Association of anemia, pre-eclampsia and eclampsia with seasonality: A realist systematic review

Geographic inequalities and determinants of anaemia among preeclamptic women: a cross-sectional sample-based study in Bangladesh

BACKGROUND

Anaemia among preeclamptic (PE) women is a major undefined health issue in Bangladesh. This study explored the risk factors associated with anaemia and mapped the regional influences to understand the geographical inequalities.

METHODS

Data from 180 respondents were prospectively collected from the Preeclampsia ward of Dhaka Medical College Hospital (DMCH), Bangladesh. Anaemia was defined as a blood haemoglobin level less than 11.0 g/dl. Preeclampsia was defined as systolic blood pressure (SBP) ≥ 140 mmHg and diastolic blood pressure (DBP) ≥ 90 mmHg with proteinuria. Factors associated with anaemia were explored using the chi-square test. Logistic regression (LR) was done to determine the level of association with the risk factors.

RESULTS

Among the participants, 28.9% were identified as having early onset and 71.1% reported late onset of PE. 38.9% of the subjects were non-anaemic, whereas mild, moderate, and severe anaemia was found among 38.3%, 17.8%, and 5% of patients respectively. The following factors were identified; including age range 25-34 (OR: 0.169, p < 0.05), a lower education level (OR: 3.106, p < 0.05), service-holder mothers (OR: 0.604, p < 0.05), pregnancy interval of less than 24 months (OR: 4.646, p < 0.05), and gestational diabetes mellitus (OR: 2.702, p < 0.05). Dhaka district (IR: 1.46), Narayanganj district (IR: 1.11), and Munshiganj district (IR: 0.96) had the highest incidence rates.

CONCLUSION

Determinants of anaemia must be considered with importance. In the future, periodic follow-ups of anaemia should be scheduled with a health care program and prevent maternal fatality and fetus morbidity in patients with PE.

Associations between type of blood collection, analytical approach, mean haemoglobin and anaemia prevalence in population-based surveys: A systematic review and meta-analysis

Background

Previous studies have observed that haemoglobin concentrations can be affected by type of blood collection, analysis methods and device, and that near-in-time population-based surveys report substantially different anaemia prevalence. We investigated whether differences in mean haemoglobin or prevalence of anaemia between near-in-time surveys of the same population were associated with differences in type of blood collection or analytic approach to haemoglobin measurement.

Methods

We systematically identified pairs of population-based surveys that measured haemoglobin in the same population of women of reproductive age (WRA) or preschool-aged children (PSC). Surveys were matched on geographic coverage, urban/rural place of residence, inclusion of pregnant women, time of data collection (within 18 months), and, to the extent feasible, age range. Differences in anaemia prevalence were presented graphically. Random-effects meta-analysis and meta-regression of difference in mean haemoglobin were carried out, with subgroups defined by comparison of type of blood collection and analytic approach within each survey pair.

Results

We included 23 survey pairs from 17 countries for PSC and 17 survey pairs from 11 countries for WRA. Meta-regression indicates that surveys measuring haemoglobin with HemoCue® Hb 301 found higher haemoglobin concentrations than near-in-time surveys using HemoCue® Hb 201+ in non-pregnant women ((NPW); 5.8 g/L (95% confidence interval (CI) = 3.2-8.3) mean difference, n = 5 pairs) and PSC (4.3 g/L (1.4-7.2), n = 6). Surveys collecting venous blood found higher haemoglobin concentrations than near-in-time surveys collecting capillary blood in PSC (3.8 g/L (0.8-6.7), n = 8), but not NPW (0.4 g/L (-1.9-2.8), n = 9).

Conclusions

Because this study is observational, differences in haemoglobin concentrations in near-in-time surveys may be caused by other factors associated with choice of analytic approach or type of blood collected. The source or sources of differences should be clarified to improve use of surveys to prioritize and evaluate public health programs.

Registration

PROSPERO CRD42022296553.

