nationwide study"

BACKGROUND

The primary cause of maternal and fetal mortality due to hypertensive disorders in pregnancy is delays in accessing healthcare services. These delays are often attributed to insufficient knowledge, attitudes at the time of diagnosis, and a lack of awareness regarding the condition, including its critical warning signs and symptoms.

AIM

To evaluate pregnant women's initial knowledge and attitudes upon receiving their first diagnosis of hypertensive disorders of pregnancy.

METHODS

A cross-sectional quantitative design was used to assess the knowledge and views of 216 expectant mothers on hypertensive disorders of pregnancy (HDP) across three high-risk clinics in Brunei Darussalam. Participants were selected through convenience sampling. Data were collected using a bilingual self-administered questionnaire, adapted from a validated instrument. Descriptive statistics and inferential analyses, including t-tests, One-Way ANOVA, and multiple regression, were conducted using SPSS (Version 23).

RESULTS

Among 216 participants, 69 % demonstrated good knowledge of hypertensive disorders during pregnancy (p < 0.001). Despite positive attitudes towards seeking medical help (p < 0.001), 69 % initially opted for home remedies, and 50 % avoided hospitals unless necessary, leading to delays in healthcare-seeking behaviour. The findings highlight the need for targeted health campaigns to bridge the gap between knowledge and practice, ensuring timely medical intervention for hypertensive disorders during pregnancy.

CONCLUSION

The study reveals significant knowledge gaps and attitudes contributing to delayed healthcare-seeking behaviours. Targeted health campaigns and culturally sensitive educational programs are essential to improve timely medical interventions and maternal outcomes in Brunei Darussalam.

Immune Cells and Infectious Diseases in Pre-eclampsia Susceptibility

Pre-eclampsia is a severe pregnancy disorder affecting approximately 10% of pregnancies worldwide, characterized by hypertension and proteinuria after the 20th week of gestation. The condition poses significant risks to both maternal and fetal health, including cardiovascular complications and impaired fetal development. Recent trends indicate a rising incidence of pre-eclampsia, correlating with factors such as advanced maternal age and cardiovascular comorbidities. Emerging evidence also highlights a notable increase in the association between autoimmune and infectious diseases with pre-eclampsia. Autoimmune conditions, such as type 1 diabetes and systemic lupus erythematosus, and infections triggered by global health challenges and climate change, including Leptospirosis, Zika, Toxoplasmosis, and Chagas' disease, are now recognized as significant contributors to pre-eclampsia susceptibility by affecting placental formation and function. This review focuses on the immunological mechanisms underpinning pre-eclampsia, exploring how immune system dysregulation and infectious triggers exacerbate the condition. It also discusses the shared pathological mechanisms, including galectins, between autoimmune and infectious diseases with pre-eclampsia and their significant risk for adverse pregnancy outcomes. We emphasize the necessity for accurate diagnosis and vigilant monitoring of immune and infectious diseases during pregnancy to optimize management and reduce risks. By raising awareness about these evolving risks and their impact on pregnancy, we aim to enhance diagnostic practices and preventive strategies, ultimately improving outcomes for pregnant women, especially in regions affected by climatic changes and endemic diseases.

Role of chronic kidney disease and risk factors in preeclampsia

BACKGROUND

Our goal was to identify what impact chronic kidney disease (CKD) and its associated risk factors, such as body mass index (BMI), diabetes and hypertension, have on preeclampsia and other adverse pregnancy outcomes in the CKD population.

METHODS

This was a population-based cohort study of women with CKD who had a pregnancy from 2010 to 2022 (n = 95). At the time of the woman's pregnancy, data was collected on demographics, clinical measures, BMI, CKD etiology and other renal parameters. Outcomes included preeclampsia, pre-term delivery, and low birth weight.

RESULTS

Pre-pregnancy BMI increased over time in patients with CKD, with a median (interquartile range) BMI of 25 (22-29) prior to 2016 and 29 (25-34) after 2016 (p = 0.01). There were significant trends of increasing age at delivery and decreasing pre-pregnancy estimated glomerular filtration rate (eGFR) by delivery year. Preeclampsia affected nearly half of pregnancies in this cohort. In multivariate analyses, BMI and chronic hypertension did not impact the odds of preeclampsia, preterm delivery or low birth weight, though a CKD etiology of diabetes (19/20 with type I diabetes), was associated with a significant increase in preeclampsia risk (odds ratio (OR) 7.41 (95 % CI 2.1-26.1)). Higher pre-pregnancy eGFR was associated with a lower odds of preterm delivery (OR 0.81 (95 % CI 0.67-0.98)) per 10 ml/min/1.73 m2).

CONCLUSION

Pre-pregnancy BMI significantly increased over time, similar to the general population. While preeclampsia was common in CKD patients, outcomes were associated with eGFR and CKD etiology as opposed to BMI and chronic hypertension.

Association Between Preeclampsia and Blood Pressure in Offspring: A Systematic Review and Meta-Analysis

PURPOSE OF REVIEW

Pregnancy-induced preeclampsia is a severe pregnancy complication and preeclampsia has been associated with an increased risk of chronic hypertension for offspring. However, the magnitude of the overall effect of exposure to preeclampsia in pregnancy on blood pressure (BP) in offspring is unknown. This systematic review and meta-analysis was sought to systematically assess the effects of preeclampsia on the BP of the offspring.

RECENT FINDINGS

Of 2550 publications identified, 23 studies were included. The meta-analysis indicated that preeclampsia increases the potential risk of hypertension in offspring. Systolic blood pressure (SBP) was 2.0 mm Hg (95% CI: 1.2, 2.8) and diastolic blood pressure (DBP) was 1.4 mm Hg (95% CI: 0.9, 1.9) higher in offspring exposed to pre-eclampsia in utero, compared to those born to normotensive mothers. The correlations were similar in stratified analyses of children and adolescents by sex, geographic area, ages, and gestational age. During childhood and young adulthood, the offspring of pregnant women with preeclampsia are at an increased risk of high BP. It is crucial to monitor their BP.

Association of Hypertensive Disorders of Pregnancy With Coronary Microvascular Dysfunction 8 to 10 Years After Delivery

BACKGROUND

Hypertensive disorders of pregnancy (HDP) are associated with subsequent adverse cardiac remodeling and cardiovascular disease. The role of myocardial microvascular disease among individuals with HDP and left ventricular (LV) remodeling as a potential link to cardiovascular disease is unknown. We aimed to determine whether individuals with HDP history have coronary microvascular dysfunction measured by coronary flow reserve 8 to 10 years after delivery and whether microvascular dysfunction correlates with LV remodeling.

METHODS

Individuals with pregnancies delivered from 2008 to 2010 underwent burst-replenishment myocardial contrast echocardiography (2017-2020) to quantify myocardial perfusion at rest and during dobutamine stress. Video intensity versus time data were used to derive β, the rate of rise of video intensity, a correlate for myocardial blood flow. Coronary flow reserve was calculated as the ratio of β at peak stress to β at rest, averaged across LV myocardial regions of interest.

RESULTS

We studied 91 individuals (aged 38±6 and 9.1±0.9 years postdelivery) and 19 with a history of HDP. Individuals with coronary microvascular dysfunction (coronary flow reserve <2.0; n=13) had a higher proportion of HDP (46.2% versus 16.7%; P=0.026) and higher prepregnancy body mass index, baseline heart rate, and hemoglobin A1c compared with those without microvascular dysfunction. The association of coronary flow reserve and HDP was attenuated after adjusting for cardiometabolic factors (P=0.133). In exploratory subgroup analyses, individuals with both LV remodeling (relative wall thickness >0.42) and HDP (n=12) had the highest proportion of microvascular dysfunction (41.7% versus +HDP-LV remodeling [n=7] 14.3%; -HDP+LV remodeling [n=26] 7.7%; P=0.0498).

CONCLUSIONS

In this small study, HDP history is associated with coronary microvascular dysfunction 1 decade after delivery, findings that may, in part, be driven by metabolic factors including obesity and diabetes. Microvascular dysfunction may contribute to cardiovascular disease among individuals with a history of HDP.

