Risk factors associated with preeclampsia in healthy nulliparous women. The Calcium for Preeclampsia Prevention (CPEP) Study Group

Exploring the Complex Interplay of Trace Elements and Their Association with the Risk of Development of Pre-eclampsia in Pregnancy: a Case-Control

Pre-eclampsia, a hypertensive disorder occurring during pregnancy, poses significant risks to maternal and fetal health worldwide. Despite extensive research, the precise cause of pre-eclampsia remains unknown. Recent studies have indicated that trace elements, essential minerals crucial for various biological processes, might be significant factors in the development of pre-eclampsia. This study examines the intricate relationship between trace elements (magnesium, copper, zinc, calcium, phosphorus, and iron) and the severity of pre-eclampsia. The study involves a total of 150 participants, categorized into three distinct groups: 50 individuals with mild pre-eclampsia, 50 with severe pre-eclampsia, and 50 healthy pregnant controls. Specifically, out of the 100 pre-eclampsia cases, 5 were identified as early-onset and 95 as late-onset. Participants were recruited from a tertiary care hospital based on stringent inclusion and exclusion criteria. All the trace elements were quantitatively measured by direct colorimetric method using the Beckman Coulter AU480 analyzer system (Beckman Coulter, USA). Pre-eclampsia cases exhibited a significantly lowered level of magnesium (2.02 mg/dL), zinc (57.62 mg/dL), calcium (8.02 mg/dL), and phosphorus (3.93 mg/dL). These levels were approximately 14.4%, 20.2%, 21.1%, and 22.6% lower when compared to healthy pregnant women. Conversely, copper (151.67 mg/dL) and iron (53 μg/dL) levels were significantly elevated in pre-eclampsia cases. Age emerged as a significant risk factor, correlating with heightened pre-eclampsia susceptibility. Magnesium showed a protective effect, correlating negatively with age and positively with gestational age. The complex relationships between trace elements, age, and pre-eclampsia underline the need for personalized interventions, potentially including magnesium supplementation, in high-risk pregnancies.

A Comparative Study of Oral Nifedipine and Intravenous Labetalol for Acute Hypertensive Management in Pregnancy: Assessing Feto-Maternal Outcomes in a Hospital-based Randomized Control Trial

Background and Objective

Hypertension is one of the most common medical complications during pregnancy and a leading cause of maternal mortality and morbidity. Severe preeclampsia is defined as blood pressure (BP) >160/110 mmHg with warning signs such as headache, blurring of vision, and epigastric pain. Nifedipine (C17H18N2O6), labetalol (C19H24N2O3), and hydralazine (C8H8N4) are commonly used drugs, and all are recommended as first-line agents. Hydralazine is associated with a higher incidence of adverse outcomes, so oral nifedipine has been proposed as a first-line alternative to intravenous labetalol. Consequently, this study aims to compare the efficacy and safety of oral nifedipine with that of intravenous labetalol. The objective is to compare the ability/effectiveness of oral nifedipine and intravenous labetalol to normalize acute hypertension in severe preeclampsia and to assess the birth outcome. Relations between different factors were established by appropriate statistical tests. The p-value <0.05 was considered statistically significant.

Methods

The study was conducted on 120 antenatal women with blood pressure ≥160/110 mmHg admitted to our hospital, a tertiary care center, from January 1st, 2020 to June 30th, 2021. Patients were randomized by a single blinding method to receive intravenous labetalol and oral nifedipine. The primary outcome measures were the time taken to control the blood pressure and the number of doses of drugs required. The secondary outcome measures were the birth outcome like a method of delivery, side effect profile, and the number of admissions in the neonatal intensive care unit.

Results

A total of 120 patients were included with 60 patients in each group. The labetalol group took 48.67 ± 17.80 minutes and the nifedipine group took 64.33 ± 9.81 minutes to achieve a target BP of <=140/90 mmHg (p < 0.05). No side effects were seen in 70% of patients in the labetalol group and 71.67% in the nifedipine group (p > 0.05).

Conclusion and Global Health Implications

Intravenous labetalol is faster in restoring blood pressure in pregnant women with preeclampsia than oral nifedipine and may be used as a first-line drug in the acute control of blood pressure in a hypertensive emergency during pregnancy. More studies are needed in order to evaluate the findings from this pilot study in a large sample of patients.

The effects of leptin on human cytotrophoblast invasion are gestational age and dose-dependent

Introduction

Leptin and its receptors are expressed by the human placenta throughout gestation, yet the role of leptin in early human placental development is not well characterized. Leptin is overexpressed in the placentas from preeclamptic (PE) pregnancies. PE can result from the impaired invasion of fetal placental cells, cytotrophoblasts (CTBs), into the maternal decidua. We hypothesized that elevated leptin levels would impair human CTB invasion.

Methods

The effects of leptin on the invasion of human CTBs were evaluated in three cell models, HTR-8/SVneo cells, primary CTBs, and placental villous explants using invasion assays. Further, leptin receptor expression was characterized in all three cell models using RT-PCR. Further phosphokinase assays were performed in HTR-8/SVneo cells to determine signaling pathways involved in CTB invasion in response to differential leptin doses.

Results

We found that, prior to 8 weeks gestation, leptin promoted CTB invasion in the explant model. After 11 weeks gestation in explants, primary CTBs and in HTR-8/SVneo cells, leptin promoted invasion at moderate but not at high concentrations. Further, leptin receptor characterization revealed that leptin receptor expression did not vary over gestation, however, STAT, PI3K and MAPK pathways showed different signaling in response to varied leptin doses.

Discussion

These data suggest that the excess placental leptin observed in PE may cause impaired CTB invasion as a second-trimester defect. Leptin's differential effect on trophoblast invasion may explain the role of hyperleptinemia in preeclampsia pathogenesis.

Diabetic and hypertensive disorders following early pregnancy loss: a systematic review and meta-analysis

Background

Spontaneous and induced abortions are common outcomes of pregnancy. There is inconsistent evidence of an association between early pregnancy loss and subsequent diabetic and hypertensive disorders in women. This systematic review and meta-analysis evaluated evidence on the risk of the subsequent development of pregnancy and non-pregnancy related diabetic and hypertensive disorders in women who experienced an early pregnancy loss.

Methods

Systematic searches were conducted in seven electronic databases (CINAHL Plus, Ovid/EMBASE, Ovid/MEDLINE, ProQuest, PubMed, Scopus, and Web of Science) from inception to 22nd December 2023. Studies were included if they reported an exposure of spontaneous abortion (SAB), induced abortion (IA) or recurrent pregnancy loss (RPL) with an outcome of gestational diabetes mellitus, pre-eclampsia, gestational hypertension, and non-pregnancy related diabetic and hypertensive disorders. Risk of bias was assessed using Risk of Bias Instrument for Non-Randomized Studies of Exposures (ROBINS-E). Random effects meta-analysis was used to pool odds of developing diabetic and hypertensive disorders following an early pregnancy loss. This study is registered with PROSPERO (CRD42022327689).

Findings

Of 20,176 records, 60 unique articles were identified for full-text review and 52 met the inclusion criteria, representing a total population of 4,132,895 women from 22 countries. Thirty-five studies were suitable for meta-analysis, resulting in a pooled odds ratio (OR) of 1.44 (95% confidence interval (CI) 1.23-1.68) for gestational diabetes mellitus following a prior SAB and a pooled OR of 1.06 (95% CI 0.90-1.26) for pre-eclampsia following a prior SAB. RPL increased the odds of developing pre-eclampsia (OR 1.37 95% CI 1.05-1.79). There was no association between IA and diabetic and hypertensive disorders.

Interpretation

A prior SAB was associated with increased odds of gestational diabetes mellitus, but not pre-eclampsia. However, women who experienced RPL had an increased risk of subsequent pre-eclampsia. Future research is required to establish evidence for an association between early pregnancy loss with non-pregnancy related diabetic and hypertensive disorders.

Funding

National Health and Medical Research Council.

Sex-Specific Obesity and Cardiometabolic Disease Risks in Low- and Middle-Income Countries: A Meta-Analysis Involving 3 916 276 Individuals

CONTEXT

There is limited knowledge about the disparities between the sexes in obesity prevalence and associated cardiovascular complications in low- and middle-income countries (LMICs).

OBJECTIVE

We undertook a systematic review and meta-analysis to assess sex-specific disparities in the prevalence of obesity and cardiometabolic diseases in LMICs, the burden in women, and variations by region, country's income status, setting, and time.

METHODS

We searched major databases from inception to March 2023. Two independent reviewers selected the studies, assessed their quality, and extracted data. We used DerSimonian and Laird random-effects models to obtain pooled estimates of odds ratios and 95% CI for the association between sex and obesity and cardiometabolic diseases, and multilevel random-effects logistic regression models to estimate the prevalence of relevant outcomes (PROSPERO CRD42019132609).