Building sustainable and resilient surgical systems: A narrative review of opportunities to integrate climate change into national surgical planning in the Western Pacific region

Five billion people lack access to surgical care worldwide; climate change is the biggest threat to human health in the 21st century. This review studies how climate change could be integrated into national surgical planning in the Western Pacific region. We searched databases (PubMed, Web of Science, and Global Health) for articles on climate change and surgical care. Findings were categorised using the modified World Health Organisation Health System Building Blocks Framework. 220 out of 2577 records were included. Infrastructure: Operating theatres are highly resource-intensive. Their carbon footprint could be reduced by maximising equipment longevity, improving energy efficiency, and renewable energy use. Service delivery Tele-medicine, outreaches, and avoiding desflurane could reduce emissions. Robust surgical systems are required to adapt to the increasing burden of surgically treated diseases, such as injuries from natural disasters. Finance: Climate change adaptation funds could be mobilised for surgical system strengthening. Information systems: Sustainability should be a key performance indicator for surgical systems. Workforce: Surgical providers could change clinical, institutional, and societal practices. Governance: Planning in surgical care and climate change should be aligned. Climate change mitigation is essential in the regional surgical care scale-up; surgical system strengthening is also necessary for adaptation to climate change.

The epidemiological landscape of anemia in women of reproductive age in sub-Saharan Africa

The role of geographical disparities of health-related risk factors with anemia are poorly documented for women of reproductive age in sub-Saharan Africa (SSA). We aimed to determine the contribution of potential factors and to identify areas at higher risk of anemia for women in reproductive age in SSA. Our study population comprised 27 nationally representative samples of women of reproductive age (15–49) who were enrolled in the Demographic and Health Surveys and conducted between 2010 and 2019 in SSA. Overall, we found a positive association between being anemic and the ecological exposure to malaria incidence [adjusted odds ratio (AOR) = 1.02, 95% confidence interval (CI) 1.02–1.02], and HIV prevalence (AOR = 1.01, CI 1.01–1.02). Women currently pregnant or under deworming medication for the last birth had 31% (AOR = 1.31, CI 1.24–1.39) and 5% (AOR = 1.05, CI 1.01–1.10) higher odds of having anemia, respectively. Similarly, women age 25–34 years old with low education, low income and living in urban settings had higher odds of having anemia. In addition, underweight women had 23% higher odds of suffering anemia (AOR = 1.23, CI 1.15–1.31). Females with low levels of education and wealth index were consistently associated with anemia across SSA. Spatial distribution shows increased risk of anemia in Central and Western Africa. Knowledge about the contribution of known major drivers and the spatial distribution of anemia risk can mitigate operational constraints and help to design geographically targeted intervention programs in SSA.

Seasonal trends and maternal characteristics as predictors of maternal undernutrition and low birthweight in Eastern Maharashtra, India

Few studies have assessed whether women and infants in rural and peri-urban communities in South Asia experience seasonal fluctuations in nutritional status; however, a handful of studies have documented seasonal variability in risk factors for undernutrition including food availability, physical activity and infections. We used data from the Maternal and Newborn Health (MNH) registry, a population-based pregnancy and birth registry in Eastern Maharashtra, India, to analyse seasonal trends in birthweight and maternal nutritional status-body mass index (BMI) and haemoglobin-in the first trimester of pregnancy. We plotted monthly and seasonal trends in birthweight, and maternal BMI and haemoglobin, and used multivariable regression models to identify seasonal and maternal characteristics that predicted each outcome. Between October 2014 and January 2018, MNH included 29,253 livebirths with recorded birthweight. BMI was assessed in 15,252 women less than 12 weeks of gestation and haemoglobin in 18,278 women less than 13 weeks of gestation. Maternal characteristics (age, education, parity and height) were significantly associated with nutritional status; however, there were minimal seasonal fluctuations in birthweight or maternal nutrition. There were significant secular trends in maternal haemoglobin; between 2014 and 2018, the prevalence of maternal anaemia decreased from 91% to 79% and moderate or severe anaemia from 53% to 37%. The prevalence of maternal underweight (45.3%) and overweight (9.8%) and low birthweight (19.1%) remained relatively constant over the study period. Our findings highlight that in some rural and peri-urban areas in South Asia, tackling systemic drivers of malnutrition may be more effective than targeted interventions based on season.

Seasonality, climate change, and food security during pregnancy among Indigenous and non-Indigenous women in rural Uganda: Implications for maternal-infant health

BACKGROUND

Climate change is expected to decrease food security globally. Many Indigenous communities have heightened sensitivity to climate change and food insecurity for multifactorial reasons including close relationships with the local environment and socioeconomic inequities which increase exposures and challenge adaptation to climate change. Pregnant women have additional sensitivity to food insecurity, as antenatal undernutrition is linked with poor maternal-infant health. This study examined pathways through which climate change influenced food security during pregnancy among Indigenous and non-Indigenous women in rural Uganda. Specific objectives were to characterize: 1) sensitivities to climate-associated declines in food security for pregnant Indigenous women; 2) women's perceptions of climate impacts on food security during pregnancy; and 3) changes in food security and maternal-infant health over time, as observed by women.