Hypertensive Disorders in Pregnancy: Global Burden From 1990 to 2019, Current Research Hotspots and Emerging Trends

Hypertensive disorders in pregnancy (HDP) constitute a worldwide health problem for pregnant women and their infants. This study provided HDP burden over 1990 to 2019 by region and age distribution, and predicted changes in related values for the next 25 years. We then conducted an econometric analysis of the author distribution, collaborative networks, keyword burst clustering, and spatio-temporal analysis of HDP-related publications from 2012 to 2022 to access current scientific developments and hotspots. The number of pregnant women with HDP has been increasing over the past 30 years, with regional and age-stratified differences in the burden of disease. Additionally, projections suggest an increase of deaths due to maternal HDP among adolescents younger than 20 years. Current research is mostly centered on pre-eclampsia, with hot keywords including trophoblast, immune tolerance, frozen-thawed embryo transfer, aspirin, gestational diabetes association, and biomarkers. Researches on the pathological mechanism, classification, and subtypes of HDP need to be further advanced.

Factors Associated with Progression to Preeclampsia with Severe Features in Pregnancies Complicated by Mild Hypertensive Disorders

In this retrospective cohort study, we aimed to investigate the variables associated with progression to preeclampsia with severe features in parturients already diagnosed with mild hypertensive disorders of pregnancy. The study was conducted in a single university-affiliated medical center between 2018 and 2020. All women admitted due to hypertensive disorders were included. Data collected was compared between parturients who progressed and did not progress to preeclampsia with severe features. Among 359 women presenting without severe features, 18 (5%) developed severe features, delivered smaller babies at lower gestational age, and with higher rates of cesarean delivery (p < 0.001 for all). Chronic hypertension, maternal diabetes, any previous gestational hypertensive disorder, gestational diabetes, number of hospitalizations, earlier gestational age at initial presentation, and superimposed preeclampsia as the preliminary diagnosis were all associated with preeclampsia progression to severe features. Previous delivery within 2-5 years was a protective variable from preeclampsia progression. Following regression analysis and adjustment to confounders, only gestational age at initial presentation and superimposed preeclampsia remained significant variables associated with progression to severe features (aOR 0.74 (0.55-0.96) and 34.44 (1.07-1111.85), aOR (95% CI), respectively, p < 0.05 for both) with combined ROC-AUC prediction performance of 0.89, 95% CI 0.83-0.95, p < 0.001. In conclusion, according to our study results, early gestational age at presentation and superimposed preeclampsia as the preliminary diagnosis are the only independent factors that are associated with progression to severe features in women already diagnosed with mild hypertensive disorders during pregnancy.

Inflammatory markers are elevated in early pregnancy, but not late pregnancy, in women with overweight and obesity that later develop preeclampsia

PROBLEM

Obesity and preeclampsia both involve a pathological inflammatory response, which may be how obesity increases preeclampsia risk. Previous studies have failed to assess robust measurements of inflammatory markers across gestation, specifically in overweight/ obese women in the context of preeclampsia.

METHOD OF STUDY

We measured 20 inflammatory markers in plasma via multiplex assay (ThermoFisher Inflammation 20 plex Human ProcartaPlex Panel) across the three trimesters of pregnancy in an existing cohort of overweight and obese women who developed preeclampsia (n = 37) and without preeclampsia (n = 74). Mann-Whitney U tests examined differences in inflammatory marker concentrations between cases and controls. Repeated measures ANOVA tests were used to explore differences in inflammatory marker concentrations over time within cases and controls.

RESULTS

Pro-inflammatory markers (IL-1α, IL-1β, IL-6, IFN-α, IFN-γ, GM-CSF, IL-12p70, IL-17α, TNF-α, IL-8) and anti-inflammatory markers (IL-4, IL-10, IL-13) were higher in the first and second trimester in participants who later developed preeclampsia compared to those who did not (p < .05). Only TNF-α and IL-8 remained elevated in the third trimester. Inflammatory markers did not change across pregnancy in preeclampsia cases but did increase across pregnancy in controls.

CONCLUSION

Our findings diverge from prior studies, predominantly of non-obese women, that report lower circulating concentrations of anti-inflammatory cytokines in preeclampsia versus normotensive pregnancy, particularly by late pregnancy. We posit that women with overweight and obesity who develop preeclampsia entered pregnancy with a heightened pro-inflammatory state likely related to obesity, which increased risk for preeclampsia. Further studies are needed to investigate if inflammatory maker profiles differ between obese and non-obese women.

Short- and Long-Term Outcomes of Preeclampsia in Offspring: Review of the Literature

Preeclampsia is a multisystemic clinical syndrome characterized by the appearance of new-onset hypertension and proteinuria or hypertension and end organ dysfunction even without proteinuria after 20 weeks of pregnancy or postpartum. Residing at the severe end of the spectrum of the hypertensive disorders of pregnancy, preeclampsia occurs in 3 to 8% of pregnancies worldwide and is a major cause of maternal and perinatal morbidity and mortality, accounting for 8-10% of all preterm births. The mechanism whereby preeclampsia increases the risk of the neurodevelopmental, cardiovascular, and metabolic morbidity of the mother's offspring is not well known, but it is possible that the preeclamptic environment induces epigenetic changes that adversely affect developmental plasticity. These developmental changes are crucial for optimal fetal growth and survival but may lead to an increased risk of chronic morbidity in childhood and even later in life. The aim of this review is to summarize both the short- and long-term effects of preeclampsia on offspring based on the current literature.

Preeclampsia: Platelet procoagulant membrane dynamics and critical biomarkers

A state-of-the-art lecture titled "Preeclampsia and Platelet Procoagulant Membrane Dynamics" was presented at the International Society on Thrombosis and Haemostasis (ISTH) Congress in 2022. Platelet activation is involved in the pathophysiology of preeclampsia and contributes to the prothrombotic state of the disorder. Still, it remains unclear what mechanisms initiate and sustain platelet activation in preeclampsia and how platelets drive the thrombo-hemorrhagic abnormalities in preeclampsia. Here, we highlight our findings that platelets in preeclampsia are preactivated possibly by plasma procoagulant agonist(s) and overexpress facilitative glucose transporter-3 (GLUT3) in addition to GLUT1. Preeclampsia platelets are also partially degranulated, procoagulant, and proaggregatory and can circulate as microaggregates/microthrombi. However, in response to exposed subendothelial collagen, such as in injured vessels during cesarean sections, preeclampsia platelets are unable to mount a full procoagulant response, contributing to blood loss perioperatively. The overexpression of GLUT3 or GLUT1 may be monitored alone or in combination (GLUT1/GLUT3 ratio) as a biomarker for preeclampsia onset, phenotype, and progression. Studies to further understand the mediators of the platelet activation and procoagulant membrane dynamics in preeclampsia can reveal novel drug targets and suitable alternatives to aspirin for the management of prothrombotic tendencies in preeclampsia. Finally, we summarize relevant new data on this topic presented during the 2022 ISTH Congress.

Preeclampsia and the Kidney: Pathophysiology and Clinical Implications

Preeclampsia and other hypertensive disorders of pregnancy are major contributors to maternal morbidity and mortality worldwide. This group of disorders includes chronic hypertension, gestational hypertension, preeclampsia, preeclampsia superimposed on chronic hypertension, and eclampsia. The body undergoes important physiological changes during pregnancy to allow for normal placental and fetal development. Several mechanisms have been proposed that may lead to preeclampsia, including abnormal placentation and placental hypoxia, impaired angiogenesis, excessive pro-inflammatory response, immune system imbalance, abnormalities of cellular senescence, alterations in regulation and activity of angiotensin II, and oxidative stress, ultimately resulting in upregulation of multiple mediators of endothelial cell dysfunction leading to maternal disease. The clinical implications of preeclampsia are significant as there are important short-term and long-term health consequences for those affected. Preeclampsia leads to increased risk of preterm delivery and increased morbidity and mortality of both the developing fetus and mother. Preeclampsia also commonly leads to acute kidney injury, and women who experience preeclampsia or another hypertensive disorder of pregnancy are at increased lifetime risk of chronic kidney disease and cardiovascular disease. An understanding of normal pregnancy physiology and the pathophysiology of preeclampsia is essential to develop novel treatment approaches and manage patients with preeclampsia and hypertensive disorders of pregnancy. © 2023 American Physiological Society. Compr Physiol 13:4231-4267, 2023.

