Urinary inositol phosphoglycan-P type: near patient test to detect preeclampsia prior to clinical onset of the disease. A study on 416 pregnant Mauritian women

A review of the role of inositols in conditions of insulin dysregulation and in uncomplicated and pathological pregnancy

Inositols, a group of 6-carbon polyols, are highly bioactive molecules derived from diet and endogenous synthesis. Inositols and their derivatives are involved in glucose and lipid metabolism and participate in insulin-signaling, with perturbations in inositol processing being associated with conditions involving insulin resistance, dysglycemia and dyslipidemia such as polycystic ovary syndrome and diabetes. Pregnancy is similarly characterized by substantial and complex changes in glycemic and lipidomic regulation as part of maternal adaptation and is also associated with physiological alterations in inositol processing. Disruptions in maternal adaptation are postulated to have a critical pathophysiological role in pregnancy complications such as gestational diabetes and pre-eclampsia. Inositol supplementation has shown promise as an intervention for the alleviation of symptoms in conditions of insulin resistance and for gestational diabetes prevention. However, the mechanisms behind these affects are not fully understood. In this review, we explore the role of inositols in conditions of insulin dysregulation and in pregnancy, and identify priority areas for research. We particularly examine the role and function of inositols within the maternal-placental-fetal axis in both uncomplicated and pathological pregnancies. We also discuss how inositols may mediate maternal-placental-fetal cross-talk, and regulate fetal growth and development, and suggest that inositols play a vital role in promoting healthy pregnancy.

Prevalence of hypertensive disorders of pregnancy and pregnancy outcomes in Sub-Saharan Africa: A systematic review and meta-analysis

Hypertensive disorders of pregnancy are one of the leading causes of poor pregnancy outcomes and are associated with increased rates of maternal mortality, preterm birth, small for gestational age newborns, stillbirth, and neonatal death. The overall and type-specific prevalence of hypertensive disorders of pregnancy and associated pregnancy outcomes are unknown in Sub-Saharan Africa. Therefore, this review aimed to identify the prevalence of hypertensive disorders of pregnancy and associated pregnancy outcomes in Sub-Saharan Africa. A systematic review and meta-analysis were conducted on observational facility-based studies irrespective of publication status, sample size, language, and follow-up duration from 19 countries between the years 2000 and 2018 in Sub-Saharan Africa. A review of studies using PubMed, EMBASE, African Index Medicus, and African Journals Online was completed with independent extraction of studies by review authors using the predefined inclusion criteria. Quality and risk of bias of individual studies were assessed using the Joanna Briggs Institute Checklist. Random effects model was used to estimate the pooled prevalence of hypertensive disorders of pregnancy and type-specific hypertensive disorders of pregnancy. A pooled adjusted odds ratio with 95% confidence interval for each study was calculated using comprehensive meta-analysis version 2 software to estimate the association of hypertensive disorders of pregnancy and its outcomes. The existence of heterogeneity was assessed using I2 and its corresponding P value. We assessed the presence of publication bias using the Egger's test. Subgroup analysis was performed to assess the potential effect of variables, and a sensitivity analysis was conducted to assess any undue influence from studies. The analysis included 70 studies. The pooled prevalence of hypertensive disorders of pregnancy (all types combined), chronic hypertension, gestational hypertension, preeclampsia, and eclampsia were 8% (95% confidence interval = [5, 10]), 0.9% (95% confidence interval = [0.4, 1.8]), 4.1% (95% confidence interval = [2.4, 7]), 4.1% (95% confidence interval = [3.2, 5.1]), and 1.5% (95% confidence interval = [1, 2]), respectively. Compared with normotensive pregnant or postpartum women, women with hypertensive disorders of pregnancy were associated with increased risk of maternal mortality, odds ratio = 17 (95% confidence interval = [9.6, 28.8]); cesarean section, odds ratio = 3.1 (95% confidence interval = [1.7, 5.6]); perinatal mortality, odds ratio = 8.2 (95% confidence interval = [2.8, 24]); low birth weight, odds ratio = 3.2 (95% confidence interval = [2, 5]); and preterm delivery, odds ratio = 7.8 (95% confidence interval = [2.5, 25.3]) according to this analysis. The pooled prevalence of hypertensive disorders of pregnancy was high in Sub-Saharan Africa compared to those reported from other regions. Pregnant or postpartum women with hypertensive disorders of pregnancy have increased risk of maternal mortality, cesarean section, preterm delivery, perinatal mortality, and low birth weight newborn. Therefore, creating awareness of the risks of hypertensive disorders of pregnancy is essential. Pregnant women with hypertensive disorders need due attention to manage appropriately and more importantly to have favorable outcomes in this population.