METHODS

Using a community-based research approach, we conducted eight focus group discussions-four in Indigenous Batwa communities and four in non-Indigenous communities-in Kanungu District, Uganda, on the subject of climate and food security during pregnancy. Thirty-six women with ≥1 pregnancy participated. Data were analysed using a constant comparative method and thematic analysis.

RESULTS

Women indicated that food insecurity was common during pregnancy and had a bidirectional relationship with antenatal health issues. Food security was thought to be decreasing due to weather changes including extended droughts and unpredictable seasons harming agriculture. Women linked food insecurity with declines in maternal-infant health over time, despite improved antenatal healthcare. While all communities described food security struggles, the challenges Indigenous women identified and described were more severe.

CONCLUSIONS

Programs promoting women's adaptive capacity to climate change are required to improve food security for pregnant women and maternal-infant health. These interventions are particularly needed in Indigenous communities, which often face underlying health inequities. However, resiliency among mothers was strong and, with supports, they can reduce food security challenges in a changing climate.

Polycystic Ovary Syndrome and Endometriosis as Reasons for Women's Admission to Outpatient Specialist Care in Poland-A Retrospective Analysis

This study aimed at presenting selected aspects of outpatient specialist care for women diagnosed with polycystic ovary syndrome (PCOS) or endometriosis. The study was carried out using a retrospective analysis of the services provided under Outpatient Specialist Care (AOS) for women, based on data from the National Health Fund (NFZ). The study included data on women with PCOS or endometriosis based on the International Statistical Classification of Diseases and Related Health Problems (ICD-10) in Poland from 2016 to 2018. The average age of women in the study group with PCOS was 25.31 (±7.02) years and, for those with endometriosis, 38.21 (±10.79). AOS patients with diagnosed PCOS most often made 2–3 visits (34.60%) to a specialist doctor, and those with diagnosed endometriosis most often made one visit (39.95%). Significant differences between patients with PCOS and endometriosis using AOS were found concerning the women’s age, the year, season, place of treatment, type of clinic, mode of admission, number of visits, and their place of residence or macroregion. With increasing age, women with PCOS made more visits to AOS, and women with endometriosis made fewer visits to the AOS specialist.

Advanced maternal age impacts physiologic adaptations to pregnancy in vervet monkeys

The trend to delay pregnancy in the USA has resulted in the number of advanced maternal age (AMA) pregnancies to also increase. In humans, AMA is associated with a variety of pregnancy-related pathologies such as preeclampsia (PE). While AMA is known to be a factor which contributes to the development of pregnancy-induced diseases, the molecular and cellular mechanisms giving rise to this phenomenon are still very limited. This is due in part to lack of a preclinical model which has physiologic relevance to human pregnancy while also allowing control of environmental and genetic variability inherent in human studies. To determine potential physiologic relevance of the vervet/African green monkey (Chlorocebus aethiops sabaeus) as a preclinical model to study the effects of AMA on adaptations to pregnancy, thirteen age-diverse pregnant vervet monkeys (3-16 years old) were utilized to measure third trimester blood pressure (BP), complete blood count, iron measurements, and hormone levels. Significant associations were observed between third trimester diastolic BP and maternal age. Furthermore, the presence of leukocytosis with enhanced circulating neutrophils was observed in AMA mothers compared to younger mothers. Moreover, we observed a negative relationship between maternal age and estradiol, progesterone, and cortisol levels. Finally, offspring born to AMA mothers displayed a postnatal growth retardation phenotype. These studies demonstrate physiologic impairment in the adaptation to pregnancy in AMA vervet/African green monkeys. Our data indicate that the vervet/African green monkey may serve as a useful preclinical model and tool for deciphering pathological mediators of maternal disease in AMA pregnancy.

Artificial intelligence-assisted prediction of preeclampsia: Development and external validation of a nationwide health insurance dataset of the BPJS Kesehatan in Indonesia

Background

We developed and validated an artificial intelligence (AI)-assisted prediction of preeclampsia applied to a nationwide health insurance dataset in Indonesia.