Trend Changes in the individual contribution of risk factors for postpartum hemorrhage over more than two decades

OBJECTIVE

Postpartum hemorrhage is an obstetric emergency with a rising incidence. The aim of this study was to identify trends in the specific contribution of various risk factors for postpartum hemorrhage by observing their odds ratios throughout different time periods.

STUDY DESIGN

In this population-based retrospective cohort study trends of change in odds ratios for known risk factors for postpartum hemorrhage occurring in three consecutive eight-year intervals between 1988 and 2014 were compared. Two multivariable logistic regression models were used in order to identify independent risk factors for postpartum hemorrhage in our population. Trends of various risk factors were compared along the time period of the study.

RESULTS

The incidence of postpartum hemorrhage increased from 0.5% to 1988 to 0.6%. Using logistic regression models, preeclampsia, vacuum extraction delivery, retained placenta, perineal or vaginal tears and delivery of a large for gestational age neonate were recognized as independent risk factors for postpartum hemorrhage. While the odds ratios for perineal or vaginal tears significantly increased, odds ratios for delivery of a large for gestational age neonate significantly decreased. Odds ratios for the other risk factors did not change significantly.

CONCLUSION

In our study, not only did the rates of statistically significant risk factors for postpartum hemorrhage change during the study period, the specific contribution of each risk factor changed as well. Having a better understanding of these trends might augment our ability to predict this grave obstetric complication and improve maternal outcomes in the future.

Engineered models for placental toxicology: Emerging approaches based on tissue decellularization

Recent increases in prescriptions and illegal drug use as well as exposure to environmental contaminants during pregnancy have highlighted the critical importance of placental toxicology in understanding and identifying risks to both mother and fetus. Although advantageous for basic science, current in vitro models often fail to capture the complexity of placental response, likely due to their inability to recreate and monitor aspects of the microenvironment including physical properties, mechanical forces and stiffness, protein composition, cell-cell interactions, soluble and physicochemical factors, and other exogenous cues. Tissue engineering holds great promise in addressing these challenges and provides an avenue to better understand basic biology, effects of toxic compounds and potential therapeutics. The key to success lies in effectively recreating the microenvironment. One strategy to do this would be to recreate individual components and then combine them. However, this becomes challenging due to variables present according to conditions such as tissue location, age, health status and lifestyle. The extracellular matrix (ECM) is known to influence cellular fate by working as a storage of factors. Decellularized ECM (dECM) is a recent tool that allows usage of the original ECM in a refurbished form, providing a relatively reliable representation of the microenvironment. This review focuses on using dECM in modified forms such as whole organs, scaffold sheets, electrospun nanofibers, hydrogels, 3D printing, and combinations as building blocks to recreate aspects of the microenvironment to address general tissue engineering and toxicology challenges, thus illustrating their potential as tools for future placental toxicology studies.

Hypertensive disorders of pregnant women with heart disease: the ESC EORP ROPAC Registry

AIMS

Hypertensive disorders of pregnancy (HDP) occur in 10% of pregnancies in the general population, pre-eclampsia specifically in 3-5%. Hypertensive disorders of pregnancy may have a high prevalence in, and be poorly tolerated by, women with heart disease.

METHODS AND RESULTS

The prevalence and outcomes of HDP (chronic hypertension, gestational hypertension or pre-eclampsia) were assessed in the ESC EORP ROPAC (n = 5739), a worldwide prospective registry of pregnancies in women with heart disease.The overall prevalence of HDP was 10.3%, made up of chronic hypertension (5.9%), gestational hypertension (1.3%), and pre-eclampsia (3%), with significant differences between the types of underlying heart disease (P < 0.05). Pre-eclampsia rates were highest in women with pulmonary arterial hypertension (PAH) (11.1%), cardiomyopathy (CMP) (7.1%), and ischaemic heart disease (IHD) (6.3%). Maternal mortality was 1.4 and 0.6% in women with vs. without HDP (P = 0.04), and even 3.5% in those with pre-eclampsia. All pre-eclampsia-related deaths were post-partum and 50% were due to heart failure. Heart failure occurred in 18.5 vs. 10.6% of women with vs. without HDP (P < 0.001) and in 29.1% of those with pre-eclampsia. Perinatal mortality was 3.1 vs. 1.7% in women with vs. without HDP (P = 0.019) and 4.7% in those with pre-eclampsia.

CONCLUSION

Hypertensive disorders of pregnancy and pre-eclampsia rates were higher in women with CMP, IHD, and PAH than in the general population. Adverse outcomes were increased in women with HDP, and maternal mortality was strikingly high in women with pre-eclampsia. The combination of HDP and heart disease should prompt close surveillance in a multidisciplinary context and the diagnosis of pre-eclampsia requires hospital admission and continued monitoring during the post-partum period.

Placental abruption: assessing trends in risk factors over time

PURPOSE

To evaluate changes in the independent contribution of different risk factors for placental abruption over time.

METHODS

In this retrospective nested case-control study, trends of change in ORs for known risk factors for placental abruption occurring in three consecutive 8-year intervals were compared. A univariate assessment of factors associated with placental abruption and two multivariable logistic regression models were constructed to identify independent risk factors for placental abruption. Trends of change in the incidence and specific contribution of various risk factors were compared along the study time-period.

RESULTS

During the study period, 295,946 pregnancies met the inclusion criteria; of these, 2170 (0.73%) were complicated with placental abruption. Using logistic regression models, previous cesarean delivery, in vitro fertilization (IVF) pregnancy, hypertensive disorders, polyhydramnios, and inadequate prenatal care were recognized as independent risk factors for placental abruption. While the relative contribution of IVF pregnancy and polyhydramnios to the overall risk for abruption decreased over the course of the study, previous cesarean delivery became a stronger contributor for placental abruption.

CONCLUSION

In our study, a change over time in the specific contribution of different risk factors for placental abruption has been demonstrated.

The relationship between obstetrical interventions and the increase in U.S. preterm births, 2014-2019

We examined the relationship between obstetrical intervention and preterm birth in the United States between 2014 and 2019. This observational study analyzed 2014-2019 US birth data to assess changes in preterm birth, cesarean delivery, induction of labor, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention (no labor cesarean or induction) after risk adjustment. The percentage of singleton preterm births in the United States increased by 9.4% from 2014-2019. The percent of singleton, preterm births delivered by cesarean increased by 6.0%, while the percent with induction of labor increased by 39.1%. The percentage of singleton preterm births where obstetrical intervention (no labor cesarean or induction) potentially impacted the gestational age at delivery increased from 47.6% in 2014 to 54.9% in 2019. Preterm interventions were 13% more likely overall in 2019 compared to 2014 and 17% more likely among late preterm births, after controlling for demographic and medical risk factors. Compared to non-Hispanic White women, Non-Hispanic Black women had a higher risk of preterm obstetric interventions. Preterm infants have higher morbidity and mortality rates than term infants, thus any increase in the preterm birth rate is concerning. A renewed effort to understand the trends in preterm interventions is needed to ensure that obstetrical interventions are evidence-based and are limited to those cases where they optimize outcomes for both mothers and babies.

Screening for preeclampsia in twin pregnancies

Twin pregnancies are an important risk factor for preeclampsia, a hypertensive disorder of pregnancy that is associated with a significant risk of maternal and perinatal morbidity. Given the burden of preeclampsia, the identification of women at high risk in early pregnancy is essential to allow for preventive strategies and close monitoring. In singleton pregnancies, the risk factors for preeclampsia are well established, and a combined first-trimester prediction model has been shown to adequately predict preterm disease. Furthermore, intervention with low-dose aspirin at 150 mg/day in those identified as high-risk reduces the rate of preterm preeclampsia by 62%. In contrast, risk factors for preeclampsia in twin pregnancies are less established, the proposed screening models have shown poor performance with high false-positive rates, and the benefit of aspirin for the prevention of preeclampsia is not clearly demonstrated. In this review, we examine the literature assessing prediction and prevention of preeclampsia in twin pregnancies.