Exploring strengths and limits of urinary D-chiro inositol phosphoglycans (IPG-P) as a screening test for preeclampsia: A systematic review and meta-analysis

Preeclampsia is a severe complication of human pregnancy as it leads to significant maternal and perinatal mortality and morbidity worldwide. A prompt recognition of women that develop this syndrome can improve clinical management, increase surveillance and, finally, improve outcomes. Different methods (based on history, ultrasound, serum and urinary biomarkers) were proposed a screening tests for this disease but their performance showed limited results. Urinary inositol phosphoglycans P-type (IPG-P) were shown to identify in advance most of the women who will develop preeclampsia in case-control and longitudinal studies, so we undertook a systematic review and meta-analysis of published studies. Seven studies met the entry criteria so were evaluated. All case-control studies showed excellent statistical performances in a quality statistical assessment. The meta-analysis considered three longitudinal, prospective studies that showed high sensitivity and specificity with ranges of 0.82- 0.99 and 0.90-1.00, respectively. Univariate measures of accuracy revealed a positive and negative likelihood ratio respectively of 3.61 (95% CI 1.56-5.67) and -2.35 (95% CI -3.79 to -0.91). By univariate approach, we found a pooled logarithm of diagnostic odds ratio of 6.15 (95% CI 2.64-9.67). A limitation of this analysis is that, although conducted in different settings (UK, Italy, France, South Africa, and Mauritius) and different clinical groups, they were based on a single academic group. According to our findings, IPG-P test showed very encouraging results as a rapid noninvasive screening test for preeclampsia. Further studies are needed to verify and to validate the reported findings.

High incidence of early onset preeclampsia is probably the rule and not the exception worldwide. 20th anniversary of the reunion workshop. A summary

The 11th workshop on Immunology of preeclampsia in Reunion 2018 celebrated its 20th candle In this paper we try to summarize the main tracks of reflections during these two decades. First, of course, the advances in immunology of reproduction in the field of preeclampsia, which was poorly developed 2 decades ago when we first started in 1998. But, this workshop has not been dedicated only to immunology. Second, one of the main reflections has always been, workshop after workshop: "why does preeclampsia exists in humans?" in an evolutionary view, as we have no established natural animal models in the other some 4500 other mammal species. Third, besides the reflections on the biological plausibility of preeclampsia-disease-of-first-pregnancies-at-a-level-of-a-couple (primipaternity rather than primigravidity), i.e. immunology, paternal-maternal conflict, we had to face an apparent conundrum: the human species should have disappeared (almost 40-50% incidence of hypertensive disorders of pregnancy in couples conceiving within the first 4 months of sexual cohabitation). We report then the dialogues we were obliged to have with zoologists who themselves had no clues on our apparent "extravagant sexuality" and strange reproduction (ridiculous low fertility rate of the human female: 25%). Fourth, debates on the main difference between early onset ("rather immunological") and late onset PE ("rather maternal vascular predispositions"). Further, the debate of why high income countries report 90% of their PE being LOP, while other countries describe epidemiologically very high incidences of EOP. Finally, and always present at all workshops, the physiopathology of the reversible systemic maternal vascular inflammation.