RESULTS

We included 345 studies (3 916 276 individuals). The odds of obesity were 2.72-fold higher in women than men (OR 2.72; 95% CI, 2.54-2.91). The sex-specific disparities varied by region, with the greatest disparities in Sub-Saharan Africa (OR 3.91; 95% CI, 3.49-4.39). Among women in LMICs, 23% (95% CI, 21%-25%) had obesity, 27% (95% CI, 24%-29%) had hypertension, and 7% (95% CI, 6%-9%) had type 2 diabetes. The prevalence of obesity and type 2 diabetes in women varied by region, country's income, and setting, with the highest prevalence in the Middle East and North Africa, upper-middle-income countries and urban settings. The odds of hypertension (OR 2.41; 95% CI, 1.89-3.08) and type 2 diabetes (OR 2.65; 95% CI, 1.76-3.98) were doubled in women with vs without obesity.

CONCLUSION

There is an urgent need for a women-centred and region-stratified approach to tackle obesity awareness, treatment, and prevention in women in LMICs.

Soluble suppression of tumorigenicity-2 in pregnancy with a small-for-gestational-age fetus and with preeclampsia

OBJECTIVE

Preeclampsia and fetal growth disorders are pregnancy-specific conditions that share common pathophysiological mechanisms. Yet, why some patients develop preeclampsia while others experience fetal growth restriction, or a combination of both clinical presentations, is unknown. We propose that the difference in severity of the maternal inflammatory response can contribute to the clinical phenotypes of preeclampsia vs. small for gestational age (SGA). To assess this hypothesis, we measured maternal plasma concentrations of the soluble isoform of suppression of tumorigenicity-2 (sST2), a member of the interleukin-1 receptor family that buffers proinflammatory responses. Previous reports showed that serum sST2 concentrations rise in the presence of intravascular inflammation and Th1-type immune responses and are significantly higher in patients with preeclampsia compared to those with normal pregnancy. The behavior of sST2 in pregnancies complicated by SGA has not been reported. This study was conducted to compare sST2 plasma concentrations in normal pregnancies, in those with preeclampsia, and in those with an SGA fetus.

METHODS

This retrospective cross-sectional study included women with an SGA fetus (n = 52), women with preeclampsia (n = 106), and those with normal pregnancy (n = 131). Maternal plasma concentrations of sST2 were determined by enzyme-linked immunosorbent assay. Doppler velocimetry of the uterine and umbilical arteries was available in a subset of patients with SGA (42 patients and 43 patients, respectively).

RESULTS

(1) Women with an SGA fetus had a significantly higher median plasma concentration of sST2 than normal pregnant women (p = .008); (2) women with preeclampsia had a significantly higher median plasma concentration of sST2 than those with normal pregnancy (p < .001) and those with an SGA fetus (p < .001); (3) patients with SGA and abnormal uterine artery Doppler velocimetry had a higher median plasma concentration of sST2 than controls (p < .01) and those with SGA and normal uterine artery Doppler velocimetry (p = .02); (4) there was no significant difference in the median plasma sST2 concentration between patients with SGA who had normal uterine artery Doppler velocimetry and controls (p = .4); (5) among patients with SGA, those with abnormal and those with normal umbilical artery Doppler velocimetry had higher median plasma sST2 concentrations than controls (p = .001 and p = .02, respectively); and (6) there was no significant difference in the median plasma sST2 concentrations between patients with SGA who did and those who did not have abnormal umbilical artery Doppler velocimetry (p = .06).

CONCLUSIONS

Preeclampsia and disorders of fetal growth are conditions characterized by intravascular inflammation, as reflected by maternal plasma concentrations of sST2. The severity of intravascular inflammation is highest in patients with preeclampsia.

Comparison of the efficacy of intravenous labetalol versus oral nifedipine in patients with severe pregnancy-induced hypertension beyond 30 weeks of gestation

Hypertensive disorders of pregnancy affect 5% to 10% of all pregnancies globally. The aim of treatment is to bring down blood pressure (BP) quickly and smoothly, which is safe for the mother and baby. The aim of our study was to study the efficacy and safety of intravenous labetalol and oral nifedipine in severe pregnancy-induced hypertension.

Materials and Methods

It is a retrospective observational study, intravenous labetalol 20 mg was given initially in escalating doses of 40 mg, 80 mg, 80 mg, and 80 mg every 15 mins up to a maximum dose of 5 or until the goal BP ≤150/100 mmHg was reached. Some women with severe pregnancy-induced hypertension were given oral nifedipine to control their BP according to the choice of the attending consultant. Nifedipine 10 mg tablet was given initially in repeated doses of 10 mg every 15 mins up to a maximum of five doses or until the goal of BP ≤150/100 mmHg was reached.

Results

In our study, we found that there was a strong statistical significance in stabilizing the BP with oral nifedipine than with intravenous labetalol drug used. The majority of the patients in the oral nifedipine group got to normal BP quicker when compared to intravenous labetalol group patients.

Conclusion

From this study, both drugs were found to be safe and effective in the reduction in BP. The use of nifedipine may be recommended in low-resource settings since it has an oral regimen and dosage is simple when compared to incremental intravenous dosing of labetalol.

Preeclampsia at term can be classified into 2 clusters with different clinical characteristics and outcomes based on angiogenic biomarkers in maternal blood

BACKGROUND

An antiangiogenic state has emerged as a mechanism of disease in preeclampsia. Angiogenic biomarkers are used in the risk assessment of this syndrome, particularly of early disease. The role of an antiangiogenic state in late preeclampsia is unclear.

OBJECTIVE

This study aimed to determine the prevalence, characteristics, and clinical significance of angiogenic/antiangiogenic factor abnormalities in women with preeclampsia stratified according to gestational age at delivery.

STUDY DESIGN

Two studies were conducted: (1) a longitudinal nested case-control study comprising women with preeclampsia (n=151) and a control group (n=540); and (2) a case series of patients with preeclampsia (n=452). In patients with preeclampsia, blood was collected at the time of diagnosis. Plasma concentrations of placental growth factor and soluble fms-like tyrosine kinase-1 were determined by enzyme-linked immunosorbent assays. An abnormal angiogenic profile was defined as a plasma ratio of placental growth factor and soluble fms-like tyrosine kinase-1 expressed as a multiple of the median <10th percentile for gestational age based on values derived from the longitudinal study. The proportion of patients diagnosed with preeclampsia who had an abnormal angiogenic profile was determined in the case-series participants and stratified by gestational age at delivery into early (≤34 weeks), intermediate (34.1-36.9 weeks), and term (≥37 weeks) preeclampsia. The demographics, clinical characteristics, and pregnancy outcomes of women with preeclampsia with and without an abnormal angiogenic profile were compared.

RESULTS

The prevalence of an abnormal angiogenic profile was higher in preterm than in term preeclampsia (for early, intermediate, and term in the case-control study: 90%, 100%, and 39%; for the case series: 98%, 80%, and 55%, respectively). Women with preeclampsia at term who had an abnormal angiogenic profile were more frequently nulliparous (57% vs 35%), less likely to smoke (14% vs 26%), at greater risk for maternal (14% vs 5%) or neonatal (7% vs 1%) complications, and more often had placental lesions consistent with maternal vascular malperfusion (42% vs 23%; all, P<.05) than those without an abnormal profile. Women with preeclampsia at term who had a normal angiogenic profile had a higher frequency of chronic hypertension (36% vs 21%) and were more likely to have class ≥2 obesity (41% vs 23%) than those with an abnormal profile (both, P<.05).

CONCLUSION

Patients with early preeclampsia had an abnormal angiogenic profile in virtually all cases, whereas only 50% of women with preeclampsia at term had such abnormalities. The profile of angiogenic biomarkers can be used to classify patients with preeclampsia at term, on the basis of mechanisms of disease, into 2 clusters, which have different demographics, clinical characteristics, and risks of adverse maternal and neonatal outcomes. These findings provide a simple approach to classify preeclampsia at term and have implications for future clinical care and research.

A Comprehensive and Bias-Free Machine Learning Approach for Risk Prediction of Preeclampsia with Severe Features in a Nulliparous Study Cohort

Objective

Preeclampsia is one of the leading causes of maternal morbidity, with consequences during and after pregnancy. Because of its diverse clinical presentation, preeclampsia is an adverse pregnancy outcome that is uniquely challenging to predict and manage. In this paper, we developed machine learning models that predict the onset of preeclampsia with severe features or eclampsia at discrete time points in a nulliparous pregnant study cohort.

Materials and Methods

The prospective study cohort to which we applied machine learning is the Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-be (nuMoM2b) study, which contains information from eight clinical sites across the US. Maternal serum samples were collected for 1,857 individuals between the first and second trimesters. These patients with serum samples collected are selected as the final cohort.

Results

Our prediction models achieved an AUROC of 0.72 (95% CI, 0.69-0.76), 0.75 (95% CI, 0.71-0.79), and 0.77 (95% CI, 0.74-0.80), respectively, for the three visits. Our initial models were biased toward non-Hispanic black participants with a high predictive equality ratio of 1.31. We corrected this bias and reduced this ratio to 1.14. The top features stress the importance of using several tests, particularly for biomarkers and ultrasound measurements. Placental analytes were strong predictors for screening for the early onset of preeclampsia with severe features in the first two trimesters.

Conclusion

Experiments suggest that it is possible to create racial bias-free early screening models to predict the patients at risk of developing preeclampsia with severe features or eclampsia nulliparous pregnant study cohort.