Methods

The BPJS Kesehatan dataset have been preprocessed using a nested case-control design into preeclampsia/eclampsia (n = 3318) and normotensive pregnant women (n = 19,883) from all women with one pregnancy. The dataset provided 95 features consisting of demographic variables and medical histories started from 24 months to event and ended by delivery as the event. Six algorithms were compared by area under the receiver operating characteristics curve (AUROC) with a subgroup analysis by time to the event. We compared our model to similar prediction models from systematically reviewed studies. In addition, we conducted a text mining analysis based on natural language processing techniques to interpret our modeling results.

Findings

The best model consisted of 17 predictors extracted by a random forest algorithm. Nine∼12 months to the event was the period that had the best AUROC in external validation by either geographical (0.88, 95% confidence interval (CI) 0.88–0.89) or temporal split (0.86, 95% CI 0.85–0.86). We compared this model to prediction models in seven studies from 869 records in PUBMED, EMBASE, and SCOPUS. This model outperformed the previous models in terms of the precision, sensitivity, and specificity in all validation sets.

Interpretation

Our low-cost model improved preliminary prediction to decide pregnant women that will be predicted by the models with high specificity and advanced predictors.

Funding

This work was supported by grant no. MOST108-2221-E-038-018 from the Ministry of Science and Technology of Taiwan.

Comparing hemoglobin distributions between population-based surveys matched by country and time

Background

Valid measurement of hemoglobin is important for tracking and targeting interventions. This study compares hemoglobin distributions between surveys matched by country and time from The Demographic and Health Survey (DHS) Program and the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project.

Methods

Four pairs of nationally representative surveys measuring hemoglobin using HemoCue® with capillary (DHS) or venous (BRINDA) blood were matched by country and time. Data included 17,719 children (6–59 months) and 21,594 non-pregnant women (15–49 y). Across paired surveys, we compared distributional statistics and anemia prevalence.

Results

Surveys from three of the four countries showed substantial differences in anemia estimates (9 to 31 percentage point differences) which were consistently lower in BRINDA compared to DHS (2 to 31 points for children, 1 to 16 points for women).

Conclusion

We identify substantial differences in anemia estimates from surveys of similar populations. Further work is needed to identify the cause of these differences to improve the robustness of anemia estimates for comparing populations and tracking improvements over time.

Magnitude, trends and causes of maternal mortality among reproductive aged women in Kersa health and demographic surveillance system, eastern Ethiopia

BACKGROUND

Despite efforts at curbing maternal morbidity and mortality, developing countries are still burdened with high rates of maternal morbidity and mortality. Ethiopia is not an exception and has one of the world's highest rates of maternal deaths. Reducing the huge burden of maternal mortality remains the single most serious challenge in Ethiopia. There is a paucity of information with regards to the local level magnitude and causes of maternal mortality. We assessed the magnitude, trends and causes of maternal mortality using surveillance data from the Kersa Health and Demographic Surveillance System (HDSS), in Eastern Ethiopia.

METHOD

The analysis used surveillance data extracted from the Kersa HDSS database for the duration of 2008 to 2014. Data on maternal deaths and live births during the seven year period were used to determine the maternal mortality ratio in the study. The data were mainly extracted from a verbal autopsy database. The sample was comprised of all reproductive aged women who died during pregnancy, childbirth or 42 days after delivery. Chi-squared test for linear trend was used to examine the significance of change in rates over time.

RESULTS

Out of the total 311 deaths of reproductive aged women during the study period, 72 (23.2%) died during pregnancy or within 42 days of delivery. The overall estimated maternal mortality ratio was 324 per 100,000 live births (95% CI: 256, 384). The observed maternal mortality ratio has shown a declining trend over the seven years period though there is no statistical significance for the reduction (χ2 = 0.56, P = 0.57). The estimated pregnancy related mortality ratio was 543 per 100,000 live births (95% CI: 437, 663). Out of those who died due to pregnancy and related causes, only 26% attended at least one antenatal care service. The most common cause of maternal death was postpartum haemorrhage (46.5%) followed by hypertensive disorders of pregnancy (16.3%).

CONCLUSION

The magnitude of maternal mortality is considerably high but has shown a decreasing trend. Community-based initiatives that aim to improve maternal health should be strengthened further to reduce the prevailing maternal mortality. Targeted information education and communication should be provided.

The Cost of Providing District-Level Surgery in Malawi

BACKGROUND

Three district hospitals in Malawi that provide essential surgery, which for many patients can be lifesaving or prevent disability, formed the setting of this costing study.