Blood Pressure and Stroke: A Review of Sex- and Ethnic/Racial-Specific Attributes to the Epidemiology, Pathophysiology, and Management of Raised Blood Pressure

Raised blood pressure (BP) is the leading cause of death and disability worldwide, and its particular strong association with stroke is well established. Although systolic BP increases with age in both sexes, raised BP is more prevalent in males in early adulthood, overtaken by females at middle age, consistently across all ethnicities/races. However, there are clear regional differences on when females overtake males. Higher BP among males is observed until the seventh decade of life in high-income countries, compared with almost 3 decades earlier in low- and middle-income countries. Females and males tend to have different cardiovascular disease risk profiles, and many lifestyles also influence BP and cardiovascular disease in a sex-specific manner. Although no hypertension guidelines distinguish between sexes in BP thresholds to define or treat hypertension, observational evidence suggests that in terms of stroke risk, females would benefit from lower BP thresholds to the magnitude of 10 to 20 mm Hg. More randomized evidence is needed to determine if females have greater cardiovascular benefits from lowering BP and whether optimal BP is lower in females. Since 1990, the number of people with hypertension worldwide has doubled, with most of the increase occurring in low- and-middle-income countries where the greatest population growth was also seen. Sub-Saharan Africa, Oceania, and South Asia have the lowest detection, treatment, and control rates. High BP has a more significant effect on the burden of stroke among Black and Asian individuals than Whites, possibly attributable to differences in lifestyle, socioeconomic status, and health system resources. Although pharmacological therapy is recommended differently in local guidelines, recommendations on lifestyle modification are often very similar (salt restriction, increased potassium intake, reducing weight and alcohol, smoking cessation). This overall enhanced understanding of the sex- and ethnic/racial-specific attributes to BP motivates further scientific discovery to develop more effective prevention and treatment strategies to prevent stroke in high-risk populations.

Substantial decrease in preeclampsia prevalence and risk over two decades: A population-based study of 1,153,227 deliveries in Norway

OBJECTIVES

Analyze secular trends of preeclampsia in Norway based on risk factors.

STUDY DESIGN

Population-based cohort study of 1,153,227 women using data from Medical Birth Registry of Norway from 1999 to 2018. Aggregated data from Norwegian Prescription Database from 2004 to 2018 were used. Main exposure variable was time period. Descriptive statistics identified the prevalence of preeclampsia, labor induction and aspirin use. Multiple logistic regression analysis was performed to estimate the risk of preeclampsia during the time periods.

MAIN OUTCOME MEASURES

Preeclampsia.

RESULTS

Overall preeclampsia prevalence decreased from 4.3% in 1999-2002 to 2.7% in 2015-2018. A reduction was observed in all subgroups of women with known risk factors (age, nulliparity, diabetes, chronic hypertension, assisted reproduction, twin pregnancy). Adjusted risk of preeclampsia was reduced by 44% from 1999-2002 to 2015-2018 (aOR = 0.56, 95%CI 0.54, 0.58), while the net prevalence of gestational hypertension remained stable over the study period. Labor induction increased 104%. Aspirin prescriptions increased among fertile women in the general Norwegian population.

CONCLUSIONS

Preeclampsia prevalence and risk were reduced regardless of risk factors and despite an increased proportion of high-risk parturients (advanced age, lower parity, use of assisted reproduction). A corresponding increase in aspirin prescriptions among fertile women and an overall increase in labor inductions were also observed, suggesting that clinical interventions may partly explain the observed reduction in preeclampsia prevalence. Lower average blood pressure and improved health in the population may also explain some of the reduction.

Disease-specific extracellular matrix composition regulates placental trophoblast fusion efficiency

The placental syncytiotrophoblast is a multinucleated layer that regulates transport between the mother and fetus. Fusion of trophoblasts is essential to form this layer, but this process can be disrupted in pregnancy-related disorders such as preeclampsia. Disease progression is also associated with changes in the extracellular matrix (ECM), but whether disease-specific ECM compositions play any causal role in establishing syncytiotrophoblast disease phenotypes remains unknown. Here, we develop a decellularization-based platform to isolate and characterize the role of human placental ECM composition on cell function, while controlling for the confounding effects of matrix structure and mechanics that can arise in conventional tissue decellularization/recellularization experiments. Using this approach, we demonstrate that ECM compositional changes that occur in preeclampsia have a statistically significant effect on adhesion, spreading, and fusion of placental trophoblasts. Proteomic analysis of ECM content then allowed us to identify and recreate selected differences in matrix composition; indicating that replacement of normally present Type IV Collagen by Type I Collagen in preeclampsia significantly affects fusion efficiency. These results indicate that disease-specific matrix compositions can play an important role in trophoblast fusion, suggesting novel matrix-targeting therapeutic strategies for pregnancy-related disorders. More broadly, this work demonstrates the utility of a decellularization-based approach in understanding the functional contributions of matrix composition in driving cellular disease phenotypes.

Pre-eclampsia and risk of early-childhood asthma: a register study with sibling comparison and an exploration of intermediate variables

BACKGROUND

We aimed to study whether pre-eclampsia is associated with childhood asthma, allergic and non-allergic asthma, accounting for family factors and intermediate variables.

METHODS

The study population comprised 779 711 children born in 2005-2012, identified from Swedish national health registers (n = 14 823/7410 exposed to mild/moderate and severe pre-eclampsia, respectively). We used Cox regression to estimate the associations of mild/moderate and severe pre-eclampsia with incident asthma, before and after age 2 years. Cox regressions were controlled for familial factors using sibling comparisons, then stratified on high and low risk for intermediate variables: caesarean section, prematurity and small for gestational age. We used logistic regression for allergic and non-allergic prevalent asthma at 6 years as a measure of more established asthma.

RESULTS

The incidence of asthma in children was 7.7% (n = 60 239). The associations varied from adjusted hazard ratio (adjHR) 1.11, 95% confidence interval (CI): 1.00, 1.24 for mild/moderate pre-eclampsia and asthma at >2 years age, to adjHR 1.78, 95% CI: 1.64, 1.95 for severe pre-eclampsia and asthma at <2 years age. Sibling comparisons attenuated most estimates except for the association between severe pre-eclampsia and asthma at <2 years age (adjHR 1.45, 95% CI: 1.10, 1.90), which also remained when stratifying for the risk of intermediates. Mild/moderate and severe pre-eclampsia were associated with prevalent non-allergic (but not allergic) asthma at 6 years, with adjusted odds ratio (adjOR) 1.17, 95% CI: 1.00, 1.36 and adjOR 1.51, 95% CI: 1.23, 1.84, respectively.

CONCLUSIONS

We found evidence that severe, but not mild/moderate, pre-eclampsia is associated with asthma regardless of familial factors and confounders.

Increased oxidative stress and endothelial activation in umbilical veins from pregnancies diagnosed with preeclampsia

Vascular dysfunction is a hallmark of cardiovascular disease (CVD). Offspring from preeclamptic pregnancies are at risk of CVD later in life. Whether fetal vasculature from preeclamptic pregnancies displays signs of vascular dysfunction (i.e., oxidative/nitrosative stress, endothelial activation) associated with increased expression of lectin-like oxidized LDL receptor-1 (LOX-1) and angiotensin-II type-1 receptor (AT₁) is unknown. We demonstrated increased superoxide, nitrotyrosine and ICAM-1 levels in umbilical vein tissues of preeclamptic vs. normal pregnancies; without changes in LOX-1 and AT₁ levels. Our findings suggest that the fetal vasculature may be impacted in preeclampsia, which could contribute to an increased risk of offspring CVD.

Epidemiological trends of maternal hypertensive disorders of pregnancy at the global, regional, and national levels: a population-based study

BACKGROUND

Relevant studies focusing on epidemiological of profiles hypertensive disorders of pregnancy from global data that report the cause-specific prevalence and trends of hypertensive disorders of pregnancy at global, regional and national levels from 1990 to 2019 by age and sociodemographic index are still limited.

METHODS

For hypertensive disorders of pregnancy, point prevalence, annual incidence, and years lived with disability numbers and age standardized rates per 100,000 population were compared at regional and national levels by age and sociodemographic index using data from the global Burden of Disease 2019 Study, covering populations from 204 countries and territories. Estimates are reported with uncertainty intervals to exhibit the changing trends during a specific period.