Safety of tacrolimus use during pregnancy and related pregnancy outcomes in patients with systemic lupus erythematosus: A retrospective single-center analysis in Japan

OBJECTIVE

Tacrolimus is one of the drugs that can be used in pregnancies complicated with systemic lupus erythematosus (SLE), but there are still few reports on its pregnancy outcomes. Although tacrolimus has been reported to cause adverse events, such as increased blood pressure, abnormal glucose metabolism, and susceptibility to infection, there have been no studies on the impact of tacrolimus in SLE pregnancies at these points. We performed a retrospective observational study of pregnancies complicated by SLE at St Luke's International Hospital in Tokyo from April 2003 to August 2021.

METHODS

Basic clinical information on SLE, pregnancy outcomes, disease activity before and after pregnancy, laboratory results, blood pressure, blood glucose levels, treatment regimens, and presence of infection was extracted from electronic medical records. We defined overall adverse pregnancy outcomes (APOs) as follows: (1) fetal death after 10 gestational weeks, (2) preterm delivery, (3) delivery due to hypertensive disorders of pregnancy, preeclampsia, or placental insufficiency, or (4) the diagnosis of small for gestational age infants. We also examined whether there was a statistical difference in APO incidence between patients treated with and without tacrolimus.

RESULTS

Pregnancy outcomes were obtained for 48 patients with a total of 60 pregnancies complicated by SLE. In 20 (33.3%) of these pregnancies, the patients took tacrolimus, and 28 (46.7%) of the pregnancies had APOs. APO incidence did not statistically differ between the tacrolimus and non-tacrolimus groups in the multivariate analysis (p = 1.00, adjusted OR 1, 95% CI: 0.23-4.39). Multiple regression analyses indicated that tacrolimus use did not significantly affect systolic blood pressure in the third trimester (B = -2.23, p = .74) or blood glucose levels in the first trimester (B = 10.2, p = .056). Incidence of infections did not significantly differ between patients treated with and without tacrolimus in the univariate analysis (10.8% vs. 21.1%, p = .42).

CONCLUSION

Tacrolimus did not significantly affect pregnancy outcomes, blood pressure, or glucose levels. Further research is required to confirm its effects in a larger population.

Pre-eclampsia

Pre-eclampsia is a life-threatening disease of pregnancy unique to humans and a leading cause of maternal and neonatal morbidity and mortality. Women who survive pre-eclampsia have reduced life expectancy, with increased risks of stroke, cardiovascular disease and diabetes, while babies from a pre-eclamptic pregnancy have increased risks of preterm birth, perinatal death and neurodevelopmental disability and cardiovascular and metabolic disease later in life. Pre-eclampsia is a complex multisystem disease, diagnosed by sudden-onset hypertension (>20 weeks of gestation) and at least one other associated complication, including proteinuria, maternal organ dysfunction or uteroplacental dysfunction. Pre-eclampsia is found only when a placenta is or was recently present and is classified as preterm (delivery <37 weeks of gestation), term (delivery ≥37 weeks of gestation) and postpartum pre-eclampsia. The maternal syndrome of pre-eclampsia is driven by a dysfunctional placenta, which releases factors into maternal blood causing systemic inflammation and widespread maternal endothelial dysfunction. Available treatments target maternal hypertension and seizures, but the only 'cure' for pre-eclampsia is delivery of the dysfunctional placenta and baby, often prematurely. Despite decades of research, the aetiology of pre-eclampsia, particularly of term and postpartum pre-eclampsia, remains poorly defined. Significant advances have been made in the prediction and prevention of preterm pre-eclampsia, which is predicted in early pregnancy through combined screening and is prevented with daily low-dose aspirin, starting before 16 weeks of gestation. By contrast, the prediction of term and postpartum pre-eclampsia is limited and there are no preventive treatments. Future research must investigate the pathogenesis of pre-eclampsia, in particular of term and postpartum pre-eclampsia, and evaluate new prognostic tests and treatments in adequately powered clinical trials.

A bibliometric review of 35 years of studies about preeclampsia

The purpose of this study is to investigate preeclampsia. It used the visualization tools of CiteSpace, VOSviewer, Gunnmap, Bibliometrix®, and Carrot2 to analyze 3,754 preeclampsia studies from 1985 to 2020 in Obstetrics and Gynecology areas. Carrot2 was used to explain each cluster in extra detail. The results found that there is an increasing trend in many publications related to preeclampsia from 1985 to 2020. The number of studies on preeclampsia has increased significantly in the last century. Analysis of the keywords found a strong relationship with preeclampsia concepts and keywords classified into five categories. Co-citation analysis was also performed which was classified into six categories. Reading the article offers important to support not only to grind the context of preeclampsia challenges but also to design a new trend in this field. The number of studies on preeclampsia has substantially improved over the decades ago. The findings of documents published from 1985 to 2020 showed three stages in research on this subject: 1985 to 1997 (a seeding stage), 1997-2005 (rapid growth stage), and 2005 onwards (development stage).

One-third of patients with eclampsia at term do not have an abnormal angiogenic profile

OBJECTIVES

An abnormal angiogenic profile is present in about one-half of women with preeclampsia at term. Few studies examined the roles of angiogenic biomarkers in eclampsia. The aims of this study were to determine (1) whether the degree of an anti-angiogenic state, reflected by a low placental growth factor (PlGF) to soluble fms-like tyrosine kinase-1 (sFlt-1) ratio, in women with eclampsia differed from that of women with severe preeclampsia; and (2) the prevalence of women who had an abnormal angiogenic profile at the diagnoses of preterm and term eclampsia.

METHODS

A cross-sectional study was conducted to include women in the following groups: (1) uncomplicated pregnancy (n=40); (2) severe preeclampsia (n=50); and (3) eclampsia (n=35). Maternal serum concentrations of PlGF and sFlt-1 were determined by immunoassays.

RESULTS

Women with preterm, but not term, eclampsia had a more severe anti-angiogenic state than those with severe preeclampsia (lower PlGF and PlGF/sFlt-1 ratio, each p<0.05). However, the difference diminished in magnitude with increasing gestational age (interaction, p=0.005). An abnormal angiogenic profile was present in 95% (19/20) of women with preterm eclampsia but in only 67% (10/15) of women with eclampsia at term.

CONCLUSIONS

Angiogenic biomarkers can be used for risk assessment of preterm eclampsia. By contrast, a normal profile of angiogenic biomarkers cannot reliably exclude patients at risk for eclampsia at term. This observation has major clinical implications given that angiogenic biomarkers are frequently used in the triage area as a test to rule out preeclampsia.

Pregnancy after living kidney donation, a systematic review of the available evidence, and a review of the current guidance

Understanding and communicating the risk of pregnancy complications post-living kidney donation is imperative as the majority of living kidney donors (LKD) are women of childbearing age. We aimed to identify all original research articles examining complications in post-donation pregnancies and compared the quality and consistency of related guidelines. We searched Embase, MEDLINE, PubMed, society webpages, and guideline registries for English-language publications published up until December 18, 2020. Ninety-three articles were screened from which 16 studies were identified, with a total of 1399 post-donation pregnancies. The outcome of interest, post-donation pregnancy complications, was not calculable, and only a narrative synthesis of the evidence was possible. The absolute risk of pre-eclampsia increased from ~1%-3% pre-donation (lower than the general population) to ~4%-10% post-donation (comparable to the general population). The risks of adverse fetal and neonatal outcomes were no different between post-donation and pre-donation pregnancies. Guidelines and consensus statements were consistent in stating the need to inform LKDs of their post-donation pregnancy risk, however, the depth and scope of this guidance were variable. While the absolute risk of pregnancy complications remains low post-donation, a concerted effort is required to better identify and individualize risk in these women, such that consent to donation is truly informed.

The impact of different endometrial preparation protocols on obstetric and neonatal complications in frozen-thawed embryo transfer: a retrospective cohort study of 3,458 singleton deliveries

BACKGROUND

Frozen-thawed embryo transfer (FET) is thought to be associated with obstetric and neonatal complications after in vitro fertilization/intracytoplasmic single sperm injection (IVF/ICSI) treatment. The study aimed to determine whether the endometrial preparation protocol is an influencing factor for these complications.

METHODS

We conducted a retrospective cohort study of 3,458 women who had singleton deliveries after IVF/ICSI-FET treatment at the Centre for Reproductive Medicine of Shanghai First Maternity and Infant Hospital between July 2016 and April 2021. The women were divided into three groups according to the endometrial preparation protocols: 2,029 women with programmed cycles, 959 with natural cycles, and 470 with minimal ovarian stimulation cycles. The primary outcomes were the incidence rates of obstetric and neonatal complications, namely, hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), intrahepatic cholestasis of pregnancy (ICP), placenta previa, preterm rupture of membranes (PROM), preterm delivery, postpartum haemorrhage, large for gestational age (LGA), small for gestational age (SGA), and macrosomia.