No effects without causes: the Iron Dysregulation and Dormant Microbes hypothesis for chronic, inflammatory diseases

Since the successful conquest of many acute, communicable (infectious) diseases through the use of vaccines and antibiotics, the currently most prevalent diseases are chronic and progressive in nature, and are all accompanied by inflammation. These diseases include neurodegenerative (e.g. Alzheimer's, Parkinson's), vascular (e.g. atherosclerosis, pre-eclampsia, type 2 diabetes) and autoimmune (e.g. rheumatoid arthritis and multiple sclerosis) diseases that may appear to have little in common. In fact they all share significant features, in particular chronic inflammation and its attendant inflammatory cytokines. Such effects do not happen without underlying and initially 'external' causes, and it is of interest to seek these causes. Taking a systems approach, we argue that these causes include (i) stress-induced iron dysregulation, and (ii) its ability to awaken dormant, non-replicating microbes with which the host has become infected. Other external causes may be dietary. Such microbes are capable of shedding small, but functionally significant amounts of highly inflammagenic molecules such as lipopolysaccharide and lipoteichoic acid. Sequelae include significant coagulopathies, not least the recently discovered amyloidogenic clotting of blood, leading to cell death and the release of further inflammagens. The extensive evidence discussed here implies, as was found with ulcers, that almost all chronic, infectious diseases do in fact harbour a microbial component. What differs is simply the microbes and the anatomical location from and at which they exert damage. This analysis offers novel avenues for diagnosis and treatment.

Incidence and natural history of preeclampsia/eclampsia at the university maternity of Antananarivo, Madagascar: high prevalence of the early-onset condition

Objectives: To investigate the incidence of early - (delivery <34 weeks) (EOP) versus late-onset (delivery ≥34 weeks) (LOP) in Madagascar. Study design: Eight months observational study of all preeclamptic/eclamptic women delivering at the maternity of the University Hospital of Befelatanana, Antananarivo, Madagascar. Sociodemographical and obstetrical risk factors are analyzed. Results: Over the study period, we found 142 combined preeclampsia/eclampsia among 4316 births (incidence 3.3% for singleton pregnancies), of which 65 eclampsia (1.5% of all deliveries). The rate of delivery <34 weeks of gestation in preeclamptic women was 37.3% and 38.5% in eclamptic ones. The overall rate of fetal and neonatal mortality was of 50% (71/142). In EO forms the infant death rate was 83% (44/53), of which approximately 33% were due to intrauterine fetal death. In LO forms, the infant death rate was 20% in preeclampsia (15% of fetal deaths), while in case of maternal eclamptic seizures the infant mortality rate was doubled (40%). There were seven maternal deaths (of which four were eclamptic women). Conclusions: We have in Madagascar a high rate of early-onset preeclampsia/eclampsia EOP (37% versus approximately 10% in international literature) and a consequent worrying rate of maternal-fetal mortality. We could find other high incidence of EOP in nine other geographical locations: Guadeloupe (31%), Réunion (31%), Mauritius (34%), Cameroon (37.4%), China (38%), Zimbabwe (58%), Thailand (34%), Turkey (29%), and India (26%). Emerging and tropical countries may belong to the "high rate of EOP standard." There is an urgent need to have additional data from these areas to confirm the hypothesis.

New insights into early and late onset subgroups of preeclampsia from longitudinal versus cross-sectional analysis of urinary inositol-phosphoglycan P-Type

Most pre-eclampsia (PE) studies have used cross-sectional data to derive conclusions regarding the pathophysiology of the condition. This has led to the concept that there exists early (<34 weeks) and late-onset (>34 weeks) disease according to gestational age at diagnosis. Survival time models have predicted that if the pregnancy was to continue indefinitely, all women would develop PE. In this study we have performed a longitudinal analysis of the urinary biomarker, inositol phosphoglycan (IPG), in a cohort of women giving birth in Mauritius (n-920). We have analysed the PE data in the traditional cross-sectional manner for n = 77 women who developed PE and also then looked at the longitudinal data for 71/77 of the same women. The data allows us to use longitudinal values to calculate a date of onset (first presence of biomarker in urine) and compare that to date of clinical diagnosis (cross sectional). We find two populations for both analysis consistent with an early and late stage subgroup. The calculated date of onset had subgroups (early and late) at 28.4 ± 0.41 weeks and 35.37 ± 0.26 weeks and for clinical date of diagnosis, 32.3 ± 0.59 weeks and 37.04 ± 0.62 weeks, respectively. The presence of the same biomarker in both subgroups and its ability to predict clinical onset 2-4 weeks prior to clinical diagnosis suggest that both groups may have similar aetiology.