RESULTS

The incidence of hypertensive disorders of pregnancy increased from 16.30 million to 18.08 million globally, with a total increase of 10.92 % from 1990 to 2019. The age-standardized incidence rate decreased, with an estimated annual percent change of -0.68 (95 % confidence interval [CI] -0.49 to -0.86). The number of deaths due to hypertensive disorders of pregnancy was approximately 27.83 thousand in 2019, representing a 30.05 % decrease from 1990. Based on the incidence and prevalence, the number of deaths and years lived with disability were highest in the group aged 25-29 years, followed by the groups aged 30-34 and 20-24 years, while the lowest estimated incidence rate was observed in the group aged 25-29 years and higher incidence rates were observed in the youngest and oldest groups. Positive associations between incidence rates and the sociodemographic index and human development index were found for all countries and regions in 2019. Age-standardized incidence rates were higher in countries/regions with lower sociodemographic indices and human development indices.

CONCLUSIONS

Our study provides a comprehensive overview of the global burden of hypertensive disorders of pregnancy. The death and incidence rates are decreasing in most countries and all regions except for those with low sociodemographic and human development indexes. This difference is mainly due to the increasing attention to prenatal examinations and health education. Further investigations should focus on forecasting the global disease burden of specific hypertensive disorders of pregnancy and modifiable risk factors.

Cognition and Cerebrovascular Reactivity in Midlife Women With History of Preeclampsia and Placental Evidence of Maternal Vascular Malperfusion

Background: Preeclampsia is emerging as a sex-specific risk factor for cerebral small vessel disease (SVD) and dementia, but the reason is unknown. We assessed the relationship of maternal vascular malperfusion (MVM), a marker of placental SVD, with cognition and cerebral SVD in women with and without preeclampsia. We hypothesized women with both preeclampsia and MVM would perform worst on information processing speed and executive function.

Methods: Women (n = 45; mean 10.5 years post-delivery; mean age: 41 years; 42.2% Black) were classified as preeclampsia-/MVM-, preeclampsia+/MVM-, or preeclampsia+/MVM+. Information processing speed, executive function, and memory were assessed. In a pilot sub-study of cerebrovascular reactivity (CVR; n = 22), cerebral blood flow during room-air breathing and breath-hold induced hypercapnia were obtained via arterial spin labeling MRI. Non-parametric tests and regression models were used to test associations.

Results: Between-group cognitive differences were significant for information processing speed (p = 0.02); preeclampsia+/MVM+ had the lowest scores. Cerebral blood flow increased from room-air to breath-hold, globally and in all regions in the three groups, except the preeclampsia+/MVM+ parietal region (p = 0.12). Lower parietal CVR (less change from room-air breathing to breath-holding) was correlated with poorer information processing speed (partial ρ = 0.63, p = 0.005) and executive function (ρ = 0.50, p = 0.03) independent of preeclampsia/MVM status.

Conclusion: Compared to women without preeclampsia and MVM, midlife women with both preeclampsia and MVM have worse information processing speed and may have blunted parietal CVR, an area important for information processing speed and executive function. MVM in women with preeclampsia is a promising sex-specific indicator of cerebrovascular integrity in midlife.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

Association of Ambient air Pollution with risk of preeclampsia during pregnancy: a retrospective cohort study

BACKGROUND

Ambient air pollution is becoming a serious environmental problem in China. The results were inconsistent on that air pollution was a risk factor of preeclampsia in pregnancy.

METHODS

Total 116,042 pregnant women were enrolled from 22 hospitals in 10 cities of Hebei Province, China from January 1, 2015 to December 31, 2017. The parturients were divided into preeclampsia group (PE group) and non-preeclampsia group (non-PE group). The data of air pollutants, namely, particulate matter (PM)2.5, PM10, NO2, SO2, CO, O3 were collected from China Environmental Inspection Station.

RESULTS

Among the 116,042 pregnant women, 2988 (2.57%) pregnant women were diagnosed with preeclampsia. The concentrations of exposed PM2.5, PM10, NO2 and O3 in the PE group were significantly higher than those in the non-PE group, and they were risk factors of the PE group in the first and second trimester of pregnancy respectively. The concentrations of exposed SO2 and CO in PE patients and non-PE women were not different, but high concentration of these air pollutants were risk factors to PE in the second trimester.

CONCLUSION

The exposure to PM2.5, PM10, NO2, O3 were risk factors for preeclampsia in the first and second trimester of pregnancy, while only at high level, SO2 and CO were risk factors for preeclampsia in the second trimester of pregnancy.

Association between the reproductive health of young women and cardiovascular disease in later life: umbrella review

OBJECTIVE

To consolidate evidence from systematic reviews and meta-analyses investigating the association between reproductive factors in women of reproductive age and their subsequent risk of cardiovascular disease.

DESIGN

Umbrella review.

DATA SOURCES

Medline, Embase, and Cochrane databases for systematic reviews and meta-analyses from inception until 31 August 2019.

REVIEW METHODS

Two independent reviewers undertook screening, data extraction, and quality appraisal. The population was women of reproductive age. Exposures were fertility related factors and adverse pregnancy outcomes. Outcome was cardiovascular diseases in women, including ischaemic heart disease, heart failure, peripheral arterial disease, and stroke.

RESULTS

32 reviews were included, evaluating multiple risk factors over an average follow-up period of 7-10 years. All except three reviews were of moderate quality. A narrative evidence synthesis with forest plots and tabular presentations was performed. Associations for composite cardiovascular disease were: twofold for pre-eclampsia, stillbirth, and preterm birth; 1.5-1.9-fold for gestational hypertension, placental abruption, gestational diabetes, and premature ovarian insufficiency; and less than 1.5-fold for early menarche, polycystic ovary syndrome, ever parity, and early menopause. A longer length of breastfeeding was associated with a reduced risk of cardiovascular disease. The associations for ischaemic heart disease were twofold or greater for pre-eclampsia, recurrent pre-eclampsia, gestational diabetes, and preterm birth; 1.5-1.9-fold for current use of combined oral contraceptives (oestrogen and progesterone), recurrent miscarriage, premature ovarian insufficiency, and early menopause; and less than 1.5-fold for miscarriage, polycystic ovary syndrome, and menopausal symptoms. For stroke outcomes, the associations were twofold or more for current use of any oral contraceptive (combined oral contraceptives or progesterone only pill), pre-eclampsia, and recurrent pre-eclampsia; 1.5-1.9-fold for current use of combined oral contraceptives, gestational diabetes, and preterm birth; and less than 1.5-fold for polycystic ovary syndrome. The association for heart failure was fourfold for pre-eclampsia. No association was found between cardiovascular disease outcomes and current use of progesterone only contraceptives, use of non-oral hormonal contraceptive agents, or fertility treatment.

CONCLUSIONS

From menarche to menopause, reproductive factors were associated with cardiovascular disease in women. In this review, presenting absolute numbers on the scale of the problem was not feasible; however, if these associations are causal, they could account for a large proportion of unexplained risk of cardiovascular disease in women, and the risk might be modifiable. Identifying reproductive risk factors at an early stage in the life of women might facilitate the initiation of strategies to modify potential risks. Policy makers should consider incorporating reproductive risk factors as part of the assessment of cardiovascular risk in clinical guidelines.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019120076.

Trends in prevalence of pre-existing diabetes and perinatal outcomes: a large, population-based study in Catalonia, Spain, 2006-2015

INTRODUCTION

This study aims to assess trends in the prevalence of pre-existing diabetes and whether the risk of adverse perinatal outcomes decreased in women between 2006 and 2015 in Catalonia, Spain.

RESEARCH DESIGN AND METHODS

A population-based study of 743 762 singleton deliveries between 2006 and 2015 in Catalonia, Spain, was conducted using data from the Spanish Minimum Basic Data Set. Cases of type 1 diabetes (T1DM) and 'type 2 diabetes and other pre-existing diabetes' ('T2DM and other PGD') were identified using International Classification of Diseases, Ninth Revision, Clinical Modification codes. Crude and age-adjusted annual prevalences were calculated. Poisson regression model was used to assess trends in prevalence and perinatal outcomes during the study period.