RESULTS

After adjustments for confounding variables by multivariate logistic regression analysis, the results showed that programmed cycles had an increased risk of HDP (aOR = 1.743; 95% CI, 1.110-2.735; P = 0.016) and LGA (aOR = 1.269; 95% CI, 1.011-1.592; P = 0.040) compared with natural cycles. Moreover, programmed cycles also increased the risk of LGA (aOR = 1.459; 95% CI, 1.083-1.965; P = 0.013) but reduced the risk of SGA (aOR = 0.529; 95% CI, 0.348-0.805; P = 0.003) compared with minimal ovarian stimulation cycles. There were no significant differences between natural cycles and minimal ovarian stimulation cycles.

CONCLUSIONS

During IVF/ICSI-FET treatment, the risk of HDP and LGA was increased in women with programmed cycles. Therefore, for patients with thin endometrium, irregular menstruation or no spontaneous ovulation, minimal ovarian stimulation cycles may be a relatively safer option than programmed cycles.

Antibiotic Prophylaxis to Prevent Obesity-Related Induction Complications in Nulliparae at Term: a pilot randomized controlled trial

BACKGROUND

Women with obesity are at increased risk of complications during and after labor and delivery, including puerperal infection and cesarean delivery. As labor induction has become increasingly common, it is crucial to find ways to decrease complication rates in this high-risk population.

OBJECTIVE

This study aimed to explore the effect of prophylactic antibiotics during labor induction of nulliparous women with obesity on the rates of cesarean delivery and puerperal infection and to estimate the parameters needed to calculate the sample size for a larger, multicenter trial.

STUDY DESIGN

In this randomized, placebo-controlled pilot trial, nulliparous patients with a body mass index of ≥30 kg/m2 were randomized to either prophylactic antibiotics (500 mg azithromycin for 1 dose and 2 g cefazolin every 8 hours for up to 3 doses) or placebo, administered starting at the beginning of labor induction. The exclusion criteria were known fetal anomaly, fetal demise, multifetal gestation, ruptured membranes >12 hours, infection requiring antibiotics at the start of labor induction, and/or allergy to azithromycin or beta-lactam antibiotics. The co-primary outcomes were rates of puerperal infection (composite of chorioamnionitis, endometritis, and/or cesarean delivery wound infection) and cesarean delivery. Participants were followed up for 30 days after delivery, and maternal and neonatal demographic and outcome data were collected. Proportions and 95% confidence limits were calculated for each of these outcomes.

RESULTS

From January 2019 to May 2021, 101 patients were randomized in the class III stratum (1 patient who was randomized ultimately did not undergo labor induction). From February 2020 to May 2021, 38 and 47 patients were randomized to class I and II strata, respectively (to assess the effect of obesity class on the outcomes expected to be influenced by antibiotic prophylaxis). In the antibiotics and placebo groups, the rates of cesarean delivery were 29.0% (95% confidence interval, 19.8-38.3) and 39.8% (95% confidence interval, 29.8-49.7), respectively, and puerperal infection occurred in 8.6% (95% confidence interval, 2.9-14.3) and 9.7% (95% confidence interval, 3.7-15.7), respectively. In the subgroup with class III obesity, in the antibiotics and placebo groups, the rates of cesarean delivery were 33.3% (95% confidence interval, 20.4-47.9) and 46.0% (95% confidence interval, 32.2-59.8), respectively, and puerperal infection occurred in 7.8% (95% confidence interval, 0.5-15.2) and 10.0% (95% confidence interval, 1.7-18.3), respectively. Note that this pilot study was not powered to detect differences of this magnitude but rather to estimate parameters.

CONCLUSION

The administration of prophylactic antibiotics during labor induction of nulliparous patients with obesity resulted in a 27% lower cesarean delivery rate overall and a 28% lower rate in patients with class III obesity. A larger trial is warranted to evaluate these differences.

Maternal circulating concentrations of soluble Fas and Elabela in early- and late-onset preeclampsia

OBJECTIVE

The Fas/Fas ligand (FASL) system and Elabela-apelin receptor signaling pathways are implicated in the pathophysiology of preeclampsia. The aim of the current study was to investigate whether a model combining the measurement of sFas and Elabela in the maternal circulation may serve as a clinical biomarker for early- and/or late-onset preeclampsia more effectively than measures of each biomarker individually.

METHODS

Blood samples were collected from 214 women in the following groups: (1) normal pregnancy sampled <34 weeks of gestation (n = 56); (2) patients who developed early-onset preeclampsia (n = 54); (3) normal pregnancy sampled ≥34 weeks of gestation (n = 52); (4) patients who developed late-onset preeclampsia (n = 52). Maternal circulating soluble Fas and Elabela concentrations were determined using sensitive and validated immunoassays. Two sample t-tests, multivariate logistic regression, and receiver operating characteristic curves were used for analyses.

RESULTS

(1) Women with early-onset preeclampsia, and those with late-onset preeclampsia with placental lesions of maternal vascular malperfusion, had increased concentrations of sFas compared to their gestational age-matched normal controls; (2) women with late-onset preeclampsia, but not those with early-onset preeclampsia, had increased concentrations of Elabela compared to their gestational age-matched counterparts; and (3) an increase in both Elabela and sFas concentrations was more strongly associated with late-onset preeclampsia than early-onset preeclampsia relative to models including either of the markers alone.

CONCLUSIONS

A combined model of maternal sFas and Elabela concentrations provides a stronger association with late-onset preeclampsia than either protein alone. This finding demonstrates the possibility to improve the classification of late-onset preeclampsia by combining the results of both molecular biomarkers.

Diseases and complications of the puerperium

BACKGROUND

In terms of maternal morbidity and mortality, the puerperium is just as significant as pregnancy and childbirth. Nearly half of all maternal deaths occur in the time after delivery.

METHODS

This review is based on pertinent articles in English and German from the years 2000- 2020 that were retrieved by a selective search in MEDLINE and EMBASE, as well as on the available guidelines in English and German and on German-language textbooks of obstetrics.

RESULTS

The most common and severe complications are, in the post-placental phase, bleeding and disturbances of uterine involution; in the first seven days after delivery, infection (e.g., endomyometritis, which occurs after 1.6% [0.9; 2.5] of all births) and hypertension-related conditions. Thromboembolism, incontinence and disorders of the pelvic floor, mental disease, and endocrine disturbances can arise at any time during the puerperium. In an Australian study, the incidence of embolism was 0.45 per 1000 births, with 61.3% arising exclusively after delivery.

CONCLUSION

Basic familiarity with the most common and severe diseases in the puerperium is important for non-gynecologists as well, among other things because highly acute, lifethreatening complications can arise that demand urgent intervention.

Association Between Preeclampsia Risk and Fine Air Pollutants and Acidic Gases: A Cohort Analysis in Taiwan

Background: Fine air pollutant particles have been reported to be associated with risk of preeclampsia. The association between air pollutant exposure and preeclampsia risk in heavily air polluted Taiwan warrants investigation.

Methods: We combined data from Taiwan National Health Insurance (NHI) Research Database (NHIRD) and Taiwan Air Quality Monitoring Database. Women aged 16–55 years were followed from January 1, 2000, until appearance of ICD-9 coding of preeclampsia withdrawal from the NHI program, or December 31, 2013. Daily concentration of NOx, NO, NO₂, and CO was calculated by Kriging method. The Cox proportional hazard regression model was used for risk assessment.

Results: For NOx, Relative to Quartile [Q] 1 concentrations, the Q2 (adjusted hazard ratio adjusted = 2.20, 95% CI = 1.50–3.22), Q3 (aHR = 7.28, 95% CI = 4.78–11.0), and Q4 (aHR = 23.7, 95% CI = 13.7–41.1) concentrations were associated with a significantly higher preeclampsia or eclampsia risk. Similarly, for NO, relative to Q1 concentrations, the Q2 (aHR = 1.82, 95% CI = 1.26–2.63), Q3 (aHR = 7.53, 95% CI = 5.12–11.0), and Q4 (aHR = 11.1, 95% CI = 6.72–18.3) concentrations were correlated with significantly higher preeclampsia or eclampsia risk. Furthermore, for NO₂, relative to Q1 concentration, the Q2 (aHR = 1.99, 95% CI = 1.37–2.90), Q3 (aHR = 6.15, 95% CI = 3.95–9.57), and Q4 (aHR = 32.7, 95% CI = 19.7–54.3) concentrations also associated with a significantly higher preeclampsia or eclampsia risk.

Conclusion: Women exposed to higher NO_X, NO, NO₂, and CO concentrations demonstrated higher preeclampsia incidence.

Incidence and Predictors of Pre-Eclampsia Among Pregnant Women Attending Antenatal Care at Debre Markos Referral Hospital, North West Ethiopia: Prospective Cohort Study

Background

Pre-eclampsia is a pregnancy-induced hypertension that occurs after 20 weeks of gestation. It is the leading cause of maternal and perinatal morbidity and mortality globally, but it is higher in developing countries. In Ethiopia, conducting research on the incidence and predictors of pre-eclampsia is crucial due to the paucity of information.

Methods

A prospective cohort study was undertaken using 242 pregnant women between November 1, 2018 and March 30, 2019 at Debre Markos Referral Hospital. All eligible women who fulfilled the inclusion criteria were included in this study. Data were entered into the epic-data Version 4.2 and analyzed using the STATA Version 14.0 software. The Cox-proportional hazard regression model was fitted and Cox-Snell residual test was used to assess the goodness of fit. Pre-eclampsia free survival time was estimated using the Kaplan–Meier survival curve. Both bivariable and multivariable Cox-proportional hazard regression models were fitted to identify predictors of pre-eclampsia.