METHODS

All resources used at district hospitals for the delivery of surgery were identified and quantified. The hospital departments were divided into three categories of cost centres-the final cost centre, intermediate and ancillary cost centres. All costs of human resources, buildings, equipment, medical and non-medical supplies and utilities were quantified and allocated to surgery through step-down accounting.

RESULTS

The total cost of surgery, including post-operative care, ranged from US$ 329,000 per year to more than twice that amount at one of the hospitals. At two hospitals, it represented 16-17% of the total cost of running the hospital. The main cost drivers of surgery were transport and inpatient services, including catering. The cost of a C-section ranged from $ 164 to 638 that of a hernia repair from $ 137 to 598. Evacuations from uterus were cheapest mainly because of the shorter duration of patient stay.

CONCLUSION

Low bed occupancy rates and utilisation rates of the operating theatres suggest overcapacity but may also indicate a potential to scale up surgery. This may be achieved by adding surgical staff, although there may be rate-limiting steps, such as demand for surgery in the community or capacity to provide anaesthesia. If a scale-up of surgery cannot be realised, hospital managers may be forced to reduce the number of beds, reorganise wards and/or reallocate staff to achieve better economies of scale.

Seasonality of hypertensive disorders of pregnancy - A South Australian population study

OBJECTIVES

To investigate the seasonal variation of hypertensive disorders of pregnancy (HDP) in South Australia.

STUDY DESIGN

Retrospective population study including all 107,846 liveborn singletons during 2007-2014 in South Australia. Seasonality in incidence of HDP in relation to estimated date of conception (eDoC) and date of birth (DoB) were examined using Fourier series analysis.

MAIN OUTCOME MEASURES

Seasonality of HDP in relation to eDoC and DoB.

RESULTS

During 2007-2014, the incidence of HDP was 7.1% (n = 7,612). Seasonal modeling showed a strong relationship between HDP and eDoC (p < .001) and DoB (p < .001). Unadjusted and adjusted models (adjusted for maternal age, body mass index, ethnicity, parity, type of health care, smoking and gestational diabetes mellitus) demonstrated the presence of a peak incidence (7.8%, 7.9% respectively) occurring among pregnancies with eDoC in late Spring (November) and a trough (6.4% and 6.3% respectively) among pregnancies with eDoC in late Autumn (May). Both unadjusted and adjusted seasonal modelling showed a peak incidence of HDP for pregnancies with DoB in August (8.0%, 8.1% respectively) and a nadir among pregnancies with eDoB in February (6.2%).

CONCLUSION

The highest incidence of HDP was associated with pregnancies with eDoC during late spring and summer and birth in winter, while the lowest incidence of HDP was associated with pregnancies with eDoC during late autumn and early winter and birth in summer. Nutrient intake, in particular vitamin D, sunlight exposure and physical activity may affect maternal, fetal and placental adaptation to pregnancy and are potential contributors to the seasonal variation of HDP.

Immunological Tolerance, Pregnancy, and Preeclampsia: The Roles of Semen Microbes and the Father

Although it is widely considered, in many cases, to involve two separable stages (poor placentation followed by oxidative stress/inflammation), the precise originating causes of preeclampsia (PE) remain elusive. We have previously brought together some of the considerable evidence that a (dormant) microbial component is commonly a significant part of its etiology. However, apart from recognizing, consistent with this view, that the many inflammatory markers of PE are also increased in infection, we had little to say about immunity, whether innate or adaptive. In addition, we focused on the gut, oral and female urinary tract microbiomes as the main sources of the infection. We here marshall further evidence for an infectious component in PE, focusing on the immunological tolerance characteristic of pregnancy, and the well-established fact that increased exposure to the father's semen assists this immunological tolerance. As well as these benefits, however, semen is not sterile, microbial tolerance mechanisms may exist, and we also review the evidence that semen may be responsible for inoculating the developing conceptus (and maybe the placenta) with microbes, not all of which are benign. It is suggested that when they are not, this may be a significant cause of PE. A variety of epidemiological and other evidence is entirely consistent with this, not least correlations between semen infection, infertility and PE. Our view also leads to a series of other, testable predictions. Overall, we argue for a significant paternal role in the development of PE through microbial infection of the mother via insemination.