RESULTS

Overall prevalences of pre-existing diabetes, T1DM and 'T2DM and other PGD' were 0.52% (95% CI 0.51 to 0.54), 0.17% (95% CI 0.17 to 0.18) and 0.35% (95% CI 0.33 to 0.36), respectively. From 2006 to 2015, rates increased for pre-existing diabetes (from 0.43 (95% CI 0.39 to 0.48) to 0.56% (0.50 to 0.62), p<0.001), T1DM (from 0.14 (0.11 to 0.17) to 0.20% (0.17 to 0.23), p<0.001) and 'T2DM and other PGD' (from 0.29 (0.25 to 0.33) to 0.36% (0.31 to 0.40), p<0.001). Pre-eclampsia rose in women with pre-existing diabetes (from 4.38% to 8.97%, adjusted p<0.001), T1DM (from 3.85% to 12.88%, p=0.005) and 'T2DM and other PGD' (from 4.63% to 6.78%, adjusted p=0.01). Prevalence of prematurity, cesarean section and small for gestational age remained stable in all diabetes groups. However, the prevalence of macrosomia fell in women with pre-existing diabetes (from 18.18% to 11.9%, adjusted p=0.011) and 'T2DM and other PGD' (from 14.71% to 11.06%, non-adjusted p=0.022, adjusted p=0.305) and large for gestational age decreased in all diabetes groups (from 39.73% to 30.25% in pre-existing diabetes, adjusted p=0.004).

CONCLUSIONS

The prevalence of pre-existing diabetes increased significantly in Catalonia between 2006 and 2015. Despite improvements in outcomes related to excessive birth weight, pre-eclampsia rates are rising and overall perinatal outcomes in women with pre-existing diabetes continue to be markedly worse than in the population without diabetes.

Preeclampsia may influence offspring neuroanatomy and cognitive function: a role for placental growth factor†

Preeclampsia (PE) is a common pregnancy complication affecting 3-5% of women. Preeclampsia is diagnosed clinically as new-onset hypertension with associated end organ damage after 20 weeks of gestation. Despite being diagnosed as a maternal syndrome, fetal experience of PE is a developmental insult with lifelong cognitive consequences. These cognitive alterations are associated with distorted neuroanatomy and cerebrovasculature, including a higher risk of stroke. The pathophysiology of a PE pregnancy is complex, with many factors potentially able to affect fetal development. Deficient pro-angiogenic factor expression is one aspect that may impair fetal vascularization, alter brain structure, and affect future cognition. Of the pro-angiogenic growth factors, placental growth factor (PGF) is strongly linked to PE. Concentrations of PGF are inappropriately low in maternal blood both before and during a PE gestation. Fetal concentrations of PGF appear to mirror maternal circulating concentrations. Using Pgf-/- mice that may model effects of PE on offspring, we demonstrated altered central nervous system vascularization, neuroanatomy, and behavior. Overall, we propose that development of the fetal brain is impaired in PE, making the offspring of preeclamptic pregnancies a unique cohort with greater risk of altered cognition and cerebrovasculature. These individuals may benefit from early interventions, either pharmacological or environmental. The early neonatal period may be a promising window for intervention while the developing brain retains plasticity.

Family History of Hypertension, Cardiovascular Disease, or Diabetes and Risk of Developing Preeclampsia: A Systematic Review

Preeclampsia is a severe pregnancy complication with high potential for adverse effects on maternal and fetal health during the perinatal period. It is also associated with an increased risk of maternal cardiovascular disease later in life. Development of preeclampsia can be decreased by prescribing low-dose aspirin to high-risk women. At present, maternal and pregnancy factors are used to assess the risk of preeclampsia. One additional factor that could add to the assessment of risk is a family history of hypertension, cardiovascular disease, or diabetes, especially for nulliparous women who do not have a pregnancy history to inform treatment decisions. Therefore, we conducted a systematic review to assess the association between family history of the aforementioned conditions and preeclampsia. Four databases including MEDLINE, EMBASE, the Cochrane Library, and CINAHL/pre-CINAHL were searched for observational studies that examined a family history of hypertension, cardiovascular disease, or diabetes in women with preeclampsia and in a control population. Studies were evaluated for quality using the Newcastle-Ottawa Scale. A total of 84 relevant studies were identified. A meta-analysis was not conducted due to suspected heterogeneity in the included studies. Most studies reported a positive association between a family history of hypertension or cardiovascular disease and the development of preeclampsia. The majority of studies examining family history of diabetes reported non-significant associations. Overall, family history of hypertension or cardiovascular disease is associated with a higher risk for developing preeclampsia and should be considered when assessing women in the first trimester for low-dose aspirin.

Profile of congenital heart disease in infants born following exposure to preeclampsia

BACKGROUND

Events in pregnancy play an important role in predisposing the newborn to the risk of developing CHD. This study evaluated the association between maternal preeclampsia and her offspring risk of CHD.

METHODS

This is a cohort study of 90 sex-matched neonates (45 each born to women with preeclampsia and normal pregnancy) in Jos, Nigeria. Anthropometry was taken shortly after delivery using standard protocols. Echocardiography was performed within 24 hours of life and repeated 7 and 28 days later. SPSS version 25 was used in all analyses. Statistical significance was set at p<0.05.

RESULTS

Congenital heart disease (CHD) was observed in 27 (30.0%) of newborns of women with preeclampsia compared with 11 (12.1%) of newborns without preeclampsia (p<0.001) at the end of 7 days and in 19 (21.1%) of newborns of women with preeclampsia and 3 (3.3%) of newborns of women without preeclampsia by the end of the 4th week of life (p<0.001). Overall, ASD (4 newborns), PDA (21 newborns), patent foramen ovale (14 newborns) and VSD (2 newborns) were the prevalent lesions found among all the newborns studied in the first week of life. Isolated atrial and ventricular septal defects were seen in 4 (4.4%) of the newborns of women with preeclampsia. Being the infant of a woman with preeclampsia was associated with about 8-fold increased risk of having CHD (OR = 7.9, 95% CI = 2.5-24.9, p<0.001).

CONCLUSION

CHD may be more common in newborns of women with preeclampsia underscoring the need for fetal and newborn screening for CHD in women with preeclampsia so as to improve their infant's well being.

In utero exposure to pre-eclampsia as an independent risk factor for long-term respiratory disease

INTRODUCTION

Pre-eclampsia has a considerable effect on the intrauterine environment, yet not much is understood about how this impacts the respiratory health of the offspring. The aim of the present study is to determine if pre-eclampsia correlates with a higher incidence of respiratory disease in the offspring.

METHODS

This cohort study assessed the differences in respiratory disease patterns between singletons born to mothers with and without pre-eclampsia. The study was conducted between 1991 and 2014 in a regional tertiary medical center. A generalized estimating equation (GEE) model was used to control for confounders and maternal clusters.

RESULTS

253 808 deliveries were included in the study. Of these, 3.0% were to mothers diagnosed with pre-eclampsia (n = 7660), 0.9% with severe pre-eclampsia (n = 2366), and 0.03% with eclampsia (n = 81). A significant linear association was noted between the severity of the pre-eclampsia (no pre-eclampsia, mild, severe pre-eclampsia, and eclampsia) and respiratory disease of the offspring (5.7%, vs 6.0% vs 7.3% vs 9.9%, respectively; P = .003). The offspring of mothers who developed pre-eclampsia had significantly higher rates of asthma (1.1%, vs 1.3% vs 1.4% vs 1.2% correspondingly; P = .018). In the GEE model, controlling for gestational diabetes, maternal age, gestational age, and length of follow up, pre-eclampsia was found to be an independent risk factor for respiratory morbidity in the offspring (adjusted odds ratio = 1.32; 95% confidence interval, 1.21-1.45).

CONCLUSION

Exposure to maternal pre-eclampsia is an independent risk factor for long-term respiratory morbidity in the offspring. Specifically, the prenatal exposure to pre-eclampsia was significantly associated with asthma of the offspring.

Implementing Screening Guidelines for Preeclampsia Prevention in a Birth Center: A Quality Improvement Project

The aim of the project was to identify women at risk for developing preeclampsia who present for birth center care in order to initiate preventative treatment and retain them within the birth center practice. Birth center patients with preeclampsia disqualify for birth center care requiring hospital transfer. The target population consisted of pregnant women choosing birth center care with certified nurse midwives. Quality improvement method was utilized. Over 5-weeks, patients with 12 to 28 weeks' gestation were screened for preeclampsia risk factors; patients with high risk for preeclampsia initiated low-dose aspirin (LDA). All patients were evaluated for preeclampsia diagnosis up to 2 weeks postpartum. Outcomes were evaluated through chart audits. Screening for preeclampsia risk significantly increased LDA use. Preeclampsia screening did not statistically reduce incidences of preeclampsia but did show a moderate reduction. Use of LDA did not statistically reduce preeclampsia diagnoses but had a large reduction effect. Screening for preeclampsia in birth center patients results in increased use of LDA and potentially decreased rates of hospital transfer. Implementing preeclampsia screening is cost-effective and allows for increased patient retention.