Results

The overall incidence rate of pre-eclampsia was 3.35 per 100 person-years. Having a pre-existing history of diabetes mellitus [AHR=2.7 (95% CI=1.43–8.81)], having a history of multiple pregnancy [AHR=3.4 (95% CI=2.8–6.9)] and being ≥35 years old age [AHR=2.5 (95% CI=1.42–3.54)] were the significant predictors of pre-eclampsia.

Conclusion

The incidence of pre-eclampsia was high in this study. Having (pre-existing diabetes and multiple pregnancy) and being ≥35 years old age were the significant predictors of pre-eclampsia. Inspiring pregnant women’s health-seeking behavior should provide a chance to diagnose pre-eclampsia early to prevent the medical complication of pre-eclampsia.

Risk of pre-eclampsia in patients with a maternal genetic predisposition to common medical conditions: a case-control study

OBJECTIVE

To assess whether women with a genetic predisposition to medical conditions known to increase pre-eclampsia risk have an increased risk of pre-eclampsia in pregnancy.

DESIGN

Case-control study.

SETTING AND POPULATION

Pre-eclampsia cases (n = 498) and controls (n = 1864) in women of European ancestry from five US sites genotyped on a cardiovascular gene-centric array.

METHODS

Significant single-nucleotide polymorphisms (SNPs) from 21 traits in seven disease categories (cardiovascular, inflammatory/autoimmune, insulin resistance, liver, obesity, renal and thrombophilia) with published genome-wide association studies (GWAS) were used to create a genetic instrument for each trait. Multivariable logistic regression was used to test the association of each continuous scaled genetic instrument with pre-eclampsia. Odds of pre-eclampsia were compared across quartiles of the genetic instrument and evaluated for significance.

MAIN OUTCOME MEASURES

Genetic predisposition to medical conditions and relationship with pre-eclampsia.

RESULTS

An increasing burden of risk alleles for elevated diastolic blood pressure (DBP) and increased body mass index (BMI) were associated with an increased risk of pre-eclampsia (DBP, overall OR 1.11, 95% CI 1.01-1.21, P = 0.025; BMI, OR 1.10, 95% CI 1.00-1.20, P = 0.042), whereas alleles associated with elevated alkaline phosphatase (ALP) were protective (OR 0.89, 95% CI 0.82-0.97, P = 0.008), driven primarily by pleiotropic effects of variants in the FADS gene region. The effect of DBP genetic loci was even greater in early-onset pre-eclampsia cases (at <34 weeks of gestation, OR 1.30, 95% CI 1.08-1.56, P = 0.005). For other traits, there was no evidence of an association.

CONCLUSIONS

These results suggest that the underlying genetic architecture of pre-eclampsia may be shared with other disorders, specifically hypertension and obesity.

TWEETABLE ABSTRACT

A genetic predisposition to increased diastolic blood pressure and obesity increases the risk of pre-eclampsia.

Clinical Course, Associated Factors, and Blood Pressure Profile of Delayed-Onset Postpartum Preeclampsia

OBJECTIVE

To identify clinical risk factors associated with development of delayed-onset postpartum preeclampsia, and to characterize management and subsequent risk of cardiovascular disease.

METHODS

This is a case-control study of women admitted to the hospital with delayed-onset postpartum preeclampsia (defined as a new diagnosis of preeclampsia presenting between 48 hours and 6 weeks postpartum) compared with women with full-term, uncomplicated pregnancies without a hypertensive diagnosis or diabetes. Included women delivered between January 2014 and June 2018 at a single tertiary care center. Women with an antenatal diagnosis of preeclampsia or chronic hypertension were excluded. Univariate analysis was used to identify risk factors associated with delayed-onset postpartum preeclampsia and to compare rates of hypertension and antihypertensive medication use, with follow-up beyond 3 months postpartum among a subset of women in the control group who were matched 2:1 with women in the case group. Multivariable logistic regression was performed and included covariates identified in a backward stepwise approach.

RESULTS

Compared with women in the control group (n=26,936), women with delayed-onset postpartum preeclampsia (n=121) were significantly more likely to be of non-Hispanic black race (31.4% vs 18.0%), obese (39.7% vs 20.1%), and deliver by cesarean (40.5% vs 25.8%), all P<.01. For women diagnosed with delayed-onset postpartum preeclampsia, the median postpartum day of presentation was 7.0 (interquartile range 5.0-9.0), with 93.4% presenting secondary to symptoms, which was most commonly a headache. A majority (73.6%) underwent imaging studies, and 49.6% received intravenous antihypertensive agents. A total of 86 (71.0%) women with delayed-onset postpartum preeclampsia and 169 (72.8%) women in the control group had longer term information available, with a median follow-up time of 1.5 years (interquartile range 0.8-2.8). Delayed-onset postpartum preeclampsia was associated with higher blood pressures at 3 months postpartum or later (median systolic 130 mm Hg vs 112 mm Hg and median diastolic 80 mm Hg vs 70 mm Hg, P<.001).

CONCLUSION

Delayed-onset postpartum preeclampsia is associated with variable management strategies. There is substantial overlap between the clinical risk factors for delayed-onset postpartum preeclampsia and antepartum preeclampsia. Our findings suggest that delayed-onset postpartum preeclampsia is also associated with an increased risk of progression to chronic hypertension.

Impact of a Policy to Deliver at 39 Weeks for the Indication of Class III Obesity

OBJECTIVE

The aim of this study was to evaluate the effect of a policy to deliver at 39 weeks for class III obesity.

METHODS

This was a retrospective cohort study of women with class III obesity delivering at ≥ 37 weeks before (May 2012 to April 2014) and after the policy (September 2014 to August 2016). The primary outcome was the cesarean rate. Secondary outcomes included maternal morbidities and a neonatal morbidity composite. Modified Poisson regression was used to adjust for demographic differences between groups.

RESULTS

The study included a total of 1,210 patients, 580 before the policy and 630 after the policy. Before and after the policy, cesarean rates were similar (41.6% vs. 47.1%; risk ratio [RR]: 1.13 [95% CI: 1.00-1.29]; adjusted RR [aRR]: 1.03 [95% CI: 0.92-1.14]). In adjusted comparisons of women undergoing labor induction, parous women had lower cesarean rates (aRR: 0.62; 95% CI: 0.41-0.94) but nulliparous women had higher cesarean rates (aRR: 1.32; 95% CI: 1.04-1.68) after the policy (P for interaction = 0.01). Rates of chorioamnionitis, endometritis, and cesarean wound infection were not different between groups. Composite neonatal morbidity was not different between pre- and postpolicy groups.

CONCLUSIONS

A policy of delivery at 39 weeks for class III obesity did not affect overall cesarean rate or rates of maternal or neonatal morbidity. Further investigation should evaluate subsets of women who may have a higher cesarean rate with this policy.

Hypertensive disorders of pregnancy and risks of adverse pregnancy outcomes: a retrospective cohort study of 2368 patients

Hypertensive disorders of pregnancy (HDP) comprise a group of hypertension-related diseases and represent the most common medical disorders in pregnancy. The aim of this study was to investigate the risks of adverse pregnancy outcomes in patients with different types of HDP, including gestational hypertension, chronic hypertension, preeclampsia (PE, early or late onset), PE superimposed on chronic hypertension (superimposed PE), eclampsia, and HELLP syndrome. Data from a multicenter retrospective patient cohort in China were analyzed. Seventeen adverse maternal or perinatal outcomes were evaluated. Logistic regression was used to estimate the risk of adverse outcomes for each HDP subgroups, using the gestational hypertension group as the reference. The final analysis included 2368 patients with HDP. Of these, 39.9% of patients reported at least one adverse pregnancy outcome. Patients with early onset PE had the highest risk for having both adverse maternal and perinatal outcomes (OR = 7.28, 95% CI: 2.68, 19.79). The risk of perinatal death significantly increased in HELLP syndrome, superimposed PE, and early onset PE, (OR = 13.81, 6.32, and 4.84, respectively, p < 0.05) groups. This study highlights that among patients with HDP, those with early onset PE had the highest risk for having both adverse maternal and perinatal outcomes, and patients with HELLP syndrome had the highest risk for perinatal death.

Efficacy of combined medication of nifedipine and magnesium sulfate on gestational hypertension and the effect on PAPP-A, VEGF, NO, Hcy and vWF

Objective

To investigate the effects of combined medication of nifedipine and magnesium sulfate on the blood pressure, pregnancy-associated plasma protein A (PAPP-A), vascular endothelial growth factor (VEGF), nitric oxide (NO), homocysteine (Hcy) and von Willebrand factor (vWF) in gestational hypertension patients.

Methods

A total of 220 gestational hypertension patients were enrolled as the subjects, and divided into two groups randomly, i.e. the observation group and the control group. In observation group, patients took combined medication of nifedipine and magnesium sulfate, while those in the control group only took magnesium sulfate for treatment. Clinical efficacy, and the changes in blood pressure, PAPP-A, VEGF, NO, Hcy and vWF before and after treatment were compared between two groups.

