Maternal pre-eclampsia is associated with childhood epilepsy in South Carolina children insured by Medicaid

Hypertensive disorders of pregnancy and occurrence of ADHD, ASD, and epilepsy in the child: A meta-analysis

AIM

To synthesize epidemiologic literature pertaining to the association between preeclampsia (PE), attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), and epilepsy.

METHOD

A systematic search of PubMed and Embase was performed supplemented by hand-searching of reference lists of eligible studies. Two independent reviewers screened abstracts following a prepared protocol. Data extraction and quality appraisal using the Newcastle Ottawa Scale were performed by an independent reviewer. PRISMA guidelines were followed throughout. Random-effects meta-analyses were performed. Adjusted pooled Odds Ratios and their 95% confidence intervals were reported.

RESULTS

Fifteen out of 121 identified studies were eligible for inclusion. Six reported adjusted estimates for ADHD, resulting in a pooled odds ratio of 1.29 (95% CI: 1.20, 1.38). Eight reported adjusted estimates for ASD, resulting in a pooled odds ratio of 1.27 (95% CI:1.22, 1.32). Three reported adjusted estimates for epilepsy, resulting in a pooled odds ratio of 1.35 (95% CI: 1.12, 1.63).

INTERPRETATION

Intrauterine exposure to PE increased the risk of ADHD, ASD, and epilepsy, though it is unclear whether the true association is with pre-term birth. To our knowledge, this is the first meta-analysis to quantify the association between PE and epilepsy. The results of this meta-analysis can inform screening strategies among children born to preeclamptic mothers for early identification and treatment.

Quality and Content Concordance of International Clinical Guidelines on Hypertensive Disorders of Pregnancy Using the AGREE II Instrument: An Updated Systematic Review

Utilization of high-quality clinical practice guidelines has the potential to positively impact health outcomes. This study aimed to assess the quality and content concordance of national and international recommendations on hypertensive disorders of pregnancy (HDPs). Searches were conducted of the MEDLINE database and reference lists generated from national and international agencies. Covidence software was used for the management of the systematic review process, the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool was used to assess guidelines for quality, and three reviewers independently screened records. The research team identified and screened a total of 399 records of which 10 were deemed high quality. Guidelines were assessed and compared regarding the treatment, prevention, and categorization of disorders. The quality of guidelines varied across different domains, with significant variation in domain scores even within individual guidelines. Not all recommendations showed a high level of methodologic rigor, and the highest-rated guidelines were from the American Heart Association, the World Health Organization, and South Africa national guidelines. Classification of hypertension differed among the guidelines, particularly in defining chronic hypertension, severe hypertension, and preeclampsia. Prevention modalities varied across guidelines, with recommendations for aspirin, calcium supplementation, and against the use of certain approaches. Treatment modalities highlighted the importance of delivery as the definitive way to terminate hypertensive disorders of pregnancy, with other management strategies provided for symptom control. The variability in guidelines and consensus statements across different contexts may reflect regional differences in healthcare practices, available resources, and research evidence. There is potential to harmonize guidelines for HDP globally while considering the unique needs of individual countries. Where guidelines may be synthesized and condensed into an accessible format, doing so could improve their use in clinical decision-making.

The Global Pregnancy Collaboration (CoLab) symposium on short- and long-term outcomes in offspring whose mothers had preeclampsia: A scoping review of clinical evidence

Preeclampsia is a maternal syndrome characterized by the new onset of hypertension after 20 weeks of gestation associated with multisystemic complications leading to high maternal and fetal/neonatal morbidity and mortality. However, sequelae of preeclampsia may extend years after pregnancy in both mothers and their children. In addition to the long-term adverse cardiovascular effects of preeclampsia in the mother, observational studies have reported elevated risk of cardiovascular, metabolic, cerebral and cognitive complications in children born from women with preeclampsia. Less clear is whether the association between maternal preeclampsia and offspring sequelae are causal, or to what degree the associations might be driven by fetal factors including impaired growth and the health of its placenta. Our discussion of these complexities in the 2018 Global Pregnancy Collaboration annual meeting prompted us to write this review. We aimed to summarize the evidence of an association between maternal preeclampsia and neurobehavioral developmental disorders in offspring in hopes of generating greater research interest in this important topic.