Antiplatelet agents for preventing pre-eclampsia and its complications

BACKGROUND

Pre-eclampsia is associated with deficient intravascular production of prostacyclin, a vasodilator, and excessive production of thromboxane, a vasoconstrictor and stimulant of platelet aggregation. These observations led to the hypotheses that antiplatelet agents, low-dose aspirin in particular, might prevent or delay development of pre-eclampsia.

OBJECTIVES

To assess the effectiveness and safety of antiplatelet agents, such as aspirin and dipyridamole, when given to women at risk of developing pre-eclampsia.

SEARCH METHODS

For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (30 March 2018), and reference lists of retrieved studies. We updated the search in September 2019 and added the results to the awaiting classification section of the review.

SELECTION CRITERIA

All randomised trials comparing antiplatelet agents with either placebo or no antiplatelet agent were included. Studies only published in abstract format were eligible for inclusion if sufficient information was available. We would have included cluster-randomised trials in the analyses along with individually-randomised trials, if any had been identified in our search strategy. Quasi-random studies were excluded. Participants were pregnant women at risk of developing pre-eclampsia. Interventions were administration of an antiplatelet agent (such as low-dose aspirin or dipyridamole), comparisons were either placebo or no antiplatelet.

DATA COLLECTION AND ANALYSIS

Two review authors assessed trials for inclusion and extracted data independently. For binary outcomes, we calculated risk ratio (RR) and its 95% confidence interval (CI), on an intention-to-treat basis. For this update we incorporated individual participant data (IPD) from trials with this available, alongside aggregate data (AD) from trials where it was not, in order to enable reliable subgroup analyses and inclusion of two key new outcomes. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE.

MAIN RESULTS

Seventy-seven trials (40,249 women, and their babies) were included, although three trials (relating to 233 women) did not contribute data to the meta-analysis. Nine of the trials contributing data were large (> 1000 women recruited), accounting for 80% of women recruited. Although the trials took place in a wide range of countries, all of the nine large trials involved only women in high-income and/or upper middle-income countries. IPD were available for 36 trials (34,514 women), including all but one of the large trials. Low-dose aspirin alone was the intervention in all the large trials, and most trials overall. Dose in the large trials was 50 mg (1 trial, 1106 women), 60 mg (5 trials, 22,322 women), 75mg (1 trial, 3697 women) 100 mg (1 trial, 3294 women) and 150 mg (1 trial, 1776 women). Most studies were either low risk of bias or unclear risk of bias; and the large trials were all low risk of bas. Antiplatelet agents versus placebo/no treatment The use of antiplatelet agents reduced the risk of proteinuric pre-eclampsia by 18% (36,716 women, 60 trials, RR 0.82, 95% CI 0.77 to 0.88; high-quality evidence), number needed to treat for one women to benefit (NNTB) 61 (95% CI 45 to 92). There was a small (9%) reduction in the RR for preterm birth <37 weeks (35,212 women, 47 trials; RR 0.91, 95% CI 0.87 to 0.95, high-quality evidence), NNTB 61 (95% CI 42 to 114), and a 14% reduction infetal deaths, neonatal deaths or death before hospital discharge (35,391 babies, 52 trials; RR 0.85, 95% CI 0.76 to 0.95; high-quality evidence), NNTB 197 (95% CI 115 to 681). Antiplatelet agents slightly reduced the risk of small-for-gestational age babies (35,761 babies, 50 trials; RR 0.84, 95% CI 0.76 to 0.92; high-quality evidence), NNTB 146 (95% CI 90 to 386), and pregnancies with serious adverse outcome (a composite outcome including maternal death, baby death, pre-eclampsia, small-for-gestational age, and preterm birth) (RR 0.90, 95% CI 0.85 to 0.96; 17,382 women; 13 trials, high-quality evidence), NNTB 54 (95% CI 34 to 132). Antiplatelet agents probably slightly increase postpartum haemorrhage > 500 mL (23,769 women, 19 trials; RR 1.06, 95% CI 1.00 to 1.12; moderate-quality evidence due to clinical heterogeneity), and they probably marginally increase the risk of placental abruption, although for this outcome the evidence was downgraded due to a wide confidence interval including the possibility of no effect (30,775 women; 29 trials; RR 1.21, 95% CI 0.95 to 1.54; moderate-quality evidence). Data from two large trials which assessed children at aged 18 months (including results from over 5000 children), did not identify clear differences in development between the two groups.

AUTHORS' CONCLUSIONS

Administering low-dose aspirin to pregnant women led to small-to-moderate benefits, including reductions in pre-eclampsia (16 fewer per 1000 women treated), preterm birth (16 fewer per 1000 treated), the baby being born small-for-gestational age (seven fewer per 1000 treated) and fetal or neonatal death (five fewer per 1000 treated). Overall, administering antiplatelet agents to 1000 women led to 20 fewer pregnancies with serious adverse outcomes. The quality of evidence for all these outcomes was high. Aspirin probably slightly increased the risk of postpartum haemorrhage of more than 500 mL, however, the quality of evidence for this outcome was downgraded to moderate, due to concerns of clinical heterogeneity in measurements of blood loss. Antiplatelet agents probably marginally increase placental abruption, but the quality of the evidence was downgraded to moderate due to low event numbers and thus wide 95% CI. Overall, antiplatelet agents improved outcomes, and at these doses appear to be safe. Identifying women who are most likely to respond to low-dose aspirin would improve targeting of treatment. As almost all the women in this review were recruited to the trials after 12 weeks' gestation, it is unclear whether starting treatment before 12 weeks' would have additional benefits without any increase in adverse effects. While there was some indication that higher doses of aspirin would be more effective, further studies would be warranted to examine this.

Trends in prevalence of gestational diabetes and perinatal outcomes in Catalonia, Spain, 2006 to 2015: the Diagestcat Study

BACKGROUND

No recent epidemiologic studies on gestational diabetes mellitus (GDM) have been conducted in Spain. The present study aimed to explore trends in the prevalence of GDM and ascertain whether the risk of adverse perinatal outcomes changed between 2006 and 2015 in Catalonia.

METHODS

In this population-based study, all hospital admissions for singleton births in Catalonia for the period 2006 to 2015 were collected from the Spanish Minimum Basic Data Set. Cases of GDM were identified from hospital delivery discharge reports using ICD-9-CM codes. Data regarding maternal characteristics and perinatal outcomes were analysed. Crude and age-adjusted annual prevalences were calculated. The Poisson regression model was used to assess trends in prevalence and perinatal outcomes, adjusted for age and smoking habit; however, they could not be adjusted for body mass index (BMI) and ethnicity.

RESULTS

Data from 743 762 deliveries were collected. GDM prevalence over the study period was 4.80% (95% CI 4.75-4.85%). Crude GDM prevalence rose from 3.81% (95% CI 3.67-3.95%) in 2006 to 6.53% (95% CI 6.33-6.72%) in 2015 (P < 0.001). Women with GDM showed a stable trend in rates of preeclampsia (2.56%), prematurity (15.7%), and large-for-gestational age (LGA) newborns (18.3%), whereas a lower rate of macrosomia was observed during the study period (from 9.16% to 7.84%). Caesarean deliveries rose from 28% to 31%; however, significance was lost after adjustment.

CONCLUSIONS

The prevalence of GDM in Catalonia almost doubled between 2006 and 2015. During the study period, the frequency of macrosomia decreased whereas pre-eclampsia, prematurity, LGA, and age-adjusted Caesarean rates remained stable.