Results

In the observation group and the control group, total effectiveness rates were 92.7% and 70.9%, respectively (p < 0.05). After treatment, we found significant decreases in PAPP-A, VEGF, NO, Hcy and vWF in patients of two groups, with more significant decreases in the observation group (p < 0.05). Incidence rates of the adverse reactions in two groups were 5.5% and 6.4%, respectively, without any statistically significant differences (p > 0.05). In the observation group, patients had fewer complications (p < 0.05).

Conclusion

Combined medication of magnesium sulfate and nifedipine can decrease the levels of PAPP-A, VEGF, NO, Hcy and vWF in serum as well as the blood pressure of patients with gestational hypertension, with a reduction in incidence rate of complications and improvement in efficacy.

The prediction of early preeclampsia: Results from a longitudinal proteomics study

OBJECTIVES

To identify maternal plasma protein markers for early preeclampsia (delivery <34 weeks of gestation) and to determine whether the prediction performance is affected by disease severity and presence of placental lesions consistent with maternal vascular malperfusion (MVM) among cases.

STUDY DESIGN

This longitudinal case-control study included 90 patients with a normal pregnancy and 33 patients with early preeclampsia. Two to six maternal plasma samples were collected throughout gestation from each woman. The abundance of 1,125 proteins was measured using high-affinity aptamer-based proteomic assays, and data were modeled using linear mixed-effects models. After data transformation into multiples of the mean values for gestational age, parsimonious linear discriminant analysis risk models were fit for each gestational-age interval (8-16, 16.1-22, 22.1-28, 28.1-32 weeks). Proteomic profiles of early preeclampsia cases were also compared to those of a combined set of controls and late preeclampsia cases (n = 76) reported previously. Prediction performance was estimated via bootstrap.

RESULTS

We found that 1) multi-protein models at 16.1-22 weeks of gestation predicted early preeclampsia with a sensitivity of 71% at a false-positive rate (FPR) of 10%. High abundance of matrix metalloproteinase-7 and glycoprotein IIbIIIa complex were the most reliable predictors at this gestational age; 2) at 22.1-28 weeks of gestation, lower abundance of placental growth factor (PlGF) and vascular endothelial growth factor A, isoform 121 (VEGF-121), as well as elevated sialic acid binding immunoglobulin-like lectin 6 (siglec-6) and activin-A, were the best predictors of the subsequent development of early preeclampsia (81% sensitivity, FPR = 10%); 3) at 28.1-32 weeks of gestation, the sensitivity of multi-protein models was 85% (FPR = 10%) with the best predictors being activated leukocyte cell adhesion molecule, siglec-6, and VEGF-121; 4) the increase in siglec-6, activin-A, and VEGF-121 at 22.1-28 weeks of gestation differentiated women who subsequently developed early preeclampsia from those who had a normal pregnancy or developed late preeclampsia (sensitivity 77%, FPR = 10%); 5) the sensitivity of risk models was higher for early preeclampsia with placental MVM lesions than for the entire early preeclampsia group (90% versus 71% at 16.1-22 weeks; 87% versus 81% at 22.1-28 weeks; and 90% versus 85% at 28.1-32 weeks, all FPR = 10%); and 6) the sensitivity of prediction models was higher for severe early preeclampsia than for the entire early preeclampsia group (84% versus 71% at 16.1-22 weeks).

CONCLUSION

We have presented herein a catalogue of proteome changes in maternal plasma proteome that precede the diagnosis of preeclampsia and can distinguish among early and late phenotypes. The sensitivity of maternal plasma protein models for early preeclampsia is higher in women with underlying vascular placental disease and in those with a severe phenotype.

Circulating soluble fms-like tyrosine kinase-1, soluble endoglin and placental growth factor during pregnancy in normotensive women in KwaZulu-Natal, South Africa

BACKGROUND

Based on the increased pre-eclampsia and HIV antenatal incidence in South Africa, we determined the angiogenic profiles due to its mechanistic link in preeclampsia development, throughout uncomplicated pregnancies in HIV positive and negative women.

OBJECTIVE

To determine the angiogenic profiles throughout uncomplicated pregnancies in HIV positive and HIV negative women. We explored possible correlations between angiogenic serum levels and selected maternal characteristics (HIV status, gestational age, maternal factors, and pregnancy outcomes).

METHOD

This study was conducted at a primary health care facility in Durban, South Africa. Forty-six pregnant women aged 18-45 years, were enrolled at 10-20, 22-30 and 32-38 weeks' gestation, respectively through convenient sampling. Serum samples were collected and quantitatively evaluated using ELISAs. Clinical and epidemiological data were analysed using STATA (version 14). A probability level of p < 0.05 was considered statistically significant.

RESULTS

Of those enrolled, 28.3% were nulliparous, 82% were HIV positive and none developed pre-eclampsia. Systolic and diastolic blood pressure increased slightly throughout pregnancy. Fluctuating angiogenic and anti-angiogenic levels were demonstrated during pregnancy.

CONCLUSION

This study contributes to the current angiogenic knowledge in normotensive pregnancies, and may assist as a reference range against which these factors may be compared in HIV complicated pregnancies.

miR-141-5p regulate ATF2 via effecting MAPK1/ERK2 signaling to promote preeclampsia

OBJECTIVE

Preeclampsia is a pregnancy-specific syndrome characterized by hypertension and proteinuria. Impaired trophoblast invasion partly modulated by abnormal MAPK1/ERK2 signaling played important roles in the pathological process of preeclampsia. The objective of this study is to investigate miR-141-5p regulate ATF2 via effecting MAPK1/ERK2 signaling to promote preeclampsia.

STUDY DESIGN

The maternal placentae and clinical data of 30 patients with preeclampsia and 30 healthy pregnant women were collected in the Second Hospital of Shanxi Medical University from July 2015 to April 2016. Transcriptional levels of miR-141-5p in placentae were monitored using quantitative real-time reverse transcription-polymerase chain reaction. The target gene of miR-141-5p was analyzed with "TargetScanHuman Release 7.2″. To evaluate the pathways of this response, MAPK1 and ERK1/2 in placentae were detected using immunohistochemistry and Western Blot. Transfection experiment was used to verify the function of miR-141-5p regulating ATF2 to effect MAPK1/ERK2 signaling in JEG-3 cells.

RESULTS

miR-141-5p was significantly down-regulated in placentae of patients with preeclampsia, in comparison to the healthy pregnant women groups. There was no difference in MAPK1 expression between placentae of patients with preeclampsia and healthy pregnant women groups. While p-MAPK1 expression was lower in preeclampsia placentae, in comparison to the healthy pregnant women groups. Moreover, inhibition and activation experiments also validate the function of miR-141-5p in effecting p-MAPK1 level in JEG-3 cells. Bioinformatic analysis identified that ATF2 was a target gene of miR-141-5p, which was one DNA-binding protein to effect phosphatase DUSP1 transcription. DUSP1 effect MAPK1/ERK2 signaling in preeclampsia.

CONCLUSION

miR-141-5p up-regulated transcription factor ATF2 to promote phosphatase DUSP1 expression. DUSP1 expression reduces p-MAPK1 and ERK1/2 expression to promote preeclampsia.

Pre-eclampsia: pathogenesis, novel diagnostics and therapies

Pre-eclampsia is a complication of pregnancy that is associated with substantial maternal and fetal morbidity and mortality. The disease presents with new-onset hypertension and often proteinuria in the mother, which can progress to multi-organ dysfunction, including hepatic, renal and cerebral disease, if the fetus and placenta are not delivered. Maternal endothelial dysfunction due to circulating factors of fetal origin from the placenta is a hallmark of pre-eclampsia. Risk factors for the disease include maternal comorbidities, such as chronic kidney disease, hypertension and obesity; a family history of pre-eclampsia, nulliparity or multiple pregnancies; and previous pre-eclampsia or intrauterine fetal growth restriction. In the past decade, the discovery and characterization of novel antiangiogenic pathways have been particularly impactful both in increasing understanding of the disease pathophysiology and in directing predictive and therapeutic efforts. In this Review, we discuss the pathogenic role of antiangiogenic proteins released by the placenta in the development of pre-eclampsia and review novel therapeutic strategies directed at restoring the angiogenic imbalance observed during pre-eclampsia. We also highlight other notable advances in the field, including the identification of long-term maternal and fetal risks conferred by pre-eclampsia.

Top-cited articles in the Journal: a bibliometric analysis

BACKGROUND

The Journal has had a profound influence in nearly 150 years of publishing. A bibliometric analysis, which uses citation analyses to evaluate the impact of articles, can be used to identify the most impactful papers in the Journal's history.

OBJECTIVE

The objective was to identify and characterize the top-cited articles published in the Journal since 1920.

STUDY DESIGN

We used the Web of Science and Scopus databases to identify the most frequently cited articles of the Journal from 1920 through 2018. The top 100 articles from each database were included in our analysis. Articles were evaluated for several characteristics including year of publication, article type, topic, open access, and country of origin. Using the Scopus data, we performed an unadjusted categorical analysis to characterize the articles and a 2 time point analysis to compare articles before and after 1995, the median year of publication from each database list.