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

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

Clinical outcomes of hypertensive disorders in pregnancy in the offspring during perinatal period, childhood, and adolescence

Hypertensive disorders during pregnancy (HDP) could have significant clinical impact not only on the mother's, but also on the offspring's health. The clinical impact of HDP may be evident early in the perinatal period or during childhood and adolescence. The cardiovascular system seems to be primarily affected with higher rates of congenital heart defects reported from cohort studies in the offspring of mothers with HDP. HDP are associated with alterations in cardiac and vascular structure and higher BP during childhood. HDP may also affect brain development and could result in increased prevalence of adverse cognitive outcomes and neuropsychiatric disorders in children and adolescents. The kidney, immune, endocrine, and gastrointestinal system abnormalities could also have their origin in exposure to HDP. The aim of this narrative review is to examine the clinical impact of HDP on the offspring with a focus on the perinatal period, childhood, and adolescence.

Genetic Diagnosis in Children with Epilepsy and Developmental Disorders by Targeted Gene Panel Analysis in a Developing Country

Background and Purpose

In childhood epilepsy, genetic etiology is increasingly recognized in recent years with the advent of next generation sequencing. This has broadened the scope of precision medicine in intractable epilepsy, particularly epileptic encephalopathy (EE). Developmental disorder (DD) is an integral part of childhood uncontrolled epilepsy. This study was performed to investigate the genetic etiology of childhood epilepsy and DD.

Methods

In this study, 40 children with epilepsy and DD with positive genetic mutation were included retrospectively. It was done in a tertiary care referral hospital of Bangladesh from January 2019 to December 2020. Genetic study was done by next generation sequencing. In all cases electroencephalography, neuroimaging was done and reviewed.

Results

In total, 40 children were enrolled and the average age was 41.4±35.850 months with a male predominance (67.5%). Generalized seizure was the predominant type of seizure. Regarding the association, intellectual disability and attention deficit hyperactivity disorder was common. Seventeen cases had genetically identified early infantile EE and common mutations observed were SCN1A (3), SCN8A (2), SLC1A2 (2), KCNT1 (2), and etc. Five patients of progressive myoclonic epilepsy were diagnosed and the mutations identified were in KCTD7, MFSD8, and CLN6 genes. Three cases had mitochondrial gene mutation (MT-ND5, MT-CYB). Some rare syndromes like Gibbs syndrome, Kohlschütter-Tönz syndrome, Cockayne syndrome, Pitt-Hopkins syndrome and cerebral creatine deficiency were diagnosed.

Conclusions

This is the first study from Bangladesh on genetics of epilepsy and DD. This will help to improve the understanding of genetics epilepsy of this region as well as contribute in administering precision medicine in these patients.

Preeclampsia and Neurodevelopmental Outcomes: Potential Pathogenic Roles for Inflammation and Oxidative Stress?

Preeclampsia (PE) is a common and serious hypertensive disorder of pregnancy that occurs in approximately 3-5% of first-time pregnancies and is a well-known leading cause of maternal and neonatal mortality and morbidity. In recent years, there has been accumulating evidence that in utero exposure to PE acts as an environmental risk factor for various neurodevelopmental disorders, particularly autism spectrum disorder and ADHD. At present, the mechanism(s) mediating this relationship are uncertain. In this review, we outline the most recent evidence implicating a causal role for PE exposure in the aetiology of various neurodevelopmental disorders and provide a novel interpretation of neuroanatomical alterations in PE-exposed offspring and how these relate to their sub-optimal neurodevelopmental trajectory. We then postulate that inflammation and oxidative stress, two prominent features of the pathophysiology of PE, are likely to play a major role in mediating this association. The increased inflammation in the maternal circulation, placenta and fetal circulation in PE expose the offspring to both prenatal maternal immune activation-a risk factor for neurodevelopmental disorders, which has been well-characterised in animal models-and directly higher concentrations of pro-inflammatory cytokines, which adversely affect neuronal development. Similarly, the exaggerated oxidative stress in the mother, placenta and foetus induces the placenta to secrete factors deleterious to neurons, and exposes the fetal brain to directly elevated oxidative stress and thus adversely affects neurodevelopmental processes. Finally, we describe the interplay between inflammation and oxidative stress in PE, and how both systems interact to potentially alter neurodevelopmental trajectory in exposed offspring.