Season of Conception, Smoking, and Preeclampsia in Norway

BACKGROUND

Preeclampsia (PE) is a dangerous and unpredictable pregnancy complication. A seasonal pattern of risk would suggest that there are potentially preventable environmental contributors, but prior analyses have not adjusted for confounding by PE risk factors that are associated with season of conception.

METHODS

Seasonal effects were modeled and tested by representing each day of the year as an angle on a unit circle and using trigonometric functions of those angles in predictive models, using "harmonic analysis." We applied harmonic Cox regression to model confounder-adjusted effects of the estimated day of the year of conception on risk of PE for births from the Medical Birth Registry of Norway for deliveries between 1999 and 2009. We also examined effect measure modification by parity, latitude (region), fetal sex, and smoking.

RESULTS

In adjusted models, PE risk was related to season, with higher risk in spring conceptions and lower risk in autumn conceptions, with a risk amplitude (maximum compared with minimum) of about 20%. The pattern replicated across subpopulations defined by parity, latitude (region), fetal sex, and smoking.

CONCLUSIONS

These results suggest that there is a seasonal driver for PE, with effects that are not modified by parity, latitude, fetal sex, or smoking. https://doi.org/10.1289/EHP963.

Human infectious diseases and risk of preeclampsia: an updated review of the literature

BACKGROUND

Preeclampsia (PE) is one of the major causes of maternal and perinatal morbidity and mortality, especially in low- and middle-income countries. In recent years, a growing body of literatures suggests that infections by bacteria, viruses, and parasites and their related inflammations play an important role in the pathogenesis of PE.

METHODS

We searched PubMed, Google scholar, and Cochrane databases using the following search words: "infection and preeclampsia," "bacterial infection and preeclampsia," "viral infection and preeclampsia" and "parasitic infection and preeclampsia."

RESULTS

The literature review revealed that many bacteria including Helicobacter pylori, Chlamydia pneumonia, and those are involved in periodontal disease or urinary tract infections (UTIs) and some viral agents such as Cytomegalovirus, herpes simplex virus type-2, human immunodeficiency virus, and some parasites especially Plasmodium spp. and Toxoplasma gondii can be effective in development of PE. Inflammation responses against infections has major role in the inducement of PE. The shift of immunological cytokine profile of Th2 toward Th1 and high levels of pro-inflammatory cytokines (TNF-ɑ, IL-12, IFN-γ, etc.), increase of oxidative stress, increase of anti-angiogenic proteins, increase of vascular endothelial growth factor receptor 1 (sVEGFR1), and complement C5a are the main potential mechanisms related to infections and enhanced development of PE.

CONCLUSION

Thus, early diagnosis and treatment of bacterial, viral, and parasitic infections could be an effective strategy to reduce the incidence of PE.

A Dormant Microbial Component in the Development of Preeclampsia

Preeclampsia (PE) is a complex, multisystem disorder that remains a leading cause of morbidity and mortality in pregnancy. Four main classes of dysregulation accompany PE and are widely considered to contribute to its severity. These are abnormal trophoblast invasion of the placenta, anti-angiogenic responses, oxidative stress, and inflammation. What is lacking, however, is an explanation of how these themselves are caused. We here develop the unifying idea, and the considerable evidence for it, that the originating cause of PE (and of the four classes of dysregulation) is, in fact, microbial infection, that most such microbes are dormant and hence resist detection by conventional (replication-dependent) microbiology, and that by occasional resuscitation and growth it is they that are responsible for all the observable sequelae, including the continuing, chronic inflammation. In particular, bacterial products such as lipopolysaccharide (LPS), also known as endotoxin, are well known as highly inflammagenic and stimulate an innate (and possibly trained) immune response that exacerbates the inflammation further. The known need of microbes for free iron can explain the iron dysregulation that accompanies PE. We describe the main routes of infection (gut, oral, and urinary tract infection) and the regularly observed presence of microbes in placental and other tissues in PE. Every known proteomic biomarker of "preeclampsia" that we assessed has, in fact, also been shown to be raised in response to infection. An infectious component to PE fulfills the Bradford Hill criteria for ascribing a disease to an environmental cause and suggests a number of treatments, some of which have, in fact, been shown to be successful. PE was classically referred to as endotoxemia or toxemia of pregnancy, and it is ironic that it seems that LPS and other microbial endotoxins really are involved. Overall, the recognition of an infectious component in the etiology of PE mirrors that for ulcers and other diseases that were previously considered to lack one.