RESULTS

The top 100 articles from each database were included in the analysis. This included 120 total articles: 80 articles listed in both and 20 unique in each database. More than half (52%) were observational studies, 9% were RCTs, and 75% were from US authors. When the post-1995 studies were compared with the articles published before 1995, articles were more frequently cited (median 27 vs 13 citations per year, P < .001), more likely to be randomized (14.0% vs 4.8%, P = .009), and more likely to originate from international authors (33.3% vs 17.5%, P = .045).

CONCLUSION

Slightly more than half of the top-cited papers in the Journal since 1920 were observational studies and three quarters of all papers were from US authors. Compared with top-cited papers before 1995, the Journal's top-cited papers after 1995 were more likely to be randomized and to originate from international authors.

Association between alcohol consumption during pregnancy and hypertensive disorders of pregnancy in Japan: the Japan Environment and Children's Study

This study examined the association between maternal alcohol consumption during pregnancy and hypertensive disorders of pregnancy in the Japan Environment and Children's Study, a nationwide birth cohort study. A total of 76 940 pregnant women were included in the analysis. Information about alcohol consumption during pregnancy was obtained using two questionnaires: T1 and T2. The mean (standard deviation) gestational age in the T1 and T2 questionnaires were 16.5 (5.8) and 27.9 (3.7) weeks, respectively. Alcohol consumption was considered as an exposure, hypertensive disorders of pregnancy as an outcome, and possible confounding factors were included in a generalized linear mixed-effects model with a logit link function. Among the study subjects, 2 348 (3.1%) women developed hypertensive disorders of pregnancy. Compared with 25 300 women who never drank alcohol, 43 women who drank alcohol according to the T1 questionnaire and continued to drink ≥150 g ethanol/week according to the T2 questionnaire had significantly higher odds of hypertensive disorders of pregnancy. The adjusted odds ratio was 3.98 (95% confidence interval [CI], 1.33-11.9). In conclusion, alcohol consumption of ≥150 g ethanol/week during pregnancy is better avoided because of the high odds of developing hypertensive disorders of pregnancy. It may be meaningful that healthcare providers confirm information about alcohol consumption during pregnancy. Moreover, discontinuation of alcohol consumption is recommended to prevent the onset of hypertensive disorders of pregnancy in Japan.

Maternal and perinatal adverse outcomes in women with pre-eclampsia cared for at facility-level in South Africa: a prospective cohort study

Background

Hypertensive disorders of pregnancy contribute to 14% of all maternal deaths, the majority of which occur in low- and middle-income countries. The aim of the study was to describe the maternal and perinatal clinical outcomes of women with pre-eclampsia living in middle- and low-income countries.

Methods

The study was a prospective observational study of women with pre-eclampsia (n = 1547, 42 twin pregnancies) at three South African tertiary facilities. Using stepwise logistic regression model area under the receiver operating characteristic curve (AUROC) values, the association between maternal baseline and admission characteristics and risk of adverse outcomes was evaluated. Main outcome measures were eclampsia, kidney injury and perinatal death.

Results

In 1547 women with pre-eclampsia, 16 (1%) died, 147 (9.5%) had eclampsia, four (0.3%) had a stroke and 272 (17.6%) had kidney injury. Of the 1589 births, there were 332 (21.0%) perinatal deaths; of these, 281 (84.5%) were stillbirths. Of 1308 live births, 913 (70.0%) delivered <37 completed weeks and 544 (41.7%) delivered <34 weeks’ gestation. Young maternal age (AUROC = 0.76, 95% confidence interval (CI) = 0.71-0.80) and low Body Mass Index BMI (AUROC 0.65, 95% CI = 0.59-0.69) were significant predictors of eclampsia. Highest systolic blood pressure had the strongest association with kidney injury, (AUROC = 0.64, 95% CI = 0.60-0.68). Early gestation at admission was most strongly associated with perinatal death (AUROC = 0.81, 95% CI = 0.77-0.84).

Conclusions

The incidence of pre-eclampsia complications, perinatal death and preterm delivery in women referred to tertiary care in South Africa was much higher than reported in other low- and middle-income studies and despite access to tertiary care interventions. Teenage mothers and those with low BMI were at highest risk of eclampsia. This information could be used to inform guidelines, the research agenda and policy.

Analysis of preventability of hypertensive disorder in pregnancy-related maternal death using the nationwide registration system of maternal deaths in Japan

Objective: Hypertensive disorder of pregnancy (HDP) is a major cause of maternal death. The goal of this study was to investigate factors associated with maternal death due to HDP. Study design: HDP-related maternal deaths in Japan reported to the Committee of the Ministry of Health, Labor and Welfare from 2010 to 2015 were examined. Results: Out of 47 cases of HDP, 30 were identified as the major cause of maternal death. The median maternal age was 34 years (range 24-45) and the mortality in women aged ≥40 years was seven times higher that than in women aged <34 years. The etiologies were intracerebral hemorrhage (n = 22), subarachnoid hemorrhage (n = 3), subcapsular hematoma of the liver (n = 2), peripartum cardiomyopathy (n = 2), and eclampsia (n = 1), and 19 cases were deemed preventable. The most frequent antepartum problems were delays in hospitalization, maternal transfer, and termination of pregnancy. In four cases, diagnosis of HELLP syndrome was too late because laboratory data were not checked, despite the patient reporting epigastric pain or showing elevation of blood pressure (BP). Treatment for lowering of BP was improper in 2/3 intrapartum cases, even though BP was elevated during pregnancy (144 versus 188 mmHg, p < .001). There was inadequate lowering of BP and lack of use of magnesium sulfate in 7/11 postpartum cases (64%), despite aspartate aminotransferase (AST) (p < .005), alanine aminotransferase (ALT) (p < .01), lactate dehydrogenase (LDH) (p < .005), and platelet count (PLT) (p < .01) all significantly worsening after delivery. Conclusion: HDP accounts for 11% of maternal deaths in Japan. Mothers aged ≥40 years are most at risk for HDP-related maternal death. Major concerns for preventabilities were late hospitalization, maternal transportation, and termination of pregnancy for term or near-term HDP. Regular vital checks and prompt lowering of BP were lacked during labor in most cases. HELLP syndrome should be managed at a general hospital with sufficient medical resources.

The profiles of soluble adhesion molecules in the "great obstetrical syndromes". J Matern Fetal Neonatal Med 2018;32:2113-2136. [PMID: 29320948 DOI: 10.1080/14767058.2018.1427058]

OBJECTIVE

The objective of this study was to determine the profiles of maternal plasma soluble adhesion molecules in patients with preeclampsia, small-for-gestational-age (SGA) fetuses, acute pyelonephritis, preterm labor with intact membranes (PTL), preterm prelabor rupture of the membranes (preterm PROM), and fetal death.

MATERIALS AND METHODS

A cross-sectional study was conducted to determine maternal plasma concentrations of sE-selectin, sL-selectin, and sP-selectin as well as sICAM-1, sVCAM-1, and sPECAM-1 in patients with (1) an uncomplicated pregnancy (control, n = 100); (2) preeclampsia (n = 94); (3) SGA fetuses (in women without preeclampsia/hypertension, n = 45); (4) acute pyelonephritis (n = 25); (5) PTL (n = 53); (6) preterm PROM (n = 24); and (7) fetal death (n = 34). Concentrations of soluble adhesion molecules and inflammatory cytokines (tumor necrosis factor (TNF)-α and interleukin (IL)-8) were determined with sensitive and specific enzyme-linked immunoassays.

RESULTS

In comparison to women with a normal pregnancy, (1) women with preeclampsia had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1, and a lower concentration of sL-selectin (all p values < .001); (2) patients with SGA fetuses had higher median concentrations of sE-selectin, sP-selectin, and sVCAM-1 (all p values < .05); (3) patients with a fetal death had higher median concentrations of sE-selectin and sP-selectin (all p values < .05); (4) patients with acute pyelonephritis had higher median plasma concentrations of sE-selectin, sICAM-1, and sVCAM-1 (all p values < .001); (5) patients with preeclampsia and acute pyelonephritis, plasma concentrations of sVCAM-1, sE-selectin, and sP-selectin correlated with those of the proinflammatory cytokines TNF-α and interleukin (IL)-8 (all p values < .05); (6) patients with PTL had a higher median concentration of sP-selectin and a lower median concentration of VCAM-1 (all p values < .05); and (7) women with preterm PROM had lower median concentrations of sL-selectin and sVCAM-1 (all p values < .05).

CONCLUSIONS

The results of this study show that endothelial cell activation/dysfunction reflected by the plasma concentration of sE-selectin is not specific to preeclampsia but is present in pregnancies complicated by SGA fetuses, acute pyelonephritis, and fetal death. Collectively, we report that each obstetrical syndrome appears to have a stereotypical profile of soluble adhesion molecules in the peripheral circulation.

Blood lead and preeclampsia: A meta-analysis and review of implications

BACKGROUND

Multiple cross-sectional studies suggest that there is an association between blood lead and preeclampsia.

OBJECTIVES

We performed a systematic review and meta-analysis to summarize information on the association between preeclampsia and lead poisoning.