Association of Preeclampsia in Term Births With Neurodevelopmental Disorders in Offspring

IMPORTANCE

Preeclampsia during pregnancy has been linked to an increased risk of cerebral palsy in offspring. Less is known about the role of preeclampsia in other neurodevelopmental disorders.

OBJECTIVE

To determine the association between preeclampsia and a range of adverse neurodevelopmental outcomes in offspring after excluding preterm births.

DESIGN, SETTING, AND PARTICIPANTS

This prospective, population-based cohort study included singleton children born at term from January 1, 1991, through December 31, 2009, and followed up through December 31, 2014 (to 5 years of age), using Norway's Medical Birth Registry and linked to other demographic, social, and health information by Statistics Norway. Data were analyzed from May 30, 2018, to November 17, 2019.

EXPOSURES

Maternal preeclampsia.

MAIN OUTCOMES AND MEASURES

Associations between preeclampsia in term pregnancies and cerebral palsy, attention-deficit/hyperactivity disorder (ADHD), autism spectrum disorder (ASD), epilepsy, intellectual disability, and vision or hearing loss using multivariable logistic regression.

RESULTS

The cohort consisted of 980 560 children born at term (48.8% female and 51.2% male; mean [SD] gestational age, 39.8 [1.4] weeks) with a mean (SD) follow-up of 14.0 (5.6) years. Among these children, 28 068 (2.9%) were exposed to preeclampsia. Exposed children were at increased risk of ADHD (adjusted odds ratio [OR], 1.18; 95% CI, 1.05-1.33), ASD (adjusted OR, 1.29; 95% CI, 1.08-1.54), epilepsy (adjusted OR, 1.50; 95% CI, 1.16-1.93), and intellectual disability (adjusted OR, 1.50; 95% CI, 1.13-1.97); there was also an apparent association between preeclampsia exposure and cerebral palsy (adjusted OR, 1.30; 95% CI, 0.94-1.80).

CONCLUSIONS AND RELEVANCE

Preeclampsia is a well-established threat to the mother. Other than the hazards associated with preterm delivery, the risks to offspring from preeclampsia are usually regarded as less important. This study's findings suggest that preeclampsia at term may have lasting effects on neurodevelopment of the child.

Association between hypertensive disorders of pregnancy and the development of offspring mental and behavioural problems: A systematic review and meta-analysis

Hypertensive disorders of pregnancy are a major cause of maternal and offspring morbidity and mortality worldwide. However, its effect on offspring mental and behavioural disorders is unclear. The aim of this study is to provide the best scientific evidence on the association between hypertensive disorders of pregnancy and offspring mental and behavioural problems. We systematically searched Scopus, PubMed, Cochrane, EMBASE, CINAH and PsycINFO databases. A total of 23 studies (11 included in meta-analysis) were identified. Of the 23 studies included in this review, 15 studies found that hypertensive disorders of pregnancy had a negative impact for at least one mental or behavioural disorder. The pooled effect of 11 studies included in the meta-analysis showed that preeclampsia was associated with increased risk of offspring schizophrenia. However, we found inconclusive finding on the effect of hypertensive disorders of pregnancy and other mental and behavioural disorders. Further high quality, large sample, birth cohort studies are needed to further progress this area of research.