Point-of-care diagnostics to improve maternal and neonatal health in low-resource settings

Each day, approximately 830 women and 7400 newborns die from complications during pregnancy and childbirth. Improving maternal and neonatal health will require bringing rapid diagnosis and treatment to the point of care in low-resource settings. However, to date there are few diagnostic tools available that can be used at the point of care to detect the leading causes of maternal and neonatal mortality in low-resource settings. Here we review both commercially available diagnostics and technologies that are currently in development to detect the leading causes of maternal and neonatal mortality, highlighting key gaps in development where innovative design could increase access to technology and enable rapid diagnosis at the bedside.

Historical evolution of ideas on eclampsia/preeclampsia: A proposed optimistic view of preeclampsia

Eclampsia (together with epilepsy) being the first disease ever written down since the beginning of writings in mankind 5000 years ago, we will make a brief presentation of the different major steps in comprehension of Pre-eclampsia. 1) 1840. Rayer, description of proteinuria in eclampsia, 2) 1897 Vaquez, discovery of gestational hypertension in eclamptic women, 3) In the 1970's, description of the "double" trophoblastic invasion existing only in humans (Brosens & Pijnenborg,), 4) between the 1970's and the 1990's, description of preeclampsia being a couple disease. The "paternity problem" (and therefore irruption of immunology), 5) at the end of the 1980's, a major step forward: Preeclampsia being a global endothelial cell disease (glomeruloendotheliosis, hepatic or cerebral endotheliosis, HELLP, eclampsia), inflammation (J.Roberts.C Redman, R Taylor), 6) End of the 1990's: Consensus for a distinction between early onset preeclampsia EOP and late onset LOP (34 weeks gestation), EOP being rather a problem of implantation of the trophoblast (and the placenta), LOP being rather a pre-existing maternal problem (obesity, diabetes, coagulopathies etc…). LOP is predominant everywhere on this planet, but enormously predominant in developed countries: 90% of cases. This feature is very different in countries where women have their first child very young (88% of world births), where the fatal EOP (early onset) occurs in more than 30% of cases. 7) What could be the common factor which could explain the maternal global endotheliosis in EOP and LOP? Discussion about the inositol phospho glycans P type.

PKB/Akt and MAPK/ERK phosphorylation is highly induced by inositols: Novel potential insights in endothelial dysfunction in preeclampsia

PKB/Akt and MAP/ERK are intracellular kinases regulating cell survival, proliferation and metabolism and as such hold a strategical role in preeclampsia. In fact intracellular pathways related to immunological alterations, endothelial dysfunction and insulin resistance in preeclampsia converge on these molecules. Inositol second messengers are involved in metabolic and cell signaling pathways and are highly expressed during preeclampsia. To evaluate the pathophysiological significance of this response, the effect of myo-inositol and d-chiro inositol on the activation of PKB/Akt and MAPK/ERK was assessed in human endothelial cells in vitro. Time-course and dose-response analyses of phosphorylation following incubation with inositols showed an approximately 6-fold and 15-fold increase for myo-inositol and d-chiro inositol (p<0.05), respectively. Both inositols promoted a significantly higher PKB/Akt and MAPK/ERK phosphorylation than insulin. Thus, exogenously administered inositols can activate PKB/Akt and MAPK/ERK in human endothelial cells in vitro. The increased production of d-chiro inositol phosphoglycans (IPG-P) during preeclampsia may thus represent a compensatory response, potentially promoting cell survival and metabolism.

10 workshops on Immunology of preeclampsia

For the 10th issue of the « island workshops », now the Reunion Workshops, organised by Pierre Yves Robillard since the first one in Tahiti challenging the "vascular disease only" theory of pre eclampsia and introducing the primipaternity concept, we examined the reasons for considering an Immunological approach to the disease. This (brief) overview thus examines several important topics in an Immunological framework. I have chosen to present here the evolution of the main themes rather than a purely chronological vision.

Evaluation of biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes mellitus: A systematic review

BACKGROUND

Pre-eclampsia is a leading cause of maternal and perinatal morbidity and mortality. Women with type 1 diabetes are considered a high-risk group for developing pre-eclampsia. Much research has focused on biomarkers as a means of screening for pre-eclampsia in the general maternal population; however, there is a lack of evidence for women with type 1 diabetes.