METHODS

Searches of Medline, Web of Science, Scopus, Pubmed, Science Direct and ProQuest (dissertations and theses) identified 2089 reports, 46 of which were downloaded after reviewing the abstracts, and 11 studies were evaluated as meeting the selection criteria. Evaluation using the ROBINS-I template (Sterne, et al., 2016), indicated moderate risk of bias in all studies.

RESULTS

We found that blood lead concentrations were significantly and substantially associated with preeclampsia (k = 12; N = 6069; Cohen's d = 1.26; odds ratio = 9.81; odds ratio LCL = 8.01; odds ratio UCL = 12.02; p = 0.005). Eliminating one study produced a homogeneous meta-analysis and stronger estimates, despite the remaining studies coming from eight separate countries and having countervailing risks of bias.

CONCLUSIONS

Blood lead concentrations in pregnant women are a major risk factor for preeclampsia, with an increase of 1μg/dL associated with a 1.6% increase in likelihood of preeclampsia, which appears to be the strongest risk factor for preeclampsia yet reported. Pregnant women with historical lead exposure should routinely have blood lead concentrations tested, especially after mid-term. Women with concentrations higher than 5μg/dL should be actively monitored for preeclampsia and be advised to take prophylactic calcium supplementation. All pregnant women should be advised to actively avoid lead exposure.

Associations of hypertensive disorders of pregnancy and outcomes of labor induction with prostaglandin vaginal inserts

OBJECTIVE

To evaluate the association between hypertensive (HTNsive) disorders of pregnancy and outcomes of labor induction, in two cohorts of women induced with either misoprostol vaginal insert (MVI) or dinoprostone vaginal insert (DVI).

STUDY DESIGN

This investigation was a post-hoc analysis of data from three Phase II and III, multi-center, double blind, randomized controlled trials of women induced with identical efficacy endpoints. A competing risk framework investigated the association between HTNsive disorders of pregnancy and the time-to-event endpoints of onset of active labor and vaginal delivery. We analyzed the overall incidence of the competing risk, cesarean delivery, by logistic regression to identify potential differences between the proportion of patients with cesarean and vaginal deliveries for each cohort.

RESULTS

401 women with HTNsive disorders during pregnancy underwent induction of labor in these studies (175 with DVI and 226 with MVI). Significant differences were noted in the cumulative incidence of vaginal delivery 24 hours following insertion between the non-HTNsive and HTNsive groups for both treatments, (57.1% vs. 47.4% (p=0.023) among MVI patients and 39.9% vs. 27.2% (p=0.017) among DVI patients). However, upon adjusting for potential confounders, the estimated relative rates of vaginal delivery among HTNsive vs. non-HTNsive patients was 0.947 (95% CI (0.637, 1.371), p=0.631) and 0.904 (95% CI (0.735, 1.113) p=0.341) within the MVI and DVI sub-groups respectively.

CONCLUSION

After adjustment for confounders, such as BMI, baseline modified Bishop score and gestational age, time-to-event outcomes for induction of labor using MVI or DVI in HTNsive women are not significantly different from non-HTNsive women.

Pre-pregnancy BMI, gestational weight gain and risk of preeclampsia: a birth cohort study in Lanzhou, China

BACKGROUND

To evaluate the independent and joint effects of maternal pre-pregnancy BMI and gestational weight gain (GWG) on the risk of preeclampsia and its subtypes.

METHODS

A birth cohort study was conducted from 2010 to 2012 in Lanzhou, China. Three hundred fourty seven pregnant women with preeclampsia and 9516 normotensive women at Gansu Provincial Maternity and Child Care Hospital were included in the present study. Unconditional logistic regression models were used to evaluate the associations between pre-pregnancy BMI, GWG, and risk of preeclampsia and its subtypes.

RESULTS

Compared to women with normal pre-pregnancy BMI, those who were overweight/obese had an increased risk of preeclampsia (OR = 1.81; 95%CI: 1.37-2.39). Women with excessive GWG had an increased risk of preeclampsia (OR = 2.28; 95%CI: 1.70-3.05) compared to women with adequate GWG. The observed increased risk was similar for mild-, severe- and late-onset preeclampsia. No association was found for early-onset preeclampsia. Overweight/obese women with excessive GWG had the highest risk of developing preeclampsia compared to normal weight women with no excessive weight gain (OR = 3.78; 95%CI: 2.65-5.41).

CONCLUSIONS

Our results suggested that pre-pregnancy BMI and GWG are independent risk factors for preeclampsia and that the risk might vary by preeclampsia subtypes. Our study also proposed a potential synergistic effect of pre-pregnancy BMI and GWG that warrants further investigation.

Cigarette smoking during pregnancy and preeclampsia risk: a systematic review and meta-analysis of prospective studies

Although evidence from epidemiological studies evaluating the association between cigarette smoking during pregnancy and preeclampsia risk has been systematically reviewed, the findings have been out of date. To further clarify the relationship, we conducted this comprehensive meta-analysis of prospective studies. We searched PubMed and Web of Science up to August 2015 to identify prospective studies that evaluated the association between cigarette smoking during pregnancy and preeclampsia risk. Random-effects models were used to estimate summarized relative risk (RR) and 95% confidence intervals (CIs). Seventeen prospective studies involving 62,089 preeclampsia patients from a total of approximately 1.8 million subjects were included. Overall, there was a significant negative association between smoking during pregnancy and incidence of preeclampsia (RR = 0.67, 95% CI: 0.60–0.75), with significant heterogeneity (I² = 91.7%). Such an inverse association was also detected in strata of subgroup analyses according to study location, study sample size, parity of populations, singleton pregnancy, and adjustment for potential confounders including maternal age, diabetes mellitus, chronic hypertension, body mass index, and gender of infant. In summary, this meta-analysis suggests that smoking during pregnancy is inversely associated with incidence of preeclampsia. Further large scale multi-center prospective studies are warranted to validate our findings.

Preeclampsia and ESRD: The Role of Shared Risk Factors

BACKGROUND

Several registry-based studies, using diagnostic codes, have suggested that preeclampsia is a risk factor for end-stage renal disease (ESRD). However, because the 2 diseases share risk factors, the true nature of their association remains uncertain. Our goals were to conduct a population-based study to determine the magnitude of the association between preeclampsia and ESRD and evaluate the role of shared risk factors.

STUDY DESIGN

Population-based nested case-control study.

SETTING & PARTICIPANTS

The US Renal Data System was used to identify women with ESRD from a cohort of 34,581 women who gave birth in 1976 to 2010 in Olmsted County, MN. 44 cases of ESRD were identified and each one was matched to 2 controls based on year of birth (±1 year), age at first pregnancy (±2 years), and parity (±1 or ≥4).

PREDICTOR

Preeclamptic pregnancy, confirmed by medical record review.

OUTCOME

ESRD.

MEASUREMENTS

Prepregnancy serum creatinine and urine protein measurements were recorded. Comorbid conditions existing prior to pregnancy were abstracted from medical records and included kidney disease, obesity, diabetes, and hypertension.

RESULTS

There was evidence of kidney disease prior to the first pregnancy in 9 of 44 (21%) cases and 1 of 88 (<1%) controls. Per chart review, 8 of 44 (18%) cases versus 4 of 88 (5%) controls had preeclamptic pregnancies (unadjusted OR, 4.0; 95% CI, 1.21-13.28). Results were similar after independent adjustment for race, education, diabetes, and hypertension prior to pregnancy. However, the association was attenuated and no longer significant after adjustment for obesity (OR, 3.25; 95% CI, 0.93-11.37).

LIMITATIONS

The limited number of ESRD cases and missing data for prepregnancy kidney function.

CONCLUSIONS

Our findings confirm that there is a sizable association between preeclampsia and ESRD; however, obesity is a previously unexplored confounder. Pre-existing kidney disease was common, but not consistently coded or diagnosed.

Antenatal care visits during pregnancy and their effect on maternal and fetal outcomes in pre-eclamptic patients

AIM

The frequency of antenatal care visits during pregnancy was examined to determine their effect on maternal and fetal outcomes in patients with pre-eclampsia.

METHODS

This study included 150 pregnant women with pre-eclampsia who attended the Outpatient Clinic of the Obstetrics and Gynecology Department, Ismailia General Hospital. The women were interviewed and their antenatal care visits recorded. Blood pressure control, cardiotocography, ultrasonographic and Doppler evaluations and the administration of methyldopa were recorded. We calculated the distribution of women who attended an adequate versus an inadequate number of antenatal care visits, examined the characteristics of the groups using significance tests, computed the risk of poor maternal and fetal outcomes and created regression analysis models. We also calculated the incidence rate of poor maternal and fetal outcomes, odds ratios and 95% confidence intervals.

RESULTS

Women who attended an inadequate number of antenatal care visits had a significantly higher risk of post-partum hemorrhage, eclampsia, and intensive care unit admission compared with women who attended an adequate number of visits. Women who attended an inadequate number of visits had a 12-fold risk of a poor maternal outcome, a 53-fold risk of a poor fetal outcome and a significantly higher risk of neonatal mortality in comparison to women who attended an adequate number of antenatal visits.

CONCLUSIONS

The frequency of antenatal care visits during pregnancy has a significant effect on maternal and fetal outcomes in patients with pre-eclampsia.