Etiology, syndrome diagnosis, and cognition in childhood-onset epilepsy: A population-based study

Objective

To evaluate the prevalence of various etiologies of epilepsies and epilepsy syndromes and to estimate cognitive function in cases of childhood‐onset epilepsy.

Methods

A population‐based retrospective registry study. We identified all medically treated children with epilepsy born in 1989–2007 in Finland's Kuopio University Hospital catchment area, combining data from the birth registry and the national registry of special‐reimbursement medicines. We reevaluated the epilepsy diagnoses and syndromes and gathered data on etiologies and cognitive impairment.

Results

We identified 289 children with epilepsy. The annual incidence rate of epilepsies and epilepsy syndromes was 38 in 100,000, and the misdiagnosis rate was 3%. A specific etiology was identified in 65% of the cases, with a structural etiology accounting for 29% and a genetic or presumed genetic etiology for 32%. Most patients with unknown‐etiology epilepsy had focal epilepsy and were of normal intelligence. Intellectual disability was detected in 35% of cases, and only 17% in this group had an unknown etiology for the epilepsy. Electroclinical syndromes (mainly West syndrome) were recognized in 35% of the patients.

Significance

Epilepsy is a complex disease that encompasses many etiologies and rare syndromes. The etiology and specific epilepsy syndrome are important determinants of the outcome and key factors in treatment selection. Etiological diagnosis can be achieved for the majority of children and syndromic diagnosis for only a third.

Infertility treatment and umbilical cord length-novel markers of childhood epilepsy?

Background

Epilepsy is one of the most common neurologic disorders of childhood, affecting about 0.4−0.8% of all children up to the age of 20.

Methodology

A population-based retrospective cohort study. Aim was to determine incidence and identify perinatal and reproductive risk factors of epilepsy in children born between 1989 and 2008 among women (n = 43,389) delivered in Kuopio University Hospital. Risk factors of childhood epilepsy were determined by using logistic regression analysis.

Principal Findings

The incidence of childhood epilepsy was 0.7% (n = 302 of 43,389). Maternal epilepsy, major congenital anomalies and use of assisted reproductive technology (ART) were associated with 4.25-, 3.61-, and 1.67- fold increased incidence of childhood epilepsy. A 10 cm increase in umbilical cord length was associated with a 15% decrease in the incidence of epilepsy (adjusted OR 0.85, 95% CI 0.78−0.94). However, the above reproductive factors accounted for less than 2% of total incidence, whereas maternal epilepsy proved to be the highest risk factor.

Conclusions

Perinatal and reproductive factors were shown to be minor risk factors of childhood epilepsy, implying that little can be done in obstetric care to prevent childhood epilepsy. Infertility treatment and umbilical cord length, independent of gestational age and congenital malformations, may be novel markers of childhood epilepsy.

Maternal hypertension and intrapartum fever are associated with increased risk of ischemic stroke during infancy

AIM

To examine maternal hypertension, diabetes, and intrapartum fever as potential risk factors for ischemic stroke in infants.

METHOD

We conducted a retrospective cohort study of 226,117 children born from January 2000 to December 2007 who were enrolled in the South Carolina Medicaid program. We linked maternal and child Medicaid billing records and birth certificate data. Children with ischemic stroke were identified based on the International Classification of Diseases, Ninth Revision (ICD-9), code 434 in the child's billing data. Independent variables and covariates were identified using ICD-9 codes and birth certificate data. We modeled the odds of ischemic stroke diagnosis in infants, either before 30 days of life or before 365 days.

RESULTS

Forty-three children were diagnosed with ischemic stroke before 30 days and 161 before 365 days. Maternal hypertension (odds ratio 2.31 before 30 d) and intrapartum fever (odds ratio 3.36 <30 d) were significantly associated with odds of ischemic stroke before 30 days and before 365 days; maternal diabetes was not.

INTERPRETATION

Maternal hypertension and intrapartum fever appear to be risk factors for ischemic stroke in infants. Additional research is needed to determine the mechanism(s) underlying these associations and to develop effective preventive methods for high-risk infants.