A best-practice position statement on pregnancy after kidney transplantation: focusing on the unsolved questions. The Kidney and Pregnancy Study Group of the Italian Society of Nephrology

Kidney transplantation (KT) is often considered to be the method best able to restore fertility in a woman with chronic kidney disease (CKD). However, pregnancies in KT are not devoid of risks (in particular prematurity, small for gestational age babies, and the hypertensive disorders of pregnancy). An ideal profile of the potential KT mother includes "normal" or "good" kidney function (usually defined as glomerular filtration rate, GFR ≥ 60 ml/min), scant or no proteinuria (usually defined as below 500 mg/dl), normal or well controlled blood pressure (one drug only and no sign of end-organ damage), no recent acute rejection, good compliance and low-dose immunosuppression, without the use of potentially teratogen drugs (mycophenolic acid and m-Tor inhibitors) and an interval of at least 1-2 years after transplantation. In this setting, there is little if any risk of worsening of the kidney function. Less is known about how to manage "non-ideal" situations, such as a pregnancy a short time after KT, or one in the context of hypertension or a failing kidney. The aim of this position statement by the Kidney and Pregnancy Group of the Italian Society of Nephrology is to review the literature and discuss what is known about the clinical management of CKD after KT, with particular attention to women who start a pregnancy in non-ideal conditions. While the experience in such cases is limited, the risks of worsening the renal function are probably higher in cases with markedly reduced kidney function, and in the presence of proteinuria. Well-controlled hypertension alone seems less relevant for outcomes, even if its effect is probably multiplicative if combined with low GFR and proteinuria. As in other settings of kidney disease, superimposed preeclampsia (PE) is differently defined and this impairs calculating its real incidence. No specific difference between non-teratogen immunosuppressive drugs has been shown, but calcineurin inhibitors have been associated with foetal growth restriction and low birth weight. The clinical choices in cases at high risk for malformations or kidney function impairment (pregnancies under mycophenolic acid or with severe kidney-function impairment) require merging clinical and ethical approaches in which, beside the mother and child dyad, the grafted kidney is a crucial "third element".

Environmental noise pollution and risk of preeclampsia

BACKGROUND

Environmental noise exposure is associated with a greater risk of hypertension, but the link with preeclampsia, a hypertensive disorder of pregnancy, is unclear.

OBJECTIVES

We sought to determine the relationship between environmental noise pollution and risk of preeclampsia during pregnancy.

METHODS

We analyzed a population-based cohort comprising 269,263 deliveries on the island of Montreal, Canada between 2000 and 2013. We obtained total environmental noise pollution measurements (LA_eq24, L_den, L_night) from land use regression models, and assigned noise levels to each woman based on the residential postal code. We computed odds ratios (OR) and 95% confidence intervals (CI) for the association of noise with preeclampsia in mixed logistic regression models with participants as a random effect, and adjusted for air pollution, neighbourhood walkability, maternal age, parity, multiple pregnancy, comorbidity, socioeconomic deprivation, and year of delivery. We assessed whether noise exposure was more strongly associated with severe or early onset preeclampsia than mild or late onset preeclampsia.

RESULTS

Prevalence of preeclampsia was higher for women exposed to elevated environmental noise pollution levels (LA_eq24h ≥ 65 dB(A) = 37.9 per 1000 vs. <50 dB(A) = 27.9 per 1000). Compared with 50 dB(A), an LA_eq24h of 65.0 dB(A) was not significantly associated the risk of preeclampsia (OR 1.09, 95% CI 0.99-1.20). Associations were however present with severe (OR 1.29, 95% CI 1.09-1.54) and early onset (OR 1.71, 95% CI 1.20-2.43) preeclampsia, with results consistent across all noise indicators. The associations were much weaker or absent for mild and late preeclampsia.

CONCLUSIONS

Environmental noise pollution may be a novel risk factor for pregnancy-related hypertension, particularly more severe variants of preeclampsia.

Heat and pregnancy-related emergencies: Risk of placental abruption during hot weather

INTRODUCTION

Outdoor heat increases the risk of preterm birth and stillbirth, but the association with placental abruption has not been studied. Placental abruption is a medical emergency associated with major morbidity and mortality in pregnancy. We determined the relationship between ambient temperature and risk of placental abruption in warm seasons.

MATERIAL AND METHODS

We performed a case-crossover analysis of 17,172 women whose pregnancies were complicated by placental abruption in Quebec, Canada from May to October 1989-2012. The main exposure measure was the maximum temperature reached during the week before abruption. We computed odds ratios (OR) and 95% confidence intervals (CI) for the association of temperature with placental abruption, adjusted for humidity and public holidays. We assessed whether associations were stronger preterm or at term, or varied with maternal age, parity, comorbidity and socioeconomic status.

RESULTS

Compared with 15°C, a maximum weekly temperature of 30°C was associated with 1.07 times the odds of abruption (95% CI 0.99-1.16). When the timing of abruption was examined, the associations were significantly stronger at term (OR 1.12, 95% CI 1.02-1.24) than preterm (OR 0.96, 95% CI 0.83-1.10). Relationships were more prominent at term for women who were younger than 35years old, nulliparous or socioeconomically disadvantaged, but did not vary with comorbidity. Associations were stronger within 1 and 5days of abruption. Temperature was not associated with preterm abruption regardless of maternal characteristics.

CONCLUSIONS

Elevated temperatures in warm seasons may increase the risk of abruption in women whose pregnancies are near or at term. Pregnant women may be more sensitive to heat and should consider preventive measures such as air conditioning and hydration during hot weather.

Preeclampsia and the risk of cataract extraction in life

BACKGROUND

Pregnancy-related risk factors for cataract are understudied, including the possibility that preeclampsia increases the risk of cataract later in life.

OBJECTIVE

We sought to evaluate the long-term risk of cataract extraction following a preeclamptic pregnancy.

STUDY DESIGN

We carried out a historic cohort study of 1,108,541 women who delivered at least 1 infant in any hospital in the province of Quebec, Canada, from 1989 through 2013, including 64,350 with preeclampsia and 5732 with cataract extractions. We categorized preeclampsia by onset time and severity, and followed up women for up to 25 years after delivery. We calculated the incidence of inpatient cataract extraction for women with and without preeclampsia, and used Cox proportional hazard models to estimate hazard ratios and 95% confidence intervals for later risk of cataract extraction, adjusting for age at first delivery, total parity, metabolic disease, asthma, socioeconomic deprivation, and time period.

RESULTS

Women with preeclampsia had a higher incidence of cataract extraction compared with no preeclampsia (21.0 vs 15.9/1000) and 1.20 times the risk (95% confidence interval, 1.08-1.34). Women with early-onset preeclampsia had 1.51 times the risk of cataract extraction compared with no preeclampsia (95% confidence interval, 1.14-2.00), whereas women with late-onset preeclampsia had 1.16 times the risk (95% confidence interval, 1.04-1.30). Risk was elevated by about 20% for both severe and mild preeclampsia. Preeclampsia with diabetes was associated with significantly greater risk (hazard ratio, 4.32; 95% confidence interval, 3.60-5.19).

CONCLUSION

Women with preeclampsia, particularly preeclampsia of early onset or with diabetes, may have greater risk of cataract later in life. The underlying pathways linking preeclampsia with cataract require further investigation.

Hypertensive disorders of pregnancy

PURPOSE

In this continuing professional development module, we review recent Society of Obstetricians and Gynaecologists of Canada (SOGC) guidelines for the classification and diagnosis of hypertensive disorders of pregnancy (HDP) as well as review the clinical features, laboratory investigations, and outcomes of HDP. We explore the evidence for anesthetic management and prevention of end-organ damage in women with HDP and describe the role and contribution of anesthesiologists as part of a multidisciplinary care team.

PRINCIPAL FINDINGS

Hypertensive disorders of pregnancy can have variable presentations with clinical signs and symptoms that often do not correlate with the underlying severity and progression of the disease. Failure of timely diagnosis and treatment contributes significantly to adverse maternal (neurologic complications, pulmonary edema, and postpartum hemorrhage) and neonatal (respiratory and neurologic complications and stillbirth) outcomes. In the Canadian context, improvements in medical care have led to better maternal and neonatal outcomes. Timing of delivery is crucial in balancing maternal risks and fetal benefits of ongoing pregnancy. Evidence-based SOGC guidelines regarding diagnosis and management of HDP address many aspects of clinical care relevant to anesthesiologists, who have an important role in the multidisciplinary care team.

CONCLUSIONS

Hypertensive disorders of pregnancy are on the rise worldwide, and this trend is expected to continue. The major contributors to maternal mortality are failure to recognize HDP promptly or to treat the condition adequately. It is essential that anesthesiologists understand the disease process and acquire knowledge of the guidelines governing current obstetrical care in order to provide evidence-based multidisciplinary quality care to these patients. Anesthetic management helps prevent potentially deleterious maternal and fetal outcomes.