OBJECTIVES

To undertake a systematic review to identify potential biomarkers for the prediction of pre-eclampsia in women with type 1 diabetes.

SEARCH STRATEGY

We searched Medline, EMBASE, Maternity and Infant Care, Scopus, Web of Science and CINAHL SELECTION CRITERIA: Studies were included if they measured biomarkers in blood or urine of women who developed pre-eclampsia and had pre-gestational type 1 diabetes mellitus Data collection and analysis A narrative synthesis was adopted as a meta-analysis could not be performed, due to high study heterogeneity.

MAIN RESULTS

A total of 72 records were screened, with 21 eligible studies being included in the review. A wide range of biomarkers was investigated and study size varied from 34 to 1258 participants. No single biomarker appeared to be effective in predicting pre-eclampsia; however, glycaemic control was associated with an increased risk while a combination of angiogenic and anti-angiogenic factors seemed to be potentially useful.

CONCLUSIONS

Limited evidence suggests that combinations of biomarkers may be more effective in predicting pre-eclampsia than single biomarkers. Further research is needed to verify the predictive potential of biomarkers that have been measured in the general maternal population, as many studies exclude women with diabetes preceding pregnancy.

Putative Key Role of Inositol Messengers in Endothelial Cells in Preeclampsia

Immunological alterations, endothelial dysfunction, and insulin resistance characterize preeclampsia. Endothelial cells hold the key role in the pathogenesis of this disease. The signaling pathways mediating these biological abnormalities converge on PKB/Akt, an intracellular kinase regulating cell survival, proliferation, and metabolism. Inositol second messengers are involved in metabolic and cell signaling pathways and are highly expressed during preeclampsia. Intracellular action of these molecules is deeply affected by zinc, manganese, and calcium. To evaluate the pathophysiological significance, we present the response of the intracellular pathways of inositol phosphoglycans involved in cellular metabolism and propose a link with the disease.

Endothelial dysfunction and metabolic syndrome in preeclampsia: an alternative viewpoint

Several clinical and basic science reports have elucidated partial aspects of the pathophysiology of preeclampsia and have led many authors to conclude that different "subtypes" of the disease exist. All these subtypes share the main clinical features of the disease and present additional characteristics that define different clinical phenotypes. Nevertheless, immunological alterations, endothelial dysfunction, and insulin resistance constantly characterize this syndrome. These aspects are intimately related at a molecular level; thus, we propose an alternative approach to explaining biologically the main intracellular processes that occur in preeclampsia and this may yield an insight into the pathogenesis.

First trimester PBMC microRNA predicts adverse pregnancy outcome

PROBLEM

Prior to the end of the first trimester, pathogenic mechanisms may commit pregnancies to adverse outcome such as pre-eclampsia and miscarriage. A long-term search for biomarkers predicting these adverse outcomes has not identified any that reliably succeed prior to the beginning of the second trimester. MicroRNAs, with their important role as regulators of signaling and metabolic pathways within living cells, may offer a new approach.

METHODS

Optimal maternal PBMC microRNA markers were investigated using a series of sequential experiments, and 30 microRNAs were selected based on these results. Quantitative RT-PCR was then performed on these 30 microRNAs for 39 patients [19 healthy deliveries, 12 pre-eclampsia (seven late onset and five early onset) and eight miscarriages] during the first trimester of pregnancy. Results were scored, and their predictive values assessed.

RESULTS

MicroRNA quantification in the early first trimester (mean 34.9 ± 19.2 days post-implantation) predicted miscarriage and late pre-eclampsia with a P value of P < 0.0001 and achieved an AUC of 0.90 for miscarriage and 0.90 for late pre-eclampsia.

CONCLUSION

MicroRNA quantification of maternal blood cells offers the clinician a single test result that is simple to interpret and available much earlier in pregnancy than previously obtainable. In addition, it is the only early pregnancy marker, to date, that can successfully predict late pre-eclampsia. Although the studies that we report are preliminary, we hope that future research will build upon our discoveries and enhance the power of maternal cell microRNA to predict adverse pregnancy outcome in the clinic.